Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: incidence and significance of systolic anterior motion.

OBJECTIVE. This study was designed to delineate the utility and results of intraoperative transesophageal echocardiography in the evaluation of patients undergoing mitral valve repair for mitral regurgitation. BACKGROUND. Mitral valve reconstruction offers many advantages over prosthetic valve replacement. Intraoperative assessment of valve competence after repair is vital to the effectiveness of this procedure. METHODS. Intraoperative transesophageal echocardiography was performed in 143 patients undergoing mitral valve repair over a period of 23 months. Before and after repair, the functional morphology of the mitral apparatus was defined by two-dimensional echocardiography; Doppler color flow imaging was used to clarify the mechanism of mitral regurgitation and to semiquantitate its severity. RESULTS. There was significant improvement in the mean mitral regurgitation grade by composite intraoperative transesophageal echocardiography after valve repair (3.6 +/- 0.8 to 0.7 +/- 0.7; p less than 0.00001). Excellent results from initial repair with grade less than or equal to 1 residual mitral regurgitation were observed in 88.1% of patients. Significant residual mitral regurgitation (grade greater than or equal to 3) was identified in 11 patients (7.7%); 5 underwent prosthetic valve replacement, 5 had revision of the initial repair and 1 patient had observation only. Of the 100 patients with a myxomatous mitral valve, the risk of grade greater than or equal to 3 mitral regurgitation after initial repair was 1.7% in patients with isolated posterior leaflet disease compared with 22.5% in patients with anterior or bileaflet disease. Severe systolic anterior motion of the mitral apparatus causing grade 2 to 4 mitral regurgitation was present in 13 patients (9.1%) after cardiopulmonary bypass. In 8 patients (5.6%), systolic anterior motion resolved immediately with correction of hyperdynamic hemodynamic status, resulting in grade less than or equal to 1 residual mitral regurgitation without further operative intervention. Transthoracic echocardiography before hospital discharge demonstrated grade less than or equal to 1 residual mitral regurgitation in 86.4% of 132 patients studied. A significant discrepancy (greater than 1 grade) in residual mitral regurgitation by predischarge transthoracic versus intraoperative transesophageal echocardiography was noted in 17 patients (12.9%). CONCLUSIONS. Transesophageal echocardiography is a valuable adjunct in the intraoperative assessment of mitral valve repair.     

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。     

Aspekte der Mitralklappenrekonstruktion bei der chirurgischen Therapie der Mitralklappeninsuffizienz

Mitral valve repair (MVR) is the golden standard for the surgical treatment of mitral valve regurgitation and is superior to mitral valve replacement in terms of perioperative and long-term morbidity and mortality. However, the underlying disease has a significant impact on the functional long-term result of the repair. To evaluate the results of MVR, patients have to be divided by the underlying disease, degenerative mitral valve regurgitation, rheumatic mitral valve regurgitation, ischemic mitral valve regurgitation, and mitral valve regurgitation due to advanced cardiomyopathy. The best functional result for MVR can be achieved for degenerative mitral valve regurgitation (10-year freedom from reoperation for recurrent mitral regurgitation up to 94%) followed by patients with rheumatic mitral valve regurgitation (10-year freedom from reoperation for recurrent mitral regurgitation up to 82%). The progress in the underlying disease of the mitral valve is responsible for recurrent mitral valve regurgitation in these patients. For both underlying disease the 10-year survival rate is > 75%. For patients with ischemic mitral valve regurgitation the functional and survival rates are worse with a 5-year survival rate < 60% and recurrent mitral valve regurgitation > MI (mitral valve insufficiency) II degrees in 28% of patients within 6 months. However, ischemic mitral valve regurgitation is not a disease of the valve, it is a disease of the myocardium; thus, the myocardium is the key factor influencing the functional results of MVR and not pathologic changes in the mitral valve per se. There are no long-term results on patients operated on MI in conjunction with advanced cardiomyopathy; however, the initial mid-term results are encouraging with improved survival.Besides the underlying disease the timing of surgery is of utmost importance for the long-term survival; patients with preoperative NYHA functional class III/IV have a significantly worse short-term and long-term outcome compared to patients operated on for significant mitral valve regurgitation who have only minor or even no symptoms (NYHA class I/II). However, the compliance to undergo complex open-heart surgery via a median sternotomy in asymptomatic patients is very low. Minimally invasive endoscopic mitral valve repair may be an option to increase compliance in these patients, which will result in improved long-term survival with a normal life expectancy.     

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.     

