Presence of a congenitally bicuspid aortic valve among patients having combined mitral and aortic valve replacement

Although bicuspid aortic valve occurs in an estimated 1% of adults and mitral valve prolapse in an estimated 5% of adults, occurrence of the 2 in the same patient is infrequent. During examination of operatively excised aortic and mitral valves because of dysfunction (stenosis and/or regurgitation), we encountered 16 patients who had congenitally bicuspid aortic valves associated with various types of dysfunctioning mitral valves. Eleven of the 16 patients had aortic stenosis (AS): 5 of them also had mitral stenosis, of rheumatic origin in 4 and secondary to mitral annular calcium in 1; the other 6 with aortic stenosis had pure mitral regurgitation (MR) secondary to mitral valve prolapse in 3, to ischemia in 2, and to unclear origin in 1. Of the 5 patients with pure aortic regurgitation, each also had pure mitral regurgitation: in 1 secondary to mitral valve prolapse and in 4 secondary to infective endocarditis. In conclusion, various types of mitral dysfunction severe enough to warrant mitral valve replacement occur in patients with bicuspid aortic valves. A proper search for mitral valve dysfunction in patients with bicuspid aortic valves appears warranted.     

Infective endocarditis complicating hypertrophic obstructive cardiomyopathy.

Infective endocarditis is a rare complication of hypertrophic cardiomyopathy. It's estimated incidence is 1.4 per 1000 person/year in all patients and it increases to 3.8 per 1000 person/year in patients with left ventricular outflow obstruction. The most common site of vegetation is the ventricular aspect of anterior mitral valve leaflet. We report a case of a 43-year-old man who was admitted for mitral infective endocarditis resulting in severe mitral regurgitation complicating a hypertrophic obstructive cardiomyopathy. The patient underwent mitral valve replacement. Post-operative outcome was good with relieve of symptom and resolution of left ventricular outflow obstruction. Literature data are reviewed.     

Mitral valve endocarditis in hypertrophic cardiomyopathy: case report and literature review

Mitral endocarditis complicating hypertrophic cardiomyopathy occurs predominantly on the left ventricular aspect of the anterior mitral valve leaflet in the presence of outflow tract obstruction. It is a rare condition and the estimated cumulative 10 year probability of developing endocarditis in patients with obstruction is < 5%. Combined mitral valve replacement and septal myectomy has been reported in this setting. A case of community acquired Staphylococcus aureus mitral valve endocarditis is reported in a previously asymptomatic young man with hypertrophic obstructive cardiomyopathy. The potential treatment options are discussed.     

Frequency and significance of M-mode echocardiographic evidence of mitral valve prolapse in clinically isolated pure mitral regurgitation: analysis of 65 patients having mitral valve replacement

To assess the reliability of M-mode echocardiographic patterns of mitral valve prolapse (MVP) (echo MVP) in detection of morphologic evidence of MVP (morphologic MVP), operatively excised mitral valves and corresponding M-mode echocardiograms from 65 patients with chronic, severe, isolated, pure mitral regurgitation (MR) were studied. Of the 65 patients, 45 (69%) had echo MVP (either holosystolic or mid-to-late systolic prolapse patterns on preoperative M-mode echograms) and 42 (93%) of them had morphologic MVP; of the 3 without morphologic MVP, 2 had ruptured chordae tendineae from infective endocarditis and 1 had papillary muscle dysfunction from atherosclerotic coronary heart disease. Of the 20 patients without echo MVP, 14 (70%) had no morphologic MVP (9 had papillary muscle dysfunction from coronary heart disease, 4 had infective endocarditis on previous normal valves and 1 had rheumatic heart disease). Of the 48 patients with morphologic MVP, 42 (88%) had echo MVP and most had considerably dilated mitral anulae; the other 6 had ruptured chordae tendineae with less degrees of anular dilatation. Of the 17 patients without morphologic MVP, 3 had echo MVP (coronary artery disease in 1 and infective endocarditis on a previous normal valve in 2); of the 14 with neither echo nor morphologic MVP, 9 had papillary muscle dysfunction from coronary artery disease, 4 had infective endocarditis on previously normal valves and 1 had rheumatic heart disease. The patients with very dilated mitral anuli and leaflet areas generally had holosystolic (hammocking) patterns on echo; the patients with small anuli and leaflet areas usually had mid-to-late systolic (buckling) prolapse patterns.     

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.     

