Background Mitral valve calcification is often incidentally detected on chest computed tomography (CT) scans obtained for a variety of noncardiac indications. In this study, we evaluated the association between mitral valve calcification incidentally detected on chest CT and the presence and severity of mitral valve disease on echocardiography. Methods Of 760 patients undergoing 64-row multidetector CT of the chest, 50 with mitral valve calcification and 100 controls were referred on for echocardiography. Calcifications of the mitral valve leaflet and annulus were assessed for length, Agatston score, and site, and were compared with echocardiographic findings. Results Mitral valve calcification was noted in 59 (7.7%) patients on multidetector CT. Fifty of these patients were assessed by echocardiography, and 32 (64%) were found to have mitral annular calcification. Nine patients (18%) had posterior mitral valve leaflet calcification, and both mitral valve leaflet and annular calcification were detected in nine (18%) cases. Nine (18%) patients had mild, three (6%) had moderate, and one (2%) had severe mitral stenosis. None of the patients with isolated mitral annular calcification had mitral stenosis; however, all the patients with mitral stenosis showed mitral valve leaflet calcification with or without mitral annular calcification (P < 0.001). Moreover, patients with mitral stenosis had a larger mitral calcification length and greater Agatston scores in comparison with those without mitral stenosis (P = 0.001). While 31 patients (62%) with mitral calcification had mitral regurgitation on echocardiography, 21 (21%) in the control group showed mitral regurgitation (P = 0.001). Conclusion Mitral valve leaflet calcification, with or without annular calcification, may be an indicator of mitral stenosis. Mitral calcification can also be considered as an indicator for mitral regurgitation in general. Therefore, patients with mitral valve calcification detected incidentally on chest CT scan may benefit from functional assessment of the valve using echocardiography.
Toufan, Mehrnoush; Javadrashid, Reza; Paak, Neda; Gojazadeh, Morteza; Khalili, Majid
Background Mitral valve replacement in the presence of severe annular calcification is a technical challenge. Case report A 47-year-old lady who had undergone mitral and aortic valve replacement for rheumatic disease 27 years before presented with dyspnea. At reoperation, extensive mitral annular calcification was hindering the disc motion of the Starr-Edwards mitral prosthesis. The old prosthesis was removed and a St Jude Medical mechanical valve was implanted after thorough annular debridement. Postoperatively the patient developed paravalvular leak and hemolytic anemia, subsequently undergoing reoperation three days later. The mitral valve was replaced with an Edwards MIRA valve, with a bulkier sewing cuff, after more aggressive annular debridement. Although initially there was no paravalvular leak, it recurred five days later. The patient also developed a small cerebral hemorrhage. As the paravalvular leak and hemolytic anemia gradually worsened, the patient underwent reoperation 14 days later. A Carpentier-Edwards bioprosthetic valve with equine pericardial patches, one to cover the debrided calcified annulus, another as a collar around the prosthesis, was used to eliminate paravalvular leak. At 7 years postoperatively the patient is doing well without any evidence of paravalvular leak or structural valve deterioration. Conclusion Mitral valve replacement using a bioprosthesis with equine pericardial patches was useful to overcome recurrent paravalvular leak due to severe mitral annular calcification.
Factors correlating to mitral annulus calcification (MAC) include risk factors predisposing to atherosclerosis. In patients with mitral valve (MV) prolapse (MVP), other anatomic or mechanical factors have been supposed to facilitate MAC. The aims of this study were, in patients with MVP undergoing MV repair, (1) to describe the prevalence and characteristics of MAC, (2) to correlate MAC with clinical risk factors, coronary involvement, and aortic valve disease, and (3) to describe prevalence, site, and extension of MAC in fibroelastic deficiency (FED) versus Barlow's disease (BD) and correlate MAC to surgical outcomes (repair vs replacement). In 410 consecutive patients with MVP suitable for surgical MV repair, detailed clinical and echocardiographic data were collected to characterize MAC in BD and FED. MAC was found in 99 patients (24%). Age, female gender, coronary artery disease, and cardiovascular risk factors were correlated with MAC. MAC was equally distributed in FED and BD groups despite patients with FED being older with more cardiovascular risk factors. The most common localization of MAC was annular involvement adjacent to P2 (75%), P1 (31%), and P3 (35%). The presence of MAC affected surgical outcomes in both groups (8% patients with MAC underwent replacement after a first attempt of repair vs 3% without MAC). MAC is a common finding in patients undergoing MV repair, and several clinical characteristics correlate with MAC either in FED or BD. In conclusion, despite very high percentage of repairability, MAC influences surgical outcomes and very detailed echo evaluation is advocated. PMID:24837266
Fusini, Laura; Ghulam Ali, Sarah; Tamborini, Gloria; Muratori, Manuela; Gripari, Paola; Maffessanti, Francesco; Celeste, Fabrizio; Guglielmo, Marco; Cefalù, Claudia; Alamanni, Francesco; Zanobini, Marco; Pepi, Mauro
Mitral valve annulus calcification is a degenerative cardiac condition often found at autopsy in the elderly. While usually considered incidental to the cause of death, we report two cases where mitral valve annulus calcification with valve stenosis was associated with sudden death. Case 1: a 61-year-old female who had underlying atherosclerosis and hypertension collapsed at home. At autopsy there was marked mitral valve annulus calcification with valve stenosis and cardiomegaly. Case 2: a previously well 74-year-old female collapsed in a toilet. At autopsy there was marked calcification of the mitral valve annulus with valve stenosis. In both cases death was attributed to the effects of the calcified mitral valve annulus. Although such calcification may be unrelated to the terminal lethal mechanism, the association with left atrial enlargement, atrial fibrillation, mitral regurgitation, mitral stenosis, bacterial endocarditis, ischaemic and thromboembolic stroke, myocardial infarction, and arrhythmias, means that it should not be overlooked in the differential diagnosis in cases of sudden and unexpected death. PMID:23622459
Quick, Esther; Byard, Roger W
An 80-year-old woman was referred to our institution because of acute heart failure due to moderate mitral stenosis and severe regurgitation. After medical treatment of heart failure, she underwent mitral valve surgery. Intraoperatively severe calcification of the posterior mitral annulus was revealed. We excised only the anterior mitral leaflet and preserved the posterior mitral leaflet to prevent a fatal complication such as left ventricular rupture, injury of the coronary artery or embolism. Partial resection of the calcified annulus was performed using Ultrasonic Surgical System (SonoSurg), after 2-0 polyester mattress sutures were placed through the anterior and posterior annuli from the left ventricle to the left atrium. Then, mitral valve replacement was performed using a St. Jude Medical mechanical heart valve at the supra-annular position. The postoperative course was uneventful. We concluded that partial resection of a severely calcified posterior mitral annulus by the ultrasonic device was a safe and simple procedure. PMID:24008639
Kuriyama, Mitsuhito; Kioka, Yukio; Tanabe, Atsushi
Mitral valve prolapse is the most common heart disease seen in college and university health services. It underlies most arrhythmia and many chest complaints. Activity and exercise restrictions are usually unnecessary. (Author/CJ)
Bergy, Gordon G.
Nonsurgical treatment of clinically important mitral regurgitation (MR) has evolved tremendously over the past decade. Recent studies of percutaneous mitral valve repair procedures have shown that less invasive procedures are safe and can be effective in selected patients. MitraClip has been studied most extensively. The MitraClip is attached to the middle scallop of the mitral leaflets by a transseptal-transvascular approach. The device approximates the leaflets in an edge-to-edge percutaneous repair technique that diminishes MR, improves functional status, and improves left ventricular remodeling. The subgroup that has the most benefit includes patients with older age, poorer left ventricular function, and functional MR and is considered high risk for surgical valve replacement. Other novel percutaneous mitral valve therapies under investigation include indirect and direct annuloplasty, and ventricular remodeling devices. PMID:24281977
Young, Amelia; Feldman, Ted
Objective: We sought to characterize the mechanical properties of normal and myxomatous mitral valve tissues. Methods: We tested 113 mitral valve sections from patients undergoing mitral valve repair or replacement for myxomatous mitral valve prolapse and sections from 33 normal valves obtained at autopsy. Results: Myxomatous mitral valve leaflets were more extensible than normal leaflets when tested parallel to the
J. Edward Barber; F. Kurtis Kasper; Norman B. Ratliff; Delos M. Cosgrove; Brian P. Griffin; Ivan Vesely
... from the NHLBI on Twitter. Living With Mitral Valve Prolapse Most people who have mitral valve prolapse (MVP) have no symptoms or related problems, ... them with medicine. Some people may need heart valve surgery to relieve their symptoms and prevent complications. ...
Mitral valve prolapse is extremely common in children. It is diagnosed by the presence of a nonejection click with or without an associated murmur. In isolated mitral valve prolapse, the prognosis is excellent, but regular office visits are necessary for cardiac status review and infective endocarditis prophylaxis. Patients with significant dysrhythmias represent a small subset with an unknown long-term prognosis. PMID:3825853
Greenwood, R D
Twenty two patients (four men, 18 women, mean age 56 years, range 21 to 88 years) with a history of rheumatic mitral stenosis were studied by cross sectional echocardiography before and after balloon dilatation of the mitral valve. The appearance of the mitral valve on the pre-dilatation echocardiogram was scored for leaflet mobility, leaflet thickening, subvalvar thickening, and calcification. Mitral
G T Wilkins; A E Weyman; V M Abascal; P C Block; I F Palacios
Caseous calcification of the mitral annulus is a rare form of chronic degenerative process in the mitral valve fibrous ring with a mass-like appearance that has to be in the differential of the radiologist and cardiologist. We present the case of an 82-year-old woman in whom a tumor-like calcified mass in the posterior side of the mitral valve annulus was detected at echocardiography, and the diagnosis of caseous calcification was confirmed on multidetector computed tomography (MDCT). The diagnostic features of this rare cardiac mass are described.
Limeme, Manel; Zaghouani, Houneida; Mootemri, Feriel; Majdoub, Senda; Amara, Habib; Bakir, Dejla; Kraiem, Chakib
We report a case of mitral valve replacement in a patient who had previously undergone transcatheter aortic valve implantation. A transseptal approach was used to avoid displacing the aortic prosthesis. Because of the small mitral annulus, a bioprosthetic aortic valve was used in reverse position for mitral valve replacement. The procedure did not interfere with the existing prosthesis, and a follow-up echocardiogram showed that both prosthetic valves were functioning well. To the best of our knowledge, this is the first report of mitral valve replacement in a patient who had a preceding transcatheter aortic valve implantation. We believe that the transseptal approach is promising for mitral valve replacement in such patients. Moreover, using a bioprosthetic aortic valve in reverse position is an option for mitral valve replacement when the mitral annulus is too small for placement of a standard bioprosthetic mitral valve.
Flannery, Laura D.; Lowery, Robert C.; Sun, Xiumei; Satler, Lowell; Corso, Paul; Pichard, Augusto; Wang, Zuyue
Our experience with ball valve replacement of the mitral valve during the past decade is presented in terms that allow comparison with other techniques. The use of such prostheses is characterized by ease of implantation, with an overall operative mortality of 11 per cent for isolated mitral replacement and 13 per cent for multiple valve replacement. The operative mortality for isolated mitral valve replacement during 1969 and thus far in 1970 has been nil. The late mortality was 13 per cent for isolated mitral replacement and 20 per cent for multiple valve replacement. Forty-three per cent of the total late deaths were clearly unrelated to the prosthetic device itself. The overall incidence of late infection and leak is less than 1 per cent and the immediate haemodynamic benefit is not altered by loss of structural integrity of the prosthesis. The most serious problem after mitral valve replacement with the ball valve prosthesis is that of thromboembolic complications. While thrombotic stenosis of the prosthesis is a rarity, embolic episodes, usually cerebral in type, have been noted in 63 per cent of the patients surviving mitral valve replacement with the earliest model ball valve from August 1960 to February 1966. Improvements in valve design have resulted in a remarkable decrease in this incidence as examined by actuarial techniques and taking into account the duration of follow-up. The extension of the cloth sewing margins to the orifice of the valve while maintaining a metallic orifice and metallic cage (Model 6120) resulted in a drop of the thromboembolic rate to 17 per cent from April 1965 to April 1969. The development of the totally cloth-covered prosthesis has further improved these results, with only one thromboembolic complication after isolated mitral valve replacement with the Model 6310 valve in a series of 66 consecutive patients. In clinical practice this has resulted in the avoidance of the use of anticoagulant therapy in patients in whom for a variety of reasons this carries an increased hazard. With further follow-up it may be possible to discontinue the routine use of anticoagulants. Images
Liquefaction necrosis of the mitral annulus is a rare form of peri-annular calcification that the cardiologist must be able to differentiate from other cardiac masses. It classically looks like a round or semilunar hyperdense mass with a denser peripheral rim, located mainly in the posterior mitral annulus. The case we report here was diagnosed in a 78-year-old female patient who presented with an embolic cerebral vascular accident, which raises the question of its etiopathogenic responsibility. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 42:382-383, 2014. PMID:24420234
Mallisho, Maram; Hwang, Inyong; Alsafwah, Shadwan F
We present a case of a 70 year-old woman operated due to severe mitral regurgitation. Early after surgery transthoracic echocardiography revealed the decreased effective orifice area of the implanted bioprosthetic valve and the stenotic features of transvalvular flow. Transesophageal echocardiography (TEE) disclosed a thrombotic cause of heterograft dysfunction. Due to the clinical deterioration and the unclear cause of prosthesis stenosis, the patient was reoperated. Intra-operatively bioprosthetic mitral valve thrombosis was confirmed. Precipitating factors of this rare complication including cardiac device related infective endocarditis (CDRIE) and the diagnostic applicability of TEE in this clinical scenario are discussed. PMID:22427084
Tkaczyszyn, Micha?; Olbrycht, Tomasz; Kustrzycka Kratochwil, Dorota; Sokolski, Mateusz; Sukiennik Kujawa, Ma?gorzata; Skiba, Jacek; Gemel, Marek; Banasiak, Waldemar; Jankowska, Ewa A; Ponikowski, Piotr
Background Glutaraldehyde-treated bioprosthetic heart valves are commonly used for replacement of diseased heart valves. However, calcification and wear limit their durability, and the development of new and improved bioprosthetic valve designs is needed and must be evaluated in a reliable animal model. We studied glutaraldehyde-treated valves 6 months after implantation to evaluate bioprosthetic valve complications in the mitral position in juvenile pigs. Materials The study material comprised eight, 5-month old, 60-kg pigs. All pigs received a size 27, glutaraldehyde-treated, stented, Carpentier-Edwards S.A.V. mitral valve prosthesis. After six months, echocardiography was performed, and the valves explanted for gross examination, high resolution X-ray, and histological evaluation. Results Five pigs survived the follow-up period. Preexplant echocardiography revealed a median peak and mean velocity of 1.61 m/s (range: 1.17-2.00) and 1.20 (SD = ±0.25), respectively, and a median peak and mean pressure difference of 10.42 mmHg (range: 5.83-16.55) and 6.51 mmHg (SD = ±2.57), respectively. Gross examination showed minor thrombotic depositions at two commissures in two valves and at all three commissures in three valves. High resolution X-ray imaging revealed different degrees of calcification in all explanted valves, primarily in the commissural and belly areas. In all valves, histological evaluation demonstrated various degrees of fibrous sheath formation, limited immunological infiltration, and no overgrowth of host endothelium. Conclusions Bioprosthetic glutaraldehyde-treated mitral valves can be implanted into the mitral position in pigs and function after 6 months. Echocardiographic data, calcification, and histological examinations were comparable to results obtained in sheep models and human demonstrating the suitability of the porcine model.
Aortic valve stenosis is a complex inflammatory process, akin to arterial atherosclerosis, involving lymphocytic infiltrates, macrophages, foam cells, endothelial activation and dysfunction, increased cellularity and extracellular matrix deposition, and lipoprotein accumulation. A clonal population of aortic valve myofibroblasts spontaneously undergoes phenotypic transdifferentiation into osteoblast-like cells and forms calcific nodules in cell culture. Animal models complement these cell culture models by providing in vivo systems in which to study the complex molecular and cellular interactions that cause aortic valve disease in the native hemodynamic and biochemical environment. Whereas some species, such as swine, can develop spontaneous vascular and valvular atherosclerotic lesions, others, such as rabbits and mice, have not been shown to develop lesions naturally and require an inciting factor, such as hypercholesterolemia. In this article, we review the published cell culture and animal models available to study calcific aortic valve disease. PMID:17963676
Guerraty, Marie; Mohler Iii, Emile R
Repair of the mitral valve is the treatment of choice for mitral valve regurgitation when the anatomy is favorable. It is well known that mitral valve repair enjoys better clinical and functional results than any other type of valve substitute. This fact is beyond doubt regardless of the etiology of the valve lesion and is of particular importance in degenerative diseases. This review analyzes the most important advances in the knowledge of the anatomy, pathophysiology, and chordal function of the mitral valve as well as the different alternatives in the surgical repair and clinical results of the most prevalent diseases of the mitral valve. An attempt has been made to organize the acquired information available in a practical way.
Mestres, Carlos-A.; Bernal, Jose M.
Background Many previous studies have evaluated the impact of mitral valve (MV) deformity scores on the percutaneous transvenous mitral commissurotomy (PTMC) outcome in patients with mitral stenosis; however, the relationship between mitral annulus calcification (MAC) and the PTMC result has not yet been established. The current study aimed to investigate whether MAC could independently influence the immediate result of PTMC. Methods Of all patients undergoing PTMC in our institution between April 2005 and November 2009, we included 87 patients (28.7%male, mean ± SD age = 42.8 ± 12.6 years) with rheumatic mitral stenosis who had additional data on the echocardiographic evaluation of MAC along with MV leaflets morphology. Echocardiographic assessments were repeated up to six weeks after PTMC to evaluate the immediate PTMC outcome. The frequency of the optimal PTMC result (secondary MV area > = 1.5 cm2 with > = 25% increase and without final mitral regurgitation grade > 2) was compared between two groups of patients with MAC (n = 17) and those without MAC (n = 70). Results The optimal result was obtained in 55 (63.2%) patients, whereas the result was suboptimal in 32 (36.8%) patients due to insufficient MV area increase in 31(96.9%) subjects and post-procedure mitral regurgitation grade > 2 in 1(3.1%). The rate of optimal PTMC results was less in patients with MAC in comparison to those without MAC (29.4% vs.71.4%). After adjustments for possible confounders such as age and leaflets morphological subcomponents (thickening, mobility, calcification, and subvalvular thickening), MAC remained a significant negative predictor of a suboptimal PTMC result (odds ratio = 0.154; 95%CI = 0.038-0.626, p value = 0.009) together with leaflet thickening (odds ratio = 0.214; 95%CI = 0.060-0.770, p value = 0.018). Conclusions MAC appeared to independently influence the immediate result of PTMC; therefore, mitral annulus evaluation may be considered in the echocardiographic assessment of the mitral apparatus prior to PTMC.
Leaflet escape of prosthetic valve is rare but potentially life threatening. It is essential to make timely diagnosis in order to avoid mortality. Transesophageal echocardiography and cinefluoroscopy is usually diagnostic and the location of the missing leaflet can be identified by computed tomography (CT). Emergent surgical correction is mandatory. We report a case of fractured escape of Edward-Duromedics mitral valve 27 years after the surgery. The patient presented with symptoms of acute decompensated heart failure and cardiogenic shock. She was instantly intubated and mechanically ventilated. After prompt evaluation including transthoracic echocardiography and CT, the escape of the leaflet was confirmed. The patient underwent emergent surgery for replacement of the damaged prosthetic valves immediately. Eleven days after the surgery, the dislodged leaflet in iliac artery was removed safely and the patient recovered well.
Kim, Darae; Hun, Sin Sang; Cho, In-Jeong; Shim, Chi-Young; Ha, Jong-Won; Chung, Namsik; Ju, Hyun Chul; Sohn, Jang Won
Cardiac injury after blunt trauma is common but underreported. Common cardiac trauma after the blunt chest injury (BCI) is cardiac contusion; it is very rare to have cardiac valve injury. The mitral valve injury during chest trauma occurs when extreme pressure is applied at early systole during the isovolumic contraction between the closure of the mitral valve and the opening of the aortic valve. Traumatic mitral valve injury can involve valve leaflet, chordae tendineae, or papillary muscles. For the diagnosis of mitral valve injury, a high index of suspicion is required, as in polytrauma patients, other obvious severe injuries will divert the attention of the treating physician. Clinical picture of patients with mitral valve injury may vary from none to cardiogenic shock. The echocardiogram is the main diagnostic modality of mitral valve injuries. Patient's clinical condition will dictate the timing and type of surgery or medical therapy. We report a case of mitral valve and pericardial injury in a polytrauma patient, successfully treated in our intensive care unit.
Shaikh, Nissar; Ummunissa, Firdous; Abdel Sattar, Mohamed
A disc valve of new design was used successfully for the replacement of the mitral valve in patients with rheumatic mitral valve disease. This valve would appear to have the following advantages over the mitral ball valve prosthesis: • Lower left atrial pressure after replacement. • Elimination of the hazard of left ventricular outflow tract obstruction with mitral valve replacement. • Decreased incidence of thromboembolization. • Abolition of possibility of ventricular septal irritation. Despite the better outlook for this valve compared with the ball valve for mitral valve substitution, the mitral valve should always be repaired whenever feasible. Repair is possible in the majority of patients. ImagesFigure 1.
Kay, Jerome Harold; Tsuji, Harold K.; Redington, John V.; Kawashima, Yasunaru; Kagawa, Yuzuru; Yamada, Takashi; Caponegro, Peter; Mendez, Adolfo
We report a case of acute thrombosis of bioprosthetic mitral valve in a 59 year–old Korean female, who underwent a mitral valve replacement with a 25 mm Carpentier - Edwards PERIMOUNT Plus bioprosthesis (Edwards Lifesciences, Inc.; Irvine, CA, USA) and a mini-Maze procedure for correction of mitral stenosis (MS) and atrial fibrillation (AF). On the 10th postoperative day, the patient began to complain of increasing dyspnea and general malaise. Her symptoms worsened and developed into pulmonary edema. Echocardiography revealed a mean diastolic pressure gradient (MDPG) of 10 mmHg across the mitral valve and pressure-half time (PHT) of 166 msec. Due to progressive decompensated heart failure, the patient underwent a repeat sternotomy to replace the bioprosthetic mitral valve. Intraoperatively, we found a thrombosis around the bioprosthetic mitral valve. We excised the bioprosthetic mitral valve and replaced it with a 27 mm ATS mechanical valve (ATS medical, Inc.; Minneapolis, MN, USA). We experienced a rare case that required an early reoperation for a thrombosis of the bioprosthetic valve.
Prosthetic valve thrombosis is a rare but dreaded complication of mechanical heart valves. In this clinical picture, we present an elderly female who developed mechanical mitral valve thrombosis several years after mitral valve replacement. We have provided fluoroscopy as well as intraoperative images of mitral valve thrombosis and have briefly discussed the diagnosis, and management of this complication. PMID:24748585
Hussain, Nasir; Rehman, Atiq; Cheema, Faisal H
Transcatheter aortic valve implantation, as well as interventional mitral valve repair, offer reasonable therapeutic options for high-risk surgical patients. We report a rare case of early post-interventional aortic valve prosthesis migration to the left ventricular outflow tract, with paravalvular leakage and causing severe mitral valve regurgitation. Initial successful interventional mitral valve repair using a clipped edge-to-edge technique revealed, in a subsequent procedure, the recurrence of mitral valve regurgitation leading to progressive heart failure and necessitating subsequent surgical aortic and mitral valve replacement. PMID:23864579
Wendeborn, Jens; Donndorf, Peter; Westphal, Bernd; Steinhoff, Gustav
Background:Degenerative mitral valve disease is the most common cause of mitral regurgitation in the United States. Mitral valve repair is applicable in the majority of these patients and has become the procedure of choice. Objective: This study was undertaken to identify factors influencing the durability of mitral valve repair. Patients and methods: Between 1985 and 1997, 1072 patients underwent primary
A. Marc Gillinov; Delos M. Cosgrove; Eugene H. Blackstone; Ramon Diaz; John H. Arnold; Bruce W. Lytle; Nicholas G. Smedira; Joseph F. Sabik; Patrick M. McCarthy; Floyd D. Loop
A case of parachute deformity of the mitral valve, a rare congenital form of mitral stenosis characterized by insertion of the chordae tendineae into a single posterior papillary muscle, is described in an 11-year-old girl. The eleven other cases in the English literature are reviewed. Images
Bett, J. H. N.; Stovin, P. G. I.
From 1 March 1977 through 31 December 1987, 1,252 patients underwent mitral valve replacement with a SORIN-Biomedica 60° tilting-disc prosthesis at our institution. Hospital mortality was 7.3% (91 patients); prosthesis-related deaths, expressed as a percentage of hospital mortality, accounted for 12.1% of these early deaths. The 1,161 patients who survived hospitalization have been followed up for a total of 4,835 patient-years (range, 1 to 128 months; mean, 50.4 ± 27.3 months). Forty-three (3.7%) of these patients were lost to follow-up. The late mortality was 6.3% (1.5% ± 0.2% per patient-year), and the 10-year actuarial survival rate, excluding hospital mortality, was 89.1% ± 1.6%. The 10-year actuarial (and linearized) rates of freedom from valve-related complications were as follows: embolism, 94.4% ± 1.0% (0.93% ± 0.1% per patient-year); thrombosis of the prosthesis, 99.8% ± 0.1% (0.06% ± 0.03% per patient-year; hemorrhage, 93.7% ± 1.5% (0.95% ± 0.1% per patient-year); prosthetic valve endocarditis, 99.3% ± 0.3% (0.14% ± 0.05% per patient-year); reoperation, 90.6% ± 2.1% (1.1% ± 0.2% per patient-year); and overall complications, 76.6% ± 2.5% (2.9% ± 0.2% per patient-year). No structural deterioration was noted. These data not only confirm our previous reports concerning the reliability and durability of the SORIN prosthesis but also reveal a significant reduction, over the long term, in the overall incidence of valve-related complications. (Texas Heart Institute Journal 1991;18:16-23)
Pellegrini, Alessandro; Colombo, Tiziano; Quaini, Eugenio; Russo, Claudio; Vitali, Ettore; Donatelli, Francesco
Summary Background Caseous calcification of mitral annulus is rather rare echocardiographic finding with prevalence of 0.6% in pts. with proven mitral annular calcification and 0.06% to 0.07% in large series of subjects in all ages. Echocardiographic images of caseous calcification are often heterogenous due to calcium and lipid deposits, and the masses show hyperechogenic and hypoechogenic areas. However the appearance of caseous calcification can imitate that of abscess, tumors and cysts, surgical treatment may not be needed when there is no obstruction. Case Report 76-year old obese (BMI 32 kg/m2), female patient with history of hypertension, stable coronary artery disease, diabetes type 2 and hyperlipidemia presented with no symptoms of mitral valve dysfunction and had no abnormalities on physical exam. Transesophageal echocardiography identified well-organized, composite, immobile lesion (22×15 mm) localized in the posterior part of the mitral annulus, with markedly calcified margins, and no significant impact on the valve function. In computed tomography (CT) lesion was described as calcified (24×22×17.5 mm), connected with posterior leaflet and posterior part of the mitral annulus, reducing posterior leaflet mobility. CT brought the suggestion of caseous mitral annular calcification. Coming to a conclusion, bearing in mind no mitral valve dysfunction at that time, patient was offered conservative treatment. Conclusions Although caseous mitral annular calcification is typically an incidental finding, accurate recognition is needed to avoid mistaking the lesion for a tumor or abscess, which may result in unnecessary cardiac surgery. However this entity is diagnosed on cardiac MRI, multi-modality imaging, especially non-contrast CT, allows for the confident, prospective diagnosis.
Mozenska, Olga; Sypula, Slawomir; Celinska-Spoder, Malgorzata; Walecki, Jerzy; Kosior, Dariusz A.
Acquired aortic valve disease and valvular calcification is highly prevalent in adult populations worldwide and is associated with significant cardiovascular morbidity and mortality. At present, there are no medical therapies that will prevent or regress aortic valve calcification or stenosis and surgical or transcatheter aortic valve replacement remain the only effective therapies for treating this disease. In the setting of valve injury as a result of exposure to biochemical mediators or hemodynamic forces, normal homeostatic processes are disrupted resulting in extracellular matrix degradation, aberrant matrix deposition and fibrosis, inflammatory cell infiltration, lipid accumulation, and neoangiogenesis of the valve tissue and, ultimately, calcification of the valve. Calcification of the aortic valve is now understood to be an active process that involves the coordinated actions of resident valve endothelial and interstitial cells, circulating inflammatory and immune cells, and bone marrow-derived cells. These cells may undergo a phenotype transition to become osteoblast-like cells and elaborate bone matrix, endothelial-to-mesenchymal transition, and form matrix vesicles that serve as a nidus for microcalcifications. Each of these mechanisms has been shown to contribute to aortic valve calcification suggesting that strategies that target these cellular events may lead to novel therapeutic interventions to halt the progression or reverse aortic valve calcification.
Leopold, Jane A.
Cardiovascular disease in Marfan's syndrome presenting in childhood affects the mitral valve more often than the aortic valve or the aorta, as in adults. Early evaluation of the cardiovascular system is necessary for any child in whom Marfan's syndrome is suspected. Images Figure
Marlow, N; Gregg, J E; Qureshi, S A
We report a case of a 62-year-old man who presented with right groin pain who subsequently was found to have a renal infarct secondary to calcific embolus from mitral annular calcification on CT and angiography. We briefly review the literature and discuss the importance of this entity in clinical practice.
Bande, Dinesh [University of North Dakota School of Medicine and Health Sciences, Department of Medicine (United States); Abbara, Suhny; Kalva, Sanjeeva P., E-mail: email@example.com [Massachusetts General Hospital, Department of Radiology (United States)
This study aimed to characterize the mechanical properties of aged human anterior mitral leaflets (AML) and posterior mitral leaflets (PML). The AML and PML samples from explanted human hearts (n = 21, mean age of 82.62 ± 8.77-years-old) were subjected to planar biaxial mechanical tests. The material stiffness, extensibility, and degree of anisotropy of the leaflet samples were quantified. The microstructure of the samples was assessed through histology. Both the AML and PML samples exhibited a nonlinear and anisotropic behavior with the circumferential direction being stiffer than the radial direction. The AML samples were significantly stiffer than the PML samples in both directions, suggesting that they should be modeled with separate sets of material properties in computational studies. Histological analysis indicated the changes in the tissue elastic constituents, including the fragmented and disorganized elastin network, the presence of fibrosis and proteoglycan/glycosaminoglycan infiltration and calcification, suggesting possible valvular degenerative characteristics in the aged human leaflet samples. Overall, stiffness increased and areal strain decreased with calcification severity. In addition, leaflet tissues from hypertensive individuals also exhibited a higher stiffness and low areal strain than normotensive individuals. There are significant differences in the mechanical properties of the two human mitral valve leaflets from this advanced age group. The morphologic changes in the tissue composition and structure also infer the structural and functional difference between aged human valves and those of animals. © 2013 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 102A: 2692-2703, 2014. PMID:24039052
Pham, Thuy; Sun, Wei
Calcific aortic valve stenosis is the most common valvular disease in developed countries, and the major reason for operative valve replacement. In the US, the current annual cost of this surgery is approximately 1 billion dollars. Despite increasing morbidity and mortality, little is known of the cellular basis of the calcifications, which occur in high-perfusion zones of the heart. The case is presented of a patient with calcific aortic valve stenosis and colonies of progressively mineralized nanobacteria in the fibrocalcific nodules of the aortic cusps, as revealed by transmission electron microscopy. Consistent with their outstanding bioadhesivity, nanobacteria might serve as causative agents in the development of calcific aortic valve stenosis. PMID:17315391
Jelic, Tomislav M; Chang, Ho-Huang; Roque, Rod; Malas, Amer M; Warren, Stafford G; Sommer, Andrei P
Terminal warm blood cardioplegia has had a profound impact on cardiac surgery, especially in coronary artery bypass surgery, but there have been few studies on its use in mitral valve replacement. The purpose of this study was to determine whether terminal warm blood cardioplegia offers any advantages in mitral valve replacement. Forty patients with mitral valve disease were prospectively randomized
Chareonkiat Rergkliang; Apirak Chetpaophan; Voravit Chittithavorn; Prasert Vasinanukorn; Vorapong Chowchuvech
Objective: To assess whether microbubbles are associated with a specific type of mitral valve prosthesis and to investigate the relationship of microbubbles to ventricular function and mitral regurgitation. One of the types of spontaneous echocardiographic contrast observed in patients with prosthetic heart valves has been described as microbubbles. Methods: Clinical data and videotapes of patients with a prosthetic mitral valve
Denis J Levy; John S Child; Edmond Rambod; Morteza Gharib; Simcha Milo; Shimon A Reisner
Recently, transcatheter valve-in-valve implantation has emerged as a new alternative to surgical reoperation for degenerated bioprosthetic valves, either in the aortic or mitral position. The early experience and outcome of this strategy appears promising in highly selected patient groups. Here we report a case of early structural valve degeneration in the aortic and mitral position in a patient with chronic hemodialysis successfully treated with transthoracic transcatheter valve-in-valve implantation. PMID:24996712
Yamane, Kentaro; Nazif, Tamim M; Khalique, Omar; Hahn, Rebecca T; Leon, Martin B; Kodali, Susheel K; Williams, Mathew R; George, Isaac
Background Robotic mitral surgery is the most common robotic cardiac procedures. However, in mitral endocarditis the repair become more challenging especially in minimally approach. We applied robotic surgery in mitral endocarditis repair and reviewed our surgical methods and results. Patients From January 2012 to December 2013, 12 patients with mitral endocarditis in National Taiwan University Hospital were operated via robotic assisted repair. Age of them was among 21 to 65 years old, mean 43. Results The vegetation involves anterior leaflet in 3, posterior leaflet in 8 and commissural leaflet in 4. Mean cardiopulmonary bypass time is 124 minutes and cross clamp time is 89 minutes. There was no stroke and no operation death. Mitral valve repair technique including anterior leaflet patch augmentation in 2, direct closure of rupture hole on anterior leaflet in one, plication commissural leaflet in 2, and artificial chordae in 10. There was no mitral regurgitation detected immediately after weaning of cardiopulmonary bypass. All of them got free-from-regurgitation or -stenosis rate was 100% at one-year follow. Conclusions Although mitral infective endocarditis is complex and difficult to repair, robotic mitral repair in infective endocarditis is feasible. Even in the complex repair group, the cardiopulmonary bypass time is not prolonged and the result is good.
Chi, Nai-Hsin; Huang, Chi-Hsiang; Huang, Shu-Chien; Yu, Hsi-Yu; Chen, Yih-Sharng; Wang, Shoei-Shen
Robotic mitral valve surgery is the most common robotic cardiac procedure performed today. Benefits include smaller, less invasive incisions resulting in less pain, shorter length of hospital stay, improved cosmesis, quicker return to preoperative level of functional activity, and decreased blood transfusion requirements. The history and evolution of robotic mitral valve surgery is detailed in this article. Our institution has performed over 800 robotic mitral valve surgeries, and our technique and outcomes are described. Outcomes and operative times are similar to that for sternotomy and minimally invasive approaches to mitral valve surgery. The benefits and limitations of robotic mitral valve surgery are compared with conventional approaches, and future directions are also discussed.
Bush, Bryan; Nifong, L. Wiley; Alwair, Hazaim
A patient with myxomatous mitral valve prolapse underwent mitral mitral valve repair due to severe symptomatic mitral regurgitation. Preoperative echocardiography demonstrated systolic anterior motion of the mitral valve. This finding disappeared once spontaneous chordal rupture occurred, resulting in a flail posterior mitral leaflet. As the patient was considered at high risk of developing post-repair SAM, he was operated on using surgical techniques aimed at lowering the risk of this complication. Despite this, post-repair SAM did develop and could only be eliminated by a surgical edge-to-edge (Alfieri) repair.
Eyal, Allon; Raanani, Ehud; Shapira, Yaron
We present the case of a caseous calcification of the mitral annulus, responsible for two strokes, in a 72-year-old female patient. The brain computed tomography (CT) scan confirmed the presence of a calcific embolus. The echocardiography showed a liquidy, pseudotumoral mass combined with numerous calcifications located in the posterior part of the mitral annulus and extending toward the inferior surface of the left ventricle. During surgery, we found a direct communication between the caseous necrosis and the lumen of the left ventricle at the level of its inferior wall. We performed a valve repair procedure and excision of the caseous necrosis, combined with injection of bioglue into the cavity, to avoid recurrence. Six months after the procedure, the patient was in good health, and had no recurrence of stroke with a satisfactory echocardiography. This is the first description of spontaneous fistulization of a caseous necrosis in the lumen of the left ventricle, explaining a new mechanism for cerebral embolism during the course of calcifying diseases of the mitral annulus. PMID:21376613
Chevalier, Benjamin; Reant, Patricia; Laffite, Stephane; Barandon, Laurent
Objective: The aim of the study was to evaluate the prognostic factors for return to sinus rhythm after mitral valve repair. Method: One hundred ninety-one patients underwent surgery for mitral valve repair, including 142 procedures for valve repair only (74%). The patients with preoperative atrial fibrillation (50.5%) were older, clinically more symptomatic, and had a greater degree of left atrial
Jean F. Obadia; Mazen el Farra; Olivier H. Bastien; Michel Lièvre; Yvan Martelloni; Jean F. Chassignolle
Background. Current techniques of mitral valve repair rely on decreasing valve area to increase leaflet apposition, but fail to address subvalvular dysfunction. A novel repair has been introduced with partial left ventriculectomy, which apposes the anterior leaflet to a corresponding point on the posterior leaflet creating a double-orifice valve, with reported adequate control of mitral regurgitation.Methods. We started to use
Juan P Umaña; Bijan Salehizadeh; Joseph J DeRose; Tamanna Nahar; Alan Lotvin; Shunichi Homma; Mehmet C Oz
In children, systemic heart valve replacement with bioprostheses is associated with accelerated valve degeneration, and mechanical prostheses require permanent anticoagulation. Novel "biomechanical" polymeric valve prostheses ("bio" = flexible, "mechanical" = synthetic), solely made of polycarbonate urethane (PCU), were tested in vitro and in a growing animal (calf) model with the aim of improved durability without permanent anticoagulation. The trileaflet aortic prosthesis has diminished pressure loss and reduced stress and strain peaks. The asymmetric bileaflet mitral valve mimics natural nonaxial inflow. The valves underwent long-term in vitro testing and in vivo testing in growing calves for 20 weeks [mitral (7), aortic (7)] with comparison to different commercial bioprostheses [mitral (7), aortic (2)]. In vitro durability of PCU valves was proved up to 20 years. Survival of PCU valves versus bioprostheses was 7 versus 2 mitral and 5 versus 0 aortic valves, respectively. Two animals with PCU aortic valves died of pannus overgrowth causing left ventricular outflow tract obstruction. Degeneration and calcification were mild (mitral) and moderate (aortic) in PCU valves but were severe in biological valves. There was no increased thrombogenicity of the PCU valves compared to bioprostheses. The novel polymeric valve prostheses revealed superior durability compared to current bioprostheses in growing animal model without permanent anticoagulation and thus, may be a future option for pediatric patients. PMID:16966862
Sachweh, Joerg S; Daebritz, Sabine H
Prevention is better than cure best applies here. As per many authors, posterior leaflet chordae preservation prevent Left ventricular rupture (LVR) and preserve LV geometry. We are presenting here 5 types of left ventricular rupture (LVR) post Mitral valve replacement (MVR) with different methods to repair with the advantages and disadvantages of each. The mortality rate is still very high despite the advances in cardiac surgery. Many therapeutic approaches have been adopted. Yet, none is ideal.
Sersar, Sameh I.; Jamjoom, Ahmed A.
Resection of the chordopapillary apparatus during mitral valve replacement has been associated with a negative impact on survival. Mitral valve replacement with the preservation of the mitral valve apparatus has been associated with better outcomes, but surgeons remain refractory to its use. To determine if there is any real difference in preservation vs non-preservation of mitral valve apparatus during mitral valve replacement in terms of outcomes, we performed a systematic review and meta-analysis using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for clinical studies that compared outcomes (30-day mortality, postoperative low cardiac output syndrome or 5-year mortality) between preservation vs non-preservation during mitral valve replacement from 1966 to 2011. The principal summary measures were odds ratios (ORs) with 95% confidence interval and P-values (that will be considered statistically significant when <0.05). The ORs were combined across studies using a weighted DerSimonian-Laird random-effects model. The meta-analysis was completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, NJ, USA). Twenty studies (3 randomized and 17 non-randomized) were identified and included a total of 3835 patients (1918 for mitral valve replacement preservation and 1917 for mitral valve replacement non-preservation). There was significant difference between mitral valve replacement preservation and mitral valve replacement non-preservation groups in the risk of 30-day mortality (OR 0.418, P <0.001), postoperative low cardiac output syndrome (OR 0.299, P <0.001) or 5-year mortality (OR 0.380, P <0.001). No publication bias or important heterogeneity of effects on any outcome was observed. In conclusion, we found evidence that argues in favour of the preservation of mitral valve apparatus during mitral valve replacement. PMID:23027596
Sá, Michel Pompeu Barros de Oliveira; Ferraz, Paulo Ernando; Escobar, Rodrigo Renda; Martins, Wendell Santos; de Araújo e Sá, Frederico Browne Correia; Lustosa, Pablo César; Vasconcelos, Frederico Pires; Lima, Ricardo Carvalho
A 64-year-old woman with dizziness and blurry vision underwent an evaluation for a possible stroke with a head-neck CT scan and a transthoracic echocardiogram. The head-neck CT scan was unremarkable, but the echocardiogram was notable for a 2.0 × 2.3?cm heterogeneous echodensity attached to the mitral valve. After a transesophageal echocardiogram and chest CT scan, the mass was determined to be a caseous mitral annular calcification, CMAC. This entity is a rare variant of MAC with an estimated prevalence of 0.068%. Echocardiographic techniques can distinguish CMAC from other intracardiac masses such as tumor, cyst, or abscess. CMAC is associated with cerebrovascular accidents; however, optimal treatment is controversial given the rarity of this clinical finding. Management strategies should be tailored based on the patient's presentation, risk factors, and overall clinical circumstances.
Shapera, Emanuel A.; Karimi, Afshin; Castellanos, Luis R.
Purpose In mitral valve prolapse, determining whether the valve is suitable for surgical repair depends on the location and mechanism of regurgitation. We assessed whether cardiovascular magnetic resonance (CMR) could accurately identify prolapsing or flail mitral valve leaflets and regurgitant jet direction in patients with known moderate or severe mitral regurgitation. Methods CMR of the mitral valve was compared with trans-thoracic echocardiography (TTE) in 27 patients with chronic moderate to severe mitral regurgitation due to mitral valve prolapse. Contiguous long-axis high temporal resolution CMR cines perpendicular to the valve commissures were obtained across the mitral valve from the medial to lateral annulus. This technique allowed systematic valve inspection and mapping of leaflet prolapse using a 6 segment model. CMR mapping was compared with trans-oesophageal echocardiography (TOE) or surgical inspection in 10 patients. Results CMR and TTE agreed on the presence/absence of leaflet abnormality in 53 of 54 (98%) leaflets. Prolapse or flail was seen in 36 of 54 mitral valve leaflets examined on TTE. CMR and TTE agreed on the discrimination of prolapse from flail in 33 of 36 (92%) leaflets and on the predominant regurgitant jet direction in 26 of the 27 (96%) patients. In the 10 patients with TOE or surgical operative findings available, CMR correctly classified presence/absence of segmental abnormality in 49 of 60 (82%) leaflet segments. Conclusion Systematic mitral valve assessment using a simple protocol is feasible and could easily be incorporated into CMR studies in patients with mitral regurgitation due to mitral valve prolapse.
Gabriel, Ruvin S; Kerr, Andrew J; Raffel, Owen C; Stewart, Ralph A; Cowan, Brett R; Occleshaw, Christopher J
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.
Li, Feng P.; Rajchl, Martin; Moore, John; Peters, Terry M.
The mitral valve apparatus is a complex three–dimensional functional unit that is critical to unidirectional heart pump function. This review details the normal anatomy, histology and function of the main mitral valve apparatus components 1) mitral annulus, 2) mitral valve leaflets, 3) chordae tendineae and 4) papillary muscles. 2 and 3 dimensional Echocardiography is ideally suited to examine the mitral valve apparatus and has provided insights into the mechanism of mitral valve disease. An overview of standardized image acquisition and interpretation is provided. Understanding normal mitral valve apparatus function is essential to comprehend alterations in mitral valve disease and the rationale for repair strategies.
Dal-Bianco, Jacob P.; Levine, Robert A.
Background: The interest in beating heart surgery is growing since better results can be obtained with this procedure compared to conventional myocardial protection techniques using cardioplegic solutions. This led us to consider mitral valve replacement with beating heart. Objectives: This study aimed to determine the safety and efficacy of beating heart mitral valve replacement without cross clamp. Methods: This prospective study was conducted on the patients with isolated mitral valve disease requiring mitral valve replacement according to ACC / AHA guidelines. In this study, 15 patients underwent mitral valve replacement using beating heart technique (Group A) and 15 ones underwent mitral valve replacement using arrested heart technique (Group B). The patients were randomized using block randomization. The data were analyzed using the SPSS statistical software. Results: Preoperative parameters were comparable in the two groups. Most of the patients in both study groups were in NYHA class III or IV. Postoperatively, however, most of the patients in the two groups were either in NYHA class I or II. No mortality occurred in the beating heart group, while one mortality occurred in the arrested heart group. The results showed a significant difference between the two groups regarding the mean bypass time, mean operating time, mean ICU stay, and mean length of hospital stay. Conclusions: Beating heart mitral valve replacement is equally safe as the arrested heart technique. Thus, it is recommended as an appropriate alternative to the arrested heart technique for mitral valve replacement.
Wani, Mohd Lateef; Ahangar, Abdul Gani; Singh, Shyam; Irshad, Ifat; ul-Hassan, Nayeem; Wani, Shadab Nabi; Ahmad Ganie, Farooq; Bhat, Mohd Akbar
Objective: We sought to document the feasibility, safety, and effectiveness of performing mitral valve repair using a totally endoscopic approach.Methods: Between February 1997 and October 1, 2001, 187 patients underwent totally endoscopic mitral valve repair at our institution. The mean age was 60.7 ± 13.1 years, and 62% were male. Median preoperative functional class and degree of mitral regurgitation were
Filip P. Casselman; Sam Van Slycke; Helge Dom; Dave L. Lambrechts; Yvette Vermeulen; Hugo Vanermen
An 81-year-old woman was evaluated for prosthetic mitral valve function. She had received a Harken disk mitral valve 29 years earlier due to severe mitral valve disease. This particular valve prosthesis is known for premature disk edge wear and erosion. The patient's 2-dimensional Doppler echocardiogram showed the distinctive appearance of a disk mitral valve prosthesis. Color Doppler in diastole showed a unique crown appearance, with initial flow acceleration around the disk followed by convergence to laminar flow in the left ventricle. Cineradiographic imaging revealed normal valve function and minimal disk erosion. We believe this to be the longest reported follow-up of a surviving patient with a rare Harken disk valve. We present images with unique echocardiographic and cineangiographic features. (Tex Heart Inst J 2003;30:319–21)
Hsi, David H.; Ryan, Gerald F.; Taft, Janice; Arnone, Thomas J.
