Mechanical haemolytic anaemia after valve repair operations for non-rheumatic mitral regurgitation.

Two cases are described in which severe mechanical haemolytic anaemia developed shortly after operation for repair of non-rheumatic mitral regurgitation. One patient had a "floppy" valve and the other cleft mitral leaflets, and both had chordal rupture. In both there was residual regurgitation after repair though in one this was initially only trivial. Clinically manifest haemolysis ceased after replacement of the valve by a frame-mounted xenograft. There are two previously reported cases in which haemolytic anaemia followed an unsuccessful mitral valve repair operation. Subclinical haemolysis or mild haemolytic anaemia may occur with unoperated valve lesions, but hitherto frank haemolytic anaemia has been observed only when turbulent blood flow is associated with the presence of a prosthetic valve or patch of prosthetic fabric. In these four cases, however, polyester or Teflon sutures were the only foreign material, and it is suggested that when these are used for the repair of leaflets, particularly in non-rheumatic mitral valve disease, they may increase the damaging effect of turbulence on circulating red blood cells.     

Severe mitral regurgitation and heart failure due to caseous calcification of the mitral annulus

Caseous calcification is a rare form of mitral annular calcification. Echocardiography reveals an echodense mass in the inferior mitral annulus with smooth borders and an echolucent inner core. We present a case where caseous calcification of the mitral annulus caused severe mitral regurgitation, atrial fibrillation and heart failure. Transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance and computed tomography were performed and ensured the diagnosis. The mass was surgically removed and a prosthetic valve was implanted. We conclude that caseous calcification of the mitral annulus should be considered not only in the differential diagnosis of cardiac masses but also in the background of mitral regurgitation, atrial fibrillation and heart failure. This case also represents the usefulness of multimodal imaging in identifying cardiac masses.     

Left ventricular outflow tract obstruction after bioprosthetic mitral valve replacement with posterior mitral leaflet preservation

We present a case of transient left ventricular outflow tract obstruction after mitral valve replacement with a high-profile bioprosthesis; only the posterior native mitral valve leaflet was preserved. A 76-year-old woman was admitted to our institution with pulmonary edema. Two weeks earlier, she had undergone mitral valve replacement at our hospital due to severe mitral stenosis and 2+ mitral regurgitation complicated by cardiac failure and atrial fibrillation. The patient was taking digoxin, furosemide, and warfarin at the time of readmission. Echocardiography showed a narrowed left ventricular outflow tract. Doppler echocardiography revealed a peak 64-mmHg gradient between the septum and the strut of the bioprosthesis. The patient was successfully treated medically. This case indicates that the risk of left ventricular outflow tract obstruction after bioprosthetic mitral valve replacement is not always eliminated by removal of the anterior mitral valve leaflet when the posterior mitral leaflet is preserved.     

Emergency mitral valve replacement for traumatic mitral insufficiency following balloon mitral valvotomy: an early haemodynamic study

Acute severe mitral insufficiency may occur during percutaneous transvenous balloon mitarl valvotomy. Urgent surgical intervention in the form of mitral valve repair or replacement may be necessary in these patients. The haemodynamic measurements at various stages in these patients were obtained and compared with those of patients undergoing elective mitral valve replacement for chronic mitral regurgitation. Between September 1995 and December 1947, urgent mitral valve replacement was performed in 14 patients out of a total of 1688 patients who underwent balloon mitral valvotomy. Haemodynamic measurements could be obtained in 7 of these patients and they constituted group I. Eight other patients undergoing elective mitral valve replacement during the same period for chronic mitral regurgitation constituted group II. Standard haemodynamic measurements were obtained at the following stages: (1) Baseline- 20-30 min after endotracheal intubation; (2) stage 1- 20-30 min after termination of the cardiopulmonary bypass: (3) stage 2- four hours after the patient was transferred to ICU and (4) stage 3-30 min after extubation. All the patients were suffering from severe pulmonary hypertension. However, the indices of pulmonary artery hypertension such as mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance as well as right ventricular systolic and end-diastolic pressures did not decrease after surgery in group I. In contrast, in group II, there was significant decrease in mean pulmonary artery pressure (p<0.05), pulmonary capillary wedge pressure (p<0.05), right ventricular systolic (p<0.001) and end-diastolic pressures (p<0.05) at stage 1. These changes persisted throughout the study period. Pulmonary vascular resistance showed a decreasing trend, but attained statistical significance at stage 1 only. Two patients died; one of intractable cardiac failure and another from septicaemia and multiple organ failure in group I, but there were no deaths in group II. Reactive pulmonary hypertension secondary to acute mitral regurgitation may not recover immediately following mitral valve replacement and may be responsible for poor outcome in these patients.     

