Mitral Leaflet Prolapse Research Articles

Mitral valve repair with leaflet resection versus preservation for degenerative posterior leaflet prolapse

ObjectivesThe optimal technique for repairing posterior mitral valve leaflet prolapse remains undetermined. We aimed to compare leaflet resection and neochordae implantation in patients undergoing mitral valve repair for posterior leaflet prolapse, focusing on transmitral pressure gradient and recurrence of mitral regurgitation. MethodsWe enrolled patients undergoing mitral valve repair using either leaflet resection or neochordae implantation for single-segment prolapse of posterior mitral valve leaflet between 2000 and 2021 at our institution. Longitudinal outcomes were evaluated after adjustments with inverse-probability-of-treatment weighting. Repeat echocardiographic measurements (n = 3473, 5.4/patient) of transmitral pressure gradient and significant (moderate or severe) mitral regurgitation recurrence were estimated using nonlinear mixed-effect models. Subgroup analyses were conducted based on the size and type of prosthesis. ResultsAmong 639 patients, leaflet resection was used in 479 (75.0%) and neochordae implantation was used in 160 (25.0%). In the inverse-probability-of-treatment weighting adjusted cohort, the risk of death (P = .623) and mitral valve reoperation (P = .340) did not significantly differ between the 2 groups during a median follow-up of 97.3 months. Echocardiographic data showed comparable mean (at 5 years, 3.8 vs 4.0 mm Hg; P = .442) and peak (9.6 vs 10.4 mm Hg; P = .131) pressure gradients between groups, which persisted in most subgroup analyses. However, neochordae implantation was associated with a higher probability of significant mitral regurgitation recurrence compared with leaflet resection (at 5 years, 16.1% vs 7.0%; P < .001). ConclusionsLeaflet resection yielded similar clinical outcomes and transmitral pressure gradients compared with neochordae implantation after mitral valve repair, with a lower mitral regurgitation recurrence rate. These findings underscore the need to reassess the efficacy of neochordae implantation relative to leaflet resection.

IATROGENIC ACUTE MITRAL INSUFFICIENCY FOLLOWING IMPELLA–ASSISTED INTERVENTIONAL PROCEDURE

Abstract Background Short–term left ventricle mechanical assistance device could be useful in assist interventional cardiologist during high–risk procedures. Abiomed Impella is one of the most frequently used device in this respect due to the high flow available with a low rate of reported complications. Here we report a rare but potentially catastrophic complication related to the Impella device. Case Description A 78 years old patient was referred to our Division by a peripheral hospital for a severe, symptomatic (NYHA III) mitral regurgitation (MR) due to posterior mitral leaflet prolapse (with focal eversion of P3) and chordal rupture (Fig 1a). Medical history included a previous admission in the some hospital due to a scheduled Impella–assisted PTCA (left main/left anterior descending artery) . Pre–procedural trans–thoracic ECHO (TTE) did not show significant MR (Fig 1b). Results Patient underwent urgent surgical procedure. At operation postero–medial mitral commissure was seen to be completely everted with multiple rupture of P3 and A3 chordae. Surgical procedure (Fig 1c) included: P3 plication + posterior–medial commissure edge–to–edge plasty + complete mitral semi–rigid ring (Simulus) n.30. Left atrial appendage was also closed using an external Atriclip. Postoperative course was without significant complications except a superficial wound dehiscence which delayed hospital discharge till 20th postoperative day. Conclusion Despite being a feasible and attractive option for short–term mechanical circulation assistance during high–risk interventional procedure, Impella device insertion could cause significant mitral valve damage leading to clinical deterioration. Such potentially catastrophic complication should be, therefore, mandatory excluded before patient discharge following interventional procedure.

