Relationship between auscultatory events and structural abnormalities in mitral valve prolapse: a two-dimensional echocardiographic evaluation

The purpose of this study was to examine the relationship between the valvular abnormalities and auscultatory findings of patients with mitral valve prolapse (MVP). Forty patients with typical auscultatory and two-dimensional echocardiographic (2DE) findings were studied. Eleven of 14 patients with anterior leaflet MVP (group I) had mid to late systolic clicks without murmurs of mitral regurgitation, while eight of nine patients with posterior leaflet prolapse (group II) and 13 of 17 patients with combined anterior and posterior prolapse (group III) had murmurs of mitral regurgitation. In each subgroup the mitral anulus size was greater than a control group (group I = 3.8 +/- 0.1 cm, p less than 0.025; group II = 3.9 +/- 0.1 cm, p less than 0.005; group III = 4.2 +/- 0.2 cm, p less than 0.001; and control = 3.4 +/- 0.1 cm), but the largest anulus was present in patients with combined prolapse. As demonstrated by 2DE, prolapse of a single mitral leaflet may occur in many instances of MVP. Murmurs of mitral regurgitation occur frequently when the posterior mitral leaflet alone prolapses, while isolated clicks are found with anterior mitral leaflet prolapse.     

Relation of echocardiographic morphology of the mitral apparatus to mitral regurgitation in mitral valve prolapse: assessment by Doppler color flow imaging

Few data exist regarding the relationship of valvular anatomy and coaptation to the presence of mitral regurgitation (MR) in patients with mitral valve prolapse (MVP). Therefore this study was undertaken to assess the ability of two-dimensional echocardiographic features of mitral valve morphology to predict the presence, direction, and magnitude of MR as assessed by color Doppler flow imaging. MR was present in 21 of 46 patients with MVP on two-dimensional echocardiography. Echocardiograms were specifically evaluated for leaflet apposition, leaflet morphology, and mitral anulus diameter. Color flow images were analyzed for presence of MR, direction of the regurgitant jet, and area encompassing the largest jet visible in any view. Abnormal mitral leaflet coaptation on two-dimensional echocardiography was strongly associated with the presence of MR (p = 0.003), being present in 15 of 21 patients with as compared with 5 of 25 patients without MR. Similarly, mitral leaflet thickness and MR were closely associated (p = 0.0035), with the latter being present in 9 of 30 patients with normal and 12 of 16 patients with excessive leaflet thickness. MR jet direction tended to be anterior to central with posterior leaflet prolapse and posterior or central with anterior leaflet prolapse (p = 0.02). Maximal jet area of MR tended to be larger in patients with compared with those without mitral annular dilatation (5.4 +/- 2.3 versus 2.1 +/- 1.9 cm2, p = 0.001), and in those with abnormal rather than normal leaflet thickness (4.5 +/- 2.7 versus 2.0 +/- 1.6 cm2, p = 0.009). Thus the presence, direction, and size of MR jets in MVP are related to structural abnormality of the mitral apparatus on echocardiography.     

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 echoes in patients with mitral valve prolapse syndrome.

Echocardiology is an important tool in diagnosing patients with the mitral valve prolapse (MVP) syndrome. An unusual echocardiographic finding reported in this study was observed in 12 of 83 patients (14.5 per cent) with MVP syndrome. The finding consisted of a pattern of multiple, high-intensity parallel echoes behind the anterior mitral leaflet noted throughout diastole which in character were closely akin to those previously observed in left atrial myxoma or hemodynamically significant flail mitral valve leaflet. These latter diagnoses were excluded by other criteria. The prevalence of this finding in patients with MVP was significantly increased (P < .01 by Chi-square contingency testing) when contrasted with 44 patients without MVP. There was no identifying feature in the clinical history or physical examination which could be used to predict those in whom the diastolic echoes were observed. However, a significant increase in dysrhythmias as recorded by routine electrocardiogram or 24-hour Holter monitoring was noted. Angiographic information obtained in selected patients suggested that the posterior leaflet per se caused these diastolic echoes. Because of patulous transformation of the valve, elongation of the chordae, or loss of support of the papillary muscle from the posterior free wall, the posterior leaflet appeared drawn forward toward the anterior leaflet, perhaps from a venturi-like effect caused by the rapid ingress of blood during diastolic filling. This malpositioning of the posterior leaflet was not associated with significant mitral regurgitation and appears to represent but another facet in the spectrum of mitral valve prolapse.     

