Fenestrated Aneurysm of the Mitral Valve

Aneurysms of the cardiac valves remain rare. In this report, we describe the first case of a left ventricular to mitral valve aneurysm to left atrial shunt through a fenestrated aneurysm of the mitral valve diagnosed and successfully repaired under the guidance of transesophageal echocardiography. The transesophageal echocardiography provided substantial additional data to the transthoracic echocardiography, and was valuable in planning the surgical approach. Transesophageal echocardiography should be considered when clear-cut transthoracic echocardiographic interpretation cannot be made in patients with mitral regurgitation. (ECHOCARDIOGRAPHY, Volume 8, September 1991)     

Mitral Valve Prolapse in Marfan Syndrome: An Old Topic Revisited

Background: The echocardiographic features of mitral valve prolapse (MVP) in Marfan syndrome have been well described, and the incidence of MVP in Marfan syndrome is reported to be 40–80%. However, most of the original research was performed in the late 1980s and early 1990s, when the diagnostic criteria for MVP were less specific. Our goal was to investigate the characteristics of MVP associated with Marfan syndrome using currently accepted diagnostic criteria for MVP. Methods: Between January 1990 and March 2004, 90 patients with definitive diagnosis of Marfan syndrome (based on standardized criteria with or without genetic testing) were referred to Massachusetts General Hospital for transthoracic echocardiography. Patients' gender, age, weight, height, and body surface area at initial examination were recorded. Mitral valve thickness and motion, the degree of mitral regurgitation and aortic regurgitation, and aortic dimensions were quantified blinded to patients' clinical information. Results: There were 25 patients (28%) with MVP, among whom 80% had symmetrical bileaflet MVP. Patients with MVP had thicker mitral leaflets (5.0 ± 1.0 mm vs. 1.8 ± 0.5 mm, P < 0.001), more mitral regurgitation (using a scale of 1–4, 2.2 ± 1.0 vs. 0.90 ± 0.60, P < 0.0001), larger LVEDD, and larger dimensions of sinus of Valsalva, sinotubular junction, aortic arch, and descending aorta indexed to square root body surface area, when compared with those without MVP. When echocardiographic features of patients younger than 18 years of age and those of patients older than 18 were compared, adult Marfan patients had larger LA dimension (indexed to square root body surface area), larger sinotubular junction (indexed to square root body surface area), and more mitral regurgitation and aortic regurgitation. Conclusions: The prevalence of MVP in Marfan syndrome is lower than previously reported. The large majority of patients with MVP have bileaflet involvement, and those with MVP have significantly larger aortic root diameters, suggesting a diffuse disease process.     

Rare Mycotic Aneurysm of the Mitral Valve without Aortic Valve Involvement

Mycotic aneurysms can be a rare, but serious complication of infectious endocarditis. We report the case of a 20‐year‐old woman who presented with fever and malaise from streptococcal bacteremia and found to have vegetation on the anterior leaflet of the mitral valve. On follow‐up visit, the patient was noted to have a mycotic aneurysm of the anterior mitral valve without aortic involvement. Her clinical course was complicated by mitral valve chordal rupture, severe mitral regurgitation, and dyspnea from severe mitral regurgitation for which she underwent successful surgical repair of the mitral valve.     

Visualization of Mitral Valve Tunnel Aneurysm by Transesophageal Echocardiography

We report the echocardiographic findings in a patient with a mitral valve aneurysm, probably occurring as a complication of aortic valve endocarditis. Transesophageal echocardiography showed a tunnel-shaped aneurysm of the atrial side of the anterior mitral leaflet, expanding in systole and collapsing in diastole. Transesophageal echocardiography is a useful diagnostic tool for the evaluation of mitral valve pathology.     

