Mitral Valve Repair Surgery Research Articles

Lawrence Harvey Cohn, MD: A Conversation With the Editor

Larry Cohn was born in San Francisco, California, in 1937 and that is where he grew up. He received a BA in history from the University of California at Berkley in 1958 and his MD degree in 1962 from Stanford University School of Medicine. His internship and junior assistant residency in surgery was on the Harvard Surgical Service at Boston City Hospital from 1962 to 1964. He then was at the National Institutes of Health in Bethesda, Maryland, for 2 years as a surgical associate in the Surgery Branch of the National Heart Institute. In 1966, he returned to San Francisco for a 3-year residency in general surgery including chief resident at the University of California. From 1969 to 1971 he was resident and chief resident in cardiothoracic surgery at the Stanford University School of Medicine. In July 1971, he and his family moved to Boston, Massachusetts, where he initially was assistant professor of surgery at the Harvard Medical School and a member of the division of cardiothoracic surgery at the Brigham and Women’s Hospital. By 1980 he was full professor of surgery and in 1999 he became the Virginia and James Hubbard Professor of Cardiac Surgery at Harvard Medical School. From 1987 to 2005, Dr. Cohn served as Chief of Cardiac Surgery at the Brigham and Women’s Hospital. During his nearly 35 years at the Brigham and Women’s Hospital, Dr. Cohn has published extensively, mainly in peer reviewed medical journals. He has evaluated a number of prosthetic and bioprosthetic heart valves. He has been a major force in simplifying cardiac surgery and making it safer and more effective. He has always been on the forefront of mitral valve repair operations and has personally performed over 2,000 of these operations. His contributions to coronary bypass procedures and those for patients with heart failure have been extensive. He continues to be an extremely active and busy cardiac surgeon. His publications in medical journals number over 400; his invited articles, editorials and reviews number nearly 100; his chapters in books number just over 100, and he has authored or edited 11 books, including the 2nd edition of Cardiac Surgery in the Adult, a major textbook in his field. His editorial activities have been extensive. For 6 years he was editor of Modern Techniques in Surgery, the founding editor of Journal of Cardiac Surgery (1985 to 1995) and presently he is editor of Operative Techniques in Cardiothoracic Surgery. He has lectured at >600 medical centers and postgraduate courses throughout the world.

Cardiac robotics: a review and St. Mary's experience

The introduction of the laparoscope led to the progress of surgery to a new era, where surgeries that were deemed major are now being performed through keyhole incisions with comparable outcomes to open surgery. However, with this new technique rose several problems like inaccurate depth perception, diminished tactile feedback, need for experienced assistance, and reduction in degrees of motion of the surgeons hands all of which inspired surgeons and engineers to look for mechanical tools to help in reducing these problems. Henceforth; came the application of robotics in surgery. A PubMed and Medline search was performed on cardiac robotic surgery and its applications in mitral valve repair and coronary artery surgery. A total of twenty one articles were picked that allude to the subject. A history of robotic surgery was outlined followed by applications of robotic manipulation in cardiac surgery was narrated. A quick overview of this technology in telemedicine was then outlined followed by future prospects of this technology in surgery was contemplated. The experience of the group from St. Mary's Hospital, London in this field was outlined. During the period of 4 years a total of 102 cases of robotic cardiac surgery were performed. The mean length of hospital stay was 3.1 days with a standard deviation of 1.4 days and the morbidity of the series explained. There was no mortality. Early studies have shown that minimally invasive cardiac surgery is feasible and yields results similar to conventional cardiac surgery, yet it is more technically demanding on the surgeon. As advantageous as this new modality is, further multicenter studies are needed to prove its efficacy.

Transesophageal Echocardiography for Mitral Valve Repair Surgery

Mitral valve repair has become the procedure of choice for most diseases of the mitral valve as it preserves both the valvular and subvalvular apparatus. In contrast to mitral valve replacement surgery, patients undergoing mitral valve repair have lower in-hospital mortality and length of stay and improved long-term survival. Several factors have contributed to the evolution of new techniques for mitral valvuloplasty, including changing patient demographics and increased use of intraoperative transesophageal echocardiography (IOE).1-3 Demographically, there are fewer patients with rheumatic disease and more patients with mitral valve disorders that are amenable to repair, such as primary mitral valve degenerative disease or mitral regurgitation (MR} resulting from coronary artery disease. Concurrently, improved diagnostics by physicians skilled in using IOE have increased the potential candidates for mitral valve repair-for example, patients whose mitral valve disease can be diagnosed at the time of coronary artery bypass surgery. Information derived from IOE data can help determine the cause and severity of the mitral valve disease, assess the feasibility of performing a repair, and determine the success of the repair or if further intervention is needed. Medical causes of postoperative MR (systolic anterior motion of the anterior mitral leaflet or the chordae) must be ruled out in advance.4-6

