Tachycardia culprit near the mitral annulus

Effect of catheter device closure of atrial septal defect on diastolic mitral annular motion

Over the past few decades, it has become apparent that mitral valve repair is preferable to mitral valve replacement for the majority of patients undergoing surgery for mitral regurgitation (MR). The advantages of mitral valve repair include low rates of thromboembolism, resistance to endocarditis, excellent late durability reported for as long as 25 years, and no need for anticoagulation in the majority of patients.1–5 Because of these advantages of repair over replacement, the threshold for performing mitral valve repair has been lowered to include patients with MR who have early symptoms or even those who are asymptomatic, assuming that the chance of successful repair is ≥90% according to the latest American College of Cardiology/American Heart Association guidelines.6,7 Recently, surgeons have evaluated new techniques to further improve mitral valve repair, and cardiologists and surgeons are increasingly interested in the potential for percutaneous approaches to mitral valve repair.8 Myxomatous MR affects 1% to 2% of the population and therefore is a common pathology for mitral valve surgery, but the complexity of the operation may be difficult, which leads to generally low rates of repair. In a recent review, only 44.3% of patients in the United States who required mitral valve surgery for MR received a mitral valve repair,9 and in the Euro Heart Survey, repair rates were similarly low (46.5%).10 The goals of mitral repair are to maintain leaflet mobility, remodel the annulus, and allow normal coaptation of the anterior and posterior leaflets. Recent advances in techniques and new concepts for mitral repair are important to cardiologists and other clinicians interested in the management of patients with mitral valve disease. Accordingly, an improved understanding of these concepts will aid in the development of innovative techniques to create safe, durable, reliable, and reproducible mitral valve repair techniques, both …

Aorto-mitral annular dynamics

Percutaneous mitral valve therapy became a reality more than 25 years ago with the first description of balloon valvuloplasty for rheumatic mitral stenosis.1 More recently, percutaneous closure of paravalvular leaks after surgical valve implantation has been shown to have a potential, but limited, role.2–4 However, valvular mitral regurgitation (MR) remains largely the purview of surgery. Recently, the potential for less invasively replicating these successful surgical procedures without the need for thoracotomy or cardiopulmonary bypass has generated considerable interest. For the most part, these new approaches are modeled after established surgical strategies. Percutaneous approaches to mitral repair can be broadly divided into procedures that address the various components of the mitral valve. For purposes of discussion, the mitral valve can be considered to have several component parts: leaflets, subvalvular apparatus (chordate tendinae and papillary muscles), annulus, left atrium, and left ventricle.5 All are integral to the normal function of the mitral valve and each is a potential avenue for repair. Although many such avenues may not lead to an effective surgical option, it may be unwise to dismiss the possibility that others will achieve some measure of success. We briefly review the current percutaneous therapies being developed and evaluated for the management of MR. The current status of various percutaneous therapies is presented in Table 1. View this table: Table 1. Current Status of Percutaneous Mitral Valve Repair Procedures ### Leaflet Repair Complex leaflet repair is currently beyond the reach of a percutaneous approach. However, the relatively simple but, in selected patients, effective “double-orifice” surgical repair initially described by Alfieri and coworkers6 can be reproduced. In the surgical procedure, the free edges of the mitral leaflets are sutured together in the mid portion creating 2 separated orifices. Generally, surgical leaflet repair is combined with implantation of an annuloplasty ring. The surgical literature …