经食道超声心动图在二尖瓣关闭不全瓣膜修补术中的应用

对严重的二尖瓣关闭不全病人进行二尖瓣修补术与置换相比，有着明显的利益，然而，部分病例修补术后可能持续存在二尖瓣返流，且传统的术中评价二尖瓣修补术效果的方法往往不可靠。本组术中经食道超声心动图（TEE）发现二尖瓣修补术后仍有22％（2／9）的病例存在严重的二失瓣返流，根据这一信息．这2例病人当即进行了二尖瓣置换术。随访16～24个月，7例二尖瓣修补术的病人心功能一级，无需再次手术。因此，术中TEE技术是快速准确的评价瓣膜修补术效果的方法，保证了手术的成功，能使更多更复杂的病例进行二尖瓣修补术。     

Three-Dimensional Echocardiographic Evaluation of Aortic and Mitral Valve Stenosis

Dynamic volume rendered three-dimensional echocardiography allows the spatial recognition of anatomy and function of the aortic and mitral valves with acceptable image quality. The aortic valve can be best visualized in a view from the ascending aorta down to the valve level, thus allowing an overview of the aortic aspect of the valve in a surgeon's perspective in ∼ 80% of patients. Planimetric measurement of the aortic valve area was possible in 88% of patients, and there is no systematic overestimation or underestimation of aortic valve area compared with two-dimensional echocardiography and catheterization. The entire valvular circumference of the mitral valve can be assessed from both a left atrial and a left ventricular perspective. Advantages of the three-dimensional transesophageal echocardiography mitral valve area determination compared with transthoracic two-dimensional planimetry and Doppler-derived pressure half-time method are present in patients with severely calcified mitral valves and in those with combined aortic regurgitation.     

Systolic Papillary Muscle Dyssynchrony Predicts Recurrence of Mitral Regurgitation in Patients with Ischemic Cardiomyopathy (ICM) Undergoing Mitral Valve Repair

Objective: We investigated the impact of papillary muscle dyssynchrony (DYS‐PAP) in predicting recurrent mitral regurgitation (MR) in patients with ischemic cardiomyopathy (ICM) undergoing undersized mitral ring annuloplasty (UMRA). Methods: One hundred forty‐four ICM patients (left ventricular ejection fraction <35%) in sinus rhythm undergoing UMRA between January 2001 and December 2010 at three Institutions (University Hospital, Maastricht, The Netherlands; Careggi Hospital, Florence, Italy; Civic Hospital, Brescia, Italy) were recruited. The primary endpoint was the recurrence of MR at the latest echocardiographic study defined as insufficiency ≥2+ in patients with no/trivial MR at discharge. The assessment of DYS‐PAP was performed by applying two‐dimensional (2D) speckle‐tracking imaging. Results: In patients with MR recurrence, DYS‐PAP significantly worsened (84.1 ± 8.8 msec vs.65.4 ± 8.8 msec at baseline, P < 0.001) whereas in patients with no MR recurrence, DYS‐PAP did not vary (22.3 ± 5.3 msec vs. 25.9 ± 7.2 msec at baseline, P = 0.8). Recurrent MR was positively correlated with preoperative DYS‐PAP (P < 0.001), baseline anterior mitral leaflet tethering angle α (P < 0.001) and tethering symmetry index α/β before surgery (P < 0.001). There was no significant correlation between MR recurrence and other echocardiographic parameters. Logistic regression analysis revealed that baseline values of DYS‐PAP (OR: 5.4 [95% CI: 3.1–7.7], P < 0.001), α (OR: 5.0 [2.6–6.7], P < 0.001), and α/β (OR: 3.9 [2.5–5.7], p < 0.001) were predictors of recurrent MR. A DYS‐PAP value ≥ 58 msec predicted recurrence of MR with 100% sensitivity and 83% specificity (area under the curve [AUC]: 0.92 [0.7–1], P < 0.001). Conclusions: A DYS‐PAP cutoff value of 58 msec is useful to identify patients in whom UMRA is likely to fail. That way decision making in ischemic functional MR might be facilitated.     

