Recommended transoesophageal echocardiographic evaluation of mitral valve regurgitation

Valve replacement in patients with mitral valve regurgitation is indicated when symptoms occur or left ventricular function becomes impaired. Using different surgical techniques, mitral valve reconstruction has lead to earlier interventions with good clinical results. In order to determine the possibility of a mitral valve reconstruction, echocardiographic parameters are necessary. With transoesophageal echocardiography a segmental analysis of the entire mitral valve can be performed; mitral valve motion abnormalities and severity and direction of the regurgitation jet can be judged. From this analysis clues for underlying pathology can be derived as well as the eligibility of a successful mitral valve reconstruction. This article focuses on transoesophageal examination with segmental analysis in patients with mitral valve regurgitation.     

Is mitral valve repair safe procedure in elderly patients?

The aim of this randomized, prospective, study was to evaluate postoperative hospital mortality and morbidity after mitral valve repair by comparing two surgical techniques for resolving mitral valve insufficiency in elderly patients. In comparison were: mitral valve repair vs. mitral valve replacement in patients older than 70 years. In period from January 1st 2006 until August 30th 2009. Eighty patients with mitral valve disease, isolated or associated with other comorbidities, were scheduled for mitral valve repair or mitral valve replacement in our institution. Patients were randomized in two groups, one scheduled for mitral valve repair and another one for mitral valve replacement using the envelope method with random numbers. Results show no difference in hospital mortality and morbidity postoperatively in both groups. In group undergoing valve replacement we had one significant complication of ventricle rupture in emphatically calcified posterior part of mitral valve annulus. In conclusion we found no distinction in postoperative hospital mortality and morbidity after using one of two surgical techniques.     

Clinical Use of a New Mitral Disc Valve

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.     

Exuberant accessory mitral valve tissue with possible true parachute mitral valve: a case report

ABSTRACT: INTRODUCTION: A parachute mitral valve is defined as a unifocal attachment of mitral valve chordae tendineae independent of the number of papillary muscles. Data from the literature suggests that the valve can be distinguished on the basis of morphological features as either a parachute-like asymmetrical mitral valve or a true parachute mitral valve. A parachute-like asymmetrical mitral valve has two papillary muscles; one is elongated and located higher in the left ventricle. A true parachute mitral valve has a single papillary muscle that receives all chordae, as was present in our patient. Patients with parachute mitral valves during childhood have multilevel left-side heart obstructions, with poor outcomes without operative treatment. The finding of a parachute mitral valve in an adult patient is extremely rare, especially as an isolated lesion. In adults, the unifocal attachment of the chordae results in a slightly restricted valve opening and, more frequently, valvular regurgitation. CASE PRESENTATION: A 40-year-old Caucasian female patient was admitted to a primary care physician due to her recent symptoms of heart palpitation and chest discomfort on effort. Transthoracic echocardiography showed chordae tendineae which were elongated and formed an unusual net shape penetrating into left ventricle cavity. The parasternal short axis view of her left ventricle showed a single papillary muscle positioned on one side in the posteromedial commissure receiving all chordae. Her mitral valve orifice was slightly eccentric and the chordae were converting into a single papillary muscle. Mitral regurgitation was present and it was graded as moderate to severe. Her left atrium was enlarged. There were no signs of mitral stenosis or a subvalvular ring. She did not have a bicuspid aortic valve or coarctation of the ascending aorta. The dimensions and systolic function of her left ventricle were normal. Our patient had a normal body habitus, without signs of heart failure. Her functional status was graded as class I according to the New York Heart Association grading. CONCLUSIONS: A recently published review found that, in the last several decades, there have been only nine adult patients with parachute mitral valve disease reported, of which five had the same morphological characteristics as our patient. This case presentation should encourage doctors, especially those involved in echocardiography, to contribute their own experience, knowledge and research in parachute mitral valve disease to enrich statistical and epidemiologic databases and aid clinicians in getting acquainted with this rare disease.     

