Infective endocarditis (IE) presenting as isolated valvular stenosis is a rare phenomenon; valvular regurgitation is seen much more commonly. The increasing accessibility of echocardiography has placed a premium on this particular component of the modified Duke criteria. However, IE-related valvular stenosis is notably absent from these criteria, and transthoracic echocardiography (TTE) may not provide enough sensitivity to reliably characterize valvular abnormalities. We present a case of rapidly progressive heart failure caused by prosthetic mitralvalvestenosis in the setting of florid IE.
A 17-year-old young man with a univentricular physiology admitted Mingci Cardiovascular Center, Wuxi with complaints of dyspnea and syncope asso- ciated to intermittent atrial fibrillation. No surgery treatment was performed before. He was referred for surgery of the mitralvalvestenosis. The patient’s in- tellectual and somatic development was normal; his body weight and length was 70 kg and 182 cm, respectively. At rest, the breath rate was normal and only dis- crete cyanotic clinical signs were recognizable (pulseoximetry oxygen saturation, SaO 2 90% - 93%). Also after admission, syncope’s became obvious correlated to
Over time, these changes become progressive leading to funnel-shaped ste- notic MV. Rheumatic involvement of subvalvular apparatus might be in the form of fusion, thickening, retraction, shortening, and calcification. As a result, the free interchordal space decreases and the opened “leaflet–chordae tendineae tunnel” available for diastolic flow is reduced . In MS, if it is considered that fibrosis mainly involves the valve and adjacent structures including the APM & PPM, measuring the longitudinal strain of papillary muscles and the underlying myocardium by 2D S and Sr is new quantitative method for the evaluation of mitralvalve apparatus.
more fully and the catheter is pulled back gently to confirm that the inflated distal portion of the balloon is secure across the mitralvalve. As further volume is added to the balloon, the proximal end inflates to lock the valve between the proximal and distal balloon. Inflation to pre calibrated volume then dilates the valve orifice to the corresponding preset size. The sequential filling and positioning of the Inoue balloon is done. It is then allowed to deflate passively before it is withdrawn into the left atrium. The pressure gradient across the mitralvalve is measured after each balloon dilatation, and echocardiography may be used to assess the mitralvalve area 24 , leaflet mobility, and the degree of mitral regurgitation. If the first inflation has not resulted in a satisfactory increase in the mitralvalve area, and the degree of mitral regurgitation has not increased, the balloon is then readvanced across the mitralvalve and inflation repeated with the balloon diameter increased by 1 or 2 mm by delivery of slightly more of the pre calibrated syringe volume in a stepwise dilatation process that is repeated until the desired result is achieved.
The patients were divided into tertiles according to NLR: 0.85, NLR #1.85 (n = 100), 1.86# NLR #2.46 (n = 100), and 2.47# NLR #7.08 (n = 100). Patients with RMS were divided into three groups based on the degree of MS as mild, moderate, and severe RMS. Valve disease severity was defined according to the American Society of Echocardiography and American College of Cardiology/ American Heart Association guidelines for the manage- ment of valvular heart disease. 10 Venous peripheral blood
In a prospective study of 760 patients aged over 30 years who underwent multidetector CT of the chest for noncar- diac indications, 50 (6.6%) were incidentally found to have mitralvalve calcification. These patients were then referred to a cardiologist (MT) to perform echocardiography within a maximum of 2 months to evaluate mitralvalve function and to screen for mitralvalvestenosis or regurgitation. To decrease the effect of confounding variables such as age, a control group of 100 individuals (58 females and 42 males), with no evidence of mitralvalve calcification on multidetector CT, was randomly selected. All controls selected were aged . 60 years, given that all of the cases positive for mitralvalve calcification were within this age group. Patients with a history of valvuloplasty, mitralvalve replacement surgery, or rheumatic heart disease were excluded. The study was approved by the local ethics committee, and written informed consent was obtained from all participants prior to the study.
