Separation anxiety: Extreme dehiscence of a mitral annuloplasty ring

We report a patient admitted with acute pulmonary edema 3 months after mitral valve repair, with no history of inter‐current febrile illness. Transesophageal echocardiography (TEE) demonstrated severe mitral regurgitation (MR) and an abnormally positioned annuloplasty ring, suggestive of dehiscence. The extreme extent of ring dehiscence was visualized on 3‐dimensional TEE (3D), with near‐complete separation of the ring. Strept.Mitis and Cristatus were isolated from the ring following redo mitral valve surgery, confirming endocarditis as the mechanism for dehiscence. This report highlights the additive role and superior ability of 3D TEE in the identification and anatomic delineation of mitral ring dehiscence.     

经导管二尖瓣修复治疗二尖瓣反流所致心力衰竭的进展与展望

二尖瓣关闭不全主要是由于瓣膜的异常所导致的原发性或退化性的二尖瓣反流（mitral valve regurgitation,MR）,也可由继发性心肌病变引起功能性、继发性MR。药物治疗可以缓解相应症状,但却无法阻止病程进展。目前,尽管有明确的指南建议对伴有左心功能不全症状和体征的中至重度（NYHA分级超过Ⅲ级）MR患者进行手术,但由于种种客观与主观的原因大多数严重MR患者仍没有接受手术。随着经导管二尖瓣介入手术修复治疗的蓬勃发展,目前的经导管二尖瓣修复治疗的理念主要来源于外科修复技术,分别以缘对缘、人工腱索修复、人工瓣环成形等方式为代表,有不同种类的器械进入临床,取得了良好的效果。经导管介入治疗MR为二尖瓣手术高危患者提供了新的选择。本文将综述手术治疗MR所致心力衰竭的新进展。     

The use of stress echocardiography in the assessment of mitral valvular disease

Stress echocardiography plays an important role in evaluating asymptomatic patients with significant mitral stenosis and symptomatic patients with only mild disease at rest, as it correlates the exercise-induced symptoms with changes in transmitral gradients, pulmonary pressures, and mitral valve area. In patients with mitral regurgitation (MR), exercise or dobutamine protocols assess for the change in the degree of regurgitation and the pulmonary artery pressure (PAP) in response to high flow states, and detect underlying left ventricular (LV) dysfunction prior to valvular surgery. Exercise echocardiography also helps in the prognostic assessment of patients with mitral valve prolapse as new MR, or latent LV dysfunction may be provoked to identify a group of high risk individuals with normal resting echocardiographic parameters. Finally, it evaluates the proper functioning of prosthetic mitral valves and helps on the monitoring of transmitral gradients and PAPs after mitral valve surgery.     

Images in cardiovascular medicine: prosthetic aortic valve and conduit dehiscence with large periconduit cavity, ascending aortic aneurysm and severe mitral regurgitation

Prosthetic aortic valve and conduit dehiscence with periconduitcavity and ascending aortic aneurysm is an uncommon complicationof aortic root surgery. It is usually recognizable at echocardiographydue to an abnormal position of the prosthetic valve and conduitin relation to the native aortic annulus in conjunction withan abnormal echolucent periconduit space that fills with colorflow. Mitral regurgitation is an unusual complication of thiscondition. We present a patient with severe mitral regurgitation secondaryto prosthetic aortic valve and conduit dehiscence with a largepericonduit cavity and aneurysm of the intervalvular fibrosa.The mechanism of mitral regurgitation is secondary to functionalinvolvement of the anterior mitral valve leaflet and intervalvularfibrosa with anterior mitral leaflet restriction in conjunctionwith mild left ventricular remodeling. Significant mitral regurgitationpersisted post resection of the periconduit cavity and aorticvalve replacement, requiring mitral valve replacement. This case study reports a new mechanism of mitral regurgitationin the setting of prosthetic aortic valve and conduit dehiscence.     

Mitral regurgitation in patients with heart failure

Mitral regurgitation (MR) is a common complication in heart failure patients, severely worsening their outcome. Because of the high perioperative risk, mitral valve surgery, which is the standard therapy for MR, is often not offered to these patients. Interventional therapies for mitral valve therapy might therefore constitute a novel therapeutic option particularly in this group. This article gives an overview of the available and evolving interventional strategies for mitral valve repair with a special emphasis on heart failure patients.     

