Leaflet Mobility Research Articles

Evaluation of carcinoid heart disease using delayed enhancement imaging

We read with interest the case report by Martos et al. [1] entitled ‘‘Cardiac carcinoid: tricuspid delayed hyperenhancement on cardiac 64-slice multidetector CT and magnetic resonance imaging’’, published in the Irish Journal of Medical Science. Imaging characteristics of this rare disorder can be found in the literature; especially those features obtained using echocardiography and magnetic resonance imaging (MRI). The main morphological characteristics of the disease are thickening and restricted mobility of the tricuspid leaflets and subvalvular apparatus with consequent tricuspid stenosis and insufficiency. Although Martos et al. [2, 3] cite papers where characteristics of tricuspid-delayed enhancement were previously described, after careful reading we did not find any of them in the cited articles. Delayed-MRI enhancement can delineate zones of fibrous tissue 10–30 min after intravenous administration of gadolinium chelate contrast agent [4]. Similar depiction of scar and fibrous tissue can be obtained using computed tomography by delayed scanning after intravenous administration of iodinated contrast material [5]. In the case report Martos et al. describe delayed enhancement of tricuspid annulus in a patient with carcinoid heart disease, but, unfortunately, they did not give their explanation why they observed late enhancement in this region. We believe that in patients with carcinoid heart disease delayed enhancement should be seen only in endocardial region of the right cardiac chambers including tricuspid leaflets. This type of late enhancement would represent distribution of endocardial fibrous deposits that can be seen on pathological specimens. Considering that tricuspid annulus consists mainly of fibrous tissue, we believe that its late enhancement could be physiological, rather than related to carcinoid heart disease. For better understanding of the case report, we would like to add that figures 3B and 4A were mixed, so that figure 3B represents MDCT exam and figure 4A delayed enhancement on MRI examination. Furthermore, references 5 and 6 are the same with incorrectly spelled last name of the first author in the reference 6.

Transapical aortic valve implantation after previous mitral valve surgery

Transcatheter aortic valve implantation is a new method for treatment of very high-risk patients with aortic valve stenosis. Especially in patients who have had previous cardiac surgery, the operative risk can be reduced. Nevertheless, this new procedure has some potential risks in patients with previous mitral valve surgery, owing to the increased risk by direct contact between the 2 valves with inhibition of mechanical mitral leaflet mobility, in view of potential mitral annulus pressure or leaflet damage caused by transcatheter wires. Between April 2008 and April 2010, 217 consecutive patients (mean EuroSCORE: 40% ± 20%; mean Society of Thoracic Surgeons mortality score: 21 ± 17%; mean age: 79 ± 9 years, 67 men, 150 women) underwent transapical aortic valve implantation. In 6 patients a previous mitral operation (1 valve reconstruction, 5 valve replacements) had been performed. In all 6 patients the aortic valve could be implanted by the transapical approach, and the procedure was successful. In 2 patients the heart-lung machine was used electively owing to low ejection fraction (10% and 15%). In 2 patients there was slight paravalvular leakage of the aortic prosthesis. Neither increased mitral valve regurgitation nor mitral leaflet damage was observed. One patient had endocarditis develop 8 months postoperatively and another with severe reduced left ventricular function died early postoperatively. Transcatheter valve implantation can be performed successfully after previous mitral valve surgery. Particular care should be taken to achieve optimal valve positioning and not to damage mitral leaflets during manipulation with guide wires.

