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.     

A novel design of posterior leaflet butterfly resection for mitral valve repair

A new design for posterior leaflet resection, "butterfly resection," is proposed. It is a combination of two triangular resections in the prolapsing posterior leaflet segment. This method minimizes resection in the target segment, and it prevents systolic anterior motion by reducing the height of the posterior leaflet according to the amount of excess tissue. We have used this technique for 60.4% (29 of 48) of posterior leaflet prolapse cases with zero hospital mortality and no morbidity. Postbypass transesophageal echocardiography identified no more than mild regurgitation and no sign of systolic anterior motion. During 13.1 ± 6.8 months of follow-up, patients neither died nor needed reoperation.     

Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.     

Quantitative analysis of mitral valve morphology in atrial functional mitral regurgitation using real-time 3-dimensional echocardiography atrial functional mitral regurgitation

Background

Atrial fibrillation (AF) can result in atrial functional mitral regurgitation (MR), but the mechanism remains controversial. Few data about the relationship between the 3-dimensional morphology of the MV and the degree of MR in AF exist.

Methods

Real-time 3-dimensional transesophageal echocardiography (3D-TEE) of the MV was acquired in 168 patients with AF (57.7% persistent AF), including 25 (14.9%) patients with moderate to severe MR (the MR+ group) and 25 patients without AF as controls. The 3-dimensional geometry of the MV apparatus was acquired using dedicated quantification software.

Results

Compared with the group of patients with no or mild MR (the MR- group) and the controls, the MR+ group had a larger left atrium (LA), a more dilated mitral annulus (MA), a reduced annular height to commissural width ratio (AHCWR), indicating flattening of the annular saddle shape, and greater leaflet surfaces and tethering. MR severity was correlated with the MA area (r²?=?0.43, P?<?0.01) and the annulus circumference (r²?=?0.38, P?<?0.01). A logistic regression analysis indicated that the MA area (OR: 1.02, 95% CI: 1.01–1.03, P?<?0.01), AHCWR (OR: 0.24, 95% CI: 0.14–0.35, P?=?0.04) and MV tenting volume (OR: 3.24, 95% CI: 1.16–9.08, P?=?0.03) were independent predictors of MR severity in AF patients.

Conclusions

The mechanisms of “atrial functional MR” are complex and include dilation of the MA, flattening of the annular saddle shape and greater leaflet tethering.

     

Using a human cardiovascular-respiratory model to characterize cardiac tamponade and pulsus paradoxus

Background  

Cardiac tamponade is a condition whereby fluid accumulation in the pericardial sac surrounding the heart causes elevation and equilibration of pericardial and cardiac chamber pressures, reduced cardiac output, changes in hemodynamics, partial chamber collapse, pulsus paradoxus, and arterio-venous acid-base disparity. Our large-scale model of the human cardiovascular-respiratory system (H-CRS) is employed to study mechanisms underlying cardiac tamponade and pulsus paradoxus. The model integrates hemodynamics, whole-body gas exchange, and autonomic nervous system control to simulate pressure, volume, and blood flow.     

Primary malignant lymphoma of the heart. Antemortem cytologic diagnosis

A case of primary malignant lymphoma of the heart diagnosed cytologically is reported. The patient presented with pericardial tamponade and ventricular arrhythmias and developed rapidly progressive and intractable cardiac failure. Two-dimensional echo-cardiography, which demonstrated the pericardial effusion, showed progressive impairment of the left ventricular contraction. The pericardial fluid contained malignant lymphoid cells. Despite vigorous treatment and chemotherapy, the patient died within 15 days; postmortem examination showed malignant lymphoma confined to the myocardium.     

Visual complications of mitral leaflet prolapse.

Four young women and six older men with mitral leaflet prolapse presented with visual disturbances consistent with embolism in the ophthalmic or posterior cerebral circulation. Cardiac arrhythmias were common, but these are rarely associated with focal ischaemia. The evidence that mitral leaflet prolapse caused the embolism in these patients is suggestive but not conclusive. Further studies are needed. All patients with acute cerebral or ocular ischaemia should undergo through cardiovascular assessment, which should include routine echocardiography.     

Cardiac tamponade as a presentation of malignant thymoma

Morphologic, cytochemical and immunocytochemical studies of pericardial fluid from a 30-year-old man presenting with cardiac tamponade are described. Based on the results of the immunocytochemical studies and the histologic examination of excised pericardium, a diagnosis of malignant thymoma was made. This is the first documented case in which malignant cells were found in the pericardial effusion in a patient with invasive thymoma. The significance of using a multidisciplinary approach to the study of body fluids is discussed.     