We report an unusual case of early pericardial tissue valve prosthesis deterioration that required replacement. Four years after mitral valve replacement, 1 of the 3 leaflets of the valve was thickened and retracted in a fixed open position, which resulted in severe mitral insufficiency. The cause of this was adhesion of the leaflet and the patient's own retained posterior mitral valve leaflet. The finding was confirmed at operation and by histologic examination. PMID:24996713
Rohn, Vilem; Spacek, Miroslav; Sachl, Robert; Vitkova, Ivana
Background One of the most important factors responsible for the calcific failure of bioprosthetic heart valves is glutaraldehyde cross-linking. Ethanol (EtOH) incubation after glutaraldehyde cross-linking has previously been reported to confer anti-calcification efficacy for bioprostheses. The present studies investigated the anticalcification efficacy in vivo of the novel cross-linking agent, triglycidyl amine (TGA), with or without EtOH incubation, in comparison to glutaraldehyde. Methods TGA cross-linking (+/? EtOH) was used to prepare porcine aortic valves for both rat subdermal implants and sheep mitral valve replacements, for comparisons with glutaraldehyde-fixed controls. Thermal denaturation temperature (Ts), an index of cross-linking, cholesterol extraction, and hydrodynamic properties were quantified. Explant endpoints included quantitative and morphologic assessment of calcification. Results Ts after TGA were intermediate between unfixed and glutaraldehyde-fixed. EtOH incubation resulted in almost complete extraction of cholesterol from TGA or glutaraldehyde-fixed cusps. Rat subdermal explants (90days) demonstrated that TGA-EtOH resulted in a significantly greater level of inhibition of calcification than other conditions. Thus, TGA-ethanol stent mounted porcine aortic valve bioprostheses were fabricated for comparisons with glutaraldehyde-pretreated controls. In hydrodynamic studies, TGA-EtOH bioprostheses had lower pressure gradients than glutaraldehyde-fixed. TGA-ethanol bioprostheses used as mitral valve replacements in juvenile sheep (150 days) demonstrated significantly lower calcium levels in both explanted porcine aortic cusp and aortic wall samples compared to glutaraldehyde-fixed controls. However, TGA-EtOH sheep explants also demonstrated isolated calcific nodules and intracuspal hematomas. Conclusions TGA-EtOH pretreatment of porcine aortic valves confers significant calcification resistance in both rat subdermal and sheep circulatory implants, but with associated structural instability.
Connolly, Jeanne M.; Bakay, Marina A.; Alferiev, Ivan S.; Gorman, Robert C.; Gorman, Joseph H.; Kruth, Howard S.; Ashworth, Paul E.; Kutty, Jaishankar K.; Schoen, Frederick J.; Bianco, Richard W.; Levy, Robert J.
Background. Tissue properties may contribute to intrinsic calcification of bioprosthetic heart valves. Phospholipids have been proposed as potential nucleation sites for calcification. Other tissue properties might also be important in calcification.Methods. Commercial and control bioprosthetic valve tissues were characterized by shrinkage temperature, moisture content, free amine content, phospholipid content, and calcification level after 90-day rat subcutaneous implantation as described.Results. Shrinkage
Crystal M Cunanan; Christine M Cabiling; Tan T Dinh; ShihHwa Shen; Phihoa Tran-Hata; James H Rutledge; Michael C Fishbein
Aortic valve calcification is the most common form of valvular heart disease, but the mechanisms of calcific aortic valve disease (CAVD) are unknown. NOTCH1 mutations are associated with aortic valve malformations and adult-onset calcification in families with inherited disease. The Notch signaling pathway is critical for multiple cell differentiation processes, but its role in the development of CAVD is not well understood. The aim of this study was to investigate the molecular changes that occur with inhibition of Notch signaling in the aortic valve. Notch signaling pathway members are expressed in adult aortic valve cusps, and examination of diseased human aortic valves revealed decreased expression of NOTCH1 in areas of calcium deposition. To identify downstream mediators of Notch1, we examined gene expression changes that occur with chemical inhibition of Notch signaling in rat aortic valve interstitial cells (AVICs). We found significant downregulation of Sox9 along with several cartilage-specific genes that were direct targets of the transcription factor, Sox9. Loss of Sox9 expression has been published to be associated with aortic valve calcification. Utilizing an in vitro porcine aortic valve calcification model system, inhibition of Notch activity resulted in accelerated calcification while stimulation of Notch signaling attenuated the calcific process. Finally, the addition of Sox9 was able to prevent the calcification of porcine AVICs that occurs with Notch inhibition. In conclusion, loss of Notch signaling contributes to aortic valve calcification via a Sox9-dependent mechanism.
Koenig, Sara N.; Nichols, Haley A.; Galindo, Cristi L.; Garner, Harold R.; Merrill, Walter H.; Hinton, Robert B.; Garg, Vidu
Six flexible-leaflet prosthetic heart valves, fabricated from a polyetherurethaneurea (PEUE), underwent long-term fatigue and calcification testing. Three valves exceeded 800 million cycles without failure. Three valves failed at 775, 460, and 544 million cycles, respectively. Calcification was observed with and without associated failure in regions of high strain. Comparison with similar valves fabricated from a polyetherurethane (PEU) suggests that the PEU is likely to fail sooner as a valve leaflet. Localized calcification developed in PEUE leaflets at the primary failure site of PEU leaflets, close to the coaptation region of the three leaflets. The failure mode in PEU valves had the appearance of abrasion wear associated with calcification. High strains in the same area may render the PEUE leaflets vulnerable to calcification. Intrinsic calcification of this type, however, is a long-term phenomenon unlikely to cause early valve failure. Both polymers performed similarly during static in vitro and in vivo calcification testing and demonstrated a much lesser degree of calcification than bioprosthetic types of valve materials. Polyurethane valves can achieve the durabilities required of an implantable prosthetic valve, equaling the fatigue life of currently available bioprosthetic valves. PMID:9086407
Bernacca, G M; Mackay, T G; Wilkinson, R; Wheatley, D J
Objectives To evaluate mineral metabolism markers as potential risk factors for calcific aortic valve disease. Background Mineral metabolism disturbances are common among older people and may contribute to cardiac valvular calcification. Associations of serum mineral metabolism markers with cardiac valvular calcification have not been evaluated in a well-characterized general population of older adults. Methods We measured serum levels of phosphate, calcium, parathyroid hormone, and 25-hydroxyvitamin D in 1,938 Cardiovascular Health Study participants who were free of clinical cardiovascular disease and who underwent echocardiography measurements of aortic valve sclerosis (AVS), mitral annular calcification (MAC), and aortic annular calcification (AAC). We used logistic regression models to estimate associations of mineral metabolism markers with AVS, MAC, and AAC after adjustment for relevant confounding variables, including kidney function. Results The respective prevalences of AVS, MAC, and AAC were 54%, 39%, and 44%. Each 0.5 mg/dl higher serum phosphate concentration was associated with a greater adjusted odds of AVS (odds ratio 1.17, 95% confidence interval 1.04 to 1.31, p = 0.01), MAC (odds ratio 1.12, 95% confidence interval 1.00 to 1.26, p =0.05), and AAC (odds ratio 1.12, 95% confidence interval 0.99 to 1.25, p = 0.05). In contrast, serum calcium, parathyroid hormone, and 25-hydroxyvitamin D concentrations were not associated with aortic or mitral calcification. Conclusions Higher serum phosphate levels within the normal range are associated with valvular and annular calcification in a community-based cohort of older adults. Phosphate may be a novel risk factor for calcific aortic valve disease and warrants further study.
Linefsky, Jason P.; O'Brien, Kevin D.; Katz, Ronit; de Boer, Ian H.; Barasch, Eddy; Jenny, Nancy S.; Siscovick, David S.; Kestenbaum, Bryan
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.
Katsi, Vasiliki; Raftopoulos, Leonidas; Aggeli, Constantina; Vlasseros, Ioannis; Felekos, Ioannis; Tousoulis, Dimitrios; Stefanadis, Christodoulos; Kallikazaros, Ioannis
Background Patients undergoing mitral valve surgery were assessed for morphology and function by Transoesophageal Echocardiography (TEE)\\u000a at surgery over a 5 year period.\\u000a \\u000a \\u000a \\u000a \\u000a Methods From January 1994 through May 1998, 591 patients underwent mitral valve surgery. Four hundred and eleven patients (mean age\\u000a 22+3.6 yrs, range 8 years to 55 years, 186 male) underwent mitral valve reconstruction, 143 patients (mean age 24.5+4.2
Arkalgud Sampath Kumar; Anita Saxena
A 3-dimensional echocardiographic view of the mitral valve, called the "en face" or "surgical view," presents a view of the mitral valve similar to that seen by the surgeon from a left atrial perspective. Although the anatomical landmarks of this view are well defined, no comprehensive echocardiographic definition has been presented. After reviewing the literature, we provide a definition of the left atrial and left ventricular en face views of the mitral valve. Techniques used to acquire this view are also discussed. PMID:22859687
Mahmood, Feroze; Warraich, Haider Javed; Shahul, Sajid; Qazi, Aisha; Swaminathan, Madhav; Mackensen, G Burkhard; Panzica, Peter; Maslow, Andrew
Purpose Transcatheter mitral valve replacement would represent a major advance in heart valve therapy. Such a device requires a specialized anchoring and sealing technology. This study was designed to test the feasibility of a novel mitral valve replacement device (the sutureless mitral valve [SMV]) designed to anchor and seal in the mitral position without need for sutures. Description The SMV is a self-expanding device consisting of a custom-designed nitinol framework and a pericardial leaflet valve mechanism. Evaluation Ten sheep underwent successful surgical SMV device implantation. All animals underwent cardiac catheterization 6 hours postoperatively. Hemodynamic, angiographic, echocardiographic and necroscopic data were recorded. The mean aortic cross-clamp time was 9.5 ± 3.1 minutes. Echocardiography and angiography revealed excellent left ventricular systolic function, no significant perivalvular leak, no mitral valve stenosis, no left ventricular outflow tract obstruction, and no aortic valve insufficiency. Necropsy demonstrated that the SMV devices were anchored securely. Conclusions This study demonstrates the feasibility and short-term success of sutureless mitral valve replacement using a novel SMV device.
Gillespie, Matthew J.; Minakawa, Masahito; Morita, Masato; Vergnat, Mathieu; Koomalsingh, Kevin J.; Robb, J. Daniel; Kondo, Norihiro; Shuto, Takashi; Takebe, Manabu; Shimaoka, Toru; McGarvey, Jeremy R.; Gorman, Robert C.; Gorman, Joseph H.
A new clinical entity is described in which free aortic regurgitation from congenital aortic valve disease caused rupture of the chordae to the anterior leaflet of the mitral valve in 7 men aged 45 to 63 years (mean 52 years); 2 of the patients also had rupture of chordae to the posterior leaflet. Comparing these patients with those with ruptured mitral chordae in association with rheumatic heart disease and patients with spontaneous chordal rupture, differences were evident. No patient had a history of rheumatic fever and none had active infection. The typical clinical presentation was of acute mitral regurgitation into a small left atrium, with severe pulmonary oedema which was often resistant to medical treatment. The cause of chordal rupture in these patients was in part the result of progressive left ventricular dilatation, of direct trauma to the anterior cusp of the mitral valve, and possibly of a genetic factor. The anatomical features of both aortic and mitral valves are described, and in 3 histology of the mitral valve was available; 2 had myxomatous degeneration similar to that seen in patients with spontaneous chordal rupture, and in 1 there was degeneration of collagen tissue. All patients were treated surgically but the mortality was high (5 out of 7,70%). Early operation with replacement of the aortic and mitral valves is recommended if this high mortality is to be reduced. Images
Joseph, S; Emanuel, R; Sturridge, M; Olsen, E
... Mitral Valve Prolapse Questions to Discuss with Your Doctor: Have you had an echocardiogram? What did it ... develop any side effects from these medications? Your Doctor Might Examine the Following Body Structures or Functions: ...
Tri-leaflet polyurethane heart valves have been considered as a potential candidate in heart valve replacement surgeries. In this study, polyurethane (Angioflex(®)) heart valve prostheses were fabricated using a solvent-casting method to evaluate their calcification resistance. These valves were subjected to accelerated life testing (continuous opening and closing of the leaflets) in a synthetic calcification solution. Results showed that Angioflex(®) could be considered as a potential material for fabricating prosthetic heart valves with possibly a higher calcification resistance compared to tissue valves. In addition, calcification resistance of bisphosphonate-modified Angioflex(®) valves was also evaluated. Bisphosphonates are considered to enhance the calcification resistance of polymers once covalently bonded to the bulk of the material. However, our in-vitro results showed that bisphosphonate-modified Angioflex(®) valves did not improve the calcification resistance of Angioflex(®) compared to its untreated counterparts. The results also showed that cyclic loading of the valves' leaflets resulted in formation of numerous cracks on the calcified surface, which were not present when calcification study did not involve mechanical loading. Further study of these cracks did not result in enough evidence to conclude whether these cracks have penetrated to the polymeric surface. PMID:24411385
Boloori Zadeh, Parnian; Corbett, Scott C; Nayeb-Hashemi, Hamid
Objectives: This study evaluates the feasibility of video-assisted minimally invasive mitral valve surgery by means of the Port-Access system. The aim of the study was to minimize surgical access and to develop a video-assisted surgical technique. Methods: The Port-Access system allows for closed chest endoluminal aortic clamping, cardioplegic arrest, and decompression of the heart. The mitral valve was either repaired
F. W. Mohr; V. Falk; A. Diegeler; T. Walther; J. A. M. van Son; R. Autschbach; Hans G. Borst
Three-dimensional echocardiography is a growing imaging modality, particularly for the evaluation of mitral valve pathology.\\u000a Functional anatomy in disease states such as mitral regurgitation and stenosis as well as prosthetic valves can be effectively\\u000a studied, offering superior knowledge to treating physicians. Additionally, three-dimensional echocardiography has the ability\\u000a to help guide operative and percutaneous interventions, allowing for improved patient outcomes and
Carrie B. Chapman; Peter S. Rahko
Background Mitral annular disjunction (MAD) consists of an altered spatial relation between the left atrial wall, the attachment of the mitral leaflets, and the top of the left ventricular (LV) free wall, manifested as a wide separation between the atrial wall-mitral valve junction and the top of the LV free wall. Originally described in association with myxomatous mitral valve disease, this abnormality was recently revisited by a surgical group that pointed its relevance for mitral valve reparability. The aims of this study were to investigate the echocardiographic prevalence of mitral annular disjunction in patients with myxomatous mitral valve disease, and to characterize the clinical profile and echocardiographic features of these patients. Methods We evaluated 38 patients with myxomatous mitral valve disease (mean age 57 ± 15 years; 18 females) and used standard transthoracic echocardiography for measuring the MAD. Mitral annular function, assessed by end-diastolic and end-systolic annular diameters, was compared between patients with and without MAD. We compared the incidence of arrhythmias in a subset of 21 patients studied with 24-hour Holter monitoring. Results MAD was present in 21 (55%) patients (mean length: 7.4 ± 8.7 mm), and was more common in women (61% vs 38% in men; p = 0.047). MAD patients more frequently presented chest pain (43% vs 12% in the absence of MAD; p = 0.07). Mitral annular function was significantly impaired in patients with MAD in whom the mitral annular diameter was paradoxically larger in systole than in diastole: the diastolic-to-systolic mitral annular diameter difference was -4,6 ± 4,7 mm in these patients vs 3,4 ± 1,1 mm in those without MAD (p < 0.001). The severity of MAD significantly correlated with the occurrence of non-sustained ventricular tachycardia (NSVT) on Holter monitoring: MAD›8.5 mm was a strong predictor for (NSVT), (area under ROC curve = 0.74 (95% CI, 0.5-0.9); sensitivity 67%, specificity 83%). There were no differences between groups regarding functional class, severity of mitral regurgitation, LV volumes, and LV systolic function. Conclusions MAD is a common finding in myxomatous mitral valve disease patients, easily recognizable by transthoracic echocardiography. It is more prevalent in women and often associated with chest pain. MAD significantly disturbs mitral annular function and when severe predicts the occurrence of NSVT.
We describe an unusual sequela of mitral valve replacement in a 50-year-old woman who had undergone a closed mitral commissurotomy in 1975. She was admitted to our hospital because of mitral restenosis in November 1993, at which time her mitral valve was replaced with a mechanical prosthesis. On the 8th postoperative day, the patient developed symptoms of heart failure; transesophageal echocardiography revealed dissection and rupture of the left atrial wall. At prompt reoperation, we found an interlayer dissection and rupture of the atrial wall into the left atrium. We repaired the ruptured atrial wall with a prosthetic patch. The postoperative course was uneventful, and postoperative transesophageal echocardiography showed normal prosthetic valve function and no dissection. Images
Lukacs, L; Kassai, I; Lengyel, M
We report a case of severe mechanical hemolysis occurring 8 years after insertion of a bioprosthetic mitral valve in a patient who also suffered from aortic valve stenosis. It is suggested that the coexistence of two malfunctioning valves may lead to hemolysis via hemodynamic and turbulence alteration and that this condition is more frequent than expected for isolated valve involvement.Copyright
Kostas Konstantopoulos; Tasos Kasparian; John Sideris; Ersi Voskaridou; Dimitris Loukopoulos
Transventricular mitral valve surgery combined with left ventricular restoration avoids atriotomy and provides a larger operative field. We describe a series of 5 patients in whom we performed transventricular mitral valve repair by various techniques, such as band annuloplasty, papillary muscle reattachment, chordal cutting, and edge-to-edge repair. The more acute forms of ischemic mitral regurgitation, as found in our patients, can coexist with post-myocardial infarction contained rupture or post-myocardial infarction ventricular septal rupture. Because these patients already have an indication for ventriculotomy, concomitant transventricular repair of the mitral valve can render a separate atriotomy unnecessary and thereby shorten the duration of cardiopulmonary bypass. Moreover, in patients with acute presentations, the absence of atrial dilation (this last associated with chronic cases) might make transventricular repair a better choice than the more difficult atrial approach.
Gedik, Hikmet Selcuk; Korkmaz, Kemal; Budak, Baran; Yener, Umit; Lafci, Gokhan
Transventricular mitral valve surgery combined with left ventricular restoration avoids atriotomy and provides a larger operative field. We describe a series of 5 patients in whom we performed transventricular mitral valve repair by various techniques, such as band annuloplasty, papillary muscle reattachment, chordal cutting, and edge-to-edge repair. The more acute forms of ischemic mitral regurgitation, as found in our patients, can coexist with post-myocardial infarction contained rupture or post-myocardial infarction ventricular septal rupture. Because these patients already have an indication for ventriculotomy, concomitant transventricular repair of the mitral valve can render a separate atriotomy unnecessary and thereby shorten the duration of cardiopulmonary bypass. Moreover, in patients with acute presentations, the absence of atrial dilation (this last associated with chronic cases) might make transventricular repair a better choice than the more difficult atrial approach. PMID:24955051
Cagli, Kerim; Gedik, Hikmet Selcuk; Korkmaz, Kemal; Budak, Baran; Yener, Umit; Lafci, Gokhan
Calcific aortic valve disease (CAVD), once thought to be a degenerative disease, is now recognized to be an active pathobiological process, with chronic inflammation emerging as a predominant, and possibly driving, factor. However, many details of the pathobiological mechanisms of CAVD remain to be described, and new approaches to treat CAVD need to be identified. Animal models are emerging as vital tools to this end, facilitated by the advent of new models and improved understanding of the utility of existing models. In this paper, we summarize and critically appraise current small and large animal models of CAVD, discuss the utility of animal models for priority CAVD research areas, and provide recommendations for future animal model studies of CAVD.
Sider, Krista L.; Blaser, Mark C.; Simmons, Craig A.
[Percutaneous mitral valve annuloplasty with the carillon mitral contour system by cardiac dimensions. A minimally invasive therapeutic option for the treatment of severe functional mitral valve regurgitation].
Morbidity in patients with systolic heart failure is significantly increased by functional mitral valve regurgitation. In addition to pharmaceutical treatment or surgical reconstruction of the impaired valve, minimally invasive procedures have continuously advanced into the focus of interest. The Carillon Mitral Contour System (Cardiac Dimensions) is a new catheter-based method to converge dehiscent mitral valve leaflets with implantation of a nitinol clip into the coronary sinus, leading to a closer approach of the valve leaflets with subsequent decrease in mitral regurgitation. The device is implanted via a central venous catheter, using a special delivery system under fluoroscopy. The immediate success of minimizing mitral valve regurgitation is verified by online transesophageal echocardiography (TEE), device-related impairment of perfusion of contiguous coronary vessels is ruled out by coronary angiography performed simultaneously during deployment of the device. As soon as reduction of the mitral valve regurgitation is demonstrated in TEE, the Carillon System is disconnected from the delivery system, before, however, the Carillon device can be withdrawn into the delivery system as necessary. Following the successful implantation of the Carillon Mitral Contour System, a left ventricular lead for cardiac resynchronization therapy can still be successfully placed alongside through the coronary sinus. PMID:19784563
Degen, Hubertus; Lickfeld, Thomas; Stoepel, Carsten; Haude, Michael
Redo mitral valve surgery is hazardous, hence we explored an alternative approach using a port-access system that avoids reentry. Between October 1997 and December 2000, 32 patients underwent mitral reoperation using the system. All patients had previous cardiac operations. This procedure consisted of a right anterolateral minithoracotomy and femorofemoral cannulation using special port-access instruments and endoaortic clamping in 24 patients or direct transthoracic sliding-rod aortic clamping in 8. The valve disease was of rheumatic etiology in 28 patients and degenerative in 4. The valve was replaced in 31 cases and a paravalvular leak after mitral valve replacement was closed in 1. In 2 cases, the tricuspid valve was repaired along with mitral valve replacement. Mean total operating time was 4.5 +/- 1.2 hours, cardiopulmonary bypass time 162 +/- 72 minutes, and aortic crossclamp time 62 +/- 21 minutes. There was no mortality, and mean stay in the intensive care unit was 22 +/- 7 hours and hospital stay 6.4 +/- 1.2 days. Postoperative blood transfusion was required in 12 patients. In view of the favorable results, we recommend using the port-access system as a standard approach for mitral reoperation. PMID:12213742
Trehan, Naresh; Mishra, Yugal K; Mathew, Satish G; Sharma, Krishna K; Shrivastava, Sameer; Mehta, Yatin
In this study we aimed to analyze, with reference to mitral regurgitation (MR), the incidence and predictors of left atrial (LA) thrombus and spontaneous echo contrast in patients with rheumatic valve disease before and after mitral valve replacement. The incidence of LA thrombus is known to be less in patients with MR. The impact of mitral valve replacement on this
Mehmet Özkan; Cihangir Kaymaz; Cevat Kirma; Ali Civelek; Ali Riza Cenal; Cevat Yakut; Ubeydullah Deligonul
This report presents a patient with an unusual clinical course associated with a mitral "mass" recorded by M-mode and cross-sectional echocardiography. The "mass" was confirmed at operation to be redundant myxomatous mitral valve leaflets. The problem of echocardiographic resolution in the setting of mitral valve prolapse and of the differential diagnosis of mitral mass is discussed in detail. Images
Chun, P K; Sheehan, M W
Prosthetic heart valve dysfunction due to thrombus or pannus formation can be a life-threatening complication. The present report describes a 47-year-old woman who developed valvular cardiomyopathy after chorda-sparing mitral valve replacement, and subsequently underwent heart transplantation for progressive heart failure. The explanted mitral valve prosthesis showed significant thrombus and pannus leading to reduced leaflet mobility and valvular stenosis. The present report illustrates the role of the subvalvular apparatus and pannus in prosthesis dysfunction.
Khan, Nasir A; Butany, Jagdish; Leong, Shaun W; Rao, Vivek; Cusimano, Robert J; Ross, Heather J
Introduction: Mitral valve prolapse syndrome (MVP) is the most common valvular abnormalityin the young and is correlated with increased frequency of cardiac dysrhythmias and sudden death.The aim of this study was to compare frequency of “early repolarization” in electrocardiogram(ECG) between MVP patients and healthy adults. Methods: In this cross-sectional study, we compared ECG presentations of early repolarizationincluding notch in descending arm of QRS and J-point and/or ST segment changes in 100 patientswith MVP with 100 healthy individuals. MVP patients were referred to cardiology clinic withsymptoms of palpitation, chest pain or anxiety. Results: The mean age in patients with MVP was significantly less than healthy subjects (29.5 ±9.3 years versus 31.0 ± 6.9 years in control group, P= 0.1967). We detected early repolarizationas a prevalent sign in ECG of patients which was a notch in descending arm of QRS and/or STsegment or J-point elevation seen in 74% of patients ( 51% in inferior leads and 23% in I and aVLleads) , whilst the same findings were seen in 8 men (8%) in control group (P= 0.0001). Conclusion: Early repolarization in ECG presented as a notch in descending arm of QRS and/or ST segment or J-point elevation is more frequent in in young patients with MVP syndrome.
Peighambari, Mohammad Mehdi; Alizadehasl, Azin; Totonchi, Ziae
Introduction: Mitral valve prolapse syndrome (MVP) is the most common valvular abnormalityin the young and is correlated with increased frequency of cardiac dysrhythmias and sudden death.The aim of this study was to compare frequency of "early repolarization" in electrocardiogram(ECG) between MVP patients and healthy adults. Methods: In this cross-sectional study, we compared ECG presentations of early repolarizationincluding notch in descending arm of QRS and J-point and/or ST segment changes in 100 patientswith MVP with 100 healthy individuals. MVP patients were referred to cardiology clinic withsymptoms of palpitation, chest pain or anxiety. Results: The mean age in patients with MVP was significantly less than healthy subjects (29.5 ±9.3 years versus 31.0 ± 6.9 years in control group, P= 0.1967). We detected early repolarizationas a prevalent sign in ECG of patients which was a notch in descending arm of QRS and/or STsegment or J-point elevation seen in 74% of patients ( 51% in inferior leads and 23% in I and aVLleads) , whilst the same findings were seen in 8 men (8%) in control group (P= 0.0001). Conclusion: Early repolarization in ECG presented as a notch in descending arm of QRS and/or ST segment or J-point elevation is more frequent in in young patients with MVP syndrome. PMID:24753827
Peighambari, Mohammad Mehdi; Alizadehasl, Azin; Totonchi, Ziae
The high complexity of the mitral valve (MV) anatomy and function is not yet fully understood. Studying especially the dynamic movement and interaction of MV components to describe MV physiology during the cardiac cycle remains a challenge. Imaging is the key to assessing details of MV disease and to studying the lesion and dysfunction of MV according to Carpentier. With the advances of computational geometrical and biomechanical MV models, improved quantification and characterization of the MV has been realized. Geometrical models can be divided into rigid and dynamic models. Both models are based on reconstruction techniques of echocardiographic or computed tomographic data sets. They allow detailed analysis of MV morphology and dynamics throughout the cardiac cycle. Biomechanical models aim to simulate the biomechanics of MV to allow for examination and analysis of the MV structure with blood flow. Two categories of biomechanical MV models can be distinguished: structural models and fluid-structure interaction (FSI) models. The complex structure and dynamics of MV apparatus throughout the cardiac cycle can be analyzed with different types of computational models. These represent substantial progress in the diagnosis of structural heart disease since MV morphology and dynamics can be studied in unprecedented detail. It is conceivable that MV modeling will contribute significantly to the understanding of the MV.
Kiefer, Philipp; Ionasec, Razvan; Voigt, Ingmar; Mansi, Tammaso; Vollroth, Marcel; Hoebartner, Michael; Misfeld, Martin; Mohr, Friedrich-Wilhelm; Seeburger, Joerg
Mitral valve disease is quite variable and can occur as an isolated defect or in association with other complex left sided lesions. These lesions are often best described with detailed pre-operative imaging studies to define the valve anatomy and to access associated left heart disease. Depending on the type of mitral valve disease, various surgical repair techniques have led to improved survival in the recent era. We describe lesion specific approach to mitral valve repair and results.
Baird, Christopher W; Myers, Patrick O; Marx, Gerald; del Nido, Pedro J
Mitral annular calcification (MAC) is closely related to cardiovascular disorders including coronary artery disease, atherosclerosis, heart failure, and stroke. The clinical risk factors for cardiovascular diseases, including age, obesity, hypertension, hyperlipidemia, and diabetes mellitus, are the same for MAC and atherosclerosis. The aim of this study was to assess the neutrophil-lymphocyte ratio (NLR), an inflammatory marker, in patients with MAC. The study group consisted of 117 patients with MAC. Age and sex-matched control group was composed of 38 patients who were admitted to echocardiography laboratory due to suspicion of organic heart disease and eventually found to be free of MAC. We measured hematological indices in patients and control individuals. NLR ratio was significantly higher in patients with MAC than in control individuals (3.3?±?1.8 vs. 1.6?±?0.4, respectively; P?0.001), and NLR ratio was positively correlated with MAC (P?0.001, r?=?0.58). Red cell distribution width was also significantly higher in patients with MAC than in control individuals (16.2?±?3.3 vs. 13.4?±?0.9%, respectively; P?0.001). We have shown that NLR was significantly elevated in patients with MAC and it was correlated with MAC. PMID:24561537
Varol, Ercan; Aksoy, Fatih; Ozaydin, Mehmet; Erdogan, Dogan; Dogan, Abdullah
Thrombosis of a mechanical prosthetic valve is a serious and fortunately it is a rare complication of cardiac valve replacement. We present a case of prosthetic mechanical valve On-X 31/33 mm thrombosis thrombus size 8 x 14 mm on a mitral position, which was treated with a successful intravenous thrombolytic therapy of streptokinase infusion over 10 hours repeated twice with no complications. PMID:19618017
Obied, Hamoud Y; Ibrahim, Mohammed F; Latroche, Bendehiba S; Mroue, Maya M
In standard textbooks of anatomy it is generally accepted that the fibrous ring of the mitral valve lies in a single plane throughout its entire circumference. Some authors have stated otherwise, but there are no morphometric studies. 30 formalin-fixed hearts were sectioned to reveal the shape of the fibrous ring of the mitral valve and studied by morphometric, radiographic and histological methods. It was noted that the fibrous ring adopted a horizontal "S" shape around the two commissures and the average distance between the highest and lowest parts of the fibrous ring was found to be 7.1 mm (range 6.2-12.5 mm). Radiographic evaluation revealed that the fibrous ring lies approximately in two planes rather than in one. Histological study showed that the fibrous tissue of the mitral valve is continuous with the aortic fibrous ring, and that a slight but significant thickening marks the insertion of the mitral valve. The mitral valve thus lies in two planes, and it is hoped that this information will contribute to cardiac and valvuloplastic surgery. PMID:7741275
Kopuz, C; Erk, K; Baris, Y S; Onderoglu, S; Sinav, A
Mitral regurgitation has become recognized as an important health problem. More specifically, functional mitral regurgitation is associated with worse outcomes in heart failure, postmyocardial infarction, and perioperative coronary artery bypass surgery patients. Many patients with severe mitral regurgitation are denied or refused mitral valve surgery. A less invasive procedure with possibly fewer potential complications may thus be attractive for patients with severe mitral regurgitation. Devices used for coronary sinus (CS) mitral annuloplasty are directed toward patients with functional mitral regurgitation. Because of its easy accessibility and close relationship to the posterior mitral annulus (MA), alterations of the CS geometry with percutaneous devices may translate to displacement of the posterior annulus and correct mitral leaflet coaptation. This review will focus on the contemporary CS annuloplasty devices: (1) Edwards MONARC system; (2) Cardiac Dimensions CARILLON; and (3) Viacor Shape Changing Rods system. In addition, important information obtained from recent imaging studies describing the relationship between the CS, MA, and coronary arteries will be reviewed. PMID:18042055
Piazza, Nicolo; Bonan, Raoul
Objective To determine the association of long-term exposure to atherosclerosis risk factors with valvular calcification. Background Traditional atherosclerosis risk factors have been associated with aortic and mitral valve calcium in cross-sectional studies but long-term prospective data is lacking. Methods Prospective community-based cohort study with 27-year follow-up (median follow-up 26.9 years; range 23.1–29.6 years). Participants from the Framingham Offspring Study (n=1323, enrolled between 1971–1975, mean age at enrollment 34±9 years, 52% women) underwent cardiac multi-detector computed tomography testing between 2002–2005. Associations between the long-term average of each cardiovascular risk factor and valve calcium were estimated using logistic regression. Results Aortic valve calcium was present in 39% of participants and mitral valve calcium in 20%. In multivariable models, the odds ratio for aortic valve calcium associated with every standard deviation (SD) increment in long-term mean total cholesterol was 1.74 (P<0.0001), with every SD increment in high-density lipoprotein cholesterol, 0.77 (P=0.002), and with every 9 cigarettes smoked per day, 1.23 (P=0.002). Associations of similar magnitude were seen for mitral valve calcium. The mean of three serum C-reactive protein measurements was associated with mitral valve calcium (OR 1.29 per-SD increment in CRP levels, P=0.002). A higher Framingham risk score in early adulthood (?40 years age) was associated with increased prevalence and severity of aortic valve calcium measured three decades later. Conclusions Exposure to multiple atherosclerotic risk factors starting in early to mid-adulthood is associated with aortic and mitral valve calcium. Studies evaluating early risk factor modification to reduce the burden of valve disease are warranted.
Thanassoulis, George; Massaro, Joseph M.; Cury, Ricardo; Manders, Emily; Benjamin, Emelia J.; Vasan, Ramachandran S.; Cupples, L. Adrienne; Hoffmann, Udo; O'Donnell, Christopher J.; Kathiresan, Sekar
Mitral valve prolapse syndrome (MVPS) is a relatively common disorder of the mitral valve and most cases take a benign clinical course. Only a subset of patients develop severe clinical symptoms such as arrhythmia, insufficiency of the mitral valve or infective endocarditis. As a consequence, sudden death might occur in these patients, thought to be caused by an arrhythmogenic event.
Sven Anders; Samir Said; Friedrich Schulz; Klaus Püschel
Objective: This study was carried out to evaluate the long-term results of mitral valve repair for mitral regurgitation caused by myxomatous disease of the mitral valve and the late effects of chordal replacement with expanded polytetrafluoroethylene sutures in this operation. Methods: A total of 324 patients with mitral regurgitation caused by myxomatous disease underwent mitral valve repair from 1981 to
Tirone E. David; Ahmad Omran; Susan Armstrong; Zhao Sun; Joan Ivanov
Background: In some inherited connective tissue diseases with involvement of the cardiovascular system, for example, Marfan syndrome, early impairment of left ventricular function, which have been described as Marfan-related cardiomyopathy has been reported. Our aim was to evaluate the left ventricular function in young adults with mitral valve prolapse without significant mitral regurgitation using two-dimensional strain imaging and to determine the possible role of the transforming growth factor-? pathway in its deterioration. Methods: We studied 78 young adults with mitral valve prolapse without mitral regurgitation in comparison with 80 sex-matched and age-matched healthy individuals. Longitudinal strain and strain rates were defined using spackle tracking. Concentrations of transforming growth factor-?1 and ?2 in serum were determined by enzyme-linked immunosorbent assays. Results: In 29 patients, classic relapse was identified with a leaflet thickness of ? 5 mm; 49 patients had a non-classic mitral valve prolapse. Despite the similar global systolic function, a significant reduction in global strain was found in the classic group (-15.5 ± 2.9%) compared with the non-classic group (-18.7 ± 3.8; p = 0.0002) and the control group (-19.6 ± 3.4%; p < 0.0001). In young adults with non-classic prolapse, a reduction in longitudinal deformation was detected only in septal segments. Transforming growth factor-?1 and ?2 serum levels were elevated in patients with classic prolapse as compared with the control group and the non-classic mitral valve prolapse group. Conclusions: These changes in the deformations may be the first signs of deterioration of the left ventricular function and the existence of primary cardiomyopathy in young adults with mitral valve prolapse, which may be caused by increased transforming growth factor-? signalling. PMID:23880103
Malev, Eduard; Reeva, Svetlana; Vasina, Lyubov; Timofeev, Eugeny; Pshepiy, Asiyet; Korshunova, Alexandra; Prokudina, Maria; Zemtsovsky, Eduard
Three-dimensional echocardiography has markedly improved our understanding of normal and pathologic mitral valve (MV) mechanics. Qualitative and quantitative analysis of three-dimensional (3D) data on the mitral valve could have a clinical impact on diagnosis, patient referral, surgical strategies, annuloplasty ring design and evaluation of the immediate and long-term surgical outcome. This review covers the contribution of 3D echocardiography in the diagnosis of MV disease, its role in selecting and monitoring surgical procedures, and in the assessment of surgical outcomes. Moreover, advantages of this technique versus the standard 2D modality, as well as future applications of advanced analysis techniques, will be reviewed. PMID:23686753
Maffessanti, Francesco; Mirea, Oana; Tamborini, Gloria; Pepi, Mauro
Glutaraldehyde-treated porcine aortic valve xenografts frequently fail due to calcification. Calcification in the prostheses begins intracellularly. In a previous study, various types of cell injury to canine valvular fibroblasts, including glutaraldehyde treatment, led to calcification. An influx of extracellular Ca2+ into the phosphate-rich cytosol was theorized to be the mechanism of calcification. To test the Ca2+ influx theory, cytosolic Ca2+ and Pi concentrations were assessed in glutaraldehyde-treated porcine aortic valve fibroblasts, and their relationship to a subsequent calcification was studied. Glutaraldehyde caused an immediate and sustained massive cytosolic Ca2+ increase that was dose dependent and a several-fold increase in Pi. Calcification of cells followed within a week. The earliest calcification was observed in blebs formed on glutaraldehyde-treated cells. Live control cells or cells fixed with glutaraldehyde in Ca2+-free solution did not calcify under the same conditions. Concomitant increases in Ca2+ and Pi in glutaraldehyde-treated cells appear to underlie the mechanism of calcification, and the presence of extracellular Ca2+ during glutaraldehyde fixation promotes calcification.
Kim, Kookmin M.; Herrera, Guillermo A.; Battarbee, Harold D.
Glutaraldehyde-treated porcine aortic valve xenografts frequently fail due to calcification. Calcification in the prostheses begins intracellularly. In a previous study, various types of cell injury to canine valvular fibroblasts, including glutaraldehyde treatment, led to calcification. An influx of extracellular Ca2+ into the phosphate-rich cytosol was theorized to be the mechanism of calcification. To test the Ca2+ influx theory, cytosolic Ca2+ and Pi concentrations were assessed in glutaraldehyde-treated porcine aortic valve fibroblasts, and their relationship to a subsequent calcification was studied. Glutaraldehyde caused an immediate and sustained massive cytosolic Ca2+ increase that was dose dependent and a several-fold increase in Pi. Calcification of cells followed within a week. The earliest calcification was observed in blebs formed on glutaraldehyde-treated cells. Live control cells or cells fixed with glutaraldehyde in Ca2+-free solution did not calcify under the same conditions. Concomitant increases in Ca2+ and Pi in glutaraldehyde-treated cells appear to underlie the mechanism of calcification, and the presence of extracellular Ca2+ during glutaraldehyde fixation promotes calcification. PMID:10079262
Kim, K M; Herrera, G A; Battarbee, H D
Congenital mitral regurgitation is rare and usually part of complex cardiac anomalies. When needed, early surgery represents a great challenge. In small babies avoiding valve replacement is desirable, but valve repair may be extremely complex. We describe an isolated congenital mitral regurgitation, successfully treated with conservative surgery about 1 h after birth. In a 30-year-old pregnant woman, fetal echocardiography revealed mitral annular dilatation with massive regurgitation, functional aortic atresia and a very small patent foramen ovale. Realizing that the baby had a poor chance of survival after birth, a cesarean section was scheduled at 37 weeks of pregnancy. The procedure was performed in the operating room next to the cardiac surgery theatre, where the newborn was urgently transferred. After an unsuccessful attempt of percutaneous atrial septostomy, a rescue surgical mitral repair was performed. To avoid mitral replacement, moderate residual regurgitation was accepted. Postoperative hospital stay was 57 days and the baby was discharged in good clinical condition. Residual mitral regurgitation was moderate at discharge and decreased thereafter. During a five-year follow-up the child remained asymptomatic with normal growth. Preserved ventricular function and progressive volume reduction of left heart chambers were observed. PMID:20709700
Deorsola, Luca; Chiappa, Enrico; Agnoletti, Gabriella; Abbruzzese, Pietro Angelo
We report the case of a 74-year-old woman who underwent an elective procedure to replace her mitral valve with a 27-mm CarboMedics bileaflet valve (CarboMedics, Inc.; Austin, Tex) to correct mitral incompetence. Massive thrombosis of the prosthesis was clinically evident on the 6th postoperative day, despite administration of warfarin therapy according to our usual protocol. After an unsuccessful attempt at thrombolysis with recombinant tissue plasminogen activator, the mechanical prosthesis was replaced with a bioprosthesis. The cause of the thrombosis is unknown, but transient suboptimal anticoagulation is assumed to be responsible. Although very early massive valve thrombosis is a rare occurrence, it is a known risk of prosthetic valve implantation. Antiplatelet therapy, in addition to the usual warfarin anticoagulation, can help to prevent it. If thrombosis is diagnosed, it can be managed by thrombolysis or, when thrombolysis is unsuccessful, by reoperation. Transesophageal echocardiography is fundamental in the diagnosis and management of this sequela. Images
Masiello, P; Mastrogiovanni, G; Santoro, G; Iesu, S; Di Benedetto, G
A new case of assumed parasitic cardiac disease is reported once more; a 67 year old woman with a trematode injection presenting with mitral incompetence and left ventricular failure. Biventricular endomyocardial fibrosis predominating at the apex was diagnosed at angiography and confirmed at surgery. Mitral incompetence was related to retraction of the papillary muscles which were surrounded by fibrosis, the rest of the mitral apparatus being normal. There was no indication for endocardectomy and so, mitral valve replacement alone was performed. There are few previous reports of parasitic cardiac disease: one case of left ventricular endomyocardial fibrosis, one case of biventricular fibroplastic parietal endocarditis and one case of cardiomyopathy. This report emphasises the need for cardiac examination in patients with parasitic diseases. PMID:6800330
Potier, J C; Grollier, G; Le Clerc, A; Mandard, J C; Rousselot, P; Maiza, D; Khayat, A; Verwaerde, J C; Valla, A; Foucault, J P
In hypokinesia, edema of all the layers of the mitral value was observed, which resulted in morphological changes of the cellular and noncellular components. An increase in ratio of elastic and collagenic fibers in the value was also observed along with and changes in their structural and staining properties. The observed changes can limit valve mobility and can result in manifestations of cardiac valve insufficiency, which is found clinically.
Strelkovska, V. Y.
The prosthetic heart valves were fabricated from a polyurethane containing a 4,4?-diphenylmethane diisocyanate hard segment, chain-extended with butanediol and with a polyether soft segment. The rate of calcification of these polyurethane heart valves was much slower in a dynamic in vitro test system than similar bioprosthetic heart valves. The calcified deposits were located exclusively at regions of material failure. Fourier
G. M. Bernacca; T. G. Mackay; R. Wilkinson; D. J. Wheatley
In the recent years minimally invasive mitral valve surgery (MIMVS) has become a well-established and increasingly used option for managing patients with a mitral valve pathology. Nonetheless, whether the purported benefits of MIMVS translate into clinically important outcomes remains controversial. Therefore, in this paper we provide an overview of MIMVS and discuss results, morbidity, mortality, and quality of life following mitral minimally invasive procedures. MIMVS has been proven to be a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Reported benefits of MIMVS include also decreased postoperative pain, improved postoperative respiratory function, reduced surgical trauma, and greater patient satisfaction. Finally, compared to standard surgery, MIMVS demonstrated comparable efficacy across a range of long-term efficacy measures such as freedom from reoperation and long-term survival.
Luca, Fabiana; van Garsse, Leen; Rao, Carmelo Massimiliano; Parise, Orlando; La Meir, Mark; Puntrello, Calogero; Rubino, Gaspare; Carella, Rocco; Lorusso, Roberto; Gensini, Gian Franco; Maessen, Jos G.; Gelsomino, Sandro
OBJECTIVETo determine predictors of systolic anterior motion and left ventricular outflow tract obstruction (SAM\\/LVOTO) after mitral valve repair (MVRep) in patients with myxomatous mitral valve disease.BACKGROUNDMechanisms for the development of SAM\\/LVOTO after MVRep have been described; however, predictors of this complication have not been explored. We hypothesize that pre-MVRep transesophageal echocardiography (TEE) can predict postrepair SAM\\/LVOTO.METHODSUsing TEE, the lengths of
Andrew D. Maslow; Meredith M. Regan; J. Michael Haering; Robert G. Johnson; Robert A. Levine
Myxomatous mitral valve disease in dogs is heritable, and it is therefore important to detect the early signs of the disease. This study was conducted to assess the predictive value of early echocardiographic and auscultatory signs of mitral valve prolapse, measured in terms of the leaflet thickness, the area of the regurgitant jet, and the intensity of the murmur, on the increases in left ventricular end diastolic diameter (LVEDD) and left atrial diameter (LAD) in a population of 190 clinically healthy dachshunds followed up for three years. The most significant predictor of an increase in LVEDD was the interaction between the index of mitral valve prolapse and the area of the regurgitant jet (P < 0.0001). In dogs with a jet area greater than 50 per cent of the left atrium, the disease progressed more quickly in terms of increases in LVEDD in relation to the severity of the prolapse at the initial examination. In dogs with smaller jets, the initial prolapse index was not significantly associated with increases in LVEDD. The initial index of mitral valve prolapse, the area of the jet and the intensity of the heart murmur were all significant predictors of an increase in LAD. PMID:12650472
Olsen, L H; Martinussen, T; Pedersen, H D
Terminal warm blood cardioplegia has had a profound impact on cardiac surgery, especially in coronary artery bypass surgery, but there have been few studies on its use in mitral valve replacement. The purpose of this study was to determine whether terminal warm blood cardioplegia offers any advantages in mitral valve replacement. Forty patients with mitral valve disease were prospectively randomized to one of two groups of 20 with different techniques of myocardial protection: group A had cold blood cardioplegia, and group B had cold blood cardioplegia with terminal warm blood cardioplegia. Intraoperative and postoperative variables were used to assess primary outcomes. Postoperative troponin T release was measured as a secondary outcome. Improved spontaneous recovery of sinus rhythm was observed in group B, but the difference was not significant. The maximum doses of inotropics, duration of inotropic support, intensive care unit stay, and postoperative left ventricular ejection fraction were similar in both groups. Troponin T release at 0 and 6 h postoperatively was not different between the two groups. This study did not find any benefit of terminal warm blood cardioplegia in either clinical outcome or troponin T release after mitral valve replacement. PMID:16551821
Rergkliang, Chareonkiat; Chetpaophan, Apirak; Chittithavorn, Voravit; Vasinanukorn, Prasert; Chowchuvech, Vorapong
In symptomatic mitral valve prolapse patients (MVP): (1) the frequency and nature of symptoms were analyzed (n = 313); (2) metabolic studies were performed (n = 20), and (3) the response to isoproterenol infusions were studied (n = 16). Chest pain is more often the initial symptom in men; palpitations are more common initially in women. Fatigue, palpitations, dyspnea and
Harisios Boudoulas; Bernard D. King; Charles F. Wooley
Degenerative valvular heart disease, the most common form of valve disease in the Western world, can lead to aortic stenosis (AS) or mitral regurgitation (MR). In current guidelines for the management of patients with degenerative valvular disease, surgical intervention is recommended at the onset of symptoms or in the presence of left ventricular systolic impairment. Whether surgery is appropriate for
Valentin Fuster; Martin Goldman; Robert O. Bonow; Prashant Vaishnava
The mitral annulus plays an essential role in mitral valve (MV) competency. When surgical intervention is needed, the placement of an annular ring is considered a major component of MV repair. However, the use of a foreign material increases the risk of infectious and thromboembolic complications and is problematic in children as it does not allow for annular growth. Herein is reported a case of infective endocarditis affecting a mitral ring that was implanted to treat severe mitral valve regurgitation (MR) some 10 years earlier. Surgery was performed to remove the MV vegetation, and subsequent echocardiography revealed only trace MR. The concept that the ring may be needed for a limited period of time to induce valve remodeling is consistent with new data on biodegradable rings. These rings degrade over months, inducing dense fibrous tissue that replaces the ring and maintains valve competency. The present case is one of the first human examples to support the potential efficacy of a biodegradable ring. PMID:24597407
Slipczuk, Leandro; Trento, Alfredo; Luo, Huai; Siegel, Robert J
The morphology of the mitral valve apparatus was assessed on 100 normal left ventriculograms. Four distinct types of mitral valve were identified according to the position of the mitral fulcrum (the point of attachment of the leaflets to the annulus) and the configuration of the adjacent left ventricular wall (left ventricular fornix) during diastole. Types I and II closely simulated
H Spindola-Franco; L Bjork; D F Adams; H L Abrams
Uncontrollable severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy, significantly contributing to heart failure in these patients, and predicts a poor survival. Although elimination of mitral valve regurgitation could be most beneficial in this group, corrective mitral valve surgery has not been routinely undertaken in these very ill patients because of the presumed prohibitive operative mortality. We studied
Steven F. Bolling; G. Michael Deeb; Louis A. Brunsting; David S. Bach
The role of intraoperative transesophageal echocardiography (TEE) has increased tremendously since its first use in 1979. Today intraoperative TEE is a class I indication for surgical mitral valve reconstruction for evaluation of mitral valve pathology, graduation of mitral regurgitation and detection of potential risk factors as well as post-repair assessment. Real-time three-dimensional TEE offers anatomical visualization of the mitral valve apparatus, fundamental for virtual surgical planning of proper annuloplasty ring size. As minimally invasive and even off-pump techniques for mitral valve repair become more popular, image guidance by intraoperative TEE will play an essential role.
Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining “mitral valve” with the following terms: ‘minimally invasive’, ‘reoperation’, and ‘alternative approach’. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed “mini” thoracotomy or “port access”. The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.
Cannata, Aldo; Bruschi, Giuseppe; Fratto, Pasquale; Taglieri, Corrado; Russo, Claudio Francesco; Martinelli, Luigi
Since its early days, cardiac surgery has typically involved large incisions with complete access to the heart and the great vessels. After the popularization of the minimally invasive techniques in general surgery, cardiac surgeons began to experiment with minimal access techniques in the early 1990s. Although the goals of minimally invasive cardiac surgery (MICS) are fairly well established as decreased pain, shorter hospital stay, accelerated recuperation, improved cosmesis, and cost effectiveness, a strict definition of minimally invasive cardiac surgery has been more elusive. Minimally invasive cardiac surgery started with mitral valve procedures and then gradually expanded towards other valve procedures, coronary artery bypass grafting, and various types of simple congenital heart procedures. In this paper, the authors attempt to focus on the evolution, techniques, results, and the future perspective of minimally invasive mitral valve surgery (MIMVS).
Ritwick, Bhuyan; Chaudhuri, Krishanu; Crouch, Gareth; Edwards, James R. M.; Worthington, Michael; Stuklis, Robert G.
Severe mitral valve regurgitation due to systemic lupus erythematosus is a rare cause of valvular heart disease, necessitating valve surgery. Currently, there are 36 case reports in the world medical literature of mitral valve replacement or repair in patients who have lupus. The current trend in mitral valve surgery is toward anatomic valve repair. In patients who have systemic lupus erythematosus, however, valve repair often leads to repeat surgery and valve replacement. We report the cases of 5 patients with lupus and severe mitral valve regurgitation who underwent mitral valve surgery. In 3 of these patients, replacement with a mechanical prosthetic mitral valve was performed with good long-term results. In the other 2 patients, mitral valve repair was performed, but only 1 of the repairs was successful. The 2nd patient required subsequent replacement with a mechanical valve. To our knowledge, this report of 5 patients is the largest series of mitral valve surgery in patients with lupus. These results, along with a review of the literature, suggest the superiority of mechanical prosthetic valve replacement to repair in patients who have systemic lupus erythematosus.
Hakim, John P.; Mehta, Anurag; Jain, Abnash C.; Murray, Gordon F.
Aortic valve calcification can aggravate aortic stenoses, and it is a significant cause of sudden cardiac death. The increasing number of patients with age-related calcification is a problem in developed nations. However, the only treatment option currently available is highly invasive cardiac valve replacement. Therefore, clarification of the etiology of calcification is urgently needed to develop drug therapies and prevention methods. Recent studies have revealed that calcification is not a simple sedimentation of a mineral through a physicochemical phenomenon; various factors dynamically contribute to the mechanism. Further, we are finally beginning to understand the cellular origins of calcification, which had been unclear for a long time. Based on these findings that help to clarify potential drug targets, we expect to establish drug therapies that reduce the stress on patients. In this paper, I introduce the latest findings on cells that are most likely to contribute to calcification and on calcification-related factors that may lead to the development of drug therapies. PMID:24463776
We report on a 77-year-old woman in whom percutaneous left atrial appendage (LAA) closure was performed. The patient had a left atrial myxoma resection 3 years previously, and 2 years later, she suffered a transient ischemic attack. Atrial fibrillation was detected and anticoagulation therapy was established. An episode of intracranial bleeding forced interruption of anticoagulation. Thus, percutaneous LAA closure with an Amplatzer Amulet LAA Occluder (St Jude Medical) was proposed. During the procedure, the LAA occluder migrated and became trapped in the mitral valve. Secondary massive mitral regurgitation and hemodynamic instability forced emergent cardiac surgery. Successful removal of the Amplatzer Amulet LAA Occluder was achieved. PMID:24182760
González-Santos, Jose María; Arnáiz-García, María Elena; Arribas-Jiménez, Antonio; López-Rodríguez, Javier; Rodríguez-Collado, Javier; Vargas-Fajardo, María del Carmen; Dalmau-Sorlí, María José; Bueno-Codoñer, María Encarnación; Arévalo-Abascal, R Adolfo
Transfemoral aortic valve implantation has emerged as a promising alternative to surgical aortic valve replacement for high-risk patients with severe symptomatic aortic stenosis. In the setting of previous mechanical mitral valve replacement, the procedure represents a challenge due to the risk of interference and subsequent functional impairment of the mechanical prosthesis. The authors report a case of successful transfemoral implantation of a selfexpandable aortic bioprosthesis in a patient with a Björk-Shiley tilting-disk valve in mitral position demonstrating that the implantation is also feasible in this setting but requires careful preinterventional evaluation. Prior balloon aortic valvuloplasty with thorough observation of the mitral prosthesis during balloon inflation may be a helpful tool for indicating feasibility of this approach. PMID:20024645
Kahlert, Philipp; Eggebrecht, Holger; Thielmann, Matthias; Wendt, Daniel; Jakob, Heinz G; Sack, Stefan; Erbel, Raimund
We experienced a case in which live 3D transoesophageal echocardiography (TEE) was found much more valuable than 2D TEE in assessing mitral lesions in circumferential direction and making surgical plans for mitral valve prolapse. PMID:18786947
Uno, Kansei; Takenaka, Katsu; Ebihara, Aya; Nawata, Kan; Hayashi, Naoto; Nagasaki, Mika; Sonoda, Makoto; Takayuki, Ohno; Ono, Minoru; Kyo, Shunei; Nagai, Ryozo; Takamoto, Shinichi
We describe a case that demonstrates and confirms the usefulness of 3D transesophageal echocardiography in the morphological analysis of the mitral valve in a rare occurrence of postrheumatic mitral leaflet perforation. PMID:23442809
D'Aloia, Antonio; Vizzardi, Enrico; Rovetta, Riccardo; Bugatti, Silvia; Bonadei, Ivano; Curnis, Antonio
Transcatheter implantation of a balloon expandable valve in calcified severely stenosed native mitral valves has recently been described. The two cases reported so far utilized the surgical transapical approach generally used for transapical transcatheter aortic valve replacement. A percutaneous approach has not been published. We report the first successful percutaneous implantation of a balloon expandable transcatheter valve in the native mitral valve without a surgical incision. © 2014 Wiley Periodicals, Inc. PMID:24532349
Guerrero, Mayra; Greenbaum, Adam; O'Neill, William
Mitral regurgitation may result from left ventricular dilatation and cause progression of heart failure. Percutaneous techniques for mitral valve repair are under development. Techniques utilizing a trans-coronary venous approach exploit the anatomical relationship between the mitral annulus and the venous system of the heart. The coronary sinus, great cardiac vein and the origin of the anterior interventricular vein surround the posterior mitral annulus. This enables percutaneous approaches to annuloplasty for mitral regurgitation. Devices can be implanted into the coronary veins that modify the shape and size of the mitral annulus. We present a case of ischaemic mitral regurgitation successfully treated by use of a percutaneous approach, the Carillon Mitral Contour System. Significant reduction of the mitral regurgitation jet was observed. The patient was discharged 4 days after the procedure. During the follow-up visits, the patient showed an improved general condition and increased exercise capacity. Procedural steps are shown in detail and the current status of the coronary sinus based technique is discussed. Percutaneous techniques for mitral valve repair may be an attractive alternative to cardiac surgery in heart failure patients with secondary mitral regurgitation. The Carillon Mitral Contour System is under ongoing clinical evaluation in the AMADEUS trial. PMID:17436155
Siminiak, Tomasz; Firek, Ludwik; Jerzykowska, Olga; Ka?mucki, Piotr; Wo?oszyn, Maciej; Smuszkiewicz, Piotr; Link, Rafa?
A severely calcified mitral annulus represents a unique challenge during mitral valve replacement. To ensure proper healing of the sewing ring of the prosthesis and to avoid periprosthetic regurgitation, the mitral annulus often must be debrided for secure attachment. However, the extensive debridement that can be required in some cases could increase the risk of atrioventricular groove disruption, with a subsequent increase in morbidity and mortality. Bypass of the mitral valve with a left atrial to left ventricular-valved conduit has been described for difficult cases with congenital mitral valve stenosis. In our report, we describe its use as a safe alternative to standard mitral valve replacement in a patient with a densely calcified annulus and severe mitral stenosis. PMID:24656669
Said, Sameh M; Schaff, Hartzell V
Prosthetic heart valve obstruction is a severe and potentially fatal complication. We present a patient with a Bjork-Shiley prosthetic mitral and aortic valve implantation and recurrent pulmonary edema. Echocardiogram showed a rate-dependent "obstruction alternans" of the prosthetic mitral valve due to pannus formation. PMID:19699940
Schurmans, Joris; Ferdinande, Bert; Keuleers, Siegmund; Herijgers, Paul; Budts, Werner
Objectives. We report the clinical course and unique hemodynamic findings after placement of a supraannular mitral valve prosthesis.Background. Children with symptomatic mitral valve disease whose annulus is too small for the smallest prosthesis are difficult to manage. One option is valve replacement with a prosthesis positioned entirely within the left atrium (LA).Methods. We reviewed 17 patients (median age 10 months)
Ian Adatia; Phillip M Moore; Richard A Jonas; Steven D Colan; James E Lock; John F Keane
75 cases of mitral valve prolapse (MVP) for which no cause was found underwent electromyography (EMG). In 64 cases (85.3%) EMG showed changes suggestive of spasmophilia. The symptoms observed were those already described in this condition. The specific clinical signs of spasmophilia were often elicited with a positive Chvostek sign in 20 out of 30 cases (73.3%). Radiological, echocardiographical and haemodynamic studies underlined the hyperkinetic state of the left ventricle. Biochemical investigations showed a high incidence of low erythrocytic magnesium levels. Chest pain suggestive of angina pectoris, mitral valve prolapse and spasmophilia are frequently associated. The role of the low erythrocyte magnesium on left ventricular hyperkinesis and the production of MVP is discussed. PMID:117769
Gérard, R; Luccioni, R; Gatau-Pelanchon, J; Duport, G; Jullien, G; Bouteau, J M; Chabrillat, Y; Duport, M Y
We report a 65-year-old woman with chronic diastolic congestive heart failure, pulmonary hypertension, and severe mitral valve regurgitation. She was not a candidate for percutaneous mitral valve repair and was turned down for an open heart operation by 2 institutions based on her severe pectus excavatum deformity. A left posterior lateral thoracotomy approach provided excellent exposure for central cannulation and replacement of the mitral valve. PMID:23992732
Bastidas, Juan G; Razzouk, Anees J; Hasaniya, Nahidh W; Bailey, Leonard L
In mitral valvuloplasty, the saline injection test is commonly employed. However, discrepancies in regurgitation between the naked eye findings during the saline injection test and the postoperative echocardiographical findings are noted. Here, we describe a technique that allows direct transatrial evaluation of the valve in the fully loaded, beating heart without the risks of air embolism. Physiological systolic mitral valve movement is reproduced under aortic cross-clamping. This novel evaluation enables a complete and safe mitral valve repair. PMID:23315958
Tachibana, Kazutoshi; Higami, Tetsuya; Miyaki, Yasuko; Takagi, Nobuyuki
This case illustrates the awareness that must be taken of the high morphological risk due to the calcifications of both, the aortic and mitral annulus in elderly patients when performing transapical aortic valve implantation. In an 86-year-old, multimorbid woman (logistic EuroSCORE = 27%) with symptomatic aortic stenosis (annular diameter = 23.4 mm) and severe mitral annular calcification, the implantation of a 26-mm Edwards SAPIEN (Edwards Lifesciences, Irvine, California, United States) valve in aortic position was primary successful, with no paravalvular leakage, valve instability, or coronary malperfusion. Second, a persisting transmural bleeding led to hypovolemic shock, which could not be stabilized even after going on cardiopulmonary bypass, and the patient died in the operation room. The autopsy showed a subvalvular ventricular rupture due to a transmural perforation of the calcified fibrotic annulus during valvuloplasty. PMID:23169104
Haldenwang, Peter L; Bechtel, Matthias; Schlömicher, Markus; Lindstaedt, Michael; Strauch, Justus T
Treadmill exercise echocardiography with Doppler evaluation during effort has been used for several years in our department. The usefulness of this methodology in the management of patients with coronary heart disease is recognized but it is being increasingly used in patients with valvular heart disease. We report the case of a 44-year-old man with parachute mitral valve, in which transesophageal echocardiography characterized the pathology and exercise stress echocardiography was important for accurate functional assessment and clinical decisions. PMID:19480316
Almeida, Sofia; Cotrim, Carlos; Miranda, Rita; Lopes, Luís; Almeida, Ana Rita; Loureiro, Maria J; Simões, Otília; Cordeiro, Pedro; Fazendas, Paula; João, Isabel; Carrageta, Manuel
Structured Abstract Objectives We developed and tested a novel transcatheter circumferential annuloplasty technique to reduce mitral regurgitation in porcine ischemic cardiomyopathy. Background Catheter-based annuloplasty for secondary mitral regurgitation exploits the proximity of the coronary sinus to the mitral annulus, but is limited by anatomic variants and coronary artery entrapment. Methods The procedure, “cerclage annuloplasty,” is guided by MRI roadmaps fused with live X-ray. A coronary sinus guidewire traverses a short segment of basal septal myocardium to reenter the right heart where it is exchanged for a suture. Tension is applied interactively during imaging and secured with a locking device. Results We found two feasible suture pathways from the great cardiac vein across the interventricular septum to create cerclage. Right-ventricular septal reentry required shorter fluoroscopy times than right atrial reentry, which entailed a longer intramyocardial traversal but did not cross the tricuspid valve. Graded tension progressively reduced septal-lateral annular diameter but not end-systolic elastance or regional myocardial function. A simple arch-like device protected entrapped coronary arteries from compression even during supra-therapeutic tension. Cerclage reduced mitral regurgitation fraction (from 22.8 ± 12.7% to 7.2 ± 4.4%, p=0.04) by slice-tracking velocity-encoded MRI. Flexible cerclage reduced annular size but preserved annular motion. Cerclage also displaced the posterior annulus towards the papillary muscles. Cerclage introduced reciprocal constraint to the left ventricular outflow tract and mitral annulus that enhanced leaflet coaptation. A sample of human coronary venograms and CT angiograms suggested that most have suitable venous anatomy for cerclage. Conclusions Transcatheter mitral cerclage annuloplasty acutely reduces mitral regurgitation in porcine ischemic cardiomyopathy. Entrapped coronary arteries can be protected. MRI provided insight into the mechanism of cerclage action.
Kim, June-Hong; Kocaturk, Ozgur; Ozturk, Cengizhan; Faranesh, Anthony Z.; Sonmez, Merdim; Sampath, Smita; Saikus, Christina E.; Kim, Ann H.; Raman, Venkatesh K.; Derbyshire, J. Andrew; Schenke, William H.; Wright, Victor J.; Berry, Colin; McVeigh, Elliot R.; Lederman, Robert J.
The myxomatous mitral valve is the most common form of valvular heart disease. The pathologic presentation of myxomatous mitral valve disease varies between valve thickness, degree of leaflet prolapse and the presence or absence of flail leaflets. Recent molecular biology studies have confirmed that the myxomatous changes in mitral valve prolapse equals a cartilage phenotype, which is regulated by the Lrp5 receptor. Clinically, echocardiography defines the valve pathology to determine the surgical approach to valve repair or replacement. Furthermore, the timing of surgical valve repair is controversial and is the subject of a current multicenter trial. The results will resolve the timing of whether watchful waiting versus early surgical valve repair decreases morbidity and mortality of this disease process. This review will summarize the current understanding of the cellular and hemodynamic mechanisms of myxomatous mitral valve disease, which may have future implications in the targeted therapy of this disease process.
Rajamannan, Nalini M
Mitral valve regurgitation is a relatively common and important heart valve lesion in clinical practice and adequate assessment is fundamental to decision on management, repair or replacement. Disease localised to the posterior mitral valve leaflet or focal involvement of the anterior mitral valve leaflet is most amenable to mitral valve repair, whereas patients with extensive involvement of the anterior leaflet or incomplete closure of the valve are more suitable for valve replacement. Echocardiography is the recognized investigation of choice for heart valve disease evaluation and assessment. However, the technique is depended on operator experience and on patient's hemodynamic profile, and may not always give optimal diagnostic views of mitral valve dysfunction. Cardiac catheterization is related to common complications of an interventional procedure and needs a hemodynamic laboratory. Cardiac magnetic resonance (MRI) seems to be a useful tool which gives details about mitral valve anatomy, precise point of valve damage, as well as the quantity of regurgitation. Finally, despite of its higher cost, cardiac MRI using cine images with optimized spatial and temporal resolution can also resolve mitral valve leaflet structural motion, and can reliably estimate the grade of regurgitation.
Apostolakis, Efstratios E; Baikoussis, Nikolaos G
There is a current trend to design innovative mitral valve replacements that mimic the native mitral valve (MV). A prerequisite for these new designs is the characterization of MV structure. This study was conducted to determine the distribution of MV collagen and glycosaminoglycan (GAGs) in MV anterior leaflets. Methods: Specimens from the mid-line of eight sheep MV anterior leaflets were
David W. Quick; Karyn S. Kunzelman; Richard P. Cochran
Cardiac valves function in a mechanically complex environment, opening and closing close to a billion times during the average human lifetime, experiencing transvalvular pressures and pulsatile and oscillatory shear stresses, as well as bending and axial stress. Although valves were originally thought to be passive pieces of tissue, recent evidence points to an intimate interplay between the hemodynamic environment and biological response of the valve. Several decades of study have been devoted to understanding these varied mechanical stimuli and how they might induce valve pathology. Here, we review efforts taken in understanding the valvular response to its mechanical milieu and key insights gained from in vitro and ex vivo whole-tissue studies in the mechanobiology of aortic valve remodeling, inflammation, and calcification.
Balachandran, Kartik; Sucosky, Philippe; Yoganathan, Ajit P.
A rare case of left atrial rhabdomyosarcoma is presented in a patient with symptoms of congestive heart failure mimicking a hemodynamically obstructive mitral stenosis and secondary pulmonary hypertension. Although the diagnosis of a cardiac neoplasm is often difficult, it should be suspected in any patient with idiopathic heart failure refractory to conventional therapy, or with systemic or pulmonary emboli without an obvious source. The possibility of a "tumor plop" should always be considered during auscultation of a diastolic click. If clinically suspected, echocardiography will usually establish the diagnosis and allow follow-up for recurrences. If the tumor is benign, cardiac surgery will be curative and, if malignant, chemotherapy or radiotherapy should be considered. PMID:15227049
Villasenor, H R; Fuentes, F; Walker, W E
Patients with rheumatic valvular heart disease who have undergone valve surgery may present later with progression of disease in other valves. We report a case of successful percutaneous transvenous mitral commissurotomy (PTMC) in a 58-year-old male who underwent aortic valve replacement (AVR) with a No. 23 Björk-Shiley valve for severe rheumatic aortic regurgitation in 1982. At AVR, echocardiography revealed mild mitral stenosis (MS) and mitral valve area (MVA) 2.5 cm2. Over 18 years, the mitral valve disease progressed to severe MS and the patient presented with class III exertional dyspnea. He underwent successful PTMC (Inoue balloon technique). Post-procedure echocardiography revealed a MVA of 2.0cm2 and grade II mitral regurgitation. Anticoagulation management, infective endocarditis prophylaxis and procedural modifications are discussed. PMID:11767192
Faizal, A; Umesan, C V; Radhakrishnan, N; Lakshmi, V; Hemalatha, R
ObjectivesWe sought to determine clinical and laboratory correlates of calcification of the coronary arteries (CAs), aorta and mitral and aortic valves in adult subjects with end-stage renal disease (ESRD) receiving hemodialysis.
Paolo Raggi; Amy Boulay; Scott Chasan-Taber; Naseem Amin; Maureen Dillon; Steven K Burke; Glenn M Chertow
Background Ventricular arrhythmias are common in patients with mitral valve prolapse (MVP). Previous studies have provided evidence that a higher degree of systolic mitral valve displacement and the presence of a thickened anterior mitral leaflet are related to an increased incidence of complex ventricular arrhythmias and risk of sudden death in these patients. The aim of our study was to
E. G. Zouridakis; F. I. Parthenakis; G. E. Kochiadakis; E. M. Kanoupakis; P. E. Vardas
Background Valve dysfunction is a common cardiovascular pathology. Despite significant clinical research, there is little formal study of how valve dysfunction affects overall circulatory dynamics. Validated models would offer the ability to better understand these dynamics and thus optimize diagnosis, as well as surgical and other interventions. Methods A cardiovascular and circulatory system (CVS) model has already been validated in silico, and in several animal model studies. It accounts for valve dynamics using Heaviside functions to simulate a physiologically accurate "open on pressure, close on flow" law. However, it does not consider real-time valve opening dynamics and therefore does not fully capture valve dysfunction, particularly where the dysfunction involves partial closure. This research describes an updated version of this previous closed-loop CVS model that includes the progressive opening of the mitral valve, and is defined over the full cardiac cycle. Results Simulations of the cardiovascular system with healthy mitral valve are performed, and, the global hemodynamic behaviour is studied compared with previously validated results. The error between resulting pressure-volume (PV) loops of already validated CVS model and the new CVS model that includes the progressive opening of the mitral valve is assessed and remains within typical measurement error and variability. Simulations of ischemic mitral insufficiency are also performed. Pressure-Volume loops, transmitral flow evolution and mitral valve aperture area evolution follow reported measurements in shape, amplitude and trends. Conclusions The resulting cardiovascular system model including mitral valve dynamics provides a foundation for clinical validation and the study of valvular dysfunction in vivo. The overall models and results could readily be generalised to other cardiac valves.
Background Application of annuloplasty rings during mitral valve (MV) repair has been shown to significantly change the mitral annular geometry. Until recently, a comprehensive two-dimensional echocardiographic evaluation of annular geometric changes was difficult owing to its nonplanar orientation. In this study, an analysis of the three-dimensional intraoperative transesophageal echocardiographic evaluation of the MV annulus is presented before and immediately after repair. Methods We performed three-dimensional geometric analysis on 75 patients undergoing MV repair during coronary artery bypass graft surgery for mitral regurgitation or myxomatous mitral valve disease. Geometric analysis of the MV was performed before and immediately after valve repair with full rings and annuloplasty bands. The acquired three-dimensional volumetric data were analyzed in the operating room. Specific measurements included annular diameter, leaflet lengths, the nonplanarity angle, and the circularity index. Before and after repair data were compared. Results Complete echocardiographic assessment of the MV was feasible in 69 of 75 patients (92%) within 2 to 3 minutes of acquisition. Placement of full rings resulted in an increase in the nonplanarity angle or a less saddle shape of the native mitral annulus (137 ±14 versus 146 ± 14; p = 0.002. By contrast, the nonplanarity angle did not change significantly after placement of partial rings. Conclusions Mitral annular nonplanarity can be assessed in the operating room. Application of full annuloplasty rings resulted in the mitral annulus becoming more planar. Partial annuloplasty bands did not significantly change the nonplanarity angle. Neither of the two types of rings restored the native annular planarity.
Mahmood, Feroze; Subramaniam, Balachundhar; Gorman, Joseph H.; Levine, Robert M.; Gorman, Robert C.; Maslow, Andrew; Panzica, Peter J.; Hagberg, Robert M.; Karthik, Swaminathan; Khabbaz, Kamal R.
To characterize the spectrum of mitral regurgitation in mitral valve prolapse, one hundred patients were studied by color Doppler flow mapping. The findings were correlated with the clinical presentation and with the possible complications. Mitral regurgitation was absent in 46 patients, mild in 26 patients, moderate in 18 patients and severe in 10 patients. The jet orientation was central in 15 patients, antero-medial in 13 patients and postero-lateral in 26 patients. The regurgitation was early systolic in 7 patients, late systolic in 20 patients and holosystolic in 27 patients. A good agreement was observed between the color flow patterns and the presence, timing and radiation of a murmur. Systolic clicks were not predictors of the presence or the severity of regurgitation. The grade of mitral regurgitation was positively correlated with, age, left heart enlargement and valvular redundancy. No sex difference was observed. The prevalence of serious arrhythmias or cerebral ischemic events was not significantly increased when a regurgitation was present. PMID:2286773
Decoodt, P; Péperstraete, B; Kacenelenbogen, R; Verbeet, T; Bar, J P; Telerman, M
Objective. – Recent studies have suggested that valvular calcification in calcific aortic stenosis (AS) may be actively regulated. “Receptor Activator of Nuclear factor ?B Ligand” (RANKL) and osteoprotegerin (OPG) are members of a cytokine system involved in bone turnover and vascular calcification. Their role in calcific AS is not known.Methods and Results. – By immunohistochemistry using human aortic valves, RANKL
Jens J. Kaden; Svetlana Bickelhaupt; Rainer Grobholz; Karl K. Haase; Asl?han Sar?koç; Ref?ka K?l?ç; Martina Brueckmann; Siegfried Lang; Ingrid Zahn; Christian Vahl; Siegfried Hagl; Carl-Erik Dempfle; Martin Borggrefe
Cloth-covered Starr-Edwards caged ball valves implanted in the aortic and mitral valve positions for 39 years were extracted. Both showed valve dysfunction resulting from pannus overgrowth. The metal cages of the Starr-Edwards valves were covered with worn cloth. This case indicates the extended durability of Starr-Edwards valves and the importance of the design and materials of prosthetic heart valves to avoid pannus overgrowth and prosthetic valve abrasion. PMID:21674313
Misawa, Shun-ichi; Aizawa, Kei; Kaminishi, Yuichiro; Muraoka, Arata; Misawa, Yoshio
The current surgical technique of using an artificial chord (composed of expanded polytetrafluoroethylene [ePTFE] sutures) to repair mitral prolapse is technically difficult to perform. Slippery knot tying and the difficulty of changing the chordae length after the hydrostatic test are frustrating problems. The loop technique solves the problem of slippery knot tying but not the problem of changing the chordae length. Our "loop with anchor" technique consists of the following elements: construction of an anchor at the papillary muscle; determining the loop length; tying the loop to the anchor; suturing the loop to the mitral valve; the hydrostatic test; and re-suturing or changing the loop, if needed. Adjustments can be made for the entire procedure or for a portion of the procedure. PMID:22156285
Isoda, Susumu; Osako, Motohiko; Kimura, Tamizo; Mashiko, Yuji; Yamanaka, Nozomu; Nakamura, Shingo; Maehara, Tadaaki
Background. A computerized 48-channel mapping system was used to investigate the characteristics of an atrial epicardial electrogram during chronic atrial fibrillation (AF) in patients with solitary mitral valve disease. We have devised a simple left atrial procedure to eliminate the chronic AF during a mitral valve operation.Methods. Using this mapping system, we performed intraoperative atrial mapping in 11 patients with
Taijiro Sueda; Hideyuki Nagata; Hiroo Shikata; Kazumasa Orihashi; Satoru Morita; Masafumi Sueshiro; Kenji Okada; Yuichiro Matsuura
A 22-year-old woman required emergency mitral valve replacement three weeks post partum because of thrombotic obstruction of her prosthetic mitral valve. Low dose subcutaneous heparin was administered from the 17th week of pregnancy. Though there was a successful fetal outcome, heparin did not prevent thrombosis on the prosthesis and its continuation into the puerperium proved nearly fatal. Images
McLeod, A A; Jennings, K P; Townsend, E R
BackgroundMany outcomes and complications of minimally invasive and conventional cardiac surgery await comparison. Patients undergoing mitral valve surgery commonly sustain renal injury. Using peak postoperative fractional change of serum creatinine as a marker of renal injury, we tested the hypothesis that mitral valve surgery with port access minithoracotomy (Port) and conventional surgery with a median sternotomy (MS) incision are associated
Brian J McCreath; Madhav Swaminathan; John V Booth; Barbara Phillips-Bute; Sophia T. H Chew; Donald D Glower; Mark Stafford-Smith
A 55-year-old male presented with stroke. Transesophageal echocardiogram and cardiac computed tomography revealed an unrecognized congenital malformation of the anterior mitral leaflet associated with anomalous left coronary circumflex artery, arising from the right coronary artery, diagnosed first by echocardiogram. This case represents a unique unforeseen mitral valve anomaly that might be considered as potential cardiac source of embolism. This finding broadens the spectrum of known mitral valve anomalies.
Hutchison, Stuart J.; Said, Nazmi
A 55-year-old male presented with stroke. Transesophageal echocardiogram and cardiac computed tomography revealed an unrecognized congenital malformation of the anterior mitral leaflet associated with anomalous left coronary circumflex artery, arising from the right coronary artery, diagnosed first by echocardiogram. This case represents a unique unforeseen mitral valve anomaly that might be considered as potential cardiac source of embolism. This finding broadens the spectrum of known mitral valve anomalies. PMID:24753810
Elhussein, Tarek A; Hutchison, Stuart J; Said, Nazmi
A case of mitral stenosis following mitral valve replacement in a patient with endocardial fibroelastosis is reported. A 14-year-old\\u000a boy presented with cardiac failure. He had been diagnosed as having endocardial fibroelastosis at the age of 7 months and\\u000a had undergone resection of endocardial fibrous tissue in the left ventricle at that time. Five years later his mitral valve\\u000a was
S. Dinarevic; A. Redington; M. Rigby; M. N. Sheppard
We herein describe a simple method for the fine length adjustment of expanded polytetrafluoroethylene (e-PTFE) using the loop technique for mitral valve repair. The loops are temporarily anchored to the mitral leaflet with a second e-PTFE suture by tying only once (one-knot technique). This anchor suture can be easily removed and repositioned if necessary. We believe that this simple technique allows for the more precise and reproducible repair of mitral valve prolapse. PMID:23238885
Sakaguchi, Taichi; Nishi, Hiroyuki; Miyagawa, Shigeru; Yoshikawa, Yasushi; Fukushima, Satsuki; Yoshioka, Daisuke; Ueno, Takayoshi; Sawa, Yoshiki
The surgical repair of degenerative mitral valve disease involves a number of technical points of importance. The use of artificial chordae for the repair of degenerative disease has increased as a part of the move from mitral valve replacement to repair of the mitral valve. The use of artificial chordae provides an alternative to the techniques pioneered by Carpentier (including the quadrangular resection, transfer of native chordae and papillary muscle shortening/plasty), which can be more technically difficult. Despite a growth in their uptake and the indications for their use, a number of challenges remain for the use of artificial chordae in mitral valve repair, particularly in the determination of the correct length to ensure optimal leaflet coaptation. Here, we analyse over 40 techniques described for artificial chordae mitral valve repair in the setting of degenerative disease.
Ibrahim, Michael; Rao, Christopher; Athanasiou, Thanos
Obstructive apneas produce high negative intrathoracic pressure that imposes an afterload burden on the left ventricle. Such episodes might produce structural changes in the left ventricle over time. Doppler echocardiograms were obtained within 2 months of attended polysomnography. Patients were grouped according to apnea-hypopnea index (AHI): mild/no obstructive sleep apnea (OSA; AHI <15) and moderate/severe OSA (AHI ?15). Mitral valve tenting height and area, left ventricular (LV) long and short axes, and LV end-diastolic volume were measured in addition to tissue Doppler parameters. Comparisons of measurements at baseline and follow-up between and within groups were obtained; correlations between absolute changes (?) in echocardiographic parameters were also performed. After a mean follow-up of 240 days mitral valve tenting height increased significantly (1.17 ± 0.12 to 1.28 ± 0.17 cm, p = 0.001) in moderate/severe OSA as did tenting area (2.30 ± 0.41 to 2.66 ± 0.60 cm(2), p = 0.0002); ?tenting height correlated with ?LV end-diastolic volume (rho 0.43, p = 0.01) and ?tenting area (rho 0.35, p = 0.04). In patients with mild/no OSA there was no significant change in tenting height; there was a borderline significant increase in tenting area (2.20 ± 0.44 to 2.31 ± 0.43 cm(2), p = 0.05). Septal tissue Doppler early diastolic wave decreased (8.04 ± 2.49 to 7.10 ± 1.83 cm/s, p = 0.005) in subjects with moderate/severe OSA but not in in those with mild/no OSA. In conclusion, in patients with moderate/severe OSA, mitral valve tenting height and tenting area increase significantly over time. This appears to be related, at least in part, to changes in LV geometry. PMID:22264596
Pressman, Gregg S; Figueredo, Vincent M; Romero-Corral, Abel; Murali, Ganesan; Kotler, Morris N
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.
The pulmonary status is a vital factor for patients undergoing open heart surgery. The cardiac surgery itself deteriorates the actual pulmonary functions. Today, patients are no longer living with a cardiac disease due to compromised respiratory functions secondary to various pathologies, patients with lung disorders more often seek solutions for their cardiac disease and they are commonly operated. However, the resection of a lobe or a whole lung is a major challenge for the patients planned for cardiac surgery. In this report, we present a 65-year-old patient, who had left pnemonectomy which had been performed 8 years ago and was admitted for mitral valve replacement and subaortic membrane resection.
Us, Melih Hulusi; Ugurlucan, Murat; Basaran, Murat; Selimoglu, Ozer; Kocailik, Ali
Left atrial thrombus in the presence of diseased mitral valve and atrial fibrillation is a well known entity. But it is very rare to occur in the presence of normal mitral valve apparatus. We report the case of a 36 year old female who presented with left atrial ball valve thrombus and normal mitral valve apparatus and underwent surgery. This patient with gangrene of right lower limb came for cardiac evaluation. She had infarct in left middle cerebral artery territory- ten months prior to this admission and was on treatment for infertility. She had atrial fibrillation. Emergency surgery to remove the thrombus should be considered given its potential life threatening embolic nature.
Chidambaram, Sundar; Rajkumar, Arunkumar; Ganesan, Gnanavelu; Sangareddi, Venkatesan; Ramasamy, Alagesan; Dhandapani, V.E.; Ravi, M.S.
Ischemic mitral valve (MV) is a common complication of pathologic remodeling of the left ventricle due to acute and chronic coronary artery diseases. It frequently represents the pathologic consequences of increased tethering forces and reduced coaptation of the MV leaflets. Ischemic MV function has been investigated from a biomechanical perspective using finite element-based computational MV evaluation techniques. A virtual 3D MV model was created utilizing 3D echocardiographic data in a patient with normal MV. Two types of ischemic MVs containing asymmetric medial-dominant or symmetric leaflet tenting were modeled by altering the configuration of the normal papillary muscle (PM) locations. Computational simulations of MV function were performed using dynamic finite element methods, and biomechanical information across the MV apparatus was evaluated. The ischemic MV with medial-dominant leaflet tenting demonstrated distinct large stress distributions in the posteromedial commissural region due to the medial PM displacement toward the apical-medial direction resulting in a lack of leaflet coaptation. In the ischemic MV with balanced leaflet tenting, mitral incompetency with incomplete leaflet coaptation was clearly identified all around the paracommissural regions. This computational MV evaluation strategy has the potential for improving diagnosis of ischemic mitral regurgitation and treatment of ischemic MVs.
Rim, Yonghoon; McPherson, David D.; Kim, Hyunggun
Background. This study analyzes a single institutional experience with minimally invasive mitral valve operations of 6 years, reviewing short-term morbidity and mortality and long-term echocardiographic follow-up data.Methods. Seven hundred fourteen consecutive patients had minimally invasive mitral valve procedures between November 1995 and November 2001; concomitant procedures included 91 multiple valves and 18 coronary artery bypass grafts. Of these 714 patients,
Eugene A Grossi; Aubrey C Galloway; Angelo LaPietra; Greg H Ribakove; Patricia Ursomanno; Julie Delianides; Alfred T Culliford; Costas Bizekis; Rick A Esposito; F. Gregory Baumann; Marc S Kanchuger; Stephen B Colvin
The results after 282 consecutive double (aortic & mitral) valve replacements (DVR) are compared with our previously reported experience after mitral (MVR, n=810) and aortic valve re- placement (AVR, n = 1753). All but one patient re- ceived Bjork-Shiley valves. The follow-up which closed on August 1, 1985 was 99.3% and covered 16 869 patient-years (mean 6.3 years\\/patient). Autopsies were
D. Lindblom; U. Lindblom; B. Aberg
There are compelling reasons to develop a tissue-engineered mitral valve, but this endeavor has not received the same attention\\u000a as tissue engineering strategies for the semilunar valves. Challenges in regenerating a mitral valve include recapitulating\\u000a the complex heterogeneity in terms of anatomy (differently sized leaflets, numerous chordae), extracellular matrix composition,\\u000a biomechanical behavior, valvular interstitial cell and endothelial cell phenotypes, and
K. Jane Grande-Allen; Jun Liao
Quadrangular resection of the posterior leaflet of the mitral valve is a well-established technique for the treatment of mitral regurgitation from prolapse of P2. Recently, Suri described triangular resection of the prolapsing scallop, a technique that, avoiding the plication of the annulus corresponding to the resected leaflet, maintains the geometry of the mitral annulus, allowing a more physiologic function of the mitral valve. In this paper, we report multiple triangular resection for the treatment of multiple prolapse of the posterior leaflet. PMID:19483638
Gregorini, Renato; Chiappini, Bruno; De Remigis, Franco; Petrella, Licia; Villani, Carmine; Di Eusanio, Mauro; Ciocca, Marco; Giancola, Raffaele; Minuti, Ugo; Di Pietrantonio, Fabrizio; Pavicevic, Srdan; Mazzola, Alessandro
Calcific aortic valve stenosis (CAVS) is a major health problem facing aging societies. The identification of osteoblast-like and osteoclast-like cells in human tissue has led to a major paradigm shift in the field. CAVS was thought to be a passive, degenerative process, whereas now the progression of calcification in CAVS is considered to be actively regulated. Mechanistic studies examining the contributions of true ectopic osteogenesis, non-osseous calcification, and ectopic osteoblast-like cells (that appear to function differently from skeletal osteoblasts) to valvular dysfunction have been facilitated by the development of mouse models of CAVS. Recent studies also suggest that valvular fibrosis, as well as calcification, may play an important role in restricting cusp movement, and CAVS may be more appropriately viewed as a fibrocalcific disease. High resolution echocardiography and magnetic resonance imaging have emerged as useful tools for testing the efficacy of pharmacological and genetic interventions in vivo. Key studies in humans and animals are reviewed that have shaped current paradigms in the field of CAVS, and suggest promising future areas for research.
Miller, Jordan D.; Weiss, Robert M.; Heistad, Donald D.
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 regurgitation, by virtue of their key features as well as effective crimping. These models will be fabricated and put to all the aforementioned tests before being taken for animal trials. PMID:24746106
Kumar, Gideon Praveen; Cui, Fangsen; Phang, Hui Qun; Su, Boyang; Leo, Hwa Liang; Hon, Jimmy Kim Fatt
Myxomatous Mitral valve prolapse (MVP) is the most common cardiac valvular abnormality in industrialized countries and a leading cause of mitral valve surgery for isolated mitral regurgitation. The key role of valvular interstitial cells (VICs) during mitral valve development and homeostasis has been recently suggested, however little is known about the molecular pathways leading to MVP. We aim to characterize Bone Morphogenetic Protein 4 (BMP4) as a cellular regulator of mitral valvular interstitial cell activation towards a pathologic synthetic phenotype and to analyze the cellular phenotypic changes and extracellular matrix (ECM) reorganization associated with the development of myxomatous mitral valve prolapse. Microarray analysis showed significant up regulation of BMP4-mediated signaling molecules in myxomatous MVP when compared to controls. Histological analysis and cellular characterization suggest that during myxomatous MVP development, healthy quiescent mitral VICs undergo a phenotypic activation via up regulation of BMP4-mediated pathway. In vitro hBMP4 treatment of isolated human mitral VICs mimics the cellular activation and ECM remodeling as seen in MVP tissues. The present study characterizes the cell biology of mitral VICs in physiological and pathological conditions and provides insights into the molecular and cellular mechanisms mediated by BMP4 during MVP. The ability to test and control the plasticity of VICs using different molecules may help in developing new diagnostic and therapeutic strategies for myxomatous MVP.
Sainger, Rachana; Grau, Juan B.; Branchetti, Emanuela; Poggio, Paolo; Seefried, William F.; Field, Benjamin C.; Acker, Michael A.; Gorman, Robert C.; Gorman, Joseph H.; Hargrove, Clark W.; Bavaria, Joseph E.; Ferrari, Giovanni
We report a case of discrete type subaortic stenosis disclosed by hemolytic anemia 7 years after aortic and mitral prosthetic valve replacement. A 53-year-old female complained of general fatigue, dyspnea, macrohematuria and hemolysis. She had undergone aortic valve replacement for non-coronary cusp perforation 15 years before, and mitral valve replacement and tricuspid annuloplasty 7 years before. Echocardiography showed mitral prosthetic valve regurgitation (III/IV degree) and symptomatic hemolysis might be caused by accelerated blood flow through the prosthetic valve. A mild aortic stenosis (peak flow verocity:3.73 m/s) was alsopointed out. The redo double valve replacement was performed. Intraoperative findings showed discrete type subaortic stenosis due to extensive pannus formation, but that the previously implanted prosthetic valves were intact. The blood flow biased by the interference of the subaortic stenosis might have obstructed closure of the mitral prosthetic valve and caused mitral regurgitation. Postoperatively, hemolysis and mitral regurgitation were diminished, and aortic stenosis was improved. PMID:24743533
Kawahara, Yu; Inage, Yuichi; Masaki, Naoki; Kobayashi, Yuriko; Jinbu, Ryota; Toyama, Shuji; Fukasawa, Manabu
Paravalvular leak (PVL) after prosthetic valve implantation is a significant complication and it usually occurs early in the postoperative period. We report a case of multiple PVL 17?years after the second mitral valve replacement without evidence of infection. The valve sutures were neither cut nor loosened. None of the sewing cuff of the mitral valve was covered with fibrous tissue. The sewing cuff was floated over the native annulus and large and multiple leakage was developed. The valve was easily removed and replaced with a new mechanical prosthesis.
Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification and a common echocardiographic finding. CCMA discovery is mostly incidental, considered as benign tumor and may be unrelated to patient symptoms. Multimodality imaging may have an additional value for the diagnosis of CCMA. We report the cases of two CCMA revealed by acute pulmonary oedema and stroke, respectively. The aims of this presentation are: to illustrate the variety of cardiac symptoms that led to the diagnosis of CCMA; and to highlight the usefulness of thoracic multisliced computed tomography for the diagnosis of CCMA. PMID:23806861
Cetran, L; Corneloup, O; Dijos, M; Montaudon, M; Roudaut, R; Coste, P; Laurent, F; Gerbaud, E
Currently, there is a growing interest in minimally invasive cardiac surgery, and despite early criticisms, it has become the preferred method of mitral valve repair and replacement in many institutions worldwide with excellent results. The interest in performing cardiac valve opera tions through minimal incisions was stimulated by Port Access technology and has evolved to include robotically assisted video-enhanced valve
Harry W. Donias; Hratch L. Karamanoukian; Giuseppe DAncona; Eddie L. Hoover
The mitral valve (MV) has complex 3-dimensional (3D) morphology and motion. Advance in real-time 3D echocardiography (RT3DE) has revolutionized clinical imaging of the MV by providing clinicians with realistic visualization of the valve. Thus far, RT3DE of the MV structure and dynamics has adopted an approach that depends largely on subjective and qualitative interpretation of the 3D images of the valve, rather than objective and reproducible measurement. RT3DE combined with image-processing computer techniques provides precise segmentation and reliable quantification of the complex 3D morphology and rapid motion of the MV. This new approach to imaging may provide additional quantitative descriptions that are useful in diagnostic and therapeutic decision-making. Quantitative analysis of the MV using RT3DE has increased our understanding of the pathologic mechanism of degenerative, ischemic, functional, and rheumatic MV disease. Most recently, 3D morphologic quantification has entered into clinical use to provide more accurate diagnosis of MV disease and for planning surgery and transcatheter interventions. Current limitations of this quantitative approach to MV imaging include labor-intensiveness during image segmentation and lack of a clear definition of the clinical significance of many of the morphologic parameters. This review summarizes the current development and applications of quantitative analysis of the MV morphology using RT3DE.??(Circ J?2014; 78: 1029-1037). PMID:24717235
Lee, Alex Pui-Wai; Fang, Fang; Jin, Chun-Na; Kam, Kevin Ka-Ho; Tsui, Gary K W; Wong, Kenneth K Y; Looi, Jen-Li; Wong, Randolph H L; Wan, Song; Sun, Jing Ping; Underwood, Malcolm J; Yu, Cheuk-Man
Background: Pregnant patients with mechanical heart valves require anticoagulation. The risk of bleeding and embryopathy associated with oral anticoagulants must be weighed against the risk of valve thrombosis. Methods: In this prospective study, undertaken between 1999 and 2009, 53 pregnancies (47 women with mechanical mitral valves; 29.8 ± 4.8 years old) were studied. Patients were divided into two groups: group I (n = 43) received Warfarin throughout the pregnancy, while group II (n = 10) received Heparin in the first trimester and then Warfarin until the 36th week. Results: Thirty-two (60.4%) pregnancies resulted in live births, whereas 18 (34%) abortions, 2 (3.8%) stillbirths, and one (1.9%) maternal death occurred. In group I, there were 26 (60.5%) live births, one (2.3%) stillbirth, and 15 (34.9%) abortions. In group II, there were 6 (60%) live births, one (10%) stillbirth, and 3 (30%) abortions. There were no significant differences between the two groups in terms of fetal outcome. Thirty-nine (90.7%) of the pregnancies in group I and 50% of those in group II (p value = 0.001) were without complications. There were no congenital malformations in the two groups. Conclusion: Fetal outcome was almost the same between the Warfarin and Heparin regimens. In maternal outcome, the Warfarin regimen is safer than Heparin.