Anomalous Mitral Arcade in Twin-Twin Transfusion Syndrome

Echocardiography has documented acquired pulmonary stenosis and cardiomyopathy in recipient fetuses in twin-twin transfusion syndrome. At autopsy, we also have identified anomalous mitral arcade, a rare valve deformity associated with mitral regurgitation. To identify a profile for anomalous mitral arcade, we compared clinicopathological data from 11 sets of autopsied twin-twin transfusion syndrome fetuses, including 4 twin pairs in whom the recipient had anomalous mitral arcade (affected) and 7 pairs in whom both had structurally normal mitral valves (unaffected). Anomalous mitral arcade was characterized by a thick fibrous band at the free margin of the leaflets tethering papillary muscles and absent/short tendinous cords. One affected recipient also had pulmonary stenosis and tricuspid valve dysplasia. In all 11 sets, recipient hearts were larger than paired donor hearts. All 11 recipients had moderate to severe cardiac dysfunction by echocardiography. Echocardiography disclosed left atrial enlargement in all affected recipients but none of the unaffected recipients. Mitral regurgitation was present before demise in all affected recipients evaluated with color Doppler. Progressive decrease in mitral leaflet mobility was noted in those affected recipients with serial echocardiography. Previously unreported in twin-twin transfusion syndrome, anomalous mitral arcade was identified in 4 of 11 recipient fetuses (36%) in this autopsy series. Ultrasound or echocardiographic evidence of left atrial dilation, mitral regurgitation, and decreased leaflet mobility in recipients should raise suspicion for anomalous mitral arcade. Development of anomalous mitral arcade in twin-twin transfusion syndrome recipients suggests that the lesion is an acquired valve deformity in this setting, not a malformation.

Pulmonary valve repair late after right ventricular outflow tract reconstruction in children and adolescents

Here, we report our experience with pulmonary valve (PV) repair using neoleaflet implantation in children and adolescents. Between April 2005 and May 2009, 20 patients underwent late PV repair with neoleaflet implantation for pulmonary regurgitation (PR) after reconstruction of the right ventricular outflow tract at <18 years of age. In patients with sufficient remaining native PV leaflets, the neoleaflet was implanted with a polytetrafluoroethylene membrane or fresh autologous pericardium to coapt with the remaining native PV leaflets. The median age at operation was 13 years (2-18 years). The median follow-up duration was 12 months (2-51 months). There was no early or late death. During follow-up, no significant PR was observed, but significant pulmonary stenosis (PS) developed in two patients who had a combined PS. The indexed right ventricular end diastolic dimension decreased during follow-up. At the latest follow-up, all patients were in New York Heart Association functional class I or II. PV repair with neoleaflet implantation can be performed safely and the outcome is satisfactory in the short-term, but attention must be paid in cases with combined PS. Longer follow-up should be carried out to investigate the changes in leaflet mobility and function, and pulmonary annular growth.

Correção cirúrgica da estenose aórtica supravalvar com modificação da técnica de Sousa

Report of a patient with seven years old and effort intolerance progressing. The child had tachycardia, pansystolic murmur in the aortic focus. Echocardiography showed left ventricle hypertrophy and aortic narrowing at the level of sinotubular junction with sistolic gradient of 190 mmHg. Cardiac catheterization confirmed the diagnostic suggesting left coronary ostium stenosis. The surgery was performed modification the technique, described by Sousa. Immediate post-operative has presented no complications, with gradient of 23 mmHg, and good leaflets mobility.

Polytetrafluoroethylene Bicuspid Pulmonary Valve Implantation: Experience With 126 Patients

This article reports our initial experience in 126 consecutive patients treated with placement of a surgically created polytetrafluoroethylene (PTFE) bicuspid pulmonary valve at The Congenital Heart Institute of Florida (CHIF). A bicuspid pulmonary valve is created with PTFE and sutured into the right ventricular outflow tract. PTFE bicuspid pulmonary valves were placed in 126 patients (age: range, 3.1-64.7 years, mean, 17.9 years; weight: range, 14.2-113.6 kg, mean, 55.4 kg). All patients had pulmonary insufficiency, pulmonary stenosis, or both, most commonly after previous repair of tetralogy of Fallot (71 patients). Follow-up was up to 8.3 years (range, 0-8.3 years, mean, 3.34 years). Operative mortality was 1 patient (0.8%). Late mortality was non-valve-related in 3 patients (2.4%). The initial 84 patents in this series received valves constructed from PTFE with 0.6-mm thickness. The next 42 patients received valves constructed from PTFE with 0.1-mm thickness. Six patients of 126 (4.8%) required replacement of the PTFE bicuspid pulmonary valve because of immobile and calcified leaflets. All 6 who required replacement of the PTFE bicuspid pulmonary valve initially received a valve constructed from porous 0.6-mm PTFE material. We currently use nonporous 0.1-mm PTFE, which does not allow cellular in-growth and thickening. Early echocardiographic follow-up of these valve leaflets made with 0.1-mm PTFE has demonstrated improved leaflet mobility and pliability and lower transvalvar gradients. PTFE bicuspid pulmonary valve implantation is safe and effective and demonstrates acceptable performance for the intermediate term. It is anticipated that using thinner 0.1-mm PTFE will improve valve function and durability. Long-term follow-up is necessary to determine the true value of this technique.

