A New Type of Mitral Valve Operation Using a Novel Stentless Mitral Valve made from Autologous Pericardium for Unrepairable Valve

BACKGROUND AND AIM OF THE STUDY

The study aim was to create a new form of mitral valve surgery with a novel stentless mitral valve (SMV) made from autologous pericardium, for use in patients with an unrepairable valve.

METHODS

A newly designed two-leaflet SMV ('NORMO') was developed, the excellent hydrodynamic function of which had been evaluated previously using a pulsatile simulator (data reported elsewhere). The operation involved constructing the NORMO valve by using autologous pericardium and a flexible ring, before instituting cardiopulmonary bypass and implanting the valve. The new-style operation was performed successfully in seven patients with complicated mitral valve disease who had requested valve repair rather than replacement.

RESULTS

Postoperative echo-Doppler studies of the seven patients, performed at between six and 26 months (mean 18 months) after surgery, revealed mild mitral regurgitation (MR) in two cases and no or only trivial MR in the other five cases.

CONCLUSION

Although its long-term durability is unknown, this new surgery might represent an alternative for mitral valve repair, especially in those patients with a complicated valve pathology where the feasibility of repair is low.

Progression of degenerative mitral stenosis: insights from a cohort of 254 patients

BACKGROUND AND AIM OF THE STUDY

Degenerative mitral stenosis (DMS) is an increasingly common echocardiographic finding, yet the clinical and biological behavior and rate of progression of the condition are unknown.

METHODS

A total of 254 patients was identified from the authors' echocardiographic database with DMS, defined as severe mitral annular calcification with extension into the mitral leaflets resulting in transmitral flow acceleration with a mean diastolic gradient of >2 mmHg in the absence of commissural fusion. Each patient required paired echocardiograms to have been recorded at least three months apart. Clinical, biochemical and pharmacological data were collected from each patient and related to the annualized rate of increase in mean diastolic mitral gradient and stenosis severity on a scale of 0 to 3.

RESULTS

The characteristics of the patients were as follows: mean age 71 +/- 15 years; female gender 73%; and left ventricular ejection fraction 66 +/- 13%. Diabetes was present in 50% of patients, renal insufficiency in 40%, and coronary artery disease in 50%. Over a follow up period of 2.6 +/- 2.2 years, the mean gradient was increased by 0.8 +/- 2.4 mmHg (range: 0-15 mmHg) per year, while the stenosis grade was increased by 0.18 +/- 0.5 (range: 0-3) per year. The rate of progression was faster in patients with lesser degrees of stenosis (p = 0.01) and low serum albumen levels (p = 0.04), and slower in those receiving beta-blockers (p = 0.01). Milder stenosis, diabetes mellitus and lack of beta-blocker use were independent predictors of faster DMS progression.

CONCLUSION

DMS progression is highly variable, but generally slow; its progression is accelerated in the presence of diabetes mellitus, but is retarded by beta-blocker use. DMS may be an active biological process offering potentially modifiable targets for intervention.

The pulmonary capillary wedge pressure accurately reflects both normal and elevated left atrial pressure

BACKGROUND

Pulmonary capillary wedge pressure (PCWP) is routinely used as an indirect measure of the left atrial pressure (LAP), although the accuracy of this estimate, especially under pathological hemodynamic conditions, remains controversial.

OBJECTIVES

The aim of this prospective study was to investigate the reliability of PCWP for the evaluation of LAP under different hemodynamic conditions.

METHODS

Simultaneous left and right heart catheterization data of 117 patients with pure mitral stenosis, obtained before and immediately after percutaneous mitral comissurotomy, were analyzed.

RESULTS

A strong correlation and agreement between PCWP and LAP measurements was demonstrated (correlation coefficient = 0.97, mean bias ± CI, 0.3 ± -3.7 to 4.2 mm Hg). Comparison of measurements performed within a 5-minute interval and those performed simultaneously revealed that simultaneous pressure acquisition yielded better agreement between the 2 methods (bias ± CI, 1.82 ± 1.98 mm Hg). In contrast to previous observations, the discrepancy between the 2 measures did not increase with elevated PCWP. Multiple regression analysis failed to identify hemodynamic confounders of the discrepancy between the 2 pressures. The ability of PCWP to distinguish between normal and elevated LAP (cutoff set at 12 and 15 mm Hg, respectively), as tested by receiver operating characteristics analysis, demonstrated a remarkably high diagnostic accuracy (area under the curve: 0.989 and 0.996, respectively).

CONCLUSIONS

Although the described limits of agreement may not allow the interchangeability of PCWP and LAP, especially at lower pressure ranges, our data support the clinical use of PCWP as a robust and accurate estimate of LAP.

Transapical aortic valve and mitral valve in ring prosthesis implantation - a new advance in transcatheter procedures

Transcatheter valve implantation offers a new treatment modality to those patients whose general condition makes conventional surgery very risky. However, the transcatheter option has only been available for the aortic valve. We describe a case of a successful implantation of two Edwards SAPIEN(®) 26 and 29 mm transapical valves, respectively, in aortic and mitral positions, on a 74-year-old patient with severe aortic and mitral stenosis. The procedure progressed uneventfully. Predischarge echocardiogram showed a peak aortic gradient of 20 mmHg, mild periprosthetic regurgitation, peak and mean mitral gradients of 12 and 4, respectively, and moderate (II/IV) periprosthetic regurgitation. Indications for transapical valve implantation will rapidly increase in the near future. It is essential to individualize the treatment be applied for each patient, in order to optimize the success of the procedure.

Importance of preservation of chordal apparatus in mitral valve replacement

Mitral valve replacement often involves disruption of the chordal apparatus with disturbance of the annulo-papillary continuity. This results in significant downgrading of ventricular function. Analyzes various reports to accurately assess the advantages of chordal preservation. This review briefly briefly reviews the surgical techniques. The advantages of chordal preservation are analyzed, with particular emphasis on the technical difficulties and potential complications involved.

Impact of rheumatic mitral stenosis on aortic elastic properties

BACKGROUND AND AIM OF THE STUDY

Although mitral stenosis has profound effects on the circulation and hemodynamics, few data exist regarding its impact on aortic elastic properties. The study aim was to determine the association between mitral stenosis and aortic elastic properties by using strain and distensibility as a surrogate.