Concomitant Transcatheter Edge-to-Edge Treatment of Secondary Tricuspid and Mitral Regurgitation: An Expert Opinion

Secondary (functional) tricuspid regurgitation (sTR) is common in patients with mitral regurgitation (MR). Because combined valvular heart disease affects long-term survival, in comparison with isolated MR or tricuspid regurgitation, it is essential to offer patients adequate treatment. Despite considerable experience, no conclusive data are yet available on the prognostic impact of concomitant tricuspid valve surgery at the time of mitral valve surgery. Emerging transcatheter treatments offer the opportunity to treat both conditions (MR and sTR) simultaneously or in a stepwise fashion. This review provides a clinical overview on available data regarding the rationale for treatment of sTR in patients with relevant MR undergoing mitral transcatheter edge-to-edge repair, focusing on clinical and anatomical selection criteria.     

Severe mitral regurgitation due to mitral valve prolapse: risk factors for development, progression, and need for mitral valve surgery

Patients with mitral valve prolapse (MVP) may develop severe mitral regurgitation (MR) and require valve surgery. Preliminary data suggest that high body weight and blood pressure might add to the irreversible factors of older age and male gender in increasing risk of these complications. Fifty-four patients with severe MR due to MVP were compared with 117 control subjects with uncomplicated MVP to elucidate factors independently associated with severe MR: the need for valve surgery and the cumulative risk of requiring mitral valve surgery. Patients with severe MR were older (p<0.00005), more overweight (p = 0.002), had higher systolic (p = 0.0003) and diastolic (p = 0.007) blood pressures, and were more likely to have hypertension (p = 0.0001) and to be men (p<0.001). In both groups, men had higher blood pressure and relative body weight than women. In multivariate analysis, older age was most strongly associated with MR; higher body mass index, hypertension, and gender were independent predictors of severe MR in analyses that excluded age. Among the 54 patients with severe MR, the 32 (59%) who underwent mitral valve surgery during 11 years of follow-up were older, more overweight, and more likely to be hypertensive than those not requiring surgery. Among patients undergoing mitral valve surgery in 3 centers, mitral prolapse was the etiology in 25%, 67% of whom were men. Using these data and national statistics, we estimate that the gender-specific cumulative risk for requiring valvular surgery for severe MR in subjects with MVP is 0.8% in women and 2.6% in men before age 65, and 1.4% and 5.5% by age 75. Thus, subjects with MVP who are older, more overweight, and hypertensive are at greater risk for severe MR and valve surgery. Higher blood pressure and relative weight in men with MVP appear to contribute to the gender difference in risk for severe MR.     

Mitral valve repair for severe mitral regurgitation: the way forward?

Severe primary mitral regurgitation (MR) has a poor outcome if left uncorrected. Successful mitral valve repair has the unique potential to restore normal life expectancy and is superior to valve replacement. Despite this, mitral repair is performed relatively infrequently and many patients with potentially reparable valves have a replacement instead, subjecting them to unnecessary risk. Surgery in asymptomatic patients is a particularly difficult issue with some units advocating surgery irrespective of symptoms, based purely on the severity of regurgitation. This strategy cannot be widely adopted with the current patchy provision of high-quality valve repair surgery. Misplaced enthusiasm for early operation runs the risk of a failed repair and the hazards of a mechanical prosthesis. To ensure optimal treatment for patients with MR, cardiologists must be aware of the indications for valve repair and ensure that patients with potentially reparable valves are referred to surgeons with proven expertise, even if this means a shift from established practice. Surgical units need to promote subspecialization and rigorously audit their outcomes. There are currently no agreed standards for best practice in mitral valve repair and this is an area where professional societies may wish to take a role.     

Percutaneous edge-to-edge mitral valve repair

In the past few years, a myriad of technologies have been developed for percutaneous repair of the mitral valve for patients with severe mitral regurgitation (MR) and at high risk for traditional open-heart mitral valve surgery. Among them, MitraClip has emerged as the only clinically safe and effective method for percutaneous mitral valve repair. This device mimics the surgical edge-to-edge mitral valve repair initially described by Dr. Alfieri. In this article, we review the current clinical evidence on the use of the MitraClip—from the randomized control trial EVEREST II to the information derived from expert high-volume centers.     

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.     

