Life-saving PTMC for critical calcific mitral stenosis in cardiogenic shock with balloon impasse

A 32-year-old male patient, a case of critical calcific mitral stenosis (following closed mitral valvotomy in 1989) was admitted for mitral valve replacement in September 2001. In hospital, he developed cardiogenic shock, pulmonary oedema and oliguria precluding surgery. An emergency percutaneous transatrial balloon mitral commissurotomy as a life-saving procedure in a valve with unfavourable morphology and 'balloon impasse' is discussed.     

Indication and timing of percutaneous mitral balloon valvotomy and the role of atrial fibrillation

Percutaneous transvenous mitral balloon valvotomy (PTMV) has been proven to be an effective and safe method for treatment of patients with severe mitral valve stenosis. This technique has become an accepted alternative for surgical commissurotomy, not only in young patients with pliable valves, but also in selected older patients with extensive valvular pathology. This review highlights the significance of coexisting atrial fibrillation, patient selection and timing of PTMV in patients with mitral valve stenosis.     

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.     

CRITERIA FOR MITRAL VALVOTOMY—Roentgen Evidence in Pulmonary Hypertension

Although catheterization is the most accurate and sometimes the only adequate method of measuring pulmonary hypertension as an indication for mitral valvotomy in rheumatic heart disease, it is so costly and complex that simpler methods are desirable. Clinical evidence of pulmonary hypertension is least accurate; electrocardiography is confirmatory in half of all cases. Roentgenologic findings are more helpful; moderate or severe enlargement in the pulmonary arteries has been associated in 92 per cent of cases with resting systolic pressure of 50 to 90 mm. of mercury in the pulmonary artery. In cases in which there is little or no enlargement, hypertension may still be present and demonstrable only by catheterization. Other roentgen signs noted as helpful are abrupt narrowing of the large branches of the pulmonary artery in the middle and lower lobes, and the septal lines of Kerley.     

Association Between the Interferon Gamma 874 T/A Polymorphism and the Severity of Valvular Damage in Patients with Rheumatic Heart Disease

Interferon gamma (IFN-γ) is a multifunctional cytokine that plays an important role in modulating almost all phases of the immune response and may be responsible for the increased valvular fibrosis and calcification in the pathogenesis of rheumatic heart disease (RHD). The aim of this study was to investigate the possible relationship between the IFN-γ +874 T/A polymorphism and the severity of valvular damage in the Turkish population. The IFN-γ genotypes were determined in 152 RHD patients and 151 healthy controls by ARMS-PCR. Differences in genotype distribution between patients with RHD and control were evaluated by the χ² test. All statistical analyses were performed with SPSS 15.0 Software program. Frequency of the AA genotype was found to be significantly lower and the TT genotype significantly higher in the RHD group compared to controls (p = 0.002 and p = 0.018, respectively). The TT genotype was found to be significantly higher (26.8% vs. 9.1%, p = 0.009) and the AA genotype significantly lower (29.1% vs. 8.2%, p = 0.001) in the severe valvular disease (SVD) group compared to mild valvular disease group. In the SVD group, 79 patients had mitral balloon valvotomy and/or mitral valve replacement and had significantly higher TT genotype compared to patients with medical follow-up (30.4% vs. 19%, p = 0.001). The data demonstrated that TT genotype is associated with both RHD and the severity of RHD.     

Criteria for mitral valvotomy; roentgen evidence in pulmonary hypertension

Although catheterization is the most accurate and sometimes the only adequate method of measuring pulmonary hypertension as an indication for mitral valvotomy in rheumatic heart disease, it is so costly and complex that simpler methods are desirable. Clinical evidence of pulmonary hypertension is least accurate; electrocardiography is confirmatory in half of all cases. Roentgenologic findings are more helpful; moderate or severe enlargement in the pulmonary arteries has been associated in 92 per cent of cases with resting systolic pressure of 50 to 90 mm. of mercury in the pulmonary artery. In cases in which there is little or no enlargement, hypertension may still be present and demonstrable only by catheterization. Other roentgen signs noted as helpful are abrupt narrowing of the large branches of the pulmonary artery in the middle and lower lobes, and the septal lines of Kerley.     

