Mitral valve palpitations

Few disorders ever provoked more interest and controversy than mitral valve prolapse (MVP). Past echocardiographic over-diagnosis led to it becoming a whipping boy for otherwise unexplained chest pain, palpitation, arrhythmias and emboli. Surgical centres reported a high incidence of endocarditis and severe regurgitation. Most investigators who have studied the prevalence of arrhythmias in MVP have concluded that they are more common in this syndrome than in the general population and that there is a causal rather than a fortuitous relationship. However, the prevalence of arrhythmias in reported studies is probably higher than in unselected MVP patients. Multiple ventricular premature beats, ventricular tachycardia and sudden death have been reported. Suggested mechanisms have included a focal cardiomyopathy with incoordinate contraction and relaxation, QRS dispersion, a long QT, traction on papillary muscles by prolapsed leaflets, interference with the blood supply of the papillary muscles, stimulation of the endocardium by the chordae and diastolic depolarisation of muscle fibres in redundant leaflets with triggered repetitive automaticity. MVP has been associated with pre-excitation giving rise to atrioventricular re-entry tachycardia. Autonomic dysfunction and a hyperadrenergic state has been claimed and this may also be responsible for supraventricular arrhythmias including atrioventricular nodal re-entry tachycardia, flutter and fibrillation. Electrophysiological studies have yielded contradictory results which may be due to the heterogeneity of the patients studied and variability of the mechanisms. Whatever the true prevalence, arrhythmias in MVP are usually benign. Syncope and sudden death are rare. Anti-arrhythmic therapy is only warranted in patients with frequent and distressing symptoms shown to be due to the arrhythmias or when arrhythmias are judged potentially life threatening. Beta-blockers are particularly helpful in the syndrome.     

二尖瓣成形术的临床体会

目的总结36例二尖瓣成形术的临床经验。方法实施二尖瓣成形术36例，其中后叶矩形切除13例，“双孔法”3例，后叶腱索转移1例，后叶矩形切除＋“双孔法”4例，前、后交界环缩2例，单纯放人工瓣环11例，瓣叶裂修补1例，二尖瓣肿瘤切除1例。28例置入人工瓣环，其中Edward软环19例、Medtronie软环9例。结果术后经食管超声心动图（TEE）检查，二尖瓣反流消失或微量反流26例，少量反流10例。1例术后第10天发生心律失常死亡。患者术前心脏彩超检查：左房（LA）（49．06±13．79）mm，左室（LV）（59．79±11．23）mm。术后心脏彩超检查：左房（39．47±6．63）mm，左室（50．21±5．07）mm。术后3个月随访心脏彩超检查：左房（35．26±5．42）mm，左室（45．18±4．25）mm。35例随访1～18个月，心功能I级31例、Ⅱ级4例。结论二尖瓣关闭不全采用相应的成形技术，可以取得良好的早、中期治疗效果。     

预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂

目的:回顾预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂,探讨此手术对二尖瓣脱垂的治疗效果。方法:2008年1月至2012年12月间,回顾性分析北京安贞医院收治的15例二尖瓣脱垂患者,其中男性10例,女性5例,年龄(48.5±3.2)岁,SBE后腱索断裂导致关闭不全2例,单纯腱索断裂导致关闭不全8例,腱索延长导致关闭不全5例。术前超声心动图(TEE)显示:根据Carpentier标准,前叶脱垂10例,后叶脱垂3例,前叶合并后叶脱垂2例。所有患者二尖瓣均为重度关闭不全,反流面积(11.0±0.9)cm2,1例合并三尖瓣重度反流。术前射血分数(EF)平均(64.9±1.9)%,左心室舒张末直径(LVDD)平均(54.9±1.4)mm,左心房直径(LA)平均(42.9±1.7)mm。所有患者均经胸正中切口,体外循环下行预制人工腱索环移植,移植腱索数量为(3.6±0.3)根,腱索长度(15.4±1.5)mm,平均体外循环时间(113±11.7)min,平均主动脉阻断时间(86±9.8)min。3例患者置入SJ成形环,12例患者置入爱德华成形环,1例患者同时行三尖瓣成形术。结果:术后无死亡,无恶性心律失常及其他严重并发症。术后复查TEE显示少量反流3例,微量反流8例,未见反流4例。术后EF平均(60.2±2.9)%,未见明显改变。LVDD平均(46.5±1.1)mm,LA平均(32.9±1.2)mm,均较术前明显改善。随访12~57个月,平均(35.7±4.3)个月,少量反流3例,无或微量反流12例。结论:预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂近中期效果确切,但是远期预后尚需进一步观察。     

Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery

BACKGROUND:

Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated.