Samiei, Niloufar; Kashfi, Fahimeh; Khamoushi, Amirjamshid; Hosseini, Saeid; Alizadeh Ghavidel, Alireza; Taheripanah, Robabeh; Mirmesdagh, Yalda
Between 1980 and 1993, 20 patients less than 1 year of age underwent operations for congenital mitral valve disease. Ten patients had congenital mitral incompetence and 10 had congenital mitral stenosis. Mean age was 6.6 ± 3.4 months and mean weight was 5.6 ± 1.5 kg. Atrioventricular canal defects, univentricular heart, class III\\/IV hypoplastic left heart syndrome, discordant atrioventricular and
Miguel Sousa Uva; Lorenzo Galletti; François Lacour Gayet; Dominique Piot; A. Serraf; Jacqueline Bruniaux; Juan Comas; R. Roussin; A. Touchot; Jean Paul Binet; Claude Planché
Anterior leaflet (AL) stiffening during isovolumic contraction (IVC) may aid mitral valve closure. We tested the hypothesis that AL stiffening requires atrial depolarization. Ten sheep had radioopaque-marker arrays implanted in the left ventricle, mitral annulus, AL, and papillary muscle tips. Four-dimensional marker coordinates (x, y, z, and t) were obtained from biplane videofluoroscopy at baseline (control, CTRL) and during basal interventricular-septal pacing (no atrial contraction, NAC; 110–117 beats/min) to generate ventricular depolarization not preceded by atrial depolarization. Circumferential and radial stiffness values, reflecting force generation in three leaflet regions (annular, belly, and free-edge), were obtained from finite-element analysis of AL displacements in response to transleaflet pressure changes during both IVC and isovolumic relaxation (IVR). In CTRL, IVC circumferential and radial stiffness was 46 ± 6% greater than IVR stiffness in all regions (P < 0.001). In NAC, AL annular IVC stiffness decreased by 25% (P = 0.004) in the circumferential and 31% (P = 0.005) in the radial directions relative to CTRL, without affecting edge stiffness. Thus AL annular stiffening during IVC was abolished when atrial depolarization did not precede ventricular systole, in support of the hypothesis. The likely mechanism underlying AL annular stiffening during IVC is contraction of cardiac muscle that extends into the leaflet and requires atrial excitation. The AL edge has no cardiac muscle, and thus IVC AL edge stiffness was not affected by loss of atrial depolarization. These findings suggest one reason why heart block, atrial dysrhythmias, or ventricular pacing may be accompanied by mitral regurgitation or may worsen regurgitation when already present.
Swanson, Julia C.; Krishnamurthy, Gaurav; Kvitting, John-Peder Escobar; Craig Miller, D.
The anterior leaflet of the mitral valve (MV), viewed traditionally as a passive membrane, is shown to be a highly active structure in the beating heart. Two types of leaflet contractile activity are demonstrated: 1) a brief twitch at the beginning of each beat (reflecting contraction of myocytes in the leaflet in communication with and excited by left atrial muscle) that is relaxed by midsystole and whose contractile activity is eliminated with ?-receptor blockade and 2) sustained tone during isovolumic relaxation, insensitive to ?-blockade, but doubled by stimulation of the neurally rich region of aortic-mitral continuity. These findings raise the possibility that these leaflets are neurally controlled tissues, with potentially adaptive capabilities to meet the changing physiological demands on the heart. They also provide a basis for a permanent paradigm shift from one viewing the leaflets as passive flaps to one viewing them as active tissues whose complex function and dysfunction must be taken into account when considering not only therapeutic approaches to MV disease, but even the definitions of MV disease itself.
Itoh, Akinobu; Krishnamurthy, Gaurav; Swanson, Julia C.; Ennis, Daniel B.; Bothe, Wolfgang; Kuhl, Ellen; Karlsson, Matts; Davis, Lauren R.; Miller, D. Craig; Ingels, Neil B.
The pulmonary status is a vital factor for patients undergoing open heart surgery. The cardiac surgery itself deteriorates the actual pulmonary functions. Today, patients are no longer living with a cardiac disease due to compromised respiratory functions secondary to various pathologies, patients with lung disorders more often seek solutions for their cardiac disease and they are commonly operated. However, the resection of a lobe or a whole lung is a major challenge for the patients planned for cardiac surgery. In this report, we present a 65-year-old patient, who had left pnemonectomy which had been performed 8 years ago and was admitted for mitral valve replacement and subaortic membrane resection. PMID:20204179
Us, Melih Hulusi; Ugurlucan, Murat; Basaran, Murat; Selimoglu, Ozer; Kocailik, Ali
Myxomatous mitral valve disease (MMVD) is the most commonly diagnosed cardiovascular disease in the dog accounting for more than 70% of all cardiovascular disease in dogs. As are most canine diseases with genetic underpinnings, risk of MMVD is greatly increased in a subset of breeds. What is uncommon is that the vast majority of the breeds at elevated risk for MMVD are small or toy breeds with average adult weights under 9 kg. These breeds appear to have little in common other than their diminutive size. In the following review we propose a number of mechanisms by which relatively unrelated small breeds may have developed a predisposition for chronic valvular disorders. Although factors such as age are key in the expression of MMVD, taking a comprehensive look at the commonalities, as well as the differences, between the susceptible breeds may assist in finding the causal variants responsible for MMVD and translating them to improved treatments for both dogs and humans. PMID:22356836
Parker, Heidi G; Kilroy-Glynn, Paul
We report a case of a 61-year-old man with aortic dissection, which was detected after mitral valve replacement. The presenting manifestation was a moderate, dull and steady pain in his right scapular region, which started on the 40th postoperative day and irradiated to the back and lower limbs. The dissection and its extent was diagnosed on transthoracic echocardiography and CT scanning and the patient improved on conservative management with beta blockers. The main purpose of reporting this case is to emphasize challenges involved with early diagnosis of this ominous condition due to nonspecific symptoms and unreliable clinical examination, and to highlight the role of the imaging studies to confirm the diagnosis of this entity. PMID:21798138
dos Santos, Vitorino Modesto; Martins, Rosane Rodrigues; dos Santos Barcelos, Maria; Andrade, Loana Márquez; Silva Paz, Bruno César; Soares, Liliane Aparecida
Objective: The aim of this study is to report our results with the central doubleorifice technique used for the treatment of complex mitral valve lesions. Methods: The central double-orifice repair has been used in 260 patients (mean age, 56 ± 14.3 years) over a period of 7 years. The mechanism responsible for mitral regurgitation was prolapse of both leaflets in
Ottavio Alfieri; Francesco Maisano; Michele De Bonis; Pier Luigi Stefano; Lucia Torracca; Michele Oppizzi; Giovanni La Canna
This report describes an early diagnosis and successful correction of a disrupted “improved” Björk-Shiley prosthetic valve in the mitral position. The role of 2-Dimensional echocardiography in the diagnosis is emphasized. Images
Patel, Ramesh R.; Senan, Pushpendra; Nair, Modhusudanan; Ramesh, Makum L.; Ticzon, Andres R.
We report a very rare case of a 43-year-old patient with fatal left ventricular subepicardial aneurysm rupture complicating embolic myocardial infarction due to mitral valve infective endocarditis. PMID:24447262
Caspar, Thibault; Delabranche, Xavier; Mazzucotelli, Jean-Philippe; Samet, Hafida; Morel, Olivier; Ohlmann, Patrick
Background Nonsustained ventricular tachycardia (VT), frequent in unoperated severe mitral regurgitation (MR), confers mortality risk (sudden [SD] and cardiac [CD]). The prognostic value of VT after mitral valve surgery (MVS) is unknown; we aimed to define this, and to assess its modulation by left (LV) and/or right (RV) ventricular ejection fraction (EF), for mortality after MVS. Methods In 57 patients (53% female; age 58±12 years) with severe MR prospectively followed before and after MVS we performed 24-hr ambulatory electrocardiograms approximately annually. LVEF and RVEF were determined within 1 year after MVS by radionuclide cineangiography. Results During 9.52±3.49 end-point free follow-up years, late postoperative CD occurred in 11 pts (7 sudden, 4 heart failure [HF]). In univariable analysis,, >1 VT episode after MVS predicted SD (p<.01) and CD (SD or HF, p<.04). Subnormal postoperative RVEF predicted CD (p<.04). When adjusted for preoperative age, gender, etiology, or antiarrhythmics, both postoperative VT and RVEF predicted CD (p?.05). When postoperative VT and RVEF were both in the multivariable model, only subnormal RVEF predicted CD (p<.04). Among those with normal RVEF, VT >1 episode predicted SD (p=.03). Conclusion Postoperative VT and subnormal RVEF predict late postoperative deaths in nonischemic MR. Their assessment may aid patient management.
Olafiranye, Oladipupo; Hochreiter, Clare A.; Borer, Jeffrey S.; Supino, Phyllis G.; Herrold, Edmund M.; Budzikowski, Adam S.; Hai, Ofek Y.; Bouraad, Dany; Kligfield, Paul D.; Girardi, Leonard N.; Krieger, Karl H.; Isom, O. Wayne
Background:?Increased sympathetic activity, commonly reported in mitral valve prolapse, indicates that the sympathetic nervous system might play an important role in regulating mitral interstitial cells. Hence, the aim of this study is to determine the level and pattern of adrenergic receptors expressed in human mitral valve leaflets and to investigate the effect of norepinephrine on physiologic behaviors of mitral interstitial cells. Methods and Results:?Immunohistochemistry displayed significantly increased expressions of ?1, ?2, and ?1 adrenergic receptors in mitral valve prolapse. Norepinephrine was found to activate the phenotype of interstitial cells with increased ?-SMA expression (2.26 fold). In synthesis, norepinephrine downregulated levels of mRNA for type I to type III collagen in ratio, but increased the elastin gene transcription and glycosaminoglycan levels in valve interstitial cells greatly. In view of the extracellular matrix remodel, sympathetic effects presented catabolic metabolism displaying significantly increased expressions of total, secretory and active MMP-2 protein (matrix metalloproteinase-2), as well as MMP-9 protein. Diminished MMP inhibitor expression, TIMP2, also could reflect this effect in the norepinephrine medium. Conclusions:?A novel role for the sympathetic effect in influencing physiologic behaviors in mitral interstitial cells was identified. It is indicated that sympathetic activity could promote myxomatous degeneration in mitral valve prolapse, propagating the disease severity, which might identify potential therapeutic targets.??(Circ J?2014; 78: 1486-1493). PMID:24670922
Hu, Xiang; Wang, Hao-Zhe; Liu, Jun; Chen, An-Qin; Ye, Xiao-Feng; Zhao, Qiang
Summary Aortic valve calcification (AVC) is a common disease of the elderly. It is a progressive disease ranging from mild valve thickening to severe calcification with aortic valve stenosis. Risk factors for AVC are similar to those for atherosclerosis: age, gender, hypercholesterolemia, diabetes, hypertension, smoking and renal failure. AVC shares many similarities to atherosclerosis, including inflammatory cells and calcium deposits, and correlates with coronary plaque burden. Presence of AVC is associated with increased risk of adverse cardiovascular events. The objective for this review is to discuss the clinical features, natural history and prognostic significance of aortic valve calcifications, including mechanical and hemodynamic factors of flow distribution.
Wasilewski, Jaroslaw; Mirota, Kryspin; Wilczek, Krzysztof; Glowacki, Jan; Polonski, Lech
Background Robotic telemanipulators have evolved to assist the challenges of minimally invasive mitral valve surgery (MVS). A systematic review was performed to provide a synopsis of the literature, focusing on clinical outcomes and cost-effectiveness. Method Structured searches of MEDLINE, Embase, and Cochrane databases were performed in August 2013. All original studies except case-reports were included in qualitative review. Studies with ?50 patients were presented quantitatively. Results After applying inclusion and exclusion criteria to the search results, 27 studies were included in qualitative review, 16 of which had ?50 patients. All studies were observational in nature, and thus the quality of evidence was rated low to medium. Patients generally had good left ventricular performance, were relatively asymptomatic, and mean patient age ranged from 52.6-58.4 years. Rates of intraoperative outcomes ranged from: 0.0-9.1% for conversion to non-robotic surgery, 106±22 to 188.5±53.8 min for cardiopulmonary bypass (CPB) time and 79±16 to 140±40 min for cross-clamp (XC) time. Rates of short-term postoperative outcomes ranged from: 0.0-3.0% for mortality, 0.0-3.2% for myocardial infarction (MI), 0.0-3.0% for permanent stroke, 1.6-15% for pleural effusion, 0.0-5.0% for reoperations for bleeding, 0.0-0.3% for infection, and 1.1-6% for prolonged ventilation (>48 hours), 1.5-5.4% for early repair failure, 12.3±6.7 to 36.6±24.7 hours for intensive care length of stay, 3.1±0.3 to 6.3±3.9 days for hospital length of stay (HLOS) and 81.7-97.6% had no or trivial mitral regurgitation (MR) before discharge. Conclusions All subtypes of mitral valve prolapse are repairable with robotic techniques. CPB and XC times are long, and novel techniques such as the Cor-Knot, Nitinol clips or running sutures may reduce the time required. The overall rates of early postoperative mortality and morbidity are low. Improvements in postoperative quality of life (QoL) and expeditious return to work offset the increase in equipment and intraoperative cost. Evidence for long-term outcomes is as yet limited.
Seco, Michael; Cao, Christopher; Modi, Paul; Bannon, Paul G.; Wilson, Michael K.; Vallely, Michael P.; Phan, Kevin; Misfeld, Martin; Mohr, Friedrich
From January 1969 to December 1992, mitral valve reconstructive operations were performed on 155 patients with degenerative mitral valve disease. There were 102 male and 53 female patients, with a mean age of 60.5 ± 9.2 years, a mean duration of symptoms of 3.8 ± 2.7 years, and 34% were in atrial fibrillation. All patients were in New York Heart
J. M. Alvarez; C. W. Deal; K. Loveridge; P. Brennan; R. Eisenberg; M. Ward; K. Bhattacharya; S. J. Atkinson; C. Choong
We describe a rare case of an ascending aortic pseudoaneurysm 31 years after mitral valve replacement with a Björk-Shiley mechanical valve. The aneurysm presumably expanded gradually during the years following surgery. As the valve was functioning normally, it was left in situ while the ascending aorta was replaced. This report provides valuable information regarding the long-term nature of this patient's pseudoaneurysm, and the long-term durability of the Björk-Shiley spherical valve in the mitral position. PMID:24585911
Ikenaga, Shigeru; Mikamo, Akihito; Kudo, Tomoaki; Kurazumi, Hiroshi; Suzuki, Ryo; Hamano, Kimikazu
Mitral valve aneurysms (MVAs) are rarely encountered in echocardiography laboratories. Although they are commonly associated with endocarditis of the aortic valve, various mechanisms have been suggested for the etiopathogenesis of MVAs associated with non-infectious conditions. 5,887 patients who underwent transesophageal echocardiography (TEE) between 2007 and 2012 were evaluated retrospectively for MVA. Mitral valve aneurysm is defined as a localized saccular bulging of the mitral leaflet towards the left atrium with systolic expansion and diastolic collapse. The color flow Doppler image of a perforation was described as a high-velocity turbulent jet traversing a valve leaflet in systole. We found that 12 of 5,887 patients (0.204 %) had MVA in TEE examinations. The mean age of patients with MVA was 53 years (range 21-80 years), including four females and eight males. Nine patients presented with symptoms of endocarditis. On TEE, aneurysms were located in the anterior mitral leaflet in 11 patients, and in the posterior mitral leaflet in one patient. Eight patients had severe, three had moderate, and one had trace mitral regurgitation. Of the nine patients with perforated leaflets, eight patients had severe and one patient had moderate mitral regurgitation. Aortic regurgitation was present in nine patients, being severe in three, moderate in two, mild in two, and trace in two patients. Two patients without severe mitral regurgitation were followed-up conservatively, while nine patients underwent surgery. Two patients died from septic shock, one in the postoperative period and the other one prior to surgery. Although MVAs occur during the course of aortic valve endocarditis and, in particular, due to aortic regurgitation jet, it should be borne in mind that they may develop as an isolated valvular pathology and may be misdiagnosed as chordal rupture, other cardiac masses, or vegetation. Thus, MVAs may not be so infrequent as they are thought; they may justify to be considered in the differential diagnosis of masses seen on the mitral valve on echocardiographic examination. PMID:24420419
Guler, Ahmet; Karabay, Can Y; Gursoy, Ozan M; Guler, Yeliz; Candan, Ozkan; Akgun, Taylan; Bulut, Mustafa; Pala, Selcuk; Izgi, Akin I; Esen, Ali M; Kirma, Cevat; Ozkan, Mehmet
AIM: Incidental aortic valve calcification is often detected during computed tomography. The aim was to compare the severity of valvular stenosis and calcification in patients with aortic stenosis.MATERIALS AND METHODS: One hundred and fifty-seven patients aged 68±11 years (range: 34–85) with aortic valve stenosis underwent multislice helical computed tomography and Doppler echocardiography performed by independent, blinded observers. The aortic valve
S. J Cowell; D. E Newby; J Burton; A White; D. B Northridge; N. A Boon; J Reid
An 80-year-old woman had undergone initial mitral valve replacement using a Björk-Shiley mechanical valve owing to mitral stenosis 25 years earlier. Suddenly, she had anemia and an increased lactic dehydrogenase (LDH) level. Transesophageal echography (TEE) showed perivalvular leakage. In a redo operation, two side-by-side stitches of the valve on the posterior annulus were loosened without cutting and the sewing cuff at that site was floated over the annulus, leading to the perivalvular leakage. The valve was easily removed; and round, hard, degenerative calcified tissue composed of remnant mitral valve in the suture site during the initial operation was found just under the sewing cuff. After resection of this calcified round tissue, a 25-mm bioprosthesis was put in place. Her postoperative recovery was uneventful, and 47 days after surgery she was discharged without perivalvular leakage or anemia. PMID:18791673
Minami, Hiroya; Asada, Tatsuro; Gan, Kunio
Intraoperative assessment of a repaired mitral valve is of paramount importance for reparative mitral surgery. From September 2010 through November 2012, 20 consecutive patients underwent mitral valve plasty for mitral regurgitation. The patients who underwent surgery after June 2012 received assessment of the repair with the heart beating (HB group, n = 10), and the patients who underwent the operation before May 2012 were assessed for the repair only under cardioplegic heart arrest (non-HB group, n = 10). Intermittent cold retrograde blood cardioplegia was used in all patients. In the HB-group, after completion of the procedures, pump blood without a crystalloid additive was delivered into the coronary sinus. The function of the mitral valve was assessed under beating conditions. There were no differences between the two groups in aortic cross clamp time and operation time, although operative and concomitant procedures were slightly more complicated in the HB group than in the non-HB group. Postoperative echocardiography revealed none or mild mitral regurgitation in all the patients in both groups. Reopening of the closed left atrium for additional repair was necessary only in one patient in the HB group and 3 patients in the non-HB group. In conclusion, the method of perfusing the myocardium retrogradely via the coronary sinus with warm blood is safe and effective for assessing the competency of the mitral valve in a beating heart. PMID:23924929
Miyairi, Takeshi; Miura, Sumio; Taketani, Tsuyoshi; Kusuhara, Takayoshi; Lee, Yangsin; Unai, Shinya; Ohno, Takayuki; Fukuda, Sachito; Takamoto, Shinichi
We report a 73-year-old male with late onset monomorphic ventricular tachycardia following mitral valve repair (MVR). Typically, injury to epicardial arteries following mitral valve repair/replacement presents immediately as ventricular tachycardia/fibrillation, difficulty weaning from cardiopulmonary bypass, worsening ECG changes, increasing cardiac biomarkers, or new wall motion abnormalities. Our case illustrates a “late complication” of a distorted circumflex artery following mitral valve repair and the importance of early diagnostic angiography and percutaneous intervention.
South, Harry L.; Osoro, Moses; Overly, Tjuan
Calcific aortic valve disease (CAVD) is a major contributor to cardiovascular morbidity and mortality and, given its association with age, the prevalence of CAVD is expected to continue to rise as global life expectancy increases. No drug strategies currently exist to prevent or treat CAVD. Given that valve replacement is the only available clinical option, patients often cope with a deteriorating quality of life until diminished valve function demands intervention. The recognition that CAVD results from active cellular mechanisms suggests that the underlying pathways might be targeted to treat the condition. However, no such therapeutic strategy has been successfully developed to date. One hope was that drugs already used to treat vascular complications might also improve CAVD outcomes, but the mechanisms of CAVD progression and the desired therapeutic outcomes are often different from those of vascular diseases. Therefore, we discuss the benchmarks that must be met by a CAVD treatment approach, and highlight advances in the understanding of CAVD mechanisms to identify potential novel therapeutic targets. PMID:24445487
Hutcheson, Joshua D; Aikawa, Elena; Merryman, W David
Experience with patients undergoing left ventricular assist device (LVAD) implantation with preexisting mitral valve prostheses is limited. Patients with mechanical heart valves might have an increased risk of thromboembolism; in patients with biologic valves, there might be a risk of structural deterioration of the leaflets. Out of 597 patients supported with a LVAD system between 2000 and 2009, 18 patients had mitral valve surgery prior to implantation. We excluded all patients below 18 years of age, those with postcardiotomy failure, and patients who had had mitral valve reconstruction. Only 1% of the studied patient population (n= 6) had mitral valve replacement. The mitral valve implantation has been performed 7.4 ± 9.4 years prior to LVAD insertion. None of the valves (one biologic, five mechanical) were exchanged or explanted. LVAD implantation was done either with left lateral thoracotomy (n= 5) or with midline resternotomy (n= 1). Temporary right ventricular assist device support was necessary in one case (16.6%); 30-day mortality was 16.6% (n= 1). Median support time was 14 ± 15 months. Two patients received heart transplantation after 6 and 26 months on the device; four patients died on mechanical circulatory support after 1, 2, 5, and 40 months. No valve or pump thrombosis or other clinically relevant thromboembolic events were observed. Only a small number of patients (1%) had a preexisting mitral valve prosthesis prior to LVAD implantation. No severe adverse events were observed when the prosthesis was left in place. Attention should be paid to the anticoagulation regime. PMID:21951108
Schweiger, Martin; Stepanenko, Alexander; Vierecke, Juliane; Drews, Thorsten; Potapov, Evgenij; Hetzer, Roland; Krabatsch, Thomas
We report a mitral valve repair for a broad prolapse in the high posterior leaflet. Prolapse in the high redundant posterior leaflet with elongation of the chordae had caused the severe mitral valve regurgitation in a 45-year-old man. At operation, the prolapsed portion of the middle scallop was quadrangularly resected in 22 mm wide and 17 mm high. We combined the sliding leaflet technique with the posterior leaflet folding plasty to reduce the height of the posterior leaflet and to lessen the degree of mitral annular plication. Mitral valve regurgitation disappeared after the operation. No left ventricular outflow obstruction associated with systolic anterior motion and no injury to the left circumflex artery were confirmed. These procedures after a broad resection of the high posterior leaflet could successfully prevent systolic anterior motion and injury to the left circumflex artery, and reduce the stress on the suture line of the leaflet. PMID:13677920
Yoshikai, M; Kamohara, K; Yunoki, J; Fumoto, H
In this article we review the currently available data on percutaneous mitral valve annulorrhaphy devices using the coronary sinus in patients with functional mitral valve regurgitation (MR). Of these devices the greatest clinical experience exists for the Carillon mitral contour system which has gained increasing application also outside trials in the last 2 years. The advantages include the ease of use with an effective reduction in functional MR and a subsequent improvement of echocardiographic and clinical parameters. A limitation is the compromise of flow in the circumflex artery in some patients especially with a crossing of the coronary sinus with this artery. Future investigations need to focus on the evaluation of this coronary sinus-based technology versus mitral valve clipping technology for the treatment of functional MR. PMID:23836012
Degen, H; Schneider, T; Wilke, J; Haude, M
Mucopolysaccharidosis VII (MPS VII) is due to the deficient activity of ?-glucuronidase (GUSB) and results in the accumulation of glycosaminoglycans (GAGs) in lysosomes and multisystemic disease with cardiovascular manifestations. The goal here was to determine the pathogenesis of mitral valve (MV) disease in MPS VII dogs. Untreated MPS VII dogs had a marked reduction in the histochemical signal for structurally-intact collagen in the MV at 6 months of age, when mitral regurgitation had developed. Electron microscopy demonstrated that collagen fibrils were of normal diameter, but failed to align into large parallel arrays. mRNA analysis demonstrated a modest reduction in the expression of genes that encode collagen or collagen-associated proteins such as the proteoglycan decorin which helps collagen fibrils assemble, and a marked increase for genes that encode proteases such as cathepsins. Indeed, enzyme activity for cathepsin B (CtsB) was 19-fold normal. MPS VII dogs that received neonatal intravenous injection of a gamma retroviral vector had an improved signal for structurally-intact collagen, and reduced CtsB activity relative to that seen in untreated MPS VII dogs. We conclude that MR in untreated MPS VII dogs was likely due to abnormalities in MV collagen structure. This could be due to upregulation of enzymes that degrade collagen or collagen-associated proteins, to the accumulation of GAGs that compete with proteoglycans such as decorin for binding to collagen, or to other causes. Further delineation of the etiology of abnormal collagen structure may lead to treatments that improve biomechanical properties of the MV and other tissues. PMID:23856419
Bigg, Paul W; Baldo, Guilherme; Sleeper, Meg M; O'Donnell, Patricia A; Bai, Hanqing; Rokkam, Venkata R P; Liu, Yuli; Wu, Susan; Giugliani, Roberto; Casal, Margret L; Haskins, Mark E; Ponder, Katherine P
This paper presents an approach to modeling the closure of the mitral valve using patient-specific anatomical information derived from 3D transesophageal echocardiography (3D TEE). Our approach uses physics-based modeling to solve for the stationary configuration of the closed valve structure from the patient-specific open valve structure, which is recovered using a user-in-the-loop, thin-tissue detector segmentation. The method utilizes a tensile shape finding approach based on energy minimization. This method is used to predict the aptitude of the mitral valve leaflets to coapt. We tested the method using ten intraoperative 3D TEE sequences by comparing (a) the closed valve configuration predicted from the segmented open valve, with (b) the segmented closed valve, taken as ground truth. Experiments show promising results, with prediction errors on par with 3D TEE resolution and with good potential for applications in pre-operative planning.
Burlina, Philippe; Sprouse, Chad; Mukherjee, Ryan; DeMenthon, Daniel; Abraham, Theodore
Polyurethane heart valves can be functionally durable with minimal calcification, in vitro. In vivo, these characteristics will depend on the resistance of the polyurethane to thrombogenesis and biodegradation. Surface modification may improve the polyurethane in these respects, but may adversely affect calcification and durability. This study investigates the effects of surface modifications of two polyurethane heart valves (PEU and PEUE) on their in vitro fatigue and calcification behaviour. Modifications included heparin, taurine, 3-aminopropyltriethoxysilane and polyethylene oxide (PEO). Neither hydrodynamic function nor leaflet thickness distribution was significantly altered by surface modification. PEO-modification was detrimental to valve fatigue durability and calcification. Heparin, taurine or aminosilane modifications of PEU valves increased durability. Aminosilane modification of PEUE valves increased durability compared with PEO modification. Appropriate surface modification may be useful to improve blood compatibility of implantable polyurethanes, and may also be advantageous as regards fatigue durability of flexing materials in longterm applications. PMID:9988359
Bernacca, G M; Wheatley, D J
Etiopathogenetic mechanisms in calcific aortic valve stenosis are still poorly understood despite this being the third major cause of heart disease in western world. In prior in vitro cultures simulating metastatic calcification, pro-calcific effects on aortic valve interstitial cells (AVICs) resulted by adding bacterial endotoxin lipopolysaccharide (LPS) at high inorganic phosphate (Pi) levels. Here we accomplished improved in vitro models simulating either metastatic (Pi = 2.6 mM) or dystrophic calcification (Pi = 1.3 mM), in which LPS-stimulated bovine AVICs underwent extra-stimulation with macrophage-cytokine-containing media derived from parallel cultures of allogeneic monocyte/macrophages in turn stimulated with LPS. In dystrophic calcification-like cultures, lower calcium amount was spectrometrically assessed with parallel reduced alkaline phosphatase activity with respect to metastatic calcification-like cultures, with an about three-fold slower progression of mineralization. Hydroxyapatite crystal precipitation was ultrastructurally found to correlate with AVIC degeneration processes culminating with the formation of phthalocyanin-positive lipidic layers (PPLs) at the surface of cells and cell-derived matrix-vesicle-like bodies, acting as calcium nucleators according to a pattern mirroring those we had previously found in in vivo conditions. In conclusion, an in vitro model has been developed enabling reliable simulations of the effects exerted on AVICs by putatively pro- or anti-calcific agents. PMID:21073003
Ortolani, Fulvia; Rigonat, Luca; Bonetti, Antonella; Contin, Magali; Tubaro, Franco; Rattazzi, Marcello; Marchini, Maurizio
Traditional imaging modalities such as computed tomography, although perfectly adept at identifying and quantifying advanced calcification, cannot detect the early stages of this disorder and offer limited insight into the mechanisms of mineral dysregulation. This review presents optical molecular imaging as a promising tool that simultaneously detects pathobiological processes associated with inflammation and early stages of calcification in vivo at the (sub)cellular levels. Research into treatment of cardiovascular calcification is lacking, as shown by clinical trials that have failed to demonstrate the reduction of calcific aortic stenosis. Hence the need to elucidate the pathways that contribute to cardiovascular calcification and to develop new therapeutic strategies to prevent or reverse calcification has driven investigations into the use of molecular imaging. This review discusses studies that have used molecular imaging methods to advance knowledge of cardiovascular calcification, focusing in particular on the inflammation-dependent mechanisms of arterial and aortic valve calcification.
New, Sophie E. P.; Aikawa, Elena
Aim: Long standing mitral valve disease is usually associated with severe pulmonary hypertension. Perioperative pulmonary hypertension is a risk factor for right ventricular (RV) failure and a cause for morbidity and mortality in patients undergoing mitral valve replacement. Phosphodiesterase 5 inhibitor-sildenafil citrate is widely used to treat primary pulmonary hypertension. There is a lack of evidence of effects of oral sildenafil on secondary pulmonary hypertension due to mitral valve disease. The study aims to assess the effectiveness of preoperative oral sildenafil on severe pulmonary hypertension and incidence of RV failure in patients undergoing mitral valve replacement surgery. Materials and Methods: A total of 40 patients scheduled for mitral valve replacement with severe pulmonary hypertension (RV systolic pressure (RVSP) ?60 mmHg) on preoperative transthoracic echo were randomly treated with oral sildenafil 25 mg (N = 20) or placebo (N = 20) eight hourly for 24 h before surgery. Hemodynamic variables were measured 20 min after insertion of pulmonary artery catheter (PAC) under anesthesia (T1), 20 min at weaning from cardiopulmonary bypass (CPB) (T2) and after 1,2, and 6 h (T3, T4, T5, respectively) during the postoperative period. Results: Systolic and mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI) were significantly lower (P < 0.0001) in sildenafil group at all times. Ventilation time and postoperative recovery room stay were significantly lower (P < 0.001) in sildenafil group. Conclusion: Sildenafil produces significant pulmonary vasodilatory effect as compared with placebo in mitral valve replacement patients with severe pulmonary hypertension. It also reduces ventilation time and intensive care unit (ICU) stay time as compared with placebo. It is concluded that sildenafil is effective in reducing pulmonary hypertension when administered preoperatively in patients with severe pulmonary hypertension undergoing mitral valve replacement surgery.
Gandhi, Hemang; Shah, Bipin; Patel, Ramesh; Toshani, Rajesh; Pujara, Jigisha; Kothari, Jignesh; Shastri, Naman
Background. This study was designed to better define the merits of the bileaflet and tilting-disc valves.Methods. We prospectively randomized 156 patients (mean age, 59 years) to receive either the St. Jude (n = 80) or the Medtronic Hall (n = 76) mitral valve prosthesis between September 1986 and December 1997. The two groups were not significantly different with respect to
Andrew C Fiore; Hendrick B Barner; Marc T Swartz; Lawrence R McBride; Arthur J Labovitz; Kathy J Vaca; Jan St. Vrain; Gary L Grunkemeier; George C Kaiser
SUMMARY The present study addresses constitutive modelling and implementation of transversely isotropic hyper- elastic material models for the analysis of the mitral valve. This valve separates the left atrium and left ventricle in the heart. Two convex strain energy potentials are employed in derivation of stress tensors and elasticity tensors. The plane stress and incompressibility conditions are accounted for directly.
V. Prot; B. Skallerud; G. A. Holzapfel
Valve interstitial cells (VICs) are essential for valvular pathogenesis. However, the transcriptional profiles and cellular functions of human aortic VICs (hAVICs) and mitral VICs (hMVICs) have not been directly compared. We performed NimbleGen gene expression profiling analyses of hAVICs and hMVICs. Seventy-eight known genes were differentially expressed between hAVICs and hMVICs. Higher expression of NKX2-5, TBX15, OGN, OMD, and CDKN1C and lower expression of TBX5, MMP1, and PCDH10 were found in hAVICs compared to hMVICs. The differences in these genes, excepting OGN and OMD, remained in rheumatic VICs. We also compared cell proliferation, migration, and response to mineralization medium. hMVICs proliferated more quickly but showed more calcium deposition and alkaline phosphatase activity than hAVICs after culture in mineralization medium, indicating that hMVICs were more susceptible to in vitro calcification. Our findings reveal differences in the transcription profiles and cellular functions of hAVICs and hMVICs. PMID:23542235
Sun, Wei; Zhao, Rong; Yang, Yang; Wang, Hui; Shao, Yongfeng; Kong, Xiangqing
Thirty-five consecutives patients with classic or definite rheumatoid arthritis underwent echocardiography to evaluate the motion of the anterior mitral valve leaflet. Adequate echocardiograms were obtained in 31 patients. All 31 patients showed normal valve motion and a normal EF slope. If meticulous technique was not observed, a falsely low value for the EF slope was obtained and a normal slope was found when the method was improved. This study shows that echocardiographic abnormalities of the anterior mitral valve leaflet rarely, if ever, occur in patients with rheumatoid arthritis, provided that careful attention to recording method is observed. PMID:1166980
Davia, J E; Cheitlin, M D; de Castro, C M; Lawless, O; Niemi, L
Objective Mitral annular calcification (MAC) is a degenerative process of the mitral fibrous annulus associated with cardiac disease and stroke. Although thought to be more prevalent in type 2 diabetes (T2DM), MAC remains poorly characterized in this population, due to confounding by renal and cardiac disease. Our goal was to study the risk factors for MAC in asample of T2DM subjects without renal and cardiac disease. Methods The Penn Diabetes Heart Study (PDHS) is a cross-sectional study of diabetic individuals without clinical cardiovascular or renal disease. We quantified and analyzed MAC Agatston scores in baseline cardiac CTs from 1753 individuals. Logistic and tobit regression were used to assess MAC’s relationship with risk factors and coronary artery calcification (CAC). Results MAC was present in 12.0% of -subjects, with a median Agatston score of 72.3 [Interquartile range (22.2 256.9)]. Older age, diabetes female gender, Caucasian race, and longer duration were independently associated with both the presence and extent MAC even after controlling for the CAC; hypertension, hyperlipidemia, comorbidities however, tobacco use, CRP levels, and other were not associated. CAC was strongly associated with MAC [OR of 4.0, (95% CI 2.4-6.6)] in multivariable models. Conclusions Age, AC female gender, Caucasian race, and diabetes duration were associated with the presence and extent of MAC in T2DM subjects, independent of CAC, which was also strongly associated with MAC. These data suggest that additional mechanisms for MAC formation in diabetics may exist which are distinct from those related to generalized atherosclerosis and deserve further investigation.
Qasim, Atif N.; Rafeek, Hashmi; Rasania, Suraj P.; Churchill, Timothy W.; Yang, Wei; Ferrari, Victor A.; Jha, Saurabh; Master, Stephen; Mulvey, Claire K.; Terembula, Karen; Dailing, Chris; Budoff, Matthew J; Kawut, Steven; Reilly, Muredach P.
BACKGROUND: Mitral annulus calcification (MAC) is an important echocardiographic finding that is significantly associated with valvular abnormalities. However, the effect of documented MAC on all-cause mortality is not known. Using a large database, associations between MAC and long-term all-cause mortality were evaluated. METHODS: A retrospective analysis of 3169 echocardiograms, which were performed for clinical reasons in southern California between 1983 and 1998 in patients between 16 and 99 years of age, was performed. Mortality data were extracted from the national mortality database at the end of 2007. Using uni- and multivariate analysis, associations between total mortality and the echocardiographic presence of MAC documented in the final report by the interpreting cardiologist were evaluated. RESULTS: MAC was significantly associated with all-cause mortality (174 of 334 [52.1%] patients with MAC died versus 709 of 2835 [25.0%] patients without MAC; OR 3.26 [95% CI 2.58 to 4.10]; P<0.001). Using multivariate analysis adjusting for age, left ventricular hypertrophy, sex, abnormal left ventricular systolic function and significant valvular abnormalities, MAC remained independently associated with all-cause mortality (OR 2.50 [95% CI 1.81 to 3.45]; P<0.001). CONCLUSION: Using a large echocardiographic database, MAC was found to be independently associated with all-cause mortality. This finding confirms the importance of an abnormal mitral annulus as an important prognostic marker.
Ramaraj, Radhakrishnan; Manrique, Coraly; Hashemzadeh, Mehrnoosh; Movahed, Mohammad Reza
Three-dimensional (3-D) echocardiography allows the generation of anatomically correct and time-resolved geometric mitral valve (MV) models. However, as imaged in vivo, the MV assumes its systolic geometric configuration only when loaded. Customarily, finite element analysis (FEA) is used to predict material stress and strain fields rendered by applying a load on an initially unloaded model. Therefore, this study endeavors to provide a framework for the application of in vivo MV geometry and FEA to MV physiology, pathophysiology, and surgical repair. We hypothesize that in vivo MV geometry can be reasonably used as a surrogate for the unloaded valve in computational (FEA) simulations, yielding reasonable and meaningful stress and strain magnitudes and distributions. Three experiments were undertaken to demonstrate that the MV leaflets are relatively nondeformed during systolic loading: 1) leaflet strain in vivo was measured using sonomicrometry in an ovine model, 2) hybrid models of normal human MVs as constructed using transesophageal real-time 3-D echocardiography (rt-3DE) were repeatedly loaded using FEA, and 3) serial rt-3DE images of normal human MVs were used to construct models at end diastole and end isovolumic contraction to detect any deformation during isovolumic contraction. The average linear strain associated with isovolumic contraction was 0.02 ± 0.01, measured in vivo with sonomicrometry. Repeated loading of the hybrid normal human MV demonstrated little change in stress or geometry: peak von Mises stress changed by <4% at all locations on the anterior and posterior leaflets. Finally, the in vivo human MV deformed minimally during isovolumic contraction, as measured by the mean absolute difference calculated over the surfaces of both leaflets between serial MV models: 0.53 ± 0.19 mm. FEA modeling of MV models derived from in vivo high-resolution truly 3-D imaging is reasonable and useful for stress prediction in MV pathologies and repairs.
Xu, Chun; Brinster, Clay J.; Jassar, Arminder S.; Vergnat, Mathieu; Eperjesi, Thomas J.; Gorman, Robert C.; Gorman, Joseph H.
OBJECTIVES--To determine whether biplane transoesophageal imaging offers advantages in the evaluation of mitral prostheses when compared with standard single transverse plane imaging or the precordial approach in suspected prosthetic dysfunction. DESIGN--Prospective mitral valve prosthesis in situ using precordial and biplane transoesophageal ultrasonography. SETTING--Tertiary cardiac referral centre. SUBJECTS--67 consecutive patients with suspected dysfunction of a mitral valve prosthesis (16 had bioprostheses and 51 mechanical prostheses) who underwent precordial, transverse plane, and biplane transoesophageal echocardiography. Correlative invasive confirmation from surgery or angiography, or both, was available in 44 patients. MAIN OUTCOME MEASURES--Number, type, and site of leak according to the three means of scanning. RESULTS--Transverse plane transoesophageal imaging alone identified all 31 medial/lateral paravalvar leaks but only 24/30 of the anterior/posterior leaks. Combining the information from both imaging planes confirmed that biplane scanning identified all paravalvar leaks. Five of the six patients with prosthetic valve endocarditis, all three with valvar thrombus or obstruction, and all three with mitral annulus rupture were diagnosed from transverse plane imaging alone. Longitudinal plane imaging alone enabled diagnosis of the remaining case of prosthetic endocarditis and a further case of subvalvar pannus formation. CONCLUSIONS--Transverse plane transoesophageal imaging was superior to the longitudinal imaging in identifying medial and lateral lesions around the sewing ring of a mitral valve prosthesis. Longitudinal plane imaging was superior in identifying anterior and posterior lesions. Biplane imaging is therefore an important development in the study of mitral prosthesis function. Images
Groundstroem, K; Rittoo, D; Hoffman, P; Bloomfield, P; Sutherland, G R
The Model 6120 ball valve prosthesis introduced in 1965 is still strongly supported as a mitral valve substitute in many centers around the world. A current reassessment of the performance of this prosthesis is therefore pertinent to current medical practice. In this institution since 1974, 227 Starr-Edwards caged ball valves have been implanted in the mitral position during isolated valve replacement. Two models of caged ball valves were used concurrently: the silastic ball valve in 108 patients (48%) and the composite strut "tract" valve in 119 (52%). Hospital mortality was 7%, and 8-year survival (standard error) was 74 (6%), with 100% follow-up, documenting 752 total patient-years. No late deaths were known to be valve related, and there were no cases of prosthetic thrombosis. The actuarial estimate of patients free from thromboembolism at 8 years was 89 (4%) with a linearized rate of 1.3% per year. At the most recent follow-up, 95% of the patients were in the New York Heart Association (NYHA) Classes I or II. These good results were partly due to an awareness at operation of ventricular outflow tract size requirements and to strict control of postoperative anticoagulation. We conclude that the Starr-Edwards ball valve is the mitral valve of choice in the young patient who is able to take anticoagulation drugs and has a left ventricular outflow tract of satisfactory size. PMID:15227040
Cotrufo, M; Renzulli, A; Esposito, V; Vosa, C; Nappi, G; DeLuca, L; Casale, D; Bellitti, R; Festa, M
The Model 6120 ball valve prosthesis introduced in 1965 is still strongly supported as a mitral valve substitute in many centers around the world. A current reassessment of the performance of this prosthesis is therefore pertinent to current medical practice. In this institution since 1974, 227 Starr-Edwards caged ball valves have been implanted in the mitral position during isolated valve replacement. Two models of caged ball valves were used concurrently: the silastic ball valve in 108 patients (48%) and the composite strut “tract” valve in 119 (52%). Hospital mortality was 7%, and 8-year survival (standard error) was 74 (6%), with 100% follow-up, documenting 752 total patient-years. No late deaths were known to be valve related, and there were no cases of prosthetic thrombosis. The actuarial estimate of patients free from thromboembolism at 8 years was 89 (4%) with a linearized rate of 1.3% per year. At the most recent follow-up, 95% of the patients were in the New York Heart Association (NYHA) Classes I or II. These good results were partly due to an awareness at operation of ventricular outflow tract size requirements and to strict control of postoperative anticoagulation. We conclude that the Starr-Edwards ball valve is the mitral valve of choice in the young patient who is able to take anticoagulation drugs and has a left ventricular outflow tract of satisfactory size.
Cotrufo, Maurizio; Renzulli, Attilio; Esposito, Vincenzo; Vosa, Carlo; Nappi, Giannantonio; Deluca, Luigi; Casale, Domenico; Bellitti, Renato; Festa, Michele
A 52-year old woman was submitted to mitral valve replacement. The operation proceeded without complications. Jaundice had been noted since the first postoperative (po) day and increased progressively due to conjugated bilirubin. Abdominal examination was normal and no signs of infection or circulatory failure were noted. Conjugated bilirubin levels increased from 6 mg/dl on the second po day to 20.4 mg/dl on the sixth po day and to 32 mg/dl on the tenth po day. Gammaglutamyl transferase levels were 600 U/L (normal up to 18 U/L) and lactate dehydrogenase levels were 396 U/L (normal) up to 240 U/L) on the seventh po day. Alkaline phosphatase levels were 1880 U/L (normal up to 170 U/L) whereas glutamic oxalacetic transaminase levels were 60 U/L (normal up to 15 U/L) and glutamic pyruvic transaminase levels were 66 U/L (normal up to 17 U/L) on the tenth po day. Abdominal ultrasonography did not disclose dilatation of intra and extra-hepatic biliary system. The patient died after a percutaneous hepatic biopsy procedure. The jaundice was attributed to a cholestatic syndrome after cardiac surgery and cardiopulmonary bypass, due to an impairment of the excretory function of the hepatocyte. PMID:2288528
Lagudis, S; Mansur, A J; Damião, A O; Falzoni, R; Grinberg, M; Bellotti, G
Starr-Edwards ball valves removed more than 15 years after implantation were retrospectively investigated macroscopically. Eight patients required re-operation. Valve models used in the initial operations were a non-cloth-covered valve in 2 patients and a cloth-covered valve in 6. Two patients had replacement of an aortic ball valve (model 1260 and model 2320) and 6 underwent mitral valve replacement (model 6120 in one, model 6320 in 5). The mean time to re-operation was 23.0 +/- 4.8 years after implantation. Cloth wear causing significant hemolysis was observed in all cloth-covered valves, regardless of valve position. Autologous tissue growth was noted on the orifice ring and struts in both aortic and mitral prostheses. Thrombus formation was not found in any of the valves. Ball variance in silicone rubber balls was mild in the non-cloth-covered valves, even in the aortic position. The most significant problem with the cloth-covered ball valve was cloth wear. Cloth wear should always be considered when 15 years or more have passed since valve implantation. Significant hemolysis, elevation of lactate dehydrogenase values, and echocardiographic detection of transvalvular regurgitation are diagnostic of cloth wear, and are indications for replacement of a cloth-covered ball valve. PMID:17130320
Aoyagi, Shigeaki; Fukunaga, Shuji; Arinaga, Koichi; Yokokura, Yoshinori; Yokokura, Hiroko; Egawa, Noriko
Liquefaction necrosis of mitral annular calcification (LNMAC): review of pathology, prevalence, imaging and management: proposed diagnostic imaging criteria with detailed multi-modality and MRI image characterization
Liquefactive necrosis within a large spheroid zone of mitral annular calcification (LNMAC) is an atypical but increasingly\\u000a recognized variant of mitral annular calcification (MAC). Proposed MRI, echo, and CT imaging criteria for diagnosis of this\\u000a unusual disease entity are discussed along with a review of the prognosis, histopathology, and management implications. A\\u000a comprehensive ECHO, CT, and MRI imaging approach to
S. Sanjay Srivatsa; Michael D. Taylor; Kan Hor; David A. Collins; Melissa King-Strunk; Robert A. Pelberg; Wojciech Mazur
Mitral valve prolapse (MVP) is a common human phenotype, yet little is known about the pathogenesis of this condition. MVP can occur in the context of genetic syndromes, including Marfan syndrome (MFS), an autosomal-dominant connective tissue disorder caused by mutations in fibrillin-1. Fibrillin-1 contributes to the regulated activation of the cytokine TGF-?, and enhanced signaling is a consequence of fibrillin-1 deficiency. We thus hypothesized that increased TGF-? signaling may contribute to the multisystem pathogenesis of MFS, including the development of myxomatous changes of the atrioventricular valves. Mitral valves from fibrillin-1–deficient mice exhibited postnatally acquired alterations in architecture that correlated both temporally and spatially with increased cell proliferation, decreased apoptosis, and excess TGF-? activation and signaling. In addition, TGF-? antagonism in vivo rescued the valve phenotype, suggesting a cause and effect relationship. Expression analyses identified increased expression of numerous TGF-?–related genes that regulate cell proliferation and survival and plausibly contribute to myxomatous valve disease. These studies validate a novel, genetically engineered murine model of myxomatous changes of the mitral valve and provide critical insight into the pathogenetic mechanism of such changes in MFS and perhaps more common nonsyndromic variants of mitral valve disease.
