The Alfieri stitch: the advantages for mitral valve repair in difficult circumstances

In certain complex cases, where there is severe calcification of the mitral annulus but significant mitral regurgitation or systolic anterior motion (SAM), or in high-risk cases where prolonged bypass is to be avoided, the Alfieri-stitch repair of the mitral valve may be the most appropriate option available, particularly as it can be performed quickly through the aortic valve. We describe three cases undergoing aortic valve replacement, in which this technique was successfully applied in patients in whom more conventional repair techniques or valve replacement would have been hazardous, due to annular calcification and patient frailty.     

Case in which landiolol hydrochloride improved left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve following mitral valve plasty

We report a case of left ventricular outflow tract (LVOT) obstruction caused by systolic anterior motion of the mitral valve (SAM) following mitral valve plasity (MVP). A 65-year-old man underwent mitral valve plasty for grade III mitral valve regurgitation. The plasty was done smoothly and the patient was weaned from cardiopulmonary bypass successfully with continuous dobutamine infusion. However, about 30 minutes after the weaning, severe cardiovascular collapse developed. Inotropic agent, such as dobutamine, ephedrine, or calcium hydrochloride was not effective. Trans-esophageal echocardiography (TEE) showed severe mitral valve regurgitation with LVOT obstruction due to SAM. The collapse was successfully treated with volume loading and a small amount of a beta1-adrenergic antagonist, landiolol hydrochloride. We conclude that acute LVOT obstruction with SAM could develop following MVP. TEE was a much useful tool for early diagnosis and landiolol hydrochloride would be a notable agent for nonsurgical treatment of LVOT obstruction with SAM.     

A rapid structural degeneration of a porcine mitral valve

A 73-year-old woman underwent both mitral and aortic valve replacements with porcine heart valve prostheses because of severe mitral regurgitation and severe aortic regurgitation. Ten months after surgery, maximal flow velocity of the aortic valve reached 4.6 m/sec and moderate mitral regurgitation was detected. Repeated mitral and aortic valve replacements with mechanical heart valves were performed. The excised mitral valve showed thinning of the 3 cusps, and 2 of them were perforated. There was pannus overgrowth on the flow surface of the porcine aortic valve. Histologic examination of the excised mitral valve revealed marked inflammatory changes with macrophages.     

Aortic valve papillary fibroelastoma in a patient with mitral valve regurgitation

Papillary fibroelastoma is a rare cardiac tumour. We describe a patient with mitral valve regurgitation and aortic valve papillary fibroelastoma. The patient was 62-year-old woman. She was referred to us for surgical treatment of mitral valve. Preoperative echocardiography showed rheumatic mitral valve regurgitation (Sellers grade III) and it also demonstrated mobile masses of the aortic valve. At operation, mitral valve was repaired by a posterior annuloplasty. Through the aortotomy, small tumors were found to be attached to each cusps of the aortic valve and they were successfully removed. The histopathologic diagnosis was papillary fibroelastoma of the aortic valve. The postoperative course was uneventful.     

Aortic valve replacement for aortic stenosis in patients with concomitant mitral regurgitation: should the mitral valve be dealt with?