Mitral valve prolapse syndrome

Mitral valve prolapse is a common valvular defect. In its overt clinical form, the condition known as mitral valve leaflet prolapse syndrome, or also known as Barlow's syndrome or flaccid valve syndrome, is a significant clinical problem, worsening the quality of life of patients, and in its severe forms is a risk factor for diseases such as congestive heart failure, endocarditis or cardiac arrhythmias, or even lead to death from sudden cardiac death. The development of methods, as well as the increasing general availability of echocardiography methods, makes a specific diagnosis early enough to allow the right treatment strategy to be chosen. Thanks to reliable reports in recent years, it has been possible to identify a group of patients whose cardiovascular risk predisposes them to a more severe course of the disease and thus these patients require special observation and attention in the process of diagnosis and treatment. Recent years have allowed the development of a new method of interventional treatment in patients burdened with multimorbidity for whom conventional surgery would be associated with a significant risk of worsening of the general condition.

Neochordae implantation versus leaflet resection in mitral valve posterior leaflet prolapse and dilated left ventricle: a propensity score matching comparison with long-term follow-up.

Uncorrected severe mitral regurgitation (MR) due to posterior prolapse leads to left ventricular dilatation. At this stage, mitral valve repair becomes mandatory to avoid permanent myocardial injury. However, which technique among neochoardae implantation and leaflet resection provides the best results in this scenario remains unknown. We selected 332 patients with left ventricular dilatation and severe degenerative MR due to posterior leaflet (PL) prolapse who underwent neochoardae implantation (85 patients) or PL resection (247 patients) at our institution between 2008 and 2020. A propensity score matching analysis was carried on to decrease the differences at baseline. Matching yielded 85 neochordae implantations and 85 PL resections. At 10 years, freedom from cardiac death and freedom from mitral valve reoperation were 92.6 ± 6.1% vs 97.8 ± 2.1% and 97.7 ± 2.2% vs 95 ± 3% in the neochordae group and in the PL resection group, respectively. The MR ≥2+ recurrence rate was 23.9 ± 10% in the neochordae group and 20.8 ± 5.8% in the PL resection group (P = 0.834) at 10 years. At the last follow-up, the neochordae group showed a higher reduction of left ventricular end-diastolic diameter (44 vs 48 mm; P = 0.001) and a better ejection fraction (60% vs 55%; P < 0.001) compared to PL resection group. In this subgroup of patients, both neochordae implantation and leaflet resection provide excellent durability of the repair in the long term. Neochordae implantation might have a better effect on dilated left ventricle.

Impact of bench repair for donor mitral valve before orthotopic heart transplantation: a case report

BackgroundThe use of donor hearts with valvular disease has been considered debatable in heart transplantation for many years. However, few reports indicate successful heart transplantation using donor hearts with mitral regurgitation that underwent mitral valve repair on the back bench.Case presentationWe report two cases of a 38-year-old and a 48-year-old woman with implantable left ventricular assist devices who underwent heart transplantation at our institution. Transthoracic echocardiography of donor hearts just before the explant revealed that each donor heart had preserved cardiac function and significant mitral regurgitation due to mitral posterior leaflet prolapse and annular dilatation, respectively. Bench mitral valve repair was accomplished using triangular resection for one patient and annuloplasty for the other. This was followed by confirmation of excellent mitral leaflet coaptation without residual mitral regurgitation. Transthoracic echocardiography and right heart catheterization performed 6 months after transplantation clarified the favorable cardiac function of each transplanted heart without mitral regurgitation recurrence.ConclusionsEfficient utilization of donor hearts with mitral regurgitation may be acceptable when the cardiac function of donor hearts with mitral regurgitation is preserved and heart transplantation, including bench mitral valve repair, is feasible within an acceptable ischemic time.

What Is the Optimal Mitral Valve Repair for Isolated Posterior Leaflet Prolapse to Achieve Long-Term Durability?

