This was the first national population-based study to evaluate the association between operations, including frequency and type thereof, and the mortality risk of mitralvalvedisease. We determined that patients with mitralvalvedisease had a higher rate of mortality than patients who underwent other operations, namely other CVD, respiratory condition, or urinary system opera- tions. Patients who underwent a heart valve operation had a higher mortality rate among patients with comor- bidity, namely diabetes, emphysema, and CKD. The mortality rate of patients with mitralvalvedisease who underwent the heart valve operations, including closed heart valvotomy, open heart valvuloplasty, replacement of heart valve, was lower than that of patients who did not. Finally, we purposed that patients with mitralvalvedisease who underwent more heart valve operations exhibited a lower rate of mortality, which contrasted Table 1 Basic characteristics of the study participants from 2002 to 2013
Although significant MR is associated with increased short and long term mortality in patients undergoing TAVR, they are comparable to the mortality rates for our study cohort of similar patients undergoing con- comitant aortic and mitralvalve surgery. As such, surgi- cal correction of both valves may not alter the long term outcomes in these high risk patients as compared to TAVR alone. Furthermore, the advent of percutaneous in- terventions for treating mitralvalvedisease may offer ap- propriate patients percutaneous alternatives for the management of residual MR after TAVR . Percutanous edge to edge mitralvalve repair with MitraClip (Abbott Vascular, Menlo Park, CA) has been the most widely used and studied for the treatment of significant MR after TAVR. Rudolph et al. reported a case series of 11 patients receiving both TAVR and MitraClip therapy with success- ful reduction of MR severity to <2+ in 10 patients . Another case series of 12 patients who underwent MitraClip placement after TAVR by Kische et al. reported a 100% procedural success rate with MitraClip with no patients with greater than 1+ MR after MitraClip. All pa- tients in that series also experienced functional improve- ment after MitraClip . A contemporary series of 14 patients undergoing MitraClip after TAVR reported a 92.9% procedural success rate with 21.4% of patients with
Dyspnea can also be caused by pleural effusion or ascites due to right heart failure. Right heart failure in MMVD is a sign of progressive mitralvalvedisease and pulmonary hypertension that can be accompanied by tricuspid valve degeneration. Clinical signs may develop gradually and progress or they may come acutely due to sudden worsening of the disease. The owner may not have noticed the gradual declining of the dog’s physical activity, or acute disease may be caused by a rupture of chordae tendinae, the onset of arrhythmia (usually atrial fibrillation) or some kind of stress that puts the animal over the edge (separation from the owner, new environment, exertion). Hearing the typical murmur over the mitral area can determine the diagnosis of MMVD, and heart failure can be confirmed by thoracic radiography (Fig 3). Echocardiography further documents the individual chamber enlargement, the magnitude of regurgitant flow, the severity of mitral degeneration, valve prolapse, chordal rupture and pulmonary hypertension (Fig 6). Systolic function is difficult to assess in MMVD due to the enhanced sympathetic tone (24).
The present study has some limitations. Because there were few cases with mitral stenosis, we could not determine a cutoff length for detecting mitral stenosis. Therefore, further studies with a larger sample size seem necessary. On the other hand, chest CT for a noncardiac indication is generally performed without electrocardiographic gating, and motion artifact may negatively influence measurement of the exact length of calcification.
Mitralvalve repair is known to be superior to mitralvalve replacement in terms of operative mortality, functional term survival primarily in degenerative et al., 1995). Mitralvalve repair has become the procedure of choice in non rheumatic mitral The appropriateness of mitralvalve repair in rheumatic etiology remains controversial in term of feasibility and durability of repair due to complexity of pathology and chronic and progressive nature of disease. (Yankah et al., 2011) Mechanical prosthesis has attending complications of life-long compliance of patient for oral et al., 1994) Several studies have shown better outcome of repair in rheumatic patients in comparison to valve replacement (Kumar et al., 2006; Kim et ., 1998; Chauvaud et al., 2001; DiBardino et al., 2010). In the present study, we present our experience of mitralvalve repair in rheumatic mitralvalvedisease.