Chordal Replacement Versus Quadrangular Resection for Repair of Isolated Posterior Mitral Leaflet Prolapse

In the past, chordal replacement techniques with expanded polytetrafluoroethylene sutures have been primarily reserved for anterior leaflet pathology, whereas the more frequent posterior leaflet prolapse was treated by resection. This study reports midterm results of isolated posterior prolapse repair with chordal replacement without resection as opposed to the quadrangular resection. An analysis was made of 397 consecutive patients who underwent mitral valve repair for isolated posterior leaflet prolapse between 2000 and 2007. Of them, 205 patients (52%) underwent quadrangular resection (group R, "resection") and 192 patients (48%) underwent a neochordal repair (group NR, "no resection"). The follow-up is 98% complete (mean follow-up of 383 survivors is 1.9+/-1.4 years). Overall 30-day mortality was 1.0% (4 of 397). Ten patients (2.5%) died late. Actuarial survival at 4 years for group R and group NR was 94%+/-3% and 98%+/-1%, respectively (p=0.99). Ten patients (2.5%) required a mitral valve-related reoperation after an average of 1.9+/-2 months. Freedom from reoperation at 4 years was 96%+/-1% for group R and 99%+/-1% for group NR (p=0.08). Generally, in patients of group NR, a larger annuloplasty ring could be implanted (mean size 32+/-2.5 versus 30+/-2, p<0.001). At latest follow-up, 94% of the patients showed no or grade I regurgitation, with no difference between groups. Repair of posterior mitral leaflet prolapse by chordal replacement is equally effective as classic quadrangular resection, permits the use of larger annuloplasty rings, offers a potentially more physiological repair with preserved leaflet mobility, and can be performed with excellent midterm results and a low incidence of reoperation.

The papillary muscle sling for ischemic mitral regurgitation

Our objective was to evaluate long-term stability of mitral repair and reverse remodeling in patients with severe ischemic left ventricular dysfunction and functional mitral regurgitation. Since June 2000, a total of 37 patients with ischemic functional mitral regurgitation have benefited from a double-level mitral repair that comprises an intraventricular peripapillary muscle sling completed by a classic intra-atrial mitral annuloplasty ring (mean age, 56 years; left ventricular end-diastolic diameter, 70 +/- 0 mm; left ventricular end-systolic diameter, 55 +/- 5.6 mm; ejection fraction, 15% to 45%; pulmonary hypertension > 60 in all patients; all were in New York Heart Association class III-IV). All patients had both papillary muscles encircled with a 4-mm polytetrafluoroethylene tube, correcting their lateral and downward displacement. Annuloplasty rings were moderately undersized or normal. Efficiency was evaluated on mitral stability, ventricular parameters, and functional status. According to the Leyden algorithm based on preoperative end-diastolic and end-systolic left ventricular diameters, only a minority of our patients were expected to experience reverse remodeling. Regurgitation is none to trivial in 31 and mild to moderate in 4. Follow-up (3-84 months; mean, 55 +/- 22 months) shows stability of all initially successful double-level mitral repairs. Follow-up beyond 1 year shows improvements in ventricular diameters (56 +/- 5 mm), ejection fraction (49 +/- 6), volume (130 +/- 10 mL), and sphericity index (0.55). Two patients died during follow-up and 1 underwent transplantation. Reapproximating the papillary muscles has an immediate effect on mitral leaflet mobility by suppressing the tethering resulting from displacement of the papillary muscles. It has an effect in preventing recurrent mitral regurgitation by avoiding further papillary muscle displacement. In this cohort of severely disabled patients, reverse remodeling can be expected with the double-level repair.