二尖瓣成形环瓣环环缩术在缺血性二尖瓣返流中的应用

目的 研究应用二尖瓣成形环行瓣环环缩术治疗缺血性二尖瓣返流的手术效果。方法 选择2000年1月~2015年12月在我院行二尖瓣成形术的缺血性二尖瓣返流并发室壁瘤的患者72例,根据二尖瓣病变部位及性质选择成形方案,其中33例使用二尖瓣成形环进行瓣环环缩术。回顾性分析手术的近期、远期治疗效果。结果 围手术期死亡4例（6%）。术后二尖瓣返流程度较术前明显改善,中度及中度以上二尖瓣返流1例（1%）。术后随访(5±3)年,随访期死亡11例（16%）,出现中度及中度以上二尖瓣返流12例（18%）。是否使用成形环进行瓣环环缩术后早期二尖瓣返流程度无统计学差异,但远期成形环环缩组较对照组二尖瓣返流程度有显著改善（P<0.05）。结论 缺血性二尖瓣返流并发室壁瘤的患者中,二尖瓣成形术可安全、有效地重建二尖瓣功能。使用成形环进行瓣环环缩可改善远期效果。     

“缘对缘”联合人工瓣环修复术治疗二尖瓣关闭不全42例分析

【】 目的 探讨“缘对缘”联合人工瓣环修复二尖瓣成形术治疗二尖瓣关闭不全的手术效果。方法 回顾性分析2004年1月至2008年12月对42例非风湿性二尖瓣关闭不全患者行“缘对缘”联合人工瓣环修复二尖瓣成形术的临床资料,男25例,女17例;年龄12～69岁(36.42±14.28岁),其中先天性二尖瓣病变12例,瓣膜退行性病变20例,缺血性二尖瓣关闭不全7例,感染性心内膜炎3例。术前心脏彩超提示：前叶病变27例,前叶 后叶病变17例;二尖瓣重度反流19例,中度至重度14例,中度反流9例;42例患者均在全身麻醉低温体外循环下应用“缘对缘”联合人工瓣环修复术进行二尖瓣成形术。术中应用250mL注射器向左心室注冰盐水观察评价成形后二尖瓣反流情况,脱离体外循环后经食管超声心动图观察成形结果。分别测量术前及术后二尖瓣反流面积、二尖瓣开口面积、左房内径及左室舒张末期内径,左室射血分数,应用t检验,研究手术前后二尖瓣反流、心脏大小变化、心功能改善情况。检验水准α=0.05。结果 全组无死亡病例,出院时心脏功能(NYHA分级)I级32例,Ⅱ级10例。随访39例,随访时间1-60(24.6±18.2)个月。超声心动图提示：术前二尖瓣反流面积为11.0cm₂±3.8cm₂,术后1年无或微量反流13例,轻度反流17例,轻度至中度反流9例,轻度二尖瓣狭窄1例,反流面积为4.1cm₂±1.4cm₂;术前二尖瓣开口面积4.14 cm₂±1.54cm₂,术后一年为3.58 cm₂±1.10cm₂;术前左心房内径为48.6mm±12.4mm,术后1年为36.5 mm±9.4mm;术前左心室舒张末径为64.3 mm±11.4mm,术后1年为50.6 mm±7.6mm;术前左心室射血分数为54.6%±6.2％,术后1年提高为63.4%±4.0％。结论“缘对缘”联合人工瓣环修复二尖瓣成形术治疗二尖瓣关闭不全手术方法安全、有效,可获得良好的治疗效果。     

Combined aortic and mitral regurgitation - a scenario difficult to manage

ObjectivesThe simultaneous presence of substantial regurgitation of both the aortic and the mitral valve imposes a massive volume load and, due to the aortic regurgitation, a pressure load on the left ventricle. This condition usually is caused by primary aortic regurgitation and concomitant functional mitral regurgitation due to left ventricular enlargement, but lesions can also be primary in both valves, as in endocarditis, carcinoid disease, or due to the cardiotoxicity of appetite-depressant drugs. Because dilatation of the left ventricle caused by chronic aortic regurgitation mostly is not fully reversible by aortic valve surgery, it is unlikely that severe or moderate mitral regurgitation will regress significantly after aortic valve surgery alone. In such cases, simultaneous repair of a severely regurgitant mitral valve is recommended by the guidelines, but the recommendation should probably be extended to moderate mitral regurgitation too.ConclusionIn treating combined aortic and mitral regurgitation, the incomplete reversibility of left ventricular dilatation due to aortic regurgitation should be kept in mind. If indications for aortic valve replacement are fulfilled, concomitant mitral valve repair should be strongly considered.     

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.     