Calcification and degeneration following mitral valve reconstruction in patients requiring chronic dialysis

BACKGROUND AND AIM OF THE STUDY: Abnormal calcium homeostasis in patients with end-stage renal failure results in dystrophic calcification; this limits the use of heterograft tissue valve prostheses in patients on chronic dialysis. Mitral valve reconstruction offers advantages over mitral replacement in many patients without renal failure, and offers theoretical advantages in patients requiring dialysis. This study was performed to determine the outcome of mitral valve reconstruction in patients with renal failure requiring chronic dialysis. METHODS: Ten patients with end-stage renal failure and on chronic dialysis who underwent mitral valve repair were identified retrospectively and followed for clinical and echocardiographic outcome. All patients had good results immediately following surgical valve mitral repair, with no more than mild mitral regurgitation and low transmitral gradients on intraoperative transesophageal echocardiography. RESULTS: Clinical and echocardiographic follow up was available for eight patients at an average of 2.3 +/- 1.4 years after surgery. Despite there being no significant valve calcification at the time of surgery, visible mitral leaflet calcification was evident in seven of these patients, and the transmitral gradient for the group was significantly increased (from 4.8 +/- 1.7 mmHg to 8.3 +/- 3.9 mmHg, p = 0.04). Two patients required reoperation for failed mitral repair; one at six months due to chordal rupture, and one at 15 months due to mitral calcification with stenosis. CONCLUSION: Despite good early surgical results, there was accelerated calcification of the repaired mitral valve, a rapid increase in postoperative mitral gradients, and a high incidence of failure of the reconstruction. Additional prospective studies are required to evaluate the optimal intervention for patients with end-stage renal failure who require mitral valve surgery.     

Severe, non-infectious mitral valve endocarditis after mitral valve reconstruction in a 32-year old female with primary antiphospholipid syndrome

BACKGROUND: A 32-year old female with primary antiphospholipid syndrome presented 8 months after mitral valve reconstruction with progressive exertional dyspnea and echocardiographically demonstrable critical mitral stenosis and regurgitation. Tachycardia, weight loss, sleep disturbances and increasing nervosity led to the diagnosis of concomitant hyperthyroidism. After the patient stopped the oral anticoagulation by herself, a 'catastrophic antiphospholipid syndrome' with multiple microthromboembolic events in several organs developed rapidly within a few weeks. Severe respiratory failure was observed 14 days after admission at our hospital because of a pulmonary edema. TREATMENT: Removal of the annuloplasty ring and alloplastic mitral valve replacement with a 25 mm bilifleat valve. Postoperatively, the patient was placed on oral anticoagulation. Several pre- and postoperative plasmaphereses lowered the level of antiphospholipid antibodies. The patient additionally underwent radioiodtherapy 5 months postoperatively. RESULTS: While hemodynamics and diuresis remained sufficient, ventilatory support with tracheostomy was necessary for 16 postoperative days to achieve stable respiration. Thirty months later, the patient is well and without further cardiac and neurological dysfunction. CONCLUSION: Secondary cardiac valve operations on patients with primary antiphospholipid syndrome may be successfully performed within a multidisciplinary approach. Oral anticoagulation remains the treatment of choice to prevent further thromboembolic events.     