Ng, Connie M.; Cheng, Alan; Myers, Loretha A.; Martinez-Murillo, Francisco; Jie, Chunfa; Bedja, Djahida; Gabrielson, Kathleen L.; Hausladen, Jennifer M.W.; Mecham, Robert P.; Judge, Daniel P.; Dietz, Harry C.
Objective: The first generation of pericardial valves was withdrawn from the market because of a high rate of premature failure. With an original design, Carpentier-Edwards pericardial valves promised improved results.Methods: One hundred fifty patients who underwent isolated mitral valve replacement, between July 1984 and December 1993, with Carpentier-Edwards pericardial bioprostheses in our institution were followed up. Patient mean age was
M. R. Aupart; P. H. Neville; S. Hammami; A. L. Sirinelli; Y. A. Meurisse; M. A. Marchand
Previous research in our lab suggested that heart valve tissues cultured without mechanical stimulation do not retain their\\u000a in vivo microstructure, i.e., cell density decreased within the deep tissue layers and increased at the periphery. In this study,\\u000a a splashing rotating bioreactor was designed to apply mechanical stimulation to a mitral valve leaflet segment. Porcine valve\\u000a segments (n = 9–10 per group)
Janet E. Barzilla; Anna S. McKenney; Ashley E. Cowan; Christopher A. Durst; K. Jane Grande-Allen
The left circumflex coronary artery is susceptible to injury during mitral valve surgery because of its proximity to the mitral valve annulus. We report the case of a 73-year-old woman who had undergone mitral valve repair and experienced a perioperative myocardial infarction due to occlusion of the left circumflex coronary artery. After percutaneous coronary intervention, a fistulous communication had developed between the stented portion of the left circumflex coronary artery and the left atrium, which, to our knowledge, is the first report of such a complication. The patient underwent successful mitral valve replacement. Although injuries to the left circumflex coronary artery are rare during mitral valve surgery, we believe that increasing awareness of the risk will help to prevent potentially fatal complications. We also recommend that surgeons gather as much detail as possible about the patient's anatomy before operation, use careful and meticulous surgical techniques, and use transesophageal echocardiography to look for wall-motion abnormalities before closing the incision. PMID:22412241
Somekh, Nir N; Haider, Ali; Makaryus, Amgad N; Katz, Stanley; Bello, Steven; Hartman, Alan
Dystrophic calcification has been the long-standing major cause of bioprosthetic heart valve failure, and has been well studied in terms of the underlying causative mechanisms. Such understanding has yielded several anti-calcification strategies involving biomaterial modification at the preparation stage: chemical alteration, extraction of calcifiable components, or material modification with small-molecule anti-calcific agents. However, newer therapeutic opportunities are offered by the
Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.
This case, involving a 74 year old man who underwent mitral valve and aortic valve replacements, provides detailed insight into the perioperative echocardiographic and haemodynamic changes occurring when a mitral valve prosthesis intermittently obstructs. It illustrates the early sequence of electromechanical dissociation which would lead to cardiac arrest should a tilting disc prosthesis be immobilised in the closed position.???Keywords: prosthetic valve replacement; echocardiography; intermittent obstruction
Keeble, W; Cobbe, S
The most predictable cause of failure of a biological prosthetic heart valve is calcification. The deposition process appears to be related both to the biomaterial composition and to the presence of dynamic stresses in the leaflets. A dynamicin vitro test has been developed to investigate the calcification process. The test apparatus consists of a modified Rowan Ash fatigue tester with
G. M. Bernacca; A. C. Fisher; T. G. Mackay; D. J. Wheatley
Background Left ventricular remodeling after postero-basal myocardial infarction can lead to ischemic mitral regurgitation. This occurs as a consequence of leaflet tethering due to posterior papillary muscle displacement. Methods A finite element model of the left ventricle, mitral apparatus, and chordae tendineae was created from magnetic resonance images from a sheep that developed moderate mitral regurgitation after postero-basal myocardial infarction. Each region of the model was characterized by a specific constitutive law that captured the material response when subjected to physiological pressure loading. Results The model simulation produced a gap between the posterior and anterior leaflets, just above the infarcted posterior papillary muscle, which is indicative of mitral regurgitation. When the stiffness of the infarct region was reduced, this caused the wall to distend and the gap area between the leaflets to increase by 33%. Additionally, the stress in the leaflets increased around the chordal connection points near the gap. Conclusions The methodology outlined in this work will allow a finite element model of both the left ventricle and mitral valve to be generated using non-invasive techniques.
Wenk, Jonathan F.; Zhang, Zhihong; Cheng, Guangming; Malhotra, Deepak; Acevedo-Bolton, Gabriel; Burger, Mike; Suzuki, Takamaro; Saloner, David A.; Wallace, Arthur W.; Guccione, Julius M.; Ratcliffe, Mark B.
Arterial endothelial cells maintain vascular homeostasis and vessel tone in part through the secretion of nitric oxide (NO). In this study, we determined how aortic valve endothelial cells (VEC) regulate aortic valve interstitial cell (VIC) phenotype and matrix calcification through NO. Using an anchored in vitro collagen hydrogel culture system, we demonstrate that three-dimensionally cultured porcine VIC do not calcify in osteogenic medium unless under mechanical stress. Co-culture with porcine VEC, however, significantly attenuated VIC calcification through inhibition of myofibroblastic activation, osteogenic differentiation, and calcium deposition. Incubation with the NO donor DETA-NO inhibited VIC osteogenic differentiation and matrix calcification, whereas incubation with the NO blocker l-NAME augmented calcification even in 3D VIC–VEC co-culture. Aortic VEC, but not VIC, expressed endothelial NO synthase (eNOS) in both porcine and human valves, which was reduced in osteogenic medium. eNOS expression was reduced in calcified human aortic valves in a side-specific manner. Porcine leaflets exposed to the soluble guanylyl cyclase inhibitor ODQ increased osteocalcin and ?-smooth muscle actin expression. Finally, side-specific shear stress applied to porcine aortic valve leaflet endothelial surfaces increased cGMP production in VEC. Valve endothelial-derived NO is a natural inhibitor of the early phases of valve calcification and therefore may be an important regulator of valve homeostasis and pathology.
Richards, Jennifer; El-Hamamsy, Ismail; Chen, Si; Sarang, Zubair; Sarathchandra, Padmini; Yacoub, Magdi H.; Chester, Adrian H.; Butcher, Jonathan T.
The impact of aortic valve replacement (AVR) on the dynamic geometry and motion of the mitral annulus remains unknown. We analyzed the effects of AVR on the dynamic geometry and motion of the mitral annulus. We used 3-dimensional transesophageal echocardiography to analyze 39 consecutive patients undergoing elective surgical AVR for aortic stenosis. Intraoperative 3-dimensional transesophageal echocardiography was performed immediately before and after AVR. Volumetric data sets were analyzed using a software package capable of dynamically tracking the mitral annulus and leaflets during the entire systolic ejection phase. After AVR, there were significant decreases (p <0.01) in annular dimensions such as anteroposterior (3.5 ± 0.1 vs 3.2 ± 0.1 cm), anterolateral-posteromedial (3.7 ± 0.1 vs 3.5 ± 0.1 cm), and commissural diameters (3.7 ± 0.1 vs 3.3 ± 0.1 cm), as well as annular circumference (12.0 ± 0.30 vs 11.1 ± 0.2 cm) and 3-dimensional mitral annular area (mean 10.9 ± 0.6 vs 9.3 ± 0.3 cm(3)). Vertical mitral annular displacement was also reduced (6.2 ± 3.1 vs 4.3 ± 2.2 mm). Mitral annular nonplanarity angle (154 ± 1.5° vs 161 ± 1.6°) and aorto-mitral angle (133 ± 3.3° vs 142 ± 2.0°) were both increased after AVR, suggesting reduced nonplanar shape of the mitral annulus and reduced aorto-mitral flexion. In conclusion, these data demonstrate that mitral annular size is reduced immediately after AVR and that the dynamic motion of the mitral annulus is restricted. These findings may have important clinical implications for patients undergoing AVR with concurrent mitral regurgitation. PMID:23891429
Warraich, Haider J; Matyal, Robina; Bergman, Remco; Hess, Philip E; Khabbaz, Kamal; Manning, Warren J; Mahmood, Feroze
The purpose of this report is to review the results of mitral valve replacement since a first report in the Annals of Surgery in 1961, in order to determine the relative importance of new valve designs versus other surgical variables. The continued use of the silastic ball valve in its 1966 configuration (Model 6120), by providing a comparative data base for other new prosthetic valves, allows this analysis. For a valid comparison with the tilting disc (Bjork-Shiley) and the porcine (Hancock and Carpentier-Edwards) valves, only results with the silastic ball valves implanted during comparable time frames should be used. (Formula: see text) Thus, there are no significant differences in the results obtained with the silastic ball valve in time frames comparable to other contemporary valves introduced in the early 1970s. Improved results, therefore, must be non-prosthetic valve related. PMID:4037910
Cobanoglu, A; Grunkemeier, G L; Aru, G M; McKinley, C L; Starr, A
The purpose of this report is to review the results of mitral valve replacement since a first report in the Annals of Surgery in 1961, in order to determine the relative importance of new valve designs versus other surgical variables. The continued use of the silastic ball valve in its 1966 configuration (Model 6120), by providing a comparative data base for other new prosthetic valves, allows this analysis. For a valid comparison with the tilting disc (Bjork-Shiley) and the porcine (Hancock and Carpentier-Edwards) valves, only results with the silastic ball valves implanted during comparable time frames should be used. (Formula: see text) Thus, there are no significant differences in the results obtained with the silastic ball valve in time frames comparable to other contemporary valves introduced in the early 1970s. Improved results, therefore, must be non-prosthetic valve related. Images FIG. 1. FIG. 2. FIG. 3.
Cobanoglu, A; Grunkemeier, G L; Aru, G M; McKinley, C L; Starr, A
This study was designed to identify the specific proteoglycans and glycosaminoglycans (GAGs) in the leaflets and chordae of the mitral valve and to interpret their presence in relation to the tensile and compressive loads borne by these tissues. Leaflets and chordae from normal human mitral valves (nà 31, obtained at autopsy) were weighed and selected portions digested using proteinase K,
K. Jane Grande-Allen; Anthony Calabro; Vishal Gupta; Thomas N. Wight; Vincent C. Hascall; Ivan Vesely
A transient multi-physics model of the mitral heart valve has been developed, which allows simultaneous calculation of fluid flow and structural deformation. A recently developed contact method has been applied to enable simulation of systole (the stage when blood pressure is elevated within the heart to pump blood to the body). The geometry was simplified to represent the mitral valve
Daniel M. Espino; Duncan E. T. Shepherd; David W. L. Hukins
Purpose An in vitro study using explanted porcine hearts was conducted to evaluate a novel annuloplasty band, reinforced with a two-phase, shape memory alloy, designed specifically for minimally invasive mitral valve repair. Description In its rigid (austenitic) phase, this band provides the same mechanical properties as the commercial semi-rigid bands. In its compliant (martensitic) phase, this band is flexible enough to be introduced through an 8-mm trocar and is easily manipulated within the heart. Evaluation In its rigid phase, the prototype band displayed similar mechanical properties to commercially available semi-rigid rings. Dynamic flow testing demonstrated no statistical differences in the reduction of mitral valve regurgitation. In its flexible phase, the band was easily deployed through an 8-mm trocar, robotically manipulated and sutured into place. Conclusions Experimental results suggest that the shape memory alloy reinforced band could be a viable alternative to flexible and semi-rigid bands in minimally invasive mitral valve repair.
Purser, Molly F.; Richards, Andrew L.; Cook, Richard C.; Osborne, Jason A.; Cormier, Denis R.; Buckner, Gregory D.
The case is reported of a patient with a previously undiagnosed cause of severe congestive heart failure (CHF) caused by the presence of a discrete subaortic stenosis (SAS) from a subvalvular membrane (SVM). The clinical decision making was complicated by the concurrent presence of systolic anterior motion (SAM) of the mitral valve leaflet. Due to the limitations and eventual failure of physiologically opposing medical management strategies, the patient eventually required an open-heart surgical approach and underwent intraoperative SVM resection. A persistent intraoperative left ventricular outflow tract (LVOT) gradient of 50 mmHg due to SAM prompted mitral valve replacement, which resulted in a complete resolution of the LVOT gradient and symptoms. In this extremely rare scenario of SAS and SAM, when SVM resection is thought to be inadequate to relieve LVOT obstruction due to the concurrent presence of SAM, mitral valve replacement represents a reasonable therapeutic approach. PMID:24224427
Choi, Andrew D; Ahmad, Soha; Mathias, Martin; Boyce, Steven; Goldstein, Steven; Morrissey, Richard
Subaortic stenosis was considered for a long time as a congenital anomaly, but it is considered now as an acquired form of obstacle to the left ventricle ejection. It constitutes 8 to 20% of the causes of obstacle left ventricle. Ventricular septal defect and aortic coarctation are the most frequent anomalies associated with the subaortic stenosis. The anomalies of mitral valve and especially muscularization of the anterior mitral valve leaflet remain very rare and underestimated. The diagnosis is made by the echocardiography and must be systematically looked for because its misunderstanding in preoperative can be at the origin of recurrences. We report in this work two cases of muscularization of the anterior mitral valve leaflet associated to subaortic stenosis. Through these cases and through a review of the literature, we are going to put the point on this rare anomaly. PMID:20580343
Fettouhi, H; Amri, R; Tamdy, A; Zarzour, J; Cherti, M
As a dreadful complication after the mechanical heart valve replacement, prosthetic valve obstruction caused by pannus formation occurs increasingly with time. The authors here present a case of 42-year-old woman who was urgently admitted to hospital with acute heart failure symptoms due to the mechanical mitral valve failure only 3?months after surgery. Transthoracic and transesophageal echocardiography demonstrated that the bileaflet of the mitral prosthesis were completely immobilized with only a small transvalvular jet remained. During the reoperation, the reason of the prosthetic valve obstruction was attributed to the noncircular pannus ingrowth extending from the atrioventricular side. For a better understanding of the prosthetic valve dysfunction caused by pannus formation, the authors then compile a literature review to briefly discuss the status quo of the clinical characteristics of this uncommon complication.
The aortic heart valve undergoes geometric and mechanical changes over time. The cusps of a normal, healthy valve thicken and become less extensible over time. In the disease calcific aortic stenosis (CAS), calcified nodules progressively stiffen the cusps. The local mechanical changes in the cusps, due to either normal aging or pathological processes, affect overall function of the valve. In this paper, we propose a computational model for the aging aortic valve that connects local changes to overall valve function. We extend a previous model for the healthy valve to describe aging. To model normal/uncomplicated aging, leaflet thickness and extensibility are varied versus age according to experimental data. To model calcification, initial sites are defined and a simple growth law is assumed. The nodules then grow over time, so that the area of calcification increases from one model to the next model representing greater age. Overall valve function is recorded for each individual model to yield a single simulation of valve function over time. This simulation is the first theoretical tool to describe the temporal behavior of aortic valve calcification. The ability to better understand and predict disease progression will aid in design and timing of patient treatments for CAS.
Weinberg, Eli J.; Schoen, Frederick J.; Mofrad, Mohammad R. K.
OBJECTIVE. The purpose of this study was to correlate the severity and location of aortic valve calcifications, as an incidental finding at chest CT of elderly persons, with pressure gra- dients across the valve. MATERIALS AND METHODS. One hundred fifteen subjects who were 60 years old or older and who showed aortic valve calcification on chest CT (5-mm reconstructed section
Franklin Liu; Courtney A. Coursey; Cairistine Grahame-Clarke; Robert R. Sciacca; Anna Rozenshtein; Shunichi Homma; John H. M. Austin
Mitral valve prolapse was observed in 26 of 92 animals in a harem breeding colony of rhesus monkeys (Macaca mulatta). The affected animals had a systolic murmur best auscultated over the mitral region with the animal in a sitting position. Mid-to-late systolic clicks were also heard. Phonocardiographic examination also demonstrated systolic murmurs and clicks in six of 16 animals. Twenty-three of the animals were studied by M mode and/or two-dimensional echocardiography. The diagnosis was confirmed in 12 animals that had a murmur during the examination. Electrocardiograms revealed T wave abnormalities in five animals and left or right ventricular hypertrophy in five. Four adult animals that died during the course of the study were confirmed at necropsy as having prolapse of the posterior and/or anterior mitral valve leaflets into the atrium. Analysis of the breeding records suggested that mitral valve prolapse was a dominant genetic trait with an approximate birth incidence of 16% to 20% in the colony. The existence of mitral valve prolapse in a nonhuman primate species provides a unique opportunity to study the disease in an experimental animal. PMID:3964716
Swindle, M M; Blum, J R; Lima, S D; Weiss, J L
Objective: This study was done to determine the potential benefits of minimally invasive mitral surgery performed with intraoperative video assistance. Methods: From May 1996 until March 1997, a minithoracotomy and video assistance were used in 31 consecutive patients undergoing mitral repair (n = 20) and replacement (n = 11). Their ages ranged from 18 to 77 years (59 ± 2.6
W. Randolph Chitwood; Christopher L. Wixon; Joseph R. Elbeery; Jon F. Moran; William H. H. Chapman; Robert M. Lust
We investigate the behaviour of a dynamic fluid-structure interaction model of a chorded polyurethane mitral valve prosthesis, focusing on the effects on valve dynamics of including descriptions of the bending stiffnesses of the valve leaflets and artificial chordae tendineae. Each of the chordae is attached at one end to the valve annulus and at the other to one of two chordal attachment points. These attachment points correspond to the positions where the chords of the real prosthesis would attach to the left-ventricular wall, although in the present study, these attachment points are kept fixed in space to facilitate comparison between our simulations and earlier results obtained from an experimental test rig. In our simulations, a time-dependent pressure difference derived from experimental measurements drives flow through the model valve during diastole and provides a realistic pressure load during systole. In previous modelling studies of this valve prosthesis, the valve presents an unrealistically large orifice at beginning of diastole and does not close completely at the end of diastole. We show that including a description of the chordal bending stiffness enables the model valve to close properly at the end of the diastolic phase of the cardiac cycle. Valve over-opening is eliminated only by incorporating a description of the bending stiffnesses of the valve leaflets into the model. Thus, bending stiffness plays a significant role in the dynamic behaviour of the polyurethane mitral valve prosthesis. PMID:22042381
Luo, X Y; Griffith, B E; Ma, X S; Yin, M; Wang, T J; Liang, C L; Watton, P N; Bernacca, G M
Calcific aortic valve disease is frequently driven by ageing and the obesity-associated metabolic syndrome, and the increasing impact of these factors indicates that valve disease will become a cardiovascular disease of considerable significance. This disease is now thought to be an active cell-based disease process, which may therefore be amenable to therapeutic intervention. Some similarities are apparent with atherosclerosis. The
K. J. Grande-Allen; N. Osman; M. L. Ballinger; H. Dadlani; S. Marasco; P. J. Little
Rationale Calcification of heart valve structures is the most common form of valvular disease and is characterized by the appearance of bone-like phenotypes within affected structures. Despite the clinical significance, the underlying etiology of disease onset and progression is largely unknown and valve replacement remains the most effective treatment. The SRY-related transcription factor Sox9 is expressed in developing and mature heart valves, and its function is required for expression of cartilage-associated proteins, similar to its role in chondrogenesis. In addition to cartilage-associated defects, mice with reduced sox9 function develop skeletal bone prematurely, however the ability of sox9 deficiency to promote ectopic osteogenic phenotypes in heart valves has not been examined. Objective This study aims to determine the role of Sox9 in maintaining connective tissue homeostasis in mature heart valves using in vivo and in vitro approaches. Methods and Results Using histological and molecular analyses we report that Sox9fl/+;Col2a1-cre mice develop calcific lesions in heart valve leaflets from 3 months of age associated with increased expression of bone-related genes and activation of inflammation and matrix remodeling processes. Consistently, ectopic calcification is also observed following direct knockdown of Sox9 in heart valves in vitro. Further, we show that retinoic acid treatment in mature heart valves is sufficient to promote calcific processes in vitro, which can be attenuated by Sox9 overexpression. Conclusions This study provides insights into the molecular mechanisms of heart valve calcification and identifies reduced Sox9 function as a potential genetic basis for calcific valvular disease.
Peacock, Jacqueline D; Levay, Agata K; Gillaspie, Devin B; Tao, Ge; Lincoln, Joy
We evaluated the long-term outcome of mitral valve replacement with a Harken caged-disc prosthesis for up to 11 years (range, 50 to 130 months; mean, 81 months) in 170 patients whose mean age was 55 years. The early (30-day) mortality was 11.2% (19 out of 170 patients). Late follow-up information was obtained for 144 (95%) of the 151 survivors. The actuarial survival was 57% at 5 years and 40% at 10 years. Overall mortality was associated with advanced age, male sex, an ischemic origin for the mitral valve disease, and nonuse of warfarin anticoagulation. Late deaths (n=59) were valve-related in 46%, cardiac but non-valve-related in 44%, and noncardiac in 10% of the cases. One thromboembolic event or more occurred in 41 patients (incidence, 5.7% per patient year), 14 of whom died (24% of the late deaths). All four patients who were not on warfarin, aspirin, or other antithrombotic therapy experienced thromboemboli. This complication was correlated with the nonuse of warfarin-type anticoagulation, with mitral regurgitation, and with late cardiac death. Mechanical prosthetic failure resulted in reoperation or death in 7.6% of the late survivors (1.5% per patient year). In 75 patients with normally functioning prostheses, the disc-to-sewing ring ratio was established by means of cinefluoroscopy (0.93 ± 0.04, mean ± 25D). Because of the high proportion of cardiac valve-related deaths (46%), the high incidence of late mortality due to thromboembolic events (24%), and the 7.6% incidence of reoperation or death resulting from mechanical valve failure, close follow-up with cinefluoroscopy and continued warfarin anticoagulation (alone or in combination with dipyridamole) are essential after mitral valve replacement with the Harken caged-disc prosthesis. (Texas Heart Institute Journal 1987; 14:411-417) Images
Gray, Richard J.; Czer, Lawrence S.C.; Chaux, Aurelio; Sethna, Dhun; Derobertis, Michele; Raymond, Marjorie; Matloff, Jack M.
\\u000a Heart valves are functionally complex, making surgical repair difficult. Simulation-based surgical planning could facilitate\\u000a repair, but current finite element studies are prohibitively slow for rapid, clinically-oriented simulations. An anisotropic,\\u000a nonlinear mass-spring (M-S) model is used to approximate the behavior of valve leaflets and applied to fully image-based mitral\\u000a valve models to simulate valve closure for fast applications like intraoperative surgical
Peter E. Hammer; Pedro J. del Nido; Robert D. Howe
The Edwards MIRA bileaflet mechanical prosthesis, a heart valve not yet available in the United States, is designed with a unique hinge mechanism, curved leaflets, and thin titanium housing. We performed this study to investigate its clinical performance and postoperative hemodynamic results. We implanted 58 Edwards MIRA prostheses in 51 patients in the aortic (n=18), mitral (n=26), and aortic and mitral (n=7) positions. Patients' ages ranged from 25 to 84 years (mean age, 53.7 ± 13.6). Operative mortality was 2% (n=1), and late mortality was 4% (n=2). Thromboembolic events were observed in 2 patients (valve thrombosis in 1 and a cerebrovascular event in 1). There were no complications related to anticoagulation. No signs of valvular dysfunction or paravalvular leakage were observed. Peak transvalvular gradients of the aortic prostheses ranged from 24.25 ± 5.32 mmHg for the 21-mm valve to 11 ± 1.41 mmHg for the 25-mm valve. The effective orifice area ranged from 1.99 ± 0.12 cm2 for the 21-mm valve to 2.44 ± 0.17 cm2 for the 25-mm valve. The mean transvalvular gradients of the mitral prostheses ranged from 5.85 ± 2.91 mmHg for the 27-mm valve to 4.5 ± 0 mmHg for the 31-mm valve. The effective orifice area ranged from 2.31 ± 0.03 cm2 for the 27-mm valve to 2.64 ± 0.05 cm2 for the 33-mm valve. These preliminary data suggest good hemodynamic function and a low rate of valve-related complications in the use of the Edwards MIRA mechanical prosthesis.
Kale, Arzum; Yildiz, Ulku; Can, Benhur; Kandemir, Ozer; Tokmakoglu, Hilmi; Tezcaner, Tevfik; Zorlutuna, Yaman
The clinical improvement and the hemodynamic performance at rest and during bicycle exercise in 22 patients 1 year after implantation of a St. Jude Medical mitral valve (SJMM) were compared with the results of 40 patients after implantation of a Björk-Shiley mitral valve (BSM). In both subjective and functional improvement were significant. In the SJMM group no thromboembolic event occurred, while five patients in the BSM group suffered from embolism during the first year postoperative year (12.5%). Hemolysis was significantly lower in the BSM group but remained subclinical in the SJMM group. This may be explained by a premature backward movement of the posterior leaflet of the SJMM prosthesis in the late diastole, which resulted in a change of flow pattern. Low resistance to blood flow in the SJMM prosthesis could be verified by a small diastolic transvalvular gradient. In valves with equal tissue annulus diameters (29 mm), the calculated effective valve orifices were significantly different (3.07 +/- 1.36 cm2 in SJMM, 1.85 +/- 0.53 cm2 in BSM). In both groups, the mean pulmonary artery pressure was significantly reduced at the time of reinvestigation but increased during exercise. Durability may become a problem because of the two moving parts of SJMM, but we have observed no malfunction. The SJMM appears to be a good alternative in mitral valve replacement. PMID:7249324
Horstkotte, D; Haerten, K; Herzer, J A; Seipel, L; Bircks, W; Loogen, F
Percutaneous mitral valve repair with the MitraClip is a new promising therapeutic option for symptomatic severe mitral regurgitation (MR). Acute myocardial infarction (MI) is a well recognized cause of papillary muscle rupture (PMR). If PMR is untreated, the prognosis is poor and the mortality could be as high as 80% during the first week of post MI. For patients with PMR, the standard therapy for MR is open surgical repair or replacement. However, in our case, percutaneous mitral valve repair with the MitraClip was chosen technique because of the metastatic colon cancer. We report the case of a 60-year-old woman who underwent successful percutaneous mitral valve repair with the MitraClip system for the treatment of acute MI complicated by PMR. PMID:23592592
Bilge, Mehmet; Alemdar, Recai; Yasar, Ayse Saatci
The aortic valve is highly responsive to cyclical and continuous mechanical forces, at the macroscopic and cellular levels. In this report, we delineate mechanokinetics (effects of mechanical inputs on the cells) and mechanodynamics (effects of cells and pathologic processes on the mechanics) of the aortic valve, with a particular focus on how mechanical inputs synergize with the inflammatory cytokine and other biomolecular signaling to contribute to the process of aortic valve calcification.
Merryman, W. David; Schoen, Frederick J.
Purpose: Patient-specific shape analysis of the mitral valve from real-time 3D ultrasound (rt-3DUS) has broad application to the assessment and surgical treatment of mitral valve disease. Our goal is to demonstrate that continuous medial representation (cm-rep) is an accurate valve shape representation that can be used for statistical shape modeling over the cardiac cycle from rt-3DUS images. Methods: Transesophageal rt-3DUS data acquired from 15 subjects with a range of mitral valve pathology were analyzed. User-initialized segmentation with level sets and symmetric diffeomorphic normalization delineated the mitral leaflets at each time point in the rt-3DUS data series. A deformable cm-rep was fitted to each segmented image of the mitral leaflets in the time series, producing a 4D parametric representation of valve shape in a single cardiac cycle. Model fitting accuracy was evaluated by the Dice overlap, and shape interpolation and principal component analysis (PCA) of 4D valve shape were performed. Results: Of the 289 3D images analyzed, the average Dice overlap between each fitted cm-rep and its target segmentation was 0.880+/-0.018 (max=0.912, min=0.819). The results of PCA represented variability in valve morphology and localized leaflet thickness across subjects. Conclusion: Deformable medial modeling accurately captures valve geometry in rt-3DUS images over the entire cardiac cycle and enables statistical shape analysis of the mitral valve.
Pouch, Alison M.; Yushkevich, Paul A.; Jackson, Benjamin M.; Gorman, Joseph H., III; Gorman, Robert C.; Sehgal, Chandra M.
Though mitral valve (MV) repair surgical procedures have increased in the United States [Gammie, J. S., et al. Ann. Thorac. Surg. 87(5):1431–1437, 2009; Nowicki, E. R., et al. Am. Heart J. 145(6):1058–1062, 2003], studies suggest that altering MV stress states may have an effect on tissue homeostasis, which could impact the long-term outcome [Accola, K. D., et al. Ann. Thorac. Surg. 79(4):1276–1283, 2005; Fasol, R., et al. Ann. Thorac. Surg. 77(6):1985–1988, 2004; Flameng, W., P. Herijgers, and K. Bogaerts. Circulation 107(12):1609–1613, 2003; Gillinov, A. M., et al. Ann. Thorac. Surg. 69(3):717–721, 2000]. Improved computational modeling that incorporates structural and geometrical data as well as cellular components has the potential to predict such changes; however, the absence of important boundary condition information limits current efforts. In this study, novel high definition in vivo annular kinematic data collected from surgically implanted sonocrystals in sheep was fit to a contiguous 3D spline based on quintic-order hermite shape functions with C2 continuity. From the interpolated displacements, the annular axial strain and strain rate, bending, and twist along the entire annulus were calculated over the cardiac cycle. Axial strain was shown to be regionally and temporally variant with minimum and maximum values of ?10 and 4%, respectively, observed. Similarly, regionally and temporally variant strain rate values, up to 100%/s contraction and 120%/s elongation, were observed. Both annular bend and twist data showed little deviation from unity with limited regional variations, indicating that most of the energy for deformation was associated with annular axial strain. The regionally and temporally variant strain/strain rate behavior of the annulus are related to the varied fibrous-muscle structure and contractile behavior of the annulus and surrounding ventricular structures, although specific details are still unavailable. With the high resolution shape and displacement information described in this work, high fidelity boundary conditions can be prescribed in future MV finite element models, leading to new insights into MV function and strategies for repair.
Eckert, Chad E.; Zubiate, Brett; Vergnat, Mathieu; Gorman, Joseph H.; Gorman, Robert C.; Sacks, Michael S.
Background: Thromboembolic events (TEs) are frequent after mechanical mitral valve replacement (MVR), but their association to anticoagulation quality is unclear and has never been studied in a population-based setting with patients who have a complete anticoagulation record. Methods: We compiled a complete record of all residents of Olmsted County, MN, who underwent mechanical MVR between 1981 and 2004, for all TE, bleeding episodes, and international normalized ratios (INRs) measured from prosthesis implantation. Results: In the 112 residents (mean [± SD] age, 57 ± 16 years; 60% female residents) who underwent mechanical MVR, 19,647 INR samples were obtained. While INR averaged 3.02 ± 0.57, almost 40% of INRs were < 2 or > 4.5. Thirty-four TEs and 28 bleeding episodes occurred during a mean duration of 8.2 ± 6.1 years of follow-up. There was no trend of association of INR (average, SD, growth variance rate, or intensity-specific incidence of events) with TE. Previous cardiac surgery (p = 0.014) and ball prosthesis (hazard ratio [HR], 2.92; 95% CI, 1.43 to 5.94; p = 0.003) independently determined TE. With MVR using a ball prosthesis, despite higher anticoagulation intensity (p = 0.002), the 8-year rate of freedom from TE was considerably lower (50 ± 9% vs 81 ± 5%, respectively; p < 0.0001). Compared with expected stroke rates in the population, stroke risk was elevated with non-ball prosthesis MVR (HR 2.6; 95% CI, 1.3 to 5.2; p = 0.007) but was considerable with ball prosthesis MVR (HR 11.7; 95% CI, 7.5 to 18.4; p < 0.0001). INR variability (SD) was higher with a higher mean INR value (p < 0.0001). INR variability (HR 2.485; 95% CI, 1.11 to 5.55; p = 0.027) and cancer history (p < 0.0001) independently determined bleeding rates. Conclusion: This population-based comprehensive study of anticoagulation and TE post-MVR shows that, in these closely anticoagulated patients, anticoagulation intensity was highly variable and not associated with TE incidence post-MVR. Higher anticoagulation intensity is linked to higher variability and, thus, to bleeding. The MVR-ball prosthesis design is associated with higher TE rates notwithstanding higher anticoagulation intensity, and its use should be retired worldwide.
Le Tourneau, Thierry; Lim, Vanessa; Inamo, Jocelyn; Miller, Fletcher A.; Mahoney, Douglas W.; Schaff, Hartzell V.; Enriquez-Sarano, Maurice
Mitral valve prolapse has been associated with septal to aortic root angle abnormalities determined by echocardiography. Thallium 201 imaging in the anterior view permits visualization of the left ventricular long axis. In the present study, the vertical angle was defined as the angle formed by the long axis of the left ventricle and a horizontal line. The vertical angle was determined in 25 patients who had 201 TL stress testing and M-mode echocardiography. Group I (11 patients) had mitral valve prolapse and group II (14 patients) did not have mitral valve prolapse. The vertical angle and ultrasound were read blinded to each other. Height, weight, and body surface area were compared for the two groups, and receiver operator curve analysis performed. Vertical angle measured by TL 201 was significantly more vertical in patients with mitral valve prolapse. Receiver operator curve analysis showed that an angle of greater than 30 degrees successfully identified 9/11 patients with mitral valve prolapse, with a sensitivity of 82% and a specificity of 79%. There were no significant differences in height, weight, or body surface area between the two groups. Thus, patients with mitral valve prolapse have more vertically positioned hearts than patients without mitral valve prolapse, independent of body habitus. The different appearance of a vertically oriented heart may contribute to false-positive readings of TL 201 images.
Arora, R.R.; Horowitz, S.F.; Machac, J.; Goldman, M.E.
Between 1973 and 1985, 349 patients had isolated mitral valve replacement by a Bjork-Shiley prosthesis with an overall early (30 day) mortality of 5.1%. Of the 331 survivors, 294 patients have been traced and their clinical outcome was followed for up to 13 years in order to define the long term performance of the mitral Bjork-Shiley models MBRP-standard, MBRC-convexo concave and MMSM-monostrut. Cumulative follow-up extends to 6620 patient years (mean 5.75 years). The MBRP valve was implanted in 236 patients, the MBRC valve used in 44 patients and the MMSM valve inserted in 14 patients. The late mortality and morbidity was 0.8% and 0.6% per patient year at 13 years respectively. Actuarial survival rate for the whole group excluding operative deaths was 85% at 5 years, 66% at 10 years and 58.5% at 13 years. The freedom from all valve related complications at 13 years was 70.75%. Bjork-Shiley models MBRP, MBRC and MMSM mitral valve prosthesis show excellent durability with only one case of mechanical failure over a 13 year period. PMID:2600129
Fessatidis, I T; Vassiliadis, K E; Monro, J L; Ross, J K; Shore, D F; Drury, P J
We report a patient and his family, who have branchio-oto-renal (BOR) syndrome and coexisting mitral valve prolapse. A literature review of BOR syndrome failed to identify any similar families and we report this as a new observation. During the preoperative assessment of a patient with BOR syndrome, tachycardia was noted and a cardiologic examination including echocardiography revealed mitral valve prolapse. Members of his extended family were investigated, including carrying out cardiology and otolaryngology examinations to determine whether they had signs of either BOR syndrome or cardiac problems. Mitral valve prolapse was identified in five (71.4%) of the seven BOR syndrome patients in the family. Deafness was present in all patients. Distribution of the other clinical findings of the BOR syndrome patients were as follows: branchial fistula in five (71.4%), preauricular pits in four (57.1%), ear deformity in two (28.5%), renal anomalies in three (42.8%), lacrimal duct anomaly in two (28.5%) and orbital anterior compartment anomaly in one (14.2%). We conclude that mitral valve prolapse can be associated with BOR syndrome. Further large studies are needed to clarify this association. PMID:20845527
Ayçiçek, Abdullah; Sa?lam, Hayrettin; Koço?ullari, Cevdet U?ur; Haktanir, Nurten Turhan; Dereköy, Fevzi Sefa; Solak, Mustafa
Numerous studies have reported increased cardiac vagal activity in well endurance-trained athletes. However, no clear data exist regarding the cardiac autonomic activity in athletes with common cardiovascular findings, such as mild mitral valve prolapse (MVP) and transient benign arrhythmias. Therefore, the purpose of this study was to investigate and compare the cardiac autonomic outflow by heart rate variability (HRV) analysis
N. Koutlianos; E. Kouidi; A. Deligiannis
This study examines the incidence, predictors, and evolution of postoperative atrioventricular block (AVB) after mitral valve repair (MVR) in 115 consecutive patients using Carpentier’s technique (between November 1996 and April 1997). Postoperative AVB occurred in 27 patients (23%). Third-degree AVB was found in 7 patients (6%) in the immediate postoperative period, but in 4 it was transient, resolving partially or
Patrick Meimoun; Rachid Zeghdi; Nicola D’Attelis; Alain Berrebi; Eric Braunberger; Alain Deloche; Jean Noel Fabiani; Alain Carpentier
One difficulty with external repair of left ventricular rupture after mitral valve replacement is collateral bleeding in friable myocardium adjacent to the rupture. The bleeding is caused by tension on the closing sutures, whether or not pledgets have been used. We report the case of a 69-year-old woman who underwent an uneventful mitral valve replacement. After cardiopulmonary bypass was terminated, brisk bleeding started from high in the posterior left ventricular wall, typical of a type III defect. We undertook external repair, placing a plug of Teflon felt into the cavity of the rupture and sandwiching it into place with pledgeted mattress and figure-of-8 sutures. The space occupied by the plug decreased the distance needed to obliterate the defect and thereby reduced the tension on the sutures necessary to achieve hemostasis. This simple technique enabled closure of the defect and avoided collateral tears that would have compromised an otherwise successful repair. Two years postoperatively, the patient had normal mitral valve function and no left ventricular aneurysm. In addition to reporting the patient's case, we review the types of left ventricular rupture that can occur during mitral valve replacement and discuss the various repair options.
Lee, Myles E.; Tamboli, Mallika; Lee, Anthony W.
One difficulty with external repair of left ventricular rupture after mitral valve replacement is collateral bleeding in friable myocardium adjacent to the rupture. The bleeding is caused by tension on the closing sutures, whether or not pledgets have been used. We report the case of a 69-year-old woman who underwent an uneventful mitral valve replacement. After cardiopulmonary bypass was terminated, brisk bleeding started from high in the posterior left ventricular wall, typical of a type III defect. We undertook external repair, placing a plug of Teflon felt into the cavity of the rupture and sandwiching it into place with pledgeted mattress and figure-of-8 sutures. The space occupied by the plug decreased the distance needed to obliterate the defect and thereby reduced the tension on the sutures necessary to achieve hemostasis. This simple technique enabled closure of the defect and avoided collateral tears that would have compromised an otherwise successful repair. Two years postoperatively, the patient had normal mitral valve function and no left ventricular aneurysm. In addition to reporting the patient's case, we review the types of left ventricular rupture that can occur during mitral valve replacement and discuss the various repair options. PMID:24808783
Lee, Myles E; Tamboli, Mallika; Lee, Anthony W
From 1997 to 2000, 221 patients underwent mitral valve surgery through a mini-thoracotomy, using a port-access endovascular cardiopulmonary bypass system in 38 and a transthoracic clamp in 183. In 120 patients, exposure of the mitral valve was facilitated by an endoscope attached to a voice-controlled robotic arm (AESOP 3000). The mitral valve was repaired in 26 patients and replaced in 195; 24 were redo cases. Operating time was 3.5 +/- 1.2 hours, aortic crossclamp time was 58 +/- 16 minutes, intensive care unit stay was 22 +/- 7 hours, and hospital stay was 6.4 +/- 1.2 days. Median postoperative blood loss was 332 +/- 104 mL. There was 1 hospital death. On follow-up at 16.4 +/- 12.2 months, there was no late death or reoperation. New York Heart Association functional class improved from 2.6 +/- 0.5 to 1.4 +/- 0.8. Use of video and robotic assistance minimized incision length and allowed visualization of the whole mitral valve apparatus. The transthoracic clamp facilitated aortic crossclamping and injection of cardioplegia. These findings indicate that the procedure is safe and effective and suggest advantages over conventional surgery in terms of cost, cosmesis, blood loss, postoperative discomfort, intensive care unit and hospital stay. PMID:12079936
Trehan, Naresh; Mishra, Yugal K; Sharma, Mitesh; Bazaz, Surinder; Mehta, Yatin; Sharma, Krishan Kant; Shrivastava, Sameer
The new percutaneous mitral valve repair techniques are at an early stage. Preliminary series show that they are feasible; however, they need to be further evaluated in comparison with contemporary treatment to accurately assess their efficiency. Potential applications may benefit high-risk patients after thorough evaluation.
Himbert, Dominique; Brochet, Eric; Messika-Zeitoun, David
A 59-year-old male was referred for surgery resulting from a paravalvular leak at the mitral position. The patient underwent his first mitral valve replacement with a Bjork-Shiley valve 33 years before this situation arose. He underwent his second mitral valve replacement with a St. Jude Medical mechanical prosthesis for valve thrombosis 10 years later. Serial echocardiography had always shown good results until this time; thus the leak suddenly occurred 23 years after his second mitral valve replacement without any preceding signs. At surgery, a small fistula was observed. The paravalvular leak was successfully repaired by a direct suture repair. Although his postoperative course was complicated by a deep sternal infection, he has fully recovered and currently is in the New York Heart Association class 1 three years after the surgery. PMID:21263431
Abe, Tomonobu; Ito, Toshiaki; Yoshizumi, Tomo; Nakayama, Tomohiro; Hagiwara, Hiroaki; Nakayama, Masato
Background: Primary intra cardiac tumors are rare. In this article, we present papillary fibroelastoma of mitral valve chordae. Case Presentation: A 35-year old man presented with atypical chest pain and palpitation. Physical examination and electrocardiogram were normal. Transesophageal echocardiography (TEE) revealed a mass of 1015 mm attached to chordae of anteromedial papillary muscle of mitral valve. The tumor was completely resected and the mitral valve chordae tendineae was preserved successfully. The pathological diagnosis was papillary fibroelastoma. Conclusion: In any patient with atypical chest pain and palpitation, valvular tumor should be considered in differential diagnosis.
Ziabakhsh, Shervin; Jalalian, Rozita; Mokhtari-Esbuie, Farzad
Dystrophic calcification has been the long-standing major cause of bioprosthetic heart valve failure, and has been well studied in terms of the underlying causative mechanisms. Such understanding has yielded several anti-calcification strategies involving biomaterial modification at the preparation stage: chemical alteration, extraction of calcifiable components, or material modification with small-molecule anti-calcific agents. However, newer therapeutic opportunities are offered by the growing illustration of the pathology as a dynamic, actively regulated process involving several gene products, such as osteopontin (OPN), matrix-gla protein (MGP) and glycosaminoglycans (GAGs). Osteopontin, a multi-functional matricellular glycosylated phosphoprotein has emerged as a prime candidate for the role of an in vivo inhibitor of ectopic calcification with two putative mechanisms: crystal poisoning and mineral-dissolution. The full therapeutic realization of its potential necessitates a better understanding of the mechanisms of anti-calcification by osteopontin, as well as appropriate in vivo models in which to evaluate its efficacy, potency and molecular mechanisms. In this work, we pursued the development and characterization of a reliable in vivo model with the OPN-null mouse to simulate the calcification of bioprosthetic valve material, namely glutaraldehyde-fixed bovine pericardium (GFBP) tissue. Subsequently, we used the calcification model to evaluate hypotheses based on the anti-calcific potential of osteopontin. Several modes of administering exogenous OPN to the implant site in OPN-null mice were explored, including soluble injected OPN, OPN covalently immobilized on the biomaterial, and OPN adsorbed onto the biomaterial. An investigation of the structure-function aspects of the anti-calcific ability of OPN was also pursued in the in vivo model. The OPN-null mouse was also used as an in vivo test-bed to evaluate the anti-calcific potential of other biomolecules, namely hyaluronic acid (HA) and natural reducing agents, such as glutathione. Direct rescue of the calcification phenotype in the OPN-null mice was achieved by administration of exogenous OPN, providing strong evidence of OPN's ability to mitigate ectopic calcification. Significant reduction in calcification was observed on administering OPN in soluble injected form and also when immobilized (adsorbed) onto the biomaterial. Mechanistic insights were also gained, since maximal anti-calcific effect was offered by OPN only when the protein had adequate phosphorylation as well as a functional RGD domain---suggesting synergy between these two structural elements and also a "threshold effect" for the degree of phosphorylation. In addition, the OPN-null in vivo calcification model was employed to gain evidence for the anti-calcific potential of covalently-immobilized hyaluronic-acid (HA) and the natural reducing agent glutathione.
Disorders of the mitral valve are second most frequent, cumulating 14 percent of total number of deaths caused by Valvular Heart Disease each year in the United States and require elaborate clinical management. Visual and quantitative evaluation of the valve is an important step in the clinical workflow according to experts as knowledge about mitral morphology and dynamics is crucial for interventional planning. Traditionally this involves examination and metric analysis of 2D images comprising potential errors being intrinsic to the method. Recent commercial solutions are limited to specific anatomic components, pathologies and a single phase of cardiac 4D acquisitions only. This paper introduces a novel approach for morphological and functional quantification of the mitral valve based on a 4D model estimated from ultrasound data. A physiological model of the mitral valve, covering the complete anatomy and eventual shape variations, is generated utilizing parametric spline surfaces constrained by topological and geometrical prior knowledge. The 4D model's parameters are estimated for each patient using the latest discriminative learning and incremental searching techniques. Precise evaluation of the anatomy using model-based dynamic measurements and advanced visualization are enabled through the proposed approach in a reliable, repeatable and reproducible manner. The efficiency and accuracy of the method is demonstrated through experiments and an initial validation based on clinical research results. To the best of our knowledge this is the first time such a patient specific 4D mitral valve model is proposed, covering all of the relevant anatomies and enabling to model the common pathologies at once.
Voigt, Ingmar; Ionasec, Razvan Ioan; Georgescu, Bogdan; Houle, Helene; Huber, Martin; Hornegger, Joachim; Comaniciu, Dorin
Background Advances in the understanding of mitral valve pathology have laid to mitral valve plasty (MPL) as the procedure of choice of all the mitral intervention as compared to mitral valve replacement (MVR). This study is aimed to compare the outcome mortality and reoperation and to estimate failure of repair between the two procedures during the follow up time. Material and methods A cohort of 355 patients with mitral valve disease operated between January 1993 to January 2007 with closing date first of mars 2011. There were 214 MPL and 141 MVR at the Hospital discharge. This retrospective cohort had the design of exposed (MPL) versus non-exposed (MVR) with outcome total mortality and reoperation during follow up. Also echocardiography follow-up was undertaken to estimate the true long-term failure rate of repair. Results The mean follow up was 5.3 years SE (3.82) maximum follow up was 14.1 years. Considering the patient time model the association between repair/replacement and total mortality RR?=?0.43 95% (0.28-074) p?=?0.002 controlling for the confounding effect of 3-vessels disease. Those results were confirmed by propensity score analysis. As far as outcome re-operation, presence of atrial fibrillation AF was an effect modifier indicating lower reoperation rate for MPL compared to MVR for patients without AF, RR?=?0.32 95% CL (0.13-0.81) p?=?0.017 while no difference in reoperation rates between MPL/MVR for patients with AF RR?=?1.82 95% CL (0.52-6.4) p?=?0.344. Echocardiography follows up showed incidence of moderate and severe recurrent mitral regurgitation was 1.34 per 100 patients years and 0.27 per 100 patients years during the follow-up time. Conclusion In a cohort of patient with mitral valve disease undergoing MPL/MVR was examined. MPL was associated with better survival, and lower reoperation rate for patients without AF but same rate for patients with AF. We advocate more attention in controlling risk factors of AF in the clinical management of mitral disease. Long-term failure rate of MPL was low during follow up time. A replication of our results by a randomized clinical trial is mandatory.