Evaluation of Anatomic Valve Opening and Leaflet Morphology in Aortic Valve Bioprosthesis by Using Multidetector CT: Comparison with Transthoracic Echocardiography

To prospectively determine whether cardiac-gated multidetector computed tomography (CT) allows visualization of aortic valve leaflets after bioprosthetic aortic valve replacement (AVR), to provide an accurate method for measuring the aortic valve opening, and to provide morphologic and functional information regarding the mechanism underlying poor function of the bioprosthetic valve. The institutional review board approved the study protocol; informed consent was given. Fifty-four patients (27 men; mean age, 75 years + or - 8 [standard deviation]) with bioprosthetic AVR implanted 2 years + or - 3 earlier underwent 64-section CT and transthoracic echocardiography (TTE). Two blinded observers manually planimetered the aortic valve area (AVA) by using a computer workstation on end-systolic short-axis CT images and measured opening angles (OAs) between the bioprosthesis annulus base and the free margin on long-axis images. These measurements were compared with those of the effective orifice area (EOA) of the valve at Doppler continuity-equation TTE by using regression and Bland-Altman methods. Morphology and mobility of leaflets in normally functioning (EOA indexed to body surface area [EOA(i)] > 0.65 cm(2)/m(2)) and dysfunctional (EOA(i)< 0.65 cm(2)/m(2)) AVRs were compared. AVA at CT correlated highly to EOA at TTE (r = 0.93, P < .001) but was significantly larger (1.2 cm(2) + or - 0.4 vs 1.1 cm(2) + or - 0.3, P < .001) than EOA at TTE. In dysfunctional bioprostheses (n = 34), CT results showed a variety of morphologic abnormalities, such as leaflet thickening (n = 9), presumed thrombotic material (n = 6), and leaflet calcification (n = 1). Multidetector CT results demonstrated restriction of leaflet motion indicated by lower OA (64 degrees + or - 5 vs 79 degrees + or - 3, P < .0001) in dysfunctional AVRs than in normally functioning AVRs (n = 11). Sixty-four-section CT can help accurately measure AVA in bioprosthetic AVR compared with EOA at TTE. It can also show morphologic abnormalities and reduced leaflet motion in a dysfunctional bioprosthesis, thereby potentially unraveling the mechanism of dysfunction.

Validation of a New Score for the Assessment of Mitral Stenosis Using Real-Time Three-Dimensional Echocardiography

The aim of this study was to validate a new real-time three-dimensional echocardiography (RT3DE) score for evaluating patients with mitral stenosis (MS). A two-staged study was conducted. In the first stage, the feasibility of a new RT3DE score was assessed in 17 patients with MS. The second stage was planned to validate the RT3DE score in 74 consecutive patients undergoing percutaneous mitral valvuloplasty. The new RT3DE score was constructed by dividing each mitral valve (MV) leaflet into 3 scallops and was composed of 31 points (indicating increasing abnormality), including 6 points for thickness, 6 for mobility, 10 for calcification, and 9 for subvalvular apparatus involvement. The total RT3DE score was calculated and defined as mild (<8), moderate (8-13), or severe (>or=14). MV morphology was assessed using Wilkins's score and compared with the new RT3DE score. In the first stage, the RT3DE score was feasible and easily applied to all patients, with good interobserver and intraobserver agreement. In the second stage, RT3DE improved MV morphologic assessment, particularly for the detection of calcification and commissural splitting. Both scores were correlated for assessment of thickness and calcification (r = 0.63, P < .0001, and r = 0.44, P < .0001, respectively). Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins's score were leaflet calcification and subvalvular apparatus involvement, and those by RT3DE score were leaflet mobility and subvalvular apparatus involvement. The incidence and severity of mitral regurgitation were associated with high-calcification RT3DE score. The new RT3DE score is feasible and highly reproducible for the assessment of MV morphology in patients with MS. It can provide incremental prognostic information in addition to Wilkins's score.