Background This study assessed risk factors for mitral regurgitation (MR) recurrence or functional mitral stenosis during long-term follow-up in patients undergoing mitral valve repair for isolated posterior mitral leaflet prolapse. Methods and Results We assessed a consecutive series of 511 patients who underwent primary mitral valve repair for isolated posterior leaflet prolapse between 2001 and 2021. Annuloplasty using a partial band was selected in 86.3%. The leaflet resection technique was used in 83.0%, whereas the chordal replacement without resection was used in 14.5%. Risk factors were analyzed for MR recurrence ≥grade 2 or functional mitral stenosis with mean transmitral pressure gradient ≥5 mm Hg using a multivariable Fine-Gray regression model. The 1-, 5-, and 10-year cumulative incidence of MR ≥grade 2 was 7.8%, 22.7%, and 30.1%, respectively, whereas that of mean transmitral pressure gradient ≥5 mm Hg was 8.1%, 20.6%, and 29.3%, respectively. Risk factors for MR ≥grade 2 included chordal replacement without resection (hazard ratio [HR], 2.50, P<0.001) and larger prosthesis size (HR, 1.13, P=0.023), whereas factors for functional mitral stenosis were use of a full ring (partial band versus full ring, HR, 0.53, P=0.013), smaller prosthesis size (HR, 0.74, P<0.001), and larger body surface area (HR, 3.03, P=0.045). Both MR ≥grade 2 and mean transmitral pressure gradient ≥5 mm Hg at 1 year post surgery were significantly associated with the long-term incidence of reoperation. Conclusions Leaflet resection with a large partial band may be an optimal strategy for isolated posterior mitral valve prolapse.

P403 MITRAL VALVE PROLAPSE AND RISK OF SUDDEN CARDIAC DEATH IN A PATIENT WITH VENTRICULAR ARRHYTHMIAS: THE PROGNOSTIC ROLE OF CARDIAC MAGNETIC RESONANCE IMAGING

Abstract Introduction in most cases mitral valve prolapse is a benign condition, however in 2% of cases it has been associated with the risk of sudden cardiac death (SCD). Basso et al have demonstrated papillary muscle’s and left ventricle’s inferolateral wall fibrosis on cardiac magnetic resonance imaging (MRI), in patients who died from SCD with mitral valve prolapse. Clinical case A 59–year–old patient was admitted to the Cardiology Department of Pertini Hospital (Rome, Italy) for episodes of vertigo and not sustained ventricular tachycardia in two morphologies at 24–hour ECG monitoring. The patient had negative history for cardiovascular risk factors, but an echocardiogram had demonstrated a moderate mitral valve regurgitation, secondary to valve prolapse with mitral annular disjunction (MAD) (Fig.1). Considering patient‘s age associated with low pre–test probability of coronary artery disease, the patient underwent coronary CT that showed a coronary artery tree free from injury. Cardiac MRI showed increased volumes in the left ventricle and slightly reduced systolic function and valve prolapse of both mitral leaflets determining moderate regurgitation. In addition, intra–myocardial Late Gadolinium Enhancement (LGE) showed fibrosis of the inferior and inferolateral wall with extension to the proximal portion of the inferior papillary muscle (Fig.2). Considering such findings, an intracavitary electrophysiological study (EPS) was performed for an evaluation of the arhythmic burden, by administrating the patient a double extra stimulus from the outflow tract of the right ventricle; the treatment induced a polymorphic ventricular tachycardia, starting from the inferior papillary muscle and degenerating into ventricular fibrillation (Fig.3). Discussion considering all the above findings, a mitral valve prolapse at high risk of malignant arrhythmias has been diagnosed and a subcutaneous cardiac defibrillator was implanted. Conclusions in mitral valve prolapse associated with complex ventricular arrhythmias, evaluation with cardiac MRI increasingly plays a crucial role in prognostic stratification for defibrillator implantation in primary prevention.

Successful bailout clipping for rare complication of anterior mitral leaflet dissection during transcatheter edge-to-edge mitral valve repair