Anatural mitral valve starts closing before systole. Conventional mechanical mitral valves start their closing motion after systole. In order to let the mechanical mitral valves start closing before systole, we propose a new self-closing valve by adjusting the center of gravity of the leaflet. As a first step, we adjusted the center of gravity by attaching a block of lead to the leaflet of a CarboMedics bileaflet valve and evaluated it using a pulse duplicator and an x-ray high-speed video camera. Comparative study was conducted under 60 bpm and 4 L/min as the mean flow rate. It was clarified that the self-closing valve started closing before systole, no influence on inflow volume was found, the final closing speed of the self-closing valve just before complete closure was slower than the conventional valve (1.9-0.34 m/s), a design strategy of a self-closing valve (sewing ring diameter 29 mm) was obtained from the experiment that momentum of inertia of the leaflet should be less than 14.9 x 10-9 kg.m2 and the torque caused by gravity should be more than 4.2 x 10-6 N. m, and only one leaflet should be designed as self-closing, and surgeons need to pay attention to the positioning of the two leaflets. In conclusion, the preliminary study showed the ability of starting to close before systole and the design strategy for future prototyping. PMID:10491036
Naemura, K; Umezu, M; Dohi, T
Myxomatous mitral regurgitation (type II Carpentier's functional classification) affects about 1-2% of the population. This represents a very common indication for valve surgery resulting in a low percentage of repairs compared to replacement which is actually performed. In the last decades, several methods for mitral valve repair have been developed, to make the surgical feasibility easier, improve the long-term follow-up thus avoiding the need for reoperations. A very interesting method is represented by the combination of various valve repair techniques, depending on the involvement of the anterior, posterior, or both leaflets, and the use of PTFE artificial chordae tendineae when excessive chordal elongation or rupture due to myxomatous degeneration co-exists. The aim of this review is to summarize the evolution of these techniques from the beginning till now.
One each of 17 commercially available prosthetic mitral valves has been subjected to in vitro testing using a pulse duplicator. Measurements of mean diastolic pressure difference, incompetence, dimensions, mechanical movements, and turbulence were made, and the quality of manufacture was examined. Although most valves would be effective in the treatment of incompetence, only those with large orifice diameters produced no significant stenosis. All the valves tested were in clinical use at some time in the period 1966-71. Most of the prostheses were obtained in 1968 or 1969. Many of this group showed a manufacturing standard which was less than impeccable. Images
Wright, J. T. M.; Temple, L. J.
Background and aim of the study Intraoperative real-time three-dimensional transesophageal echocardiography (RT-3D TEE) was used to examine the geometric changes that occur in the mitral annulus immediately after aortic valve replacement (AVR). Methods A total of 35 patients undergoing elective surgical AVR under cardiopulmonary bypass was enrolled in the study. Intraoperative RT-3D TEE was used prospectively to acquire volumetric echocardiographic datasets immediately before and after AVR. The 3D echocardiographic data were analyzed offline using TomTec® Mitral Valve Assessment software to assess changes in specific mitral annular geometric parameters. Results Datasets were successfully acquired and analyzed for all patients. A significant reduction was noted in the mitral annular area (-16.3%, p <0.001), circumference (-8.9% p <0.001) and the anteroposterior (-6.3%, p = 0.019) and anterolateral-posteromedial (-10.5%, p <0.001) diameters. A greater reduction was noted in the anterior annulus length compared to the posterior annulus length (10.5% versus 62%, p <0.05) after AVR. No significant change was seen in the non-planarity angle, coaptation depth, and closure line length. During the period of data acquisition before and after AVR, no significant change was noted in the central venous pressure or left ventricular end-diastolic diameter. Conclusion The mitral annulus undergoes significant geometric changes immediately after AVR Notably, a 16.3% reduction was observed in the mitral annular area. The anterior annulus underwent a greater reduction in length compared to the posterior annulus, which suggested the existence of a mechanical compression by the prosthetic valve.
Mahmood, Feroze; Warraich, Haider J.; Gorman, Joseph H.; Gorman, Robert C.; Chen, Tzong-Huei; Panzica, Peter; Maslow, Andrew; Khabbaz, Kamal
A 67-year-old female patient was referred to our clinic for coronary artery bypass graft and severe mitral regurgitation (MR) treatment. The patient had a history of coronary disease and MR treated in 2007 with a CARILLON device. Left mammary and saphenous vein were used to graft the diseased coronaries. MR was corrected with a saddle ring; however, we had some difficulties anchoring ring sutures to the mitral annulus caused by the protruding CARILLON. The ring was finally stitched, and the patient was weaned from bypass. A transoesophageal echo showed a competent valve. The patient was transferred to the intensive care unit on moderate catecholamines. PMID:21422158
Bartkowiak, Marek; Bugajski, Pawel; Jedlinski, Ireneusz; Kalawski, Ryszard
BACKGROUND AND OBJECTIVES: Mitral annular calcification (MAC) is associated with osteoporosis and there is evidence of reduced bone mineral density (BMD) in patients with renal stone formation (RSF). Therefore, we designed this study to test if RSF was associated with MAC and if this association could be linked to bone resorption. METHODS: Fifty-nine patients (mean age, 41.5 years) with RSF and 40 healthy subjects (mean age, 44.2 years) underwent screening for MAC and BMD, and measuurements were taken of serum and urine electrolytes, parathyroid hormone, alkaline phosphatase and urine dypyridoline. RESULTS: MAC was diagnosed in 11 (18%) patients with RSF compared with 1 (2.5%) control (P=.01). Urine phosphorus, magnesium, sodium, potassium and chloride levels were lower (P<.001, P=.02, P<.001, P<.001 and P<.001, respectively), but serum alkaline phosphatase, calcium and potassium levels were higher (P=.008, P=.007 and P=.001, respectively) in patients with RSF versus those without RSF. None of these abnormalities were found in patients or subjects with MAC. Urine pyridoline levels were higher and T-scores were more negative (more osteopenic) in patients and subjects with MAC than in those without MAC (P=.01 and P=.004, respectively). In a multivariate analysis, only T-scores and urine dipyridoline level were predictive of MAC (P=.03 and P=.04, respectively). CONCLUSIONS: Screening for MAC and bone resorption markers in patients with RSF demonstrated a high incidence of MAC in these patients. The presence of MAC in patients with RSF was associated with bone resorption markers. This seemingly complex interrelationship between RSF, MAC and bone loss needs to be clarified in further studies.
Celik, Ahmet; Davutoglu, Vedat; Sarica, Kemal; Erturhan, Sakip; Ozer, Orhan; Sari, Ibrahim; Yilmaz, Mustafa; Baltaci, Yasemin; Akcay, Murat; Al, Behcet; Yuce, Murat; Yilmaz, Necat
This study is to quantitatively evaluate abnormal movement of mitral apparatus (MA) in patient with congenital mitral valve regurgitation using self-designed three dimensional motion analyses software and enable doctors to intuitionistic and \\
K. Sun; X. Yan; L. P. Yao; Q. Guo; L. P. Wu; Y. F. Shang
Background—Mitral and aortic valves are known to be coupled via fibrous tissue connecting the two annuli. Previous studies evaluating this coupling have been limited to experimental animals using invasive techniques. The new matrix array transesophageal transducer provides high-resolution real-time 3D images of both valves simultaneously. We sought to develop and test a technique for quantitative assessment of mitral and aortic
Federico Veronesi; Cristiana Corsi; Lissa Sugeng; Victor Mor-Avi; Enrico G. Caiani; Lynn Weinert; Claudio Lamberti; Roberto M. Lang
Heart valve surgery in high-risk patients with severe jaundice, congestive hepatomegaly and renal impairment is associated with considerable morbidity and mortality. Without operation the consequences are invariably grave. A 35 years old gentleman with congestive cardiac failure was initially treated in coronary care unit (CCU). Mitral valve area was 0.5cm², pulmonary arterial systolic pressure (PASP) was 110mmHg, serum bilirubin was 20mg/dl, SGPT & SGOT were 1024iu/l and 1027iu/l respectively. Serum creatinine was 3.35mmol/l. Serum bilirubin gradually diminished to 3.1mg/dl after 12 days treatment in Coronary Care Unit but next day it increased to 3.6mg/dl. Mitral valve was replaced on an emergency basis. Echocardiogram on the 5th post operative day showed well functioning prosthetic mitral valve in situ. Serum bilirubin decreased to 2.2mg/dl, SGPT, SGOT and serum creatinine to 43iu/l, 40iu/l and 1.34mmol/l respectively. After 8 weeks of postoperative follow up his serum bilirubin decreased to 0.8mg/dl. PMID:24292322
Zahangir, N M; Hoque, K Z; Khan, M H; Haque, M A; Haider, M Z
Background We hypothesized that mitral valve areas (MVAs) with echocardiography, using 3D planimetry technique (measured at one point at maximal opening of mitral valve) versus pressure half-time technique (PHT, measured during entire diastolic phase) in mitral valve repair surgery (MVR) would be different. Methods Patients who had undergone MVR were retrospectively reviewed, and two different observers measured the MVAs using PHT and 3D planimetry technique. The MVAs derived from recorded medical data, using PHT and 3D planimetry technique were abbreviated to MVA-PHT1 and MVA-3D1, and data from the PHT and 3D planimetry techniques by observer A and observer B were determined as MVA-PHT2 and MVA-3D2, and MVA-PHT3 and MVA-3D3, respectively. The MVA derived by post-operative transthoracic echocardiography using the PHT technique was determined as MVA-TTE. Results Intraclass correlation coefficients were 0.90 for the intra-operative PHT technique and 0.78 for the intra-operative 3D planimetry technique. MVA-3D1 (2.91?±?0.65 cm2), MVA-3D2 (3.00?±?0.63 cm2) and MVA-3D3 (2.97?±?0.88 cm2) were significantly larger than MVA-TTE (2.40?±?0.59 cm2), but intra-operative MVAs-PHT were not. The biases and precisions were larger, and the correlation coefficients were lower in 3D planimetry technique compared with PHT technique. Conclusions MVA measured by 3D planimetry technique with TEE at the intra-operative post-MVR period was seemed to be larger than that measured by the PHT technique with TTE at the post-operative period. However, it did not mean that the 3D planimetry technique was inaccurate but needs cautions at determination of MVA using different techniques.
Surgical repair of the mitral valve is preferred in most cases over valve replacement, but replacement is often performed instead due to the technical difficulty of repair. A surgical planning system based on patient-specific medical images that allows surgeons to simulate and compare potential repair strategies could greatly improve surgical outcomes. In such a surgical simulator, the mathematical model of mechanics used to close the valve must be able to compute the closed state quickly and to handle the complex boundary conditions imposed by the chords that tether the valve leaflets. We have developed a system for generating a triangulated mesh of the valve surface from volumetric image data of the opened valve. We then compute the closed position of the mesh using a mass-spring model of dynamics. The triangulated mesh is produced by fitting an isosurface to the volumetric image data, and boundary conditions, including the valve annulus and chord endpoints, are identified in the image data using a graphical user interface. In the mass-spring model, triangle sides are treated as linear springs, and sides shared by two triangles are treated as bending springs. Chords are treated as nonlinear springs, and self-collisions are detected and resolved. Equations of motion are solved using implicit numerical integration. Accuracy was assessed by comparison of model results with an image of the same valve taken in the closed state. The model exhibited rapid valve closure and was able to reproduce important features of the closed valve.
Hammer, Peter E.; Perrin, Douglas P.; del Nido, Pedro J.; Howe, Robert D.
Objective To assess the surgical risk of additional mitral valve repairs in patients with ischemic cardiomyopathy. Summary Background Data Severe mitral regurgitation in patients with ischemic cardiomyopathy increases the death rate and symptomatic status. The 1-year survival rate for medical therapy in this subset of patients is less than 20%. Transplantation is usually not feasible because of donor shortage and death while on the waiting list. Methods To assess additive risk, a retrospective chart review from 1993 to 1998 was performed comparing patients with ischemic cardiomyopathy (ejection fraction [EF] <25%) and severe mitral regurgitation undergoing mitral valve repair and coronary artery bypass graft operations with patients with an EF of <25% undergoing coronary artery bypass graft alone. These groups were also compared with 140 patients receiving heart transplants since 1993 (group 3). Results The overall hospital death rate for group 1 was 6.3%. The one death occurred 2 weeks after surgery secondary to sepsis. This was not significantly different from the death rate of 4.1% in group 2. In group 1, there were two deaths at 1 year (87% survival rate), one related to heart failure. One patient was New York Heart Association (NYHA) class IV at 1 year; the remainder of patients were NYHA class I–II. These results were not significantly different than the 8% death rate noted with transplantation. There was no change in EF and minimal residual mitral regurgitation in group 1 based on postoperative transesophageal echocardiography, whereas group 2 had an average 11.7% improvement in EF. Conclusions Previously, severe mitral regurgitation in the setting of ischemic cardiomyopathy has been associated with poor survival. In these authors’ experience, repairing the mitral valve along with coronary artery bypass grafting does not increase the surgical risk, yields improvement in symptomatic status, and compares favorably to coronary artery bypass grafting alone and cardiac transplantation. However, the lack of change in EF in these patients probably represents an overestimation of the EF before surgery secondary to severe mitral regurgitation.
Gangemi, James J.; Tribble, Curtis G.; Ross, Scott D.; McPherson, John A.; Kern, John A.; Kron, Irving L.
\\u000a When considered separately from mitral valve anomalies associated with atrioventricular septal defects and with hypoplastic\\u000a left heart syndrome, congenital mitral valve malformations resulting in mitral stenosis are rare. Reported prevalence is 0.4–0.5%\\u000a of congenital heart defects [1–3]. Acquired mitral stenosis is primarily related to rheumatic heart disease and, though uncommon\\u000a in the United States, remains a considerable problem for children
Kristin P. Barton; Jacqueline Kreutzer; Victor O. Morell; Ricardo Muñoz
Background Since reduction annuloplasty alone for ischemic mitral regurgitation (MR) cannot prevent late recurrence of MR or improve survival for those with left ventricular (LV) dysfunction, and the surgical approach to this etiology is still controversial, we conducted a study to assess the efficacy of the additional papillary muscle approximation (PMA) procedure for ischemic MR by comparing the different subtypes of PMA. Methods We studied 45 patients who underwent mitral annuloplasty and papillary muscle approximation (PMA) for ischemic MR between 2003 and 2012. Papillary muscles were approximated entirely (cPMA: complete PMA, n?=?32) through an LV incision or partially from the tips to mid-parts (iPMA: incomplete PMA, n?=?13) through the mitral and aortic valves. Twenty-three patients with cPMA also underwent LV plasty (LVP). We assessed the outcomes after PMA by comparing cPMA and iPMA. Results The baseline MR grade, NYHA class, LV end-diastolic diameter, and LV ejection fraction (LVEF) were 2.8?±?1.0, 3.2?±?0.6, 67?±?6 mm, and 30?±?10%, respectively. There were no significant differences in these parameters among those with iPMA, cPMA/LVP-, and cPMA/LVP+, though iPMA patients had better LVEF than others. Three patients died before discharge and 12 died during the follow-up. Recurrence of grade 2+ and 3+ MR occurred in 8 and 2 patients, respectively. Reoperation for recurrent MR was performed only for the 2 patients with recurrence of grade 3+ MR. The cPMA was associated with lower mortality (log-rank P?=?0.020) and a lower rate of recurrence of MR ?2+ (log-rank P?=?0.005) than iPMA. In contrast, there were no significant differences in the mortality (log-rank P?=?0.45) and rate of recurrence (log-rank P?=?0.98) between those with cPMA/LVP- and cPMA/LVP+. The 4-year survival rate and rate of freedom from recurrence of MR ?2+ were 83% and 85% for those with cPMA, repectively. In contrast, the rates were 48% and 48% for those with iPMA, respectively. Conclusions Complete PMA could be associated with lower postoperative mortality and higher durability of mitral valve repair for ischemic MR.
Calcific aortic valve disease (CAVD) is a chronic process leading to fibrosis and mineralization of the aortic valve. Investigations in the last several years have emphasized that key underlying molecular processes are involved in the pathogenesis of CAVD. In this regard, the processing of lipids and their retention has been underlined as an important mechanism that triggers inflammation. In turn, inflammation promotes/enhances the mineralization of valve interstitial cells, the main cellular component of the aortic valve. On the other hand, transformation of valve interstitial cells into myofibroblasts and osteoblast-like cells is determined by several signaling pathways having reciprocal cross-talks. In addition, the mineralization of the aortic valve has been shown to rely on ectonucleotidase and purinergic signaling. In this review, the authors have highlighted key molecular underpinnings of CAVD that may have significant relevance for the development of novel pharmaceutical therapies. PMID:24857537
Mathieu, Patrick; Boulanger, Marie-Chloé; Bouchareb, Rihab
Calcified aortic valve (AV) cusps have increased expression of bone morphogenic proteins (BMPs) and transforming growth factor-?1 (TGF-?1). Elevated stretch loading on the AV is known to increase expression of matrix remodeling enzymes and pro-inflammatory proteins. Little, however, is known about the mechanism by which elevated stretch might induce AV calcification. We investigated the hypothesis that elevated stretch may cause valve calcification via a BMP-dependent mechanism. Porcine AV cusps were cultured in a stretch bioreactor, at 10% (physiological) or 15% (pathological) stretch and 70 beats per minute for 3, 7, and 14 days, in osteogenic media supplemented with or without high phosphate (3.8 mmol/L), TGF-?1 (1 ng/ml), as well as the BMP inhibitor noggin (1, 10, and 100 ng/ml). Fresh cusps served as controls. Alizarin red and von Kossa staining demonstrated that 15% stretch elicited a stronger calcification response compared with 10% stretch in a fully osteogenic medium containing high phosphate and TGF-?1. BMP-2, -4, and Runx2 expression was observed after 3 days on the fibrosa surface of the valve cusp and was stretch magnitude-dependent. Cellular apoptosis was highest at 15% stretch. Tissue calcium content and alkaline phosphatase activity were similarly stretch-dependent and were significantly reduced by noggin in a dose dependent manner. These results underline the potential role of BMPs in valve calcification due to altered stretch.
Balachandran, Kartik; Sucosky, Philippe; Jo, Hanjoong; Yoganathan, Ajit P.
We present the case of a 49-year-old male patient with prosthetic mitral valve endocarditis associated with QT prolongation and torsades de pointes. He was asymptomatic until the end of January 2012, when he was admitted to our hospital emergency unit because of syncope, fever, and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. All cultures were positive for methicillin-sensitive Staphylococcus aureus. The corrected QT (QTc) interval was markedly prolonged upon admission (QTc 540 ms). He experienced torsades de pointes (TdP) several times and he was recovered after bystander cardiopulmonary resuscitation. The clinical course and the long QTc interval with deep inverted T wave were completely normalized 4 weeks after. He continued on triple antibiotic therapy for 45 days with a good revolution. The clinical features and the possible mechanisms of QT prolongation (inflammation, infection) of this patient are discussed.
Tounsi, A.; Abid, L.; Akrout, M.; Hentati, M.; Kammoun, S.
Alterations of normal mitral valve (MV) function lead to mitral insufficiency, i.e., mitral regurgitation (MR). Mitral repair is the most popular and most efficient surgical intervention for MR treatment. An annuloplasty ring is implanted following complex reconstructive MV repairs to prevent potential reoccurrence of MR. We have developed a novel finite element (FE)-based simulation protocol to perform patient-specific virtual ring annuloplasty following the standard clinical guideline procedure. A virtual MV was created using 3D echocardiographic data in a patient with mitral annular dilation. Proper type and size of the ring were determined in consideration of the MV apparatus geometry. The ring was positioned over the patient MV model and annuloplasty was simulated. Dynamic simulation of MV function across the complete cardiac cycle was performed. Virtual patient-specific annuloplasty simulation well demonstrated morphologic information of the MV apparatus before and after ring implantation. Dynamic simulation of MV function following ring annuloplasty demonstrated markedly reduced stress distribution across the MV leaflets and annulus as well as restored leaflet coaptation compared to pre-annuloplasty. This novel FE-based patient-specific MV repair simulation technique provides quantitative information of functional improvement following ring annuloplasty. Virtual MV repair strategy may effectively evaluate and predict interventional treatment for MV pathology.
Choi, Ahnryul; Rim, Yonghoon; Mun, Jeffrey S.; Kim, Hyunggun
A test rig has been developed to investigate the function of prosthetic heart valves under pulsatile flow conditions. The rig uses a servo-controlled pump to produce a physiological flow waveform through the valve. The pressure difference across the valve and flow through the valves are measured to assess the valve function. The mean pressure difference, root mean square (RMS) forward flow and regurgitant volumes are calculated on a computer. In the initial study, seven popular mechanical prostheses (sizes 29 and 27 mm) were evaluated in the mitral position under five different flow conditions. The mean pressure difference was dependent on the position of the downstream pressure tapping, the orientation of the valve and the time interval used to average the signals. The orientation of some valves also affected the regurgitant volumes. These variations (10-25%) were similar in size to the differences measured between individual valves. Test conditions have to be specified very carefully for accurate comparison of valve function to be made. PMID:2937603
Fisher, J; Jack, G R; Wheatley, D J
Mechanical heart valves implanted in mitral position have a great effect on the ventricular flow. Changes include alteration of the dynamics of the vortical structures generated during the diastole and the onset of turbulence, possibly affecting the efficiency of the heart pump or causing blood cell damage. Modifications to the hemodynamics in the left ventricle, when the inflow through the mitral orifice is altered, were investigated in vitro using a silicone rubber, flexible ventricle model. Velocity fields were measured in space and time by means of an image analysis technique: feature tracking. Three series of experiments were performed: one with a top hat inflow velocity profile (schematically resembling physiological conditions), and two with mechanical prosthetic valves of different design, mounted in mitral position-one monoleaflet and the other bileaflet. In each series of runs, two different cardiac outputs have been examined by changing the stroke volume. The flow was investigated in terms of phase averaged velocity field and second order moments of turbulent fluctuations. Results show that the modifications in the transmitral flow change deeply the interaction between the coherent structures generated during the first phase of the diastole and the incoming jet during the second diastolic phase. Top hat inflow gives the coherent structures which are optimal, among the compared cases, for the systolic function. The flow generated by the bileaflet valve preserves most of the beneficial features of the top hat inflow, whereas the monoleaflet valve generates a strong jet which discourages the permanence of large coherent structures at the end of the diastole. Moreover, the average shear rate magnitudes induced by the smoother flow pattern of the case of top hat inflow are nearly halved in comparison with the values measured with the mechanical valves. Finally, analysis of the turbulence statistics shows that the monoleaflet valves yield higher turbulence intensity in comparison with the bileaflet and, with top hat inflow, there is not a complete transition to turbulence.
Querzoli, G.; Fortini, S.; Cenedese, A.
Background Surgical ablation has emerged as an acceptable treatment modality for patients with atrial fibrillation (AF) undertaking concomitant cardiac surgery. However, the efficacy of surgical ablation in patient populations undergoing mitral valve surgery is not well established. The present meta-analysis aims to establish the current randomized evidence on clinical outcomes of surgical ablation versus no ablative treatment in patients with AF undergoing mitral valve surgery. Methods Electronic searches were performed using six databases from their inception to September 2013, identifying all relevant randomized controlled trials (RCTs) comparing surgical ablation versus no ablation in AF patients undergoing mitral valve surgery. Data were extracted and analyzed according to predefined clinical endpoints. Results Nine relevant RCTs were identified for inclusion in the present analysis. The number of patients in sinus rhythm (SR) was significantly improved in the surgical ablation group compared to the non-ablation group at discharge. This effect on SR remained at all follow-up periods until >1 year. Results indicated that there was no significant difference between surgical ablation and no ablation in terms of 30-day mortality, all-cause mortality, pacemaker implantation, stroke, thromboembolism, cardiac tamponade, reoperation for bleeding and myocardial infarction. Conclusions Results from the present meta-analysis demonstrate that the addition of surgical ablation for AF leads to a significantly higher rate of sinus rhythm in mitral valve surgical patients, with no increase in the rates of mortality, pacemaker implantation, stroke and thromboembolism. Further research should be directed at correlating different surgical ablation subtypes to cardiac and cerebrovascular events at long-term follow-up.
Phan, Kevin; Xie, Ashleigh; Tian, David H.; Shaikhrezai, Kasra
An incompressible transversely isotropic hyperelastic material for solid finite element analysis of a porcine mitral valve\\u000a response is described. The material model implementation is checked in single element tests and compared with a membrane implementation\\u000a in an out-of-plane loading test to study how the layered structures modify the stress response for a simple geometry. Three\\u000a different collagen layer arrangements are
V. Prot; B. Skallerud
For cardioplegia delivery and removing air from the aorta in minimally invasive mitral valve operations, we would like to propose a cost-effective pigtail method. The 8F pigtail punctures the aorta, delivers cardioplegia, and stays in place for removing air from the aorta. We then slide its tip out of the aorta as an accessory drain. With more than 100 successes, we are using it in every case and would like to share it with peer surgeons. PMID:23438572
Chiu, Kuan-Ming; Chen, Robert Jeen-Chen; Lin, Tzu-Yu; Chen, Jer-Shen; Huang, Jih-Hsin; Chu, Shu-Hsun
Doppler echocardiography was performed in 104 patients with a Björk-Shiley prosthetic valve in the mitral position. Valves of size 25 mm and 27 mm were inserted in 39 and 65 patients, respectively. Each valve had two models; the older convexo-concave model (22 and 40, of 25 and 27 mm size, respectively). Inflow velocities were recorded using Doppler techniques and the gradients calculated using the Bernoulli principle. The area of the mitral valve was determined by the T1/2 method. Comparison of the two models for both sizes did not reveal any significant differences in either the gradients across the valves or the area of the valve. Trivial mitral regurgitation was detected in a higher percentage of monostrut valves (18% and 20% for the 25 and 27 mm older convexo-concave models and 59.9% and 52% for the 25 and 27 mm monostrut valve). We conclude that the newer monostrut model of the Björk-Shiley valve in the mitral position does not offer any additional haemodynamic benefit. PMID:2788623
Radhakrishnan, S; Dev, V; Saxena, A; Bahl, V K; Venugopal, P; Shrivastava, S
Cardiac arrhythmias and myocardial malfunction are very frequent in uremic patients. The pathogenesis and etiology of arrhythmias are very complex and still unknown. The sedimentation of calcium salt in myocardial structures is one of the reasons for emergence of cardiac arrhythmias (AV conduction defects, ectopic arrhythmias). The appearance of mitral annular calcification (MAC), as the expression of the speed up process of atherosclerosis, was noted in younger uremic patients especially during hemodialysis. The aim of our research was to compare the incidence of MAC and cardiac arrhythmias in patients on hemodialysis. Our study included 40 patients, 24 male and 16 female, in the age between 20 and 60. Patients were mostly from Zagreb and the Counties of Zagreb (35%), Karlovac (10%), Slavonski Brod (7.5%), Varazdin (5%) and Pozega (5%). All 40 patients received 24 hours of Holter monitoring and 2-D echocardiography of M-mode. The patients were divided in two groups: I MAC+ (N = 23) and II MAC- (N = 17). Frequency of cardiac arrhythmias in group I was: atrial fibrillation N = 0; conduction defects N = 2 (1%); ventricularectopy Lown grade 3-5 N = 15 (65%); supraventricular ectopy N = 8 (34%), while the frequency of cardiac arrhythmias in group II was: atrial fibrillation N = 0; conduction defects N = 0; ventricular ectopy Lown grade 3-5 N = 6 (35%), supraventricular ectopy N = 6 (35%). During statistical processing the significant connection of MAC+ and frequency of cardiac arrhythmias was noticed. For both groups we have not noticed statistical significance in cardiac arrhythmia compared to electrolytes, risk factors PTH, and age. The time of hemodialysis treatment is one of possible factors for incidence of cardiac arrhythmias influenced by MAC. We noticed statistically significant (p < 0.05) difference of rhythm disorders between group I and group II especially for the ventricular ectopic activity, the frequency of which was higher in group I than in group II. MAC has probably significant role in dialysis patients for the development of cardiac arrhythmias within the framework of series of complicated multifactorial patogenetic mechanisms. PMID:9225510
Jeren-Struji?, B; Raos, V; Jeren, T; Horvatin-Godler, S
Summary Mitral valve prolapse is a common valvular abnormality that is caused by myxomatous degeneration, characterized macroscopically by leaflet thickening and redundancy accompanied with histologically marked proliferation of the spongiosa and mucopolysaccharide acid replacement of leaflet collagen in the prolapse leaflets. Nevertheless, the discrepant natural history and various concomitant syndromes cannot be explained completely by the current genetic autosomal dominant inheritance theory. In addition, autonomic dysregulation has been commonly reported in mitral valve prolapse, but has never been indicated as a major underlying cause. This article attempts to interpret the occurrence of primary pathology and progression in mitral valve prolapse on a common basis of improper autonomic tone. The imbalanced background of autonomic nervous firing leads to disharmonized synthetic/catabolism balance in the extracellular matrix, disrupted transition in the interstitial cellular component and invalided anti-inflammatory pathway in the endothelium, which trigger and accelerate the progression of this condition. Such a hypothesis not only unifies the seemingly disparate syndromes and valvular disorder, but also has implications for future biopharmaceutical and mechanical treatment.
Hu, Xiang; Zhao, Qiang
We present the case of a 70-year old woman who had elective mitral and aortic valve surgery. She underwent surgery without complications for about 4h until 4 pm. Approx. 3h after surgery her condition deteriorated. 1500ml of blood were collected in the chest drainage until 11 pm. An emergency thoracotomy in the patient's bed showed a ventricular rupture. Death occurred around 11:30 pm. At autopsy, the implants of the biological mitral and aortic valves were found to be sewn tightly. There was no vascular injury and no unusual bleedings to the mediastinum. In the left ventricular wall, a rupture of 1cm and a surrounding fresh myocardial infarction area of 10cm×6cm was noted. Preparation of the coronary arteries showed moderate coronary atherossclerosis without stenosis or clots. The left circumflex coronary artery (LCX) showed a sharp, obviously stenosing kink which had been caused by the mitral valve surgery. Exsanguination due to ventricular rupture following myocardial infarction caused by implant-related "kinking" of a coronary artery, was found to be the cause of death. PMID:22579449
Schyma, C; Kernbach-Wighton, G; Madea, B
Fifty-three patients were studied with combined echo-phonocardiography or phonocardiography alone following prosthetic valve replacement. In sixteen of these patients, clinical deterioration developed, and all subsequently underwent cardiac catheterization and/or surgery. Two patients came to autopsy. Included in this group of sixteen patients were five with obstructed prosthesis, six with paravalvular regurgitation, and five with left ventricular dysfunction. Measurements were made of the time interval from the aortic valve closure sound to the peak opening of the mitral prosthesis determined echocardiographically or to the mitral prosthetic opening click (A2-MVO). Echocardiographic studies of left ventricular wall motion were also performed. The A2-MVO interval was significantly shortened (P less than 0.01) with prosthetic valve obstruction (.05 +/- .02 sec) and paravalvular regurgitation (.05 +/- .01 sec) compared with normally functioning prostheses (Starr-Edwards ball valves .10 +/- .02 sec, Lillehei-Kaster tilting disc prostheses .09 +/- .01 sec). Shortening of this interval was not specific for these conditions because it was sometimes shortened with left ventricular dysfunction. Echocardiographic studies of left ventricular wall motion were helpful in distinguishing among prosthetic valve obstruction, paravalvular regurgitation and left ventricular dysfunction. The combined echo-phonocardiographic technique was especially helpful in detecting malfunction of tilting disc prostheses, because the technique enables measurement of the A2-MVO interval in the absence of an audible opening click. PMID:1244259
Brodie, B R; Grossman, W; McLaurin, L; Starek, P J; Craige, E
Severe haemolytic anaemia is a rare complication of prosthetic valve thrombosis (PVT). Emergent surgical replacement of the affected valve is normally the treatment of choice unless contraindicated, such as in high surgical risk patients. Systemic thrombolysis is the alternative to surgical valve replacement. The purpose of this report is to highlight the unique case of an elderly man with New York Heart Association class IV heart failure, history of extensive cardiopulmonary surgeries and haemorrhagic stroke, who presented with severe haemolytic anaemia secondary to prosthetic mitral valve thrombosis. After weighing the risks and benefits, our decision was to use systemic thrombolytic therapy, even in light of the patient's previous intracranial haemorrhage. Pretreatment and post-treatment Doppler echocardiography showed markedly reduced regurgitant jetting that ultimately resolved completely, thereby eliminating the underlying cause of haemolysis and achieving symptom resolution. PMID:24879723
Beckord, Brian; Berkowitz, Robert; Espinoza, Cholene; Anand, Neil
Mitral valve degeneration is a key component of the pathophysiology of Marfan syndrome. The biomechanical consequences of aging and genetic mutation in mitral valves are poorly understood because of limited tools to study this in mouse models. Our aim was to determine the global biomechanical and local cell-matrix deformation relationships in the aging and Marfan related Fbn1 mutated murine mitral valve. To conduct this investigation, a novel stretching apparatus and gripping method was implemented to directly quantify both global tissue biomechanics and local cellular deformation and matrix fiber realignment in murine mitral valves. Excised mitral valve leaflets from wild-type and Fbn1 mutant mice from 2 weeks to 10 months in age were tested in circumferential orientation under continuous laser optical imaging. Mouse mitral valves stiffen with age, correlating with increases in collagen fraction and matrix fiber alignment. Fbn1 mutation resulted in significantly more compliant valves (modulus 1.34±0.12 vs. 2.51±0.31 MPa, respectively, P<.01) at 4 months, corresponding with an increase in proportion of GAGs and decrease in elastin fraction. Local cellular deformation and fiber alignment change linearly with global tissue stretch, and these slopes become more extreme with aging. In comparison, Fbn1 mutated valves have decoupled cellular deformation and fiber alignment with tissue stretch. Taken together, quantitative understanding of multi-scale murine planar tissue biomechanics is essential for establishing consequences of aging and genetic mutations. Decoupling of local cell-matrix deformation kinematics with global tissue stretch may be an important mechanism of normal and pathological biomechanical remodeling in valves.
Gould, Russell A.; Sinha, Ravi; Aziz, Hamza; Rouf, Rosanne; Dietz, Harry C.; Judge, Daniel P.; Butcher, Jonathan
Cardiac calcification usually occurs in patients with end-stage renal disease. However, rapid progression of cardiac calcification is rarely associated with secondary hyperparathyroidism of end-stage renal disease. We report a patient with end-stage renal disease who showed moderate left ventricular hypertrophy at the first echocardiography, and showed severe myocardial calcification and severe mitral valve stenosis 4 years later. We suspected a rapid progression 'porcelain heart' cardiomyopathy secondary to hyperparathyroidism of end-stage renal disease. The patient underwent parathyroidectomy, and considered mitral valve replacement.
Lee, Hyeon-Uk; Shim, Byung-Ju; Lee, Seung-Jae; Park, Mi-Youn; Jeong, Jin-Uk; Gu, Gwan-Min; Jeon, Hui-Kyung; Lee, Ji-eun; Kwon, Byung-Jin
Background Saddle-shaped annuloplasty rings are being increasingly used during mitral valve (MV) repair to conform the mitral annulus to a more nonplanar shape and possibly reduce leaflet stress. In this study utilizing three-dimensional transesophageal echocardiography we compared the effects of rigid flat rings with those of the saddle rings on the mitral annular geometry. Specifically we measured the changes in nonplanarity angle (NPA) before and after MV repair. Methods Geometric analysis on 38 patients undergoing MV repair for myxomatous and ischemic mitral regurgitation with full flat rings (n = 18) and saddle rings (n = 18) were performed. The acquired three-dimensional volumetric data were analyzed utilizing the “Image Arena” software (TomTec GmBH, Munich, Germany). Specifically, the degree of change in the NPA was calculated and compared before and after repair for both types of rings. Results Both types of annuloplasty rings resulted in significant changes in the geometric structure of the MV after repair. However, saddle rings lead to a decrease in the NPA (7% for ischemic and 8% for myxomatous MV repairs) (ie, made the annulus more nonplanar), whereas flat rings increased the NPA (7.9% for ischemic and 11.8% for myxomatous MV repairs) (ie, made the annulus less nonplanar); p value 0.001 or less. Conclusions Implantation of saddle-shaped rings during MV repair surgery is associated with augmentation of the nonplanar shape of the mitral annulus (ie, decreases NPA). This favorable change in the mitral annular geometry could possibly confer a structural advantage to MV repairs with the saddle rings.
Mahmood, Feroze; Gorman, Joseph H.; Subramaniam, Balachundhar; Gorman, Robert C.; Panzica, Peter J.; Hagberg, Robert C.; Lerner, Adam B.; Hess, Philip E.; Maslow, Andrew; Khabbaz, Kamal R.
A combination of M mode and Doppler echocardiography was used to study patients with mitral disc valve prostheses. The probe used in these investigations consisted of a circular Doppler crystal mounted around the M mode crystal in the same plane. Because of the strong echoes produced by the prosthesis the transducer (probe) could be angled for optimum Doppler signals without losing the M mode echocardiographic recording of the prosthesis. With this equipment mean and maximum blood velocities and Doppler amplitude signals could be measured simultaneously with M mode echocardiography. A depth indication line in the M mode recording ensured that the Doppler signal was recorded in the region of interest. The Doppler ultrasound technique was also used separately in both the pulsed wave and the continuous wave mode. The data show the usefulness of this technique in patients with normally functioning valve prostheses and in three patients with valve malfunction due to thrombus formation. The data in the latter three cases seem to indicate that the Doppler technique provides valuable information in addition to that obtained by M mode echocardiography in recognising mitral valve prosthetic malfunction. Images
Previous research in our lab suggested that heart valve tissues cultured without mechanical stimulation do not retain their in vivo microstructure, i.e., cell density decreased within the deep tissue layers and increased at the periphery. In this study, a splashing rotating bioreactor was designed to apply mechanical stimulation to a mitral valve leaflet segment. Porcine valve segments (n = 9-10 per group) were cultured in the bioreactor for 2 weeks (dynamic culture), negative controls were cultured without mechanical stimulation (static culture), and baseline controls were fresh uncultured samples. Overall changes in cellularity and extracellular matrix (ECM) structure were assessed by H&E and Movat pentachrome stains. Tissues were also immunostained for multiple ECM components and turnover mediators. After 2 weeks of culture, proliferating cells were distributed throughout the tissue in segments cultured in the bioreactor, in contrast to segments cultured without mechanical stimulation. Most ECM components, especially collagen types I and III, better maintained normal expression patterns and magnitudes (as found in baseline controls) over 2 weeks of dynamic organ culture compared to static culture. Lack of mechanical stimulation changed several aspects of the tissue microstructure, including the cell distribution and ECM locations. In conclusion, mechanical stimulation by the bioreactor maintained tissue integrity, which will enable future in vitro investigation of mitral valve remodeling. PMID:20661646
Barzilla, Janet E; McKenney, Anna S; Cowan, Ashley E; Durst, Christopher A; Grande-Allen, K Jane
There are many difficulties for young women with a Starr-Edwards ball valve who want to attempt pregnancy. There is no consensus regarding whether they should maintain anticoagulation therapy throughout pregnancy with the risk of a thromboembolism or to undergo a reoperation with bioprosthetic heart valves, followed by a third operation when the valve deteriorates. This report presents two cases of young women who underwent mitral valve replacement (MVR) with Starr-Edwards ball valves (model 6120: 1M) during their childhood. Although they did not have any cardiac symptoms, transthoracic echocardiography and cardiac catheterization data demonstrated that both the patients had asymptomatic mild relative mitral stenosis. They both wished to bear a child. After the patients and their family provided thorough informed consent, redo MVRs were preformed safely with biological prostheses. The presence of significant pannus formation along the strut and sewing ring of the excised valves could also have a positive impact on the decision to undergo reoperation. PMID:19639442
Asano, Ryota; Nakano, Kiyoharu; Kodera, Kojiro; Murai, Noriyuki; Sasaki, Akihito; Ikeda, Masahiro; Kataoka, Go; Yamaguchi, Akiko; Domoto, Satoru; Takeuchi, Yasuo
Background Fetuin-A is a multifunctional hepatic secretory protein that inhibits dystrophic vascular and valvular calcification. Lower serum fetuin-A concentrations are associated with valvular calcification in persons with end-stage renal disease. Whether fetuin-A is associated with valvular calcification in other patient populations is unknown. Methods and Results We evaluated the associations among serum fetuin-A concentrations, mitral annular calcification, and aortic stenosis in 970 ambulatory persons with coronary heart disease and without severe kidney disease. The presence or absence of mitral annular calcification and aortic stenosis was determined by transthoracic echocardiography. The subjects’ mean age was 66 years; 81% were men; 189 (20%) had mitral annular calcification; and 79 (8%) had aortic stenosis. Participants were categorized by tertiles of fetuin-A concentrations. Those within the highest fetuin-A tertile had significantly lower odds of mitral annular calcification compared with the lowest tertile (adjusted odds ratio, 0.47; 95% confidence interval, 0.29 to 0.77; P=0.002); this association was similar regardless of diabetes status (P for interaction=0.34). In contrast, the association of fetuin-A with aortic stenosis was modified by the presence or absence of diabetes mellitus (P for interaction=0.03). Among participants without diabetes, the highest fetuin-A tertile had a significantly lower odds of aortic stenosis compared with the lowest tertile (adjusted odds ratio, 0.37; 95% confidence interval, 0.15 to 0.92; P=0.03), whereas among participants with diabetes, no statistically significant association was observed between fetuin-A and aortic stenosis (adjusted odds ratio, 1.49; 95% confidence interval, 0.48 to 4.63; P=0.49). Conclusions Among persons with coronary heart disease, we observed an inverse association of fetuin-A and mitral annular calcification. An inverse association also was observed between fetuin-A and aortic stenosis among participants without diabetes mellitus. Fetuin-A may represent an important inhibitor of dystrophic calcification in persons with coronary heart disease.
Ix, Joachim H.; Chertow, Glenn M.; Shlipak, Michael G.; Brandenburg, Vincent M.; Ketteler, Markus; Whooley, Mary A.
Echocardiographic and phonocardiographic records of 19 patients with a normally functioning Cooley-Cutter mitral valve were analyzed in order to provide quantitative baseline values for this prosthesis. The average duration between the second heart sound and peak opening of the valve (A2-OC interval) was 83 ± 4 (standard error of the mean) msec. The Q-CC interval (from the electrocardiographic Q wave to closure of the valve) was 71 ± 2 msec. Mean opening and closing velocities of the disc were similar (396 ± 11 mm/sec and 393 ± 12 mm/sec, respectively). Amplitude of disc excursion ranged from 6 to 9 mm, but this measurement was not possible in all patients due to the presence of spurious echoes. Early onset of prosthetic valve closure was a relatively common finding in patients with atrial fibrillation or with various forms of atrioventricular block, and frequently resulted in a variety of phonocardiographic alterations. Except for the A2-OC interval and amplitude of disc excursion, there was no significant correlation between valve size and echo-phonocardiographic measurements. Results of this study are compared with values previously reported for other types of caged disc valves, and the usefulness and limitations of echo-phonocardiographic assessment of prosthetic valve function are briefly discussed. Images
Pechacek, Leonard W.; Zarrabi, Ali; Massumkhani, Ali; Garcia, Efrain; De Castro, Carlos M.; Hall, Robert J.
Numerical models of the mitral valve have been used to elucidate mitral valve function and mechanics. These models have evolved from simple two-dimensional approximations to complex three-dimensional fully coupled fluid structure interaction models. However, to date these models lack direct one-to-one experimental validation. As computational solvers vary considerably, experimental benchmark data are critically important to ensure model accuracy. In this study, a novel left heart simulator was designed specifically for the validation of numerical mitral valve models. Several distinct experimental techniques were collectively performed to resolve mitral valve geometry and hemodynamics. In particular, micro-computed tomography was used to obtain accurate and high-resolution (39 µm voxel) native valvular anatomy, which included the mitral leaflets, chordae tendinae, and papillary muscles. Threedimensional echocardiography was used to obtain systolic leaflet geometry for direct comparison of resultant leaflet kinematics. Stereoscopic digital particle image velocimetry provided all three components of fluid velocity through the mitral valve, resolved every 25 ms in the cardiac cycle. A strong central filling jet was observed during peak systole, with minimal out-of-plane velocities (V~0.6m/s). In addition, physiologic hemodynamic boundary conditions were defined and all data were synchronously acquired through a central trigger. Finally, the simulator is a precisely controlled environment, in which flow conditions and geometry can be systematically prescribed and resultant valvular function and hemodynamics assessed. Thus, these data represent the first comprehensive database of high fidelity experimental data, critical for extensive validation of mitral valve fluid structure interaction simulations.
Rabbah, Jean-Pierre; Saikrishnan, Neelakantan; Yoganathan, Ajit P.
Hypereosinophilic syndrome (HES) is defined as a prolonged, unexplained peripheral eosinophilia in a patient presenting with end-organ damage. The heart is frequently involved, resulting in eosinophilic endomyocardial disease, which is characterized by mural thrombus formation and endocardial fibrosis. Thromboembolic complications in HES are mediated by material released from eosinophilic granules. Herein is reported the case of a patient who presented, 15 years after valve replacement with a mechanical prosthesis, with clinical signs of recurrent prosthetic valve thrombosis that was caused by missed hypereosinophilia. The unique feature of the case was that the mitral prosthetic valve obstruction was the result of an eosinophilic thrombus, though no tissue infiltration or inflammation had been detected by random biopsy of the left ventricular myocardium. After nine years of effective treatment of HES there were no cardiac or extracardiac complications. PMID:17044383
Jánoskuti, Lívia; Förhécz, Zsolt; Lengyel, Mária
Mitral regurgitation (MR) has previously been classified into rheumatic, primary, and secondary MR according to the underlying disease process. Carpentier's/Duran functional classifications are apt in describing the mechanism(s) of MR. Modern management of MR, however, depends primarily on the severity of MR, status of the left ventricular function, and the presence or absence of symptoms, hence the need for a management-oriented classification of MR. In this paper we describe a classification of MR into 4 phases according to LV function: phase I = MR with normal left ventricle, phase II = MR with normal ejection fraction (EF) and indirect signs of LV dysfunction such as pulmonary hypertension and/or recent onset atrial fibrillation, phase III = EF ? 30%–< 50% and/or mild to moderate LV dilatation (ESID 40–54?mm), and phase IV = EF < 30% and/or severe LV dilatation (ESDID ? 55?mm). Each phase is further subdivided into three stages: stage “A” with an effective regurgitant orifice (ERO) < 20?mm, stage “B” with an ERO = 20–39?mm, and stage “C” with an ERO ? 40?mm. Evidence-based indications and outcome of intervention for MR will also be discussed.
El Oakley, Reida; Shah, Aijaz
Anterior mitral leaflet stiffness during isovolumic contraction (IVC) is much greater than that during isovolumic relaxation (IVR). We have hypothesized that this stiffening is due to transient early systolic force development in the slip of cardiac myocytes in the annular third of the anterior leaflet. Because the atrium is excited before IVC and leaflet myocytes contract for ?250 ms, this hypothesis predicts that IVC leaflet stiffness will drop to near-IVR values in the latter half of ventricular systole. We tested this prediction using radiopaque markers and inverse finite element analysis of 30 beats in 10 ovine hearts. For each beat, circumferential (Ec) and radial (Er) stiffness was determined during IVC (?t1), end IVC to midsystole (?t2), midsystole to IVR onset (?t3), and IVR (?t4). Group mean stiffness (Ec ± SD; Er ± SD; in N/mm2) during ?t1 (44 ± 16; 15 ± 4) was 1.6–1.7 times that during ?t4 (28 ± 11; 9 ± 3); ?t2 stiffness (39 ± 15; 14 ± 4) was 1.3–1.5 times that of ?t4, but ?t3 stiffness (32 ± 12; 11 ± 3) was only 1.1–1.2 times that of ?t4. The stiffness drop during ?t3 supports the hypothesis that anterior leaflet stiffening during IVC arises primarily from transient force development in leaflet cardiac myocytes, with stiffness reduced as this leaflet muscle relaxes in the latter half of ventricular systole.