Mitral valve hemodynamics after repair of acute posterior leaflet prolapse: Quadrangular resection versus triangular resection versus neochordoplasty

Leaflet prolapse resulting from acute chordal rupture is one presentation of fibroelastic deficiency that is associated with minimal leaflet changes in the prolapsing segment. Minimizing resection and preserving leaflet tissue may be an optimal surgical strategy. We examined the importance of the leaflet preservation concept by comparing resective and nonresective surgical procedures in practice today. Eight porcine mitral valves were evaluated in an in vitro heart simulator before surgical manipulation. Mitral regurgitation was created in these valves by transecting the posterior marginal chordae resulting in severe P2 prolapse. After confirmation of mitral regurgiation via regurgitant flow measurement (mL/beat), regurgitation was corrected by three repairs: neochordoplasty with polytetrafluoroethylene sutures (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz), triangular resection, and quadrangular resection with annular compression. Postrepair valve hemodynamics were quantified under pulsatile conditions of 120 mm Hg peak transmitral pressure and 5 L/min cardiac output at 70 beats/min. Furthermore, hemodynamic, geometric, and echocardiographic indices were measured. Transecting the marginal chordae resulted in severe P2 prolapse and significant mitral regurgiation (19.3 +/- 4.3 mL/beat). Regurgitant volume was significantly reduced after any of the three surgical approaches (quadrangular, 4.38 +/- 1.6 mL/beat; triangular, 2.56 +/- 1.0 mL/beat; neochordal, 2.86 +/- 1.24 mL/beat). In comparison with the baseline normal valves, leaflet coaptation length and posterior leaflet mobility were significantly reduced in the quadrangular resection group, whereas they were partially restored in the triangular resection and fully preserved in the neochordoplasty group. Although the three repair procedures are hemodynamically comparable, valve function and leaflet kinematics were significantly better after a nonresection or limited resective correction of leaflet prolapse in this experimental model of acute chordal rupture with otherwise normal leaflet geometry.

Mechanisms of Recurrent Functional Mitral Regurgitation After Mitral Valve Repair in Nonischemic Dilated Cardiomyopathy

Recurrent functional mitral regurgitation (MR) has been reported after mitral valve repair with annuloplasty in patients with dilated cardiomyopathy, but the mechanism is not understood completely. The authors sought to identify abnormalities of the mitral valve and left ventricle that are associated with recurrent MR after mitral annuloplasty. In 104 patients with idiopathic dilated cardiomyopathy who underwent annuloplasty for functional MR, basal mitral anterior leaflet angle, distal mitral anterior leaflet angle (ALAtip), posterior leaflet angle, coaptation depth, tenting area, mitral annular dimensions, left ventricular volumes, and MR severity were quantified by echocardiography before surgery and at 6-month intervals after it. Compared with patients without MR recurrence (n=79), patients with recurrent MR (defined as > or =2+) (n=25) had greater ALAtip (P<0.001) and basal mitral anterior leaflet angle (P<0.001), greater coaptation depth and tenting area (P<0.001), larger left ventricular volumes (P<0.001), and worse left ventricular ejection fraction (P<0.05) but similar mitral annular dimensions and postoperative exaggeration in posterior leaflet angle. Multivariable analysis identified postoperative ALAtip as the major determinant of postoperative MR. Receiver operator characteristic curves identified preoperative ALAtip as the best predictor of MR recurrence (area under curve, 0.98). For ALA(tip) >25 degrees, the sensitivity, specificity, and positive and negative predictive values in predicting recurrent MR were 88%, 94%, 82%, and 93%, respectively. Three distinct patterns of anterior leaflet tethering (minimal, basal, and distal) with an increasing risk of recurrent MR were identified. Posterior leaflet tethering is invariable after mitral annuloplasty, rendering postoperative mitral competence highly dependent on distal anterior leaflet mobility.