Experimental cardiac tamponade: correlation of pressure, flow velocity, and echocardiographic changes

Seven episodes of experimental cardiac tamponade were induced in five anesthetized closed-chest dogs. Simultaneous pericardial and intracavitary pressures were synchronized with superior vena caval and transvalvular pulsed-Doppler flow tracings. The earliest indication of tamponade was the development of a negative transmural right atrial pressure that occurred during early ventricular diastole and was associated with echocardiographic evidence of right atrial collapse. This was also associated with reversal of diastolic flow in the superior vena cava and with diminished early diastolic flow velocity across the tricuspid as well as the mitral valve. During more advanced cardiac tamponade, the transmural right atrial pressure became negative during both early and late ventricular diastole as well as during isovolumic ventricular systole. This was associated with a disappearance of early diastolic ventricular filling and right ventricular diastolic collapse as observed on two-dimensional echocardiography. In hypotensive cardiac tamponade (cardiac output diminished by 70%), the decreased transmural right atrial pressure that developed during ventricular systole was accompanied by diminished antegrade flow in the superior vena cava. In advanced and hypotensive tamponade, ventricular filling occurred mainly during atrial contraction.     

Surgical properties and survival of a pericardial window via left minithoracotomy for benign and malignant pericardial tamponade in cancer patients

ABSTRACT: BACKGROUND: Surgical drainage is a rapid and effective treatment for pericardial tamponade in cancer patients. We aimed to investigate the effectiveness of pericardial window formation via minithoracotomy for treating pericardial tamponade in cancer patients, and to evaluate clinical factors affecting long-term survival. METHODS: Records of 53 cancer patients with pericardial tamponade treated by pericardial window formation between 2002 and 2008 were examined. Five patients were excluded due to insufficient data. Kaplan-Meier and Cox regression analysis were used for analysis. RESULTS: Forty-eight patients (64.7% male), with a mean age of 55.20 +/- 12.97 years were included. Patients were followed up until the last control visit or death. There was no surgery-related mortality and the 30-day mortality rate was 8.33%; all died during postoperative hospitalization. Morbidity rate was 18.75%. Symptomatic recurrence rate was 2.08%. Cancer type and nature of the pericardial effusion were the major factors determining long-term survival (P <0.001 and P <0.004, respectively). Overall median survival was 10.41 +/- 1.79 months. One- and 2-year survival rates were 45 +/- 7% and 18 +/- 5%, respectively. CONCLUSION: Pericardial window creation via minithoracotomy was proven to be a safe and effective approach in surgical treatment of pericardial tamponade in cancer patients. Cancer type and nature of pericardial effusion were the main factors affecting long-term survival.     

Characterization of IL-2-activated TILs and their use in intrapericardial immunotherapy in malignant pericardial effusion

Pericardial effusion (PE) and cardiac tamponade caused by malignant pericarditis are critical conditions in cancer patients, which still lack a recommended protocol for their long-term management. Percutaneous pericardiocentesis and simple drainage are commonly performed as the initial treatment. The aims of this study were to investigate the presence of cytotoxic T lymphocytes (CTLs) in malignant PE and to determine the clinical response to administering autologous tumor-infiltrating lymphocytes (TILs) into the pericardial cavity. Initially, we identified human lymphocyte antigen class-I-restricted and tumor-specific CTLs within the interleukin-2 (IL-2)-activated TILs in PEs from four patients, on the basis of interferon-γ production and lactate dehydrogenase-release assays. Clinically we observed favorable responses to the pericardial transfer of IL-2-activated autologous TILs in four patients: one male with advanced esophageal cancer, one female with recurrent lung cancer and two females with recurrent breast cancer, respectively. Autologous TILs from PEs were expanded in vitro with IL-2, characterized for CD3, CD4 and CD8 markers, checked for contamination and then infused into the patient’s pericardial space through a catheter. This was repeated biweekly. After treatment, there were no signs of recurrence of PE in either case, as determined by radiography, echocardiography and computed tomography. The only adverse effects seen were grade 1 fevers. These results suggested that intrapericardial cellular immunotherapy with autologous TILs could be a safe and effective treatment for controlling malignant pericarditis with associated cardiac tamponade, and that tumor-specific CTLs present in malignant PE might be important for tumor rejection.     

