风湿性二尖瓣病变行二尖瓣成形术的效果分析

目的 探讨风湿性二尖瓣病变行二尖瓣成形术的临床效果。 方法 选取2016年1月至2020年1月在郑州大学第一附属医院心外科因风湿性二尖瓣病变治疗的133例患者为研究对象。其中46例患者行二尖瓣成形术（观察组）,87例患者行二尖瓣置换术（对照组）。观察组中男性10例,女性36例,平均年龄（53.80±8.87）岁;对照组中男性25例,女性62例,平均年龄（56.54±9.88）岁。收集两组患者的基线资料、术前超声结果、围手术期资料、随访资料（术后6个月）,分析二尖瓣成形术的临床效果。 结果 观察组的主动脉阻断时间、体外循环时间、住院时间与对照组相比,差异无统计学意义（P > 0.05）。观察组术后呼吸机辅助时间较对照组短[（9.4±1.6）h比（12.9±1.5）h],差异有统计学意义（P < 0.05）。观察组与对照组术后 6个月左房内径[（41.00±8.00）mm比（46.75±10.13）mm]、左室舒张末期内径[（45.49±5.90）mm比（47.87±5.66）mm]差异有统计学意义,且观察组小于对照组（P < 0.05）。 结论 二尖瓣成形术治疗风湿性二尖瓣病变的早期临床效果满意,有利于心脏重构,值得临床推广应用。     

经食管二维与实时三维超声结合在风湿性二尖瓣病变成形术中的应用

目的:研究经食管二维与实时三维超声结合在风湿性二尖瓣病变成形术中的作用。方法:26例临床诊断为风湿性二尖瓣病变拟行二尖瓣成形术患者,术前联合应用经食管二维超声与实时三维超声,对二尖瓣功能不全进行分类,详细定位病变部位,测量二尖瓣前后叶厚度、长度及瓣环径。术后即刻评价疗效。结果:术前超声诊断单纯风湿性二尖瓣关闭不全10例(38.5%),单纯二尖瓣狭窄4例(15.4%),二尖瓣关闭不全重度伴狭窄轻度9例(34.6%),二尖瓣关闭不全重度伴狭窄中度3例(11.5%);瓣膜功能不全Ⅱ型4例(15.4%),ⅡAⅢa-P型18例(69.2%),Ⅲa-AⅢa-P型4例(15.4%)。术后即刻超声评价疗效,3例在超声指导下2次成形,其中2例最终选择瓣膜置换术。结论:经食管二维和实时三维超声心动图结合,在风湿性二尖瓣病变成形术前对瓣膜功能不全进行分类诊断,能准确评估二尖瓣叶厚度和长度,指导术式和人工瓣环的选择。术后即刻评价疗效,在风湿性二尖瓣成形术中有重要的应用价值。     

Surgical rheumatic mitral valve repair compared with percutaneous balloon mitral valvuloplasty in mitral stenosis in current era: a propensity score matching study

BackgroundMany comparative studies of percutaneous balloon mitral valvuloplasty (PBMV) and surgical mitral commissurotomy (SMC) in rheumatic mitral stenosis (MS) were done in the last few decades. With the development of valve repair techniques, various surgical rheumatic valve repair techniques have been applied in clinic, but there is a lack of comparison with PBMV. Our study was designed to compare the perioperative and mid-term outcomes of PBMV and mitral valve repair with “four-step” procedure in the treatment of rheumatic MS.MethodsPatients with MS were treated with PBMV or rheumatic mitral valve repair (rMVP) at Beijing Anzhen Hospital between January 1, 2013 and September 30, 2018 were selected. By using propensity score matching (PSM) method, we compared the changes in post-operation clinical outcomes between the two matched groups. Kaplan-Meier analyses was used for survival analysis and drawing the curve, and log-rank test were used to compare intergroup differences.ResultsA total of 252 cases were enrolled after selection, 74 cases in PBMV and 178 cases in rMVP. Seventy-four pairs were matched successfully after PSM. There were 53 females in PBMV and 54 in rMVP. The mean age of two groups was 46.95±12.50 and 47.55±11.91 years respectively. There was no significantly differences in mitral valve orifice area (MVOA) (1.05±0.32 vs. 0.97±0.24 cm², P=0.12) and left ventricular ejection fraction (EF) (62.36%±5.17% vs. 62.52%±4.94%, P=0.76) between two groups preoperatively. Baseline characteristics were basically balanced after PSM. In each group, there was one case transferred to surgical mitral valve replacement due to the failure of valvuloplasty before discharge. All patients survived the interventions and no severe complications were found. MVOA were significantly increased in rMVP compared with PBMV postoperatively, as well as grading of MS and tricuspid regurgitation (TR) were significantly improved in rMVP. Three cases in PBMV were lost during the follow-up. Mitral replacement was performed in 11 patients and one of them died in PBMV, while none of patients underwent re-intervention in rMVP, but one patient died of pneumonia.ConclusionsFor selected patients with rheumatic MS in China, our study shows that there are comparable clinical outcomes in terms of operative, mid-term mortality and complications between PBMV and surgical rMVP with “four-step” procedure. Surgical rMVP shows more advantageous in the correction of valve stenosis and the management of concomitant tricuspid valve lesions and atrial fibrillation (AF).     