Left ventricular endocardial longitudinal and transverse changes during isovolumic contraction and relaxation: a challenge

Left ventricular (LV) longitudinal and transverse geometric changes during isovolumic contraction and relaxation are still controversial. This confusion is compounded by traditional definitions of these phases of the cardiac cycle. High-resolution sonomicrometry studies might clarify these issues. Crystals were implanted in six sheep at the LV apex, fibrous trigones, lateral and posterior mitral annulus, base of the aortic right coronary sinus, anterior and septal endocardial wall, papillary muscle tips, and edge of the anterior and posterior mitral leaflets. Changes in distances were time related to LV and aortic pressures and to mitral valve opening. At the beginning of isovolumic contraction, while the mitral valve was still open, the LV endocardial transverse diameter started to shorten while the endocardial longitudinal diameter increased. During isovolumic relaxation, while the mitral valve was closed, LV transverse diameter started to increase while the longitudinal diameter continued to decrease. These findings are inconsistent with the classic definitions of the phases of the cardiac cycle.     

Hemodynamic correlates of effective arterial elastance in mitral stenosis before and after balloon valvotomy

Colin, Patrice, Michel Slama, Alec Vahanian, YvesLecarpentier, Gilbert Motté, and Denis Chemla. Hemodynamiccorrelates of effective arterial elastance in mitral stenosis beforeand after balloon valvotomy. J. Appl.Physiol. 83(4): 1083-1089, 1997.This study hadthe purpose of documenting the hemodynamic correlates of effectivearterial elastance (Ea; i.e., an accurate estimate of hydraulic load)in mitral stenosis (MS) patients. The main hypothesis tested was thatEa relates to the total vascular resistance (R)-to-pulse intervalduration (T) ratio(R/T) in MS patients both before andafter successful balloon mitral valvotomy (BMV). High-fidelity aorticpressure recordings were obtained in 10 patients (40 ± 12 yr)before and 15 min after BMV. Ea value was calculated as the ratio ofthe steady-state end-systolic aortic pressure (ESAP) to stroke volume(thermodilution). Ea increased after BMV (from 1.55 ± 0.63 to 1.83 ± 0.71 mmHg/ml; P < 0.05). Throughout the procedure, there was a strong linearrelationship between Ea and R/T: Ea = 1.09R/T  0.01 mmHg/ml,r = 0.99, P = 0.0001. This ultimately dependedon the powerful link between ESAP and mean aortic pressure [MAP;r = 0.99, 95% confidence interval for the difference (MAP  ESAP) from 18.5 to +4.5 mmHg].Ea was also related to total arterial compliance (area method) and towave reflections (augmentation index), although to a lesser extent. After BMV, enhanced and anticipated wave reflections were observed, andthis was likely to be explained by decreased arterial compliance. Thepresent study indicated that Ea depended mainly on the steady componentof hydraulic load (i.e., R) and on heart period (i.e., T) in MS patients.

     

Open-Heart Correction of Mitral Valvular Disease: Review of 30 Cases

Thirty patients with mitral valve disease operated upon by the open-heart technique during the period 1958-1962 were studied. In 15 insufficiency predominated. Clinical, radiological and pathological findings included the following: aortic valve disease is the commonest associated lesion; cusp calcification is uncommon in mitral insufficiency; left atrial enlargement is more pronounced in mitral insufficiency; a relaxed annulus is the commonest pathological lesion associated with mitral insufficiency, with ruptured chordae in second place. Five of the 15 patients with mitral insufficiency and four of the 15 with mitral stenosis died during the postoperative period, while clinical improvement was apparent in seven and 11, in the respective groups. The standard techniques of annuloplasty, suturing of ruptured chordae, and open commissurotomy were found to provide satisfactory results. Partial Ivalon prosthetic replacement was unsatisfactory. The study suggests that a more liberal use of the open-heart procedure in surgical correction of complicated mitral valve lesions is indicated.     

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.     

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.     

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.     

Surgical Treatment of Mitral Insufficiency

Sixty-four patients with pure mitral insufficiency were operated upon. Thirty of them had torn chordae tendineae. It was possible to repair the mitral valve in 57 patients and there were five operative deaths. One patient had a femoral artery embolus and another had a cerebral embolus. The incidence of peripheral embolization was 4 per cent compared with 40 per cent reported for ball valve replacement.Forty-eight of the 57 patients with repair (84 per cent) were living and well with at most a grade II/VI apical systolic murmur up to seven and a half years after operation. There has been no evidence of recurrence in these patients.In approximately 90 per cent of patients with pure mitral insufficiency, repair should be performed. When feasible, repair is more satisfactory than valvular replacement, with not only excellent long-term results, but far less morbidity than is reported with ball valve replacement.     