Comparison of accuracy of transesophageal versus transthoracic echocardiography for the detection of mitral valve prolapse with ruptured chordae tendineae (flail mitral leaflet)

The accuracy of transesophageal echocardiography was compared with that of transthoracic echocardiography in the detection of ruptured chordae tendineae (flail mitral leaflet) in 27 patients with mitral valve prolapse (MVP) who underwent valve repair or replacement for mitral regurgitation. Confirmation of the presence of ruptured chordae resulting in a flail leaflet was available at surgery in all cases. The echocardiographic studies were read blindly by 2 independent observers with any differences resolved by a third. Mean (+/- standard deviation) age was 63 +/- 13 years. Men (n = 20) outnumbered women (n = 7) (p less than 0.02), and tended to be younger (p = 0.06). Flail leaflets were identified in 20 of 27 patients. In 1 patient, both leaflets were involved and in the remaining 19 patients posterior leaflets (15 patients) were more frequently affected than anterior leaflets (4 patients). Transesophageal echocardiography correctly identified all 20 patients with flail leaflets, but 1 false positive study occurred among the 7 patients without a flail leaflet. In contrast, transthoracic echocardiography identified only 12 of 20 patients with flail leaflets, with no false positive studies. Transesophageal echocardiography was more accurate, correctly classifying 26 of 27 (96%) cases versus 19 of 27 (70%) by the transthoracic approach (p less than 0.01). This study suggests a higher incidence of chordal rupture to the posterior leaflet in patients with MVP and demonstrates improved accuracy of transesophageal over transthoracic echocardiography in the detection of flail leaflets.     

Early outcome with the Alfieri mitral valve repair

OBJECTIVES: Mitral regurgitation in cases of prolapse of the anterior leaflet, posterior leaflet with calcified annulus, or prolapse of both leaflets is thought to be difficult to repair. The Alfieri repair has been developed to address these conditions. METHODS: Seven patients (four men and three women, mean age 71 +/- 9 years) underwent the Alfieri repair for mitral regurgitation at Austin and Repatriation Medical Centre between January 1999 and December 1999. The mechanism of mitral regurgitation was prolapse of the posterior leaflet with calcified annulus in one patient, prolapse of the anterior leaflet in two, and prolapse of both leaflets in four. Mitral regurgitation before operation was severe in all patients. The Cosgrove ring was used in all patients. Four patients underwent combined operation, coronary artery bypass surgery in three and tricuspid annuloplasty in one. RESULTS: There was no hospital death. Two patients had postoperative complications, transient ischemic attack in one patient and rapid atrial fibrillation in one. The mean hospital stay was 11.3 +/- 8.7 days. Mitral regurgitation after operation was mild in five patients and trivial in two. Mean pressure gradient of the transmitral valve was 4.0 +/- 1.4 mmHg. CONCLUSIONS: The Alfieri mitral valve repair is a simple and satisfactory technique to repair mitral regurgitation in selected patients. Long-term follow-up is required to evaluate the durability of this technique.     

Comparison of cardiac findings in patients with mitral valve prolapse who die suddenly to those who have congestive heart failure from mitral regurgitation and to those with fatal noncardiac conditions.