Transesophageal Echocardiography For Mitral Valve Repair Surgery

Mitral valve repair has become the procedure of choice for most diseases of the mitral valve as it preserves both the valvular and subvalvular apparatus. In contrast to mitral valve replacement surgery, patients undergoing mitral valve repair have lower in-hospital mortality and length of stay and improved long-term survival.Several factors have contributed to the evolution of new techniques for mitral valvuloplasty, including changing patient demographics and increased use of intraoperative transesophageal echocardiography (IOE).1-3 Demographically, there are fewer patients with rheumatic disease and more patients with mitral valve disorders that are amenable to repair, such as primary mitral valve degenerative disease or mitral regurgitation (MR} resulting from coronary artery disease. Concurrently, improved diagnostics by physicians skilled in using IOE have increased the potential candidates for mitral valve repair-for example, patients whose mitral valve disease can be diagnosed at the time of coronary artery bypass surgery. Information derived from IOE data can help determine the cause and severity of the mitral valve disease, assess the feasibility of performing a repair, and determine the success of the repair or if further intervention is needed. Medical causes of postoperative MR (systolic anterior motion of the anterior mitral leaflet or the chordae) must be ruled out in advance.4-6

517 A novel approach for the quantification of mitral regurgitation: direct assessment of proximal jet area by real-time three-dimensional echocardiography

leaflet prolapse; type II1: leaflet restriction. Results were compared to data obtained by TEE. Results: cMRI and TTE estimates of RV were highly correlated (r=0.95, p 20 mL. cMRI correctly identified the mechanism of MR as type I in 1 patient, type II in 5 patients and type III in the remaining 4 patients according to TEE. Yet, presence of ruptured chordae was only identified by cMRI in 2/4 pts as compared to TEE. Conclusion: cMRI allows to accurately quantify the severity of MR and to precisely evaluate its mechanism. This suggests that this test could be used in the preoperative evaluation of patients before mitral valve repair surgery.

Effect of Training in Mitral Valve Repair Surgery on the Early and Late Outcome

Preservation of the native mitral valve provides important advantages over valve replacement. The aim of this study was to evaluate the effect of training for mitral valve repair on the outcome. Between 1997 and 2004, 471 patients underwent mitral valve repair procedures in a single firm. Of these procedures, 300 (64%) were performed by a consultant (TJS) (consultant group) and 171 (36%) by trainees supervised by the same consultant (trainees group). Atrial fibrillation was more prevalent in the consultant group (p = 0.02) but there were no significant differences in the demographics, etiology of mitral regurgitation, and other comorbidity between the groups. Posterior leaflet prolapse was more prevalent in the trainees group (p < 0.0001) and anterior leaflet prolapse (p < 0.0001), bileaflet prolapse (p = 0.003), and Barlow's syndrome (p = 0.0003) in the consultant group. The consultant performed a higher proportion of concomitant coronary artery bypass grafting (p = 0.04), aortic valve replacement (p = 0.02), procedures, and nonelective cases (p = 0.03) with shorter bypass (p = 0.01) and ischemic times (p = 0.0004) than trainees. The complication rate was similar in the two groups (26% vs 22%), but the consultant had a higher operative mortality than the trainees (5% vs 0.6%) (p = 0.01). A similar proportion in the two groups exhibited recurrent mitral regurgitation (8% vs 9%). Kaplan-Meier five-year freedom from reoperation (95.6 +/- 1.6 vs 95.7 +/- 2.2%) (p = 0.7) and survival (82 +/- 4% vs 88 +/- 4%) (p = 0.09) were similar in the two groups. With appropriate patient selection, cardiothoracic trainees can be taught mitral valve repair surgery without a negative effect on the early or late outcome.