Clinico-pathological classification of rheumatic mitral valve damage and surgical strategy

BackgroundThere is a lack of established pathological indications for rheumatic valve repair. Therefore, we summarized the pathological classifications of rheumatic heart diseases and their correlations with the surgical strategies.MethodsThis observational study enrolled patients with rheumatic heart diseases who underwent mitral valve repair (MVP) or replacement at our centre between January 2017 and January 2019. Mitral leaflet, mitral commissural, and sub-valvular apparatus were classified into three grades from mild to severe, according to their degree of pathological damage. Based on certain principles and the grade of mitral leaflet, mitral commissural, and sub-valvular apparatus damage, three pathological types were identified (types I to III), based on which all patients were classified. The features of each pathological type were summarised. Differences between the three pathological types were analysed using chi-square test of tendency. These data were used to propose a clinico-pathological classification of rheumatic mitral valve damage in Chinese patients.ResultsOf 398 patients, 284 (70%) underwent MVP for rheumatic mitral valve diseases. There were 58 type I (15%) patients in the study, all of whom underwent repair (repair rate, 100%). Preoperative moderate-to-severe regurgitation with mild pathological lesions was observed in 64% of these patients. In 260 type II (65%) patients, the repair rate was 76% (197/260); preoperative moderate-to-severe stenosis was observed in 88% of these patients. In 80 type III (20%) patients, the repair rate was 36% (29/80); the preoperative rates of extremely severe stenosis and moderate-to-severe regurgitation in these patients were 50% and 40%, respectively. Several preoperative parameters show the change in trend with the increase in the pathological classification severity.ConclusionsOur clinico-pathological classification of rheumatic mitral valve damage is applicable to MVP. Considering that the classification principles are based on the possibility of mitral repair, it provides a phased and achievable target ratio for MVP and a principle of screening patients who should undergo rheumatic MVP.     

Predictors of left atrial thrombus in mitral valve disease

Objective:To determine the risk factors for left atrial thrombus (LAT) and the prevalence of thrombi in cases of mitral valve disease whose severity was fudged to necessitate surgical intervention. Design:Hospital record review of all operative cases from 1982 to 1985. Setting:A community serving a referral population encompassing 1.5 million people. Only two hospitals in the geographic area performed cardiac surgery, and both hospitals’ records were reviewed. Patients:All 372 patients who underwent either mitral valve replacement or open mitral commissurotomy. Main results:Twenty-six patients (7%) were noted to have LAT at surgery. Five preselected factors were significantly (p<0.05) associated with LAT in univariate analysis: female gender, prior history of embolism, prior anticoagulant therapy, mitral stenosis (MS), and atrial fibrillation (AF). In logistic regression analysis, only MS and AF remained as significant independent predictors of LAT. Mitral stenosis patients in sinus rhythm had a relatively low [2.4±3.3% (observed ±95% confidence interval)] likelihood of having an LAT. Likewise, mitral regurgitation patients in sinus rhythm (n=139)had an extremely low (0.7±1.4%) prevalence of LAT. In contrast, MS patients in AF (n=122)had a prevalence of LAT of 18.0±6.8%. Conclusions:These findings indicate that, overall, LAT in mitral valve disease may be less common than previous studies have suggested. In addition, mitral valve disease patients who remain in sinus rhythm appear to have a low risk of barboring an LAT. Conversely, MS patients, especially those in AF, appear to be at high risk of barboring an LAT. These results may be helpful in formulating strategies for the use of prophylactic anticoagulation in categories of patients with clinically severe mitral valve disease, or perhaps in estimating the likelihood of a cardiac source of embolism in mitral valve disease patients with suspected cerebral or peripheral emboli. Received from the General Medicine and Cardiology Units, Department of Medicine, the University of Rochester School of Medicine and Dentistry, Rochester, New York. Dr. Davison is currently at Washington University, St. Louis, Missouri.     