Percutaneous valve repair for mitral regurgitation using the Carillon Mitral Contour System. Description of the method and case report

Mitral regurgitation may result from left ventricular dilatation and cause progression of heart failure. Percutaneous techniques for mitral valve repair are under development. Techniques utilizing a trans-coronary venous approach exploit the anatomical relationship between the mitral annulus and the venous system of the heart. The coronary sinus, great cardiac vein and the origin of the anterior interventricular vein surround the posterior mitral annulus. This enables percutaneous approaches to annuloplasty for mitral regurgitation. Devices can be implanted into the coronary veins that modify the shape and size of the mitral annulus. We present a case of ischaemic mitral regurgitation successfully treated by use of a percutaneous approach, the Carillon Mitral Contour System. Significant reduction of the mitral regurgitation jet was observed. The patient was discharged 4 days after the procedure. During the follow-up visits, the patient showed an improved general condition and increased exercise capacity. Procedural steps are shown in detail and the current status of the coronary sinus based technique is discussed. Percutaneous techniques for mitral valve repair may be an attractive alternative to cardiac surgery in heart failure patients with secondary mitral regurgitation. The Carillon Mitral Contour System is under ongoing clinical evaluation in the AMADEUS trial.     

先天性二尖瓣关闭不全的再次手术

目的:回顾性分析先天性二尖瓣关闭不全再次手术的问题。方法:自2002年至2009年间共438例先天性二尖瓣关闭不全(不包括完全性或部分性房室通道)患儿行二尖瓣成形手术,所有患儿中有15例(3.4%)行再次二尖瓣手术,其中再次行二尖瓣成形术12例(组1),二尖瓣置换术3例(组2)。再次手术的原因包括:严重溶血和残余或复发二尖瓣关闭不全。术中根据瓣膜病变情况选择合适的成形方法,包括二尖瓣瓣环环缩、腱索转移、双孔成形和瓣膜置换手术。对所有患者均行临床评估和超声心动图检查评估二尖瓣功能。结果:全组患儿无死亡病例,所有15例随访患儿亦无死亡。组2患儿年龄、体质量和心胸比均大于组1。组1患儿中术中见原缝线撕裂2例,瓣环扩大4例,瓣叶局部裂3例,组1患儿术后超声心动图见二尖瓣关闭不全较术前明显减轻(P0.01)。组2中3例患儿均行二尖瓣双叶机械瓣置换。结论:二尖瓣成形术仍是先天性二尖瓣关闭不全再次手术的首选术式,对术前心功能差且瓣膜条件不理想的患儿行瓣膜置换手术是理智的选择。     

Progression of isolated tricuspid regurgitation late after mitral valve surgery for rheumatic mitral valve disease

BACKGROUND AND AIMS OF THE STUDY: Severe tricuspid regurgitation (TR) may develop late after mitral valve surgery without significant mitral stenosis, regurgitation and other causes of left heart failure. The study aim was to investigate severe isolated TR late after mitral valve surgery for rheumatic mitral valve disease. METHODS: A total of 208 patients who underwent mitral valve surgery (valve replacement in 121, commissurotomy in 62, valvuloplasty in 25) was investigated. The mean (+/-SD) follow up was 13+/-6 years. Severe isolated TR was defined clinically by elevated venous pressure, and echocardiographically by grade 4+ TR without significant mitral stenosis, regurgitation, other causes of left heart failure, pulmonary hypertension or rheumatic tricuspid valve. RESULTS: Severe isolated TR was identified in 30 patients (14%) at four to 24 years after mitral valve surgery. All patients had atrial fibrillation. Of these patients, 23 had medical treatment and seven had tricuspid valve surgery. Three of the medically treated patients were in NYHA class IV and died from multiple organ failure at three to seven years after severe TR was diagnosed. Among surgically treated patients, four were in NYHA class IV and had postoperative complications (one early death, one late death), while three NYHA class II/III patients had very few postoperative complications. CONCLUSION: Severe isolated TR was detected in 14% of patients after mitral valve surgery. It is important to detect patients with progressive heart failure and to indicate earlier reoperation in order to prevent significant late mortality.     

