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.     

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.     

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.     

A case of aortic prosthetic valve endocarditis with aortic root aneurysm

A 72-year-old male who underwent patch closure of atrial septal defect and aortic valve replacement (AVR) 10 years ago was diagnosed as aortic prosthetic valve endocarditis for recurrent fever, coexisting paravalvular leakage and aortic root aneurysm by transthoracic and transesophageal echocardiography. Operative findings showed mechanical prosthesis was dehiscenced in part and limited subannular aneurysm that was healed macroscopically. The hole of the aneurysm was closed by direct suture. Re-AVR, mitral valve replacement and tricuspid annuloplasty for complicating mitral valve stenosis and regurgitation and tricuspid valve regurgitation was performed. The patient is now doing well for one year after the reoperation.     

A case of aortic prosthetic valve endocarditis with aortic root aneurysm]

A 72-year-old male who underwent patch closure of atrial septal defect and aortic valve replacement (AVR) 10 years ago was diagnosed as aortic prosthetic valve endocarditis for recurrent fever, coexisting paravalvular leakage and aortic root aneurysm by transthoracic and transesophageal echocardiography. Operative findings showed mechanical prosthesis was dehiscenced in part and limited subannular aneurysm that was healed macroscopically. The hole of the aneurysm was closed by direct suture. Re-AVR, mitral valve replacement and tricuspid annuloplasty for complicating mitral valve stenosis and regurgitation and tricuspid valve regurgitation was performed. The patient is now doing well for one year after the reoperation.     

Two cases of quadricuspid aortic valve: preoperative diagnosis and surgical treatment.

Two cases of severe aortic regurgitation were treated surgically. Both patients had a quadricuspid aortic valve, which was diagnosed preoperatively by aortography and/or transesophageal echocardiography (TEE). In the first patient, both aortic and mitral valve replacement were performed with an ATS prosthetic valve. In the second patient, only aortic valve replacement was performed. The postoperative course was uneventful in both cases. Quadricuspid aortic valve is relatively rare. We discuss the preoperative diagnosis of quadricuspid aortic valve, as well as reviewing the relevant literature.     

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.     

On pump beating heart mitral valve repair without aortic cross-clamp for low ejection fraction ischemic mitral regurgitation after coronary artery bypass grafting; report of a case

A 59-year-old male with congestive heart failure caused by impaired left ventricular function after coronary artery bypass grafting (CABG) was referred to our hospital, and massive ischemic mitral regurgitation was detected by echocardiography. This patient underwent on-pump beating-heart mitral valve repair without aortic cross-clamp successfully through right thoracotomy. Postoperative echocardiography revealed no mitral regurgitation. The patient recovered uneventfully and was discharged on the 17th postoperative day. At 6th month after the operation, he is well without mitral regurgitation.     

Systolic anterior motion of the mitral valve and severe mitral regurgitation immediately after transcatheter aortic valve replacement

We report a high-risk patient with severe symptomatic aortic stenosis who showed systolic anterior motion of the mitral valve (SAM) and severe mitral regurgitation immediately after transcatheter aortic valve replacement (TAVR). The patient did not have either SAM or mitral regurgitation, but showed significant septal hypertrophy on preoperative transthoracic echocardiography which could be associated with the occurrence of SAM. Caution should be exercised in patients with significant interventricular septal hypertrophy before TAVR.     

Intraoperative transesophageal color-coded Doppler echocardiography for evaluation of residual regurgitation after mitral valve repair

Because mitral valve competence after mitral valve reconstruction is awkward to assess during this procedure, we evaluated in this respect transesophageal color-coded Doppler echocardiography in 23 patients undergoing mitral valve reconstruction for severe mitral regurgitation. Transesophageal echocardiographic examinations were performed after induction of anesthesia but before sternotomy (baseline), after mitral valve repair before decannulation, and at sternal closure, all at similar mean aortic pressure and echocardiographic instrument settings. The degree of mitral regurgitation by transesophageal color Doppler flow mapping was visually quantified on a 5-point scale (0 to 4), pending the left atrial extent of the regurgitant jet. This was compared with the degree of mitral regurgitation by left ventricular cineangiography performed within several weeks after operation and also visually quantified on a 5-point scale (0 to 4), with use of the right anterior oblique projection. There was good correlation between the two methods (r = 0.83; p less than 0.001). We conclude that residual mitral regurgitation, as assessed by transesophageal color flow mapping in the operating room, highly correlates with the ultimate mitral regurgitation by cineangiography. Therefore transesophageal echocardiography can be helpful for evaluation of mitral valve competence during mitral valve reconstruction, and hence, in case of repair failure, allow valve replacement in the same surgical session, thus avoiding reoperation.     