Pathology of mitral valve stenosis and pure mitral regurgitation—Part I

This two-part article examines the histologic and morphologic basis for stenotic and purely regurgitant mitral valves. In Part I, conditions producing mitral valve stenosis are reviewed. In over 99% of stenotic mitral valves, the etiology is rheumatic disease. Other rare causes of mitral stenosis include congenitally malformed valves, active infective endocarditis, massive annular calcium, and metabolic or enzymatic abnormalities. In Part II, conditions producing pure mitral regurgitation will be discussed. In contrast to the few causes of mitral stenosis, the causes of pure (no element of stenosis) mitral regurgitation are multiple. Some of the conditions producing pure regurgitation include floppy mitral valves, infective endocarditis, papillary muscle dysfunction, rheumatic disease, and ruptured chordae tendineae.     

Pathology of mitral valve stenosis and pure mitral regurgitation—Part II

This two-part article examines the histologic and morphologic basis for stenotic and purely regurgitant mitral valves. in Part I, conditions producing mitral valve stenosis were reviewed. in over 99% of stenotic mitral valves, the etiology is rheumatic disease. Other rare causes of mitral stenosis include congenitally malformed valves, active infective endocarditis, massive annular calcium, and metabolic or enzymatic abnormalities. in Part II, conditions producing pure mitral regurgitation are discussed. in contrast to the few causes of mitral stenosis, the causes of pure (no element of stenosis) mitral regurgitation are multiple. Some of the conditions producing pure regurgitation include floppy mitral valves, infective endocarditis, papillary muscle dysfunction, rheumatic disease, and ruptured chordae tendineae.     

瓣膜置换术中双极射频消融治疗风湿性心脏病合并心房颤动

目的 探讨风湿性心脏瓣膜病合并心房颤动（AF）患者同期行瓣膜替换术及双极射频消融迷宫术的近期手术效果.方法 选取风湿性心脏瓣膜病合并心房颤动患者18例（消融组）,同期行瓣膜替换术及双极射频消融迷宫术治疗心房颤动.18例配对仅行心脏瓣膜替换术而未行双极射频消融迷宫术的患者作为对照组.患者年龄36～65岁,平均53.5岁,房颤持续时间1～10年,平均5年,左心房内径为44～67 mm.比较两组患者的手术治疗结果.结果 消融组18例患者术后窦性心律16例,房颤心律1例,结性心律1例;随访8个月,15例维持窦性心律,3例阵发性房颤心律.对照组13例术中心脏复跳后即为房颤心律,5例心脏复跳后为窦性心律,术后24 h内均转为房颤心律,应用胺碘酮不能持续恢复窦性心律.两组术后左房内径均较术前显著降低（P＜0.01）,消融组术后左房内径小于对照组[（33.06±2.88）mm比（36.16±2.43）mm,P＜0.05].结论 风湿性心脏瓣膜病合并慢性心房颤动患者在行瓣膜替换术的同时行附加的双极射频消融手术疗效良好,安全简便.     

Spectrum of congenital mitral valve abnormalities associated with solitary undifferentiated papillary muscle in adults

BackgroundCongenital anomaly wherein the mitral valve leaflets are directly attached to the papillary muscle(s) (PM) with or without short under-developed chords is rarely reported in adults. Patients with two PMs with an intervening fibrous bridge have also been included under this head in previous studies.MethodsEchocardiography enables accurate evaluation of the morphology and function of valve leaflets, chordae tendineae, and PM. This report describes a series of six patients aged 56–84 years who had abnormal mitral valve with a large solitary and anomalously inserted PM seen over a period of 3 years. Only those patients who had a single pillar or bridge-like PM and either absent tendinous chords or small under-developed chords were included in the analysis.ResultsAmong 9600 consecutive echocardiograms performed, six patients met the criteria of an abnormal mitral valve with solitary large PM. Two patients underwent mitral valve replacement with partial excision of the PM wherein echocardiographic observations were confirmed. The patients were previously followed with the diagnosis of hypertrophic cardiomyopathy (3) and rheumatic mitral valve disease (3). Multi-planar reconstruction of 3D echocardiographic images provided incremental value in assessing the detailed patho-anatomy of PMs in these cases.ConclusionIn adult patients, a high index of suspicion is required to detect congenital mitral stenosis/regurgitation with large solitary PM (resembling a parachute mitral valve) which may masquerade as hypertrophic cardiomyopathy or rheumatic mitral valve disease.     

