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.     

Arrhythmia in patients with mitral valve prolapse syndrome and the status of the sympathetic nervous system]

The study aimed at evaluating a possible relationship between the adrenergic system tone determined with the excretion of catecholamines with the urine and an incidence of the ventricular arrhythmias in patients with the mitral valve prolapse. The study included 20 patients (13 women and 7 men aged between 20 and 50 years; mean = 31.6 years) with the mitral valve prolapse syndrome diagnosed with the aid of the patients' history, physical examinations and echocardiography. Echocardiograms have shown anterior mitral leaflet prolapse in 7 patients, posterior mitral leaflet prolapse in 8 patients, and both mitral leaflets prolapse in the remaining 5 patients. Daily excretion of adrenaline and noradrenaline was measured with Van Euler and Lishajko's fluorimetric technique. Cardiac arrhythmias were determined with a 24-hour ECG monitoring and classified according to Lown. Premature ventricular contractions of class I were seen in 1 patient, of class II in 5, class III in 1, class IV in 2, and class V in 3 patients. Holter monitoring technique did not show the arrhythmias in 8 patients. Daily adrenaline and noradrenaline excretion with the urine was within the normal values (3.2-30.8 ug and 0.2-16.2 ug, respectively) in all examined patients. Daily urine noradrenaline was higher in patients with serious ventricular arrhythmias (Lown's class V) than mean values in the whole examined group.     

Arrhythmia in patients with mitral valve prolapse]

An incidence of cardiac arrhythmias was evaluated in 119 patients with mitral valve prolapse. The disease was made basing on the results of clinical symptoms, echo-, angio- and phonocardiography. Electrocardiograms were recorded from the standard 12 lead and Holter technique for 24 hours in each patient to assess present arrhythmias. It was found that the most frequent cardiac arrhythmias accompanying mitral valve prolapse are ventricular extrasystolic contractions of Lown's class 1a and 1b. Only examination of strictly selected groups of patients (age groups with or without co-existing mitral valve insufficiency for adequate period of time) will facilitate precise evaluation of an incidence of different cardiac arrhythmias accompanying the underlying disease.     

Echocardiographic Findings in Marfan's Syndrome

Echocardiographic studies of 11 patients with Marfan''s syndrome showed that in all adult patients aortic root diameters were larger than 35 mm (normal range 24 to 35, mean 30±2 mm). Prolapse of the mitral valve was present in seven of 11 patients. There was no relationship between the degree of aortic root enlargement and the presence of prolapse. However, in five of seven patients with prolapse there were premature ventricular contractions recorded during the echocardiogram or on a separate electrocardiogram. In four patients without prolapse, no premature atrial or ventricular contractions were seen.     

Hemodynamic Response to Exercise After Beta-Adrenergic Blockade with Propranolol in Patients with Mitral Valve Obstruction

Propranolol (P) .13 mg./kg. was given to seven patients with mitral valve obstruction the changes in resting and exercise hemodynamics were followed by means of combined right and left heart catheterization. Changes were variable. At rest there was a decrease in heart rate of 10 beats/min. with no consistent change in stroke volume, cardiac output, left ventricular systolic (LVS) or left atrial (LA) pressure after P. Mean left ventricular end-diastolic (LVED) pressure was increased 3 mm., mean pulmonary artery (PA) pressure was increased 4 mm., and mean mitral valve gradient was reduced 3 mm. Hg by P. During exercise, mean LVS pressure was decreased 31 mm., mean LVED pressure increased 3 mm., mean LA pressure decreased 3 mm., and mean mitral valve gradient was reduced 5 mm. Hg after P. Mean exercise PA pressure was unchanged, cardiac output was reduced 0.9 1./min., and mean heart rate was reduced 37 beats/min., while stroke volume increased 3 ml./beat after P. Exercise pulmonary vascular resistance was increased from 6.1 to 8.2 units by P. Despite a slower heart rate, the diastolic filling period was not increased. P has no place in the treatment of the majority of patients with mitral stenosis because it further reduces cardiac performance below normal.     