In vitro dynamic strain behavior of the mitral valve posterior leaflet

Knowledge of mitral valve (MV) mechanics is essential for the understanding of normal MV function, and the design and evaluation of new surgical repair procedures. In the present study, we extended our investigation of MV dynamic strain behavior to quantify the dynamic strain on the central region of the posterior leaflet. Native porcine MVs were mounted in an in-vitro physiologic flow loop. The papillary muscle (PM) positions were set to the normal, taut, and slack states to simulate physiological and pathological PM positions. Leaflet deformation was measured by tracking the displacements of 16 small markers placed in the central region of the posterior leaflet. Local leaflet tissue strain and strain rates were calculated from the measured displacements under dynamic loading conditions. A total of 18 mitral valves were studied. Our findings indicated the following: (1) There was a rapid rise in posterior leaflet strain during valve closure followed by a plateau where no additional strain (i.e., no creep) occurred. (2) The strain field was highly anisotropic with larger stretches and stretch rates in the radial direction. There were negligible stretches, or even compression (stretch < 1) in the circumferential direction at the beginning of valve closure. (3) The areal strain curves were similar to the stretches in the trends. The posterior leaflet showed no significant differences in either peak stretches or stretch rates during valve closure between the normal, taut, and slack PM positions. (4) As compared with the anterior leaflet, the posterior leaflet demonstrated overall lower stretch rates in the normal PM position. However, the slack and taut PM positions did not demonstrate the significant difference in the stretch rates and areal strain rates between the posterior leaflet and the anterior leaflet. The MV posterior leaflet exhibited pronounced mechanically anisotropic behavior Loading rates of the MV posterior leaflet were very high. The PM positions influenced neither peak stretch nor stretch rates in the central area of the posterior leaflet. The stretch rates and areal strain rates were significantly lower in the posterior leaflet than those measured in the anterior leaflet in the normal PM position. However, the slack and taut PM positions did not demonstrate the significant differences between the posterior leaflet and the anterior leaflet. We conclude that PM positions may influence the posterior strain in a different way as compared to the anterior leaflet.     

In vivo dynamic strains of the ovine anterior mitral valve leaflet

Understanding the mechanics of the mitral valve is crucial in terms of designing and evaluating medical devices and techniques for mitral valve repair. In the current study we characterize the in vivo strains of the anterior mitral valve leaflet. On cardiopulmonary bypass, we sew miniature markers onto the leaflets of 57 sheep. During the cardiac cycle, the coordinates of these markers are recorded via biplane fluoroscopy. From the resulting four-dimensional data sets, we calculate areal, maximum principal, circumferential, and radial leaflet strains and display their profiles on the averaged leaflet geometry. Average peak areal strains are 13.8±6.3%, maximum principal strains are 13.0±4.7%, circumferential strains are 5.0±2.7%, and radial strains are 7.8±4.3%. Maximum principal strains are largest in the belly region, where they are aligned with the circumferential direction during diastole switching into the radial direction during systole. Circumferential strains are concentrated at the distal portion of the belly region close to the free edge of the leaflet, while radial strains are highest in the center of the leaflet, stretching from the posterior to the anterior commissure. In summary, leaflet strains display significant temporal, regional, and directional variations with largest values inside the belly region and toward the free edge. Characterizing strain distribution profiles might be of particular clinical significance when optimizing mitral valve repair techniques in terms of forces on suture lines and on medical devices.     

OPERATIONS ON THE PERICARDIUM—A Review of Current Surgical Procedures

Improved management of pericardial disease has resulted from a better understanding of the pathological physiology and refined surgical technique.In acute cardiac tamponade from trauma, our experience has shown that simple pericardial aspiration, because it relieves the tamponade, renders open operation unnecessary unless the hemorrhage is unusually severe. However, in chronic tamponade, from prolonged pericardial bleeding or effusion, the “pericardio-pleural window” operation described in this article will safely decompress the pericardium without secondary infection and the necessity of reoperation. With chronic constrictive pericarditis, on the other hand, catheterization studies reveal that left heart constriction is more important than that of the right heart or vena cavae. So it is important to pay more attention to decortication of the left heart than was formerly believed.Excision of pericardial tumors, most often cystic, is indicated because they are indistinguishable from malignant growths, although they in themselves are not of serious import.Fatty and fibrous pericardium have proved to be suitable viable material for various plastic operations on the heart, lung and esophagus. Finally, experience with poudrage to revascularize the myocardium is proving that this is a very satisfactory technique which can be performed with minimal risk.     

