Detachment of the mitral valve anterior leaflet as a complication of aortic valve replacement

Mitral regurgitation after aortic valve replacement is generally reported as a complication of a Manouguian's procedure for annulus enlargement. However, even if no annular enlargement procedure is performed, this complication may be encountered after isolated aortic valve replacement because of either extensive decalcification of the aortic annulus or progressive tension on the anterior leaflet of the mitral valve, caused by aortic valve sutures placed adjacent to firm or heavily calcified valve tissue. Routine transthoracic echocardiography may be inadequate for diagnosis of this condition; transesophageal echocardiography should be used both for preoperative diagnosis and for intraoperative management. We report the case of a patient who had severe mitral regurgitation that occurred after aortic valve replacement with a mechanical valve.     

Double perforation of anterior mitral leaflet aneurysm in a patient with mitral and aortic leaflet aneurysms

Double valve aneurysms in a single patient are a rare occurrence and even rare finding is occurrence of double perforation of anterior mitral leaflet aneurysm. We present an adult patient with bicuspid aortic valve, coarctation of aorta and previous endocarditis presenting late with these rare abnormalities.     

SAM-systolic anterior motion of the anterior mitral valve leaflet post-surgical mitral valve repair

Systolic anterior motion (SAM) is a postoperative complication experienced by patients undergoing mitral valve repair. The incidence of SAM after mitral valve repair ranges from 5 to 10%. Early recognition of the signs and symptoms of SAM is imperative to the management of these patients. This article presents the pathophysiology of mitral valve dysfunction to give the practitioner a clear understanding of the dynamics of SAM. This article's main focus is the detection and management of SAM and the most current treatment modalities. A case study is used to illustrate the complex management necessary for the patient with SAM.     

Prevention of systolic anterior motion after mitral valve repair with an anterior leaflet valvuloplasty

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair (MVR) is the preferred method of treatment of the complex floppy mitral valve. Immediate repair failure, due to systolic anterior motion (SAM), is related to excessive anterior mitral valve leaflet (AMVL) tissue and/or anterior displacement of the leaflet coaptation point by the posterior mitral valve leaflet (PMVL) with resultant left ventricular outflow tract (LVOT) obstruction. Herein are reported the authors' experience of the AMVL valvuloplasty, a simple alternative to the sliding technique, to prevent post-MVR SAM. METHODS: Between January 1996 and June 2003, elliptical excisions of the base of the AMVL and annuloplasty rings (nine Physio, 38 Seguin) were performed in 47 patients (mean age 66 years; range: 29-86 years). The surgical procedure included posterior mitral valve leaflet (PMVL) resection in 37 patients (80%), AMVL resection in 28 (61%), and transposition flaps in nine (19%). Four patients (8%) had a tricuspid valve repair, six (13%) had an aortic valve replacement, and nine (19%) had coronary bypass grafting. Intraoperative transesophageal echocardiography before and after MVR was performed to assess mitral valve anatomy, the presence and severity of mitral regurgitation (MR), and SAM. RESULTS: There was no postoperative SAM. The severity of MR was reduced to trace or mild in all 47 patients. The mean AMVL length was 3.0 cm before and 2.2 cm after MVR, a tissue reduction of 27%. In those patients with a PMVL resection, the mean length was decreased from 1.95 cm to 1.5 cm, a tissue reduction of 23%. The mean annulus diameter decreased from 3.9 cm to 3.0 cm. The mean AMVL:PMVL ratio decreased from 1.6 to 1.4. The proportional size reduction of the AMVL compared to the PMVL was 17%. The mean coaptation point to annulus distance (CPAD) decreased from 1.1 cm to 0.9 cm. There was no 30-day in-hospital mortality. CONCLUSION: The AMVL valvuloplasty eliminated postoperative SAM. There was both reduction of the AMVL surface area, limiting the excursion of the AMVL into the LVOT, and reduction of CPAD. This technique does not compromise the geometry of the mitral valve apparatus.     

二尖瓣前叶脱垂手术修复的疗效分析

目的 探讨治疗二尖瓣前叶脱垂的外科修复方法及治疗效果.方法 1998年11月至2007年10月对210例二尖瓣前叶脱垂患者行二尖瓣修复术,并在术前、术中、术后利用超声心动图对心脏结构及功能进行评价.结果 采用缘对缘技术修复二尖瓣前叶脱垂134例(63.8%).出院时心脏功能(纽约心脏病协会分级)Ⅰ级168例,Ⅱ级40例.随访1～150(25.7±29.0)个月,围术期死亡2例(0.95%).超声心动图检查显示,术前左心房舒张末径为(47.5±12.7)mm,术后1年减小为(37.7±9.2)mm(P＜0.05);术前左心室舒张末径为(67.7±10.3)mm,术后1年减小为(51.7±7.9)mm(P＜0.05);术前左心室射血分数为(52.2±6.4)%,术后1年提高为(62.2±3.2)%(P＜0.05);术前二尖瓣反流面积为(10.4±4.1)cm~2,术后1年减少为(4.1±1.7)cm~2(P＜0.01).结论 二尖瓣修复术治疗二尖瓣前叶脱垂可获得良好的手术效果.缘对缘技术修复二尖瓣前叶脱垂安全、有效.     