METHODS:

A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival.

RESULTS:

The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival.

CONCLUSIONS:

In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulation-related complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation.     

Mitral valve myxomas: an unusual entity

Primary tumours of the heart are uncommon entities, cardiacmyxomas being the most frequent. However, mitral valve myxomasare exceptionally rare. In the last 12 years, there have been25 myxomas diagnosed at our institution, with only two of themoriginating from the mitral valve. Both patients were female,the first, 25, and the second, 72 years old. The younger patientwas very symptomatic with a large mass, 4 cm long, which involvedboth leaflets causing significant obstruction to the left ventricularinflow. The second one had a smaller mass located at the atrialside of the posterior leaflet that only produced some flow divergence.Neither of them had constitutional nor embolic symptoms. Bothpatients were submitted to emergent surgical resection thatin the first case involved the mitral valve and replacementwith mechanical prosthesis. The macroscopic appearance of thesetumours suggested a malignant aetiology which may representsomewhat different features of the myxomas when originatingfrom the cardiac valves. Both patients are well reflecting thegood prognosis of this illness after resection, although theyounger patient was re-operated because of prosthetic valveobstruction and suspicion of recurrence that was not confirmed.Because of the illustrative images and different presentations,we found it interesting to report and discuss them together.     

Systematic quantification of histologic ventricular fibrosis in isolated mitral valve prolapse and sudden cardiac death

1. Download : Download high-res image (354KB)
2. Download : Download full-size image

     

经胸二维超声心动图诊断不同部位二尖瓣脱垂的准确性

目的:评价经胸二维超声心动图诊断不同部位二尖瓣脱垂的准确性及其对术式选择的指导作用。方法:本研究共入选39例患者,均经二维超声心动图诊断为二尖瓣脱垂,并对其脱垂部位,脱垂程度,反流程度及各腔室大小进行了详尽的描述。该39例患者均行外科手术治疗,并将术中所见与超声心动图结果对照,首先根据术中所见瓣叶脱垂部位将患者分为前叶病变组(n=15),后叶病变组(n=19)及双叶病变组(n=5),比较各组间临床及超声心动图特点,明确超声心动图诊断不同部位二尖瓣脱垂的准确性。同时根据手术方式将患者分为瓣膜置换者(n=23)与瓣膜成形者(n=16),比较两类患者间的超声心动图特点。结果:39例患者中,超声心动图诊断与术中所见比较二尖瓣前叶病变组,后叶病变组及双叶病变组分别为14例及15例,22例及19例、3例及5例,诊断瓣叶脱垂伴腱索断裂者为17例及22例,与术中所见比较,该四者的准确率分别为92.3%,87.1%,89.7%及72%。在选择不同手术方式的比较的结果为,二尖瓣前叶及双叶脱垂者多行瓣膜置换术,二尖瓣后叶病变者多行瓣膜成形术。结论:二维超声心动图不仅能较准确地诊断不同部位的二尖瓣脱垂,同时对手术方式的选择具有重要的指导作用。     

Mitral valve prolapse and Marfan syndrome

Marfan syndrome is a multisystemic genetic condition affecting connective tissue. It carries a reduced life expectancy, largely dependent on cardiovascular complications. More common cardiac manifestations such as aortic dissection and aortic valve incompetence have been widely documented in the literature. Mitral valve prolapse (MVP), however, has remained poorly documented. This article aims at exploring the existing literature on the pathophysiology and diagnosis of MVP in patients with Marfan syndrome, defining its current management and outlining the future developments surrounding it.     

Three-dimensional echocardiography in mitral valve disease.