The past 5 years have seen the introduction into the preclinical arena of myriad devices for the potential treatment of functional and ischemic mitral regurgitation by a percutaneous approach.1 A number of the device concepts have taken advantage of the relatively easy access to the posterior annulus of the mitral valve provided by the coronary sinus. Although attractive on initial consideration as a delivery route for devices that remodel the posterior mitral annulus, a number of potential shortcomings to this approach may ultimately limit its clinical success. Article p 377 Annular remodeling of the mitral valve for functional mitral regurgitation (FMR) has been demonstrated to have short-term and some intermediate-term efficacy in the clinical surgical setting.2 The pathophysiology of FMR in patients with dilated cardiomyopathy is central regurgitation caused by failure of mitral leaflet coaptation. The causes of this malcoaptation are multifactorial and include annular dilatation and ventricular dilation, which cause apical distraction of the papillary muscles, producing tethering of the mitral leaflets. Although the whole annulus has been demonstrated to dilate in FMR, there is a disproportionate increase in the anterior-posterior or septal-lateral diameter.3,4 The basic premise behind the surgical approach is that through the use of an undersized ring to overcorrect the dilation of the mitral annulus, both the annular dilatation and the tethering of the leaflets from apical papillary muscle displacement can be treated. The tenets for optimal surgical …

Percutaneous treatment of mitral regurgitation: So near, yet so far!

A Mitral Annular Calcification–Related Calcified Amorphous Tumor in End-Stage Renal Disease

Objective To quantitatively assess the geometry configuration of mitral valve and annulus in the ischemic mitral regurgitation(IMR) and non-ischemic mitral regurgitation(NIMR) by real-time threedimensional transesophageal echocardiography (RT-3D-TEE),and provide a basis for surgical cardiac surgery.Methods 98 patients undergone RT-3D-TEE examination were enrolled in this study,and were divided into three groups:IMR group (n =43),NIMR group (n =33),and no mitral regurgitation group (control group,n =22).Full-volume 3D dynamic images of mitral annulus and valve were obtained.The images were off-line analyzed using Qlab 7.0 MVQ workstation,and the geometry indexes:area of leaflets (A3DE),area of anterior leaflet (A3DE Ant),area of posterior leaflet (A3DE Post),perimeter of annulus (C3D),anterolateral to posteromedial diameter of annulus (DAlPm),anterior to posterior diameter of annulus (DAP),annulus height (H),maximal prolapse height (HProl),maximal tenting height (HTent),volume of leaflet prolapse (Vprol),volume of the leaflets tent (Vtent),Aortic orifice to mitral plane angle (θ),angle of anterior leaflet (θAnt),non-planar angle of leaflets (θNPA),angle of posterior leaflet (θPost)and other mitral valve leaflets and annulus,were derived and statistically analyzed.Results Compared with the control group,significant increases of A3DE,A3DE Ant,DAP and θPost,and decreases of θ and θNPA were demonstrated in IMR group,the differences were statistically significant (P ＜ 0.05).Significant increases of A3DE,A3DE Ant,DAP,HProl,Vprol and θNPA,and decreases of θ,θAnt and θPost were explored in NIMR group,the differences were statistically significant (P ＜0.05).Compared with NIMR group,a reduction of A3DE,A3DE Ant,DAP,HProl and θNPA,and increases of θAnt and θPost were found in IMR group and the differences were statistically significant (P ＜0.05).Conclusions Both IMR group and NIMR group could lead to mitral annulus dilatation,leaflets area increase,and mitral annulus geometry change,the overall mitral annulus tends to flatten were more obvious in the NIMR group than those in IMR group.The prolapse is more prominent in NIMR group than those in IMR Group.The difference of mitral annulus geometry between IMR group and NIMR group indicates that the damage of the mitral leaflets and annulus might be more serious in NIMR group. Key words: Echocardiography, transesophageal ; Mitral valve insufficiency ; Mitral valve

Euclidean and Shape-Based Analysis of the Dynamic Mitral Annulus in Children using a Novel Open-Source Framework

A Case of Submitral Aneurysm Presenting with Severe Mitral Regurgitation and Shock in an African Male Patient with Rheumatic Heart Disease

Geometric change of mitral valve leaflets and annulus after reconstructive surgery for ischemic mitral regurgitation: Real-time 3-dimensional echocardiographic study