METHODS

Sixty-six patients with echocardiographic documentation of rheumatic mitral stenosis, and 25 age- and gender-matched healthy control subjects were enrolled in the study. Aortic elasticity parameters including strain and distensibility were measured by means of echocardiography.

RESULTS

The mean age of the patient and control groups were 41.8 +/- 12.0 and 38.9 +/- 5.0 years, respectively (p = 0.12). There was a significant impairment in distensibility and strain in the patient group compared to controls (0.276 +/- 0.167 versus 0.491 +/- 0.260 cm2 x dyn(-1), p = 0.001; 6.54 +/- 3.18% versus 9.19 +/- 4.78%, p = 0.015). There was a strong correlation between distensibility and left atrial diameter (p < 0.001; r = -0.39), left atrial volume index (p < 0.001; r = -0.56), mitral valve area (p < 0.001; r = 0.40), and mean transmitral gradient (p = 0.022; r = -0.18). Strain was also associated with left atrial diameter (p = 0.002; r = -0.32), left atrial volume index (p < 0.001; r = -0.41), mitral valve area (p = 0.002; r = 0.31), and mean transmitral gradient (p = 0.035; r = -0.18).

CONCLUSION

Mitral stenosis was shown to be associated with impaired aortic elasticity, but further studies are required to clarify the clinical significance of this finding.

Three-dimensional echocardiographic assessment before and after percutaneous transvenous mitral commissurotomy in patients with rheumatic mitral stenosis

BACKGROUND AND AIM OF THE STUDY

Real-time three-dimensional transthoracic echocardiography (RT3DE) is a relatively recent imaging technique that provides excellent image quality of the mitral valve. It has been suggested that this new echocardiographic modality, which allows a precise cross-section of the mitral orifice at the tips of the leaflets with correct plane orientation, may provide a more accurate assessment of rheumatic mitral stenosis (MS) than two-dimensional echocardiography (2DE), before and after percutaneous transvenous mitral commissurotomy (PTMC).

METHODS

A total of 50 patients with symptomatic mitral stenosis who underwent PTMC was evaluated prospectively. Patients in all age groups, with evidence of severe MS admitted to the authors' institution, in whom PTMC was feasible were included.

RESULTS

A good valve opening was observed in 45 patients (90%). The mitral valve area (MVA) assessed before PTMC with 3DE (3D-MVA) correlated well with that assessed with 2DE (2D-MVA) (0.85 +/- 0.12 cm2 versus 0.86 +/- 0.13 cm2, p < 0.001); the mean difference between methods was small (0.01 +/- 0.11 cm2) and correlation excellent (r = 0.64, p < 0.001). After PTMC, values of 3D-MVA did not differ from, and correlated well with, values of 2D-MVA (1.79 +/- 0.20 cm2 versus 1.74 +/- 0.18 cm2, p = 0.006); the mean difference between methods was small (0.05 +/- 0.02 cm2) and correlation excellent (r = 0.76, p = 0.0001). Before PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.01 +/- 0.11 cm2, lower limit -0.24, upper limit 0.22). After PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.05 +/- 0.13 cm2, lower limit -0.3, upper limit 0.2). Evaluation of the commissural opening after PTMC, using RT3DE, showed that excellent commissural evaluation was possible in all patients. Compared with RT3DE, an underestimation of the degree of commissural fusion using 2DE was observed in 32%, with a weak agreement between methods.

CONCLUSION

RT3DE provided accurate measurements of MVA, similar to 2D planimetry. RT3DE also improved the description of valvular anatomy and provided a unique assessment of the extent of commissural splitting.

Mitral valve resistance correlates more closely with left atrial deformation than with conventional indices of rheumatic mitral stenosis

BACKGROUND AND AIM OF THE STUDY

The relationship between mitral valve (MV) resistance and left atrial (LA) mechanical function is unknown. Hence, the study aim was to investigate the relationship between LA mechanics and MV resistance, compared to conventional indices such as mitral valve area (MVA) and transmitral gradient, in patients with rheumatic mitral stenosis (MS).

METHODS

The study population consisted of 73 patients with MS and 30 age- and gender-matched controls. MV resistance was calculated and LA strain parameters were assessed from the apical four-chamber view by speckle tracking echocardiography (LA reservoir strain, LA pump strain, LA strain rate (SR)) in all subjects.

RESULTS

The MS group has a markedly higher MV resistance (94 +/- 46 versus 67 +/- 22 dynes x s x cm(-5), p = 0.003) and lower LA reservoir strain (24.5 +/- 7.4% versus 36.6 +/- 3.8%, p < 0.001), LA pump strain (12.0 +/- 5.0% versus 17.1 +/- 3.4%, p < 0.001) and SR (1.23 +/- 0.33 versus 1.4 +/- 0.29, p = 0.017) values compared to controls. Moreover, both LA reservoir strain and LA pump strain correlated with MV resistance more closely than did MVA and transmitral gradients. Multiple linear regression analysis revealed only MV resistance to be an independent predictor of LA reservoir strain, while MV resistance, indexed left atrial volume and mean gradient were independent predictors of LA pump strain.

CONCLUSION

It can be concluded that, in patients with MS, mitral valve resistance was more closely related to LA mechanics measurements than were conventional indices of MS.

Mid-term echocardiographic comparison of chordal preservation method of mitral valve replacement in patients with mitral stenosis

BACKGROUND AND AIM OF THE STUDY

The efficacy of chordal-preserved mitral valve replacement (MVR) on left ventricular function was investigated in patients with mitral stenosis.

METHODS

Eighty patients (25 males, 55 females; mean age 64.5 +/- 8.7 years) with pure mitral stenosis who underwent MVR between January 1999 and May 2008 were studied retrospectively. Of these patients, 20 had total chordal-preserved MVR (group I), 36 had posterior leaflet-preserved MVR (group II), and 24 had MVR without chordal preservation (group III). Echocardiographic assessments were performed preoperatively and at four years postoperatively.

