Severe intravascular hemolysis following mitral valve repair

We report two cases of severe intravascular hemolysis (IVH) following mitral valve repair using a Cosgrove-Edwards ring. In both cases, the degree of mitral regurgitation (MR) seen postoperatively worsened significantly compared to intraoperative transesophageal echocardiogram. Both patients required reoperation with mitral valve replacement with immediate resolution of the hemolysis. We hypothesize that the mitral regurgitation in the setting of an inadequate mitral valve repair is responsible for the hemolysis and propose various mechanisms to explain this pathophysiology. Although IVH remains a rare complication following mitral valve repair, possible screening recommendations should be considered for early detection and treatment given the growing number of mitral valve repairs being performed.     

Reduction of hemolysis without reoperation following mitral valve repair.

Hemolytic anemia following mitral valve repair and annular ring placement is uncommon compared with mitral valve replacement. A 60-year-old man, who had undergone mitral valve repair with a Duran ring, developed hemolytic anemia and needed a blood transfusion. Transesophageal echocardiography revealed a paravalvular mitral regurgitation jet colliding with the Duran ring. Most cases of severe hemolysis after mitral valve repair have undergone reoperation, but in the present case study, the hemolysis after mitral valve repair reduced without the need for reoperation, although the paravalvular mitral regurgitation jet continued to collide with the Duran ring.     

Chronic hemolysis and mitral insufficiency after surgical mitral valvuloplasty. Treatment by valve replacement, a case report

The authors report a case featuring a chronic increase in lactic dehydrogenase (LHD) levels, 8 years after surgical mitral valvuloplasty with residual mitral regurgitation. This increase in LDH levels was the sign of chronic haemolysis and disappeared after valve replacement with a mechanical prosthesis. This rare complication was attributed to contact between the sutures and the teflon used for mitral valvuloplasty and turbulence created by the mitral regurgitation.     

Mitral valve repair for significant mitral insufficiency.

There has been skepticism since the early days of open heart surgery that good long-term or even short-term results were possible with repair of pure mitral insufficiency. The authors report 145 patients in whom a markedly insufficient mitral valve was repaired 6 months to 17 years previously and another 55 patients in whom repair of the insufficient mitral valve was performed along with myocardial revascularization from 6 months to 7 years previously. Comparative data with other published work reveals superior results with repair than with replacement with Starr-Edwards and Hancock glutaraldehyde-treated porcine valves and with far less emboli. Conservatism is urged in operating upon patients with mitral insufficiency. Repair of the valve rather than replacement is stressed for those patients requiring surgery.     

二尖瓣成形术后溶血的机制及其处理

溶血是二尖瓣成形术后一种少见的并发症,术后超声心动图检查发现存在可疑的罪犯反流束(包括碰撞、高速、分散等特征性反流束),结合临床溶血性贫血的症状、体征,实验室检查提示血清白蛋白、乳酸脱氢酶(LDH)等特异性血液指标可作出诊断。目前认为,具高剪切应力的残余二尖瓣反流是造成溶血的必要因素,罪犯反流束不断冲击局部未完全内皮化的成形环或置入的垫片等是造成溶血的可能原因。术后早期的心脏彩色多普勒超声心动图检查对溶血的诊断和处理具有重要意义。二尖瓣成形术后溶血的处理包括药物、输血和手术治疗,再次手术行二尖瓣置换术是理想的治疗方式。     

Cardiopulmonary exercise testing before and one year after mitral valve repair for severe mitral regurgitation

For the evaluation of efficacy of cardiopulmonary exercise testing, we compared New York Heart Association functional class with peak oxygen consumption rate (VO(2)peak) in 31 patients with severe mitral regurgitation who underwent mitral valve repair surgery. One year later, the VO(2)peak values did not show significant improvement; however, the patients who had more than a mild degree of residual mitral regurgitation (n = 14) after 1 year of surgery had a VO(2)peak value that was significantly decreased (from 22.7 +/- 6.4 to 21.0 +/- 6.3 ml/kg/min, p = 0.04). Patients with a higher preoperative VO(2)peak value (>/=18.5 ml/kg/min) had a significantly better New York Heart Association functional class 1 year after surgery than patients with a lower VO(2)peak value (<18.5 ml/kg/min, p = 0.03).     