Successful repair of a large aortic abscess causing apical displacement of the anterior mitral valve

Anatomic continuity between the anterior mitral leaflet and the aortic root may predispose those patients with aortic root pathology to functional changes of the mitral valve without any involvement of this valve. A 34-year-old man presented with aortic valve endocarditis. Transthoracic echocardiograpy showed severe aortic regurgitation with a large aortic root abscess. The anterior leaflet of the mitral valve was displaced towards the apex of the heart causing moderate mitral regurgitation. The patient underwent aortic valve replacement with reconstruction of the aortic annulus and ventriculoaortic continuity. This procedure alone restored the mitral valve structure and function without any need for intervention on the mitral valve. Aortic abscess is a serious complication of aortic valve endocarditis and may alter the function of other structures of the heart, especially the mitral valve. Restoration of aortic wall integrity and left ventricular – aortic continuity usually restores the mitral valve structure and function if the valve is unaffected by the infection. A decision on the mitral valve should be made following correction of the aortic pathology.     

Mitral valve commissurotomy versus replacement. Considerations based on examination of operatively excised stenotic mitral valves.

Among 164 patients who underwent mitral valve replacement because of mitral stenosis (with or without mitral regurgitation) and had radiographs taken of their operatively excised mitral valves, 20 had absent or minimal calcific deposits in the excised valves and absent or minimal mitral regurgitation as determined, except for one patient, by left ventricular angiography preoperatively. This report focuses on these 20 patients to ask if mitral valve replacement was preferable to mitral valve commissurotomy. Although in the pre-valve replacement era, all 20 patients almost surely would have been considered good candidates for mitral commissurotomy, other factors, namely, the need to replace one or more other cardiac valves (13 patients), the utilization of cardiopulmonary bypass allowing visual inspection rather than simple palpation of the diseased mitral valve (all 20 patients), relatively little experience with mitral commissurotomy in four of the five surgeons (17 patients), displeasure with attempted commissurotomy (three patients), previous mitral commissurotomy (11 patients), and incorrect identification of mitral calcific deposits (two patients), each contributed in one or more patients to the final decision of replacement versus commissurotomy. Even though mitral commissurotomy has been in use for 30 years, the mere alternative of valve replacement may have altered somewhat the definition of the stenotic mitral valve previously considered ideal for mitral commissurotomy.     

Frequency and extent of calcific deposits in purely regurgitant mitral valves: Analysis of 108 operatively excised valves

Operatively excised purely regurgitant mitral valves in 108 patients aged 21 to 73 years (mean 55) (63% men) undergoing isolated mitral valve replacement were examined for calcific deposits. Of the 108 patients, 19 (18%) had leaflet or chordal calcific deposits or both, but in each the deposits were small and did not appear to alter mitral function. Of the 19 patients with mitral calcium, 6 had had active infective endocarditis and the calcium likely represented healed vegetations; In 6 other patients, the leaflet calcium had extended from the mitral anulus in the setting of mitral valve prolapse. The average total serum cholesterol levels were higher in the patients with compared with those without mitral calcium. Thus, calcium deposits are relatively infrequent in adults with clinically isolated pure mitral regurgitation, and when they occur, the deposits are small and in themselves do not appear to contribute to mitral dysfunction.     

Healed left-sided infective endocarditis: A clinicopathologic study of 59 patients

Clinical and morphologic observations are described in 59 patients who had a history of active left-sided infective endocarditis that had been eradicated by antibiotic therapy. Of the 59 patients, 42 were from a group of 584 necropsy patients with fatal cardiac valve disease of various types; the remaining 17 were from a group of 79 patients who had undergone mitral or aortic valve replacement, or both, because of severe mitral or aortic regurgitation, or both. Examination of the heart at necropsy (42 patients) or at valve replacement (17 patients) disclosed that 30 (51 percent) had anatomic lesions that could readily be attributed to the active infective endocarditis that healed: cuspal perforations in 16 patients, rupture of chordae tendineae in 15 and aneurysms at or near the involved valve in 3. Unequivocal residua of the valve infection were more common in the purely incompetent than in the stenotic cardiac valves. Comparison of observations in the 42 necropsy patients with healed left-sided infective endocarditis with observations previously reported in 74 necropsy patients with active left-sided infective endocarditis showed that among the patients with healed endocarditis the infection more commonly involved a previously abnormal valve, the causative organism was more likely to be alpha streptococcus and recognized predisposing factors (opiate addiction, alcoholism, immunodeficiencies, operative procedures) were less frequent.     

Valve dysfunction of the cloth-covered Starr-Edwards ball valve.