Asymptomatic chronic severe organic mitral regurgitation: contemporary management strategies

Abstract: Chronic organic mitral regurgitation resulting from mitral valve prolapse is increasing in prevalence due to aging of the population. Although "watchful waiting" has been the conventional standard for many years in patients with minimal or no symptoms and chronic severe organic mitral regurgitation, several factors including changing etiology, better understanding of the natural history, improved diagnosis and advances in surgical techniques are now paving the way for earlier mitral valve surgery. The ability to successfully repair the myxomatous mitral valve with low operative risk (< 1%) and advances in imaging in the recent years have led to a major change in the treatment paradigm for organic mitral regurgitation. It is clear from the preponderance of evidence that mitral valve repair in asymptomatic patients with preserved ejection fraction and severe organic mitral regurgitation leads to "cure" or "suppression" of the disease, underscoring the need for early surgery. Whether further advances in imaging, robotic surgery, and percutaneous mitral valve repair lead to even better outcomes remains to be seen.     

Second Time’s a Charm: Percutaneous Edge-to-Edge Repair With the MitraClip Device as Rescue Therapy After a Failed Surgical Edge-to-Edge Alfieri Stitch

Surgical mitral valve repair for mitral regurgitation is associated with an increased risk of recurrent mitral regurgitation compared to surgical mitral valve replacement. We describe the case of an 80-year-old man with recurrent severe symptomatic mitral regurgitation after a failed surgical Alfieri technique attempt, who then underwent successful MitraClip (Abbott Vascular, Santa Clara, CA) implantation.     

Percutaneous edge-to-edge mitral valve repair: 2-year follow-up in the first human case.

We report the first-in-human mitral valve repair using percutaneous technology that creates a "surgical-like" edge-to-edge repair. A catheter-delivered clip was introduced transseptally from the femoral vein, advanced through the mitral orifice, retracted to grasp the leaflets, and detached to create a functional double-orifice valve. The patient had an uncomplicated post-procedural course. Echocardiography at 1- and 2-years post procedure showed mild mitral regurgitation and positive ventricular remodeling. The success of this case suggests that percutaneous mitral valve repair may be a feasible therapy for certain patients suffering from mitral regurgitation.     

Mitral valve repair: We must do a better job

Mitral valve repair is the only heart valve operation with the potential to restore a patient to expected survival. A mandate currently exists for early surgical repair of mitral regurgitation before the onset of symptoms and significant left ventricular dysfunction. It is based upon a better understanding of the natural history of mitral regurgitation, the poor results with medical therapy, and the negative impact of abnormal left ventricular size and function, and symptoms of long-term survival. It is also based on better operative mortality, quality of life, and longevity with repair compared with replacement. Despite the existence of this mandate, overall mitral valve repair rates remain generally low in the United States. The biggest impact on mitral repair rates is likely to come from cardiologists, who would embrace the mandate and insist on mitral valve repair and refer their patients to surgeons who consistently and successfully repair mitral valves.     

Mitral valve replacement and repair. Report of 5 patients with systemic lupus erythematosus

Severe mitral valve regurgitation due to systemic lupus erythematosus is a rare cause of valvular heart disease, necessitating valve surgery. Currently, there are 36 case reports in the world medical literature of mitral valve replacement or repair in patients who have lupus. The current trend in mitral valve surgery is toward anatomic valve repair. In patients who have systemic lupus erythematosus, however, valve repair often leads to repeat surgery and valve replacement. We report the cases of 5 patients with lupus and severe mitral valve regurgitation who underwent mitral valve surgery. In 3 of these patients, replacement with a mechanical prosthetic mitral valve was performed with good long-term results. In the other 2 patients, mitral valve repair was performed, but only 1 of the repairs was successful. The 2nd patient required subsequent replacement with a mechanical valve. To our knowledge, this report of 5 patients is the largest series of mitral valve surgery in patients with lupus. These results, along with a review of the literature, suggest the superiority of mechanical prosthetic valve replacement to repair in patients who have systemic lupus erythematosus.     

CABG同期行左室成形术和二尖瓣成形术治疗左室室壁瘤并发二尖瓣关闭不全的效果

目的 评价冠状动脉旁路移植术（CABG）同期行左室成形术和二尖瓣成形术治疗左室室壁瘤并发二尖瓣关闭不全的近远期临床效果。 方法 自2000年1月~2008年12月,我院共32例患者因左室室壁瘤并发缺血性二尖瓣关闭不全同期进行左室成形术+二尖瓣成形术。左室成形术手术方式包括:线性缝合16例（50%）;心内膜环缩成形术9例（28%）;心室内环状补片成形术7例（22%）。二尖瓣成形术入路包括:左室入路20例（62%）,右房-房间隔入路11例（34%）,房间沟入路1例（3%）。全部患者均同期行CABG。本研究回顾性分析了上述患者手术中及围手术期的临床资料,并进行了46~175个月随访。 结果 围手术期死亡1例（3%）。术后1年和5年生存率分别为97%和74%。随访期间,9%（3例）出现二尖瓣中量及以上返流,9%（3例）出现NYHA心功能Ⅲ~IV级。左室成形方式及二尖瓣成形入路对远期效果无显著影响。 结论 左室成形术同期行二尖瓣成形术是治疗左室室壁瘤并发二尖瓣关闭不全的有效方法,术后的近远期临床结果令人满意。     