A 91-year-old woman underwent transcatheter edge-to-edge mitral valve repair (TEER) due to severe mitral regurgitation (MR) with the central posterior mitral leaflet (PML) prolapse (Figure 1A; Supplementary data online, Movie S1). The XTW size of MitraClip G4 (Abbott Vascular, USA) was chosen considering the larger length of PML. Before inserting the MitraClip into left ventricle, a newly developed membranous structure was suddenly detected on the central anterior mitral leaflet (AML) by transoesophageal echocardiography (TEE) (Figure 1B). The structure appeared to spread widely from the tip of the central AML toward lateral side (Figure 1C; Supplementary data online, Movie S2) and colour jet flow of TEE penetrated in-between the AML and mobile layered structure (Figure 1D; Supplementary data online, Movie S3). Based on the TEE findings, we suspected AML dissection caused by the proximal edge of MitraClip during one of the procedural steps. The dissection area was localized in the central to lateral side of AML but did not advance further. Therefore, the bailout-TEER was performed to stabilize for both the PML prolapse and iatrogenic AML dissection. The clip was placed under the mitral valve and the clippers grasped both the leaflets (Figure 1E). After successful TEER, the part of AML dissection was minimized (Figure 1F; Supplementary data online, Movie S4). The abnormal colour jet disappeared and trivial amount of MR was present after the procedure (Figure 1G and H). Postprocedural enhanced computed tomography also confirmed absence of abnormal findings in the left atrium around mitral valve. Although extremely rare complication, caution against the occurrence of mitral leaflet dissection during TEER should be exercised.

Mitral degenerative valve leaflets suspected as primary valvular tumor: a case report

BackgroundEchocardiography plays an important role in the diagnosis of heart disease. Sometimes, however, it may also provide misdiagnosis information.Case presentationWe report a rare case of a misdiagnosis of primary mitral valvular tumor with severe regurgitation by preoperative echocardiography. During the surgery, the true lesion was found to be mitral valve leaflet prolapse due to degenerative mitral valve disease.ConclusionFor individual patient, the best clinical decision not only needs the extensive application of echocardiography, but also needs the combination of clinical symptoms and more auxiliary examination.

407 AN INCIDENTAL FINDING OF A CHALLENGING MITRAL MASS

Abstract A 53-year-old woman, with no previous cardiologic history, presented to our emergency department reporting a pleomorphic symptomatology that had been affecting her in the last few months. She complained weakness, dyspnea for severe exertion and intermittent atypical chest pain worsening with the supine position. The patient had a history of migraine with aura. On admission she was asymptomatic and apyretic. Her blood pressure was 120/80 mmHg. Clinical examination revealed rhythmic heart sounds without murmurs, normal lung sounds, no jugular venous distention and no peripheral edema, no signs nor symptoms of infection. Her laboratory tests showed normal cardiac high-sensitivity troponin I (4.1 ng/L), BNP levels (4 ng/L) and C-reactive protein 0.3 mg/dL. The electrocardiogram showed a sinus rhythm with a rate of 86 beats/min, AV conduction and ventricular repolarization were within normal limits. Transthoracic echocardiogram revealed a normal sized (end-diastolic diameter 40 mm), slightly hypertrophic left ventricle (interventricular septum thickness 12 mm) with normal ejection fraction (55%), inferior-lateral wall curling and grade I diastolic dysfunction. Left atrium size was normal. A 15×14 mm globe-shaped echogenic structure was seen protruding in the left atrium throughout the whole cardiac cycle, which apparently originated from the P2 scallop (Figure 1A). There were no signs of mitral regurgitation or stenosis. Aortic valve was normal. Inferior vena cava was not dilated and collapsing. During the hospitalization she was always apyretic and asymptomatic, laboratory tests and blood culture negative. Transesophageal echocardiography showed a saccular cavitary structure, 14 mm in diameter bulging from the posterior mitral leaflet toward the left atrium throughout systole and diastole (Figure 1B). Differential diagnosis included cardiac tumor (e.g., fibroelastoma), and mitral valve aneurysm and/or excessive P2 prolapse. The absence of history of endocarditis, mitral regurgitation and the involvement of the posterior leaflet favored the first hypothesis, whilst morphology the latter. Libman-Sacks endocarditis was excluded thanks to lesions morphology and the absence of history of cancer or autoimmune disease. We performed a cardiac MRI investigation which confirmed the presence of bi-leaflet mitral prolapse with a thickened, dysmorphic and abnormal posterior mitral leaflet without any evidence of cardiac tumors (Figure 2). No regurgitation was found. Adiposus intramyocardial tissue was also reported in the inferior-lateral wall, supporting the diagnosis of atypical mitral valve prolapse with aneurysmatic posterior leaflet. Finally, a brain MRI excluded prior cerebral embolism. We therefore decided to follow-up the patient, who at 6 months remained asymptomatic without any medical therapy. Figure 1.A: transthoracic echocardiography (apical four-chamber view) showing the mitral mass. B: transesophageal echocardiography (three-chamber view with X-plane section) showing the mitral mass as an aneurysmatic posterior mitral leaflet at P2 level. C: 3D transesophageal echocardiography showing the aneurysmatic posterior mitral leaflet.Figure 2.Cardiac MRI (three-chamber view) showing the mitral posterior leaflet prolapse with aneurysm.