BACKGROUND: Between June 1968 and March 1977, Starr-Edwards cloth-covered ball valves were used for valve replacement on a routine basis. METHODS AND RESULTS: Among the 66 operative survivors who underwent an isolated aortic or mitral valve replacement, 20 patients required reoperation 22 times because of valve dysfunction, thromboembolic complication, paravalvular leakage, hemolytic anemia, and/or prosthetic valve endocarditis. Reoperation was performed at a mean of 15.9+/-9.8 years after initial replacement. Excised valves were examined and reoperation after initial operation was reviewed. Operative mortality was 10.0%. Freedom from reoperation for aortic valve replacement and mitral valve replacement was 56.2% at 34 years and 61.0% at 37 years after initial operation, respectively. Cloth wear or pannus formation were observed in all excised prostheses. Orifice cloth was more markedly worn in mitral valves than in aortic valves, particularly in mitral valves of more than 20 years old. Pannus overgrowth contributed to valve regurgitation in the older valves. CONCLUSIONS: Early diagnosis of valve dysfunction and reoperation are recommended as soon as symptoms appear.     

Hypertrophic cardiomyopathy after aortic valve replacement

The association of hypertrophic cardiomyopathy and aortic valve disease is well documented. However, the new development of the syndrome late after valve replacement has not previously been described. We present six cases, all occurring in women aged 50 to 71 years who had evidence of hypertrophic cardiomyopathy 3 to 5 years after successful valve replacement. The preoperative hemodynamic lesion was aortic stenosis in four and aortic regurgitation in two. Before operation no patient showed evidence of hypertrophic cardiomyopathy as judged by the absence of (1) asymmetric septal hypertrophy (the septal/posterior wall ratio was less than 1.4:1.0 in each case); (2) systolic anterior mitral valve motion; (3) obliteration of the left ventricular cavity on angiography; and (4) an intraventricular pressure gradient. After valve replacement no patient had significant aortic regurgitation or was hypertensive. Four patients subsequently had recurrence of symptoms including dyspnea in four, angina in three and syncope in two. The electrocardiogram revealed reappearance of left ventricular hypertrophy in four patients and left bundle branch block in one. The echocardiogram disclosed asymmetric septal hypertrophy in six (septal/posterior wall ratio greater than 1.8:1.0), systolic anterior motion in three and evidence of inflow obstruction in three. At cardiac catheterization an intraventricular gradient of 36 to 60 mm Hg was demonstrated at rest in three patients, on provocation in one patient; two patients showed no gradient. Angiograms showed obliteration of the left ventricular cavity in all six patients (ejection fraction 0.84 to 0.93). Two patients had coronary artery disease. No patient had an aortic transvalve gradient at rest or with exercise.     

Significance of mitral valve repair for active-phase infective endocarditis

Mitral valve repair is preferred to replacement in infective endocarditis, but in the active phase, it often requires extensive debridement of infected tissue and complex reconstruction. We investigated 22 consecutive native mitral valve operations during active-phase infective endocarditis. The time from initiation of medical treatment to operation was 16.8 ± 16.4 days. Mitral valve repair was performed in 15 (68.2%) patients, using prosthetic annuloplasty in 14, an autologous pericardial patch in 11, and artificial chordal replacement in 9. Hospital mortality was 9.1% (2 patients), due to subarachnoid hemorrhage and pneumonia. One patient died 26 months after valve replacement due to congestive heart failure. The postoperative left ventricular end-diastolic dimension was significantly smaller (45.7 ± 5.6 vs. 53.3 ± 10.2 mm) and ejection fraction was significantly higher (57.0% ± 14.7% vs. 40.1% ± 8.2%) in patients who underwent valve repair compared to those who had valve replacement. Mitral regurgitation requiring reoperation occurred in 3 patients during follow-up. Mitral valve repair is feasible in active-phase infective endocarditis, and results in improved regression of left ventricular dimensions compared to valve replacement. However, complex mitral valve repair with extensive leaflet resection may not have long-term durability.     