Results of valve reconstruction for mitral regurgitation secondary to mitral valve prolapse

Mitral valve prolapse (MVP), often the result of myxomatous degeneration of the mitral valve, is the most commonly known pathologic entity leading to pure mitral regurgitation (MR). Reconstruction of the mitral valve rather than replacement is particularly applicable to this pathologic defect, but is not often used in the U.S. Experience with reconstruction of the mitral valve for MR secondary to MVP during the period January 1970 to January 1984 was reviewed. A total of 479 patients with mitral valve disease underwent operation during this period, 82 (17%) of whom had MR secondary to MVP. Thirty-one patients (6%) had valve reconstruction by a technique of leaflet plication and posteromedial anuloplasty. Eleven of these patients had associated cardiac disease requiring correction: 2 requiring aortic valve replacement and 9 requiring coronary artery bypass grafting procedures. One hospital death (3%) and 6 late deaths (19%) occurred, of which only 3 were related to cardiac factors. Major complications included recurrent MR in 5 patients and cerebral embolus in 1 patient. The adjusted 5-year survival rate was 89 +/- 6 (mean +/- standard error of the mean), and the overall survival rate of patients free of cardiac-related complications was 73 +/- 9%. Thus, reconstruction of the mitral valve is a highly effective surgical approach to the management of symptomatic patients with MR secondary to MVP, and its use is favored over replacement in the management of these patients.     

Severe mitral regurgitation requiring ECMO therapy treated by interventional valve reconstruction using the MitraClip

Surgical repair is considered the gold standard in severe mitral valve regurgitation. Multi‐organ failure because of acute mitral insufficiency, however, can be challenging to manage as it aggravates to an inoperable state. We report the case of a 59 year old woman who presented with pulmonary oedema because of high grade mitral regurgitation. A recompensation prior to surgery using medical therapy failed and the patient developed a progressive multi‐organ failure including pulmonary, circulatory, and renal failure within days. Symptomatically, our patient could be stabilized employing an extracorporeal membrane oxygenation and an intra‐aortic balloon pump. A surgical mitral valve repair was ruled out because of the multi‐organ failure. We performed an interventional valve reconstruction using the MitraClip? device continuing the extracorporeal membrane oxygenation and the intra‐aortic balloon counterpulsation therapy during the procedure. After clipping, multi‐organ failure regressed and the extracorporeal membrane oxygenation could be explanted at day two after intervention. © 2013 Wiley Periodicals, Inc.     

Mitral regurgitation in chronic heart failure: More questions than answers?

The presence, implications, and approach to mitral valvular disease in the setting of a cardiomyopathy has recently become a focal issue for discussion. Although recent evidence suggests that mitral regurgitation confers a poor prognosis in heart failure, the true prevalence of mitral regurgitation as well as its pathogenic contribution to prognosis in heart failure remains uncertain. Whereas angiotensin-converting enzyme inhibitors have not been demonstrated to favorably alter mitral regurgitation, treatment with β-blockers or cardiac resynchronization therapy has been shown to induce regression of ventricular dilation, with consequent decrease in mitral regurgitation. Surgical valve reconstruction by undersized ring annuloplasty appears promising, but optimal results require skilled surgical expertise. Even in highly experienced hands, intermediate outcomes appear to be inferior to those of cardiac transplantation. Percutaneous mitral valve repair remains an investigational procedure that warrants further clinical research.     

Echocardiographic evaluation of Carpentier mitral valvuloplasty

Carpentier's technique for reconstructive mitral valve surgery is an alternative to mitral valve replacement in patients with mitral regurgitation. The procedure involves reconstruction of the mitral valve and insertion of a ring into the mitral anulus. To study the results of this operation, pre- and postoperative M-mode, two-dimensional (2DE), and Doppler echocardiography were performed on 13 patients with severe, symptomatic mitral regurgitation, who underwent reconstructive mitral surgery. A significant clinical improvement was noted in all patients. This correlated with the hemodynamic and angiographic improvement in six of the patients who underwent postoperative cardiac catheterization. Postoperative echocardiography showed that the mitral valve E-F slope decreased from 129 ± 30 mm/sec preoperatively to 53 ± 13 mm/sec postoperatively (p < 0.001). The mitral valve excursion decreased from 28 ± 6 mm preoperatively to 19 ± 2 mm postoperatively. The left ventricular minor axis shortening decreased from 32 ± 9% to 28 ± 6%. In seven patients the mitral valve area decreased from 4.5 ± 0.9 cm² to 2.8 ± 0.5 cm² (p < 0.005). In each patient a new echocardiographic finding was observed: two parallel dense linear echoes from the prosthetic ring were noted on M-mode echocardiogrphy near the base of the mitral valve. 2DE visualized the entire ring. Doppler echocardiography suggested moderate or severe mitral regurgitation in eight of eight patients studied preoperatively. Postoperatively 10 of 11 patients had no Doppler echocardiography finding of mitral regurgitation.     