Mitral valve annulus and circumflex artery: In vivo study of anatomical zones

Septal myectomy is a well-established surgical intervention for patients with hypertrophic obstructive cardiomyopathy (HOCM). However, mitral annulus dynamics in HOCM patients and the procedure's impact on them are not fully understood. This study aimed to evaluate the mitral valve annulus's dynamics and the effect of septal myectomy on its geometry and function using three-dimensional transesophageal echocardiography (3D TEE) in HOCM patients. A single-site, prospective observational study was conducted at a tertiary-level hospital; 26 patients with HOCM who underwent septal myectomy were included. Intraoperative 3D TEE was performed before and after surgery to assess mitral annular dimensions, area, and motion. Clinical outcomes, including New York Heart Association (NYHA) functional class and left ventricular outflow tract (LVOT) gradient, were also evaluated. Preoperative and postoperative transesophageal images were analyzed offline to measure mitral annular dynamics across the cardiac cycle using dedicated software and Doppler-derived pressure gradients. Throughout the four phases of the cardiac cycle (late diastole, early systole, mid-systole, and late systole), there were no significant dynamic changes in mitral annulus dimensions, specifically, the anteroposterior (AP) diameter (p = 0.286), anterolateral-posteromedial (AL-PM) diameter (p = 0.922), sphericity index (p = 0.311), inter-trigonal diameter (p = 0.982), intercommissural diameter (p = 0.999), 3D saddle-shaped annulus area (p = 0.714), 3D saddle-shaped annulus perimeter (p = 0.754), annulus height (p = 0.981), nonplanar angle (p = 0.902), aorto-mitral angle (p = 0.949), and saddling (p = 0.231). Immediately after septal myectomy, despite significant LVOT gradient reduction (88.4±45.6mmHg preoperative vs. 9.3±4.7mmHg postoperative; p<0.001), no significant improvements were detected in mitral annular parameters (p>0.05 for all parameters). 3D TEE offers critical insights into the dynamics of the mitral valve annulus across various phases of the cardiac cycle. In patients with HOCM, the mitral valve annulus exhibits reduced dynamic motion, with a notable loss of normal systolic AP contraction and saddling. Immediate postoperative assessments did not demonstrate significant improvements in mitral annulus dynamics. Therefore, further longitudinal studies are necessary to assess long-term changes in mitral annulus dynamics due to LV remodeling following septal myectomy procedures.