Sudden death occurs in a small but important subset of patients with mitral valve prolapse (MVP). Clinical criteria for identifying patients at risk for sudden death have been elusive. To determine if certain morphologic characteristics were present in hearts from patients with sudden cardiac death and MVP, autopsy hearts from persons with sudden death and isolated MVP who were previously asymptomatic or had a history of cardiac arrhythmias (n = 27) were compared with (1) hearts from patients with congestive heart failure (CHF) and mitral regurgitation (MR) secondary to MVP (n = 14), and (2) hearts from persons dying from non-cardiac causes in which MVP was an incidental finding (n = 19). Patients who died suddenly were younger than both patients with MR/CHF and incidental cases (37 +/- 10 vs 65 +/- 16 and 58 +/- 21 years, respectively, p less than 0.001). Mitral valve annular circumference, anterior and posterior mitral valve leaflet lengths, posterior mitral valve thickness, and presence and extent of endocardial plaque were greater in hearts from patients with sudden death than hearts from those with incidental MVP. Hearts from patients with MR/CHF weighed significantly more, had greater left and right atrial cavity sizes and left ventricular cavity diameter than hearts from both sudden death and incidental cases.     

Echocardiographic assessment of the mechanisms of correction of bileaflet prolapse causing mitral regurgitation with only posterior leaflet repair surgery

Recent data suggest that posterior leaflet repair alone corrects mitral regurgitation in patients with bileaflet prolapse and normal anterior chordae. The purpose of this study was to use echocardiography to define the anatomic differences between posterior and bileaflet prolapse and to determine if posterior leaflet repair alone leads to correction of bileaflet prolapse. We studied patients who underwent quadrangular resection of the posterior mitral valve leaflet to treat bileaflet prolapse (group I, N = 20) or isolated posterior leaflet prolapse (group II, N = 20). Echocardiographic characteristics were compared before and after the procedure. There were no differences in the left ventricular end-diastolic or end-systolic dimensions or function between the 2 groups. However, anterior leaflet length was greater in patients with bileaflet prolapse (3.3 ± 0.6 cm vs 2.6 ± 0.4 cm, P = 0.003). In group I, posterior leaflet repair changed anterior leaflet displacement from –0.8 ± 0.2 to 0.5 ± 0.4 cm (p <0.001) and posterior leaflet displacement from –0.8 ± 0.3 cm below to 0.5 ± 0.4 cm (p <0.001) in front of the mitral annular plane. In group II, anterior leaflet displacement was unchanged from 0.2 ± 0.1 to 0.3 ± 0.2 cm (p = 0.22), whereas posterior leaflet displacement changed from –0.7 ± 0.2 to 0.4 ± 0.2 cm (p <0.001). Thus, patients with bileaflet prolapse and no ruptured chords have excessive anterior leaflet length. In such patients, posterior leaflet repair alone corrects anterior and posterior leaflet prolapse.     

Continuity from normal to prolapsed mitral valves: two-dimensional and color Doppler echocardiographic investigations]

To investigate the continuity between the normal and prolapsed mitral valves (MVP), two-dimensional echocardiography (2DE) and color Doppler echocardiography (CDE) were performed in 508 healthy boys aged 12 to 13 years old. The distance from the plane of the mitral annulus to the coaptation of the mitral valve "c", the maximum distance between the anterior leaflet and a straight line connecting the anterior mitral annulus and the coaptation of the mitral valve "d", and the maximum distance between the posterior mitral leaflet and the straight line connecting the posterior mitral annulus and the coaptation of the mitral valve "e" were measured in the parasternal long-axis view. The locations of the anterior and posterior mitral annuli were determined to be the hing point of the anterior leaflet on the left ventricular side and the junction of the posterior leaflet on the ventricular side, respectively. Mitral regurgitation (MR) was evaluated by CDE in the parasternal long-axis view. The ratio of the duration of regurgitation to ejection time (DT/ET) was measured by M-mode CDE in the subjects with and without MVP. The values of "c" ranged from +10 mm to -3 mm, and those of "d" from +5 mm to -4 mm (minus denotes prolapse into the left atrium). Approximately normal distributions were demonstrated with the parameters "c" and "d". The value of "e" could not be measured because of a poor image of the posterior leaflet. The incidence of MVP varied from 2.5 to 13.5% depending on the criterion for applied MVP. Fifty-nine of the 487 healthy subjects turned out to have MR (12%). Coaptation of the mitral valve deviated from the posterior commissure significantly to the left atrium more in the subjects with MR than in those without MR (2.46 +/- 1.93 vs 3.41 +/- 1.84, p < 0.01). The DT/ET ratio of the MR subjects with MVP tended to be higher than that of the boys without MVP. The presence of continuity between the normal and prolapsed mitral valves suggests that MVP may be a multifactorial disorder of the valve. Associated asymptomatic MR may be related not only to the severity of MVP but also to other factors, especially in MR of normal healthy subjects.     