Edge-to-Edge Technique to Treat Post-Mitral Valve Repair Systolic Anterior Motion and Left Ventricular Outflow Tract Obstruction

Systolic anterior motion of the mitral valve causing left ventricular outflow tract obstruction is an uncommon complication of mitral valve repair that may necessitate immediate additional surgical action. We prospectively evaluated the technique of the edge-to-edge suture on post-mitral repair systolic anterior motion, which persisted despite conservative treatment. From March 2002 to March 2004, 4 of 112 patients requiring mitral valve repair surgery for chronic degenerative mitral regurgitation had systolic anterior motion with severe left ventricular outflow tract obstruction and mitral regurgitation. All 4 patients (mean age, 50 years) had posterior leaflet prolapse with chordal rupture with a billowing anterior leaflet, but without chordal rupture. Repair was achieved through a quadrangular resection of the posterior leaflet, completed by plication of the annulus in 2 patients and leaflet sliding in the other 2. All patients had mitral annuloplasty; two patients had a complete CE Physio ring (Edwards Lifesciences, Irvine, CA) inserted, whereas the other 2 patients had an open CG Future band (Medtronic, Minneapolis, MN). Routine perioperative transesophageal echocardiography showed systolic anterior motion, severe left ventricular outflow tract obstruction (> 50 mm Hg), and mitral regurgitation. After resuming cardiopulmonary bypass, all patients had an edge-to-edge suture at the middle part of the free edge of the anterior and posterior leaflets. The control transesophageal echocardiography showed in all cases disappearance of the systolic anterior motion, of the left ventricular outflow tract obstruction and of mitral regurgitation. Mean follow-up was 14 months (range, 6 to 28 months). All patients were in New York Heart Association's functional class I. With the edge-to-edge repair, the early and 2-year results were satisfactory with total disappearance of the systolic anterior motion, of the left ventricular outflow tract obstruction and of the recurrent mitral regurgitation.

Mitral Valve Repair in Rheumatic Disease: Early Results

Mitral valve repair is an accepted method of treating severe mitral valve disease due to rheumatic fever, Valve repair confers fewer complications and better survival as compared to mitral valve replacement. Since commencing open-heart surgery at SGNHC, 49 mitral valve repair operations have been performed here. There were 25 male and 24 female patients. The average age was 28.7 years (5 - 68 years). All were symptomatic with significant dyspnoea and palpitation. Other symptoms were hemoptysis in eight, peripheral embolism in one and CNS embolism in four. Associated lesions included ASD in three, an ASD and constrictive pericarditis in one and a pseudoaneurysm of the left common iliac artery with PDA in the fifth. One patient had undergone CMV nine years before presentation.

Predictors of inotrope use during separation from cardiopulmonary bypass

Objective: To identify the demographic, clinical, and echocardiographic features that predict the use of inotropic support at separation from cardiopulmonary bypass (CPB). Design: Retrospective study of consecutive patients undergoing coronary artery bypass graft (CABG) surgery. Setting: Referral center for cardiothoracic surgery at a university hospital. Participants: One thousand nine patients undergoing either CABG or combined CABG and valve surgery with CPB in whom an intraoperative transesophageal echocardiography (TEE) examination was performed. Interventions: Inotropic support was defined as the use of dopamine ≥5 μg/kg/min; any dose of epinephrine, norepinephrine, dobutamine, and milrinone; or the insertion of an IABP during separation from CPB. Support was implemented by the anesthesia care team as clinically indicated. Comprehensive TEE examinations were conducted before CPB in all patients according to published guidelines and subsequently reviewed by a single, independent operator. Measurements and Main Results: Inotropic support was used in a total of 394 patients (39%) at separation from CPB. The study identified 6 significant, independent predictors of inotrope use: (1) Wall Motion Score Index, (2) combined CABG and mitral valve repair or replacement surgery, (3) left ventricular ejection fraction <35%, (4) reoperation, (5) moderate-to- severe mitral regurgitation, and (6) aortic cross-clamp time. Conclusions: Incorporating data from a comprehensive intraoperative TEE examination, the authors identified 6 reproducible factors that independently predict the use of inotropic support at separation from CPB.