Expanding percutaneous treatment of mitral valve diseases: Transcatheter closure of mitral valve leaflet perforation

Mitral valve perforation is a rare cause of mitral regurgitation. We present a case of a 16-year-old patient with mitral valve regurgitation after redo-cardiac surgery for recurrent subaortic stenosis. Transthoracic echocardiography revealed a mitral regurgitation with an eccentric jet causing a significant regurgitation documented by the presence of a convergence flow over the hole. This finding was corroborating by transesophageal echocardiography locating the perforation from the region of A2 scallop. Three-dimensional transesophageal echocardiography confirmed these findings and played a key role guiding the procedure. Typical approach is usually a cardiac surgical procedure based on repair the perforation, but the mitral orifice was successfully closed percutaneously using an Amplatzer Duct Occluder II (ADO II; Abbott Vascular, IL).     

Latent congenital mitral insufficiency caused by an isolated mitral cleft. Diagnosis by two-dimensional echocardiography and pulsed Doppler

In this paper, the authors report the case of an 8-year-old boy with an isolated slit in his mitral valve, and who did not have a heart murmur detectable either by auscultation or by phonocardiography and who had no symptoms of heart failure. Two-dimensional echocardiography, with a left parasternal direction, in a transversal view revealed the presence of this abnormality of the endocardial leaflets accompanied by an accessory chorda tendina, and this procedure confirmed the absence of hemodynamic percussion. Doppler ultrasonography detected an abnormal turbulent systolic blood flow immediately behind the mitral valve, suggesting a minimal to moderate degree latent regurgitation. Two-dimensional echocardiography together with the Doppler ultrasound makes possible the diagnosis of an isolated slit of the mitral valve by non-invasive technique and the detection of concomitant latent mitral valve regurgitation, especially when the left atrium is not dilated and if the patient does not have low cardiac output.     

Percutaneous mitral valvuloplasty in an adult patient with calcific rheumatic mitral stenosis

A 75 year old man with long-standing rheumatic mitral stenosis who refused surgical intervention was treated with percutaneous balloon valvuloplasty. Prevalvuloplasty evaluation revealed a heavily calcified mitral valve, a mean transvalvular gradient of 18 mm Hg, a Fick cardiac index of 1.7 liters/min per m2, a mitral valve area of 0.6 cm2 and 1 + mitral regurgitation. After transeptal catheterization and balloon dilation of the interatrial septum with an 8 mm angioplasty balloon, a 25 mm valvuloplasty balloon was advanced over a guide wire across the interatrial septum and positioned across the mitral anulus. Subsequent balloon inflation at 3 atm pressure resulted in a reduction of the mean mitral valve gradient to 12 mm Hg, an increase in cardiac index to 2.5 liters/min per m2, an increase in mitral valve area in 1.4 cm2 and an increase in mitral regurgitation from 1 + to 2 +. Valvuloplasty was well tolerated without embolization of clot or valvular debris, and resulted in marked clinical improvement with decreased dyspnea and increased exercise tolerance. Repeat catheterization 2 months after valvuloplasty showed further resolution of pulmonary hypertension and no evidence of valvular restenosis or worsening mitral regurgitation, but detected a small atrial septal defect with a pulmonary to systemic blood flow ratio of 1.8. It is concluded that percutaneous valvuloplasty is possible in the adult patient with calcific rheumatic mitral stenosis, and may result in a significant improvement in valvular function without producing life-threatening complications.     