Hemodynamic effects and long-term outcome of percutaneous balloon valvuloplasty in patients with mitral stenosis and atrial fibrillation

BACKGROUND: The presence of atrial fibrillation (AF) has been identified as a predictor of a suboptimal result in some patients undergoing percutaneous balloon valvuloplasty in the treatment of symptomatic rheumatic mitral stenosis. HYPOTHESIS: Atrial fibrillation adversely affects the short- and long-term outcome of patients with mitral stenosis undergoing percutaneous balloon valvuloplasty. METHODS: A retrospective chart review of 104 consecutive patients with rheumatic mitral stenosis undergoing percutaneous balloon valvuloplasty was performed. A successful procedure was defined as a final mitral valve area > or = 1.5 cm2 and the absence of a complication. Endpoints included freedom from mitral valve replacement, death, and repeat balloon valvuloplasty at 5 years. RESULTS: A successful procedure was obtained in 89% of patients with sinus rhythm and in 78% of patients with AF (p = NS). Patients in sinus rhythm had a greater cardiac output resulting in a larger final valve area than patients in AF (1.8 vs. 1.6 cm2, p < 0.05). Freedom from valve replacement, death, and repeat balloon valvuloplasty at 5 years was 75% for patients in AF and 76% for patients in sinus rhythm (p = NS). Lower postprocedure mitral regurgitation grade and absence of prior commissurotomy were the only independent predictors of event-free survival. CONCLUSIONS: Patients with mitral stenosis and AF have lower cardiac outputs and gradients than patients with sinus rhythm, despite similar valve areas. The long-term outcome of balloon valvuloplasty is independent of the initial cardiac rhythm.     

Spontaneous echo contrast on transthoracic echocardiography and left atrial thrombus in rheumatic mitral valve disease patients: A clinicopathologic study

The association of spontaneous echo contrast and thrombus in the left atrium in patients with mitral valve disease is controversial. This study was undertaken to determine whether there is an independent association between spontaneous echo contrast on transthoracic echocardiography (TTE) and intraoperative evidence of left atrial thrombus and to evaluate the clinical implications of spontaneous echo contrast in patients with symptomatic rheumatic mitral valve disease. A total of 255 patients who underwent surgery for rheumatic mitral valve disases were preoperatively evaluated by transthoracic two-dimensional and Doppler echocardiography. Spontaneous echo contrast in the left atrium was carefully sought. The left atrium was carefully searched for evidence of thrombus intraoperatively. The association of spontaneous echo contrast and left atrial thrombus was determined by univariate and multivariate analysis. Of the patients studied, 77 (30%) had left atrial thrombus. Left atrial thrombus was found in 47 and 21 % of patients with and without spontaneous echo contrast, respectively (p < 0.001). Spontaneous echo contrast and atrial fibrillation were found to be the only two independent predictors of left atrial thrombus (odds ratio = 2.16; 95% confidence interval 1.15-4.04 p < 0.05, and odds ratio = 6.98; 95% confidence interval 3.45-14.16, p < 0.001, respectively). It was concluded that there is an independent association between spontaneous echo con trast on TTE and left auial thrombus in patients with mitral valve disease requiring surgical correction. These patients are at high risk for left atrial thrombus and should, therefore, be con sidered for long-term anticoagulation.     

Commissural fusion as etiology of bioprosthetic mitral stenosis in a patient with rheumatic heart disease

We report commissural fusion as a unique morphologic etiology of early bioprosthetic mitral valve failure in a woman with a history of rheumatic mitral stenosis. She had undergone mitral valve replacement with a 25-mm Edwards Magna Ease bovine pericardial bioprosthesis 3 years earlier and presented with progressive dyspnea. Transesophageal echocardiography revealed severe bioprosthetic stenosis due to commissural fusion. She underwent percutaneous valve-in-valve implantation with a 26-mm Edwards Sapien 3 prosthesis. Marked symptomatic improvement was noted postprocedurally. We speculate that commissural fusion may be a unique pathologic feature of failing bioprosthetic valves in patients with prior rheumatic mitral valve disease.     