Resultados da operação reconstrutora da valva mitral em pacientes com idade inferior a 15 anos

OBJETIVO: Avaliar a evolução dos pacientes portadores de regurgitação valvar mitral menores de 15 anos submetidos à operação reconstrutora da valva mitral. MÉTODO: Cento e dezessete pacientes com idade inferior a 15 anos, submetidos à plastia valvar mitral, no período de maio de 1980 a novembro de 2001. A idade variou de 1 a 15 anos, com média de 10 anos. Setenta e quatro pacientes (63,2%) eram do sexo feminino. A etiologia mais freqüente foi a doença reumática (81,2%). Oitenta e sete pacientes (63,2%) apresentavam regurgitação mitral e 30 (25,6%) estenose associada. Outras doenças estiveram presentes em 28 pacientes (23,9%), sendo a doença da valva aórtica a mais comum (13,7%). Diversas técnicas foram aplicadas na reconstrução valvar, como o encurtamento e/ou alongamento de cordas tendíneas, comissurotomia e papilarotomia. O anel valvar mitral foi remodelado em todos os pacientes. RESULTADOS: A evolução tardia mostrou 96,6% dos pacientes vivos e 88.9% com sua própria valva. Quinze pacientes (12,8%) foram reoperados. O anel mitral foi remodelado na totalidade dos pacientes, sendo utilizado o anel de Gregori-Braile em 69 (58,9%) e o de Carpentier em 35 (29,9%). As técnicas mais freqüentes foram o encurtamento de cordas em 66 pacientes (56,4%), e a comissurotomia e/ou papilotomia em 30 pacientes (25,6%). Houve um óbito hospitalar (0,9%) e três (2,6%) óbitos tardios. CONCLUSÃO: A operação reconstrutora na regurgitação valvar mitral foi factível, apresentando resultados que orientam para sua aplicabilidade neste grupo de pacientes menores de 15 anos.

&lt;![CDATA[&lt;b&gt;Outcomes of mitral valve repair surgery in under 15-year-old patients&lt;/b&gt;]]&gt;

&lt;![CDATA[&lt;b&gt;Outcomes of mitral valve repair surgery in under 15-year-old patients&lt;/b&gt;]]&gt;

Mitral valve repair with the Colvin-Galloway future band

Background A new annuloplasty device, the Colvin-Galloway Future Band, has been developed to allow simple and safe mitral valve repair surgery. Here we report its clinical use and the clinical results after a short-term, 2-year follow-up. Methods We assessed the performance of this new device in 40 consecutive patients (55% male; mean age, 68.3 ± 8.1 years) who were operated on for mitral valve incompetence between 2001 and 2002. Ninety percent of these patients had associated surgical procedures. Clinical and echocardiographic assessment was performed perioperatively and at a mean follow-up of 16.5 ± 5.7 months (range, 6 to 25 months) in all patients (100%), permitting analysis of 55 patient-years. Results Thirty-eight patients survived surgery, resulting in an overall early mortality of 5.0%. There were four noncardiac-related late deaths, resulting in an overall late mortality of 10.0%. Perioperative echocardiography showed no incidences of systolic anterior movement at the time of discharge from the hospital and satisfactory mitral repair results in 36 (95%) patients. At the time of the 2-year follow-up, echocardiography showed satisfactory mitral valve function in all but 2 patients (94%) and a significant postoperative ventricular remodeling: the left ventricular end-diastolic diameter decreased from 64.5 ± 6.2 mm preoperatively to 50.4 ± 9.5 mm postoperatively ( p < 0.1). At the time of follow-up, 29 (90.6%) patients were in New York Heart Association functional class I or II, all of them describing their quality of life as “significantly improved” if compared with their preoperative status. There were no late reoperations and no thromboembolic, bleeding, or other complications. Conclusions The clinical results of the Colvin-Galloway Future Band in this short-term follow-up of patients undergoing complex mitral valve repair seem to be promising.

Cardiopulmonary exercise testing before and one year after mitral valve repair for severe mitral regurgitation

For the evaluation of efficacy of cardiopulmonary exercise testing, we compared New York Heart Association functional class with peak oxygen consumption rate (VO 2peak) in 31 patients with severe mitral regurgitation who underwent mitral valve repair surgery. One year later, the VO 2peak values did not show significant improvement; however, the patients who had more than a mild degree of residual mitral regurgitation (n = 14) after 1 year of surgery had a VO 2peak value that was significantly decreased (from 22.7 ± 6.4 to 21.0 ± 6.3 ml/kg/min, p = 0.04). Patients with a higher preoperative VO 2peak value (≥18.5 ml/kg/min) had a significantly better New York Heart Association functional class 1 year after surgery than patients with a lower VO 2peak value (<18.5 ml/kg/min, p = 0.03).