Valve Repair With Autologous Pericardium for Organic Lesions in Rheumatic Tricuspid Valve Disease

Surgical repair of pathologic tricuspid valve disease often fails because of severe anatomic distortion of the valve apparatus, particularly in patients with rheumatic heart disease. This usually leads to tricuspid valve replacement despite the associated prosthesis-related complications. This study examines our experience of tricuspid valve repair with autologous pericardium for organic rheumatic tricuspid valve disease. From 1996 to 2007, 31 patients underwent repairs for rheumatic tricuspid valve disease characterized by retracted leaflets and inadequate leaflet area. The patients, aged 14 to 56 years, had a mean New York Heart Association (NYHA) class of 2.9 +/- 0.6. All patients presented with severe tricuspid regurgitation and coexisting left-sided heart valve disease. Glutaraldehyde-treated autologous pericardial patch was used to augment tricuspid valve leaflets. Other techniques were applied as needed, including commissurotomy, leaflet mobilization, annuloplasty, and prosthetic ring implantation. Concomitant operations included left-sided valve replacement in all, and left atrial thrombus removal in 3 patients. Follow-up duration was 4 to 126 months. No deaths or late reoperations occurred. All patients demonstrated clinical improvements on follow-up. Echocardiographic studies before hospital discharge showed less than mild tricuspid regurgitation in all patients. The most recent echocardiographic follow-up showed no tricuspid regurgitation in 10 patients (32.3%), trivial regurgitation in 12 (38.7%), mild regurgitation in 8 (25.8%), and moderate regurgitation in 1 (3.2%). In selected patients, organic rheumatic tricuspid valve disease can be treated with pericardial patch to augment the retracted leaflets in combination with other techniques. Follow-up reveals excellent tricuspid valve function.

Severe Valvular Regurgitation and Late Prosthesis Embolization After Percutaneous Aortic Valve Implantation

We report the case of a 79-year-old man with low-flow, low-gradient aortic stenosis who underwent transapical aortic valve implantation. The deployment of a 26-mm Edwards SAPIEN valve (Edwards Lifesciences Inc, Irvine, CA) was complicated with the occurrence of severe central aortic regurgitation that was successfully treated with the implantation of a second valve ("valve-in-valve"). Postoperative progress was satisfactory but 2 days after the procedure he suddenly developed cardiogenic shock secondary to the migration of the aortic bioprothesis into the left ventricular outflow tract. Open-heart surgery was undertaken to remove the valves and perform standard aortic valve replacement, but the patient died perioperatively.

