Repair of Mitral Regurgitation from Myxomatous Degeneration in the Patient with a Severely Calcified Posterior Annulus

Severe posterior annular calcification poses a particular challenge to mitral valve repair. In a series of 252 mitral valve repairs for myxomatous degeneration performed between 1980 and 1993, 14 patients had a severely calcified posterior mitral valve annulus. Ages ranged from 61 to 81 years. Twelve patients were preoperative NYHA Class III or IV, and five patients required concurrent coronary artery bypass procedures. Operative techniques included complete resection of the calcified posterior annulus, resections of portions of the posterior leaflet with leaflet advancement, and placement of an annuloplasty ring. There were no operative deaths and all patients had a postoperative echocardiographic confirmation of relief from mitral regurgitation. During a mean follow-up time of 36 months (6 months to 8 years), there has been one late valve reoperation and only one late death, from thromboembolism in a patient with atrial fibrillation. These data indicate that even in the presence of severe calcification of the posterior mitral annulus, mitral valve repair for myxomatous degeneration can be performed with a low-operative risk and satisfactory long-term results.     

二尖瓣环非平面特性在人工瓣环设计中的应用

根据二尖瓣环非平面特性，作者设计制作了一种软质的人工二尖瓣环。通过对８例病人的临床应用与８例用Ｃａｒｐｅｎｔｉｅｒ硬质人工瓣环、１３例单纯荷包式缝合和（或）环缩者的超声学对照研究显示：缝置软质环者舒张期房室血流的流向，以及二尖瓣前叶保持原有生物、生理特性的活动等方面，均较硬质环为优越。     

从二尖瓣瓣环三维形态的研究探讨合理的瓣环成形术

观察１５个固定心脏标本、１２个非固定心脏标本二尖瓣瓣环三维形态，运用动态三维超声心动图重建了１１名健康成年人的二尖瓣瓣环。发现二尖瓣瓣环为非平面的“马鞍”形，在心动周期中二尖瓣瓣环始终保持着程度不同的“马鞍”形。结果认为用硬质人工二尖瓣瓣环作瓣环成形术后的某些并发症，可能与改变了二尖瓣瓣环的天然三维形态有关。     

Comparison between Circumflex Artery Motion and Mitral Annulus Motion

Objective - To compare mitral annulus motion (MAM) with circumflex artery motion (CXM) and the motion amplitude at an endocardial site (representing MAM) with an epicardial site (representing CXM) at the most basal lateral part of the atrioventricular plane (AVP). Design - MAM and CXM were obtained in 28 patients examined by echocardiography and coronary angiography. The motion amplitude epicardially and endocardially was recorded by echocardiography in 13 patients with normal ejection fraction (EF) ( &#83 0.50) and in 13 patients with decreased EF (< 0.50). Results - CXM was higher than MAM in most patients with normal EF but lower than MAM in most patients with decreased EF. The motion amplitude epicardially was significantly higher ( p < 0.001) than endocardially in patients with normal EF, while there was no significant difference in patients with decreased EF. Conclusion - CXM represents the motion of the epicardial part of the AVP and differs from MAM, which represents the endocardial part of the wall. This must be considered when CXM is used for assessment of left ventricular systolic function.     

The Evolution of Reparative Techniques for the Mitral Valve

Forty-eight adult patients underwent mitral valve repair for nonischemic valvular incompetence between 1963 and 1981. Early in our experience, 21 individuals received wedge leaflet resection or leaflet plication with posteromedial commissural annuloplasty. More recently, midleaflet annuloplasty has been employed in 13 patients and is now our preferred technique. Operative mortality was 6.3%, and all deaths occurred prior to 1973. Eventually valve replacement was necessary in 10 patients; all replacements were done prior to 1977. Technical errors and progression of rheumatic disease each accounted for half of these replacements. Five-year survival by the life table method was 74 ± 9% for the entire group. Survival at 5 years for patients with prolapsing leaflets was significantly better (87 ± 7%) than for those with normal leaflet motion (46 ± 14%). A residual postoperative murmur of mitral insufficiency correlated with the likelihood of subsequent valve replacement. Important technical aspects of valve repair are described, and criteria for optimal patient selection are discussed. The evolution of reparative methods has led to a better understanding and broader application of mitral valve reconstruction.