Operations on the pericardium; a review of current surgical procedures

Improved management of pericardial disease has resulted from a better understanding of the pathological physiology and refined surgical technique. In acute cardiac tamponade from trauma, our experience has shown that simple pericardial aspiration, because it relieves the tamponade, renders open operation unnecessary unless the hemorrhage is unusually severe. However, in chronic tamponade, from prolonged pericardial bleeding or effusion, the "pericardio-pleural window" operation described in this article will safely decompress the pericardium without secondary infection and the necessity of reoperation. With chronic constrictive pericarditis, on the other hand, catheterization studies reveal that left heart constriction is more important than that of the right heart or vena cavae. So it is important to pay more attention to decortication of the left heart than was formerly believed. Excision of pericardial tumors, most often cystic, is indicated because they are indistinguishable from malignant growths, although they in themselves are not of serious import. Fatty and fibrous pericardium have proved to be suitable viable material for various plastic operations on the heart, lung and esophagus. Finally, experience with poudrage to revascularize the myocardium is proving that this is a very satisfactory technique which can be performed with minimal risk.     

Bioprosthetic heart valve leaflet motion monitored by dual camera stereo photogrammetry

Dual camera stereo photogrammetry (DCSP) was applied to investigate the leaflet motion of bioprosthetic heart valves (BHVs) in a physiologic pulse flow loop (PFL). A 25-mm bovine pericardial valve was installed in the aortic valve position of the PFL, which was operated at a pulse rate of 70 beats/min and a cardiac output of 5 l/min. The systolic/diastolic aortic pressure was maintained at 120/80 mmHg to mimic the physiologic load experienced by the aortic valve. The leaflet of the test valve was marked with 80 India ink dots to form a fan-shaped matrix. From the acquired image sequences, 3-D coordinates of the marker matrix were derived and hence the surface contour, local mean and Gaussian curvatures at each opening and closing phase during one cardiac cycle were reconstructed. It is generally believed that the long-term failure rate of BHV is related to the uneven distribution of mechanical stresses occurring in the leaflet material during opening and closing. Unfortunately, a quantitative analysis of the leaflet motion under physiological conditions has not been reported. The newly developed technique permits frame-by-frame mapping of the leaflet surface, which is essential for dynamic analysis of stress-strain behavior in BHV.     

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.     

Percutaneous mitral valve repair: the necessity to redefine secondary mitral regurgitation

Netherlands Heart Journal - Interest in percutaneous mitral valve repair has increased during recent years. This is mainly driven by the significant number of patients being declined for mitral...     

Comparison of mitral annulus geometry between patients with ischemic and non-ischemic functional mitral regurgitation: implications for transcatheter mitral valve implantation

Background

Transcatheter mitral valve replacement (TMVR) is a new therapeutic option for high surgical risk patients with mitral regurgitation (MR). Mitral valve (MV) geometry quantification is of paramount importance for success of the procedure and transthoracic 3D echocardiography represents a useful screening tool. Accordingly, we sought to asses MV geometry in patients with functional MR (FMR) that would potentially benefit of TMVR, focusing on the comparison of mitral annulus (MA) geometry between patients with ischemic (IMR) and non ischemic mitral regurgitation (nIMR).

Methods

We retrospectively selected 94 patients with severe FMR: 41 (43,6%) with IMR and 53 (56,4%) with nIMR. 3D MA analysis was performed on dedicated transthoracic 3D data sets using a new, commercially-available software package in two moments of the cardiac cycle (early-diastole and mid-systole). We measured MA dimension and geometry parameters, left atrial and left ventricular volumes.

Results

Maximum (MA area 10.7?±?2.5 cm² vs 11.6?±?2.7 cm², p?>?0.05) and the best fit plane MA area (9.9?±?2.3 cm² vs 10.7?±?2.5 cm², p?>?0.05, respectively) were similar between IMR and nIMR. nIMR patients showed larger mid-systolic 3D area (9.8?±?2.3 cm² vs 10.8?±?2.7 cm², p?<?0.05) and perimeter (11.2?±?1.3 cm vs 11.8?±?1.5 cm, p?<?0.05) with longer and larger leaflets, and wider aorto-mitral angle (135?±?10° vs 141?±?11°, p?<?0.05). Conversely, the area of MA at the best fit plane did not differ between IMR and nIMR patients (9?±?1.1 cm² vs 9.9?±?1.5 cm², p?>?0.05).

Conclusions

Patients with ischemic and non-ischemic etiology of FMR have similar maximum dimension, yet systolic differences between the two groups should be taken into account to tailor prosthesis’s selection.

Trial registration

N.A.

     

Takotsubo cardiomyopathy complicated by cardiac tamponade

We describe a 76-year-old patient with takotsubo cardiomyopathy complicated by cardiac tamponade. Pericardial effusion in takotsubo cardiomyopthy is common but a cardiac tamponade is very rare. The use of anticoagulants may increase the risk of pericardial effusion and should be considered with care.