Early results after mitral valvuloplasty for pure mitral regurgitation

In this study we present the results of 105 consecutive patientswith pure mitral regurgitation who underwent surgical treatment.In all patients mitral regurgitation was associated with mitralvalve prolapse: 54 patients underwent mitral valvuloplasty and51 patients mitral valve replacement. Clinical assessment and echocardiography were used as follow-upcriteria at one year after surgery. After mitral valvuloplasty,NYH A decreased from 2.7±0.8 to 1.1±0.7 (P<0.01)and workload capacity increased from 65±28% to 96±25%(P<0.001); left endsystolic atrial dimension and enddiastolicdimension decreased from 6.2±0.8 to 4.8±1.2 cm(P<0.001) and from 7.2±1.3 to 5.9±0.8 cm (P<0.01);ventricular contraction fraction did not change significantly. After mitral valve replacement, clinical and echocardiographicimprovement was significant but less remarkable than after valvuloplasty;ventricular contraction fraction fell from 39±7% to 29±8%in contrast to patients undergoing mitral valvuloplasty in whomno significant change occurred. Complications were rare in both groups though only a minorityof patients undergoing mitral valvuloplasty received anticoagulants.We conclude that mitral valvuloplasty in patients with puremitral regurgitation associated with mitral valve prolapse givesexcellent results, particularly regarding left ventricular functionwhen compared with the patients after mitral valve replacement.     

Early results after mitral valvuloplasty for pure mitral regurgitation

In this study we present the results of 105 consecutive patientswith pure mitral regurgitation who underwent surgical treatment.In all patients mitral regurgitation was associated with mitralvalve prolapse: 54 patients underwent mitral valvuloplasty and51 patients mitral valve replacement. Clinical assessment and echocardiography were used as follow-upcriteria at one year after surgery. After mitral valvuloplasty,NYH A decreased from 2.7±0.8 to 1.1±0.7 (P<0.01)and workload capacity increased from 65±28% to 96±25%(P<0.001); left endsystolic atrial dimension and enddiastolicdimension decreased from 6.2±0.8 to 4.8±1.2 cm(P<0.001) and from 7.2±1.3 to 5.9±0.8 cm (P<0.01);ventricular contraction fraction did not change significantly. After mitral valve replacement, clinical and echocardiographicimprovement was significant but less remarkable than after valvuloplasty;ventricular contraction fraction fell from 39±7% to 29±8%in contrast to patients undergoing mitral valvuloplasty in whomno significant change occurred. Complications were rare in both groups though only a minorityof patients undergoing mitral valvuloplasty received anticoagulants.We conclude that mitral valvuloplasty in patients with puremitral regurgitation associated with mitral valve prolapse givesexcellent results, particularly regarding left ventricular functionwhen compared with the patients after mitral valve replacement.     

Live 3D TEE demonstrates and guides the management of prosthetic mitral valve obstruction

A 43-year-old woman, with a remote history of rheumatic mitral stenosis and a St. Jude prosthetic mitral valve replacement, presented with shortness of breath and palpitations, shortly after a long flight. On admission, atrial fibrillation with a rapid ventricular response was noted in the setting of a long history of noncompliance with her anticoagulation. Transesophageal echocardiography (TEE) demonstrated multiple laminated thrombi in the left atrial appendage. Live three-dimensional (3D) TEE confirmed this diagnosis and demonstrated an immobile posterior leaflet of the mitral prosthesis, which had direct implications in her management. She successfully underwent surgery for mitral valve replacement, left atrial appendage ligation, and a Maze procedure on the following day. The multiple thrombi within the atrial appendage were confirmed intraoperatively and pannus formation was determined to be the etiology of the leaflet immobility.     

Echocardiography of the mitral valve

Mitral valve disease is the second most common valvular heart disease after the aortic valve worldwide. Mitral valve has historically been a structure of interest by pioneers in echocardiography. One of the earliest applications of echocardiography was in the diagnosis of valvular heart disease, particularly mitral stenosis. In this review we wish to take the reader through the structural and hemodynamic evaluation of the normal mitral valve.     