Update on percutaneous mitral valve therapy: clinical results and real life experience

Mitral regurgitation (MR) is a common valvulopathy worldwide increasing in prevalence. Cardiac surgical intervention, preferable repair, is the standard of care, but a relevant number of patients with severe MR do not undergo surgery because of high peri-operative risk. Percutaneous mitral valve repair with the MitraClip System has evolved as a new tool for the treatment of severe MR. The procedure simulates the surgical edge-to-edge technique, developed by Alfieri in 1991, creating a double orifice valve by a permanent approximation of the two mitral valve leaflets. Several preclinical studies, registries and Food and Drug Administration approved clinical trials (EVEREST, ACCESS-EU) are currently available. The percutaneous approach has been recently studied in a randomized controlled trial, concluding that the device is less effective at reducing MR, when compared with surgery, by associated with a lower adverse event rate. The patients enrolled in this trial had a normal surgical risk and mainly degenerative MR with preserved left ventricular function. On the other hand, results derived from the clinical "real life" experience, show that patients actually treated in Europe present a higher surgical risk profile, more complex mitral valve anatomy and functional MR in the most of cases. Thus these data suggest that MitraClip procedure is feasible and safe in this subgroup of patients that should be excluded from the EVEREST trial due to rigid exclusion criteria. Despite the promising results clinical experience is still small, and no data related the durability are currently available. Therefore, MitraClip device should be reserved now to high risk or inoperable patients.     

经导管介入治疗二尖瓣疾病的研究进展

二尖瓣反流（Mitral valve regurgitation,MR）逐渐成为心脏瓣膜病中最常见的疾病之一。虽然外科手术在治疗MR中起到重要作用,但由于围手术期的风险过大、老年人基础情况较差等原因,许多患者禁忌外科手术。近年来,经导管治疗MR装置的出现,给治疗MR带来了新的选择,但同时也面临着许多挑战。本文综述了经导管治疗MR装置的技术特征及其临床试验的结果。     

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。     

Kathetergestützte Therapie von Herzklappenfehlern

Severe aortic stenosis is a significant source of morbidity and mortality among the aging population. Due to prohibitive surgical risk, many patients are not candidates for surgery. Therefore, transcatheter aortic valve implantation has emerged as a promising technology for treating this group of high risk patients. With increasing experience, this procedure can be performed successfully and safely in selected high risk patients. Nevertheless, before widespread use and application to lower risk patients the results of randomized studies are mandatory. Primary (degenerative) and secondary (functional) mitral regurgitation (MR) is an important cause of heart failure. The double orifice technique of mitral valve repair using the MitraClip® system is one of many transcatheter approaches to treat significant MR in patients at high risk for conventional surgery. This technique is effective in reducing MR severity in patients suffering from both degenerative and functional MR. Percutaneous pulmonary valve implantation (PPVI) is an interventional treatment for adolescents and young adults with congenital heart disease. After corrective or palliative operation in infancy or early childhood, some patients regularly need reoperations for right ventricular outflow tract reconstruction. In the last decade, PPVI has evolved as an alternative treatment option with much less morbidity compared to repeated surgery.     

冠状动脉粥样硬化性心脏病合并中重度二尖瓣反流的外科治疗

目的总结冠状动脉粥样硬化性心脏病（冠心病）合并中重度二尖瓣反流的外科治疗临床经验。方法回顾性分析2002年7月至2011年2月期间,外科手术治疗冠心病合并中重度二尖瓣反流患者59例的临床资料。其中合并二尖瓣中度反流46例,重度反流13例,二尖瓣的病理改变主要表现为单纯瓣环扩大、瓣叶脱垂或二尖瓣腱索断裂,手术均在全麻低温体外循环下进行。其中二尖瓣成形49例;二尖瓣置换10例。结果院内死亡3例（5.08%）,50例患者随访3～72个月,二尖瓣中度反流3例,重度反流1例,余均为轻微或轻度反流,均无再次手术。结论冠心病合并中重度二尖瓣反流应积极处理,其中以二尖瓣成形为首选。     

Chordal cutting for the treatment of ischemic mitral regurgitation: two case reports

The surgical treatment for ischemic mitral regurgitation remains controversal. Ring annuloplasty results in recurrent mitral regurgitation in some cases. Strut chordal cutting is a new surgical procedure in addition to ring annuloplasty for ischemic mitral regurgitation. Two patients (63-year-old woman, 53-year-old man) with severe ischemic mitral regurgitation were treated with this procedure. The patients had congestive heart failure due to mitral regurgitation, associated with inferior myocardial infarction. Regurgitant fraction of mitral regurgitation was 70% and 52% before surgery. Mitral leaflet tethering caused by apical displacement of the papillary muscle was observed. Mitral valve repair was performed by ring annuloplasty and chordal cutting. Intraoperative echocardiography showed that chordal cutting improved the configuration of the anterior leaflet, resulting in good mitral valve coaptation without regurgitation.     