RESULTS

Both, preoperatively and intraoperatively, there were no significant differences between the three groups. Mid-term echocardiography showed significant improvements in the left ventricular ejection fraction (LVEF) of the chordal preservation groups (group I, 55 +/- 12% to 60 +/- 7%, p = 0.017; group II, 56 +/-10% to 61 +/- 8%, p = 0.025), whereas the LVEF was significantly decreased after non-chordal-preserved MVR (group III, 56 +/- 7% to 49 +/- 11%, p = 0.036). Furthermore, the non-chordal preservation group demonstrated a significant increase in left ventricular volumes (end-diastolic volume, from 92 +/- 15 ml/m2 to 107 +/- 23 ml/m2, p = 0.005, end-systolic volume, from 43 +/- 7 ml/m2 to 58 +/- 20 ml/m2, p < 0.001) and a spherical change in left ventricular geometry (sphericity index, from 1.6 +/- 0.2 to 1.3 +/- 0.2, p < 0.001).

CONCLUSION

Chordal preservation during MVR resulted in an improved ejection performance and the maintenance of left ventricular volume in mitral stenosis. However, these hemodynamic advantages were similar after total chordal preservation and posterior leaflet preservation.

Value of stress echocardiography in mitral stenosis

Mitral stenosis (MS) is a common disease that causes substantial morbidity. Timely recognition and treatment of the mitral stenotic lesion is very important. Stress echocardiography plays an important role in evaluating asymptomatic patients with significant mitral stenosis and symptomatic patients with only mild disease at rest. In patients with mitral stenosis, stress echocardiography protocols assess for the change in the mean transmitral pressure gradient and a peak pulmonary artery systolic pressure during exercise. In this review, clinical use of stress echocardiography in patients with mitral stenosis is summarized.

Left atrial coagulation activity in patient with mitral stenosis in sinus rhythm

OBJECTIVE

Anticoagulation therapy is strongly recommended in all patients with mitral stenosis (MS) in atrial fibrillation (AF) but this treatment is controversial in patients in sinus rhythm (SR). The objective of the present study was to investigate the coagulation activity in patients with MS in sinus rhythm compared to those in atrial fibrillation.

MATERIAL AND METHOD

The authors studied the levels of biochemical markers of thrombin generation (thrombin-anti-thrombin [TAT] complex,fibrinogen, and factor XIII) and fibrinolysis (D-dimer) in specimens of blood from the atria in 35 consecutive patients with moderate to severe MS (18 in sinus rhythm and 17 in AF) who underwent percutaneous balloon mitral valvotomy.

RESULTS

The levels coagulation factors in left atrium in patients with MS in SR and AF were thrombin-anti-thrombin complex = 77.21 +/- 8.87 mg/L vs. 73.48 +/- 7.78 mg/L, p = 0.755, fibrinogen = 356.57 +/- 41.86 mg/L vs. 271.62 +/- 22.47 mg/L, p = 0.089, factor XIII = 139.88 +/- 8.96 mg/L vs. 123.42 +/- 6.24 mg/L, p = 0.152, and D-dimer = 846.14 +/- 137.84 mg/L vs. 693.88 +/- 164.67 mg/L, p = 0.481. Levels of coagulation activities did not correlate with the left atrial size.

CONCLUSION

This present study demonstrates that coagulation activity is not different whether they are in SR or in AF and suggests that anticoagulation therapy should be considered in these patients.

Comparative study of heart rate responses to laryngoscopic endotracheal intubation and to endotracheal intubation using intubating laryngeal mask airway under general anaesthesia in patients with pure mitral stenosis for closed mitral commissurotomy

The various drugs and methods studied in an attempt to curb the haemodynamic stress response associated with conventional laryngoscopic endotracheal intubation have not been found to be ompletely satisfactory. The rise in heart rate can be detrimental to patients with mitral stenosis. This study was aimed to compare the heart rate responses to endotracheal intubation using conventional laryngoscope and with the help of intubating laryngeal mask airway (ILMA) in patients with isolated mitral stenosis. Thirty-four adult patients of either sex, aged between 18 and 40 years with isolated mitral stenosis to undergo closed mitral commissurotomy were randomly allocated into two groups : Group A (n=17)- To be intubated using laryngoscopy. Group B (n=17)- To be intubated with the help of ILMA. The heart rate was recorded immediately preinduction, just prior to introducing the intubating device and postintubation every minute up to first 5 minutes. On applying statistical tests, it was found that the median heart rate values in group A at 2, 3, 4 and 5 minutes postintubation were significantly higher than in group B (p<0.05). Although use of both laryngosope and ILMA for endotracheal intubation was associated with rise in heart rate, the rise was less with ILMA compared to laryngoscope. Hence, it can be concluded that use of ILMA may be a preferable device for endotracheal intubation laryngoscopy in patients with isolated mitral stenosis.

Is rheumatic mitral valve repair still a feasible alternative?: indications, technique, and results

Rheumatic heart disease is still a major cause of mitral valve dysfunction in developing countries. We present our early results of rheumatic mitral valve repair. From August 2009 through July 2011, 60 patients (24 male and 36 female) with rheumatic disease underwent mitral repair. The mean age was 51.1 ± 13.8 years (range, 16-77 yr). Forty-nine patients were in New York Heart Association functional class III or IV. Repair procedures included chordal and papillary muscle splitting, secondary chordal division, mitral ring annuloplasty (n=58), commissurotomy (n=36), chordal replacement (n=9), posterior leaflet extension (n=4), annular decalcification (n=2), and quadrangular resection (n=2). Secondary procedures included tricuspid ring annuloplasty, left atrial ablation, obliteration of left atrial appendage, aortic valve replacement, and left atrial reduction. The early (30-d) mortality rate was 1.7%. The mean follow-up time was 14.9 ± 5 months (range, 4-26 mo). Follow-up echocardiography revealed trivial or no mitral regurgitation (MR) in 35.5% and mild (1+) MR in 49.1% of patients. Only 1 patient presented with severe (3+) MR. The mean MR grade decreased from 3.2 ± 0.9 to 0.3 ± 0.4 postoperatively (P=0.001). Left ventricular end-diastolic diameter and left atrial diameter significantly decreased postoperatively (P=0.006 and P=0.001, respectively). The mean gradient over the mitral valve decreased significantly from 11 ± 5.9 mmHg to 3.5 ± 1.8 mmHg (P=0.001). Because current techniques of mitral repair can effectively correct valve dysfunction in most patients with rheumatic disease, the number of repair procedures should be increased in developing countries to prevent complications of mechanical valve placement.