Reduction of left ventricular outflow tract obstruction with transcatheter mitral valve repair

Many patients with severe mitral regurgitation cannot undergo conventional mitral valve surgery due to prohibitive surgical risk and are candidates for transcatheter repair with an edge‐to‐edge technique. Prior reports suggest efficacy with this approach for mitral regurgitation due to hypertrophic cardiomyopathy with left ventricular outflow obstruction. We present a case report of transcatheter mitral valve repair for posterior leaflet prolapse with concomitant left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve in the absence of hypertrophic cardiomyopathy.     

Complicated mitral valve repairs

The standard of care for mitral regurgitation secondary to degenerative valvular disease is mitral valve repair whenever possible. Mitral valve repair is associated with better left ventricular function preservation, fewer complications, and improved survival as compared with mitral valve replacement. Most of the mitral valve pathology involves the posterior leaflet or annulus and usually can be repaired by using standard valve repair techniques. Difficulties may arise when trying to repair the somewhat uncommon anterior leaflet prolapse or calcified mitral annulus. This article reviews these more complex mitral valve repair techniques and their outcomes.     

Simple suture mitral annuloplasty with left ventriculotomy

Surgical treatment of mitral regurgitation, especially when compounded by ventricular aneurysm, remains a challenge. Several procedures have been developed to repair the mitral valve and reduce regurgitation. We describe a technique of intraventricular annuloplasty which is much less time-consuming than mitral valve repair through a left atriotomy. This procedure is considered technically easy and useful.     

Mitralinsuffizienz

Mitral regurgitation is the second most frequent reason for valve surgery. The most important causes of mitral regurgitation are degenerative valve disease (mitral valve prolapse), left ventricular impairment and dilatation (in coronary artery disease or dilated cardiomyopathy), and infective endocarditis. The regurgitation of blood from the left ventricle into the left atrium leads to dilatation of the left atrium, increase in pulmonary capillary pressure and pulmonary congestion. In chronic severe mitral regurgitation, the left ventricle dilates and becomes impaired over time. Key symptoms are fatigue and dyspnea on exertion. The most prominent physical sign is the characteristic systolic murmur. Echocardiography identifies severity, delineates morphology, and estimates the impact of mitral regurgitation on left ventricular function. Importantly, echocardiography identifies candidates for mitral valve repair. Symptomatic patients and asymptomatic patients with impaired left ventricular function should be operated. If possible, valve repair is preferred over valve replacement to better preserve left ventricular function and to avoid the need for postoperative anticoagulation (except if atrial fibrillation persists).     

The effect of pathophysiology on the outcome of mitral valve repair for mitral regurgitation

The advantages of mitral valve repair in mitral regurgitation are well established. The aim of this study was to analyze retrospectively the early and mid-term results of primary mitral valve repair. Between January 1995 and August 2001, primary mitral valve repair operations were performed on 112 patients (76 men and 36 women) with mitral regurgitation; the mean age was 59.8 ± 16.5 years. Mitral valve repair was performed for rheumatic heart disease (13), degenerative disease (60), infective endocarditis (2), ischemic heart disease (26), congenital heart disease (2), and dilated cardiomyopathy (9). The degree of mitral regurgitation was moderate in 28 patients, moderately severe in 17 patients, and severe in 67 patients, as determined by echocardiography. Left ventricular ejection fraction (mean 41.2% ± 13.5%) was measured by radionuclide ventriculography. Fifty percent of patients underwent additional procedures (e.g., coronary artery bypass grafting). The mortality rate was 8.9% (10/112) for hospitalized patients, 19.2% (5/26) for ischemic disease, and 5% (3/60) for degenerative disease. Follow-up duration ranged from 0.37 to 84.03 months. All survivors were evaluated with serial echocardiography. At the final follow-up echocardiography of 94 patients without reoperation and 6 patients at the time of reoperation, 84% had no or mild mitral regurgitation. The survival rate at 5 years was 92.68 ± 3.57% for degenerative disease and 44.47% ± 10.89% for ischemic disease. The risk of infective endocarditis (1.78%), thromboembolism (1.78%), and anticoagulant-related complications (0.8%) was very low during the follow-up period. The pathophysiological mechanism resulting in mitral regurgitation was the most important determinant of outcome after mitral valve repair. Excellent results were achieved with mitral valve repair for degenerative disease. Because of low morbidity and acceptable mortality, we strongly recommend mitral valve repair for mitral regurgitation due to degenerative disease.