12. Cinar CS, Gurgun C, Nalbantgil S, Can L, Turkoglu C. Relationship between echocardiographic determinants of left atrial spontaneous echo contrast and thrombus formation in patients with rheumatic mitralvalvedisease. Echocardiography1999;16:331-338 13. Leung DY, Davidson PM, Cranney GB, Walsh WF. Thromboembolic risks of left atrial thrombus detected by transesophageal echocardiogram. Am J Cardiol 1997;79:626-629 14. Tabata T, Oki T, Fukuda N, et al. Influence of aging on left atrial 15. Appendage flow velocity patterns in normal subjects. J Am Soc
displacement ≥ 2 mm across the annulus plane in the parasternal long-axis view was mandatory for the diag- nosis of MVP. Patients in whom MR might be explained by mechanisms other than prolapse were excluded: left ventricular (LV) ejection fraction < 35% or end-diastolic LV diameter > 65 mm (functional MR), previous myo- cardial infarction (ischemic MR), rheumatic mitralvalvedisease or endocarditis (organic MR). Patients with flail leaflet, prior mitral annuloplasty or poor echogenicity were also excluded. The final study group was com- posed of 38 patients. All patients provided informed consent. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by local ethics committee
Chronic valvedisease is often recognized during rou- tine clinical examination on the basis of a typical heart murmur heard particular over the mitralvalve area. A direct relationship has been shown between the intensity of heart murmurs and the severity of heart disease, spe- cifically chronic valvedisease [1,2,13,15] and it has been shown that dogs with heart murmurs at are higher risk for a cardiac associated death . In our study the presence and intensity of heart murmurs generally reflected the ISACHC classification and therefore was a good indicator of disease severity (Table 6). However lack of heart murmur did not rule out chronic valvular disease. A recent study also showed a high number af- fected animals with mitralvalvedisease without heart murmurs during clinical examination and this warrants further studies to assess disease development . There was one dog with a 3/6 heart murmur that had no heart disease; a finding probably due to functional heart mur- murs, including changes in blood morphology, increased body temperature, turbulent blood flow related to stress tachycardia. This particular dog had an elevated body temperature, an increase in heart rate (160 bpm) and was subsequently diagnosed with Babesia canis infection. The second dog with a 1/6 heart murmur and no heart disease was subsequently diagnosed with Cushing’s disease, but no clear reason for this murmur was diagnosed.
Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. As the repair techniques for mitralvalvedisease evolved, so has the need for detailed and accurate imaging of the mitralvalve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation. In patients with significant mitralvalvedisease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. However, a comprehensive TEE in a patient with complex mitralvalvedisease requires great experience and skill. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitralvalve surgery. In the following sections, we review some of the crucial 2D and 3D echo images necessary for evaluation of MR based on the Carpentier classification.
reach a statistically significant difference in outcome for survival. The authors accept that as a result of the disparity in patient numbers between the two study groups, there is a suggested clinical difference. Both mitralvalve repair and replacement are good options for the rheumatic valve patient and the choice should be determined by surgical judgement and experience. Whether repairing or replacing a rheumatic mitralvalve at the time of aortic valve replace- ment makes no significant difference to long-term out- come. These results must be interpreted with caution, however, in the modern era with more myxomatous mitralvalve pathology amenable to repair. This study also demonstrates that the use of a mechanical prosthesis in this subgroup of patients results in good long-term sur- vival without the need for reoperation associated with a bioprosthetic valve.
The most common therapy and one of the greatest debates in the field is downsizing an annular MV ring so as to cause cooptation in the MV leaflets. This has worked out in the short term, but many have been concerned about the long-term therapy as the ventricles continue to dilate and the papillary muscles go down and out from the original position, even through a small ring there may be a recurrence of MR. The final therapy is MV replacement which many cardiologists now advocate is a more definitive choice in this group so there would be no recurrence of MR and the MR would be totally obliterated by a prosthetic or bioprosthetic replacement device. Obviously, with this operation the pap- illary muscles and chordal attachment should be preserved as much as possible, both anterior and posterior leaflet to preserve the residual LV function after this operation. There has been an obvious reticence to advocate MV replacement for this device, although many cardiologists believe that the recurrence of the small annuloplasty ring operation has been deleterious. Clearly, MV repair, versus replacement, leads to better survival and fewer complications but with this particu- lar disease the problem is which device to use.