Between August 1980 and May 2013, 1187 patients underwent PMV at Severance Hospital, Seoul, Korea (Baseline characteris- tics of 1187 patients are described at Supplementary Table 1, only online). Of these patients, we retrospectively analyzed those who had regular follow up visits for more than 10 years (n=742). Clinical status was determined by the New York Heart Assocation classification system. The indications of PMV were as follows: symptomatic moderate/severe MS with favorable valve morphology, asymptomatic moderate/severe MS with pulmonary hypertension and favorable valve morphology, and symptomatic moderate/severe MS with unfavorable valve morphology and unable/refused to undergo surgery. This study was approved by the Institutional Review Board of our in- stitute (IRB No: 2013-2099-001).
We used (International Classification of Diseases-Ninth Revision-Clinical Modification procedure code 35.23) to select patients aged 40 years and older who underwent bioprosthetic MVR during the study period. Patients who underwent redo valve surgery (codes 35.95), those with mitralstenosis (codes 394.0) or infective endocarditis (codes 421, 42.10, 42.11, 42.19, 03642, 09884, 11281, 1154) or had codes for mitralvalve repair or mechanical MVR during the same admission were excluded (figure 1). The outcomes of patients who underwent isolated valve replacement were then studied and compared with those of patients submitted for valve replacement combined with other cardiac surgery.
Objectives: To compare the long term outcomes between minimally invasive mitralvalve repair (MiMVR) and conventional surgery. Current retrospective comparisons between the techniques frequently report echocardiographical (echo) outcomes early after surgery and rarely report them later. Methods: Patients were selected for MiMVR by the surgical multi-disciplinary meeting from June 2008-March 2013. Patients included had at least two transthoracic post-operative echocardiograms. Echocardiographic parameters including left ventricular size and systolic function, degree of mitral regurgitation (MR) and mean mitralvalve gradient were recorded. Clinical outcomes including all-cause mortality, re-operation, recurrence of at least moderate MR and elevated mean mitralvalve gradients > 5 mmHg were recorded and compared using Kaplan-Meier survival analysis. Results: 223 patients were screened, 96 (43%) met the criteria and were included. Thirty-seven patients underwent conventional surgery and 59 underwent MiMVR. Mean clinical follow-up was 6.3 years and echo follow up was 3.2 years. There was a significantly higher recurrence of moderate MR in the conventional group (38% (n = 19) versus 17% (n = 10)). The mean LV end-diastolic diameter was 4.8 cm (con- ventional) versus 5.0 cm (MiMVR). The incidence of elevated PG was 26% (n = 13, conventional) and 23% (n = 14, MiMVR). There was no significant differ- ence in incidence in re-operation (conventional 12% (n = 6), MiMVR 8.3% (n = 5)). Long-term mortality was higher in the conventional group (1.7% vs. 18% p = 0.004) although the logistic Euroscore was significantly higher 6.8% ± 5.4 vs. 3.6% ± 1.6. Conclusions: Minimally invasive mitralvalve surgery is safe and feasible in selected patients with good medium and long-term echocar- How to cite this paper: Jackson, M.,
A number of studies have investigated, the effect of various devices on annular shape and dynamics, with conflicting results [19–23]. More importantly, in terms of clinical outcome, no clear difference between various solutions have been shown [24, 25]. These results ques- tion the rationale behind the use of more physiologic ring implants. However, most of the aforementioned studies had several methodological shortcomings. Most importantly, the patient populations were inhomogen- eous with respect of the etiology of mitral regurgitation, thereby ring selection has not been based on individual preoperative properties of the mitral apparatus in terms of 3D geometry and dynamics. Undoubtedly 3D analysis improves our understanding of the physiologic charac- teristics and pathological alterations of the mitral appar- atus. However, this knowledge will not translate into improvement in terms of surgical results until the ob- tained information is actually used to govern therapy. Little of the data available by modern imaging technol- ogy is really used in clinical decision making. Possibly the failure to demonstrate a superiority of one type of ring over another does not reflect erroneous device design concepts, but rather inadequate device selection in indi- vidual cases. The solution might lie on optimally matching the individual properties of the diseased mitral apparatus in each patient with the best surgical solution .