Mitral Annular Disjunction in Mitral Leaflet Prolapse: Prevalence, Clinical Profile and Echocardiographic Features at Tertiary Cardiac Care Centre, Rawalpindi

Objective: To determine the prevalence of Echocardiographically-recognizable Mitral Annular Disjunction in patients of Myxomatous Mitral Valve Disease/Mitral Leaflet Prolapse.&#x0D; Study design: Analytical Cross sectional .&#x0D; Place &amp; Duration of study: Armed Forces Institute of Cardiology/National Institute of Heart Disease (AFIC/NIHD),Rawalpindi Pakistan from Jul 2021 to Sep 2021.&#x0D; Methodology: A total (n=45) diagnosed patients of Myxomatous Mitral Valve disease, were included through non-probability consecutive sampling. Mitral Annular Disjunction (MAD) was assessed by 2D TTE imaging as the distance between the point of insertion of the posterior leaflet into the left atrial wall (upper boundary of the disjunction) and the link between the left atrium and the left ventricle myocardium (lower border of the disjunction)at end-systole in parasternal long axis view. A distance equal to or greater than 2mm was used as a threshold for diagnosing the presence of MAD. The data analysis was done with the help of computer software programme SPSS version 24.&#x0D; Results: Total number of patients were 45 patients with males being 32 (71.11%) while females being 13 (28.88%), with a mean age of 30.24 + 5.21 years. MAD was present in 26 (57.8%) of the patients with mean length of 2.88mm + 2.77 mm. Patients with MAD had more chest pain, palpitations and dyspnoea than those without MAD. Mitral regurgitation was more severe in patients with MAD than without. The MAD severity correlated with the presence of Non Sustained Ventricular Tachycardia.&#x0D; Conclusion: MAD is not an uncommon finding in patients having myxomatous mitral valve disease/mitral valve prolapse........

Clinical and echocardiographic predictors of the anterior mitral leaflet repair failure

Anterior mitral leaflet prolapse repair is a highly effective procedure, but despite excellent operative results still has an inferior long-term durability when compared to posterior leaflet repair. We analysed mitral repair durability in 74 consecutive patients operated for anterior leaflet prolapse between 2010 and 2021. Their pre- and postoperative clinical, echocardiographic data and repair durability as well, were compared with74 randomly assigned posterior leaflet prolapse patients who underwent valve repair during the same period. While groups were of similar age, patients with anterior leaflet prolapse had an inferior preoperative status in terms of functional reserve, atrial fibrillation, operative risk, ejection fraction and had more dilated left heart chambers as well. 1, 5, and 10-year freedom from repair failure was 87.1 ± 4.6%, 79.8 ± 6.5% and 50.7 ± 12.5% in the anterior, and 98.5 ± 1.5% respectively in the posterior leaflet group. Atrial fibrilation (hazard ratio [HR]5.365; 95%; confidence interval[CI] 1.093-26.324 p = .038) and left ventricle end-systolic diameter (HR 1.160 95%; CI 1.037-1.299 p = .010) independently predicted anterior leaflet repair failure. Receiver Operating Curve analysis established left ventricle end-systolic diameter ≤42 mm as a cut-off value associated with improved anterior leaflet repair durability. Accordingly, 10-year repair durability in a subset of patients, with preserved left ventricle end-systolic diameter (≤42 mm) was 86.4 ± 7.8%. Better long-term repair durability in patients with anterior mitral leaflet prolapse and preserved sinus rhytm and left-ventricle diameters justifies early reconstructive approach.