Krishnamurthy, Gaurav; Itoh, Akinobu; Swanson, Julia C.; Miller, D. Craig
A 27-year-old woman with a history of bileaflet mitral valve prolapse and moderate mitral regurgitation presented to our emergency with untractable polymorphic wide complex tachycardia and unstable haemodynamics. After cardiopulmonary resuscitation, return of spontaneous circulation was achieved 30 min later. Her post-resuscitation ECG showed a prolonged QT interval which progressively normalised over the same day. Her laboratory investigations revealed hypocalcaemia while other electrolytes were within normal limits. A diagnosis of ventricular arrhythmia secondary to structural heart disease further precipitated by hypocalcaemia was made. Further hospital stay did not reveal a recurrence of prolonged QT interval or other arrhythmias except for an episode of non-sustained ventricular tachycardia. However, the patient suffered diffuse hypoxic brain encephalopathy secondary to prolonged cardiopulmonary resuscitation. PMID:24827670
Rajani, Ali Raza; Murugesan, Vagishwari; Baslaib, Fahad Omar; Rafiq, Muhammad Anwer
Accessory mitral valve tissue is a rare congenital anomaly associated with congenital cardiac defects and is usually detected in the first decade of life. We describe the case of an 18-year old post-Senning asymptomatic patient who was found to have accessory mitral valve tissue on transthoracic echocardiography producing severe left ventricular outflow tract obstruction.
Panduranga, Prashanth; Eapen, Thomas; Al-Maskari, Salim; Al-Farqani, Abdullah
Calcification limits the functional lifetime of cardiac valve substitutes fabricated from glutaraldehyde preserved bovine pericardium. Host factors, mainly younger age, and implant factors, mainly glutaraldehyde cross-linking, are implicated in the calcification process. Glutaraldehyde cross-linking is believed to activate the potential sites in the tissues for biocalcification. In the present work, we investigated the possibility of using alginate azide (AA) instead of glutaraldehyde for the preservation of pericardial tissues in order to enhance the durability of bioprosthetic heart valves. Grafting with poly(GMA-BA) copolymer to the alginate azide cross-linked pericardial (AACPC) tissue was carried out to obtain better stability, strength, and anticalcification properties. The strength property and thermal stability of the AA cross-linked tissues were studied. Calcification studies in rat subdermal models reveal that AA cross-linking reduces the calcification to negligible levels. After 30 days implantation, the calcium content was found to be 10.4 +/- 1.2 and 6.1 +/- 0.3 micrograms mg-1 for untreated AACPC and polymer grafted AACPC, respectively, compared to a value of 100 +/- 1.2 micrograms mg-1 calcium recorded for control glutaraldehyde cross-linked pericardial (GCPC) tissues. PMID:9399142
Shanthi, C; Rao, K P
Calcific aortic valve disease (CAVD) results in impaired function through the inability of valves to fully open and close, but the causes of this pathology are unknown. Stiffening of the aorta is associated with CAVD and results in exposing the aortic valves to greater mechanical strain. Transforming growth factor ?1 (TGF-?1) is enriched in diseased valves and has been shown to combine with strain to synergistically alter aortic valve interstitial cell (AVIC) phenotypes. Therefore, we investigated the role of strain and TGF-?1 on the calcification of AVICs. Following TGF-?1 pretreatment, strain induced intact monolayers to aggregate and calcify. Using a wound assay, we confirmed that TGF-?1 increases tension in the monolayer in parallel with ?-smooth muscle actin (?SMA) expression. Continual exposure to strain accelerates aggregates to calcify into mature nodules that contain a necrotic core surrounded by an apoptotic ring. This phenotype appears to be mediated by strain inhibition of AVIC migration after the initial formation of aggregates. To better interpret the extent to which externally applied strain physically impacts this process, we modified the classical Lamé solution, derived using principles from linear elasticity, to reveal strain magnification as a novel feature occurring in a mechanical environment that supports nodule formation. These results indicate that strain can impact multiple points of nodule formation: by modifying tension in the monolayer, remodeling cell contacts, migration, apoptosis, and mineralization. Therefore, strain-induced nodule formation provides new directions for developing strategies to address CAVD. PMID:22307683
Fisher, Charles I; Chen, Joseph; Merryman, W David
Advanced valvular lesions often contain ectopic mesenchymal tissues, which may be elaborated by an unidentified multipotent progenitor subpopulation within the valve interstitium. The identity, frequency, and differentiation potential of the putative progenitor subpopulation are unknown. The objectives of this study were to determine whether valve interstitial cells (VICs) contain a subpopulation of multipotent mesenchymal progenitor cells, to measure the frequencies of the mesenchymal progenitors and osteoprogenitors, and to characterize the osteoprogenitor subpopulation because of its potential role in calcific aortic valve disease. The multilineage potential of freshly isolated and subcultured porcine aortic VICs was tested in vitro. Progenitor frequencies and self-renewal capacity were determined by limiting dilution and colony-forming unit assays. VICs were inducible to osteogenic, adipogenic, chondrogenic, and myofibrogenic lineages. Osteogenic differentiation was also observed in situ in sclerotic porcine leaflets. Primary VICs had strikingly high frequencies of mesenchymal progenitors (48.0 ± 5.7%) and osteoprogenitors (44.1 ± 12.0%). High frequencies were maintained for up to six population doublings, but decreased after nine population doublings to 28.2 ± 9.9% and 5.8 ± 1.3%, for mesenchymal progenitors and osteoprogenitors, respectively. We further identified the putative osteoprogenitor subpopulation as morphologically distinct cells that occur at high frequency, self-renew, and elaborate bone matrix from single cells. These findings demonstrate that the aortic valve is rich in a mesenchyma l progenitor cell population that has strong potential to contribute to valve calcification.
Chen, Jan-Hung; Yip, Cindy Ying Yin; Sone, Eli D.; Simmons, Craig A.
Calcific aortic valve disease (CAVD) results in impaired function through the inability of valves to fully open and close, but the causes of this pathology are unknown. Stiffening of the aorta is associated with CAVD and results in exposing the aortic valves to greater mechanical strain. Transforming growth factor ?1 (TGF-?1) is enriched in diseased valves and has been shown to combine with strain to synergistically alter aortic valve interstitial cell (AVIC) phenotypes. Therefore, we investigated the role of strain and TGF-?1 on the calcification of AVICs. Following TGF-?1 pretreatment, strain induced intact monolayers to aggregate and calcify. Using a wound assay, we confirmed that TGF-?1 increases tension in the monolayer in parallel with ?-smooth muscle actin (?SMA) expression. Continual exposure to strain accelerates aggregates to calcify into mature nodules that contain a necrotic core surrounded by an apoptotic ring. This phenotype appears to be mediated by strain inhibition of AVIC migration after the initial formation of aggregates. To better interpret the extent to which externally applied strain physically impacts this process, we modified the classical Lamé solution, derived using principles from linear elasticity, to reveal strain magnification as a novel feature occurring in a mechanical environment that supports nodule formation. These results indicate that strain can impact multiple points of nodule formation: by modifying tension in the monolayer, remodeling cell contacts, migration, apoptosis, and mineralization. Therefore, strain induced nodule formation provides new directions for developing strategies to address CAVD.
Fisher, Charles I.; Chen, Joseph; Merryman, W. David
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. PMID:24507881
Reimann, M J; Møller, J E; Häggström, J; Markussen, B; Holen, A E W; Falk, T; Olsen, L H
Objective Acute mitral stenosis (MS) following mitral valve (MV) repair is a rare but severe complication. We hypothesize that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair. Methods The medical records of 552 consecutive patients undergoing MV repair at a single institution were reviewed. Post-cardiopulmonary bypass peak and mean transmitral pressure gradients (TMPG), and pressure half time (PHT) were obtained from intraoperative transesophageal echocardiographic (TEE) examinations in each patient. Results Nine patients (9/552?=?1.6%) received a reoperation for primary MS, prior to hospital discharge. Interestingly, all of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not: 10.7±4.8 mmHg vs 2.9±1.6 mmHg; p<0.0001 and 22.9±7.9 mmHg vs 7.6±3.7 mmHg; p<0.0001, respectively. However, PHT varied considerably (87±37 ms; range: 20–439 ms) within the entire population, and only weakly predicted the requirement for reoperation (113±56 vs. 87±37 ms, p?=?0.034). Receiver operating characteristic curves showed strong discriminating ability for mean gradients (AUC?=?0.993) and peak gradients (area under the curve, AUC?=?0.996), but poor performance for PHT (AUC?=?0.640). A value of ?7 mmHg for mean, and ?17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not. Conclusions Intraoperative TEE diagnosis of a peak TMPG ?17 mmHg or mean TMPG ?7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair.
Segal, Scott; Fox, John A.; Eltzschig, Holger K.; Shernan, Stanton K.
Staphylococcus lugdunensis is a coagulase-negative staphylococcus (CNS). It is a major cause of prosthetic valve endocarditis; mitral valve prolapse (MVP) has emerged as a prominent predisposing structural cardiac abnormality. We describe a case of Staphylococcus lugdunensis endocarditis in an 18-year-old woman with preexisting mitral valve prolapse complaining of fever, a one-month history of continuous-remittent fever (Tmax 38.6°C). The transthoracic echocardiogram revealed large vegetation on the anterior mitral valve leaflet flopping from the atrial side to the ventricular side. Five sets of blood cultures were positive for coagulase-negative staphylococci. During hospitalization, after two weeks of antibiotic therapy, the patient complained of sudden pain in her right leg associated with numbness. Lower limb arterial Doppler ultrasound showed an arterial thrombosis of right common iliac artery. Transfemoral iliac embolectomy was promptly performed and on septic embolus S. lugdunensis with the same antibiotic sensitivity and the same MIC values was again isolated. Our patient underwent cardiac surgery: triangular resection of the A2 with removal of infected tissue including vegetation. Our case is an example of infective endocarditis by S. lugdunensis on native mitral valve in a young woman of 18 with anamnesis valve prolapse.
Pecoraro, Rosaria; Tuttolomondo, Antonino; Parrinello, Gaspare; Pinto, Antonio; Licata, Giuseppe
Two cases were reported in which malignant cardiac tumors attached to the mitral valve were diagnosed during their lifetimes using two-dimensional echocardiography. Case 1 was a 29-year-old man with speech disturbance and left hemiparesis. Histological examination of the specimen excised from the cardiac tumor during the operation revealed mesenchymal chondrosarcoma, which is extremely rare etiologically and has never been reported so far. Case 2 was a 62-year-old woman complaining of paroxysmal nocturnal dyspnea and chest pain. The diagnosis of malignant histiocytosis was made from the pathological examination of biopsy specimen taken from the rib metastasis. Using two-dimensional echocardiography, characteristic findings for the cardiac tumor were obtained. The tumor echo in Case 1 showed, unlike to that reported for myxoma, two different echogenic layers; the outer dense and the inner light in the echo density. On surgery, tumor echo was revealed to reflect the cystic lesion. In Case 2, two-dimensional echocardiography on admission revealed two separate tumor echoes which attached to the mitral valve and left atrial wall region, respectively. Within two months, they grew rapidly and finally fused into one mass resulting in so-called ball valve syndrome. Phonocardiographically, the tumor plop in Case 1 was high-pitched in quality, and was extinguished completely after the tumor was resected. The tumor plop in Case 2 was not audible on admission, but became evident after fusion of the tumor echoes and was associated with a presystolic murmur. PMID:6520424
Tashiro, N; Fujino, M; Fukuda, K; Okudaira, T; Inoue, T; Kawaguchi, H; Kumamoto, M; Hiroki, T; Arakawa, K; Sukehiro, S
Continuous monitoring of cardiac rhythm may play an important role in measuring the true symptomatic/asymptomatic atrial fibrillation (AF) burden and improve the management of anti-arrhythmic and anti-thrombotic therapies. Forty-seven patients with mitral valve disease and longstanding persistent AF (LSPAF) underwent a left atrial maze procedure with bipolar radiofrequency and valve surgery. The follow-up data recorded by an implanted loop recorder were analysed after 3, 6 and 12 months. On discharge, 40 (85.1%) patients were in stable sinus rhythm, as documented by in-office electrocardiography (ECG), 4 (8.5%) were in pacemaker rhythm and 3 (6.4%) were in AF. One (2.1%) patient died after 7 months. On 12-month follow-up examination, 30 (65.2%) patients had an AF burden <0.5% and were classified as responders. Three (6.5%) of the 16 non-responders had atrial flutter and 13 (27.7%) had documented AF recurrences with an AF burden >0.5%. Two (4.3%) patients with AF recurrences were completely asymptomatic. Among the symptomatic events stored by the patients, only 27.6% was confirmed as genuine AF recurrences according to the concomitant ECG recorded by the implanted loop recorder. A concomitant bipolar maze procedure during mitral valve surgery is effective in treating AF, as proved by detailed 1-year continuous monitoring. PMID:22514258
Bogachev-Prokophiev, Alexandr; Zheleznev, Sergey; Romanov, Alexander; Pokushalov, Evgeny; Pivkin, Alexey; Corbucci, Giorgio; Karaskov, Alexander
Significant mitral regurgitation (MR) is frequent in patients with severe aortic stenosis (AS). In these cases, concomitant mitral valve repair or replacement is usually performed at the time of surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has recently been considered as an alternative for patients at high or prohibitive surgical risk. However, concomitant significant MR in this setting is typically left untreated. Moderate to severe MR after aortic valve replacement is therefore a relevant entity in the TAVR era. The purpose of this review is to present the current knowledge on the clinical impact and post-procedural evolution of concomitant significant MR in patients with severe AS who have undergone aortic valve replacement (SAVR and TAVR). This information could contribute to improving both the clinical decision-making process in and management of this challenging group of patients. PMID:24681140
Nombela-Franco, Luis; Ribeiro, Henrique Barbosa; Urena, Marina; Allende, Ricardo; Amat-Santos, Ignacio; DeLarochellière, Robert; Dumont, Eric; Doyle, Daniel; DeLarochellière, Hugo; Laflamme, Jerôme; Laflamme, Louis; García, Eulogio; Macaya, Carlos; Jiménez-Quevedo, Pilar; Côté, Mélanie; Bergeron, Sebastien; Beaudoin, Jonathan; Pibarot, Philippe; Rodés-Cabau, Josep
Mitral valve reoperation, through a median sternotomy, for a patient with patent coronary bypass grafts is technically challenging and carries higher postoperative morbidity and mortality than a primary operation. We present a case of mitral valve repair using a beating heart technique under normothermic cardiopulmonary bypass that was performed 3 years after a coronary artery bypass operation. A limited (10 cm) right thoracotomy was made and cardiopulmonary bypass was conducted using the ascending aortic and femoral venous cannulation. The left atrium was opened while beating was maintained. Triangular resection of the prolapsed portion of the posterior leaflet and ring annuloplasty were performed. Completeness of the repair was verified by direct visualization under beating condition and transesophageal echocardiogram. This technique is a safe and feasible option for a mitral valve reoperation that excludes re-sternotomy, extensive pericardial dissection and aortic clamping, thereby minimizes risks of bleeding, graft injury and myocardial damage. PMID:24128131
Nakamura, Teruya; Izutani, Hironori; Sekiya, Naosumi; Nakazato, Taro; Sawa, Yoshiki
OBJECTIVES: We sought to develop and validate a model that estimates the risk of obstructive coronary artery disease in patients undergoing operations for mitral valve degeneration and to demonstrate its potential clinical utility. METHODS: A total of 722 patients (67% men; age, 61 +/- 12 years) without a history of myocardial infarction, ischemic electrocardiographic changes, or angina who underwent routine coronary angiography before mitral valve prolapse operations between 1989 and 1996 were analyzed. A bootstrap-validated logistic regression model on the basis of clinical risk factors was developed to identify low-risk (< or =5%) patients. Obstructive coronary atherosclerosis was defined as 50% or more luminal narrowing in one or more major epicardial vessels, as determined by means of coronary angiography. RESULTS: One hundred thirty-nine (19%) patients had obstructive coronary atherosclerosis. Independent predictors of coronary artery disease include age, male sex, hypertension, diabetes mellitus,and hyperlipidemia. Two hundred twenty patients were designated as low risk according to the logistic model. Of these patients, only 3 (1.3%) had single-vessel disease, and none had multivessel disease. The model showed good discrimination, with an area under the receiver-operating characteristic curve of 0.84. Cost analysis indicated that application of this model could safely eliminate 30% of coronary angiograms, corresponding to cost savings of $430,000 per 1000 patients without missing any case of high-risk coronary artery disease. CONCLUSION: A model with standard clinical predictors can reliably estimate the prevalence of obstructive coronary atherosclerosis in patients undergoing mitral valve prolapse operations. This model can identify low-risk patients in whom routine preoperative angiography may be safely avoided.
Lin, S. S.; Lauer, M. S.; Asher, C. R.; Cosgrove, D. M.; Blackstone, E.; Thomas, J. D.; Garcia, M. J.
In vivo human mitral valves (MV) were imaged using real-time 3D transesophageal echocardiography (rt-3DTEE), and volumetric images of the MV at mid-systole were analyzed by user-initialized segmentation and 3D deformable modeling with continuous medial representation, a compact representation of shape. The resulting MV models were loaded with physiologic pressures using finite element analysis (FEA). We present the regional leaflet stress distributions predicted in normal and diseased (regurgitant) MVs. Rt-3DTEE, semi-automated leaflet segmentation, 3D deformable modeling, and FEA modeling of the in vivo human MV is tenable and useful for evaluation of MV pathology.
Pouch, Alison M.; Xu, Chun; Yushkevich, Paul A.; Jassar, Arminder S.; Vergnat, Mathieu; Gorman, Joseph H.; Gorman, Robert C.; Sehgal, Chandra M.; Jackson, Benjamin M.
Glutaraldehyde crosslinked bioprosthetic heart valves (BHVs) have two modalities of failure: degeneration (cuspal tear due to matrix failure) and calcification. They can occur independently as well as one can lead to the other causing co-existence. Calcific failure has been extensively studied before and several anticalcification treatments have been developed; however, little research is directed to understand mechanisms of valvular degeneration. One of the shortcomings of glutaraldehyde fixation is its inability to stabilize all extracellular matrix components in the tissue. Previous studies from our lab have demonstrated that neomycin could be used as a fixative to stabilize glycosaminoglycans (GAGs) present in the valve to improve matrix properties. But neomycin fixation did not prevent cuspal calcification. In the present study, we wanted to enhance the anti-calcification potential of neomycin fixed valves by pre-treating with ethanol or removing the free aldehydes by sodium borohydride treatment. Ethanol treatment has been previously used and found to have excellent anti-calcification properties for valve cusps. Results demonstrated in this study suggest that neomycin followed by ethanol treatment effectively preserves GAGs both in vitro as well as in vivo after subdermal implantation in rats. In vivo calcification was inhibited in neomycin fixed cusps pretreated with ethanol compared to glutaraldehyde (GLUT) control. Sodium borohydride treatment by itself did not inhibit calcification nor stabilized GAGs against enzymatic degradation. Neomycin fixation followed by ethanol treatment of BHVs could prevent both modalities of failure, thereby increasing the effective durability and lifetime of these bioprostheses several fold.
Raghavan, Devanathan; Shah, Sagar R.; Vyavahare, Naren R.
Two groups of elderly patients with calcified aortic stenosis were treated by balloon dilatation. In group 1, the valve was dilated just before surgical replacement of the valve. The valvar and annular changes occurring during dilatation were examined visually. In 20 of the 26 patients in this group there was no change. In the six remaining patients mobilisation of friable calcific deposits (1 case), slight tearing of the commissure (4 cases), or tearing of the aortic ring (1 case) were seen. Dilatation did not appear to alter valvar rigidity. In 14 patients (group 2) the haemodynamic gradient across the aortic valve was measured before and immediately after dilatation and one week after the procedure. Dilatation produced an immediate significant decrease of the aortic mean gradient and a significant increase of the aortic valve area. Eight days later the mean gradient had increased and the aortic valve area had decreased. Nevertheless there was a significant difference between the initial gradient and the gradient eight days after dilatation. The initial aortic valve area was also significantly larger than the area eight days after dilatation. The aortic valve gradient rose significantly in the eight days after dilatation and at follow up the gradients were those of severe aortic stenosis. Images Fig 1 Fig 2 Fig 3 Fig 4 Fig 5 Fig 6 Fig 7
Commeau, P; Grollier, G; Lamy, E; Foucault, J P; Durand, C; Maffei, G; Maiza, D; Khayat, A; Potier, J C
A 7-month-old, sexually intact male English toy spaniel weighing 4 kg was referred for evaluation of a subclinical cardiac murmur. Echocardiography disclosed fixed left ventricular outflow tract obstruction that was caused by attachment of a cleft anterior mitral valve leaflet to the interventricular septum. Neither atrial nor ventricular septal defects were detected. Fixed obstruction of the left ventricular outflow tract by a malformed mitral valve is rare in human beings and has not been previously reported in the dog. PMID:22377653
Otoni, Cristiane; Abbott, Jonathan A
An adolescent with hypophosphatemic rickets developed cardiac calcifications in the absence of hypercalcemia or elevation of the phosphocalcic product (the product of the total serum calcium and phosphorus concentrations). Cardiac calcifications led to aortic and mitral valve dysfunction, myocardial calcification, and arrhythmia. Hyperparathyroidism probably played a significant role in the development of this complication, which emphasizes the necessity for intermittent assessment of parathyroid status in individuals receiving medical therapy for hypophosphatemic rickets. PMID:11717565
Moltz, K C; Friedman, A H; Nehgme, R A; Kleinman, C S; Carpenter, T O
Effective myocardial protection and perfusion strategies during minimally invasive mitral valve surgery (Mini-MV) have evolved over the last decade. Our institutional approach for right-sided Mini-MV has been standardized over the last 15 years in more than 4,500 cases. Cardiopulmonary bypass (CPB) is usually instituted by right-sided femoral arterial and venous cannulation with additional cannulation of the right jugular vein in patients with a body weight greater than 75 kg or when a concomitant tricuspid valve (TV) procedure and/or atrial septal defect closure is performed. A single dosage of crystalloid-based cardioplegia [Custodial- histidine-trypthophan-ketoglutarate (Custodial-HTK)] administered via the aortic root in combination with moderate hypothermia (34-35 °C) has become the standard of care for induction and maintenance of myocardial protection at our institution. The present article highlights and discusses the principal techniques of myocardial protection for Mini-MV.
Davierwala, Piroze; Seeburger, Joerg; Pfannmueller, Bettina; Misfeld, Martin; Borger, Michael A.; Mohr, Friedrich-Wilhelm
A 59-year-old male who had undergone aortic and mitral valve replacement with Starr-Edwards ball valves 27 years ago was admitted to our hospital for hemolytic anemia and heart failure. Echocardiography revealed prosthetic valve failure with a high-pressure gradient and small effective orifice area. The Starr-Edwards ball valves were successfully replaced with bileaflet mechanical valves. The explanted valves revealed no structural abnormalities. PMID:22785448
Tochii, Masato; Takagi, Yasushi; Kaneko, Kan; Ishida, Michiko; Akita, Kiyotoshi; Higuchi, Yoshiro; Ando, Motomi
We measured leaflet displacements and used inverse finite-element analysis to define, for the first time, the material properties of mitral valve (MV) leaflets in vivo. Sixteen miniature radiopaque markers were sewn to the MV annulus, 16 to the anterior MV leaflet, and 1 on each papillary muscle tip in 17 sheep. Four-dimensional coordinates were obtained from biplane videofluoroscopic marker images (60 frames/s) during three complete cardiac cycles. A finite-element model of the anterior MV leaflet was developed using marker coordinates at the end of isovolumic relaxation (IVR; when the pressure difference across the valve is ?0), as the minimum stress reference state. Leaflet displacements were simulated during IVR using measured left ventricular and atrial pressures. The leaflet shear modulus (Gcirc-rad) and elastic moduli in both the commisure-commisure (Ecirc) and radial (Erad) directions were obtained using the method of feasible directions to minimize the difference between simulated and measured displacements. Group mean (±SD) values (17 animals, 3 heartbeats each, i.e., 51 cardiac cycles) were as follows: Gcirc-rad = 121 ± 22 N/mm2, Ecirc = 43 ± 18 N/mm2, and Erad = 11 ± 3 N/mm2 (Ecirc > Erad, P < 0.01). These values, much greater than those previously reported from in vitro studies, may result from activated neurally controlled contractile tissue within the leaflet that is inactive in excised tissues. This could have important implications, not only to our understanding of mitral valve physiology in the beating heart but for providing additional information to aid the development of more durable tissue-engineered bioprosthetic valves.
Krishnamurthy, Gaurav; Ennis, Daniel B.; Itoh, Akinobu; Bothe, Wolfgang; Swanson, Julia C.; Karlsson, Matts; Kuhl, Ellen; Miller, D. Craig; Ingels, Neil B.
Dystrophic cardiac calcification is often associated with conditions causing systemic inflammation and when present, is usually extensive, often encompassing multiple cardiac chambers and valves. We present an unusual case of dystrophic left atrial calcification in the setting of end stage renal disease on hemodialysis diagnosed by echocardiography and computed tomography. Significant calcium deposition is confined within the walls of the left atrium with no involvement of the mitral valve, and no hemodynamic effects.
Jones, Christopher; Lodhi, Aadil Mubeen; Cao, Long Bao; Chagarlamudi, Arjun Kumar; Movahed, Assad
Summary Background Estimation of left ventricular end-diastolic pressure (LVEDP) among patients with mitral valve disease may help to explain their symptoms. However, conventional Doppler measurements have limitations in predicting LVEDP in this group of patients. The aim of this study was to construct a Doppler-derived LVEDP prediction model based on the combined analysis of transmitral and pulmonary venous flow velocity curves. Methods Thirty-three patients with moderate to severe mitral stenosis (MS) who had indications for left heart catheterisation enrolled. Two-dimensional, M-mode, colour Doppler and tissue Doppler imaging indices, such as annular early diastolic velocity (Ea), isovolumic relaxation time (IVRT), pulmonary vein systolic and diastolic flow velocities, velocity propagation, left atrium area (LAA), interval between the onset of mitral E and annular Ea (TE–Ea), and Tei index were obtained. LVEDP was measured in all patients during left cardiac catheterisation. Linear correlation and multiple linear regressions were used for analysis. Results The mean of LVEDP was 9.9 ± 5.3 mmHg. In univariate analysis, the only significant relationship was noted with LAA (p = 0.05, R2 = 0.11). However, in multivariate regression, LAA, Tei index and Ea remained in the model to predict LVEDP (p = 0.02, R2 = 0.26). For prediction of LVEDP ? 15 mmHg, the best model consisted of LAA, IVRT and Ea, and had a sensitivity of 85% and specificity of 85%. Conclusion Our results provided evidence that, in patients with moderate to severe MS, LVEDP can be estimated by combining Doppler echocardiographic variables of mitral flow. However, more studies are required to confirm these results.
Sattarzadeh, Roya; Tavoosi, Anahita; Tajik, Parvin
A 48 year old man was transferred to our department with cardiogenic shock, pyrexia, a high white cell count and significant serum troponin T level. Clinical evaluation revealed severe mitral regurgitation secondary to a flail of both mitral valve leaflets. An emergency cardiac catheterisation did not reveal any significant coronary artery disease. Left ventricular angiogram and echocardiography demonstrated a good left ventricular function and massive mitral regurgitation. Blood cultures were negative for aerobics, anaerobics and fungi. The patient underwent emergency mitral valve replacement with a mechanical valve. Intraoperatively, the posteromedial papillary muscle was found to be ruptured. Histology of the papillary muscle revealed myocardial necrosis with no signs of infection. Cultures obtained from a mitral valve specimen were negative. The patient's recovery was uneventful and he was discharged on the 6th postoperative day. PMID:18983645
Bizzarri, Federico; Mattia, Consalvo; Ricci, Massimo; Coluzzi, Flaminia; Petrozza, Vincenzo; Frati, Giacomo; Pugliese, Giuseppe; Muzzi, Luigi
In the present study of mitral valve replacement, we investigated whether complete preservation of both leaflets (that is, the subvalvular apparatus) is superior to preservation of the posterior leaflet alone. Seventy patients who underwent mitral valve replacement in our clinic were divided into 2 groups: MVR-B (n=16), in whom both leaflets were preserved, and MVR-P (n=54), in whom only the posterior leaflet was preserved. The preoperative and postoperative clinical and echocardiographic findings were evaluated retrospectively. No signs of left ventricular outflow tract obstruction were observed in either group. In the MVR-B group, no decrease was observed in left ventricular ejection fraction during the postoperative period, whereas a significant reduction was observed in the MVR-P group (P=0.003). No differences were found between the 2 groups in their need for inotropic agents or intra-aortic balloon pump support, or in cross-clamp time, duration of intensive care unit or hospital stays, postoperative development of new atrial fibrillation, or mortality rates. Bileaflet preservation prevented the decrease in left ventricular ejection fraction that usually followed preservation of the posterior leaflet alone. However, posterior leaflet preservation alone yielded excellent results in terms of decreased left ventricular diameter. Bileaflet preservation should be the method of choice to prevent further decreases in ejection fraction and to avoid death in patients who present with substantially impaired left ventricular function.
Ozdemir, Ahmet Coskun; Emrecan, Bilgin; Baltalarli, Ahmet
Background Mitral valve prolapse (MVP) is defined as superior displacement of the mitral valve leaflets more than 2 mm into the left atrium during systole. Easier and cheaper assessment of this common disease is a priority in cardiac health care facilities. Presentation of the hypothesis In this study I addressed electrocardiographic presentation in 300 patients with MVP compared with 100 healthy individuals. I faced a novel finding in electrocardiogram (ECG) examination of these patients. It was a notch (reverse ?-wave) in descending arm of QRS observed in 79% (237/300) of patients, consisting of 58% (174/300) in inferior leads and 21% (63/300) in I and aVL leads. The notch was identified only in 6 men in control group. Testing the hypothesis Considering the relatively higher prevalence of disease, a population-based diagnostic clinical trial study is appropriate to test the hypothesis. Implications of the hypothesis The hypothesis on diagnostic value of reverse ?-wave in MVP may help in decreasing the rate of unnessessary echocardiography in some patients.
Introduction Central venous catheterization can be necessary for patients undergoing a cardiac operation. Accidental suturing of the catheter to the heart is a rare complication that is difficult to correct; excessive traction force on the central venous catheter can lead to heart breakage or even death. Case presentation We describe the case of a 56-year-old Han Chinese woman who was scheduled to undergo mitral valve replacement. The central venous catheter placed into her right internal jugular vein was accidentally sutured to the left atrial suture line during the operation. The stuck catheter was successfully removed without having to perform a cardiopulmonary bypass. Conclusions Attaching a catheter to the heart by cardiac sutures can occur when the tip of the catheter locates directly above the atrial-caval junction. Care should be taken when closing the cephalad end of a left atrial incision in a mitral valve replacement. Although rare, accidental suturing of the central venous catheter must be kept in mind, and an approach should be chosen to remove the catheter that best avoids additional insult to the heart function.
Phonocardiography has shown a great potential for developing low-cost computer-aided diagnosis systems for cardiovascular monitoring. So far, most of the work reported regarding cardiosignal analysis using multifractals is oriented towards heartbeat dynamics. This paper represents a step towards automatic detection of one of the most common pathological syndromes, so-called mitral valve prolapse (MVP), using phonocardiograms and multifractal analysis. Subtle features characteristic for MVP in phonocardiograms may be difficult to detect. The approach for revealing such features should be locally based rather than globally based. Nevertheless, if their appearances are specific and frequent, they can affect a multifractal spectrum. This has been the case in our experiment with the click syndrome. Totally, 117 pediatric phonocardiographic recordings (PCGs), 8 seconds long each, obtained from 117 patients were used for PMV automatic detection. We propose a two-step algorithm to distinguish PCGs that belong to children with healthy hearts and children with prolapsed mitral valves (PMVs). Obtained results show high accuracy of the method. We achieved 96.91% accuracy on the dataset (97 recordings). Additionally, 90% accuracy is achieved for the evaluation dataset (20 recordings). Content of the datasets is confirmed by the echocardiographic screening.
Zajic, Goran; Reljin, Irini; Reljin, Branimir
Left atrial muscle extends into the proximal third of the mitral valve (MV) anterior leaflet and transient tensing of this muscle has been proposed as a mechanism aiding valve closure. If such tensing occurs, regional stiffness in the proximal anterior mitral leaflet will be greater during isovolumic contraction (IVC) than isovolumic relaxation (IVR) and this regional stiffness difference will be selectively abolished by ?-receptor blockade. We tested this hypothesis in the beating ovine heart. Radiopaque markers were sewn around the MV annulus and on the anterior MV leaflet in 10 sheep hearts. 4-D marker coordinates were obtained from biplane videofluoroscopy before (CRTL) and after administration of esmolol (ESML). Heterogeneous finite element models of each anterior leaflet were developed using marker coordinates over matched pressures during IVC and IVR for CRTL and ESML. Leaflet displacements were simulated using measured left ventricular and atrial pressures and a response function was computed as the difference between simulated and measured displacements. Circumferential and radial elastic moduli for ANNULAR, BELLY and EDGE leaflet regions were iteratively varied until the response function reached a minimum. The stiffness values at this minimum were interpreted as the in vivo regional material properties of the anterior leaflet. For all regions and all CTRL beats IVC stiffness was 40-58% greater than IVR stiffness. ESML reduced ANNULAR IVC stiffness to ANNULAR IVR stiffness values. These results strongly implicate transient tensing of leaflet atrial muscle during IVC as the basis of the ANNULAR IVC-IVR stiffness difference.
Krishnamurthy, Gaurav; Itoh, Akinobu; Swanson, Julia C.; Bothe, Wolfgang; Karlsson, Matts; Kuhl, Ellen; Miller, D. Craig; Ingels, Neil B.
AIM The functional significance of the autonomic nerves in the anterior mitral valve leaflet (AML) is unknown. We tested the hypothesis that remote stimulation of the vagus nerve (VNS) reduces AML stiffness in the beating heart. METHODS Forty-eight radiopaque-markers were implanted into eleven ovine hearts to delineate left ventricular and mitral anatomy, including an AML array. The anesthetized animals were then taken to the catheterization laboratory and 4-D marker coordinates obtained from biplane videofluoroscopy before and after VNS. Circumferential (Ecirc) and radial (Erad) stiffness values for three separate AML regions, Annulus, Belly and Edge, were obtained from inverse finite element analysis of AML displacements in response to trans-leaflet pressure changes during isovolumic contraction (IVC) and isovolumic relaxation (IVR). RESULTS VNS reduced heart rate: 94±9 vs. 82±10 min?1, (mean±SD, p<0.001). Circumferential AML stiffness was significantly reduced in all three regions during IVC and IVR (all p<0.05). Radial AML stiffness was reduced from control in the annular and belly regions at both IVC and IVR (P<0.05), while the reduction did not reach significance at the AML edge. CONCLUSION These observations suggest that one potential functional role for the parasympathetic nerves in the AML is to alter leaflet stiffness. Neural control of the contractile tissue in the AML could be part of a central control system capable of altering valve stiffness to adapt to changing hemodynamic demands.
Swanson, Julia C.; Krishnamurthy, Gaurav; Itoh, Akinobu; Kvitting, John-Peder Escobar; Bothe, Wolfgang; Miller, D. Craig; Ingels, Neil B.
Mitral valve annuloplasty is a common surgical technique used in the repair of a leaking valve by implanting an annuloplasty device. To enhance repair durability, these devices are designed to increase leaflet coaptation, while preserving the native annular shape and motion; however, the precise impact of device implantation on annular deformation, strain, and curvature is unknown. In this article, we quantify how three frequently used devices significantly impair native annular dynamics. In controlled in vivo experiments, we surgically implanted 11 flexible-incomplete, 11 semi-rigid-complete, and 12 rigid-complete devices around the mitral annuli of 34 sheep, each tagged with 16 equally spaced tantalum markers. We recorded four-dimensional marker coordinates using biplane videofluoroscopy, first with device and then without, which were used to create mathematical models using piecewise cubic splines. Clinical metrics (characteristic anatomical distances) revealed significant global reduction in annular dynamics upon device implantation. Mechanical metrics (strain and curvature fields) explained this reduction via a local loss of anterior dilation and posterior contraction. Overall, all three devices unfavorably caused reduction in annular dynamics. The flexible-incomplete device, however, preserved native annular dynamics to a larger extent than the complete devices. Heterogeneous strain and curvature profiles suggest the need for heterogeneous support, which may spawn more rational design of annuloplasty devices using design concepts of functionally graded materials. PMID:22037916
Rausch, Manuel K; Bothe, Wolfgang; Kvitting, John-Peder Escobar; Swanson, Julia C; Miller, D Craig; Kuhl, Ellen
Moyamoya disease is the result of progressive steno-occlusive changes in the internal carotid arteries followed by formation of bilateral abnormal vascular networks. The disease may present with cerebral ischemia causing cerebral hemorrhage in the perioperative period. There are few reports of cardiac surgeries in patients with moyamoya disease, and the management during cardiopulmonary bypass for moyamoya disease has not been established. We gave general anesthesia for mitral valve plasty in patient with the moyamoya disease. A 52-year-old woman underwent mitral valve plasty. She had been diagnosed with moyamoya disease and during the cardiopulmonary bypass, we used alpha-stat blood gas management with mild hypothermia, and maintained PaCO2 around 40 mmHg. We maintained the perfusion flow of CPB above 3.0 l x min(-1) x m(-2) and the mean perfusion pressure above 70 mmHg. In addition, we used the pulsatile perfusion assist with intraaortic balloon pumping to maintain cerebral circulation. Postoperative course was uneventful without apparent neurologic deficit, and she was discharged from hospital on 10th postoperative day. PMID:24724448
Ishikawa, Saki; Yamada, Tatsuya; Sakaguchi, Ryota; Hatori, Eiki; Morisaki, Hiroshi
Objective: Mitral valve disease tends to be treated with anterolateral minithoracotomy (ALMT) rather than median sternotomy (MS), as ALMT uses progressively smaller incisions to promote better cosmetic outcomes. This meta-analysis quantifies the effects of ALMT on surgical parameters and post-operative outcomes compared with MS. Methods: One randomized controlled study and four case-control studies, published in English from January 1996 to January 2013, were identified and evaluated. Results: ALMT showed a significantly longer cardiopulmonary bypass time (P=0.001) and aortic cross-clamp time (P=0.05) compared with MS. However, the benefits of ALMT were evident as demonstrated by a shorter length of hospital stay (P<0.00001). According to operative complications, the onset of new arrhythmias following ALMT decreased significantly as compared with MS (P=0.05); however, the incidence of peri-operative mortality (P=0.62), re-operation for bleeding (P=0.37), neurologic events (P=0.77), myocardial infarction (P=0.84), gastrointestinal complications (P=0.89), and renal insufficiency (P=0.67) were similar to these of MS. Long-term follow-up data were also examined, and revealed equivalent survival and freedom from mitral valve events. Conclusions: Current clinical data suggest that ALMT is a safe and effective alternative to the conventional approach and is associated with better short-term outcomes and a trend towards longer survival. PMID:24903989
Ding, Chao; Jiang, Da-Ming; Tao, Kai-Yu; Duan, Qun-Jun; Li, Jie; Kong, Min-Jian; Shen, Zhong-Hua; Dong, Ai-Qiang
The experience of 810 mitral valve replacements performed during a 15-year period (1969 to June 1983) is reported. All but one patient received a Björk-Shiley disc valve. Five different Björk-Shiley models were used (Delrin, n = 51; standard pyrolytic carbon, n = 307; convexo-concave with an opening angle of 60 degrees, n = 229; convexo-concave with an opening angle of 70 degrees, n = 123; and the Monostrut valve, n = 99). The follow-up was 99.8% complete and covered 4614 patient-years (mean 6.0 years). An autopsy was performed in 77% of all fatalities. Early mortality was 5.7% and decreased during the study period. The 5-, 10-, and 15-year actuarial survival rates (early mortality excluded) were 78%, 62%, and 51%, respectively, and the complication-free survival rates at the same time intervals were 67%, 51%, and 36%. Seven percent of early deaths and 25% of late deaths were valve related, and most of these were due to valve thrombosis. The incidence of valve thrombosis was significantly (p less than 0.0005) reduced after the introduction of the convexo-concave valves, and this reduction was achieved without any increase in bleeding complications. The only patient-related factor found to be related to postoperative thromboembolism was a history of preoperative embolism (p less than 0.05). Most events occurring after implant (death, embolism, valve thrombosis, reoperation, and valve failure) had a peak incidence during the first postoperative year, whereas anticoagulant-related bleedings occurred at a constant rate of 1.2/100 patient-years. The linearized incidence of embolism was 1.6/100 patient-years (actuarial incidence at 5 and 10 years 6.9% and 13.0%, respectively). Seven strut fractures occurred (0.2/100 patient-years, actuarial incidence at 5 and 10 years 1.1%), as did five instances of prosthetic valve endocarditis (0.1/100 patient-years, actuarial incidence at 5 and 10 years, 0.7% and 1.3%). A new concept of valve failure is presented and includes a distinction between events related to the surgical procedure (treatment failure; 1.9/100 patient-years, actuarial incidence at 5 and 10 years 11.0% and 13.5%) and events possibly related to the prosthesis (prosthetic failure; 1.1/100 patient-years, actuarial incidence at 5 and 10 years 7.0% and 8.0%). PMID:3339899
Purpose Functional mitral regurgitation (FMR) and myocardial dyssynchrony commonly occur in patients with dilated cardiomyopathy (DCM). The aim of this study was to elucidate changes in FMR in relation to those in left ventricular (LV) dyssynchrony as well as geometric parameters of the mitral valve (MV) in DCM patients during dobutamine infusion. Materials and Methods Twenty-nine DCM patients (M:F=15:14; age: 62±15 yrs) with FMR underwent echocardiography at baseline and during peak dose (30 or 40 ug/min) of dobutamine infusion. Using 2D echocardiography, LV end-diastolic volume, end-systolic volume (LVESV), ejection fraction (EF), and effective regurgitant orifice area (ERO) were estimated. Dyssynchrony indices (DIs), defined as the standard deviation of time interval-to-peak myocardial systolic contraction of eight LV segments, were measured. Using the multi-planar reconstructive mode from commercially available 3D image analysis software, MV tenting area (MVTa) was measured. All geometrical measurements were corrected (c) by the height of each patient. Results During dobutamine infusion, EF (28±8% vs. 39±11%, p=0.001) improved along with significant decrease in cLVESV (80.1±35.2 mm3/m vs. 60.4±31.1 mm3/m, p=0.001); cMVTa (1.28±0.48 cm2/m vs. 0.79±0.33 cm2/m, p=0.001) was significantly reduced; and DI (1.31±0.51 vs. 1.58±0.68, p=0.025) showed significant increase. Despite significant deterioration of LV dyssynchrony during dobutamine infusion, ERO (0.16±0.09 cm2 vs. 0.09±0.08 cm2, p=0.001) significantly improved. On multivariate analysis, ?cMVTa and ?EF were found to be the strongest independent determinants of ?ERO (R2=0.443, p=0.001). Conclusion Rather than LV dyssynchrony, MV geometry determined by LV geometry and systolic pressure, which represents the MV closing force, may be the primary determinant of MR severity.
Choi, Woong Gil; Kim, Soo Hyun; Kim, Soo Han; Park, Sang Don; Baek, Young Soo; Shin, Sung Hee; Woo, Sung Il; Kim, Dae Hyeok; Park, Keum Soo
Massive calcification of the mitral annulus associated with severe mitral regurgitation and underlying Marfan's syndrome was seen in a 21-year-old woman. This patient is believed to be the youngest reported with mitral annulus calcification, and the secon...
M. Grossman A. P. Knott W. J. Jacoby
Although less frequent than vascular calcification, cardiac valve calcification (CVC) is a relevant clinical problem affecting about 2%-10% of adults from the general population aged 75 years and older, and is 5- to 10-fold more prevalent in individuals with impaired kidney function. An expanding body of evidence suggests that mineral metabolism abnormalities aside from traditional cardiovascular risk factors are involved in CVC pathogenesis. Nonetheless, very few studies have investigated whether mineral metabolism manipulation impacts CVC. In this issue of the Journal of Nephrology, it is reported that a combination of low-phosphate diet and sevelamer may reduce CVC. Though the observational nature of that study and the lack of a control group significantly limit the generalizability of these results, they fit in with the ongoing debate on the role of chronic kidney disease mineral bone metabolism (CKD-MBD) in the pathogenesis of vascular disease and suggest the importance of mineral metabolism control in patients with CKD. PMID:23807642
Bellasi, Antonio; Galassi, Andrea; Papagni, Sergio; Cozzolino, Mario
BACKGROUND--The mechanism responsible for the reported high incidence of ventricular arrhythmias in mitral valve prolapse is not clear. Electrocardiographic studies show an increased occurrence of repolarisation abnormalities on the 12 lead surface electrocardiogram, indicating regional differences in ventricular recovery. The purpose of this study was to investigate whether dispersion of refractoriness was an arrhythmogenic mechanism. METHODS--QT dispersion was measured in
Tsung O Cheng; Robert G Tieleman; Harry J G M Crijns; Kong I Lie; H. P. Hamer
Objective: To evaluate the results of the maze procedure combined with mitral valve (MV) surgery in patients with chronic atrial fibrillation (AF). Methods: From 1994–1999, 47 patients with chronic AF underwent the maze procedure combined with MV surgery (maze group). They were compared to 47 patients matched for age, sex, left ventricular function and type of MV surgery (non-maze group).
Ehud Raanani; Anders Albage; Tirone E David; Terrence M Yau; Susan Armstrong
Double orifice mitral valve is a rare congenital anomaly presenting as the division of the mitral orifice into two anatomically distinct orifices, it is most often associated with other congenital heart defects such as left-sided obstructive lesions, ventricular septal defects or aortic coarctation. We report the case of a 15 year’s old boy, admitted for arterial hypertension, auscultation revealed a rude aortic systolic murmur. Femoral pulses were weak. Owing to the suspicion of aortic coarctation, transthoracic echocardiography was performed, the aortic coarctation with dilation of the aorta proximal to the stenosis was confirmed and bicuspid aortic valve was found with good function. The mitral valve was dysmorphic, having two orifices; it was divided into 2 separate valve orifices by a fibrous bridge. No mitral or aortic regurgitation was documented by color Doppler flow imaging. The left ventricular ejection fraction was normal. There was a small peri membranous ventricular septal defect with left to right shunt. Owing to the severity of the aortic coarctation and taking into account the anatomy and characteristics of the patient, he was made a surgical correction of aortic coarctation with good outcome.