QT/QS2 index in patients with arterial hypertension, mitral valve prolapse and hyperthyroidism]

QT/QS2 ratio has been assessed in 26 patients with both borderline and mild hypertension and mitral valve prolapse syndrome (19 patients), and hyperthyroidism (16 patients) in comparison with method control groups. The following polycardiographic parameters have been analyzed: QT, QTp, QS2, QT/QS2, and QTp/QS2. Higher values of QT/QS2 ratio have been noted in patients with mitral valve prolapse syndrome and hyperthyroidism than that in the control group. There has been no difference in patients with mild hypertension while the values of the analyzed parameter have been significantly lower in patients with borderline hypertension. QT has been longer than QS2 (QT)QS2 1/in 9 (56%) patients with hyperthyroidism. A positive correlation between QT/QS2 ratio and ++thyroxine levels have been noted in these patients. QT values have been higher than QS2 values only in 1 patient with mild hypertension. It seems that QT/QS2 value has limited value as an indirect index of the adrenergic activity in the dysfunction of the autonomic nervous system.     

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.     

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。     

ARRHYTHMIA WITH MITRAL VALVE PROLAPSE: RESULTS OF ANNULOPLASTY IN TWO PATIENTS

The effectiveness of posterior annuloplasty in two patients who failed to respond to medical treatment for atrial and ventricular arrhythmias related to mitral valve prolapse (MVP) is reported. Although the etiology of arrhythmia in MVP remains mostly speculative, anatomic correction of prolapse or billowing of the mitral leaflets appears to reverse the anatomic and pathologic conditions that cause the arrhythmia.     

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.     

Surgery Issue: Solving the Puzzle of Chronic Ischemic Mitral Regurgitation

Chronic ischemic mitral regurgitation is a prevalent problem among patients following a myocardial infarction. Until recently, the pathophysiology was poorly understood, resulting in surgical strategies with suboptimal results and limited durability. The surgical approach has evolved from revascularization alone to an additional mitral valve procedure, replacement, or repair. When the valve was repaired, isolated annuloplasty was performed. The dilemma that surgeons had when repairing a mitral valve was which type of ring to use and what size. In all series with annuloplasty alone, the results were poor with very high recurrence rates. The primary feature of ischemic mitral regurgitation is a prolapse of the anterior leaflet at A3 ± A2. This prolapse can be caused by fibrotic elongation of the papillary muscle supporting A3 ± A2 or tethering of P3 by a ballooning posterior left ventricular wall. Using a technique that corrects this prolapse with Gore-Tex neochords, we have achieved excellent results with effective and durable correction of the ischemic mitral regurgitation.     

Lignocaine Therapy after Acute Myocardial Infarction

Thirty-five patients with ventricular dysrhythmias and seven with other dysrhythmias after acute myocardial infarction were treated with intravenous lignocaine.Satisfactory initial suppression of ventricular ectopic beats was achieved in 27 (82%) of 33 patients after either a 50-mg. bolus or a 50-mg. bolus followed by a 100-mg. bolus of intravenous 2% lignocaine. Continuous suppression of ventricular ectopic beats was accomplished in 21 (78%) of these 27 patients by continuous intravenous lignocaine infusions of 1 to 2 mg. per minute. Recurrence of ventricular ectopic beats occurred in four patients despite lignocaine infusion rates of up to 6 mg. per minute. Six patients with ventricular ectopic beats developed ventricular fibrillation despite satisfactory initial suppression of their dysrhythmia by lignocaine. In three of them ventricular fibrillation supervened while they were receiving a lignocaine infusion and two subsequently died. Unheralded ventricular fibrillation occurred in three other patients between four and seven days after completing the full course of lignocaine therapy.Toxic effects of lignocaine were minimal in patients receiving 1 to 2 mg. per minute.     

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.     