HomeCirculationVol. 107, No. 2Tumor-Like Calcification of the Mitral Annulus Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBTumor-Like Calcification of the Mitral AnnulusDiagnosis With Multislice Computed Tomography G. Morgan-Hughes, BM, BS, L. Zacharkiw, CCSO, C. Roobottom, BM, BS and A.J. Marshall, MD G. Morgan-HughesG. Morgan-Hughes From the South West Cardiothoracic Centre, Plymouth NHS Trust, Derriford, Plymouth, United Kingdom. Search for more papers by this author , L. ZacharkiwL. Zacharkiw From the South West Cardiothoracic Centre, Plymouth NHS Trust, Derriford, Plymouth, United Kingdom. Search for more papers by this author , C. RoobottomC. Roobottom From the South West Cardiothoracic Centre, Plymouth NHS Trust, Derriford, Plymouth, United Kingdom. Search for more papers by this author and A.J. MarshallA.J. Marshall From the South West Cardiothoracic Centre, Plymouth NHS Trust, Derriford, Plymouth, United Kingdom. Search for more papers by this author Originally published21 Jan 2003https://doi.org/10.1161/01.CIR.0000047070.50407.D6Circulation. 2003;107:355–356An 83-year-old woman underwent transthoracic echocardiography (TTE) to assess her left ventricular systolic function. The TTE showed a large, round, echo-dense mass with central echo-lucencies resembling a posterior periannular tumor.There was no associated mitral valvular dysfunction, and left ventricular function was good. Further assessment was performed using electrocardiographic-gated cardiac multislice computed tomography. This demonstrated that the mass seen on TTE was due to gross calcification of the posterior portion of the mitral valve annulus (Figures 1 through 3). Unlike symmetrical mitral annular calcification, asymmetri- cal tumor-like calcification of the mitral annulus is a rare and often unrecognized condition. Download figureDownload PowerPointFigure 1. Multislice computed tomography of the heart. A 3-dimensional image, generated using volume rendering techniques, is seen in axial section at posterior mitral valve annulus level, showing the left atrium and an oblique cross section of the left ventricle in continuity with the aorta. The posterior mitral valve annulus is replaced by a large calcified mass.Download figureDownload PowerPointFigure 2. Calcified skeleton of the mitral valve annulus isolated by manipulation of the 3-dimensional data volume. There is marked asymmetry of the annular calcification (posterior is to the right and anterior to the left of the image).Download figureDownload PowerPointFigure 3. Virtual angioscopy from the left atrium orientated toward the mitral valve (voyager) again, demonstrating the marked asymmetry of the mitral annular calcification.Liquefaction necrosis of mitral annular calcification occurs in 3% of autopsied cases. Surgical findings in such cases reveal a pale caseous material that is culture-negative. It is not malignant, and surgery should be reserved for coexistent mitral valve lesions. The treatment in this case was conservative.The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.The authors are undertaking research into the clinical applications of cardiac computed tomography. The work is supported by a grant from the Royal College of Radiologists.FootnotesCorrespondence to G.J. Morgan-Hughes, SpR Cardiology, Cardiology Department, SWCC, Plymouth NHS Trust, Derriford, Plymouth PL6 8DH, UK. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By (2016) Tumors and Masses ASE's Comprehensive Echocardiography, 10.1016/B978-0-323-26011-4.09955-1, (617-658), . Matsuyama T, Ishibashi-Ueda H, Ikeda Y, Nagatsuka K, Miyashita K, Amaki M, Kanzaki H and Kitakaze M (2012) Critical multi-organ emboli originating from collapsed, vulnerable caseous mitral annular calcification, Pathology International, 10.1111/j.1440-1827.2012.02826.x, 62:7, (496-499), Online publication date: 1-Jul-2012. Goldstein S (2011) Artifacts Masquerading as Intracardiac Masses Dynamic Echocardiography, 10.1016/B978-1-4377-2262-8.00062-1, (275-279), . Watanabe N, Taniguchi M, Maruo T, Murakami M, Tou N, Tanabe Y, Miyaji K, Kusano K, Koide N and Ohe T (2005) Large Calcified Mass on the Mitral Annulus, Journal of Echocardiography, 10.2303/jecho.3.123, 3:3, (123-124), . January 21, 2003Vol 107, Issue 2 Advertisement Article InformationMetrics https://doi.org/10.1161/01.CIR.0000047070.50407.D6PMID: 12538440 Originally publishedJanuary 21, 2003 PDF download Advertisement

The establishment of a method to clarify the three-dimensional interrelations among the mitral annulus, tricuspid annulus, ascending aorta, and main pulmonary artery, which constitute the interface between the human and total artificial heart (TAH), is essential to the design of the TAH. In a previous study based on transverse magnetic resonance (MR) images of a live human heart, reconstructed images of mitral and tricuspid annuli were found to be deformed. The present study of cadaver and beating hearts revealed that the optimal conditions for atrioventricular annular reconstruction of a beating heart with electrocardiogram-gated MR imaging include use of four-chamber imaging, 5 mm slice thickness, and a slice interval ranging from 5 to 7 mm. Under these conditions, the mitral and tricuspid annuli of 3 beating hearts were reconstructed successfully. It was recognized that during the systolic phase the mitral and tricuspid annuli move anteriorly, leftward and downward, and that in late systole the right lateral margin of the tricuspid annulus is close to the sternum.