A rare complication of mechanical aortic valve replacement: Separation in the region of the mitral‐aortic intervalvular fibrosa

A 28‐year‐old man was admitted to our emergency service with a shortness of breath and palpitation. On admission, his blood pressure was high and he was in hypertensive pulmonary edema. His physical examination showed rales in both lungs and pansystolic murmur at mitral focus. His medical history included aortic valve replacement (AVR) because of native aortic valve infective endocarditis. Transthoracic echocardiography (TTE) showed normal functional aortic valve. Color flow imaging demonstrated severe mitral regurgitation with posterior eccentric jet. To examine in detail, transesophageal echocardiography (TEE) and three‐dimensional (3D) echocardiography were performed. TEE disclosed a separation in the subaortic curtain leading to severe mitral regurgitation from the left ventricle to the left atrium. In addition to severe mitral regurgitation with posterior eccentric jet, 26‐mm‐long pouch was seen in mitral‐aortic intervalvular fibrosa (MAIVF) at 120° TEE view. This pouch was separated from the mitral anterior leaflet junction releasing the mitral anterior leaflet and causing prolapse and chorda rupture in the A2 scallop of the mitral anterior leaflet. The MAIVF connects the anterior mitral leaflet to the posterior portion of the aortic annulus. The separation of the MAIVF represents a complication of the aortic valve replacement.     

Echocardiographic observations in opiate addicts with active infective endocarditis: Frequency of involvement of the various valves and comparison of echocardiographic features of right- and left-sided cardiac valve endocarditis

Echocardiographic observations are described in 25 opiate addicts with active infective endocarditis involving apparently previously normal valves. Infective endocarditis was isolated to the tricuspid valve in 11 patients, involved both right- (tricuspid valve) and left-sided valves in 7 and was isolated to the left-sided valves in 7 (mitral valve in 6). Twenty patients (80 percent) had tricuspid valve regurgitation, 12 had mitral regurgitation, 3 had aortic regurgitation and none had pulmonary valve regurgitation. Considering the 75 cardiac valves (excluding the pulmonary) in the 25 patients, echocardiographic abnormalities consistent with active infective endocarditis were detected in 26 (74 percent) of the 35 clinically incompetent valves but in none of the 40 competent valves. Comparison of the 20 incompetent tricuspid valves with the 12 incompetent mitral valves indicated that (1) the echocardiogram was less sensitive in detecting tricuspid valve lesions, (2) rupture of tricuspid valve chordae tendineae was absent or not detectable, and (3) tricuspid valve vegetations tended to be larger.     

Mechanisms of severe mitral regurgitation in mitral valve prolapse determined from analysis of operatively excised valves

Certain clinical and mitral valvular morphologic findings are described in 83 patients (age 26 to 79 years [mean, 60]; 26 women [31%] and 57 men [69%]) with mitral valve prolapse (MVP) and mitral regurgitation (MR) severe enough to warrant mitral valve replacement. All 83 operatively excised valves were examined by the same person, and all excised valves had been purely regurgitant (no element of stenosis). No patients had hemodynamic evidence of dysfunction of the aortic valve. In each valve a portion of the posterior mitral leaflet was elongated such that the distance from the distal margin to basal attachment of this leaflet was similar to the distance from the distal margin of the anterior leaflet to its basal attachment to the left atrial wall. Two major mechanisms for the severe MR were found: dilatation of the mitral anulus with or without rupture of chordae tendineae and rupture of chordae tendineae with or without dilatation of the mitral anulus. Of the 83 patients, 48 (58%) had both dilated anuli (greater than 11 cm in circumference) and ruptured chordae tendineae; 16 (19%) had dilated anuli without ruptured chordae, and 16 (19%) had ruptured chordae without significant anular dilatation. In three patients the anulus was not dilated, nor were chordae ruptured, and therefore the mechanism of the MR is uncertain. Mitral chordal rupture was nearly as frequent in the 64 patients with clearly dilated anular circumferences as in the 19 patients with normal or insignificantly dilated anular circumferences (less than or equal to 11 cm).     

Incremental Value of Three‐Dimensional Transthoracic Echocardiography in the Assessment of Ruptured Aneurysm of Anterior Mitral Leaflet

The mitral valve aneurysm is a rare complication of infective endocarditis involving mitral or aortic valve. The perforation of the mitral valve aneurysm can lead to significant mitral regurgitation (MR) or thromboembolism, which can cause sudden hemodynamic deterioration. We describe here a case of healed infective endocarditis of the aortic valve with ruptured mitral valve aneurysm that led to severe MR. The aneurysm of the anterior mitral leaflet was diagnosed by two‐dimensional transthoracic echocardiography. In this case, three‐dimensional transthoracic echocardiography demonstrated the detailed morphology of mitral valve aneurysm which resulted in successful surgical repair of the aneurysm.     