Fluoroscopy of Acutely Thrombosed Aortic Valve

HomeCirculationVol. 118, No. 22Fluoroscopy of Acutely Thrombosed Aortic Valve Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBFluoroscopy of Acutely Thrombosed Aortic Valve A. Ravandi, J.C.J. Sun, A. Lamy and N. Valettas A. RavandiA. Ravandi From the Division of Cardiology (A.R., N.V.) and Division of Cardiac Surgery (J.C.J.S., A.L.), McMaster University, Hamilton, Ontario, Canada. Search for more papers by this author , J.C.J. SunJ.C.J. Sun From the Division of Cardiology (A.R., N.V.) and Division of Cardiac Surgery (J.C.J.S., A.L.), McMaster University, Hamilton, Ontario, Canada. Search for more papers by this author , A. LamyA. Lamy From the Division of Cardiology (A.R., N.V.) and Division of Cardiac Surgery (J.C.J.S., A.L.), McMaster University, Hamilton, Ontario, Canada. Search for more papers by this author and N. ValettasN. Valettas From the Division of Cardiology (A.R., N.V.) and Division of Cardiac Surgery (J.C.J.S., A.L.), McMaster University, Hamilton, Ontario, Canada. Search for more papers by this author Originally published25 Nov 2008https://doi.org/10.1161/CIRCULATIONAHA.108.786228Circulation. 2008;118:e705A 75-year-old woman with a prior history of aortic valve replacement with a St. Jude Medical mechanical bileaflet prosthesis presented to an outside hospital with an intracranial hemorrhage. Her anticoagulation was reversed with Vitamin K therapy and she was transferred to our center for tertiary neurosurgical care. On day 10 of her admission, she developed new left-sided hemiparesis, and a computed tomography head scan confirmed a middle cerebral artery territory infarct. Physical examination revealed a harsh systolic ejection murmur, and a transthoracic echocardiogram performed to rule out a cardiac source for emboli revealed a severely stenotic mechanical aortic valve with a peak gradient of 146 mm Hg and a mean gradient of 88 mm Hg with moderate aortic insufficiency (Figure 1; online-only Data Supplement Movies I through III). The valve was also assessed by fluoroscopy (online-only Data Supplement Movies IV and V), which showed complete fixation of one leaflet and restricted mobility of the other, with an eccentric jet of aortic regurgitation. A filling defect was visualized around the nonmobile leaflet, highly suggestive of thrombus. Intraoperatively, a large thrombus was visualized around the valve (Figure 2). Fluoroscopy continues to be a simple and accurate method for both diagnosis and follow up of St. Jude valve thrombosis.1 In conjunction with 2-dimensional echocardiography, which can provide hemodynamic assessment of the valve, fluoroscopy is useful for assessing leaflet mobility.2Download figureDownload PowerPointFigure 1. Transthoracic 2-dimensional echocardiography showing severe stenosis of the mechanical aortic valve: average peak gradient of 146 mm Hg and mean pressure of 88 mm Hg.Download figureDownload PowerPointFigure 2. Intraoperative photo of the bileaflet mechanical valve as seen through an aortotomy. A large organized thrombus (T) obstructs the majority of the valve orifice. A small portion of the valve housing can still be seen (V).The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/118/22/e705/DC1.DisclosuresNone.FootnotesCorrespondence to Amir Ravandi, MD, PhD, Division of Cardiology, McMaster University, Hamilton General Hospital, 237 Barton St E, Hamilton, ON L8L 2X2, Canada. E-mail [email protected]References1 Silber H, Khan SS, Matloff JM, Chaux A, DeRobertis M, Gray R. The St. Jude valve: thrombolysis as the first line of therapy for cardiac valve thrombosis. Circulation. 1993; 87: 30–37.CrossrefMedlineGoogle Scholar2 Czer LSC, Weiss M, Bateman TM, Pfaff JM, DeRobertis M, Eigler N, Vas R, Matloff JM, Gray RJ. Fibrinolytic therapy of St. Jude valve thrombosis under guidance of digital cinefluoroscopy. J Am Coll Cardiol. 1985; 5: 1244–1249.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails November 25, 2008Vol 118, Issue 22 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.108.786228PMID: 19029472 Originally publishedNovember 25, 2008 PDF download Advertisement SubjectsImagingThrombosis

Mitral Valve Stenosis Caused by Abnormal Pannus Extension over the Prosthetic Ring and Leaflets After Duran Ring Mitral Annuloplasty

We treated a 61-year-old woman with mitral stenosis caused by pannus formation after Duran ring annuloplasty. Pannus overgrowth on the ring with extension onto both leaflets narrowed the mitral orifice and severely restricted the mobility of the valve leaflets. Mitral valve replacement with a St. Jude Medical mechanical heart valve prosthesis was successfully performed, and the postoperative course was uneventful. Patients undergoing Duran ring annuloplasty should be followed up with the consideration of possible mitral stenosis caused by pannus extension, as the cause for pannus formation remains unclear.