Concomitant transapical mitral valvuloplasty and CentriMag assist device placement: in a "no-option" patient

Left ventricular assist devices and percutaneous valve interventions have radically changed the treatment of advanced heart disease and minimized surgical morbidity in patients with end-stage heart failure who would not survive conventional surgery. We describe a successful approach to the simultaneous placement of a percutaneous left ventricular assist device and mitral valvuloplasty in a decompensated patient with end-stage ischemic cardiomyopathy, severe peripheral arterial disease, porcelain aorta, and severe mitral and aortic disease.

Effect of percutaneous mitral balloon valvuloplasty on left atrial appendage function: transesophageal echo study

BACKGROUND

To compare left atrial appendage (LAA) function by Doppler and Doppler tissue imaging (DTI) before and after percutaneous balloon mitral valvuloplasty (PBMV).

MATERIALS AND METHODS

Fifty-nine patients with symptomatic rheumatic mitral stenosis who underwent PBMV were included in this study. LAA function was measured before and after PBMV. To study LAA function, LAA late emptying (LAALE) velocity, LAA late filling (LAALF) velocity, and LAA area change percentage (LAAAC %) were measured. In the DTI study, tissue Doppler velocities of the LAA, including peak early diastolic (E(LAA)), peak late diastolic (A(LAA)), and peak systolic (S(LAA)), were measured.

RESULTS

There was significant increase in LAALE velocity, LAALF velocity, E(LAA), A(LAA), S(LAA) waves measured by Doppler and DTI after PBMV compared with baseline (p < 0.001) but there was no significant change in LAAAC% (p = not significant). Spontaneous echo contrast was present in 10 of the 59 patients before the procedure. It completely disappeared (6 patients) or decreased (4 patients) after PBMV.

CONCLUSIONS

Our results suggest that PBMV improves LAA function and, thereby, may have a favorable influence on future thromboembolic complications.

Undersized annuloplasty for functional mitral regurgitation: is it responsible for clinically relevant mitral stenosis during exercise?

BACKGROUND AND AIM OF THE STUDY

The study aim was to assess if an undersized mitral annuloplasty for functional mitral regurgitation (FMR) in dilated cardiomyopathy can determine a clinically relevant mitral stenosis during exercise.

METHODS

Both, rest and stress echocardiography were performed in 12 patients submitted to an undersized ring annuloplasty for FMR in dilated cardiomyopathy. The mean ring size was 27 +/- 1.3 mm. All patients were in NYHA functional classes I-II, were in stable sinus rhythm, and without significant residual mitral regurgitation (grade < or = 2/4).

RESULTS

At peak exercise (mean 81 +/- 12 W), the main cardiac performance indices were significantly improved, including systolic blood pressure (121 +/- 5.6 versus 169 +/- 14 mmHg, p < 0.001), stroke volume (63 +/- 15 versus 77 +/- 14 ml, p < 0.001), left ventricular ejection fraction (43 +/- 9% versus 47 +/- 9%, p = 0.001), and systolic right ventricular function (pulsed tissue Doppler index peak systolic velocity: 8.6 +/- 1.7 versus 11.1 +/- 3.2 cm/s, p = 0.004). A mild increase in planimetric mitral valve area was observed at peak exercise (2.12 +/- 0.4 versus 2.17 +/- 0.3 cm2, p = 0.05). Although the transmitral mean gradient was increased from 3.2 +/- 1.2 to 6.3 +/- 2.3 mmHg (p < 0.0001), the systolic pulmonary artery pressure did not change significantly (27 +/- 2.8 versus 30.1 +/- 6.4 mmHg, p = 0.3), thus revealing a preserved cardiac adaptation to exercise.

CONCLUSION

In these preliminary data, postoperative clinically relevant mitral stenosis was not observed in patients submitted to mitral repair for FMR. Stress echocardiography represents a valuable tool to assess an appropriate cardiac response to exercise and to detect a significant exercise-induced pulmonary hypertension after undersized annuloplasty ring surgery.

Assessment of right ventricular function for patients with rheumatic mitral stenosis by 64-slice multi-detector row computed tomography: comparison with magnetic resonance imaging

BACKGROUND

Right ventricular (RV) dysfunction ensues due to rheumatic mitral stenosis (RMS). The evaluation of RV function is clinically important for the diagnosis, treatment, and follow-up for patients with different degrees of RMS. The purpose of this study was to determine whether the 64-slice multi-detector row computed tomography (64-slice MDCT) can assess the RV function in RMS with high accuracy and reproducibility when compared to MR imaging (MRI).

METHODS

Right ventricular end-diastolic and end-systolic volumes (RV-EDV and RV-ESV), stroke volume (RV-SV), ejection fraction (RV-EF), cardiac output (RV-CO), and wall mass (RV-Mass) were measured with dedicated cardiac analysis software on 64-slice MDCT and compared with values measured with MRI in 43 consecutive patients with RMS. Agreement between MRI and 64-MDCT results were compared with Bland and Altman analysis and linear regression analysis. Repeated measurements were performed to determine intraobserver and interobserver variability.

RESULTS

No significant differences were revealed in calculated RV function parameters between the two methods. RV-EDV, RV-ESV, RV-SV, RV-EF, RV-CO, and RV-Mass by 64-slice MDCT were similar to those by MRI (P > 0.05). There were good correlations (r = 0.98, 0.97, 0.96, 0.96, 0.95 and 0.77, respectively) and close agreement (bias = -0.2 ml, -1.0 ml, 0.8 ml, 0.5%, 26.1 ml, and 0.5 g, respectively, P > 0.05). The variability in 64-slice MDCT measurements was similar to that in MRI values.

CONCLUSION

ECG-gated 64-slice MDCT could assess the RV function in RMS with high accuracy and reproducibility when compared to MRI.