Transesophageal echocardiography as predictor of mitral valve repair

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair has recently emerged as the treatment of choice in patients presenting with insufficiency due to valve prolapse. The study aims were to evaluate: (i) the clinical presentation in a consecutive series of patients with mitral valve prolapse undergoing surgical repair; (ii) the correlation between pre- and intraoperative echocardiographic features and surgical findings in these patients; and (iii) whether clinical and echocardiographic data may predict surgical outcome. METHODS: Between March 1997 and May 2000, 152 patients (110 men, 42 women; mean age 59+/-13 years) were recruited into the study. All patients had myxomatous mitral valve disease causing severe regurgitation and underwent systematic examination by transesophageal echocardiography (TEE) for clear delineation of the three scallops of the posterior leaflet and juxtaposed segments of the anterior leaflet. RESULTS: In 119 patients (78%) a flail valve was documented by TEE and confirmed on surgical inspection; an anterior leaflet chordal rupture was not visualized by TEE in one case. In 15 cases (10%) there was flail of the anterior leaflet, and in 105 cases (69%) flail of the posterior leaflet. A bileaflet complex prolapse without chordal rupture was found in 32 cases. On the basis of TEE evaluation, mitral valve replacement was performed electively in 10 patients (7%); the other 142 (93%) underwent mitral valve repair. Adequate repair was obtained in 93% of cases; residual mitral regurgitation (eight cases; grade 3+) and mitral stenosis (one case) were documented by intraoperative TEE, and nine patients (6%) underwent valve replacement. CONCLUSION: The majority of patients with myxomatous mitral valve prolapse and severe regurgitation undergoing valve repair have chordal rupture of the posterior mitral leaflet, a condition in which results of valve repair are excellent. TEE provides a powerful means to define the mechanisms of mitral regurgitation and to identify the suitability of patients for valvuloplasty.     

Chordal transfer in rheumatic mitral regurgitation: early experience

Chordal transfer and chordal replacement techniques have been quite successful for repair of anterior mitral leaflet prolapse in degenerative disease, but largely unexplored in rheumatic patients. To extend the scope of valve repair, we assessed the chordal transfer technique for correction of anterior mitral leaflet prolapse in 57 patients with rheumatic mitral regurgitation, who were treated between October 2008 and March 2010. There were 36 women and 21 men with a mean age of 25 ± 7.4 years. Normal chordae and a strip of leaflet tissue were transferred from the posterior leaflet to the free edge of the anterior leaflet; the posterior leaflet was repaired in the same manner as after quadrangular resection. Additional procedures were commissurotomy in 19 patients, aortic valve replacement in 1, tricuspid repair in 5, and cryo maze operations in 21. There was no hospital mortality. One (1.7%) patient had acute renal failure but recovered fully. There was moderate regurgitation in one patient who had undergone simultaneous aortic valve replacement. At a mean follow-up of 6.2 ± 2 months, 56/57 (98.2%) patients were asymptomatic with no significant mitral regurgitation.     