Anomalous origin of the left coronary artery from the pulmonary artery as a rare cause of mitral valve prolapse: a case report

Background Mitral valve prolapse (MVP) is an etiologically heterogeneous disorder. Early diagnosis and prompt treatment of the underlying disease are of great significance. Herein, we present a rare case of MVP caused by anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).Case presentationA 22-year-old female presented with a 16-year history of anterior mitral leaflet prolapse. However, she had never experienced any discomfort before. At a routine follow-up, a transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation, and a retrograde blood flow from an extremely dilated left coronary artery (LCA). Further coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA. She subsequently underwent successful LCA reimplantation and concomitant mitral valve replacement. Intraoperatively, her mitral annulus was mildly dilated, anterior mitral valve leaflet appeared markedly thickened with rolled edges, and a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened.ConclusionsALCAPA is a rare and potentially life-threatening congenital coronary artery anomaly that may cause mitral valve prolapse. Echocardiogram is an important screening tool for this disorder.

P3 mitral valve prolapse in a young patient, an uncommon case

 A 33-year-old patient with no cardiovascular risk factors and no history presented with shortness of breath, palpitations and fatigue. The cardiovascular examination showed an apex beat lateral and inferior displacement and a mitral systolic murmur. The electrocardiogram showed both left ventricular hypertrophy and left atrial hypertrophy. Inflammatory markers were within normal range and blood cultures were sterile. Transthoracic echocardiography showed a severe mitral regurgitation and posterior mitral leaflet prolapse and both left ventricular and auricular dilatation. The transoesophageal echocardiography showed a P3 prolapse with a mobile structure on the posterior mitral valve atrial side suggesting a chordal rupture. The patient had a surgical cure (posterior valve plasty) with good outcomes.

Mitral valve repair with a device for artificial chordal implantation at 2 years

ObjectivesThis study examines the early and midterm safety, efficacy, and durability of mitral valve repair for primary mitral regurgitation (MR) using the ChordArt device (CoreMedic) for chordal replacement. MethodsFive patients with symptomatic severe primary degenerative MR due to isolated central posterior leaflet prolapse/flail were treated with the ChordArt device in a transseptal surgical approach and followed prospectively with periodical clinical and echocardiographic assessments for 2 years. ResultsReduction of MR immediately after the implantation of artificial chords was achieved in all patients showing no or trace MR (<1+/4+). In all patients, MR <1+ was maintained during 24 months of follow-up. No dehiscence, detachment, or dislocation of the implanted ChordArt devices was observed. Transthoracic echocardiography showed that left ventricle end diastolic diameter significantly decreased during the whole follow-up period in comparison to baseline condition, especially at discharge and 1-month follow-up. Left ventricle end systolic diameter also significantly decreased during the whole follow-up period in comparison to baseline condition. Left atrial volume significantly decreased during the follow-up period in comparison to discharge. No major adverse events, as defined per protocol, were observed during the intervention or during the follow-up period. ConclusionsThe ChordArt device allows successful treatment of primary degenerative MR due to posterior mitral leaflet prolapse or flail, with a good safety profile and promising immediate clinical and echocardiographic benefits that are confirmed up to 24 months.

Usefullness of 2D/3D-TEE for guiding transapical beating heart neochordae implantation in mitral regurgitation