肥厚梗阻性心肌病的外科治疗

目的:总结肥厚室间隔切除术治疗肥厚梗阻性心肌病的手术效果,探讨外科治疗策略。方法:2002年3月至2010年10月,外科手术治疗33例肥厚梗阻性心肌病病人。其中男16例,女17例;年龄13～59岁,平均(42.7±13.6)岁;左室流出道压差(LVOTGP)70～120 mmHg(1 mmHg=0.133Kpa),平均(95.0±22.6)mmHg。其中合并二尖瓣关闭不全24例,主动脉瓣关闭不全7例,升主动脉增宽3例,冠心病2例。手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术(MVR)7例,二尖瓣成形术(MVP)7例,二尖瓣、主动脉瓣成形术(MVP+AVP)5例,二尖瓣、升主动脉成形术3例,二尖瓣、主动脉瓣成形、冠状动脉旁路移植术(MVP+AVP+CABG)2例。分析比较病人术前超声心动图(UCG),术中经食管心脏超声(TEE),以及术后1周、3月、6月、1年超声心动图结果。结果:手术死亡1例(3.0%,1/33例),主要死因为严重低心排综合症以及多脏器功能衰竭。二次开胸止血1例(3.0%,1/33例)。术中经食管心脏超声示所有病人二尖瓣前叶收缩期前向运动现象(SAM征)消失。存活病人手术效果良好,解剖狭窄解除,峰值压差降低,SAM现象基本消失。远期随访生存病人症状消失,生活质量明显改善,心功能I～II级,无远期死亡、并发症或再次手术。结论:外科治疗肥厚梗阻型心肌病具有良好的手术效果。了解病生理过程、术中仔细探察、手术切除彻底是手术成功的关键。     

An Approach to the Stepwise Management of Severe Mitral Regurgitation with Optimal Cardiac Pacemaker Function

Right ventricular apical pacing may cause or worsen mitral regurgitation (MR). Potential mechanisms for this adverse sequelae include intraventricular dyssynchrony, altered papillary muscle function, pacing-induced cardiomyopathy with left ventricular dilation, and annular dilation. In contrast, biventricular (BiV) pacing may improve MR presumably by opposing the negative effects. Whether or not left ventricular lead location is important in treating mitral regurgitation in patients with pacemakers is unknown.We report a case of severe MR and left ventricular (LV) systolic failure in a patient with right ventricular pacing. Multiple potential etiologies for the worsening valve function were noted, and a stepwise iterative optimizing scheme that included basal lateral LV pacing improved mitral valve function and ameliorated heart failure symptoms.     

Sudden interruption of leaflet opening by ventricular contractions: a mechanism of mitral regurgitation.

The motion of both mitral cusps and the presence of valvular regurgitation during ventricular contractions were investigated in seven experiments on dogs in which radiopaque markers had been sutured to the cusps and the valve annulus 1-32 wk before the studies. Cineangiograms of the left ventricle were obtained during ventricular ectopic beats, interposed throughout the cardiac cycle (20-99% of cycle length) and during induced variations in the P-R interval (0-200 ms). Mitral regurgitation was observed only during a) weak, early ectopic beats (peak pressure below 34 mmHg) which were incapable of closing the cusps and b) when ventricular contractions suddenly interrupted normal leaflet motion toward the ventricle, during three well-defined periods of diastole (diastolic valve opening, diastolic rebound, and atrial opening). Valve closure following sudden reversal of cusp opening was slow and the leaflets often did not arrive simultaneously at their closed positions. These findings suggest that sudden interruption of leaflet opening by ventricular contractions is an important mechanism of transient mitral regurgitation in the normal heart.     