Mechanism of hemolysis after mitral valve repair and new surgical management: prosthetic annuloplasty ring covered with autologous pericardium

BACKGROUND AND AIMS OF THE STUDY: Hemolysis after mitral valve repair is a rare occurrence, but is one of the complications leading to reoperation. Since 1999, mitral valve repair at the authors' institution has been performed using a prosthetic annuloplasty ring covered with autologous pericardium to prevent this complication. The study aims were to investigate the mechanism of hemolysis after mitral valve repair and to describe the surgical management of this complication. METHODS: This retrospective study comprised 204 consecutive patients who underwent mitral valve repair using an annuloplasty ring between October 1991 and April 2000 at the authors' institution. Patients were allocated to the non-covered ring group (n = 174) and the covered ring group (n = 30), and compared for the degree of mitral regurgitation (MR), serum levels of lactate dehydrogenase (LDH), and occurrence of hemolysis. The degree and flow pattern of MR, and patient prognoses were described for hemolytic patients. RESULTS: Postoperative MR and serum LDH were not significantly high in either group. A total of seven patients presented with hemolysis; postoperative echocardiography revealed MR to be mild in two patients, moderate in three and severe in two. Collision of the regurgitant jet into the artificial ring was evident in all seven patients. A beta-blocker proved effective in treating hemolysis in three patients, mitral re-repair was performed in three, and a prosthetic mitral valve was inserted in one patient. None of the patients in the covered ring group presented with hemolysis. CONCLUSION: The major cause of hemolysis after mitral repair was collision of the regurgitant jet into the artificial ring. The simple technique used herein prevented contact of the regurgitant jet with the rough surface of the ring, and may in turn have prevented hemolysis. In selected patients, hemolysis was improved by beta-blocker administration.     

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.     

瓣中瓣置入术治疗二尖瓣关闭不全16例报告

二尖瓣关闭不全患者行常规二尖瓣置换术后常有左室功能恶化，有人推测术中二尖瓣结构的破坏是导致术后左室功能不全的主要机制之一。从１９９１年５月～１９９５年５月，我们对１６例二尖瓣关闭不全患者实施了一种新的二尖瓣置换术，即“瓣中瓣”置入术。术中保留全部二尖瓣瓣叶及瓣下结构，人工瓣置入固定后，前、后瓣叶均卷缩折叠于缝合环下。术后所有患者病情平稳，仅３例需要很少量的正性肌力药物支持，且都能在术后３６小时内脱离呼吸机。经超声心动图测定，术后左室功能很快恢复，所有患者均痊愈出院。结果表明：对二尖瓣关闭不全及其合并轻度狭窄者采用瓣中瓣置入术，有利于术后左室功能的恢复，瓣中瓣置入术是一种安全和有效的手术方法。     

Anatomo-functional study of non-rheumatic mitral insufficiency with transesophageal echocardiography]

Reconstruction surgery of the mitral valve has become an alternative to mitral replacement in patients with pure mitral regurgitation. Preoperative assessment of the anatomic and functional aspects of the valvular lesion is of the utmost importance in conservative surgery. Transesophageal echocardiography is a new approach to investigating the mitral valve, and our study was undertaken with the purpose of determining its importance in the exploration of mitral regurgitation of non-rheumatic origin. Subjects included were twenty patients with pure and isolated mitral regurgitation (MR): 14 males and 6 females with an average age of 47 +/- 13 years. All the patients underwent a first transesophageal 2D and color Doppler echocardiographic examination, and 5 of them underwent a second one during cardiovascular surgery. Mitral anulus diameter, mitral valve cordae tendinae status, valvular leaflet length and coaptation were examined and color Doppler regurgitation jet area was measured. Mitral anulus diameter was 40.2 +/- 8.06 mm (diastolic) and 41.9 +/- 8.53 mm (systolic) and was above the values considered to be normal. Anterior leaflet length was 30.8 +/- 3.12 mm and posterior leaflet length was 22.9 +/- 4.74 mm; regurgitation jet area was between 1.2 cm2 and 13.52 cm2 with an average of 5.44 cm2. In the group with MR of mixomatous origin, systolic anulus diameter showed a linear correlation with regurgitation jet area (r = 0.79). In the 6 patients who underwent cardiac catheterization, angiographic semiquantitative evaluation of the MR confirmed that based on color Doppler jet area. In all twenty patients transesophageal echocardiography enabled us to identify the mechanism responsible for mitral insufficiency.(ABSTRACT TRUNCATED AT 250 WORDS)