二尖瓣关闭不全的外科治疗

目的 总结二尖瓣关闭不全外科治疗的经验.方法 2001年1月至2007年7月共治疗二尖瓣关闭不全56例,男性25例,女性31例.先天性11例,风湿性3例,非风湿性42例,合并先天性心脏病19例.中度关闭不全18例,中度-重度关闭不全17例,重度关闭不全21例.病变类型腱索异常37例,如腱索断裂,缺如,一根或多根腱索延长;腱索和乳头肌异常11例;瓣叶发育异常16例;感染性心内膜炎造成的二尖瓣关闭不全3例;瓣环扩大54例.手术方式单纯腱索短缩13例,乳头肌劈开腱索包埋短缩8例,瓣叶和腱索移植5例,人工腱索再造2例.前瓣叶楔形切除或折叠9例,后叶矩形切除与sliding技术8例,缘对缘技术1例,感染性心内膜炎造成的二尖瓣损害局部修复3例.自制涤纶带环缩2例,二尖瓣环部分环缩38例,置入Duran环16例.结果 全组没有手术死亡病例.有2例在手术后8个月和15个月发生二尖瓣返流行二尖瓣瓣膜置换术;二尖瓣功能正常29例(51.79%),残留轻度关闭不全14例(25.00%),残留轻-中度关闭不全11例(19.64%).随访1～6年(2.3年),结果良好.结论 外科修复是治疗二尖瓣关闭不全的主要方法,该方法是安全,有效的,早期效果良好.     

Transapical off-pump mitral valve repair following prior mitral valve surgery: A case report

Rationale:Redo surgeries after mitral valve repair are technically demanding. Procedures applying the NeoChord device (NeoChord Inc, St. Louis Park, MN) have proven to be safe and feasible in selected patients requiring mitral valve repair due to a leaflet prolapse or flail. However, its use for redo procedures after conventional surgical repair has not been well established yet.Patient concerns:We report the case of a 57-year-old man who presented with dyspnea upon exertion. The patient had undergone a minimally invasive surgical mitral valve repair because of a flail leaflet of the segments segment 2 of the posterior mitral valve leaflet (P₂)/segment 3 of the posterior mitral valve leaflet (P₃) 4 years before.Diagnoses:Transesophageal echocardiography identified a relapse of severe mitral valve regurgitation. The recurring regurgitant jet was caused by a flail leaflet due to newly ruptured native chords.Interventions:After discussion in an interdisciplinary heart team, we performed a minimally invasive off-pump redo procedure applying the NeoChord device under three-dimensional transesophageal echocardiographic guidance.Outcomes:The echocardiographic result with only trivial residual mitral regurgitation as well as the further clinical course of the patient were favorable.Lessons:As redo surgery after minimally invasive mitral valve repair is challenging, the NeoChord device represents a novel treatment option that does not require cardiopulmonary bypass.     

双孔成形术治疗二尖瓣关闭不全

目的总结双孔二尖瓣成形术治疗二尖瓣关闭不全的经验。方法诊断为二尖瓣关闭不全接受此手术治疗30例，男12例，女18例，年龄14～52（33±17）岁。心功能Ⅱ级5例，Ⅲ级23例，Ⅳ级2例，用超声心动图对瓣膜进行评价。结果全组术前二尖瓣反流面积（9．8±3．5）cm^2，术后为（0．72±0．31）cm^2。全组无术后死亡，痊愈出院。随访1～48个月，效果满意，心功能为Ⅰ～Ⅱ级。结论双孔二尖瓣成形术是一种简单有效的手术方法。     

Double mitral valve orifice. Apropos of a case discovered by echocardiography

The authors report a case of isolated double orifice mitral valve in a 20-year old pregnant woman. This exceptional and seldom isolated anomaly is usually discovered at autopsy or surgery. In this particular case it was diagnosed by pulsed doppler ultrasound combined with echocardiography. Data from the literature are reviewed on that occasion, and the echocardiographic images of the malformation are described. Despite its rarity, double orifice mitral valve deserves to be known and its presence should be looked for by echocardiography, notably in patients with complete or partial atrioventricular canal.     