Ischemic mitral valve repair surgery due to inferior wall infarction

Objectives: Is leaflet extension valvuloplasty safe to treat patients who had severe mitral regurgitation (MR) after inferior wall myocardial infarction?

The effect of pathophysiology on the outcome of mitral valve repair for mitral regurgitation.

The advantages of mitral valve repair in mitral regurgitation are well established. The aim of this study was to analyze retrospectively the early and mid-term results of primary mitral valve repair. Between January 1995 and August 2001, primary mitral valve repair operations were performed on 112 patients (76 men and 36 women) with mitral regurgitation; the mean age was 59.8 +/- 16.5 years. Mitral valve repair was performed for rheumatic heart disease (13), degenerative disease (60), infective endocarditis (2), ischemic heart disease (26), congenital heart disease (2), and dilated cardiomyopathy (9). The degree of mitral regurgitation was moderate in 28 patients, moderately severe in 17 patients, and severe in 67 patients, as determined by echocardiography. Left ventricular ejection fraction (mean 41.2% +/- 13.5%) was measured by radionuclide ventriculography. Fifty percent of patients underwent additional procedures (e.g., coronary artery bypass grafting). The mortality rate was 8.9% (10/112) for hospitalized patients, 19.2% (5/26) for ischemic disease, and 5% (3/60) for degenerative disease. Follow-up duration ranged from 0.37 to 84.03 months. All survivors were evaluated with serial echocardiography. At the final follow-up echocardiography of 94 patients without reoperation and 6 patients at the time of reoperation, 84% had no or mild mitral regurgitation. The survival rate at 5 years was 92.68 +/- 3.57% for degenerative disease and 44.47% +/- 10.89% for ischemic disease. The risk of infective endocarditis (1.78%), thromboembolism (1.78%), and anticoagulant-related complications (0.8%) was very low during the follow-up period. The pathophysiological mechanism resulting in mitral regurgitation was the most important determinant of outcome after mitral valve repair. Excellent results were achieved with mitral valve repair for degenerative disease. Because of low morbidity and acceptable mortality, we strongly recommend mitral valve repair for mitral regurgitation due to degenerative disease.

Minimally invasive mitral valve repair suggests earlier operations for mitral valve disease

Objective We began minimally invasive mitral valve surgery in August, 1996, to reduce hospital costs, to improve patient recovery, cosmetic appearance, and to decrease trauma, yet maintain the same quality of surgery. To validate this approach we reviewed our entire experience through May 2002. Methods From August 1996 to May 2002, we performed 413 minimally invasive mitral valve operations including 51 mitral valve replacements and 362 mitral valve repairs. Excluding 4 robotically assisted repairs, we evaluated 358 patients, using the mitral valve repairs as the basis for this retrospective survey. These operations were performed through a 6- to 8-cm minimally invasive incision, beginning with parasternal and, most recently, lower ministernotomy (181 patients). The mitral valve reparative techniques include repair of 94 prolapsed anterior leaflets, posterior leaflet resection, leaflet advancement, commissuroplasty, Polytetrafluoroethylene (PTFE; Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) chordal placement, and ring annuloplasty. Cannulation sites varied but primarily utilized a miniaturized system of 24F catheters in both the inferior and superior venae cavae with assisted venous suction. The Cosgrove ring was used in 95% of the patients undergoing this procedure. Results The operative mortality was 0/358. Perioperative morbidity included a 26% incidence of new atrial fibrillation, 2% incidence of pacemaker implantation, 0.5% incidence of deep sternal wound infection, and 1.9% incidence of stroke after an operation. There were 10 arterial and 3 venous complications. The mean length of stay was 6 days and 208 patients stayed ≤5 days. Only 25% of the patients underwent homologous blood transfusion. The mean follow-up was 36 months with 1.4% lost to follow-up. There were 12 late deaths and a survival at 5 years of 95%. There were 21 valves requiring reoperation for structural valve failure of 5.8%. The probability of freedom from reoperation at 5 years was 92%. Conclusion This study documents the safety of minimally invasive mitral valve repair surgery in 358 patients. It also documents a low incidence of homologous blood use, requirement for post–hospital rehabilitation, and general morbidity.