Abstract Background Transapical beating-heart neochord implantation (Neochord) to repair mitral valve regurgitation has been demonstrated to be a safe and effective minimally invasive alternative to open surgical repair in selected patients with mitral leaflet prolapse. Successful neochordae implantation depends on accurate localization of the site of regurgitation and careful assessment of MV morphology. The objective of this study is to demonstrate that 3D-transesophageal echocardiography (3D-TEE) has become a fundamental tool, essential in both the preoperative study and to guide the procedure and for follow-up. Methods All consecutive patients with severe symptomatic DMR due to prolapse or flail of one or both mitral leaflets that underwent the NeoChord procedure between March 2017-Jan 2021 were included. Patients were categorized according to MV anatomy by 3D-TEE; Type A isolated central posterior leaflet prolapse and/or flail, Type B posterior multi-segment prolapse and/or flail, Type C anterior and/or bi-leaflet prolapse or flail, Type D paracommissural prolapse and/or flail and/or significant leaflet and/or annular calcifications. Results 43 patients were included. Median age was 67.7±13.4 y. Median EuroSCOREII 2.7%±1.91. There were 35 Type A patients (81.4%), 4 Type B (9.3%), 1 Type C (2.3%), and 3 Type D (7%). Type A was considered the more favorable morphology. 2D/3D TEE were employed for guiding the device from the apex of the left ventricle across the mitral annulus (Figure 1, A–C), orientation of the tip of the device with regards to the prolapsing segment of the leaflet positioning and leaflet grasping (Figure 1, D, E) and evaluation of the final length and tension of the neochordae to obtain a satisfactory mitral valve competence. (Figure 1, F). Procedural success was achieved in 38 patients (88,4%). 5 patients, 2 type A and 3 type D, underwent conversion to open surgery for immediate failure. 1 high-risk patient considered inoperable died before discharge. At 19 (IQR 13–23) months median follow-up, MR ≤II was present in 29 (76.3%). Overall 2 year survival was 100%. Freedom from reintervention was 89% for overall population. Conclusions TEE-Guided Transapical beating-heart neochord implantation is a feasible, low-risk technique. 2D and 3D TEE are the fundamental and essential diagnostic tools for the correct selection and monitoring of the procedure, as well as its possible complications. Funding Acknowledgement Type of funding sources: None. Figure 1

Successful percutaneous mitral valve leaflet repair for primary mitral regurgitation results in functional improvement and positive cardiac reverse remodelling

Abstract Funding Acknowledgements Type of funding sources: None. Background Percutaneous mitral valve leaflet repair can be an effective treatment for primary mitral regurgitation (MR) patients deemed high-risk for surgery. Accurate assessment of cardiac reverse remodelling is essential to optimise future patient selection. Cardiovascular magnetic resonance (CMR) is the reference standard for cardiac volumetric assessment and compared to transthoracic echocardiography (TTE) provides superior reproducibility in MR quantification. Prior CMR studies have analysed cardiac reverse remodelling following percutaneous intervention in combined cohorts of primary and secondary MR patients. However, as aetiology of MR can significantly impact outcomes, focused studies are warranted. Purpose Assess cardiac reverse remodelling and quantify changes in MR following percutaneous mitral valve leaflet repair for primary MR using the reference standard (CMR). Methods 12 patients with at least moderate-severe MR on TTE were prospectively recruited to undergo CMR imaging and 6-minute walk tests (6MWT) at baseline and 6 months following percutaneous mitral valve leaflet repair (MitraClip). CMR protocol involved: left-ventricular (LV) short axis cines (bSSFP, SENSE-2, 10mm, no gap), transaxial right-ventricular (RV) cines (bSSFP, SENSE-2, 8mm, no gap), two and four chamber cines and aortic through-plane phase contrast imaging, planned at the sino-tubular junction. MR was quantified indirectly using LV and aortic stroke volumes. Results 12 patients underwent percutaneous mitral valve leaflet repair (MitraClip) for posterior mitral valve leaflet prolapse, however 1 patient declined follow up after single-leaflet clip detachment resulting in 11 patients (age 83 ± 5years, 9 male) completing follow up imaging. At 6-months: significant improvements occurred in New York Heart Association functional class (Table 1) and 6MWT distances (223 ± 71m to 281 ± 65m, p = 0.005) and significant reductions occurred in indexed left ventricular end-diastolic volumes (LVEDVi) (118 ± 21ml/m2 to 94 ± 27ml/m2, p = 0.001), indexed left ventricular end-systolic volumes (58 ± 19ml/m2 to 48 ± 21ml/m2, p = 0.007) and quantitated MR volume (55 ± 22ml to 24 ± 12ml, p = 0.003) and MR fraction (49 ± 9.4% to 29 ± 14%, p= &amp;lt;0.001). There were no statistically significant changes in left ventricular ejection fraction (LVEF), right ventricular dimensions/ejection fraction or bi-atrial dimensions (Table 1). All patients demonstrated decreased LVEDVi and quantified MR (Figure 1). Conclusion Successful percutaneous mitral valve leaflet repair for primary MR results in reduction in MR, positive LV reverse remodelling, preservation of LVEF, and functional improvements. Larger CMR studies are now required to further guide optimal patient selection.