Co-existent mitral regurgitation may adversely influence both morbidity and mortality in patients undergoing aortic valve replacement for severe aortic stenosis. Whilst it is accepted that concomitant mitral intervention is required in severe, symptomatic mitral regurgitation, in cases of mild–moderate non-structural mitral regurgitation, improvement may be seen following aortic valve replacement alone, avoiding the increased risk of double-valve surgery. The exact benefit of such a conservative approach is, however, yet to be adequately quantified. We performed a systematic literature review identifying 17 studies incorporating 3053 patients undergoing aortic valve replacement for aortic stenosis with co-existing mitral regurgitation. These were meta-analysed using random effects modelling. Heterogeneity and subgroup analysis were assessed. Primary end points were change in mitral regurgitation severity and 30-day, 3-, 5- and 10-year mortality. Secondary end points were end-organ dysfunction (neurovascular, renal and respiratory), and the extent of ventricular remodelling following aortic valve replacement. Our results revealed improvement in the severity of mitral regurgitation following aortic valve replacement in 55.5% of patients, whereas 37.7% remained unchanged, and 6.8% worsened. No significant difference was seen between overall data and either the functional or moderate subgroups. The overall 30-day mortality following aortic valve replacement was 5%. This was significantly higher in moderate–severe mitral regurgitation than nil–mild mitral regurgitation both overall (p = 0.002) and in the functional subgroup (p = 0.004). Improved long-term survival was seen at 3, 5 and 10 years in nil–mild mitral regurgitation when compared with moderate–severe mitral regurgitation in all groups (overall p < 0.0001, p < 0.00001 and p = 0.02, respectively). The relative risk of respiratory, renal and neurovascular complications were 7%, 6% and 4%, respectively. Reverse remodelling was demonstrated by a significant reduction in left-ventricular end-diastolic diameter and left-ventricular mass (p = 0.0007 and 0.01, respectively), without significant heterogeneity. No significant change was seen in left-ventricular end-systolic diameter (p = 0.10), septal thickness (p = 0.17) or left atrial area (p = 0.23). We conclude that despite reverse remodelling, concomitant moderate–severe mitral regurgitation adversely affects both early and late mortality following aortic valve replacement. Concomitant mitral intervention should therefore be considered in the presence of moderate mitral regurgitation, independent of the aetiology.     

Cibenzoline attenuates systolic anterior motion of the mitral valve after mitral valvoplasty

We report a patient in whom severe hemodynamic instability occurring after mitral valvoplasty (MVP) was successfully treated with cibenzoline. Left ventricular outflow tract obstruction (LVOTO) with mitral regurgitation (MR) resulting from the systolic anterior motion (SAM) of the mitral valve that occurs after MVP often leads to hemodynamic collapse. Patients who develop SAM after MVP have been managed with intravenous volume loading, reduction/discontinuation of inotropic drugs, and with increased afterload, but these strategies were often ineffective. Cibenzoline decreased myocardial contraction, attenuated SAM, and improved hemodynamics in our patient. We recommend that cibenzoline be administered before further surgical manipulation is considered for patients who develop SAM after MVP.     

Fate of mild aortic valve disease after mitral valve intervention

OBJECTIVE: This study was performed to assess the long-term outcome of untreated mild aortic valve disease present at the time of initial mitral valve intervention. METHODS: A total of 284 patients with rheumatic heart disease aged 7 to 62 years (mean, 23.5 +/- 12.2 years) who underwent mitral valve intervention and had mild aortic valve disease initially were followed up for 2 to 18 years (mean, 10.8 +/- 3.7 years). At initial intervention, 232 patients had pure mild aortic regurgitation, and 52 patients had mild aortic stenosis with or without aortic regurgitation. RESULTS: Among patients with mild aortic regurgitation initially, 11 (5%) patients progressed to moderate (n = 6) or severe (n = 5) regurgitation over an interval of 9 to 17 years (mean, 12.1 +/- 2.8 years), and 1 patient had moderate aortic stenosis and severe aortic regurgitation after 10 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic regurgitation was 100%, 97.0% +/- 1.7%, and 87.4% +/- 4.6% at 5, 10, and 15 years, respectively. Seventeen (35%) patients with initial mild aortic stenosis (with or without regurgitation) had moderate or severe stenosis (with or without moderate-severe regurgitation) after an interval of 4.9 +/- 3.8 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic stenosis was 75.6% +/- 6.2%, 61.5% +/- 8.5%, and 46.1% +/- 11.2% at 5, 10, and 15 years, respectively. Ten patients required aortic valve replacement for aortic valve dysfunction. CONCLUSIONS: Mild aortic regurgitation present at the time of mitral valve intervention progresses very slowly and less frequently requires reintervention. However, mild aortic stenosis diagnosed initially progresses more often and more rapidly and thus needs closer follow-up.     