Beh?et's disease associated with aortic and mitral regurgitation: report of two cases

Two rare cases of complicating valvular lesions in Beh?et's disease are reported. Case 1: A 45-year-old man with combined aortic and mitral regurgitation had perforation of both valves. Six months after aortic valve replacement (AVR) and mitral valvuloplasty, an aortic paravalvular leak developed again, and was treated by surgery using an artificial graft with a prosthetic aortic valve. Case 2: A 40-year-old man with congestive heart failure and inflammatory signs had aortic and mitral regurgitation. Although cardiac medications for heart failure and treatment with methylprednisolone were started, he eventually had successful aortic valve replacement. Valvular disease complicating Beh?et's disease is rare; only 15 cases, including our two, have so far been reported. Its rarity is partly because Beh?et's disease predominantly involves the venous system, not the arterial system.     

Left ventricular function in chronic mitral regurgitation: Preoperative and postoperative comparison

Objectives. The present study was designed to evaluate the effects of surgical procedure on left ventricular systolic and diastolic function in patients with mitral regurgitation.Background. Left ventricular systolic function has been shown to decline after operation in patients with chronic mitral regurgitation.Methods. Using simultaneous cineangiography and left ventricular micromanometry, we evaluated left ventricular systolic and diastolic function in 14 patients with chronic mitral regurgitation both preoperatively and at an average of 22 months after operation. Eight patients underwent mitral valve reconstruction, and six had a valve replacement with interruption of the chordae tendineae. We compared these patients with 10 control subjects.Results. Preoperatively, patients with mitral regurgitation demonstrated normal global and regional left ventricular systolic function. Peak rate of diastolic filling was increased (p < 0.01), and passive chamber stiffness was decreased, compared with that in control subjects (p < 0.01), and there was normal myocardial stiffness. Postoperatively, systolic and diastolic function returned to normal in patients undergoing mitral valve reconstruction. In contrast, global systolic function was depressed in patients after valve replacement (p < 0.05), with regional dysfunction in the area of papillary muscle attachment (p < 0.01). Diastolic function was depressed in this group, with a prolonged time constant of pressure decay (p < 0.01) and a depressed rate of early diastolic filling and strain rate (p < 0.05). Passive elastic stiffness was within the normal range in all postoperative patients.Conclusions. The type of operation performed to correct chronic mitral regurgitation has an important effect on postoperative left ventricular function. Systolic and diastolic function are preserved after mitral valve reconstruction. Mitral valve replacement with chordal interruption is associated with global and regional systolic dysfunction and early diastolic filling and relaxation abnormalities.     

Mitral valve repair for ischemic mitral regurgitation in dilated cardiomyopathy

Ischemic mitral regurgitation contributes to poor survival in patients with heart failure. The intermediate-term outcome of mitral reconstruction in 15 patients who had ischemic dilated cardiomyopathy with mitral regurgitation requiring surgical intervention was studied. They underwent mitral valve repair along with coronary artery bypass surgery. The mitral valve coaptation depth was considered an important parameter in deciding on repair. Ages ranged from 43 to 72 years. Left ventricular ejection fractions were 15-38% (mean, 26.5% +/- 4.3%). The operative technique in all 15 patients was posterior annuloplasty using Dacron felt. At a mean follow-up of 4.6 +/- 1.2 months (1-8 months), postoperative transesophageal echocardiography revealed mild mitral regurgitation in 2 patients and none in 13. There was a significant improvement in New York Heart Association functional class from 3.9 +/- 1.1 to 1.9 +/- 0.3. Mitral valve repair by posterior felt annuloplasty provides favorable results in the intermediate-term in selected patients with ischemic cardiomyopathy and severe left ventricular dysfunction.     

A complicated case of mitral valve disease

A patient with rheumatic mitral stenosis and previous cerebral embolism had a myocardial infarction during cardiac catheterisation. She later developed severe mitral regurgitation one year after open valvotomy and at valve replacement was found to have a papillary tumour of the mitral valve. Unexplained low cardiac output occurred four days after operation. Postmortem examination showed thrombotic occlusion of the xenograft prosthesis, a complication not previously seen with tissue valves. Both of these rare events were suggested by the patient's clinical course and could have been diagnosed with cross sectional echocardiography.