Surgical treatment of infective endocarditis complicated by intracranial hemorrhage in a patient with hypertrophic obstructive cardiomyopathy

A patient with hypertrophic obstructive cardiomyopathy developed mitral regurgitation due to infective endocarditis. The patient, a 29-year-old man with a 16-year history of a severe obstructive form of hypertrophic obstructive cardiomyopathy (left ventricular outflow gradient more than 100 mmHg), was admitted with bacteremia. During medical therapy with antibiotics for six months, the patient suffered an intracranial hemorrhage without a mycotic aneurysm and developed severe mitral regurgitation due to the infective endocarditis. One month after clinical stability of the cerebral damage, the patient underwent a combined mitral valve replacement and transaortic septal myectomy. Postoperative echocardiography revealed that the left ventricular outflow gradient had decreased to 15 mmHg. Ten months after the combined operation, the patient was well and asymptomatic.     

Acute mitral regurgitation due to ruptured chordae tendineae in a patient with hypertrophic obstructive cardiomyopathy: a case report

A 63-year-old woman had been followed up for hypertrophic obstructive cardiomyopathy with 85 mmHg of left ventricular outflow tract pressure gradient over 7 years. She was hospitalized because of acute dyspnea and syncope. On admission, echocardiography revealed severe mitral regurgitation with ruptured chordae tendineae at the medial scallop of the posterior mitral leaflet. Mitral valve replacement was successfully performed and her symptoms improved to 28 mmHg of left ventricular outflow tract pressure gradient. In patients with hypertrophic obstructive cardiomyopathy, elevated left ventricular systolic pressure and systolic anterior motion of the mitral leaflets may lead to mucoid degeneration in the chordae tendineae. Rupture of the mitral chordae tendineae should be considered in the differential diagnosis of acutely deteriorated mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy, because this is a rare but critical complication.     

Contemporary results of mitral valve repair for infective endocarditis

OBJECTIVES: We sought to evaluate the feasibility and immediate and late results of mitral valve repair (MVRep) for acute and healed endocarditis. BACKGROUND: Improvements in techniques of MVRep have extended its feasibility in complex lesions, but experience with endocarditis is limited. METHODS: Among 78 patients operated on for mitral endocarditis between 1990 and 1999, 63 underwent MVRep. The repair was performed for acute endocarditis in 25 patients (40%) at a median of 20 days after the onset of treatment and in 38 patients (60%) for healed endocarditis after a median of 11 months. RESULTS: Repair of the mitral valve was feasible in 63 patients (81%). This repair involved annuloplasty in 61 patients (97%), valve resection in 49 (78%), shortening or transposition of chordae in 29 (46%), suture of perforation in 18 (29%), a pericardial patch in 12 (19%), and a partial mitral homograft in 7 (11%). Associated procedures were aortic valve replacement in 11 patients, bypass grafting in 3, and tricuspid repair in 2. Early complications were two deaths (3.2%), one re-operation for severe mitral regurgitation and one re-operation for subsequent aortic endocarditis. The seven-year rate of event-free survival was 78 +/- 6% in the global series. Multivariate predictors of event-free survival were hypertension (p < 0.006) and intervention for acute endocarditis (p < 0.026). Five-year survival rates were 96 +/- 4% after MVRep for acute endocarditis and 91 +/- 5% for healed endocarditis. CONCLUSIONS: Mitral valve repair is frequently feasible and gives good results in patients with infective endocarditis. Patients operated on for acute endocarditis experience more events during follow-up than those operated on after healed endocarditis but have excellent late survival.     

Mitral valve repair in patients with infective endocarditis.

BACKGROUND: The goal of the present study was to investigate the feasibility of mitral valvle repair in patients with infective endocarditis (IE). METHODS AND RESULTS: Twenty-one patients who had undergone mitral valve surgery for IE were reviewed. Valve repair was performed in 8 patients with active and in 6 patients with healed endocarditis: 6 of these 14 patients were New York Heart Association (NYHA) functional class III or IV preoperatively. Valve replacement was performed in 5 patients with active endocarditis and in 2 with healed endocarditis: 6 of these 7 patients were NYHA functional class III or IV preoperatively. Repair techniques included annuloplasty (n=13), resection-suture (n=13), chordal transfer (n=2), and closure of the perforation (n=3). In the valve replacement group, 6 patients required concomitant aortic valve replacement. In the valve repair group, 1 patient died and 1 patient required reoperation for recurrent mitral regurgitation. Postoperative echocardiography demonstrated no (n=8) or mild (n=4) mitral regurgitation at the last follow-up examination. In the valve replacement group, 1 patient died and 1 patient required reoperation because of a paravalvular leak. No cases of recurrent infection occurred in either group. CONCLUSIONS: Mitral valve repair in patients with IE is feasible and has low morbidity.