Hemodynamic assessment of mitral stenosis: mitral valve resistance as an echocardiographic index

BACKGROUND AND AIM OF THE STUDY

Although mitral valve (MV) resistance has been proposed as a new index for the determination of hemodynamic consequence in patients with mitral stenosis (MS), the relationship between this resistance and signs of hemodynamic deterioration, such as the elevation of pulmonary artery pressure and plasma levels of brain natriuretic peptide (BNP), has not yet been investigated.

METHODS

The study population comprised 33 consecutive patients (nine males, 24 females; mean age 39 +/- 6 years) with moderate and severe MS (MV area (MVA) <1.5 cm2). The cause of MS in all patients was rheumatic valvular disease. A comprehensive echocardiographic evaluation was performed, with MVA, mean MV pressure gradient (MVPG), systolic pulmonary artery pressure (sPAP) and mitral valve resistance being calculated for all patients, in addition to plasma BNP levels.

RESULTS

Both, plasma BNP level and sPAP correlated better with MV resistance (r = 0.75, p < 0.001 and r = 0.52, p = 0.002, respectively) than with MVA by pressure half-time method (MVA-PHT) (r = -0.68, p < 0.001 and r = -0.55, p = 0.001, respectively) and mean MVPG (r = 0.62, p < 0.001 and r = 0.69, p < 0.001, respectively). A comparison of MV resistance and conventional stenotic indices showed that MV resistance correlated best with mean MVPG (r = 0.70, p < 0.001), and correlated least with MVA-PHT (r = -0.45, p = 0.009). Patients with sPAP >50 mmHg and plasma BNP level >150 pg/ml had a significantly higher MV resistance than patients with sPAP < 50 mmHg and plasma BNP level <150 pg/ml.

CONCLUSION

MV resistance appeared to be better correlated with elevated sPAP and plasma BNP levels than with conventional stenosis indices.

Inoue balloon mitral valvotomy in a 4-year-old boy: to treat fulminant rheumatic mitral stenosis

Mitral stenosis in children often has a fulminant and rapid course. Percutaneous transvenous mitral commissurotomy is accepted as the treatment of choice for mitral stenosis not only in adults, but also in younger patients who have pliable valves. Balloon mitral valvotomy has yielded good immediate and long-term results. Herein, we report successful Inoue balloon mitral valvotomy in a 4-year-old boy who had severe, symptomatic rheumatic mitral stenosis. To our knowledge, our patient is the youngest to have undergone this procedure. In addition to the case description, we discuss the features of juvenile rheumatic mitral stenosis and several technical aspects of performing the Inoue balloon mitral valvotomy procedure in children.

[The diastolic gradient of pressure and the effective area of section artifical mitral valve in aspect of its dysfunction]

In article seven-year experience of treatment 126 sick mitral heart diseases to which have been implanted domestic monofolding the MIKS and folding MEDING-2 and ROSCARDIKS artificial mitral valve. At a comparative estimation of a haemodynamic efficiency and the analysis of frequency of occurrence of dysfunctions of the specified mechanical artificial valve it is revealed, that till three years the postimlantsperiod implant the MIKS and MEDING-2 possess advantage over ROSCARDIKS on haemodynamic properties, despite priority ROSCARDIKS on a standard size. It is shown, that initially low diastolic pressure gradient on mitral artificial valve and initially big area effective apertures mitral artificial valve have crucial importance in aspect of preventive maintenance of formation valve complications and reduction of number of repeated operations by open heart.

Evaluation of transmitral pressure gradients in the intraoperative echocardiographic diagnosis of mitral stenosis after mitral valve repair

Objective

Acute mitral stenosis (MS) following mitral valve (MV) repair is a rare but severe complication. We hypothesize that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair.

Methods

The medical records of 552 consecutive patients undergoing MV repair at a single institution were reviewed. Post-cardiopulmonary bypass peak and mean transmitral pressure gradients (TMPG), and pressure half time (PHT) were obtained from intraoperative transesophageal echocardiographic (TEE) examinations in each patient.

Results

Nine patients (9/552 = 1.6%) received a reoperation for primary MS, prior to hospital discharge. Interestingly, all of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not: 10.7±4.8 mmHg vs 2.9±1.6 mmHg; p<0.0001 and 22.9±7.9 mmHg vs 7.6±3.7 mmHg; p<0.0001, respectively. However, PHT varied considerably (87±37 ms; range: 20–439 ms) within the entire population, and only weakly predicted the requirement for reoperation (113±56 vs. 87±37 ms, p = 0.034). Receiver operating characteristic curves showed strong discriminating ability for mean gradients (AUC = 0.993) and peak gradients (area under the curve, AUC = 0.996), but poor performance for PHT (AUC = 0.640). A value of ≥7 mmHg for mean, and ≥17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not.

Conclusions

Intraoperative TEE diagnosis of a peak TMPG ≥17 mmHg or mean TMPG ≥7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair.

Interatrial block and P-terminal force: a reflection of mitral stenosis severity on electrocardiography

BACKGROUND AND AIM OF THE STUDY

Interatrial block (IAB), a frequently overlooked conduction delay between the atria, is defined as prolonged P-wave on the electrocardiogram (ECG). Previously, IAB has been shown to be an indicator of dilated and impaired left atrial function, and a predictor of both atrial fibrillation and embolic stroke. The study aim was to test the hypothesis that, on ECG, IAB with P-terminal force can reflect the echocardiographic severity of mitral stenosis (MS).

METHODS

Patients with rheumatic MS who were referred to a single cardiac center for echocardiography between July and October 2009, and who met the study entry criteria (echocardiographically documented rheumatic MS), were invited to participate. Consequently, 116 such patients were studied prospectively, while a group of age- and gender-matched subjects without echocardiographic signs of rheumatic valve involvement served as controls. Transthoracic echocardiography was performed in all subjects.