Troublesome factors in mitral valve repair for mitral valve regurgitation

Limitations in the long-term results of medical treatment for mitral regurgitation are well recognized, but the advances in its surgical repair have produced good results. Therefore, early surgical intervention has been the focus of treatment in Europe and America. Increased surgical intervention depends on the development of technical skills in mitral reconstruction. This study investigated presurgical factors making surgical reconstruction difficult in 103 patients who underwent mitral operations performed from April 1994 to September 1997 in our hospital. Records were reviewed retrospectively for etiology, type of operation, and the immediate result of operation. The etiology of mitral regurgitation was prolapse in 65 patients (63%), restriction in 14, normal in 11, infectious endocarditis in 10, and others in 3. The type of prolapse involved the anterior leaflet in 22 patients (34%), posterior in 28 (43%), and both leaflets in 15 (23%). Valve repair was attempted in 74 patients, of which 16 were switched to valve replacement during operation. These included anterior leaflet prolapse in 9 patients, posterior leaflet in 1, both leaflets in 3, restriction in 2 and infectious endocarditis in 1. The success rate for reconstruction of anterior leaflet prolapse was not high. The cause of mitral regurgitation was mostly prolapse of the mitral valve, in our country as well as in Europe and America. Prolapsed posterior leaflet is much more common in Europe and America, and there is a high success rate reported for its valve reconstruction. In contrast, this study cannot recommend earlier surgical intervention because of difficult repair for anterior leaflet prolapse.     

Clinical,echocardiographic, and biomechanical differences in mitral valve prolapse affecting one or both leaflets

Mitral valve prolapse (MVP) is the most common cause of severe mitral regurgitation necessitating surgical correction. Unileaflet prolapse (ULP), usually involving the posterior leaflet, is more common than bileaflet prolapse (BLP), which is more difficult to repair. Little is known about clinical, echocardiographic, and biomechanical differences between ULP and BLP. In this study, biomechanical testing was performed on mitral valve leaflets and chordae obtained at operation for severe mitral regurgitation. Preoperative clinical characteristics and echocardiographic measurements were obtained on surgical patients (ULP = 88, BLP = 37). Men outnumbered women by a factor of 4:1 in ULP, and by 3:1 in BLP. Patients with BLP were younger (53.2 ± 1.7 vs 59.5 ± 1.1 years) than those with ULP, and this difference was greater in women (48.9 ± 2.5 vs 62.9 ± 2.2 years). BLP patients were less likely to be hypertensive, and more likely to undergo valve replacement rather than repair. Echocardiography showed that BLP leaflets were longer and thicker than ULP leaflets. The severity of mitral regurgitation was similar in both groups, although ULP patients had a much higher incidence of flail leaflets (45% vs 5% in BLP). Mechanical strength of chordae was greater in BLP than in ULP, although leaflet strength was similar. The increased chordal strength in BLP may be responsible for less flail. In patients with MVP and severe mitral regurgitation requiring surgery, ULP and BLP are distinct entities with substantial differences in the population affected, in echocardiographic manifestations including prevalence of flail, in chordal mechanics, and in the likelihood of surgical repair.     

The relationship between echocardiographic features of mitral valve and elastic properties of aortic wall and Beighton hypermobility score in patients with mitral valve prolapse