The proposed work intends to find the leakage of blood in mitralvalve region and it is also termed as Mitral Regurgitation (MR) disease. With the help of the input video the leakage was trailed and it is segmented by using Gaussian Mixture Model (GMM) and this segmented frame has diseased area. After this process, the post processing work is done. Through that the quality of segmented frame is found. Then the major work done in this paper is grading of severity of the disease and it is calculated with the help of Proximal Iso-velocity Surface Area (PISA) method. From these process finally, the framework gives an accurate view of the Mitral Regurgitation disease which comes from the Doppler Echocardiography and these result indicates that the PISA method makes progress with accurate grading.
residual MR would be one of the risk factors for intra- operative conversion to MVR and CHF requiring re- admission rather than MS. In our series, there were two cases requiring additional treatments due to residual MR. One case necessitated conversion to MVR due to unrepairable injuries of the thin leaflet after slicing dur- ing operation. Another case with CHF re-admitted for medical treatment due to postoperative MR around the commissure, in which aggressive removal of severe calci- fication had been performed. Careful handling of the thin leaflet after leaflet slicing would be one of the most important issues to improve surgical outcome. Addition- ally, commissurotomy for calcified commissure was not necessary, because effective MVA was obtained by nat- ural coaptation by native leaflets after careful decalcifica- tion and leaflet slicing. Although the leaflet extension is also one of the effective procedures for rheumatic degenerative lesion, we had not applied for such fragile leaflet after leaflet slicing to avoid unintended injuries . By our surgical strategy, mitral sclerotic lesion would be repairable even if the extent of calcification was severe, but localized.
There is a propensity for premature fibrosis, stiffening, and calcium deposition resulting in significant stenosis and cusp prolapse (due to redundancy of conjoined leaflet ), fibrotic retraction, or dilatation of the Sinotu- bular Junction resulting in Regurgitation in abnormally functioning congenital bicuspid aortic valves as “valvu- lopathy”. In addition, patients with poor lipid profile and those who smoke also act as an elevated rik of devel- oping hemodynamically significant bicuspid aortic valvestenosis . Aortopathy refers to dilated aortic root, usually associated with BAV and may lead to aortic aneurysm, dissection (the most feared complication—4%) and rupture due to accelerated degeneration of the aortic media, indicating that BAV disease is an ongoing pa- thological process and not a discrete developmental event. Certain Gene mutations (NOTCH 1) have been im- plicated in fibrillin—1 deficiency in tissues. MMPs (matrix metalloproteinases) become activated, degrading the structural support of the aorta and medial weakness, resulting aortopathy in BAV. Recently, it is stated that identification of hemodynamics for leaflet fusion patterns enables detection of specific aortic regions susceptible to dysfunction. Variance in WSS (wall shear stress) and flow displacement are important in aortic leaflet mor- phology . In BAV, helical and high velocity outflow patterns are consistent with aortic dilatation hemody- namics and RL fusion causes dilation of mid-ascending aorta, while RN fusion is associated with dilation in aor- tic root  as shown in Figure 11, distal ascending aorta and transverse arch are not dilated in this patient. Atherosclerotic aortic valvestenosis occur more frequently in patients with severe hypercholesterolemia and is observed in children with homozygous type II hyperlipoproteinemia  (total serum cholesterol >800 mg/dl from birth). Immunohistochemical evidence of chlamydia Pneumoniae has been found in early lesions of age related degenerative aortic stenosis .
In 2002, a retrospective case-control study by Ha et.al.  including 275 patients having Rheumatic heart disease (RHD) who underwent mitralvalve surgery (group A with 141 patients with mild to moderate aortic valve disease and group B with 134 without coexisting aortic valve disease). After a mean follow up of 8.2 years in group A and 10.2 years in group B, they observed aortic valve disease progression in 22 patients from group A and 6 patients from group B and only one patient progressed to severe lesion needed aortic valve replacement. In this study they suggested that there is no significant difference in either the survival rate or the event-free survival rate over the follow-up period between the two groups of mild aortic regurgitation and moderate aortic valve disease. Although the progression of aortic valve disease is more common in that group of patients who had initial lesions, progression to severe disease is uncommon. They suggested that mild and moderate aortic valve disease had slow rate of progression and prophylactic double valve replacement is not indicated.
Transesophageal echocardiogram performed after balloon valvotomy showed resumption of left atrial appendage function. This is seen within 24- 72 hours post procedure. This effect is also seen in patients with atrial fibrillation as well as in sinus rhythm. (33) Mitral regurgitation on the other hand which is hemodynamically significant also impairs the function of left atrial appendage. This is due to the dilation of left atrial appendage and left atrium and also due to the elevation of filling pressures. In spite of decrease of left atrial appendage function by mitral regurgitation, it also doesn’t cause thromboembolism due to the prevention of stasis of blood in left atrium.