Evolving Concepts and Technologies in Mitral Valve Repair

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 …

Impact of Subvalvular Procedure for Ischemic Mitral Regurgitation on Leaflet Configuration, Mobility, and Recurrence

Procedures on the subvalvular apparatus are an etiology-based treatment for ischemic mitral regurgitation (IMR). Fifty-nine patients with IMR were divided into 3 groups: mitral annuloplasty (MAP) (M group, n=27), MAP+left ventricular reconstruction (LVR) (LV group, n=18), and MAP+LVR+subvalvular procedure (S group, n=14). Tenting height and area, angle between the annular line and the line connecting leaflet base to the bending- or tip-point of either the anterior or posterior leaflet, and leaflet mobility were measured echocardiographically preoperatively and at immediate- and mid-term postoperative follow-up. The angles at the bending-point of the anterior leaflet in mid-systole remained greater than those at its tip-point in the M and LV groups, but became significantly smaller postoperatively only in the S group (p<0.05). Postoperative leaflet mobility at the bending-point in the S group became significantly greater than in the other groups (p<0.01). The grade of MR, after significant reduction by the procedure, increased again in the M and LV groups, but remained almost unchanged in the S group. Subvalvular procedures improved the configuration and mobility of the anterior leaflet, and can be expected to reduce the recurrence of IMR.

A Combined Patch-Clamp and Electrorotation Study of the Voltage- and Frequency-Dependent Membrane Capacitance Caused by Structurally Dissimilar Lipophilic Anions

Interactions of structurally dissimilar anionic compounds with the plasma membrane of HEK293 cells were analyzed by patch clamp and electrorotation. The combined approach provides complementary information on the lipophilicity, preferential affinity of the anions to the inner/outer membrane leaflet, adsorption depth and transmembrane mobility. The anionic species studied here included the well-known lipophilic anions dipicrylamine (DPA−), tetraphenylborate (TPB−) and [W2(CO)10(S2CH)]−, the putative lipophilic anion {text{B}}{left( {{text{CF}}_{3} } right)}^{ - }_{4} and three new heterocyclic W(CO)5 derivatives. All tested anions partitioned strongly into the cell membrane, as indicated by the capacitance increase in patch-clamped cells. The capacitance increment exhibited a bell-shaped dependence on membrane voltage. The midpoint potentials of the maximum capacitance increment were negative, indicating the exclusion of lipophilic anions from the outer membrane leaflet. The adsorption depth of the large organic anions DPA−, TPB− and {text{B}}{left( {{text{CF}}_{3} } right)}^{ - }_{4} increased and that of W(CO)5 derivatives decreased with increasing concentration of mobile charges. In agreement with the patch-clamp data, electrorotation of cells treated with DPA− and W(CO)5 derivatives revealed a large dispersion of membrane capacitance in the kilohertz to megahertz range due to the translocation of mobile charges. In contrast, in the presence of TPB− and {text{B}}{left( {{text{CF}}_{3} } right)}^{ - }_{4} no mobile charges could be detected by electrorotation, despite their strong membrane adsorption. Our data suggest that the presence of oxygen atoms in the outer molecular shell is an important factor for the fast translocation ability of lipophilic anions.

Echocardiographic assessment of mitral valve morphology after Percutaneous Transvenous Mitral Commissurotomy (PTMC)

AimsPTMC produces significant changes in mitral valve morphology as improvement in leaflets mobility. The determinants of such improvement have not been assessed before.Methods and resultsThe study included 291 symptomatic patients with mitral stenosis undergoing PTMC. Post-PTMC subvalvular splitting area was a determinant of post-PTMC excursion in both the anterior (B 0.16, 95% CI 0.03 to 0.30, p < 0.05) and the posterior (B 0.12, 95% CI 0.01 to 0.24, p < 0.05) leaflets. Another determinant was the post-PTMC transmitral pressure gradient for 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. The relationship between post-PTMC MVA and leaflet excursion was non-linear "S curve". There was a steep increase of both anterior (p, 0.02) and posterior (p, 0.03) leaflets excursion with increased MVA till the MVA reached a value of about 1.5 cm2; after which both linear and S curves became nearly parallel.ConclusionThe improvement in leaflets excursion after PTMC is determined by several morphologic and hemodynamic changes produced in the valve. The increase in MVA improves mobility within limit; after which any further increase in MVA is not associated by a significant improvement in mobility in both leaflets.