The present study was designed to investigate the incidence of benign joint hypermobility syndrome (BJHMS) in mitral valve prolapse (MVP) and the correlation between the echocardiographic features of the mitral valve and elastic properties of the aortic wall and Beighton hypermobility score (BHS) in patients with MVP and BJHMS. Fourty-six patients with nonrheumatic, uncomplicated, and isolated mitral anterior leaflet prolapse (7 men and 39 women, mean age; 26.1 +/- 5.9) and 25 healthy subjects (3 men and 22 women, mean age, 25.4 +/- 4.3) were studied. Patients were divided into two groups according to their BHS (group I, MVP+BJHMS; group II, MVP-BJHMS). Individuals with accompanying cardiac or systemic disease were excluded. Echocardiographic examination was performed in all subjects. The presence of BJHMS was evaluated according to Beighton's criteria. The incidence of BJHMS in patients with MVP was found to be significantly higher than that of controls (45.6%, (21/46) vs 12% (3/25), P < 0.0001). Group I (MVP + BJHMS) had significantly increased anterior mitral leaflet thickness (AMLT, 3.4 +/- 0.4 vs 3.1 +/- 0.3; P < 0.005), maximal leaflet displacement (MLD, 2.4 +/- 0.4 vs 1.7 +/- 0.4; P < 0.005), and degree of mitral regurgitation (DMR, 17.1 +/- 7.2 vs 11.2 +/- 4.4; P < 0.01) compared to group II. However, the index of aortic stiffness (IAOS) was found to be lower (17.6 +/- 6.9 vs 23.9 +/- 7.6; P < 0.005) and aortic distensibility (AOD) to be higher (0.0035 +/- 0.007 vs 0.0024 +/- 0.005; P < 0.005) in group I. There was a significant correlation between AMLT, MLD and DMR, and BHS (r = 0.57/P = 0.007, r = 0.55/P < 0.009, r = 0.51/P < 0.01, respectively). In addition, AOD correlated positively with BHS (r = 0.53/P < 0.005), but the index of aortic stiffness correlated inversely with BHS (r = -0.49/P < 0.007). The incidence of BJHMS in patients with MVP was more frequent than the normal population and there was a significant correlation between the severity of BJHMS (according to BHS) and echocardiographic features of the mitral leaflets and elastic properties of the aortic wall.     

Mitral regurgitation following mitral balloon valvotomy. Differing mechanisms for severe versus mild-to-moderate lesions

BACKGROUND. This study was designed to evaluate the incidence and mechanisms of mitral regurgitation following mitral balloon valvotomy (MBV) in 40 consecutive patients with symptomatic tight pliable mitral stenosis. METHODS AND RESULTS. Transthoracic echocardiography with color flow mapping was performed before and 24 hours after the procedure. Patients who developed significant mitral regurgitation following MBV also underwent transesophageal echocardiography. The relation between increased mitral regurgitation and both valvular morphology and procedure-related factors was examined. Gorlin mitral valve area increased from 0.81 +/- 0.3 to 1.95 +/- 0.7 cm2 (p less than 0.001). No patient had more than 2+ mitral regurgitation by angiography and color Doppler prior to MBV. There was a moderate correlation between Doppler and angiographic increase in mitral regurgitation (r = 0.73, p less than 0.0001). By Doppler criteria 33 patients had no (n = 6) or mild (n = 27) increase in mitral regurgitation (group 1), and seven developed significant new mitral regurgitation (group 2). Baseline clinical, echocardiographic, and procedure-related data for the two groups were similar. Multiple regression analysis did not select any individual valve characteristic (valvular thickening, mobility, calcification, and subvalvular disease), total echocardiographic score, balloon diameter, or ratio of balloon to mitral annular diameter as disruption with a torn anterior or posterior mitral leaflet in six and a ruptured papillary muscle in one. Two of these patients have required mitral valve replacement (6 and 9 months following the procedure), whereas the remainder are significantly symptomatic. By contrast, mitral regurgitation in group 1 either occurred at the site of commissural split (n = 20) or was associated with prolapse of the anterior mitral leaflet (n = 6). CONCLUSIONS. Thus, severe new mitral regurgitation following MBV is due to noncommissural tearing of the mitral leaflet and confers an adverse long-term prognosis. A mild increase in mitral regurgitation following MBV is frequent and occurs at the site of commissural split or is associated with prolapse of the anterior leaflet. Furthermore, in this study, an increase in mitral regurgitation could not be predicted from any valvular or procedure-related factor.     