RESULTS

A positive correlation was observed between IAB (> or = 120 ms) and the mean mitral valve gradient (R = 0.3, p <0.001). A strong negative correlation was also present between the mitral valve area (MVA) and the presence of IAB (R = -0.3, p <0.001). The presence of pulmonary hypertension and a poor NYHA functional class were associated with a high incidence of significant IAB (R = 0.4, p <0.001; R = 0.3, p <0.001, respectively), and there was a strong correlation between IAB and the P-terminal force (p <0.001). Both, the presence of significant IAB and P-terminal force were correlated with a calcific mitral valve (p <0.001). Only the MVA (beta = 0.3; p = 0.008) was a predictor of IAB in multivariate analysis.

CONCLUSION

A severe mitral gradient, a decreased MVA, an increased pulmonary artery pressure, and a poor NYHA class were shown to correlate with IAB duration and P-terminal force. Significant IAB (> or = 120 ms) and P-terminal force might be considered as a novel indicator of echocardiographic severity and associated complications during the follow up of MS. However, these interrelations must be clarified in further studies.

A simplified proximal isovelocity surface area method for mitral valve area calculation in mitral stenosis: not requiring angle correction and calculator

AIM

To simplify proximal isovelocity surface area (PISA) method for mitral valve area (MVA) calculation that does not necessitate the usage of a calculator and angle correction, and to compare values estimated using this novel method with the values obtained by the conventional PISA, planimetry and pressure half-time (PHT) methods.

METHODS

We evaluated patients with a wide range of mitral stenosis (MS) severity. The MVA was measured by the methods of PHT (MVA PHT), planimetry (MVApl), conventional PISA (MVAC-PISA) and the novel method of simple PISA (MVAS-PISA). Application of simple PISA was performed subsequently by division of the peak mitral inflow velocity by four; measurement of the radius by adjusting the aliasing velocity to this value; square of the radius gives the MVAS-PISA.

RESULTS

Twenty patients were enrolled in the study. Peak and mean pressure gradients of patients were 20 ± 6 mmHg and 10 ± 4 mmHg, respectively. The average values of MVApl, MVAPHT, MVAC-PISA, and MVA S-PISA were 1,54 ± 0,41, 1,65 ± 0,40, 1,58 ± 0,42, 1,57 ± 0,44 cm2, respectively. MVAS-PISA had a strong correlation with the MVAC-PISA, MVApl and MVAPHT . Furthermore, there was no significant difference between simple PISA and the other methods. The agreement between planimetry and simple PISA methods for detecting severe mitral stenosis (MVA <1.5 cm2) determined by ROC analysis was very good with a sensitivity and specificity of 100 % and 92%, respectively.

CONCLUSIONS

Simple PISA is a user friendly method which does not take time and gives simple and correct results. If the diagnostic power of the technique is proven by more comprehensive studies, it can supersede the conventional PISA method.

Left atrial appendage function in mitral stenosis: is it determined by cardiac rhythm?

BACKGROUND AND AIM OF THE STUDY

The left atrial appendage (LAA) is a common source of cardiac thrombus formation associated with systemic embolism in patients with mitral stenosis (MS). Low flow velocities in the LAA are important factors in the development of thrombosis. Whilst oral anticoagulant therapy is used routinely in MS with atrial fibrillation (AF), the characteristics of LAA contractile functions and the protective role of oral anticoagulant treatment in patients with MS in sinus rhythm (SR) are unclear. The study aim was to compare LAA contractile functions in patients with MS who were either in SR or had AF.

METHODS

The study population comprised 51 patients with MS, who had undergone both standard transthoracic and transesophageal echocardiography. The patients were allocated to two groups, according to the presence of AF or SR. Ten healthy, gender-matched subjects were included in the study as a control group.

RESULTS

Except for age, the characteristics of the groups were similar. In patients with SR and AF, the LAA contractile functions were significantly lower than in controls. While the LAA contractile functions of the SR group were significantly lower than the AF group (LAA emptying/filling velocity: 26 +/- 7/24 +/- 8 versus 19 +/- 5/17 +/- 5 cm/s; p = 0.002 and p = 0.001, respectively, LAA maximum/minimum area: 5.4 +/- 1.2/3.2 +/- 0.9 versus 6.2 +/- 1.1/3.7 +/- 0.8 cm2, p = 0.02 and p =0.02, respectively), no statistically significant differences were observed between patients in SR with mitral valve area (MVA) <1.5 cm2 and patients in AF. Four SR patients (13%) and six AF patients (27%) had LAA thrombus. A strong correlation was observed between the MVA and LAA peak emptying/filling velocity in patients with MS in SR (r = 0.739, p = 0.0001 and r = 0.728, p = 0.0001, respectively).

CONCLUSION

The study results showed that LAA contractile function is diminished in patients with moderate-severe MS in SR, and to a similar degree as patients in AF. It was concluded that patients with moderate-severe MS in SR have a higher risk for thromboembolic events than MS patients in AF.

Induced hypocapnia is effective in treating pulmonary hypertension following mitral valve replacement

BACKGROUND

Mitral valve stenosis is often associated with increased pulmonary vascular resistance resulting in pulmonary hypertension, which may lead to or exacerbate right heart dysfunction. Hypocapnia is a known pulmonary vasodilator. The purpose of this study was to evaluate whether induced hypocapnia is an effective treatment for pulmonary hypertension following elective mitral valve replacement in adults.

METHODS

In a prospective, crossover controlled trial, 8 adult patients with mitral stenosis were studied in the intensive care unit following elective mitral valve replacement. Hypocapnia was induced by removal of previously added dead space. Normocapnic (baseline), hypocapnic and recovery hemodynamic parameters including cardiac output, pulmonary vascular resistance, pulmonary artery pressure and systemic oxygen delivery and consumption were recorded.

RESULTS

Moderate hypocapnia (an end-tidal carbon dioxide concentration reduced to 28 +/- 5 mmHg) resulted in decreases in pulmonary vascular resistance and mean pulmonary artery pressure of 33% and 25%, respectively. Hypocapnia had no other hemodynamic or respiratory effects. The changes in pulmonary vascular resistance and mean pulmonary artery pressure were reversible.

CONCLUSION

Moderate hypocapnia was effective in decreasing pulmonary vascular tone in adults following mitral valve replacement. The application of this maneuver in the immediate postoperative period may provide a bridge until pulmonary vascular tone begins to normalize following surgery.