Surgical therapy in advanced heart failure

Congestive heart failure (CHF) affects about 1% of adults in the United States and is a contributing factor in >250,000 deaths per year. In an increasingly elderly population, the surgical treatment of CHF made great progress during the past 3 decades, consuming enormous health care resources. Heart transplantation is still the most effective therapy for end-stage heart disease, with the 10-year survival rate after transplantation approaching 50%. Efforts to increase the supply of donor organs have failed to improve the shortage, underscoring the crucial need for alternatives to cardiac allotransplantation. Alternative surgical options to end-stage heart transplantation are rapidly evolving. Left ventricular assist devices have been used as a bridge to heart transplantation for patients who otherwise might die awaiting a new heart. There is also continued interest in the use of these devices either to bridge patients to full recovery or to destination therapy, without the need for heart replacement. Left ventricular reconstruction, including the Batista and Dor procedures, along with mitral valve repair, cardiomyoplasty, and extreme coronary artery bypass graft surgery, are now being increasingly performed as alternative options. The history, status, and personal experience of surgical treatment of end-stage heart disease are discussed.

Clinical and Echocardiographic Findings in Patients who Underwent Mitral Valve repair Surgery

Clinical and Echocardiographic Findings in Patients who Underwent Mitral Valve repair Surgery

The Engineered Course of Treatment

Use of nanoscale devices is helping to revolutionize medical treatment and research. The Ohio State University recently became the first place in the country where coronary bypass and mitral valve repair operations are performed by a computer controlled robot, operated by a remotely located surgeon handling joysticks and considering a three-dimensional, enlarged view of the surgical field. With the invaluable help of many associates and students, researchers have focused on two classes of objects: devices that feature nanopore membranes, and multifunctional particulates for the delivery of medical therapeutic agents. Nanomembranes may also be used as flux regulators for the long-term release of biopharmaceuticals from implanted depots. This application embodies a purely passive mass transport mode of molecules in channels that are just a few nanometers larger than the effective radii of the molecules themselves.

Atrial endocardial changes in mitral valve disease: A scanning electron microscopy study

Background The precise contribution of left atrial appendage (LAA) endocardial damage and dysfunction to the process of thrombus formation in patients with mitral valve (MV) disease, especially in the presence of atrial fibrillation (AF), has not as yet been clearly described. This may be important because the LAA is the usual site for thrombus formation. Methods The purpose of this study was to describe endocardial surface changes, through the use of scanning electron microscopy, in the left and right atrial appendages of patients with MV disease and the differences, if any, between patients with mitral stenosis and mitral regurgitation as well as between those with AF and sinus rhythm. Our second objective was to relate endocardial changes to plasma levels of von Willebrand factor (vWf), an established marker for endothelial damage. LAA specimens were obtained immediately after commencement of cardiopulmonary bypass from 35 patients (18 men; mean age 65 years, range 20 to 85) during surgery for MV repair or replacement. Right atrial appendage (RAA) specimens were similarly obtained as controls for individual patients. The specimens were fixed in 2.5% glutaraldehyde solution overnight, stored in Sorensen’s phosphate buffer, and examined by means of scanning electron microscopy. Two independent observers documented the most advanced lesion in each specimen as follows: (1) “minimal” changes, with minimal disruption of the endocardium; (2) “intermediate” changes or prethrombotic lesions; and (3) “advanced” changes, with endocardial disruption and thrombotic lesions. Plasma levels of vWf were also measured (enzyme-linked immunosorbent assay) in all patients, and results were compared with those of age- and sex-matched healthy control patients. Results Advanced changes were more frequently seen in the endocardium of the LAA when compared with the RAA (31% vs 6%), whereas minimal changes were more frequently seen in the RAA compared with the LAA (23% vs 6%) (P =.00167). Similarly, the LAA from patients with mitral stenosis had a higher proportion of “advanced” endocardial changes when compared with patients with mitral regurgitation (67% vs 24%; P =.0066). The LAA in patients with AF had more “advanced” changes (39% vs 27%), but this was not statistically significant. Plasma vWf levels were significantly higher in patients with MV disease compared with healthy control patients (132 ± 33 IU/dL vs 99 ± 37 IU/dL; P =.0004) and in patients with advanced LAA changes compared with earlier changes (149 ± 34 IU/dL vs 121 ± 31 IU/dL; P =.042). Conclusions Endocardial damage occurs in the atrial appendages of patients with MV disease. Potentially thrombogenic changes are more commonly seen in the LAA compared with the RAA and in patients with mitral stenosis compared with mitral regurgitation. These anatomic appearances may contribute to the risk of intra-atrial thrombus formation in patients with mitral valve disease, especially if AF is present. (Am Heart J 2000;140:777-84.)