Successful percutaneous implantation of an aortic valve stent prosthesis in a patient with a mechanical mitral valve

Percutaneous aortic valve replacement represents a minimally invasive alternative to open heart valve replacement in high-risk patients. Interventional procedures are used in an increasing number of patients and indications are broadened as techniques further evolve. However, there are still many postulated contraindications for interventional aortic valve replacement. We report a case of successful transfemoral aortic valve replacement in a patient with a mechanical mitral valve, performed due to the patient's refusal to accept blood transfusions. The feasibility and good procedural result may further extend future indications for interventional valve replacement.     

Recurrent thrombosis of an aortic valve prosthesis in a pregnant woman. Treatment with urokinase

A 36 year old woman developed two thromboses on aortic valve prosthesis. The first thrombus at the 14th week of pregnancy was treated with urokinase (2,000 U/kg/h) plus heparin (700-1,000 U/h) over 24 hours and normal wing kinetics were obtained. The second thrombus developed at the 36 th week of pregnancy when the patient was receiving calciparin, and only transient improvement was obtained with similar doses of urokinase hourly over 72 hours. Progressive worsening resulted in higher doses (4,000 U/kg/h) being given without heparin and the thrombus then resolved. The use of urokinase for the first time in this indication allowed therefore, on two occasions and without hemorrhagic complications the cure of this recurrent thrombosis on aortic prosthesis, and the birth, by caesarean, of a healthy baby.     

Isolated cleft of the anterior mitral valve leaflet.

Isolated anterior mitral leaflet cleft (not associated with atrio-ventricular septal defect) is a rare cause of congenital mitral regurgitation, and the treatment consists of direct suturing of the cleft. We present a clinical case with this entity.     

复杂二尖瓣前叶脱垂不同术式选择探讨

目的:总结腱索转移、人工腱索、瓣叶折叠及双孔技术在二尖瓣成形术中的临床应用和体会,提高临床治疗效果。方法:回顾性分析2007年1月至2013年8月,采用四种成形技术治疗的以二尖瓣前叶脱垂为主病例122例,其中男性68例,女性54例,年龄18~69岁,平均(43±7.9)岁,A1区脱垂21例,A2区脱垂12例,A3区脱垂28例,A1合并A2区脱垂26例,A2合并A3区脱垂35例,合并后叶脱垂16例。术前心功能分级(NYHA分级)Ⅱ级67例,Ⅲ级55例。45例采用腱索转移技术,54例采用人工腱索技术,12例采用瓣叶折叠技术,11例采用双孔技术,5例合并冠心病同期行冠状动脉旁路移植术(前降支单支桥3例,回旋支单支桥2例,)。结果:腱索转移组和人工腱索组均无围手术期死亡,瓣叶折叠组1例患者术后第8天死于多脏器功能衰竭,双孔技术组1例患者术后13 d死于肺部感染。出院前心脏超声显示:腱索转移组少量反流6例,微量反流14例,未见明显反流25例。人工腱索组少量反流16例,微量反流15例,未见明显反流23例。瓣叶折叠组少量反流8例,微量反流4例。双孔技术组少量反流9例,微量反流2例。四组术前、出院前、术后6个月左心室射血分数、左心室舒张末内径、收缩末内径差异无统计学意义(P0.05)。四组术前舒张末内径、收缩末内径较出院前、术后6个月舒张末内径、收缩末内径差异有统计学意义(P0.05)。四组出院前射血分数较术前、术后6个月低,差异有统计学意义(P0.05)。腱索转移组术后14个月1例患者因转移的腱索缝合缘撕脱造成二尖瓣大量反流再次手术置换二尖瓣。人工腱索组1例患者术后6个月频繁出现血红蛋白尿再次手术置换二尖瓣。结论:四种成形技术可以满足各种类型复杂二尖瓣前叶脱垂的处理。腱索转移适合单纯的前叶脱垂病变;人工腱索适用范围更广泛,容易学习;瓣叶折叠适用范围稍窄,适合初学者;双孔技术适用范围较广,不应作为首选方法,可和其他方法联合应用。四种方法均有良好的近期效果,值得去掌握和应用。     

Premature valve closure in patients with a mitral Starr-Edwards prosthesis and aortic incompetence

A mitral Starr-Edwards ball valve has, in three patients with concomitant aortic incompetence, permitted recognition of intermittent premature valve closure by auscultation and this has been documented by phonocardiograms. In two instances the observations were confirmed during cardiac catheterization. The features of premature Starr valve closure are described and the mechanism is discussed.     

Avulsion of a calcified leaflet as a complication of aortic valvuloplasty

Valvuloplasty was recently introduced as a palliative treatment of calcific aortic stenosis in elderly patients. Embolisation of valvular material has not been described as complication yet. We describe the detachment of a large calcific fragment resulting in acute, severe aortic incompetence in a 76-year-old patient. During immediate operative valve replacement the calcific embolus was recovered from the abdominal aorta.     

Technique of mitral valve replacement with the Monostrut prosthesis preserving the posterior leaflet.

BACKGROUND AND AIM OF THE STUDY: Techniques of mitral valve replacement with leaflet and chordal preservation normally involve the use of a bioprosthesis or bileaflet valve to reduce the risk of obstruction of the prosthesis by the retained subvalvular apparatus. METHODS: The technique of mitral valve replacement with the Monostrut prosthesis and with preservation of the posterior leaflet is described. The stitches are placed in such a manner that the posterior leaflet is folded under the posterior aspect of the prosthetic ring. RESULTS AND CONCLUSIONS: The technique allows safe implantation of the Monostrut valve. The excellent performance of this prosthesis can be therefore combined with the beneficial effects of chordal preservation on left ventricular function.