Rheumatic mitral valve repair: 22-year clinical results

BACKGROUND AND AIM OF THE STUDY

Rheumatic mitral valve disease presents a surgical and a medical challenge to surgeons in the developing and developed world. Comprehensive reproducible repair techniques of the anatomic units in individual patients are required to restore the normal mitral valve anatomy and function.

METHODS

Between April 1986 and December 2009, a total of 2,211 patients underwent mitral valve repair at the authors' institution. Of these patients, 50 (32 women, 18 men) underwent repair at a median age of 45.6 years. Pure mitral stenosis was identified in four cases (8%), pure mitral regurgitation in 37 (74%), and mixed lesions in nine (18%). Posterior leaflet plication, Paneth posterior suture and autologous pericardial strip annuloplasty, chordal transfer and papillary muscle splitting were used to repair a rheumatically diseased mitral valve with leaflet prolapse, annulus dilatation and elongated or restricted chordae and malformed papillary muscle.

RESULTS

Three deaths (6%) occurred in hospital (< or = 30 days), and 14 late deaths occurred between 60 days and 14 years. The overall survival was 94.1 +/- 3.3%, 87.5 +/- 4.8%, 84.7 +/- 5.4%, 66.9 +/- 7.9% and 50.2 +/- 9.3% at 30 days and one, five, 10 and 15 years, respectively. Successful repair was achieved in 39 cases (78%). Actuarial freedom from severe mitral regurgitation and reoperation at one, five and 10 years was 92.7 +/- 4.1%, 77.3 +/- 7.2% and 53.4 +/- 9.6%, respectively, and was 78% for Paneth posterior suture and autologous pericardial strip annuloplasty at five and 10 years. The linearized rate for reoperation in the age groups < 20 years and > 20 years was 4.5%/pt-yr (range: 2.0-10.2%/pt-yr) and 4.3%/pt-yr (range: 2.5-7.2%/pt-yr), respectively.

CONCLUSION

Mitral valve repair in rheumatic disease is feasible, but the results are suboptimal. Pure mitral incompetence may be reparable and long-lasting, whilst mixed lesions may be reparable but fail subsequently. The predictability of repair and long-term functional results was determined by perioperative echocardiographic evaluation and the application of an appropriate repair technique to treat the complex pathology of the mitral valve apparatus.

A simple non-invasive method to predict the mitral valve geometric orifice area after edge-to-edge repair

BACKGROUND AND AIM OF THE STUDY

The edge-to-edge repair (EtER) technique consists of anchoring the free edge of the diseased leaflet of the mitral valve to the corresponding edge of the opposing leaflet. When the middle sections of the leaflets are sutured, a 'double-orifice' (DO) mitral valve is artificially created. The main consequence of this technique is that mitral valve geometric orifice area (MGOA) is sensibly reduced and a functional mitral stenosis might be created. The study aim was to determine, mathematically, the MGOA by using a simple non-invasive formula following an EtER, and to examine the influence of suture position on the resulting MGOA.

METHODS

The Lemniscate (also called the Lemniscate of Bernoulli), which has a shape similar to the DO EtER, was used to determine the MGOA following an EtER.

RESULTS

The reduction in MGOA following EtER was more dramatic for mitral valves with a small initial MGOA. For example, a centered suture reduced the MGOA by 54.9% for an initial MGOA of 6.41 cm2; this resulted in an increase in mean transmitral valve pressure gradient (TPG) of 340%, from 0.5 to 2.2 mmHg, corresponding to a mild mitral valve stenosis. In contrast, the reduction was up to 73.5% for an initial MGOA of 3.77 cm2; this resulted in an increase in TPG of 1,339%, from 1.3 to 18.7 mmHg, corresponding to a severe mitral valve stenosis.

CONCLUSION

Although the DO EtER technique appears to be effective for correcting mitral regurgitation, the significant reduction in mitral valve area may become problematic for the patient. However, this simple mathematical model may help clinicians to determine the reduction in MGOA following EtER.

Percutaneous transvenous mitral commissurotomy (PTMC) and percutaneous coronary intervention (PCI) successfully applied in one patient in same sitting

Sixty years old male with severe rheumatic mitral stenosis (MS), presented with dyspnoea New York Heart Association (NHYA) class III to IV. Coronary angiogram revealed severe occlusive coronary artery disease in left anterior coronary artery (LAD). Percutaneous Transvenous Mitral Commissurotomy (PTMC) and Percutaneous Coronary Intervention (PCI) of Left Anterior Descurery (LAD) were done in same sitting. Both procedures were successful and ended without complication. After, half an hour while shifting to coronary care unit (CCU) patient developed cardiac tamponade, which was managed successfully. Patient was followed up for three month, he is doing well and recent echocardiogram showed mild mitral stenosis with normal left ventricular function. This case demonstrates the feasibility of the combined appliance on interventional techniques in selected patients as an alternative to cardiac surgery.

Edge-to-edge repairs of P2 prolapsed mitral valves in isolated swine hearts

BACKGROUND AND AIM OF THE STUDY

The study aim was to determine if mitral stenosis occurred after edge-to-edge (E2E) repair of P2 mitral valve prolapse.

METHODS

Six swine hearts were reanimated and videoscopes placed to view the mitral valve from the left atrium and left ventricle. Image analyses provided measures of the valve annulus area, orifice area, and regurgitant area. Hemodynamic data were collected (heart rates, left ventricular (LV) pressures, left atrial pressures, maximal LV dP/dt, and maximal LV -dP/dt) from three groups: (i) native functioning valve (Normal); (ii) mitral valve following excision of strut chordae from the P2 region (Prolapse); and (iii) following E2E repair.

RESULTS

The mitral valve annulus areas were unaffected by the creation of prolapses, or following repairs (Normal 10.50 +/- 4.22 cm2; Prolapse 9.41 +/- 3.70 cm2; E2E 9.66 +/- 3.37 cm2; p < 0.01), with similar decreases in annulus areas throughout the cardiac cycles, measured at 15 +/- 3%. The orifice areas did not change with the creation of prolapses, but decreased following repairs (Normal 4.49 +/- 2.70 cm2; Prolapse 4.13 +/- 2.16 cm2; E2E 1.99 +/- 1.19 cm2; p = 0.12). The regurgitant areas increased following induced prolapse, and returned to near-normal levels upon repair (Normal 0.20 +/- 0.16 cm2; Prolapse 0.73 +/- 0.35 cm2; E2E 0.12 +/- 0.10 cm2; p < 0.01). The max LV dP/dt measures did not decrease significantly, whereas max LV -dP/dt measures were decreased.