Replacement of chordae tendineae with polytetrafluoroethylene (PTFE) sutures in mitral valve repair: early and long-term results

BACKGROUND AND AIM OF THE STUDY: A variety of reliable techniques are now available for chordal disease management and repair of the anterior mitral valve leaflet prolapse. The study aim was to review the authors' experience with polytetrafluoroethylene (PTFE), using a standardized technique for length adjustment, and to analyze the long-term results in patients who underwent mitral valve repair. METHODS: A total of 111 patients (mean age 56.2 +/- 16.1 years) underwent mitral valve repair with PTFE neochordae, in addition to a variety of other surgical procedures. Etiologies were degenerative in 82 patients (73.9%), Barlow disease in 13 (11.7%), rheumatic in 10 (9%), and infection in six (5.4%). Prolapse of the anterior leaflet was present in 78 patients (70.3%), of the posterior leaflet in 15 (13.5%), a bileaflet prolapse was present in 12 (10.8%), and a commissural prolapse in six (5.4%). In all cases the anterior annulus was used as the reference level in order to assess the appropriate length of the PTFE neochordae. RESULTS: The mean number of PTFE neochordae used was 6 +/- 4 per patient. In-hospital mortality was 1.8% (n = 2); mean follow up was 36.8 +/- 25.6 months (range: 12-94 months). There were no late deaths. At five years postoperatively the patient overall survival was 98.2 +/- 1.8%, freedom from reoperation rate 100%, and freedom from grade 1+ mitral regurgitation rate 97.2 +/- 2.8%. There were no documented thromboembolism or hemorrhagic events. CONCLUSION: In degenerative and myxomatous mitral valve disease, leaflet prolapse can be successfully repaired by implantation of PTFE neochordae. Both immediate and long-term results proved the versatility, efficiency and durability of this technique.     

The relationship between clinical and echocardiographic findings in mitral valve prolapse

Incorporating prognostically related auscultatory, M-mode, 2DE and recent Doppler echocardiographic features, the following strict criteria for establishing the diagnosis of mitral valve prolapse (MVP) have been advanced: 1. auscultatory; mid-to-late systolic clicks and a late systolic murmur at the apex or mid-to-late systolic clicks at the apex which move appropriately with maneuvers that alter LV volume or late systolic murmur at the apex in young patients (coinciding that a similar murmur in elderly population is non-specific for MVP); 2. two-dimensionally "targeted" M-mode criterion: marked (greater than 3 mm) late systolic buckling posterior to C-D line (moderate 2 mm late systolic buckling or 3 mm holosystolic displacement "arouse suspicion" but do not establish MVP); 3. two-dimensional echocardiographic criteria: severe bowing of leaflet(s) on the parasternal long axis and four-chamber view (mild to moderate bowing alone are unacceptable) or left atrial coaptation point; 4. Doppler echocardiographic criteria: moderate or severe Doppler mitral regurgitation with any degree of leaflet bowing or mild Doppler mitral regurgitation with at least moderate bowing of one leaflet (mild leaflet bowing and mild mitral regurgitation can be regarded as "probable MVP"). The concept of mitral valve prolapse syndrome encompasses that which was earlier described in patients with a high prevalence of symptoms. In controlled studies, however, it has become apparent that cardiac and psychiatric symptoms can be found as frequently in normal subjects as in those with MVP. These results indicate that clinicians may have erroneously diagnosed patients with MVP because of premature acceptance that MVP is the cause of a distinctive syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Relation of mitral valve prolapse to basal left ventricular hypertrophy as determined by cardiac magnetic resonance imaging