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.     

Aneurysm of the mitral valve: a rare complication of aortic valve endocarditis

A 45-year-old man presented to our hospital with severe dyspnea 4 months after antibiotic treatment for aortic valve endocarditis. Transesophageal echocardiography revealed severe aortic regurgitation and an aneurysm of the anterior leaflet of the mitral valve. In addition to aortic valve replacement, we excised the aneurysm and repaired the anterior leaflet of the mitral valve. Clinical suspicion, appropriate preoperative imaging, and timely surgical intervention are essential to recognize and treat this rare complication of bacterial endocarditis.     

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.     

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.     

Management of quadruple valves for severe infective endocarditis; report of a case

A 74-year-old man had pustulant bilateral arthritis complicated with sepsis and disseminated intravascular coagulation (DIC). Microbiologic study of blood sample showed Streptococcus and methicillin resistant Staphylococcus aureus (MRSA). He was complicated with postulant diskitis since then. Medical treatment for DIC and administration of antibiotics were performed. Preoperative echocardiography revealed massive aortic regurgitation and vegetation of aortic valve, moderate pulmonary regurgitation and vegetation of pulmonary valve, massive mitral regurgitation, massive tricuspid regurgitation. He was diagnosed as infective quadruple valve endocarditis. He received aortic valve replacement, pulmonary valve replacement, mitral valve repair and tricuspid valve repair. Postoperative echocardiography showed satisfactory function of bioprosthesis. Postoperative course was uneventful.     

A case report of successful mitral valve replacement for congenital mitral stenosis associated with coarctation of the aorta and ventricular septal defect

A 5-month-old infant with coarctation of the aorta, ventricular septal defect and mitral stenosis known as "Shone's anomaly" is presented. He underwent the repair of coarctation of the aorta by means of the extended aortic arch anastomosis and banding of the pulmonary trunk at 1 month of age and the patch closure of ventricular septal defect and debanding of the pulmonary trunk at 3 months of age in our institution. About 2 months after second surgery, he had been admitted to our institution due to developing tachypnea and he needed the support of mechanical ventilation. The chest X-ray showed pulmonary congestion and the echocardiography revealed only one papillary muscle of mitral valve and pressure gradient about 30 mmHg through mitral valve. Mitral stenosis due to parachute mitral valve was suspected and he was subjected to an emergent surgery. Initially we performed mitral valve repair for parachute mitral valve but echocardiography during the surgery revealed moderate grade of mitral regurgitation and a hemodynamics was not satisfactory. Eventually mitral valve replacement was successfully done with Carbo-Medics mechanical valve (19 mm in diameter) in the position of left atrial wall because his mitral annulus was so small as 10 mm in diameter. The postoperative course was uneventful and the patient has been doing well.     

Quadruple valve surgery in carcinoid heart disease

Abstract   We describe a 42-year-old male with primary carcinoid tumor of the ileum, secondary liver metastases, and subsequent severe carcinoid heart disease with quadruple valve involvement. The patient underwent tricuspid and pulmonic bioprosthetic valve replacement, mitral and aortic valve reconstruction. Transthoracic echocardiography at 25 months showed competent mitral and aortic valves with only mild regurgitation. Valve reconstruction is rarely performed in patients with carcinoid heart disease. However, in selected cases it is a valuable alternative technique with good mid-term outcome.     

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.     

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.     

Unexpected durability of Smeloff-Cutter aortic ball valve prosthesis

We report a case in which replacement of a Smeloff-Cutter aortic ball prosthesis was required 28 years after initial implantation. A 57-year-old woman underwent aortic valve replacement with a 21-mm Smeloff-Cutter ball prosthesis and open mitral commissurotomy for aortic stenosis, aortic regurgitation, and mitral stenosis in 1973. Severe aortic regurgitation occurred in April 2001, and aortic valve reoperation combined with mitral valve replacement was successfully performed. The patient's aortic ball valve was nearly intact with perivalvular leakage probably causing the aortic regurgitation. Our experience documents longer durability for the Smeloff-Cutter prosthesis than has been reported to date.