Double orifice mitral valve is a rare congenital anomaly presenting as the division of the mitral orifice into two anatomically distinct orifices, it is most often associated with other congenital heart defects such as left-sided obstructive lesions, ventricular septal defects or aortic coarctation. We report the case of a 15 year's old boy, admitted for arterial hypertension, auscultation revealed a rude aortic systolic murmur. Femoral pulses were weak. Owing to the suspicion of aortic coarctation, transthoracic echocardiography was performed, the aortic coarctation with dilation of the aorta proximal to the stenosis was confirmed and bicuspid aortic valve was found with good function. The mitral valve was dysmorphic, having two orifices; it was divided into 2 separate valve orifices by a fibrous bridge. No mitral or aortic regurgitation was documented by color Doppler flow imaging. The left ventricular ejection fraction was normal. There was a small peri membranous ventricular septal defect with left to right shunt. Owing to the severity of the aortic coarctation and taking into account the anatomy and characteristics of the patient, he was made a surgical correction of aortic coarctation with good outcome. PMID:24693935
Mouine, Najat; Amri, Rachida; Cherti, Mohamed
From April 1, 1979 to August 31, 1983, 228 patients underwent isolated aortic (AVR) (118) or mitral (MVR) (90) valve replacements with a new tilting disc valve prosthesis, the St. Jude prosthesis, at the Medical University of South Carolina. Age ranged from 6 to 84 years (mean 49.1 +/- 19.2 AVR, 44.5 +/- 16.5 MVR). Male sex predominated in the AVR group (68%) and female sex in the MVR group (68%). Thirty-five patients (16.8%) had associated coronary bypass surgery (AVR 23.7%, MVR 7.8%). There were seven deaths (3.4%) occurring during the same hospitalization (AVR: 3/118, 2.5%; MVR: 4/90, 4.4%). Follow-up is 97.6% complete and ranges from 1 to 54 months (mean 19.6 +/- 12.4). In the AVR group, nine late deaths have occurred and actuarial survival at 42 months is 86.7 +/- 3.8%. Three patients have sustained thromboembolic episodes for a linearized rate of 1.6% patient-year, and the probability of remaining free of thromboembolism at 42 months is 96.9 +/- 1.8%. The mean improvement in functional class from preoperative to postoperative is 3.1 +/- 0.7 to 1.2 +/- 0.4 (p less than 0.001). In the MVR group, there have been four late deaths, and the actuarial survival at 42 months is 89.3 +/- 3.8%. Two patients have sustained thromboembolic complications for a linearized rate of 1.2%/patient-year, and the probability of remaining free of thromboembolism at 42 months is 97.2 +/- 2%. The mean improvement in functional class from before to after surgery is 3.2 +/- 0.7 to 1.3 +/- 0.5 (p less than 0.001). There have been no thromboses of the St. Jude valve in the mitral or aortic position, no mechanical failures, and no patient has had significant valve-related hemolysis. Because of this experience, the St. Jude Medical heart valve prosthesis is our prosthesis of choice for any patient undergoing valve replacement with a mechanical prosthesis. Images Fig. 3. Fig. 4. Fig. 6.
Crawford, F A; Kratz, J M; Sade, R M; Stroud, M R; Bartles, D M
The luminal surface properties of aortic and mitral valve endothelium in hypercholesterolemic rabbits were examined with the aid of cationic ferritin (CF), ferritin-lectins (FWGA, FRCA, FSBA), and low density lipoprotein-colloidal gold (LDL-Gold) conjugates. Based upon comparative studies with normocholesterolemic rabbit valves, the number of CF and wheat germ agglutinin (FWGA) particles per 100 nm of endothelial surface was found to be reduced in moderate hypercholesterolemia (450 mg/dl). Conversely, the number of Ricinus communis agglutinin (FRCA) and soybean agglutinin (FSBA) conjugates were increased. Quantitation of the CF and FWGA particles demonstrated that the endothelium lining of the valve surfaces (i.e., the arterial surfaces of the aortic cusps, AA, and the ventricular surfaces of the mitral cusps, MV) exposed to more turbulent hemodynamic conditions displayed the greatest densities of particle counts. Cholesterol levels of 400-500 mg/dl produced a loss of characteristic differences in the number of ferritin particles that existed between the two surfaces of a cusp. Especially prominent over the AA and MV surfaces, these changes represented a reduction in the anionic properties of the endothelial glycocalyx. Enzymatic digestion demonstrated the reduction in surface sialic acid residues to be one of the major factors responsible for these early changes at the blood-endothelium interface. More severe hypercholesterolemia (700-900 mg/dl) resulted in even further reductions in the number of ferritin particles over the AA and MV surfaces but enhanced the binding of LDL-Gold. Chondroitinase studies of these specimens demonstrated that the initial loss of sialic acids at moderate serum levels unmasks deeper lying components of the glycocalyx (e.g., sulfated glycosaminoglycans) and augments the attachment of LDL molecules to the endothelial surface. The findings of this study suggest that specific macromolecular changes in the endothelial glycocalyx in diet-induced hypercholesterolemia occur at vascular locales where hemodynamic forces such as eddy formations and blood stagnation impinge against the vascular wall. PMID:3720917
Sarphie, T G
Abstract Objective: In patients with significant mitral regurgitation (MR) at high risk of mortality and morbidity from mitral valve surgery, transcatheter mitral valve repair with the MitraClip System is associated with a reduction in MR and improved quality-of-life and functional status compared with baseline. The objective was to evaluate the cost-effectiveness of MitraClip therapy compared with standard of care in patients with significant MR at high risk for mitral valve surgery from a Canadian payer perspective. Methods: A decision analytic model was developed to estimate the lifetime costs, life years, quality-adjusted life years (QALYs), and incremental cost per life year and QALY gained for patients receiving MitraClip therapy compared with standard of care. Treatment-specific overall survival, risk of clinical events, quality-of-life, and resource utilization were obtained from the Endovascular Valve Edge-to-Edge REpair High Risk Study (EVEREST II HRS). Health utility and unit costs (CAD $2013) were taken from the published literature. Sensitivity analyses were conducted to explore the impact of alternative assumptions and parameter uncertainty on results. Results: The base case incremental cost per QALY gained was $23,433. Results were most sensitive to alternative assumptions regarding overall survival, time horizon, and risk of hospitalization for congestive heart failure (CHF). Probabilistic sensitivity analysis showed MitraClip therapy to have a 92% chance of being cost-effective compared with standard of care at a willingness-to-pay threshold of $50,000 per QALY gained. Study limitations: Key limitations include the small number of patients included in the EVEREST II HRS which informed the analysis, the limited data available to inform clinical events and disease progression in the concurrent comparator group, and the lack of a comparator group from a randomized control trial. Conclusion: MitraClip therapy is likely a cost-effective option for the treatment of patients at high risk for mitral valve surgery with significant MR. PMID:24826880
Cameron, H L; Bernard, L M; Garmo, V S; Hernandez, J B; Asgar, A W
Studies of human diseased aortic valves have demonstrated increased expression of genetic markers of valve progenitors and osteogenic differentiation associated with pathogenesis. Three potential mouse models of valve disease were examined for cellular pathology, morphology, and induction of valvulogenic, chondrogenic, and osteogenic markers. Osteogenesis imperfecta murine (Oim) mice, with a mutation in Col1a2, have distal leaflet thickening and increased proteoglycan composition characteristic of myxomatous valve disease. Periostin null mice also exhibit dysregulation of the ECM with thickening in the aortic midvalve region, but do not have an overall increase in valve leaflet surface area. Klotho null mice are a model for premature aging and exhibit calcific nodules in the aortic valve hinge-region, but do not exhibit leaflet thickening, ECM disorganization, or inflammation. Oim/oim mice have increased expression of valve progenitor markers Twist1, Col2a1, Mmp13, Sox9 and Hapln1, in addition to increased Col10a1 and Asporin expression, consistent with increased proteoglycan composition. Periostin null aortic valves exhibit relatively normal gene expression with slightly increased expression of Mmp13 and Hapln1. In contrast, Klotho null aortic valves have increased expression of Runx2, consistent with the calcified phenotype, in addition to increased expression of Sox9, Col10a1, and osteopontin. Together these studies demonstrate that oim/oim mice exhibit histological and molecular characteristics of myxomatous valve disease and Klotho null mice are a new model for calcific aortic valve disease.
Cheek, Jonathan D.; Wirrig, Elaine E.; Alfieri, Christina M.; James, Jeanne F.; Yutzey, Katherine E.
Background Calcification is an independent predictor of mortality in calcific aortic valve disease (CAVD). The aim of this study was to evaluate the use of non-invasive, non-ionizing echocardiographic calibrated integrated backscatter (cIB) for monitoring progression and subsequent regression of aortic valvular calcifications in a rat model of reversible renal failure with CAVD, compared to histology. Methods 28 male Wistar rats were prospectively followed during 21 weeks. Group 1 (N=14) was fed with a 0.5% adenine diet for 9 weeks to induce renal failure and CAVD. Group 2 (N=14) received a standard diet. At week 9, six animals of each group were killed. The remaining animals of group 1 (N=8) and group 2 (N=8) were kept on a standard diet for an additional 12 weeks. cIB of the aortic valve was calculated at baseline, 9 and 21 weeks, followed by measurement of the calcified area (Ca Area) on histology. Results At week 9, cIB values and Ca Area of the aortic valve were significantly increased in the adenine-fed rats compared to baseline and controls. After 12 weeks of adenine diet cessation, cIB values and Ca Area of group 1 decreased compared to week 9, while there was no longer a significant difference compared to age-matched controls of group 2. Conclusions cIB is a non-invasive tool allowing quantitative monitoring of CAVD progression and regression in a rat model of reversible renal failure, as validated by comparison with histology. This technique might become useful for assessing CAVD during targeted therapy.
Preoperative morphological analysis by transesophageal echocardiography and predictive value of plasma landiolol concentration during systolic anterior motion mitral valve repair : a report of three cases.
We report three cases with systolic anterior motion (SAM) after mitral valve plasty. Preoperative mitral valve morphology is a risk factor for SAM. The morphological characteristics of SAM have been revealed in several studies. We found a small distance between coaptation and the interventricular septum in all cases, and cases 2, and 3 had a low AL/PL ratio, whereas case 3 had a large PML, which was revealed by transesophageal echocardiography. With the use of 3D transesophageal echocardiography, when mitral valve prolapse was investigated, in all three cases, it was easy to specify lesions. The issue for the future is 3D analysis when SAM is occurring. PMID:24162450
Yoshimura, Manabu; Kunisawa, Takayuki; Iida, Takafumi; Matsumoto, Megumi; Takakai, Hayato; Kanda, Hirotsugu; Kurosawa, Atsushi; Takahata, Osamu; Iwasaki, Hiroshi
The past 20 years have seen rapid development in heart valve surgery in China. By the late 1990s, there were 6000 heart valve operations performed each year. Statistical analysis has shown that rheumatic heart disease is still the leading cause of valvular damage leading to surgery, as it had been 40 years before. The progressive fibrosis, sclerosis and calcification of the mitral valve that characterises rheumatic heart disease caused high mortality for all forms of mitral valve surgery in China in the 1960s. At that time, the introduction of closed mitral commissurotomy, initially highly effective in alleviating symptoms, was later found to result in re-stenosis in a significant cohort of patients. This was progressively replaced with open mitral commissurotomy. Today, mitral valve replacement represents 60-70% of valvular replacement procedures, followed by double-valve (mitral and aortic) replacement (20-25%). It has been shown both in China and elsewhere that careful selection of patients for an absence of mitral calcification leads to higher success rates for surgery. Heart valve replacement surgery in China now attains international standards in terms of the numbers of cases and surgical outcomes. Further long-term data collection and analysis are essential to aid the further development of the field. PMID:16352025
BACKGROUND--The mechanism responsible for the reported high incidence of ventricular arrhythmias in mitral valve prolapse is not clear. Electrocardiographic studies show an increased occurrence of repolarisation abnormalities on the 12 lead surface electrocardiogram, indicating regional differences in ventricular recovery. The purpose of this study was to investigate whether dispersion of refractoriness was an arrhythmogenic mechanism. METHODS--QT dispersion was measured in 32 patients with echocardiographically documented mitral valve prolapse and ventricular arrhythmias on 24 hour Holter recordings. QT dispersion was defined as the difference between the maximum and minimum average QT interval in any of the 12 leads of the surface electrocardiogram. QT dispersion corrected for heart rate was calculated by Bazett's formula. The results were compared with the data from 32 matched controls without a history of cardiac disease. Patients taking drugs that influence the QT interval and patients with a QRS duration > 120 ms were excluded. RESULTS--QT dispersion was greater in patients with mitral valve prolapse than in matched controls (60 (20) v 39 (11 ms) respectively, P < or = 0.001) as was corrected QT (64 (20 ms) v 43 (12 ms) respectively, P < or = 0.001). There was no significant difference in minimum or maximum QT intervals between the two groups. CONCLUSIONS--QT dispersion on the 12 lead surface electrocardiogram was greater in patients with mitral valve prolapse with ventricular arrhythmias than in normal controls, but the maximum QT interval was not increased. The results accord with the hypothesis that regional shortening and lengthening of repolarisation times in patients with mitral valve prolapse may account for the increased dispersion of refractoriness.
Tieleman, R. G.; Crijns, H. J.; Wiesfeld, A. C.; Posma, J.; Hamer, H. P.; Lie, K. I.
Although various osteogenic inducers contribute to the calcification of human aortic valve interstitial cells, the cellular origin of calcification remains unclear. We immunohistochemically investigated the cellular origin of valve calcification using enzymatically isolated cells from both calcified and non-calcified human aortic valve specimens. CD73-, 90-, and 105-positive and CD45-negative mesenchymal stem-like cells (MSLCs) were isolated from both types of valve specimens using fluorescence-activated cell sorting. MSLCs were further sorted into CD34-negative and -positive cells. Compared with CD34-positive cells, CD34-negative MSLCs were significantly more sensitive to high inorganic phosphate (3.2 mM), calcifying easily in response. Furthermore, immunohistochemical staining showed that significantly higher numbers (~7-9-fold) of CD34-negative compared with CD34-positive MSLCs were localized in calcified aortic valve specimens obtained from calcified aortic stenosis patients. These results suggest that CD34-negative MSLCs are responsible for calcification of the aortic valve. PMID:24120498
Nomura, Anan; Seya, Kazuhiko; Yu, Zaiqiang; Daitoku, Kazuyuki; Motomura, Shigeru; Murakami, Manabu; Fukuda, Ikuo; Furukawa, Ken-Ichi
Usefulness of atrial deformation analysis to predict left atrial fibrosis and endocardial thickness in patients undergoing mitral valve operations for severe mitral regurgitation secondary to mitral valve prolapse.
In patients with severe mitral regurgitation (MR) referred for cardiac surgery, left atrial (LA) remodeling and enlargement are accompanied by mechanical stress, mediated cellular hypertrophy, and interstitial fibrosis that finally lead to LA failure. Speckle tracking echocardiography is a novel non-Doppler-based method that allows an objective quantification of LA myocardial deformation, becoming useful for LA functional analysis. We conducted a study to evaluate the relation between the traditional and novel atrial indexes and the extent of ultrastructural alterations, obtained from patients with severe MR who were undergoing surgical correction of the valvular disease. The study population included 46 patients with severe MR, referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery. The global peak atrial longitudinal strain (PALS) was measured in all subjects by averaging all atrial segments. LA tissue samples were obtained from all patients. Masson's trichrome staining was performed to assess the extent of the fibrosis. The LA endocardial thickness was measured. A close negative correlation between the global PALS and grade of LA myocardial fibrosis was found (r = -0.82, p <0.0001), with poorer correlations for the LA indexed volume (r = 0.51, p = 0.01), LA ejection fraction (r = 0.61, p = 0.005), and E/E' ratio (0.14, p = NS). Of these indexes, global PALS showed the best diagnostic accuracy to detect LA fibrosis (area under the curve 0.89), and it appears to be a strong and independent predictor of LA fibrosis. Furthermore, we also demonstrated an inverse correlation between the global PALS and LA endocardial thickness (r = -0.66, p = 0.0001). In conclusion, in patients with severe MR referred for cardiac surgery, impairment of LA longitudinal deformation, as assessed by the global PALS, correlated strongly with the extent of LA fibrosis and remodeling. PMID:23211360
Cameli, Matteo; Lisi, Matteo; Righini, Francesca Maria; Massoni, Alberto; Natali, Benedetta Maria; Focardi, Marta; Tacchini, Damiana; Geyer, Alessia; Curci, Valeria; Di Tommaso, Cristina; Lisi, Gianfranco; Maccherini, Massimo; Chiavarelli, Mario; Massetti, Massimo; Tanganelli, Piero; Mondillo, Sergio
Thrombus formation and hemolysis have both been linked to the dynamic flow characteristics of heart valve prostheses. To enhance our understanding of the flow characteristics past the mitral position of a jellyfish (JF) valve in the left ventricle under physiological pulsatile flow conditions, in vitro laser Doppler anemometry (LDA) measurements were carried out. The hydrodynamic performance of the JF valve
Yos Morsi; Masahisa Kogure; Mitsuo Umezu
Intraventricular flow is important in understanding left ventricular function; however, relevant numerical simulations are limited, especially when heart valve function is taken into account. In this study, intraventricular flow in a patient-specific left ventricle has been modelled in two-dimension (2D) with both mitral and aortic valves integrated. The arbitrary Lagrangian-Eulerian (ALE) approach was employed to handle the large mesh deformation induced by the beating ventricular wall and moving leaflets. Ventricular wall deformation was predefined based on MRI data, while leaflet dynamics were predicted numerically by fluid-structure interaction (FSI). Comparisons of simulation results with in vitro and in vivo measurements reported in the literature demonstrated that numerical method in combination with MRI was able to predict qualitatively the patient-specific intraventricular flow. To the best of our knowledge, we are the first to simulate patient-specific ventricular flow taking into account both mitral and aortic valves. PMID:24332277
Su, Boyang; Zhong, Liang; Wang, Xi-Kun; Zhang, Jun-Mei; Tan, Ru San; Allen, John Carson; Tan, Soon Keat; Kim, Sangho; Leo, Hwa Liang
Calcification currently represents a major cause of failure of biological tissue heart valves. It is a complex phenomenon influenced by a number of biochemical and mechanical factors. Recent advances in material science offer new polymers with improved properties, potentially suitable for synthetic leaflets heart valves manufacturing. In this study, the calcification-resistance efficacy and mechanical and surface properties of a new
Hossein Ghanbari; Asmeret G. Kidane; Gaetano Burriesci; Bala Ramesh; Arnold Darbyshire; Alexander M. Seifalian
Clinical research has been rapidly evolving towards the development of less invasive surgical procedures. We recently embarked on a project to improve intracardiac beating heart interventions. Our novel approach employs new surgical technologies and support from image-guidance via pre-operative and intra-operative imaging (i.e. two-dimensional echocardiography) to substitute for direct vision. Our goal was to develop a versatile system that allowed for safe cardiac port access, and provide sufficient image-guidance with the aid of a virtual reality environment to substitute for the absence of direct vision, while delivering quality therapy to the target. Specific targets included the repair and replacement of heart valves and the repair of septal defects. The ultimate objective was to duplicate the success rate of conventional open-heart surgery, but to do so via a small incision, and to evaluate the efficacy of the procedure as it is performed. This paper describes the software and hardware components, along with the methodology for performing mitral valve replacement as one example of this approach, using ultrasound and virtual tool models to position and fasten the valve in place.
Linte, Christian; Wiles, Andrew D.; Hill, Nick; Moore, John; Wedlake, Chris; Guiraudon, Gerard; Jones, Doug; Bainbridge, Daniel; Peters, Terry M.
OBJECTIVES Simulators have been proven to equip trainee surgeons with better skills than the traditional, standard approach to skill development. The purpose of this study was to develop a low-fidelity, low-cost, reusable and portable simulation device, which could provide training in nearly the full range of mitral valve surgery techniques, in both the classic, open approach as well as the minimally invasive approach. METHODS This novel simulator is made up of commonly available components. The basic elements are a classic baby bottle, with the associated feeding teat and screw ring, in combination with a sheet of dental dam. The detailed process for making this simulator is outlined in this article. Maximum suture tensile strength on the different components was tested with a digital force gauge. Reusability and the rate of wear as a result of suturing were documented. Total cost was calculated in euros (€). RESULTS This study resulted in a simulation model very similar in size to the actual anatomical dimensions of the mitral valve. Various pathological conditions, according to Carpentier's Functional Classification, could be simulated. This led to the possibility of providing training in several mitral valve surgical techniques. As the model developed, it became clear that it could also be used to practice tricuspid valve surgery techniques. Maximum mean suture tensions on the silicone teat and dental dam were 42.11 and 11.15 N/m2, respectively. The feeding teat started wearing after approximately 45 suture placements. Total cost of the study model was €5.14. CONCLUSIONS This relatively simple, low-cost, low-fidelity model can provide simulation training in nearly the full range of mitral valve and tricuspid valve surgical techniques, in both the classic open approach and the minimally invasive approach—and do so almost anywhere. Especially when used by young cardiothoracic surgeons in training, this model may contribute to the development of technical skills and procedural knowledge required for adequate performance in the operating room.
Verberkmoes, Niels J.; Verberkmoes-Broeders, Elizabeth M.P.C.
Direct planimetry of anatomic regurgitation orifice area (AROA) using 3-dimensional transesophageal echocardiography (TEE) has been described. This study sought to (1) compare mitral valve regurgitant volume (RV) derived by AROA using 3-dimensional TEE with RV obtained by cardiac magnetic resonance (CMR) imaging and (2) determine the impact of AROA and flow velocity changes throughout systole on the dynamic variation in mitral regurgitation. In 43 patients (71 ± 11 years old) with mild to severe mitral regurgitation, 3-dimensional TEE and CMR were performed. Mitral valve RV was determined based on (1) AROA at 5 subintervals of systole and analysis of the regurgitant continuous-wave Doppler signal at equal durations of systole, (2) effective regurgitation orifice area (EROA) using the proximal isovelocity surface area method, (3) CMR with subtraction of aortic outflow volume from left ventricular stroke volume. RV calculated by AROA tended to overestimate RV less than RV calculated by EROA compared to RV by CMR (average bias +20 ml, 95% confidence interval [CI] -41 to +81, vs +13 ml, 95% CI -22 to 47). In patients with RV >30 ml by CMR, overestimation of RV using the AROA method was less than using the EROA method (difference in means +18 ml, 95% CI 4 to 32, p <0.001). AROA determined by 3-dimensional TEE varied by only 18% among the 5 subintervals of systole, and the velocity time integral of the subinterval with the highest flow was 120% of the subinterval with the lowest flow. In conclusion, 3-dimensional TEE allows accurate analysis of mitral valve RV. In the clinically relevant group of patients with RV >30 ml as defined by CMR, the AROA method results in less overestimation of RV than the EROA method. Changes in AROA during systole contribute much less to dynamic variation in mitral regurgitation severity than changes in regurgitant flow velocity. PMID:22727180
Hamada, Sandra; Altiok, Ertunc; Frick, Michael; Almalla, Mohammed; Becker, Michael; Marx, Nikolaus; Hoffmann, Rainer
Aortic insufficiency from iatrogenic valve perforation from nonaortic valve operations is rarely reported despite the prevalence of these procedures. Rapid diagnosis of these defects is essential to prevent deterioration of cardiac function. In this paper, we describe a young man who reported to our institution after two open cardiac surgeries with new aortic regurgitation found to be due to an iatrogenic perforation of his noncoronary aortic valve cusp. This defect was not appreciated by previous intraoperative transesophageal echocardiography and was inadequately visualized on follow-up transthoracic and transesophageal echocardiograms. In contrast, cardiac gated computed tomography clearly visualized the defect and its surrounding structures. This case highlights the utility of cardiac gated computed tomography for cases of suspected valvular perforation when echocardiography is not readily available or inadequate imaging is obtained.
Love, Kathleen; Ramirez, Alfredo; Boswell, Gilbert; Nayak, Keshav
Percutaneous transcatheter therapies for mitral regurgitation have found a role for patients at high operative risk with both degenerative and functional pathologies. The MitraClip therapy utilizes a catheter-based system to deliver a clip-type implant to provide apposition between anterior and posterior mitral leaflets. Key to the procedure is using imaging to guide patient selection as well as intra-procedure performance. Careful patient selection remains paramount for success with the MitraClip, with imaging determination of appropriate mitral pathology. Technical success is dependent on skill with echocardiographic imaging, with three-dimensional transesophageal echocardiography particularly valuable. PMID:24057275
Lim, D Scott
This study examines the incidence, predictors, and evolution of postoperative atrioventricular block (AVB) after mitral valve repair (MVR) in 115 consecutive patients using Carpentier's technique (between November 1996 and April 1997). Postoperative AVB occurred in 27 patients (23%). Third-degree AVB was found in 7 patients (6%) in the immediate postoperative period, but in 4 it was transient, resolving partially or completely before the seventh postoperative day. Second-degree AVB (Mobitz type I) occurred in 4 patients (3%) immediately after operation and resolved in all before hospital discharge. Isolated first-degree AVB occurred in 16 patients (14%) and was permanent in 12. Neither the preoperative variables nor the mitral procedures including anterior versus posterior leaflet repair were related to postoperative AVB. A lesser systemic hypothermia during surgery was the only, modestly independent predictor of postoperative AVB (odds ratio 1.53; 95% confidence interval 1.04 to 2.25; p = 0.031). Three patients (2.6%) had permanent pacemaker implantation, on average 18 days after operation, and all had persistent third-degree AVB. With a mean follow-up of 3 years, no recurrence or worsening of conduction disturbances, no further pacemaker implantation, and no late deaths were observed. PMID:11988196
Meimoun, Patrick; Zeghdi, Rachid; D'Attelis, Nicola; Berrebi, Alain; Braunberger, Eric; Deloche, Alain; Fabiani, Jean Noel; Carpentier, Alain
BACKGROUND: The true prevalence of mitral valve prolapse (MVP) in the population has been controversial. OBJECTIVE: To evaluate the prevalence of MVP and associated valvular abnormalities in healthy teenage students. METHODS: The Anthony Bates Foundation performed screening echocardiography in high schools across the United States. A total of 2072 students between 13 and 19 years of age were identified for the present study. RESULTS: Total prevalence of MVP was 0.7%. The prevalence of MVP was significantly higher among female teenagers (nine of 690 female teenagers [1.3%] versus five of 1382 male teenagers [0.4%], P=0.01, OR 3.6, CI 1.21 to 10.70). The prevalence of mitral regurgitation (MR) and tricuspid regurgitation (TR) was higher in teenagers with MVP. MR occurred in five of 14 teenagers (35.7%) with MVP versus 15 of 2058 controls (0.7%) (P<0.001, OR 75.6, CI 22.6 to 252.5). TR occurred in one of 14 teenagers (7.1%) with MVP versus nine of 2058 controls (0.4%) (P<0.001, OR 17.5, CI 2.0 to 148.3). CONCLUSION: The prevalence of MVP in this cohort of healthy teenage students was less than 1%. Furthermore, the prevalence of MVP was higher in female teenagers and was associated with a higher prevalence of MR and TR.
Sattur, Sudhakar; Bates, Sharon; Reza Movahed, Mohammad
A novel technique is presented to study suction of the in situ left ventricle in open-chest experimental animals without requiring cardiopulmonary bypass or disturbing the native mitral valvular apparatus. In 17 dogs, left ventricular pressure (LVP) and left atrial pressure (LAP) were measured, the left atrium was cannulated and connected to a servo pump, and LAP was controlled to a setpoint near 0 mmHg by withdrawing blood from the left atrium. Heart rate [103 +/- 17 (SD) min-1], peak pressure (100 +/- 13 mmHg), minimum pressure (1.4 +/- 0.8 mmHg), and maximum rate of change of pressure with respect to time during isovolumic contraction and relaxation (2,506 +/- 775 and -1,761 +/- 855 mmHg/s, respectively) were normal. Servo control of LAP was possible to +/- 1 mmHg. LV suction was demonstrated in each heart (mean negative LVP -2.3 +/- 1.1 mmHg; P < 0.0001). This new technique demonstrates that the left ventricle can generate negative diastolic suction pressures when examined in vivo and in situ with an undisturbed mitral valve and physiologically normal preload and afterload. This adds to a growing body of evidence that, under appropriate circumstances, the heart can suck blood into itself and thereby aid in its own filling. PMID:8048601
Ingels, N B; Daughters, G T; Nikolic, S D; DeAnda, A; Moon, M R; Bolger, A F; Komeda, M; Derby, G C; Yellin, E L; Miller, D C
Patients with bicuspid aortic valve (BAV) are more likely to develop a calcific aortic stenosis (CAS), as well as a number of other ailments, as compared to their cohorts with normal tricuspid aortic valves (TAV). It is currently unknown whether the increase in risk of CAS is caused by the geometric differences between the tricuspid and bicuspid valves or whether the increase in risk is caused by the same underlying factors that produce the geometric difference. CAS progression is understood to be a multiscale process, mediated at the cell level. In this study, we employ multiscale finite-element simulations of the valves. We isolate the effect of one geometric factor, the number of cusps, in order to explore its effect on multiscale valve mechanics, particularly in relation to CAS. The BAV and TAV are modeled by a set of simulations describing the cell, tissue, and organ length scales. These simulations are linked across the length scales to create a coherent multiscale model. At each scale, the models are three-dimensional, dynamic, and incorporate accurate nonlinear constitutive models of the valve leaflet tissue. We compare results between the TAV and BAV at each length scale. At the cell-scale, our region of interest is the location where calcification develops, near the aortic-facing surface of the leaflet. Our simulations show the observed differences between the tricuspid and bicuspid valves at the organ scale: the bicuspid valve shows greater flexure in the solid phase and stronger jet formation in the fluid phase relative to the tricuspid. At the cell-scale, however, we show that the region of interest is shielded against strain by the wrinkling of the fibrosa. Thus, the cellular deformations are not significantly different between the TAV and BAV in the calcification-prone region. This result supports the assertion that the difference in calcification observed in the BAV versus TAV may be due primarily to factors other than the simple geometric difference between the two valves. PMID:18996528
Weinberg, Eli J; Kaazempur Mofrad, Mohammad R
New intra-operative mitral regurgitation is an unusual complication of tricuspid annuloplasty and maybe ischemic in etiology as a consequence of right coronary artery distortion. We report the case of a woman in whom this was treated by mitral valve annuloplasty with ensuing hemodynamic instability and ventricular arrhythmia secondary to a new left circumflex occlusion. Injury/distortion to either of the coronary arteries running in the atrio-ventricular groove is rare, and described only several times. To our knowledge, concurrent right coronary artery and circumflex artery injury/distortion has not been reported previously. PMID:23857759
Patel, Niket; Cuculi, Florim; Banning, Adrian P
A bronchopulmonary vein fistula (BVF) establishes a communication between a pulmonary vein and the alveolar space presumably secondary to alveolar rupture from increase in alveolar pressure. This rare fistula allows air to move continuously from the lungs to a pulmonary vein and into the left side of the heart causing systemic air embolization which is often fatal. We describe an adult patient undergoing a second mitral valve replacement surgery in whom intra-operative transesophageal echocardiography proved crucial in diagnosing BVF by showing persistent and increased streaming of air bubbles into the left heart from the left superior pulmonary vein during each positive pressure ventilation cycle with consequent inability to de-air the heart. This allowed initiation of appropriate management. The patient eventually had a fatal outcome from multiple organ infarcts. PMID:23710713
Hsaad, Ayman Haj; Bleich, Steven; Nanda, Navin C; Athanasuleas, Constantine L; Öz, Tu?ba Kemalo?lu
A 48 year old man was transferred to our department with cardiogenic shock, pyrexia, a high white cell count and significant serum troponin T level. Clinical evaluation revealed severe mitral regurgitation secondary to a flail of both mitral valve leaflets. An emergency cardiac catheterisation did not reveal any significant coronary artery disease. Left ventricular angiogram and echocardiography demonstrated a good
Federico Bizzarri; Consalvo Mattia; Massimo Ricci; Flaminia Coluzzi; Vincenzo Petrozza; Giacomo Frati; Giuseppe Pugliese; Luigi Muzzi
We describe a simple, safe and reliable intraoperative saline injection leak test for accomplishing and testing the efficacy of mitral valve repair when a simultaneous aortotomy is present. PMID:17670721
Nakajima, Masato; Tsuchiya, Koji; Okamoto, Yuki; Suetsugu, Fuminaga
Objective Edge-to-edge repair of the mitral valve (MV) has been described as a viable option used for the surgical management of mitral regurgitation (MR). Based on the significant changes in MV geometry associated with this technique, we hypothesized that edge-to-edge MV repairs are associated with higher intraoperative transmitral pressure gradients (TMPG) compared to conventional methods. Methods Patient records and intraoperative transesophageal echocardiography (TEE) examinations of 552 consecutive patients undergoing MV repair at a single institution over a three year period were assessed. After separation from cardiopulmonary bypass (CPB), peak and mean TMPG were recorded for each patient and subsequently analyzed. Results 84 patients (15%) underwent edge-to-edge MV repair. Peak and mean TMPG were significantly higher compared to gradients in patients undergoing conventional repairs: 10.7±0.5 mmHg vs 7.1±0.2 mmHg; P<0.0001 and 4.3±0.2 mmHg vs 2.8±0.1 mmHg; P<0.0001. Only patients with mean TMPG ?7 mmHg (n?=?9) required prompt reoperation for iatrogenic mitral stenosis (MS). No differences in peak and mean TMPG were observed among edge-to-edge repairs performed in isolation, compared to those performed in combination with annuloplasty: 11.0±0.7 mmHg vs 10.3±0.6 mmHg and 4.4±0.3 mmHg vs 4.3±0.3 mmHg. There were no differences in TMPG between various types of annuloplasty techniques used in combination with the edge-to-edge repairs. Conclusions Edge-to-edge MV repairs are associated with higher intraoperative peak and mean TMPG after separation from CPB compared to conventional repair techniques. Unless gradients are severely elevated, these findings are not necessarily suggestive of iatrogenic MS. Thus, in the immediate postoperative period mildly elevated TMPG can be expected and tolerated after edge-to-edge mitral repairs.
Hilberath, Jan N.; Eltzschig, Holger K.; Shernan, Stanton K.; Worthington, Andrea H.; Aranki, Sary F.; Nowak-Machen, Martina
There is a long-standing debate between proponents of routine intra-operative echo and those who want it restricted to selected groups of patients (such as those undergoing valve repair or correction of congenital abnormalities). We present a case where routine transesophageal echocardiography (TEE) identified completely unexpected pathology, with implications for the postoperative follow-up and for patient outcomes. A 64-year-old male, with a history of surgical repair of coarctation of the aorta in childhood, was admitted for elective valve replacement for severe aortic stenosis (AS). Previous transthoracic echocardiography had not identified any other pathology apart from AS, but routine intra-operative TEE picked up severe turbulence in the left ventricular outflow tract (LVOT). On further analysis this was due to 2 mechanisms: a localized subaortic membrane and a "cystic" mass attached to the anterior mitral leaflet, protruding into the LVOT in systole. Multiplane imaging of the mass disclosed an accessory mitral valve (MV), a rare congenital abnormality. The patient had excision of the stenosed aortic valve and of the subaortic membrane, while the accessory MV was spared, as the surgeon judged its removal might distort the mitral apparatus. Postoperative recovery was unremarkable and the patient went home with symptomatic improvement. This case illustrates the fact that even "standard" cardiac procedures can benefit from intra-operative TEE which, in our view, should be available for all patients who undergo heart surgery. PMID:24219307
Gurzun, Maria Magdalena; Husain, Farhan; Zaidi, Afzal; Ionescu, Adrian
Real-time two-dimensional echocardiographic studies of the mitral valve in short-axis view were obtained from 10 normal subjects. Stop-action frames of the video-taped echocardiograms were then photographed to obtain diastolic cross-sectional images of the valve at maximal opening. Tracings from the interior of the leaflet echoes were then digitized to provide the perimeter and area of the mitral orifice. From the perimetric data, boundary integration was used to numerically calculate the orifice area corresponding to an elliptical boundary, for aspect ratios ranging from 0.5 to 1.0 (circle). It was found that the mean orifice areas determined echocardiographically and numerically are equal for an aspect ratio of 0.42. For aspect ratios greater than this value, the elliptical areas are larger, while for smaller aspect ratios, the elliptical areas are smaller. PMID:6604380
Hearn, T C; Goldblatt, E; Mazumdar, J; Fazzalari, N L; Nandagopal, D
A study was conducted into the development of a mitral and aortic heart valve replacement that caters for patients having suffered valve damage due to stenosis or rheumatic fever. The appeal of the valve is that it is constituted from a solid frame housing pericardial tissue leaflets, and allows the patient freedom from post-operative blood-thinning medication. The valve is designed to appeal to patients in developing areas of the world, as it features a clip-in mechanism to secure the valve assembly into the sewing ring, which is stitched in independently of the frame and leaflets. Re-operative valve replacement would then be made possible when the pericardial leaflets began to calcify. Novel aspects of the design added value to the science of heart valve replacements, through the use of sintered chrome cobalt in the valve components, the insights gained into mechanical testing of pericardium, and the patient benefits offered by the complete design. Further work is planned to fatigue test the assembly, undergo animal trials and make the valve available for commercial use. PMID:22555635
Legg, Murray; Mathews, Edward; Pelzer, Ruaan
Background A paucity of data exists regarding the prevalence and relationship of hypomagnesaemia with clinical symptoms of mitral valve prolapse (MVP) in pediatric patients. Objective In this study we evaluated the prevalence of magnesium (Mg) deficiency in pediatric patients with MVP syndrome and attempted to clarify the effect of Mg therapy on alleviating their symptoms. Methods The present study was conducted from April 2010 to January 2012, and included 230 patients (90 males and 140 females) with symptoms of mitral valve prolapse and mean age of 11.6±3.66. Serum magnesium (Mg) level less than 1.5 mg/dl was defined as hypomagnesaemia. Patients with 2 mm leaflet displacement and maximum leaflet thickness of 5 mm in echocardiography were considered to have classic MVP, while those with leaflet thickness less than 5 mm were considered as non-classic MVP. Patients with hypomagnesaemia were orally treated with 4.5 mg/kg/day Mg chloride for 5 weeks followed by re-evaluation of symptoms of chest pain, palpitation, fatigue and dyspnea. Results Hypomagnesaemia was found in 19 (8.2 %) of 230 patients with mitral valve prolapse. The re-evaluation of patients with Hypomagnesaemia after 5 weeks of Mg therapy, showed statistically significant relief of chest pain (P=0.01). However, no significant changes was detected in regard to palpitation (P=0.06), fatigue (P= 0.5) and dyspnea (P=0.99). Conclusion This study revealed that the prevalence of hypomagnesaemia in pediatric patients with mitral valve prolapse is relatively low compared to adults, but treatment with oral Mg in patient with hypomagnesaemia decreases chest pain.
Amoozgar, Hamid; Rafizadeh, Hashem; Ajami, Gholamhossein; Borzoee, Mohammad
Are the symptoms of mitral valve prolapse syndrome (MVPS) related to angiotensin converting enzyme (ACE) gene compared according to their ACE genetic polymorphism results. Polymerase chain reaction (PCR) was used to determine the genotypes. Results: The overall distribution of the genotypes was found to be DD 15 (12.5%) ID 83 (69.2%) II 22 (18.3%). In MVPS cases, the distribution was
Burak Tangürek; Nihat Özer; Nurten Sayar; Ufuk Gürkan; Osman Bolca
Aortic valve calcification is a significant and serious clinical problem for which there are no effective medical treatments. Individuals born with bicuspid aortic valves, 1–2% of the population, are at the highest risk of developing aortic valve calcification. Aortic valve calcification involves increased expression of calcification and inflammatory genes. Bicuspid aortic valve leaflets experience increased biomechanical strain as compared to normal tricuspid aortic valves. The molecular pathogenesis involved in the calcification of BAVs are not well understood, especially the molecular response to mechanical stretch. HOTAIR is a long non-coding RNA (lncRNA) that has been implicated with cancer but has not been studied in cardiac disease. We have found that HOTAIR levels are decreased in BAVs and in human aortic interstitial cells (AVICs) exposed to cyclic stretch. Reducing HOTAIR levels via siRNA in AVICs results in increased expression of calcification genes. Our data suggest that ?-CATENIN is a stretch responsive signaling pathway that represses HOTAIR. This is the first report demonstrating that HOTAIR is mechanoresponsive and repressed by WNT ?-CATENIN signaling. These findings provide novel evidence that HOTAIR is involved in aortic valve calcification.
Carrion, Katrina; Dyo, Jeffrey; Patel, Vishal; Sasik, Roman; Mohamed, Salah A.; Hardiman, Gary; Nigam, Vishal
Mitral valve (MV) edge-to-edge repair (ETER) is a surgical procedure for the correction of mitral valve regurgitation by suturing the free edge of the leaflets. The leaflets are often sutured at three different positions: central, lateral and commissural portions. To study the effects of position of suture on left ventricular (LV) fluid mechanics under mitral valve ETER, a parametric model of MV-LV system during diastole was developed. The distribution and development of vortex and atrio-ventricular pressure under different suture position were investigated. Results show that the MV sutured at central and lateral in ETER creates two vortex rings around two jets, compared with single vortex ring around one jet of the MV sutured at commissure. Smaller total orifices lead to a higher pressure difference across the atrio-ventricular leaflets in diastole. The central suture generates smaller wall shear stresses than the lateral suture, while the commissural suture generated the minimum wall shear stresses in ETER. PMID:24211894
Du, Dongxing; Jiang, Song; Wang, Ze; Hu, Yingying; He, Zhaoming
Prosthetic valve thrombosis (PVT) is a rare but serious complication of valve replacement, most often encountered with mechanical prostheses. The different therapeutic modalities for PVT (fibrinolysis with heparin treatment or surgery) will largely be influenced by the presence of valvular obstruction, the valve location (left or right sided), the patient's clinical status, the existence of and expertise in therapeutic modalities at the institution, and the patient's decision. This report describes a patient with thrombosis of a prosthetic mitral valve, which was successfully treated with recombinant streptokinase in a hospital without cardiac surgery. In this context, the authors present the real-time transoesophageal echocardiographic appearance of this complication, and give a brief review of the literature. PMID:22159325
Morais, Humberto; Martins, Telmo; Roberto, José; Cáceres-Lóriga, Fidel
Objectives In this prospective randomized trial, we compared tilting disc medtronic hall valve with bileaflet valves St. Jude and ATS\\u000a valve for Hemodynamic Performance in the early post-operative period.\\u000a \\u000a \\u000a \\u000a Methods Between December, 2007 and January 2009, 85 patients were randomized to undergo Mitral Valve Replacement with or without aortic\\u000a valve replacement with either medtronic hall tilting disc valve or St. Jude or
Vikas Goyal; Sanjeev Devgarha; Shakuntala Kalla; Chandra Prakash Srivastava
Although 2-dimensional (2D) transesophageal echocardiography (TEE) is the gold standard for the diagnosis of prosthetic valve thrombosis, nonobstructive clots located on mitral valve rings can be missed. Real-time 3-dimensional (3D) TEE has incremental value in the visualization of mitral prosthesis. The aim of this study was to investigate the utility of real-time 3D TEE in the diagnosis of mitral prosthetic ring thrombosis. The clinical outcomes of these patients in relation to real-time 3D transesophageal echocardiographic findings were analyzed. Of 1,263 patients who underwent echocardiographic studies, 174 patients (37 men, 137 women) with mitral ring thrombosis detected by real-time 3D TEE constituted the main study population. Patients were followed prospectively on oral anticoagulation for 25 ± 7 months. Eighty-nine patients (51%) had thrombi that were missed on 2D TEE and depicted only on real-time 3D TEE. The remaining cases were partially visualized with 2D TEE but completely visualized with real-time 3D TEE. Thirty-seven patients (21%) had thromboembolism. The mean thickness of the ring thrombosis in patients with thromboembolism was greater than that in patients without thromboembolism (3.8 ± 0.9 vs 2.8 ± 0.7 mm, p <0.001). One hundred fifty-five patients (89%) underwent real-time 3D TEE during follow-up. There were no thrombi in 39 patients (25%); 45 (29%) had regression of thrombi, and there was no change in thrombus size in 68 patients (44%). Thrombus size increased in 3 patients (2%). Thrombosis was confirmed surgically and histopathologically in 12 patients (7%). In conclusion, real-time 3D TEE can detect prosthetic mitral ring thrombosis that could be missed on 2D TEE and cause thromboembolic events. PMID:23800549
Ozkan, Mehmet; Gürsoy, Ozan Mustafa; Astarc?o?lu, Mehmet Ali; Gündüz, Sabahattin; Cakal, Beytullah; Karakoyun, Süleyman; Kalç?k, Macit; Kahveci, Gökhan; Duran, Nilüfer Ek?i; Y?ld?z, Mustafa; Cevik, Cihan
We investigated a novel polyepoxide crosslinker that was hypothesized to confer both material stabilization and calcification resistance when used to prepare bioprosthetic heart valves. Triglycidylamine (TGA) was synthesized via reacting epichlorhydrin and NH3. TGA was used to crosslink porcine aortic cusps, bovine pericardium, and type I collagen. Control materials were crosslinked with glutaraldehyde (Glut). TGA-pretreated materials had shrink temperatures comparable to Glut fixation. However, TGA crosslinking conferred significantly greater collagenase resistance than Glut pretreatment, and significantly improved biomechanical compliance. Sheep aortic valve interstitial cells grown on TGA-pretreated collagen did not calcify, whereas sheep aortic valve interstitial cells grown on control substrates calcified extensively. Rat subdermal implants (porcine aortic cusps/bovine pericardium) pretreated with TGA demonstrated significantly less calcification than Glut pretreated implants. Investigations of extracellular matrix proteins associated with calcification, matrix metalloproteinases (MMPs) 2 and 9, tenascin-C, and osteopontin, revealed that MMP-9 and tenascin-C demonstrated reduced expression both in vitro and in vivo with TGA crosslinking compared to controls, whereas osteopontin and MMP-2 expression were not affected. TGA pretreatment of heterograft biomaterials results in improved stability compared to Glut, confers biomechanical properties superior to Glut crosslinking, and demonstrates significant calcification resistance.
Connolly, Jeanne M.; Alferiev, Ivan; Clark-Gruel, Jocelyn N.; Eidelman, Naomi; Sacks, Michael; Palmatory, Elizabeth; Kronsteiner, Allyson; DeFelice, Suzanne; Xu, Jie; Ohri, Rachit; Narula, Navneet; Vyavahare, Narendra; Levy, Robert J.
Mitral valve repair for mitral regurgitation (MR) is currently recommended based on the degree of MR and left ventricular (LV) function. The present study examines predictors of reverse remodeling after repair for degenerative disease. We retrospectively identified 439 patients who underwent repair for myxomatous mitral valve degeneration and had both pre- and postoperative echocardiographic data available. Patients were categorized based on left atrial (LA) diameter and LV diameter standards of the American Society of Echocardiography. The outcome of interest was the degree of reverse remodeling on all heart dimensions at follow-up. Mean age was 57 ± 12 years, and 37% of patients were women. Mean preoperative LV end-diastolic diameter was 5.8 ± 0.7 cm, LV end-systolic diameter 3.5 ± 0.6 cm, LA 4.7 ± 0.7 cm, and median ejection fraction 60%. Median observation time was 81 months, and time to postoperative echocardiography was 38 months. Overall, 95% of patients had normal LV diastolic dimensions postoperatively, 93% normal LV systolic dimensions, and 37% normal LA dimensions. A Cox regression analysis showed that moderate (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.3 to 3.4) or severe preoperative LA dilatation (OR 2.7, 95% CI 1.7 to 4.4), abnormal preoperative LV end-systolic dimensions (OR 1.3, 95% CI 1.1 to 1.5), and age in years (OR 1.02, 95% CI 1.01 to 1.03) were predictive of less reverse remodeling on follow-up. In conclusion, preoperative LV end-systolic dimensions and LA dilatation substantially affect the likelihood of successful LA remodeling and normalization of all heart dimensions after mitral valve repair for MR. These findings support early operation for MR before the increase in heart dimensions is nonreversible. PMID:24444780
Athanasopoulos, Leonidas V; McGurk, Siobhan; Khalpey, Zain; Rawn, James D; Schmitto, Jan D; Wollersheim, Laurens W; Maloney, Ann M; Cohn, Lawrence H
Postoperative atrial fibrillation (POAF) is common after cardiac surgery and is associated with increased morbidity, mortality, and prolonged hospital stay. Speckle tracking echocardiography (STE) has been applied recently for evaluation of LA function. The purpose of this