Increasing mitral valve repair rates with nonresectional techniques

In every common mitral pathology studied to date, repairing the patient's own diseased valve to adequate function has yielded superior long-term results as compared with prosthetic valve replacement with either tissue or mechanical devices. Thus, increasing rates of mitral repair across all valve pathologies would seem to be a logical clinical goal. Techniques for mitral valve repair have undergone continual evolution over the past 50 years. Recently, emphasis has been placed on preserving leaflet surface area and avoiding tissue resection, by combining the methods of Gore-Tex artificial chordal replacement, autologous pericardial leaflet augmentation, and full ring annuloplasty. Using combinations of these three techniques appropriate to the given valve pathology, acute mitral repair rates now are approximating 98% for all common mitral disease etiologies. Simultaneously, operative mortalities for mitral repair have fallen significantly and now are negligible, whereas long-term outcomes using these methods have been increasingly more stable. As a result of innovations from multiple sources, mitral valve surgery has been converted from a higher risk procedure to one of the safest operations in most centers. This review will detail the technical application of "nonresectional" mitral repair approaches to a broad range of mitral disease pathologies.     

Mitral valve prolapse detected during hemodynamic studies

To estimate frequency of the posterior mitral valve leaflet prolapse in routinely performed left ventriculography, 1000 consecutive ventriculograms of the right anterior oblique projection were analyzed. A group of patients consisted of 511 women and 489 men at mean age 46,5 years. Clinical diagnosis of heart lesions, myocardial disease, pulmonary hypertension or arrhythmias were indications for hemodynamic studies. In the investigated group of patients, there were no patients with clinical diagnosis of the coronary artery disease. Prolapse of the posterior mitral valve leaflet was diagnosed in 59 patients. Idiopathic mitral valve prolapse was diagnosed in 10 patients. Prolapse of the posterior mitral valve leaflet was most frequent in atrial septal defect (16.6%), myocardial lesion (12.5%), and after mitral commissurotomy (8.9%). Posterior mitral valve leaflet prolapse is not a frequent anomaly in routinely performed left ventriculography. Relatively often occurrence of the mitral valve prolapse in atrial septal defect and only occasional in the aortic lesions and dilated cardiomyopathy seems to point out at a role of the left ventricle size in pathogenesis of this syndrome.     

Minimally Invasive Mitral Valve Replacement Using the Valve-in-valve Technique

A 90-year-old woman with two previous mitral valve replacements, presented with pulmonary edema due to mitral regurgitation from degeneration of her bioprosthetic mitral valve. A minimally invasive approach was used to replace the bioprosthetic mitral valve. During surgery, the bioprosthetic valve was noted to be too adherent to the endocardium of the left atrium, making removal of the prosthesis not only difficult, but also potentially harmful. The new bioprosthetic valve was instead placed using a valve-in-valve approach.     

Accumulation of calcium and phosphorus in the mitral valve in comparison with the abdominal aorta and the scaphoid bone

To clarify why calcification of the mitral valve occurred, the authors chose the abdominal aorta and the scaphoid bone among many arteries and bones, and they studied both relationships in element contents between the mitral valve and the abdominal aorta and between the mitral valve and the scaphoid bone. The subjects consisted of 11 men and 8 women, ranging in age from 52 to 96 yr. The accumulation of calcium and phosphorus occurred progressively with aging in the mitral valve, whereas it became the highest in the sixties in the abdominal aorta and did not increase thereafter. The accumulation of calcium and phosphorus occurred in the abdominal aorta earlier than the thoracic aorta, in which it became remarkable in the seventies. It should be noted that in regard to the accumulation of calcium and phosphorus, no significant correlations were found between the mitral valve and the abdominal aorta. It is suggested that calcification of the abdominal aorta is not essentially accompanied by calcification of the mitral valve. The scaphoid bone was chosen among many bones consisting mainly of spongy bone and the relationship was examined between the calcium content in the mitral valve and the bone mineral density of the scaphoid bone. It was found that there was a low relationship between them. Therefore, it is suggested that a part of the surplus calcium released from bones is deposited in the mitral valve.     

MITRAL VALVE PROLAPSE AND CONGENITAL PYLORIC STENOSIS IN IDENTICAL TWINS

Both congenital pyloric stenosis and the mitral valve prolapse syndrome are reported to have a familial incidence. Although mitral valve prolapse has been documented in twins, only one case has received echocardiographic confirmation. The present account describes typical symptomatic mitral valve prolapse in identical twins, both of whom had undergone surgery during infancy to correct congenital pyloric stenosis.     