MITRAL OR AORTIC COMMISSUROTOMY—Criteria for Selection of Patients

In the selection of patients for mitral commissurotomy, five separate categories are to be considered: (1) true mitral block with small heart and high pulmonary artery pressure, (2) mitral stenosis without mitral block, (3) mitral stenosis with subacute carditis, (4) mitral stenosis with marked cardiac hypertrophy, and (5) mitral stenosis with embolism.Surgical results are good to excellent provided adequate preoperative evaluation has eliminated the groups with subacute carditis, and those without mitral block. Cardiac catheterization is a valuable adjunct in difficult problems.     

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。     

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。     

Left heart catheterization; the clinical importance of findings

Left heart catheterization using the transbronchial route to obtain pressures in the left atrium and left ventricle was used successfully in 29 cases with no mortality or morbidity. It was found to be useful in differentiating between mitral stenosis and mitral insufficiency, as well as determining the amount of aortic stenosis present when there was involvement of the aortic valve. The technique was also helpful in determining which is the predominant lesion when there is a disease of the aortic and mitral valves. In two patients in a series of 29, data obtained by left heart catheterization forestalled operation on the basis of a mistaken diagnosis of mitral stenosis when actually no mitral valvular disease was present. In another eight patients, the predominant lesion was found to be mitral stenosis rather than mitral insufficiency as it was thought to be before catheterization. In two patients, who had only systolic murmurs, catheterization revealed mitral stenosis rather than mitral insufficiency. In four patients who were thought to have mixed valvular disease, left heart catheterization showed only aortic valvular disease.     

Insights from in-vitro flow visualization into the mechanism of systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy under steady flow conditions.

Hypertrophic obstructive cardiomyopathy is a heart disease characterized by a thickened interventricular septum which narrows the left ventricular outflow tract, and by systolic anterior motion (SAM) of the mitral valve which can contact the septum and create dynamic subaortic obstruction. The most common explanation for SAM has been the Venturi mechanism which postulates that septal hypertrophy, by narrowing the outflow tract, produces high velocities and thus low pressure between the mitral valve and the septum, causing the valve leaflets to move anteriorly. This hypothesis, however, fails to explain why SAM often begins early in systole, when outflow tract velocities are low or negligible or why it may occur in the absence of septal hypertrophy. The goal of this study was therefore to investigate an alternative hypothesis in which structural abnormalities of the papillary muscles act as a primary cause of SAM by altering valve restraint and thereby changing the geometry of the closed mitral apparatus and its relationship to the surrounding flow field. In order to test this hypothesis, an in vitro model of the left ventricle which included an explanted human mitral valve with intact chords and papillary muscle apparatus was constructed. Flow visualization was used to observe the ventricular flow field and the mitral valve geometry. Displacing the papillary muscles anteriorly and closer to each other, as observed clinically in patients with cardiomyopathy and obstruction produced SAM in the absence of septal hypertrophy. Flow could be seen impacting on the upstream (posterior) surface of the leaflets; such flow is capable of producing form drag forces which can initiate and maintain SAM.(ABSTRACT TRUNCATED AT 250 WORDS)     

LEFT HEART CATHETERIZATION—The Clinical Importance of Findings

Left heart catheterization using the transbronchial route to obtain pressures in the left atrium and left ventricle was used successfully in 29 cases with no mortality or morbidity. It was found to be useful in differentiating between mitral stenosis and mitral insufficiency, as well as determining the amount of aortic stenosis present when there was involvement of the aortic valve. The technique was also helpful in determining which is the predominant lesion when there is a disease of the aortic and mitral valves.In two patients in a series of 29, data obtained by left heart catheterization forestalled operation on the basis of a mistaken diagnosis of mitral stenosis when actually no mitral valvular disease was present. In another eight patients, the predominant lesion was found to be mitral stenosis rather than mitral insufficiency as it was thought to be before catheterization. In two patients, who had only systolic murmurs, catheterization revealed mitral stenosis rather than mitral insufficiency. In four patients who were thought to have mixed valvular disease, left heart catheterization showed only aortic valvular disease.     

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.