Successful valve repair for congenital bicuspid aortic valve and degenerated prolapsed mitral valve

A 54-year-old man with congenital bicuspid aortic valve underwent simultaneous valve repair for aortic and mitral regurgitation. Surgical technique consisted of plication of redundant aortic valve repair and mitral annuloplasty with chordal replacement. One-year follow-up transthoracic echocardiography showed no valve regurgitation. Valve repair for both bicuspid aortic valve and mitral valve regurgitation should be the first option in this subset of patients.     

Case of systolic anterior motion of mitral valve after mitral valve repair

A 56-year-old woman was underwent mitral valve repair for prolapse of the posterior mitral leaflet. Intraoperative transesophageal echocardiography (TEE) showed systolic anterior motion (SAM) of the mitral valve at the weaning from cardiopulmonary bypass (CPB). Sliding technique was easily performed at the second pump run. Intraoperative TEE demonstrated no SAM or residual mitral regurgitation after the second pump run.     

Transventricular mitral valve operations

We report transventricular mitral valve operations in 2 patients with severe mitral regurgitation and postinfarction left ventricular rupture and pseudoaneurysm. The first patient had direct papillary muscle involvement necessitating replacement of the mitral valve. The second patient had indirect mitral involvement allowing for placement of an atrial mitral annuloplasty ring via the left ventricle. Both patients showed no mitral valve regurgitation after replacement or repair and had uneventful postoperative recoveries. These cases demonstrate a feasible, alternative, transventricular approach to mitral valve replacement and repair.     

Post-mitral valve repair systolic anterior motion produced by non-obstructive septal bulge

Objective: Systolic anterior motion (SAM) may rarely occur after mitral valve reconstruction due to different anatomic factors. Several techniques have been described to reduce the incidence of post-repair SAM, e.g. leaflet sliding plasty. However, SAM can still occur after these special procedures. We reviewed data of patients developing SAM with significant mitral regurgitation due to non-obstructive septal bulge. Methods: During a 2-year period mitral valve repair was performed in 358 patients. Five of 358 (1.4%) patients with a mean age of 52±10.5 years developed post-repair SAM with severe mitral insufficiency due to non-obstructive septal bulge. Data of these patients were analyzed retrospectively and controlled after a mean follow-up of 18±2.7 months. Results: Preoperative echocardiography showed end-diastolic septum diameter of 7, 10, 10, 11 and 15 mm. The ratio between end-diastolic septum diameter and free wall diameter was 1 in four patients and 1.25 in one patient. There was no left ventricular outflow tract obstruction (LVOT). Intraoperative data revealed large myxomatous anterior (four patients) and posterior (three patients) leaflets. Quadrangular resection of posterior leaflet was carried out in four patients and sliding plasty in one patient. Cause for post-repair mitral regurgitation was a non-obstructive septal bulge. During a second pump run septal bulge was resected. Mean aortic cross-clamp time and cardiopulmonary bypass time for this procedure was 15±1.4 and 28±3.1 min, respectively. Mitral regurgitation disappeared in all patients immediately after this procedure. The grade of mitral regurgitation at follow-up was 0–1 in all patients. One patient had subaortic gradient of 36 mmHg. Conclusions: If mitral regurgitation occurs after primary successful mitral repair, septum bulge should always be considered as the primary cause for SAM even there is no preoperative gradient in LVOT. Before performing time-consuming corrective operations to relieve SAM, a septum resection should be carried out during a short second pump run.     

A case report of perforated aneurysm of mitral valve with aortic regurgitation

The patient was a 71-year-old male who complained of palpitation and tachycardia. The echocardiogram showed a bulging of the anterior mitral valve leaflet toward the left atrium that persisted throughout cardiac cycle. The cine angiogram showed deformity of the anterior mitral valve leaflet with severe mitral regurgitation and mild aortic regurgitation. At operation, a perforated aneurysm was recognized at the anterior mitral valve leaflet without thrombus and vegetation. The size of aneurysm was 40 x 25 x 25 mm. The patient underwent MVR + AVR, and the postoperative course was uneventful. Pathological examination of the anterior mitral valve leaflet revealed scar-like fibrosis and old inflammatory change. It was judged a true aneurysm of mitral valve, because the structure of endocardium was kept.     