Three-dimensional echocardiography offers great promise for improving the understanding of the mitral valve anatomy, function, and pathology. It may have important implications for medical or surgical management of different mitral valve disease. In this article we provide an overview of the three-dimensional anatomy of the mitral valve. Based on the studies using three-dimensional echocardiography we describe the topography of the mitral valve, its nonplanarity as well as dynamics of the mitral annulus. Furthermore, we review the use of three-dimensional echocardiography in the evaluation of different mitral valve disease. Three-dimensional echocardiography has become a new clinical standard in the assessment of the severity of mitral stenosis by means of accurate mitral valve area measurement. Also, unconventional indices, like the geometry and mitral valve volume may be assessed by three-dimensional echocardiography. It is a very suitable technique for monitoring the efficacy and complications of percutaneous mitral valvuloplasty. Three-dimensional echocardiography allows accurate identification and quantification of prolapse of individual segments of the mitral valve leaflets. Three-dimensional color flow imaging makes echocardiography an accurate method also in the assessment of mitral regurgitation severity. Finally, we outline three-dimensional echocardiography as a potentially useful guide for a surgeon, particularly in mitral valve repair.     

Mitral valve repair in heart failure

Mitral regurgitation (MR) is a frequent complication of end-stage heart failure. Historically, these patients were either managed medically or with mitral valve replacement, both associated with poor outcomes. Mitral valve repair via an 'undersized' annuloplasty repair is safe and effectively corrects MR in heart-failure patients. All of the observed changes contribute to reverse remodeling and restoration of the normal left-ventricular geometric relationship. Mitral valve repair offers a new strategy for patients with MR and end-stage heart failure.     

Prevalence of mitral valve prolapse in primary spontaneous pneumothorax

BACKGROUND: Mitral valve prolapse (MVP) has been described as a common diagnosis and has been reported in 50% of patients with primary spontaneous pneumothorax (PSP). The purpose of this study was to determine the prevalence of MVP -- as diagnosed by 2D-echocardiography criteria -- in spontaneous pneumothorax. METHOD: A case-control study of 24 patients with PSP, and 40 age-matched controls. All cases underwent 2D-echocardiography by a certified cardiologist. Echocardiography and demographic features of both groups were compared and analyzed using Fisher's exact test. Classic MVP was defined as superior displacement of the mitral leaflets of more than 2 mm during systole and as a maximal leaflet thickness of at least 5 mm during diastasis, and non-classic prolapse was defined as displacement of more than 2 mm with a maximal thickness of less than 5 mm. RESULTS: MVP was found in 9 of the 24 patients (37.5%) who suffered PSP, compared to 3 out of the 40 (7.5%) age-matched controls (P=0.008). The body mass index (BMI) (weight/height2) was lower in the group with pneumothorax (P=0.001). CONCLUSION: In this study, applying an updated definition of MVP, the prevalence of MVP in PSP was lower than previously reported, but was still significantly higher than in the control group.     

Mitral valve ring dehiscence with an aorta-left atrial fistula.

In an era with the increasing use of various imaging modalities including echocardiography, ventriculography and cardiac magnetic resonance (CMR) imaging, one must be aware of the limitations of each discipline. We report a case of an individual who presented with both a partial dehiscence of a mitral valve annuloplasty ring and an aorta-left atrium fistula following surgical management of infective endocarditis that was correctly identified using transesophageal echocardiographic imaging.     

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.     

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.     

Biology of mitral valve prolapse: the harvest is big, but the workers are few

Mitral valve prolapse (MVP) represents a common degenerative disease, often requiring surgery. If untreated, MVP with considerable valve incompetence can lead to cardiovascular and systemic complications causing substantial morbidity and mortality.In contrast with the wide knowledge concerning clinical and physiological features, currently available data regarding its molecular bases are very limited.We review current knowledge concerning MVP biological mechanisms, focusing on specific aspects of haemostasis, platelet function, oxidative stress, extracellular matrix remodeling and genomics. In particular, available evidence supports the role played by tissue remodeling processes in determining MVP onset and progression. Moreover, even if a consistent although controversial perturbation of haemostatic system and alterations of the oxidative stress equilibrium have been proposed to influence disease development, it is unknown whether these changes precede or follow MVP occurrence. Consequently, the complete knowledge of all the biochemical pathways involved are far from complete.In addition, changes in the regulation pattern of adrenergic and renin-angiotensin-aldosterone systems have been described in MVP syndrome, a condition characterized by the association of MVP with other peculiar neurological and general symptoms, but it is unknown whether these abnormalities are shared by “traditional” MVP.In conclusion, MVP is probably a multi-factorial process, and many aspects still need to be clarified. As surgery can only correct the damaged valve but not the underlying mechanisms, a more complete knowledge of the involved molecular pathways is necessary, as it may allow the discovery of targeted therapeutic strategies aimed at modifying or slackening MVP natural course in the early phases.     