二尖瓣成形治疗小儿二尖瓣关闭不全

目的 总结小儿二尖瓣关闭不全外科矫治经验。方法 回顾近12年我院收治75例小儿二尖瓣关闭不全患,其中男31例,女44例,年龄1．5－12岁,平均7．1岁。单纯二尖瓣关闭不全8例,合并其它心血管畸形67例。二尖瓣关闭不全轻度7例,中度47例,重度21例。二尖瓣脱垂24例,瓣叶裂38例,瓣叶发育不良2例,单纯二尖瓣环扩大11例。手术在中低温体外循环心内直视下进行,行腱索缩短13例（含多根腱索缩短4例）,乳头肌缩短1例,腱索移植3例,瓣叶修复41例,瓣环成形25例,二尖瓣置换2例。同时矫正合并心血管畸形。结果 全组无手术死亡。完全矫正二尖瓣关闭不全54例（71．2％）,残留少量反流17例（23．3％）,中度反流4例（5．5％）。术后随访1．5－13年（平均7．8年）,1例术后4．5年因急性左心衰再次行人工瓣置换术,1例合并严重肺动脉高血压术后5年死于右心衰竭,1例人工瓣置换术后失访。其余患发育良好,心功能均恢复正常。结论 二尖瓣成形术治疗小儿二尖瓣关闭不全可取得良好的效果。     

Acute rheumatoid aortic insufficiency treated by valve replacement. Apropos of a case

Rheumatoid valvular heart disease and aortic valve replacement for a rheumatoid lesion have been previously reported in the literature. The authors report the first case of emergency surgery for acute aortic regurgitation due to necrosis and rupture of a rheumatoid granuloma: the anatomopathological lesions observed were patholognomic.     

多技术综合运用治疗复杂二尖瓣关闭不全13例

目的 总结多技术综合运用治疗复杂二尖瓣关闭不全的临床经验.方法 13例二尖瓣关闭不全且均存在2个以上反流点患者,其中男性9例,女性4例,年龄15～73 岁.病因分别为二尖瓣腱索断裂5例,二尖瓣黏液变性伴瓣叶脱垂6例,先心病继发房缺1例,冠心病伴二尖瓣乳头肌功能不全1例.二尖瓣反流程度中度4例、重度9例.术中联合应用二孔化成形、后瓣矩形切除、腱索转移、腱索缩短、人工腱索置入、人工瓣环置入等技术修补二尖瓣使其恢复功能.结果 本组无住院死亡病例,术后1周心脏彩超复查示二尖瓣无任何反流或微量反流8例,轻度返流5例,随访的患者中1例术后9个月二尖瓣由微量反流增加至中度反流,并患急性重症肝炎死亡.其余患者随访情况良好,心功能明显改善.结论 合理综合应用二孔化成形、人工腱索等多种技术治疗复杂多区域二尖瓣反流,近、中期疗效满意.     

Left endomyocardial fibrosis with severe mitral insufficiency; the case for mitral valve repair. A report of 4 cases

Left ventricular endomyocardial fibrosis accompanied by severe mitral insufficiency occurring in 4 adolescent African patients is reported. Mitral valve repair was successfully performed in all 4 cases including annuloplasty in 3 and chordal shortening in one. Short-term follow-up of up to 10 months indicated substantial clinical improvement and decrease of the cardiothoracic ratio in all. It is emphasized that mitral valve repair appears to be the method of choice in treating mitral incompetence in the localized form of endomyocardial fibrosis, where endocardiectomy is not required in the area of the papillary muscles.     

Double mitral orifice with a single atrium. Apropos of a case with functionally normal mitral valve]

The authors report a case with a double mitral orifice associated with a single auricle; it was operated on successfully. It was unnecessary to carry out any surgical procedure on the mitral valve itself, as it was functioning normally. A review of the literature follows.