Intraoperative transesophageal echocardiography for the evaluation of mitral, aortic and tricuspid valve repair A tool to optimize surgical outcome

The present study reviews the clinical applicability and usefulness of intraoperative transesophageal echocardiography (TEE) during valve repair. Intraoperative TEE was performed in 48 consecutive patients, who were divided into three groups: 1. mitral valve repair (MVR), 2. aortic valve repair (AVR), 3. tricuspid valve repair (TVR). Residual valve regurgitation was assessed by color Doppler echocardiography on a scale from 0 to 4. The ratios of the jet area (JA) to the left- and right-atrial areas (JA/LAA and JA/RAA) were analyzed before and after cardiopulmonary bypass (CPB). In group 1, 14 patients were scheduled for MVR, of which 4 patients underwent valve replacement and 10 MVR. Post-repair TEE studies showed a significant decrease of mitral regurgitation. In 2 of the 10 patients, TEE demonstrated severe residual regurgitation requiring valve replacement during the same thoracotomy. In group 2, 11 patients underwent aortic commissurotomy. Post-repair TEE showed an increase in the systolic opening diameter and opening area of the aortic valve. One patient underwent valve substitution because of severe aortic regurgitation. In group 3, 23 patients were scheduled for TVR. In 3 of them TEE showed no significant regurgitation thus rendering tricuspid valve surgery unnecessary. Twenty patients underwent TVR of whom two showed unacceptable post-repair regurgitation requiring further surgery. Eighteen patients showed a significant reduction of valve regurgitation after TVR, and a further reduction was achieved by adjusting the tricuspid annuloplasty under TEE guidance.     

A short-acting beta-blocker,landiolol, attenuates systolic anterior motion of the mitral valve after mitral valve annuloplasty

Here, we describe three patients with severe hemodynamic instability after mitral valve annuloplasty (MVP) who were treated successfully using a new ultra-short-acting beta-blocker, landiolol hydrochloride. When systolic anterior motion (SAM) of the mitral valve occurs after MVP, left ventricular outflow tract obstruction (LVOTO) and mitral regurgitation (MR) often lead to hemodynamic collapse. Treatment of SAM is very difficult, and transfusion, or the reduction/discontinuation of catecholamine or vasopressor administration, is often ineffective. In our three patients, landiolol hydrochloride decreased the heart rate, markedly attenuated SAM, and improved the hemodynamics. We recommend that landiolol be administered before further surgical manipulation is considered in patients with SAM after MVP.     

Influence of concomitant mitral valve dysfunction on survival after aortic valve replacement

Aortic valve pathology is the most common acquired valvular heart disease in the adults of western countries, and mitral regurgitation (MR) is often clinically present in patients with degenerative aortic stenosis or insufficiency. Many studies report an incidence of MR between 65-75% in patients evaluated for aortic valve replacement. Severe aortic valve disease may be associated with functional mitral regurgitation (FMR) defined as the failure of mitral valve to prevent systolic backward flow in the absence of any significant structural or intrinsic valvular disease. Increased afterload and left ventricular remodeling have been implicated to explain FMR in patients with aortic valve disease. Moreover, organic mitral valve disease can be associated with aortic stenosis and can be rheumatic or degenerative. We have examined the data of the literature to understand the evolution of MR, the impact of mitral regurgitation on the outcome of patients undergoing aortic valve replacement, and to determine clinical predictors of prognosis in patients with concomitant MR at the time of aortic valve replacement.     