We aimed to characterize the extent and distribution of focal basal left ventricular (LV) hypertrophy in patients with mitral valve prolapse (MVP). Sixty-three patients (mean age: 58 ± 14 years) with MVP and 20 age-matched normal volunteers (mean age: 53 ± 11 years) were assessed using cardiac magnetic resonance imaging. We compared the ratio of basal to mid end-diastolic wall thickness in both groups and correlated it with clinical and imaging parameters. Of the 63 patients, 44 (70%) had posterior leaflet prolapse, 2 (3%) had anterior leaflet prolapse, and 17 (27%) had bileaflet prolapse. There was a significantly increased ratio of basal to mid-ventricular end-diastolic wall thickness in all segments of the left ventricle in those with MVP compared to the controls. The inferolateral (2.1 vs 1.0, p <0.01) and anterolateral (2.1 vs 1.1) ratios (p <0.01) were the greatest compared to the other myocardial segments. The degree of mitral annular excursion had a strong positive correlation with the degree of hypertrophy (r(2) = 0.81, p <0.01) and was an independent predictor in adjusted multivariate analysis (p <0.0001). Age, body mass index, LV end-diastolic volume index, LV end -systolic volume index, LV stroke volume index, degree of prolapse, and mitral regurgitation volume did not have any significant correlation with the degree of hypertrophy. In conclusion, MVP is associated with concentric basal LV hypertrophy and good correlation between the excursion of the mitral valve annulus and the degree of relative LV hypertrophy suggests that locally increased myocardial function could be responsible for this remodeling.     

Treatment of anterior mitral valve prolapse by partial transposition of the posterior leaflet. Apropos of 7 cases

Seven patients aged 8 to 62 years with massive mitral regurgitation due to anterior leaflet prolapse related to rupture or elongation of the chordae tendinae underwent reconstructive mitral valvuloplasty between June 1984 and September 1985, consisting in transposition of a bandlet of the posterior leaflet and its chordae to the free edge of the anterior leaflet. Medium term results with 2 to 16 months follow-up (average 8 months) showed all patients to have returned to Class I of the NYHA Classification; 5 patients had no systolic murmur, a mild systolic murmur 1 and 2/6 was present in 2 cases. The quality of the repair was confirmed by pulsed Doppler examination in all patients and by catheterisation and angiography in 3 cases. This surgical technique offers a good solution to the problem of mitral regurgitation due to severe prolapse of the anterior leaflet caused by rupture or elongation of the chordae tendinae.     

Site-related difference in the prevalence of mitral valve prolapse. Relation to the prevalence and severity of mitral regurgitation.

In this study, 431 consecutive patients with mitral valve prolapse (MVP) diagnosed by two-dimensional echocardiography were employed to further investigate the site-related difference in the prevalence of MVP. Following echocardiographic determination of the site and severity of MVP, a pulsed-Doppler technique was further performed to assess the existence and severity of mitral regurgitation (MR) in all patients. These patients were then classified by age in 10-year groups with patients older than 60 years being enrolled in one group. The younger groups accounted for a large number of the patients with MVP in our study, with the number of patients being reduced with age. In addition, female patients tended to predominate up until the 50s, but not in the 50 and older groups. The prevalence of MVP at the centro-medial site of the anterior mitral leaflet (AML) predominated in all age groups, gradually decreasing with age, except for a peak in the 40s, before continuing to decline in the 50 and older groups. On the other hand, the prevalence of MVP at the lateral site of the AML and at the posterior mitral leaflet (PML) increased with age. In the 50 and older age groups, the prevalence of MVP at these sites increased steeply with age. However, the prevalence of MVP at both the lateral site of the AML and PML did not significantly increase with age. The trend shown above was not significantly different for gender. The number of patients with MR increased with age independent of the site of MVP. However, the prevalence and severity of MR associated with MVP at the lateral site of the AML and/or at the PML were significantly greater than at the other sites up until the 50s (p less than 0.05). When patients were older than 50 years, this significant site-related difference in the prevalence of MR was not observed because of the higher prevalence of MR in the older patients in this study. Forty-one patients could be followed for 2 to almost 5 years. Three of the 41 patients were observed to have MVP at the centro-medial site of the AML in the initial examination, but the site of MVP had extended to the lateral side of the AML in the final examination. Two patients with MVP at all 3 sites of the AML demonstrated an increase in the severity of MVP. However, there were no newly documented cases of MR among those patients.(ABSTRACT TRUNCATED AT 400 WORDS)