The diastolic gradient of pressure and the effective area of section artifical mitral valve in aspect of its dysfunction

In article seven-year experience of treatment 126 sick mitral heart diseases to which have been implanted domestic monofolding the MIKS and folding MEDING-2 and ROSCARDIKS artificial mitral valve. At a comparative estimation of a haemodynamic efficiency and the analysis of frequency of occurrence of dysfunctions of the specified mechanical artificial valve it is revealed, that till three years the postimlantsperiod implant the MIKS and MEDING-2 possess advantage over ROSCARDIKS on haemodynamic properties, despite priority ROSCARDIKS on a standard size. It is shown, that initially low diastolic pressure gradient on mitral artificial valve and initially big area effective apertures mitral artificial valve have crucial importance in aspect of preventive maintenance of formation valve complications and reduction of number of repeated operations by open heart.     

Osteogenesis inducers promote distinct biological responses in aortic and mitral valve interstitial cells

Both aortic and mitral valves calcify in pathological conditions; however, the prevalence of aortic valve calcification is high whereas mitral valve leaflet calcification is somewhat rare. Patterns of valvular calcification may differ due to valvular architecture, but little is known to that effect. In this study, we investigated the intrinsic osteogenic differentiation potential of aortic versus mitral valve interstitial cells provided minimal differentiation conditions. For the assessment of calcification at the cellular level, we used classic inducers of osteogenesis in stem cells: β-glycerophosphate (β-Gly), dexamethasone (Dex), and ascorbate (Asc). In addition to proteomic analyses, osteogenic markers and calcium precipitates were evaluated across treatments of aortic and mitral valve cells. The combination of β-Gly, Asc, and Dex induced aortic valve interstitial cells to synthesize extracellular matrix, overexpress osteoblastic markers, and deposit calcium. However, no strong evidence showed the calcification of mitral valve interstitial cells. Mitral cells mainly responded to Asc and Dex by cell activation. These findings provide a deeper understanding of the physiological properties of aortic and mitral valves and tendencies for calcific changes within each valve type, contributing to the development of future therapeutics for heart valve diseases.     

Orthostatic hypotension,catecholamines, and alpha-adrenergic receptors in mitral valve prolapse.

The reported association of mitral valve prolapse with autonomic dysfunction and neuroendocrine abnormalities is derived from studies of patients selected because of symptoms or specifically referred for investigation. To determine whether such associations occur in nonreferred and unselected women with mitral valve prolapse, we measured blood pressure, heart rate, and norepinephrine response to standing in 13 volunteers with mitral valve prolapse and in 11 control subjects. Platelet alpha-adrenergic receptor quantity and affinity on standing also were determined in all persons. No significant differences were found between the groups in any of these measurements. Although small subsets of women with mitral valve prolapse may indeed have associated neuroendocrine epiphenomena and autonomic dysfunction, it is probably incorrect to generalize these findings to the vast spectrum of those with mitral valve prolapse.     

Replacement of the Aortic and Mitral Valves Using the Starr-Edwards Ball-Valve Prosthesis: A Report of 50 Cases

The aortic and mitral valves were replaced in 50 patients at the University of Alberta Hospital using the Starr-Edwards ball-valve prosthesis. The basis of the selection of 20 patients for isolated aortic valve replacement and 27 for mitral valve replacement using this type of prosthesis is presented, and the techniques of insertion of the aortic and mitral valve are described in detail. Of the 27 patients in whom the mitral valve was replaced by the Starr-Edwards prosthesis six died within 30 days of surgery and two after discharge from hospital at two and a half and four months, respectively. Left atrial thrombosis was the cause of death in four of these patients. In 20 patients in whom the aortic valve was replaced, four died in hospital and two died more than 30 days after returning home. Three of these six patients died from bleeding—the result of the use of anticoagulants. The difficulty in assessing whether or not anticoagulants are needed following replacement by a Starr-Edwards prosthesis is considered. It is felt, in our present state of knowledge, that anticoagulants should be used following mitral valve replacement but are probably not essential following replacement of the aortic valve. Two patients survived replacement of both aortic and mitral valves and have been followed up 18 months and seven months, respectively.     

Mitral regurgitation due to lupus endocarditis treated with valve replacement.