Unlike single anterior or posterior mitral leaflet repair, it is difficult to decide the area of resection or length of artificial neochordae to achieve sufficient coaptation length because the geometry may be changed after every step of repair. Quadrangular resection may preserve less valve function and leaflet kinematics than triangular re- section or a non-resection technique . Adjustment of the length of the artificial neochordae is sensitive, and inappropriate length can easily cause recurrent MR. Fur- thermore, Gillinov et al. reported that 70% of patients who demonstrated bileaflet prolapse on echocardiog- raphy did not have any significant anterior chordal path- ology . This means that bileaflet prolapse can be repaired only by posterior leaflet repair, and there is a risk of performing unnecessary neochordoplasty by wrong evaluations of the MV lesions. Considering the experiences of failure in MV repair in the present study, we suggest the following sequential approaches, in ac- cordance with the suggestions by Castillo et al.  Re- pair of the posterior leaflet must be performed first by triangular resection or neochordoplasty to avoid aggres- sive leaflet resection. Next, whether anterior leaflet re- pair is needed must be re-evaluated based on the status of the chordae to the anterior leaflet . Thereafter, if neochordoplasty is required to repair the anterior mitral leaflet lesions, re-evaluation can be performed to decide if additional width or height resection of the posterior MV leaflets is required after anterior MV repair. Lastly, fine-tuning of the artificial neochordae is required.
determinant of anterior (B -0.02, 95% CI -0.04 to -0.005, p < 0.01) and posterior (B -0.01, 95% CI -0.04 to -0.005, p < 0.05) leaflets excursion. Preprocedural Wilkins' score and its 4 parameters, commissural calcium, post-PTMC MVA, commissural splitting score, left atrial diameter, left ventricle dimensions, ejection fraction, and degree of mitral regurgitation failed to predict it. We found that the relationship between post-PTMC MVA and leaflet excur- sion was non-linear "S curve" as shown in figure 5. There was a steep increase of both anterior and posterior leaflets excursion with increased MVA till the area reached a value of about 1.5 cm 2 ; after which both linear and S curves
tasis, and nonclassic prolapse was defined as disp- lacement of more than 2 mm, with a maximal leaf- let thickness of less 5 mm. We measured displace- ment of the mitral anterior leaflets in the paraster- nal and apical four chamber view. The anterior mit- ral leaflet thickness was evaluated during mid-dias- tole by measuring the distance from leading edge to the trailing edge of the thickness area of the mid- portion of the leaflet. The displacement of mitral le- aflet were measured with both 2-D and M-mode ec- hocardiography in parasternal long axis view. Co- lor-Doppler echocardiographic examination was used for the detection and semiquantitaton of mit- ral regurgitation. The degree of mitral regurgitation was assesed as the ratio of the maximal regurgi- tant jet area to the area of the left atrium in the pa- rasternal and apical long axis and apical four- chamber views. The degree of regurgitation was considered to be trace, mild, moderate, or severe on the basis of ratios of >0 to 10 , >10 to 20, >20 to 40, > 40 percent , respectively (18). Left ventricular end-diastolic dimension (LVEDD) and thickness of interventricular septum (IVST) and posterior wall (PWT) were measured at onset of the electrocardi- ographic Q wave. Left ventricular end-systolic di- mension (LVESD) was measured at time of smal- lest left ventricular (LV) diameter. LV fractional shortening (LVFS) was defined as (LVEDD- LVESD)X 100/LVEDD. Left ventricular end-diasto- lic volume (LVEDV), end-systolic volume (LVESV) and ejection fraction (LVEF) were determined from apical two or four vievs using the Modified Simpson method. Cardiac output (CO) was measured as the product of stroke volume and heart rate. Systemic vascular resistance (SVR) was calculated as fol- lows: SVR=(mPAO-mPRA/CO)X80, where mPRA is the mean right atrial pressure, considered equel to zero mm Hg in each subjects, and mPAO is me- an aortic pressure , derived by cuff-sphygmomano- meter, as diastolic blood pressure + 1/3 (systolic- diastolic blood pressure). Left ventricular myocardi-