Methods: Sixteen patients with American Society of Anesthesiologists status (ASA) II-III, age ≤ 70 yr, male or female, preoperatively NYHA II-III and EF ≥ 45%, scheduled for mitralvalve replacement (MVR) were studied. Complete intravenous general anesthesia was used for induction and anesthesia maintenance. After anesthesia induction we put the TEE probe into the esophagus. The cardiac index was determined at three periods following MVR: T1 30 minutes later following cessation of bypass, T2 60 minutes after cessation of bypass, T3 90 minutes after cessation of bypass. Statistical analysis was made with the Bland and Altman method. Results: Ninety-six measurements were compared. The cardiac index values at the level of prosthesis mitralvalve (CI MV ) ranged from 1.3 to 5.5 L·min −1 ·m −2 (mean 2.6 ±
The mitral annulus is a nonsymmetric fibrous structure with a three-dimensional (3D) saddle-shaped configuration. This consists of two horns, or peaks, separated by a nadir located in close approximation to the medial and lateral fibrous trigones (triangular-shaped fibrous structures at the inflection of the mitral annulus). The anterior horn of the mitral annulus pro- ceeds in an upward fashion to the root of the aorta, where it is in fibrous continuity with the aortic valve–a key distinguish- ing feature of the anatomic LV. This continuity is known as the “aortomitral continuity” or the “intervalvular fibrosa.” The aortomitral continuity is one of the most readily appreciable components of the fibrous endoskeleton of the heart on im- ages (Fig 1, B and D). Due to its interposition between the mitral and aortic valves, it inherently encroaches upon the LV outflow tract (LVOT). This relationship is critical for consid- eration of anatomic suitability for TMVR (examined in more detail in the section LVOT Obstruction Assessment). In non- diseased state, the posterior horn is located at the junction of the atrial and ventricular myocardium and it is where the posterior mitralvalve leaflet inserts (Fig 1, B and D). The
The characteristics of patients in groups A, R and AR are shown in Table 1. There were no significant differences in baseline characteristics between groups. The patients’ operative data is shown in Table 2. The sizes of the artificial rings (mm) in groups A, R and AR were 31.4 ± 2.0, 30.0 ± 3.3 and 32.0 ± 1.6 (p = 0.24), respectively. There were no significant differences in terms of the conco- mitant procedures performed in the three groups. Regarding the prolapse site of the posterior mitral leaflet, P2 and P3 were the most common sites of prolapse in all groups. In group A, one patient died because of low output syndrome in the perioperative period. In group R, two patients required permanent pacemaker implantations because of bradycardia with atrial fibrillation. Postoperative bleeding occurred in one patient each in groups R and AR. Bleeding in the pa- tient in group AR resulted in post-resuscitation encephalopathy. Mediastinitis and pneumonia did not occur in any of the patients. More than half of the pa- tients underwent surgery without blood transfusion.
of the heart potentially involving all layers (endocardium, pericardium and myocardium). The resulting damage to the heart from rheumatic fever is termed as rheumatic heart disease, a chronic condition characterized by . Acute rheumatic fever is a complication of up to 3 % of sporadic upper respiratory infection caused by group A B hemolytic streptococci. A complication results from acute rheumatic fever is chronic rheumatic carditis. It resuls from tructure. It resuls in fibrous tissue groth in valve leaflets and chordea tendinea with scarring and contractures. Mitralvalve is most frequently involved. Needs
whole valve in a relatively homogeneous way. In idiopathic MVP, necropsy studies show that the morphologic abnormalities can involve 1 or both leaflets, and the mor- phological changes may be heterogeneous within the leaflet itself (28). Fourth, in one recent study (29), prolapse was shown to occur in roughly half of the patients with Marfan syndrome, and in our experience it occurs even less frequently. The mouse model described by Ng et al. (26) differs from human MVP in other ways. The most significant morphologic changes were noted in the homozygous mice. While homozygous and dual heterozygous forms of FBN1 mutations in children have been reported, they appear to be lethal at an early age (30), as was the case in the homozygous mice in the Ng et al. study (26), and thus the homozygous model may be less applicable to the evolution of the human disease. Second, although the histology of the valves in this study is not described in detail, the hypercellularity of the leaflets is striking. An increase in interstitial cells has been noted in surgical specimens and valves from MVP patients; however, hypercellularity is not gener- ally a feature of MVP (31). The difference may lie in the fact that the valves avail- able for study in MVP patients generally