Mitral Annular Disjunction-A New Disease Spectrum.

Mitral annular disjunction is a structural abnormality of the mitral annulus fibrosus, which has been described by pathologists to be associated with mitral leaflet prolapse. Mitral annular disjunction is a common finding in patients with myxomatous mitral valve diseases. The prevalence of mitral annular disjunction should be checked routinely during presurgical imaging. Otherwise, mitral annular disjunction itself might be an arrhythmogenic entity, irrespective of the presence of mitral valve prolapse (MVP). Therefore, we should check echocardiography keeping in mind mitral annular disjunction. Further prospective studies are needed to address whether a causative mechanistic link exists between mitral annular disjunction and arrhythmic MVP.

Mitral valve repair for isolated posterior mitral valve leaflet prolapse: The effect of respect and resect techniques on left ventricular function

ObjectivePosterior mitral valve leaflet prolapse repair can be performed by leaflet resection or chordal replacement techniques. The impact of these techniques on left ventricular function remains a topic of debate, considering the presumed better preservation of mitral-ventricular continuity when leaflet resection is avoided. We explored the effect of different posterior mitral valve leaflet repair techniques on postoperative left ventricular function. MethodsIn total, 125 patients were included and divided into 2 groups: leaflet resection (n = 82) and isolated chordal replacement (n = 43). Standard and advanced echocardiographic assessments were performed preoperatively, directly postoperatively, and at late follow-up. In addition, left ventricular global longitudinal strain was measured and corrected for left ventricular end-diastolic volume to adjust for the significant changes in left ventricular volumes. ResultsAt baseline, no significant intergroup difference in left ventricular function was observed measured with the corrected left ventricular global longitudinal strain (resect: 1.76% ± 0.58%/10 mL vs respect: 1.70% ± 0.57%/10 mL, P = .560). Postoperatively, corrected left ventricular global longitudinal strain worsened in both groups but improved significantly during late follow-up, returning to preoperative values (resect: 1.39% ± 0.49% to 1.71% ± 0.56%/10 mL, P < .001 and respect: 1.30% ± 0.45% to 1.70% ± 0.54%/10 mL, P < .001). Mixed model analysis showed no significant effect on the corrected left ventricular global longitudinal strain when comparing the 2 different surgical repair techniques over time (P = .943). ConclusionsOur study showed that both leaflet resection and chordal replacement repair techniques are effective at preserving postoperative left ventricular function in patients with posterior mitral valve leaflet prolapse and significant regurgitation.

Echocardiographic screening for mitral valve prolapse in Turkish school children

We determined the frequency of mitral valve prolapse (MVP) in healthy Turkish school children using the current echocardiographic diagnostic criteria. This epidemiological survey was performed on 2550 school children. All children were screened with echocardiography and the family of children with MVP were also screened. The prolapse of mitral leaflets into left atrium ≥ 2mm in parasternal long-axis view was used as diagnostic criteria. MVP was classified as classical or non-classical according to anterior mitral leaflet thickness. The thickness of anterior mitral leaflet, the extent of prolapse, and the presence of mitral regurgitation were evaluated. The children were also questioned about the associated symptoms. The prevalence of MVP was 1.25% in children with a mean age of 11.1 ± 2.9years. The prevalence was 0.9%, 1.2%, and 1.6% in 5-9years, 10-13years, and 14-18years of age, respectively. 43.7% of the cases were classical MVP. The frequency of auscultation findings was 34.3%. 11/34 children had mitral regurgitation. There was no statistically significant difference between classical MVP and non-classical MVP in terms of mitral regurgitation, physical examination findings, and symptoms. Anxiety (37.5%) was the most common symptom. The frequency of MVP in the first-degree relatives of children with MVP was 11/84 (13.1%). Most patients with MVP don't have auscultation findings and symptoms, therefore echocardiography is an important tool in the diagnosis of MVP. It is also reasonable to screen first degree relatives of MVP patients with echocardiography.