非风湿性二尖瓣关闭不全的外科治疗

目的 评价二尖瓣瓣膜成形术(MVP)对非风湿性二尖瓣关闭不全的疗效.方法 2001年1月至2005年12月我院非风湿二尖瓣关闭不全心脏患者23例接受手术治疗,男性13例,女性10例,年龄16～71(49.4±5.7)岁.非风湿性二尖瓣关闭不全病因中,其中先天性5例,退行性改变12例,缺血性改变4例,感染性病变2例.术前超声心动图示二尖瓣均为大量返流,术前患者心功能Ⅲ级19例,Ⅳ级4例.瓣环成形13例,腱索短缩3例,裂修补1例,腱索转移1例,后瓣环成形 裂修补4例,部分瓣膜切除 裂修补1例.同期冠状动脉搭桥术5例,主动脉瓣膜置换术3例.结果 早期死亡率4.3%(1例),术后超声心动图示无或少量二尖瓣反流13例,少量到中量反流8例,大量反流1例.随访6～60个月(平均27个月),出院后2例患者死亡,再次手术1例.存活20例,心功能Ⅰ～Ⅱ级.结论 应用二尖瓣膜成形术治疗非风湿性二尖瓣关闭不全是可行的,可以取得良好的效果,外科技术值得进一步推广.     

Aberrant right ventricular branch of right coronary artery with mitral valve prolapse

A 37-year-old man presented with a three-week history of chest pain. Transthoracic echocardiography demonstrated a mitral valve prolapse and mild mitral insufficiency. Coronary angiography showed normal left main, circumflex, left anterior descending and right coronary arteries; however, the right ventricular branch of the right coronary artery had a separate ostium. Concomitant congenital heart abnormalities have been observed with coronary artery anomalies. Primary congenital coronary and valvular anomalies may have genetic heredity. In the present case, mitral valve prolapse was accompanied by a right ventricular coronary artery origin anomaly which, to the best of our knowledge, is the first report in the literature in which both anomalies presented together.     

Ventricular arrhythmias and the autonomic tone in patients with mitral valve prolapse.

The aim of this study was to evaluate a possible relation between the autonomic tone determined by daily urine catecholamine excretion and the incidence of ventricular arrhythmias (VA) in patients with mitral valve prolapse (MVP). The study included 53 patients (31 women and 22 men) aged 19-52 years (mean age 32.7). The diagnosis of MVP was based on medical history, physical examination, and echocardiography. Cardiac arrhythmias were detected by Holter monitoring and classified according to Lown grades. Daily heart rate and duration of corrected QT interval using Basett's formula were also analyzed. Daily urine adrenaline and noradrenaline levels were determined fluorometrically by Von Euler and Lishajko's method. The patients with Lown's grade III-V VA were evaluated with particular consideration. Student's t-test was used for statistical analysis. On Holter monitoring 26 patients showed VA, including 6 with grade I, 11 with grade II, 2 with grade III, 4 with grade IV, and 3 with grade V according to Lown's classification. The remaining 27 patients were free of cardiac arrhythmias. Mean daily heart rate ranged from 54-93 beats/min (73 +/- 8.44, mean +/- SD) and corrected QT from 336-494 ms (411 +/- 37.17). Daily adrenaline and noradrenaline excretion for the whole group of patients were 0.01-16.2 micrograms (2.1 +/- 2.38) and 1.6-31.0 micrograms (13.1 +/- 7.27), respectively, which was within normal range. However, the patients with serious ventricular arrhythmias showed significantly higher daily adrenaline excretion. Individual analysis of two-thirds of patients with ventricular arrhythmias grade III-V showed daily urine noradrenaline levels exceeding mean values for the whole group.(ABSTRACT TRUNCATED AT 250 WORDS)