An Unreported Congenital Anomaly: Aneurysm of the Lateral Half of the Mitral Valve

This case draws our attention to a new type of mitral valve anomaly, which seems to be congenital. A 42‐year‐old man with symptomatic primary severe mitral regurgitation was admitted to our hospital. Echocardiography revealed an aneurysm of the half of the valve, on the anterolateral commissure side, with significant excess tissue. The other half of the valve was normal. The two parts seemed to be separated by a continuous fibrous raphe. The anterolateral papillary muscle was hyperplasic and gave the main part of chordae tendinae.     

Isolated Cleft Mitral Valve with Posterior and Anterior Clefts: a Rare Cause of Congenital Valve Regurgitation

We report a case of isolated cleft mitral valve with two clefts in the posterior and one in the anterior leaflet. Our case adds to the few reports of posterior and multiple mitral valve clefts and to our knowledge is the first using real‐time transoesophageal three‐dimensional echocardiography (3DE) for assessment of isolated cleft mitral valve. (Echocardiography 2010;27:E50‐E52)     

Three-Dimensional Echocardiography: Advancements in Qualitative and Quantitative Analyses of Mitral Valve Morphology in Mitral Valve Prolapse

Degenerative mitral valve disease (MVD) is the leading cause of organic mitral regurgitation (MR), one of the most common valvular heart disease in western countries. Substantial progresses in the surgical treatment of degenerative MVD have improved life expectancy of patients with significant MR. However, prognosis, surgical decision and timing of surgery strongly depend on the accurate characterization of mitral valve (MV) anatomy and pathology and on the precise quantification of MR. Three-dimensional (3D) echocardiography, a major technological breakthrough in the field of cardiovascular imaging, provides several advantages over two-dimensional (2D) imaging in the qualitative and quantitative evaluations of MV apparatus. In this review, we focus on the contribution of this new modality to the diagnosis of degenerative MVD, the quantitative assessment of MR severity, the selection and monitoring of surgical and percutaneous procedures, the evaluation of procedural outcomes. The results of a systematic and exhaustive search of the existing literature, restricted to real-time 3D echocardiography in adults, are here reported.     

Intractable Hemolytic Anemia after Mitral Valve Repair: A Report of Three Cases

Although hemolytic anemia after mitral valve replacement (MVR) is well recognized, hemolytic anemia associated with mitral valve repair is an uncommon condition. Furthermore, persistent and severe hemolytic anemia despite of medical treatment subsequently requiring reoperation is extremely rare. We here report three cases of intractable hemolytic anemia after mitral valve repair leading to MVR. Collision of regurgitant jet into the annuloplasty ring was the speculated mechanism of hemolysis in all cases. After MVR, all of them experienced immediate resolution of the hemolytic anemia.     

经食管实时三维超声心动图在二尖瓣疾病中的应用

经食管实时三维超声心动图是心脏彩超发展的重大飞跃,克服了经胸超声的很多缺点,在疾病诊断与治疗都发挥着巨大作用。现就其在二尖瓣疾病的应用做一综述。     

Infective Endocarditis Complicated by Mitral Valve Aneurysm: Pathologic and Echocardiographic Correlations

Infective endocarditis is a well‐described cardiovascular disease that causes significant morbidity and mortality despite medical and surgical advances. Complications of endocarditis include heart failure, systemic embolization, and valvular destruction including valve aneurysms which increase morbidity and mortality. Mitral valve aneurysms are rarely encountered in the clinical setting. We present eight mitral valve aneurysm cases and discuss a new potential pathogenesis of this deadly endocarditis complication. Pathologic evaluation suggests that neovascularization of the anterior mitral valve leaflet predisposes this territory to abscess and aneurysm formation. In conclusion, mitral valve aneurysms appear to be another form of intravalvular abscess which has expanded and should be approached aggressively with surgical intervention if indicated.