Hemolytic anemia due to aortic valve regurgitation after mitral valve replacement

A 50-year-old woman was admitted to our hospital because of heart failure (NYHA III) due to mitral valve regurgitation (MR) with pulmonary hypertension (PH) and tricuspid valve regurgitation (TR). She had a history of chronic renal failure undergoing dialysis (peritoneal dialysis, homodialysis) since 1996. Cardiac catheterization and ultrasonic cardiography showed severe MR (Sellers III), severe TR and PH (mean pressure 33 mmHg). So we performed mitral valve replacement and tricuspid annuloplasty (DeVega). Frequent blood transfusion was needed because severe hemolytic anemia appeared after operation. Ultrasonic cardiography demonstrated moderate aortic valve regurgitation (AR) with no paravalvular prosthetic leakage. We diagnosed hemolytic anemia due to AR. We performed aortic valve replacement. Hemolytic anemia improved soon after second operation. We investigated the mechanical process of the AR. She had a very short subaortic curtain (5.9 mm) compared with the average (8.7 +/- 2.1 mm: mean +/- SD) of cardiac patients. We think that we must be very careful with suture to short subaortic curtain. In addition measurement of subaortic curtain before operation is very useful.     

Transcatheter self-expandable aortic valve implantation after undersized mitral annuloplasty

No data are available in the literature regarding the effectiveness and safety of transcatheter aortic valve implantation in patients who underwent previous mitral valve ring repair. Concerns exist related to the possible interference between the percutaneous aortic valve and the mitral annuloplasty ring. We report our experience with percutaneous aortic self-expandable valve implantation in a 76-year-old woman affected by severe aortic stenosis, previously operated on for "undersized" mitral annuloplasty repair of severe functional mitral regurgitation in dilated cardiomyopathy. No deformation of the nitinol tubing of the CoreValve device (CoreValve, Inc, Irvine, CA), neither distortion nor malfunction nor change of the conformation of the mitral ring occurred. No change in mitral function and regurgitation was evident at echocardiography monitoring, which was performed during the implant.     

Double orifice mitral valve associated with bicuspid aortic valve

A 63-year-old man with double orifice mitral valve (DOMV) and bicuspid aortic valve was reported. Preoperative echocardiography showed prolapse of the posterior leaflet and mitral regurgitation but was unable to show the existence of the duplication of the mitral valve. He underwent aortic and mitral valve replacement and did well after surgery. DOMV is a rare congenital malformation, and DOMV associated with bicuspid aortic valve is the first reported case in Japan.     

Transcatheter mitral valve therapies: State of the art

Mitral regurgitation (MR) is one of the most prevalent valvular pathologies in the developed world. There continues to be a growing population of aging patients with MR who may be too high risk for surgical management. The rapid adoption and remarkable success of transcatheter aortic valve replacement (TAVR) generated enthusiasm for transcatheter mitral valve therapies; however, the complex anatomy and pathophysiology of the mitral valve confers several unique challenges for a fully percutaneous approach. Nevertheless, several devices are under development and in various phases of preclinical or clinical testing, both for transcatheter mitral valve replacement and repair. MitraClip (Abbott Vascular), which has received FDA approval, is the most established percutaneous repair strategy and has been performed in over 80,000 patients as of 2019. The following article serves as a review of the available and upcoming devices for the various etiologies of mitral valvular disease, as well as the unique challenges and potential complications of transcatheter mitral valve intervention.     

Cerebral perfusion using the tissue oxygenation index in mitral valve repair in a patient with porcelain aorta and aortic regurgitation.

We report successful mitral valve repair in a patient with porcelain aorta, complicated by aortic regurgitation, severe cerebrovascular disease, and multiple cerebral infarctions. The patient was a 77-year-old male who had congestive heart failure as a result of severe mitral regurgitation. Mitral valve repair was performed without aortic cross-clamping, using moderate hypothermic cardiopulmonary bypass. Aortic regurgitation was likely to worsen upon retracting the atrial septum to expose the mitral valve, complicating the operative procedure. We therefore controlled the regurgitation by lowering the blood temperature and using systemic perfusion flow. During systemic low-flow perfusion, we used near-infrared spectroscopy (NIRS) and the bispectral index to prevent cerebral hypoperfusion. The tissue oxygenation index value derived from NIRS was maintained above 55% during the procedure. The repair was performed safely with no difficulty. The postoperative course was satisfactory, with no neurological complications; echocardiography revealed no mitral regurgitation. The use of NIRS is valuable in preventing neurological complications in mitral valve operations complicated by porcelain aorta and aortic regurgitation.