A murmur of mitral regurgitation developed in a 20-year-old woman with a 2-year history of systemic lupus erythematosus. Echocardiography revealed thickening of both valve leaflets and abnormal diastolic motion of the posterior one, confirming the diagnosis of mitral endocarditis. The mitral regurgitation progressed to cause congestive heart failure, which was refractory to drug therapy but was effectively treated with mitral valve replacement.     

二尖瓣成形术与二尖瓣生物瓣置换术治疗风湿性二尖瓣重度关闭不全的效果比较

目的:探讨二尖瓣成形术(Mitral valve plasty,MVP)与二尖瓣生物瓣置换术(Mitral valve replacement,MVR)治疗风湿性二尖瓣重度关闭的临床疗效和安全性。方法:选择我院2014年1月至2019年1月收治的因风湿性二尖瓣重度关闭而行二尖瓣成形术或二尖瓣生物瓣置换术的患者60例,其中二尖瓣成形术组(MVP组)27例,二尖瓣生物瓣置换术组(MVR组)33例。比较两组患者的围手术期各项指标,治疗前后的心功能指标(左心室射血分数,左心房内径、左心室收缩末期内径、左心室舒张末期内径)及二尖瓣反流情况以及术后并发症的发生情况。结果:(1)MVP组患者的手术时间、体外循环时间均明显长于MVR组(P0.05);而术中出血量、呼吸机使用时间、住院时间MVP组均显著低于MVR组(P0.05);(2)术后,MVP组的LVEF和LVEDD水平高于MVR组,而LAD和LVESD水平则低于MVR组(P 0.05);(3)出院前及末次随访时,MVP组二尖瓣反流发生率与MVR组相比差异均无统计学意义(P0.05)。(4)MVP组患者的术后并发症发生率低于MVR组(P 0.05)。结论:二尖瓣成形术治疗风湿性二尖瓣重度关闭的临床疗效和安全性优于二尖瓣生物瓣置换术,但术者需严格掌控MVP的手术适应症。     

Diabetic cardiomyopathy? An echocardiographic study of young diabetics.

An echocardiographic study was carried out on 23 young diabetics, 19 of whom had retinopathy. Their diastolic function was analysed by comparing the timing and pattern of mitral valve opening with the pattern of left ventricular wall movement. Only six patients had all their values within the normal range. Fourteen patients had abnormalities similar to those seen in patients with cardiomyopathy; the close time relation between mitral valve movement and wall movement was lost and mitral valve opening delayed in eight patients. Three other patients had considerable outward wall movement before mitral valve opening, which is characteristic of ischaemic heart disease. Although these studies provide no definite evidence of a cause, the abnormalities found may reflect a subclinical diabetic cardiomyopathy due to small-vessel disease.     

Stresses in the closed mitral valve: a model study

In the present model study on the closed mitral valve, tensile force in the chordae tendineae is related to transvalvular pressure using a mathematical model of mechanics of the closed mitral valve. Circumferential stress as well as bending stress in the valve leaflets were neglected. Without precisely knowing the mechanical properties of the leaflet material, geometry of the leaflets was estimated by applying Laplace's law, which relates leaflet stress to leaflet curvature. Independent of shape of the mitral valve orifice, under all circumstances tensile force in the chordae tendineae was calculated to be equal or greater than half the force exerted on the mitral valve orifice by the transvalvular pressure.     

Echocardiographic analysis of a malfunctioning Davila-Sierra mitral valve

Although the Davila-Sierra mitral valve prosthesis was removed from the market nearly a decade ago, a number of patients still have this valve in place. We recently studied the echocardiographic features of a malfunctioning Davila-Sierra mitral valve prosthesis. Abnormalities that suggested improper functioning of the prosthesis included a markedly delayed poppet opening and an early diastolic hump believed to represent motion of the mitral annulus. Previously described echocardiographic indications of dys-function were not observed in our patient. We report the first known echocardiographic evaluation of a Davila-Sierra prosthesis.     

Mitral Valve Replacement in a 14-Month-Old Child

In a 14-month-old child with severe congenital mitral insufficiency, the mitral valve was replaced with a Starr-Edwards valve. This resulted in dramatic improvement and the child continues to thrive one year after surgery. The authors conclude that valve replacement should be considered in a child of any age if other methods of valve repair cannot be relied upon to produce a good result.