瓣中瓣置入术治疗二尖瓣关闭不全16例报告

二尖瓣关闭不全患者行常规二尖瓣置换术后常有左室功能恶化，有人推测术中二尖瓣结构的破坏是导致术后左室功能不全的主要机制之一。从１９９１年５月～１９９５年５月，我们对１６例二尖瓣关闭不全患者实施了一种新的二尖瓣置换术，即“瓣中瓣”置入术。术中保留全部二尖瓣瓣叶及瓣下结构，人工瓣置入固定后，前、后瓣叶均卷缩折叠于缝合环下。术后所有患者病情平稳，仅３例需要很少量的正性肌力药物支持，且都能在术后３６小时内脱离呼吸机。经超声心动图测定，术后左室功能很快恢复，所有患者均痊愈出院。结果表明：对二尖瓣关闭不全及其合并轻度狭窄者采用瓣中瓣置入术，有利于术后左室功能的恢复，瓣中瓣置入术是一种安全和有效的手术方法。     

Fine versus coarse atrial fibrillation in rheumatic mitral stenosis: The impact of aging and the clinical significance

Background

Atrial fibrillation (AF) as the most rhythm disturbance in patients with rheumatic mitral stenosis (MS), is classified in to coarse and fine subtypes according to the height of fibrillatory wave amplitude. The aim of this study is to identify the factors associated with the presence of fine versus coarse morphology in patients with rheumatic MS.

Methods

In this cross‐sectional study, patients with confirmed diagnosis of severe rheumatic MS admitted between March 2013 and March 2017 were screened. Patients were categorized to sinus rhythm (SR) and AF rhythm (coarse and fine subtypes) groups according to the admission electrocardiogram. The association between various clinical and echocardiographic factors and the development of fine versus coarse AF were examined.

Results

Among 754 patients with the diagnosis of rheumatic MS, 288 (198 female) were found to have AF (38%). Among them 206 (71.5%), and 82 (28.5%) patients had fine and coarse morphology respectively. Patient in these two groups were quite similar in terms of echocardiographic parameters and comorbidities. However, patients with fine morphology AF were significantly older. (p‐Value=.007).

Conclusion

Coarse morphology of AF is common in patients with rheumatic MS. While echocardiographic or most clinical parameters do not seem to associate with the occurrence of coarse or fine morphology, age seems to be the only independent factor correlated with the presence of fine subtype of AF in this population.

     

Long-term results of the maze procedure on left ventricular function for persistent atrial fibrillation associated with mitral valve disease

Although the maze procedure is often performed as a surgical treatment for atrial fibrillation (AF) combined with mitral valve surgery, the long-term efficacy of the maze procedure concerning cardiac function has not been determined. The aim of this study was to assess long-term results of the maze procedure for left ventricular function in patients with persistent AF associated with mitral valve disease. We analyzed 38 patients who underwent the maze procedure for persistent AF and mitral valve surgery. The cardiothoracic ratio on chest X-ray and the left atrial dimension, left ventricular end-diastolic dimension, left ventricular end-systolic dimension and left ventricular ejection fraction on transthoracic echocardiography were evaluated before and 6 years after the maze procedure. Twenty-two patients maintained sinus rhythm (SR group) and 16 patients had recurrence of permanent AF (AF group) after the maze procedure. Preoperative cardiac function and the methods of mitral surgery were similar between the two groups. At the latest follow-up, left ventricular function tended to be better in the SR group than in the AF group. Cardiovascular events occurred more often in the AF group during follow-up (50 vs. 18%, p < 0.05). This retrospective study revealed that maintaining the sinus rhythm after the maze procedure for patients who underwent mitral valve surgery might be important for preserving better long-term left ventricular function and result in fewer cardiovascular events.     

Prolapse of the mitral valve in secundum atrial septal defect: A functional mechanism

Prolapse of the mitral valve in patients with secundum atrialseptal defect has been described angio-graphically and by two-dimensionalechocardiography. It has been suggested that prolapse of themitral valve in these patients is due to distortion of leftventricular shape and small left ventricular volume. To testthis hypothesis 10 patients with unrepaired secundum atrialseptal defect and 10 patients who had undergone repair of thedefect were studied by two-dimensional echocardiography. Theprevalence of mitral valve prolapse was 80% in the unrepairedgroup and 20% in the repaired group (P<0.01). Short axisof the left ventricle revealed septal bulging into the leftventricle, the end-diastolic ratio of minor to major axis being0.71 in the unrepaired group and 0.93 in the repaired group(P<0.001). Systolic and diastolic cross-sectional areas werelarger in the repaired group compared with the unrepaired group(P<0.05). Prolapse of the mitral valve in patients with secundumatrial septal defect may be related to the distorted left ventricularshape and small left ventricular volume.