CONCLUSION

In this acute assessment of E2E repair of surgically induced mitral valve P2 prolapses, it was observed that a placed A2-P2 (Alfieri) stitch did not change the annulus area, but caused a significant decrease in the orifice area while successfully eliminating regurgitation, but without causing stenosis.

Percutaneous transvenous mitral commissurotomy: with or without heparin? A randomised double blind study

BACKGROUND

Percutaneous transvenous mitral commissurotomy (PTMC) is an alternative approach to open heart surgery in patients with symptomatic mitral stenosis (MS).

AIM

To compare the outcome of performing PTMC with or without heparin administration.

METHODS

In this randomised clinical trial, 480 patients with symptomatic MS were randomly allocated to one of two groups, with or without heparin administration as part of the procedure. Echocardiographic and clinical outcomes of PTMC assessed before the procedure, during hospitalisation, and after the one-month follow-up, were compared between the two groups.

RESULTS

Baseline demographic and clinical characteristics were similar in the 240 patients with heparin administration (the Hep [+] group) and the 240 patients without heparin administration (the Hep [-] group) during the procedure. In the whole study group mitral valve area (MVA) was 0.94 ± 0.03 cm(2) prior to PTMC, and increased to 1.85 ± 0.06 cm(2) after the procedure (p = 0.0001). The mean increase in MVA was 0.85 ± 0.27 cm(2) in the Hep (+) group and 0.88 ± 0.2 cm(2) in the Hep (-) group (NS). During the procedure, or immediately after PTMC, embolic events were recorded in two (0.83%) Hep (+) patients and one (0.42%) Hep (-) patient (NS). The frequency of haematoma at puncture site (three [1.25%] Hep [+] vs two [0.83%] Hep [-]), and the need for urgent surgery (two [0.83%] Hep [+] vs five [2.1%] Hep [-]), were similar in both groups. There were no embolic events after discharge or during the one month follow-up period.

CONCLUSIONS

Our study revealed that in high volume centres and in selected patients without left atrial thrombus, heparin administration during PTMC is not associated with any additional protective effect against embolic events during short-term follow-up.

Pulmonary hypertension and elevated transpulmonary gradient in patients with mitral stenosis

BACKGROUND AND AIM OF THE STUDY

Pulmonary hypertension frequently complicates mitral stenosis, with a subset of these patients exhibiting pressures well in excess of their mitral valve hemodynamics. The prevalence of this condition and its impact on clinical outcome following percutaneous balloon mitral commissurotomy (PBMC) is unknown.

METHODS

The transpulmonary gradient (TPG) was measured in 317 patients undergoing PBMC; patients were subsequently defined as having either an appropriate or excessive TPG (< or =15 mmHg or >15 mmHg, respectively). Twenty-two patients were excluded due to valvuloplasty-related significant mitral regurgitation. The remaining 295 patients (250 females, 45 males; mean age 52 +/- 13 years) were prospectively followed up, with each patient underwent serial echocardiography.

RESULTS

Among the patients, 214 (73%) had pulmonary hypertension (pulmonary artery pressure >25 mmHg) and 55 (19%) also had an elevated TPG. Females were almost fivefold more likely than males to have an elevated TPG (p = 0.003). Patients with an elevated TPG had a worse mean NYHA functional class than those with a normal TPG (3.0 +/- 0.5 versus 2.7 +/- 0.6, p = 0.01), while the mitral valve area (MVA) was slightly smaller in patients with an elevated TPG (1.0 +/- 0.2 versus 1.1 +/- 0.2 cm2, p = 0.003). All patients demonstrated a significant increase in MVA after commissurotomy (final MVA 1.7 +/- 0.6 cm2, p < 0.001 for elevated TPG; 1.8 +/- 0.4 cm2, p < 0.001 for normal TPG), and the NYHA class at six months was improved for all patients (2.8 +/- 0.6 versus 1.6 +/- 0.7, p < 0.001). The improvements in NYHA class, TPG and MVA were sustained at 36 months.

CONCLUSION

Pulmonary hypertension with elevated TPG occurs in patients with mitral stenosis, and is significantly more common in females. Despite worse symptoms and higher right-sided pressures, PBMC is equally successful in patients with a normal TPG, and provides sustained benefit for up to 36 months after the procedure.

Echocardiographic assessment of the effects of mitral valve repair on mitral valve geometry in rheumatic mitral stenosis

BACKGROUND AND AIM OF THE STUDY

While mitral valve replacement is generally considered as the standard surgical treatment for rheumatic mitral stenosis (MS), mitral valve repair may be an alternative therapeutic option. Several techniques have been used to overcome the anatomic difficulties involved in the repair of a rheumatic mitral valve. In the present study, quantitative echocardiography was used to investigate the effects of mitral valve repair and the influence of surgical procedures on mitral valve geometry in patients with rheumatic MS.

METHODS

Mitral valve repair was successfully performed in seven patients with MS, by the same surgeon. Ring annuloplasty and slicing of the anterior mitral leaflet (AML) were performed in all patients. Concomitant surgical techniques included commissurotomy, decalcification, chordal resection, and division of the papillary muscles. The preoperative and postoperative echocardiographic findings in these patients were compared.

RESULTS

The thickness of both the AML and posterior mitral leaflet (PML) (p = 0.01 for both), the opening angles of the AML (p = 0.02) and PML (p = 0.01), and the closing angle of the PML, the extent of calcification in the AML, and the pressure half-time (PHT) (p = 0.03 for all three parameters) were all significantly improved after mitral valve repair.

CONCLUSION

In the present study, the transmitral peak velocity and mean pressure gradient were not significantly changed after mitral valve repair, whereas the PHT showed a marked improvement. Hence, the PHT may represent a suitable marker for evaluating the efficacy of mitral valve repair for MS.