肥厚梗阻性心肌病的外科治疗

目的：总结肥厚室间隔切除术治疗肥厚梗阻性心肌病的手术效果,探讨外科治疗策略。方法：2002年3月至2010年10月,外科手术治疗33例肥厚梗阻性心肌病病人。其中男16例,女17例;年龄13～59岁,平均（42.7±13.6）岁;左室流出道压差（LVOTGP）70～120 mmHg（1 mmHg=0.133Kpa）,平均（95.0±22.6）mmHg。其中合并二尖瓣关闭不全24例,主动脉瓣关闭不全7例,升主动脉增宽3例,冠心病2例。手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术（MVR）7例,二尖瓣成形术（MVP）7例,二尖瓣、主动脉瓣成形术（MVP＋AVP）5例,二尖瓣、升主动脉成形术3例,二尖瓣、主动脉瓣成形、冠状动脉旁路移植术（MVP＋AVP＋CABG）2例。分析比较病人术前超声心动图（UCG）,术中经食管心脏超声（TEE）,以及术后1周、3月、6月、1年超声心动图结果。结果：手术死亡1例（3.0%,1/33例）,主要死因为严重低心排综合症以及多脏器功能衰竭。二次开胸止血1例（3.0%,1/33例）。术中经食管心脏超声示所有病人二尖瓣前叶收缩期前向运动现象（SAM征）消失。存活病人手术效果良好,解剖狭窄解除,峰值压差降低,SAM现象基本消失。远期随访生存病人症状消失,生活质量明显改善,心功能I～II级,无远期死亡、并发症或再次手术。结论：外科治疗肥厚梗阻型心肌病具有良好的手术效果。了解病生理过程、术中仔细探察、手术切除彻底是手术成功的关键。     

Sudden,Severe Mitral Insufficiency

Five male patients with sudden, severe mitral insufficiency due solely to ruptured chordae tendineae or papillary muscle had an abrupt onset of symptoms of left and right heart failure and the sudden appearance of a harsh, widely propagated apical pansystolic murmur. None had a history of rheumatic fever. All were in sinus rhythm and had but mild left atrial and ventricular enlargement. Giant left atrial “v” waves were characteristic and exceeded pulmonary artery pressure in two instances.In contrast, when ruptured chordae tendineae were superimposed on chronic rheumatic mitral insufficiency, females predominated and there was a long history of disability. Atrial fibrillation, less elevation of left atrial pressure, and marked left atrial and ventricular enlargement were characteristic. These latter patients closely resembled patients with chronic rheumatic mitral insufficiency alone.It is concluded that the syndrome of sudden, severe mitral insufficiency develops if ruptured chordae tendineae occur on a previously normal or insignificantly diseased mitral valve. If ruptured chordae tendineae are superimposed on chronic rheumatic mitral insufficiency, the syndrome resembles that seen in the latter alone.     

Practolol in Treatment of Supraventricular Cardiac Dysrhythmias

Practolol (I.C.I. 50172) was used to treat supraventricular dysrhythmias in 32 patients with a rapid ventricular rate and with heart disease of varied aetiology. In 26 patients the average reduction in ventricular rate was 75 per minute, while immediate reversion to sinus rhythm occurred in three patients. The slowing effect was mainly due to a direct action on the atrioventricular node. The effectiveness of practolol was unrelated to the type of dysrhythmia or its aetiology. No serious adverse clinical effects were noted.     

超声心动图对缺血性二尖瓣反流血流动力学的研究

目的:应用超声心动图研究缺血性二尖瓣反流(IMR)所致左室、二尖瓣环动力学变化。方法:超声心动图检测86例缺血性二尖瓣反流患者(前壁心肌梗死49例,下壁心肌梗死37例)和30例正常人的心脏,测量左室参数及二尖瓣环形态参数。结果:IMR组左室EDV、ESV增加,LVEF减低,但与对照组无显著差异;二尖瓣环面积及位移与对照组有显著差异;不同部位心肌梗死均发生明显左室重构;下壁梗死组PPM-AMP明显延长。结论:超声心动图作为心肌梗死患者的常规检查,可以针对不同患者进行不同的参数检查,这也为临床医生选择个性化治疗方案和疗效评价提供了依据。