Posterior Mitral Valve Prolapse Research Articles

Abstract 16239: Left Atrial Function by Speckle-Tracking Echocardiography in Mitral Valve Prolapse: Evidence of a Primary Atriopathy and Clinical Implications

Background: Prior studies support the prognostic role of left atrial (LA) volume in predicting overall mortality in mitral valve prolapse (MVP). However, the prognostic impact of LA function on cardiac outcome as quantified by speckle tracking echocardiography (STE) is unknown. Moreover, whether the mitral leaflet “atrialization” observed in bileaflet MVP with mitral annular disjunction (MAD) affects LA function irrespective of mitral regurgitation (MR) severity remains unclear. We sought to investigate the prognostic role of LA global longitudinal strain (LAGLS) and MVP subtype in a large registry of MVP patients with various degrees of MR. Methods: We identified 411 consecutive patients (59±17 years, 52% women) with MVP and clinical, echocardiographic and outcome data. LAGLS was measured offline using STE. Survival analysis was performed to assess the composite risk of cardiac death, heart failure hospitalization, or new onset of atrial fibrillation. Results: Compared to other MVP subtypes, bileaftlet MVP had lower LAGLS regardless of MR severity ( Fig 1A&1B ). Of note, in the subgroup with no or mild MR, LAGLS was significantly lower in bileaflet compared to posterior MVP (p=0.003). There was a trend toward lower LAGLS according to MVP with vs without MAD (p=0.08) ( Fig 1C ). In multivariable linear regression adjusted for several risk factors, including MR grade, bileaflet MVP remained significantly associated with lower LAGLS (p=0.003). A total of 79 cardiovascular events occurred during a mean follow-up of 4.6±2.9 years. There was a significant increase in the risk of events as LAGLS decreased (log-rank: p<0.001) ( Fig 1D ). Conclusion: Bileaflet MVP is associated with lower LAGLS regardless of MR severity, suggesting a primary atriopathy in this MVP subtype. Abnormal LAGLS is linked to higher risk of cardiovascular events. Hence, assessment of LA function using STE may help improve risk stratification in MVP and could represent a useful tool in clinical practice.

Mitral Valve Prolapse, Not Always an Easy Diagnosis

Abstract We present the case of a 61-year-old male patient, with no medical history, who was presenting for an anterior chest pain, which appeared suddenly during an effort, accompanied by palpitations, fatigue and dyspnea Physical examination revealed the presence of a 4/6 systolic murmur with maximal auscultation at the apex and radiation in the left axilla. Echocardiographic evaluation revealed diagnostically suggestive elements for severe posterior mitral valve prolapse without any rupture, color Doppler showing severe mitral regurgitation, a tricuspid valve prolapse, tricuspid regurgitation grade III and pulmonary hypertension. Coronary angiography revealed coronary arteries without hemodynamically significant lesions, and Holter ECG/24-hour monitoring detected atrial fibrillation in 44% of the monitoring time. In this context, the possible causes of the anterior chest pain were: microvascular angina, traction on the chordae or pulmonary hypertension. The patient had a surgical indication for mitral valve replacement or reconstruction. The department of cardiac surgery undergoes mitral valve replacement with a mechanical prosthesis with a favorable outcome.

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.

PE-454609-2 MARFAN SYNDROME AND VENTRICULAR ARRHYTHMIAS IN PEDIATRICS: MITRAL ANNULAR DISJUNCTION, MITRAL VALVE PROLAPSE OR BOTH – WHICH IS THE REAL CULPRIT?

Mitral Annular Disjunction (MAD) and Mitral Valve Prolapse (MVP) have been associated with sudden death and ventricular arrhythmias (VA) in adults with connective tissue disease (CTD). While rare, there has been a case report of sudden cardiac death due to VA in a pediatric Marfan patient. However, risk factors have not been well described in this population. Our aim is to assess the association of MAD and MVP with VA in pediatric patients with Marfan syndrome. A retrospective single center cohort study was conducted and included all patients (≤ 21yrs) with clinical (based on Ghent’s criteria) and/or genetic diagnosis of Marfan syndrome. Clinical data including ambulatory cardiac monitoring and echocardiograms were reviewed prior to any mitral valve intervention, if applicable. 32 patients (38% female) with Marfan syndrome (66% with fibrillin 1 mutation) were included. The mean age was 13.5 ± 4.5 yrs. The results revealed MAD in 8 pts (25%), isolated MVP in 5 pts (16%) and bileaflet MVP in 14 pts (44%). Anterior MVP was seen in 16 pts (50%) and posterior MVP in 17 pts (53%). The mean MAD distance was 6.7 ± 2.3 mm. There was normal LV systolic function in 31 pts (97%). The median duration of cardiac monitoring was 58 hrs (IQR: 33-191). 26 pts (81%) had isolated ventricular ectopy (VE), 27 pts (84%) had complex VE (defined as couplets, triplets or NSVT), 4 pts (12.5%) had NSVT and none had sustained VT. The median VE per hour was 0.2 (IQR: 0-1). There was no R on T seen but short coupled VE (<350ms) was seen in 46% of isolated, 46% of couplets and 67% of triplets. Monomorphic ectopy was seen in 28% of isolated and 100% of couplets, triplets and NSVT. There were 5 total episodes of NSVT (Figure 1) with a mean HR of 159 ± 29 bpm, an absolute minimum HR of 94 bpm and maximum HR of 222 bpm. MAD was not associated with the presence of, or complexity in, ventricular arrhythmias. Anterior MVP was only associated with complexity in VE (p= 0.043), but posterior MVP and bileaflet MVP were not. MAD was associated with MVP (anterior, posterior and bileaflet; p= 0.026). There was a high incidence of complex VE and NSVT in this cohort of pediatric Marfan patients despite low overall ectopy burden. Anterior MVP but not MAD was associated with complexity in VE. However, MAD was associated with MVP. Larger studies are needed to better characterize MAD, including distance and circumferential extent, and MVP and their association with VA in pediatric patients with CTD.

PO-04-194 PROGNOSTIC SIGNIFICANCE OF ELECTROPHYSIOLOGIC TESTING FOR VENTRICULAR ARRHYTHMIAS IN PATIENTS WITH MITRAL ANNULAR DISJUNCTION

Mitral annular disjunction (MAD), with or without mitral valve prolapse (MVP), is associated with a higher risk of ventricular arrhythmias (VA) and sudden cardiac death. The prognostic significance of VA inducibility during electrophysiological studies (EPS) in patients with MAD is unclear. To assess the prognostic significance of VA inducibility in patients with MAD undergoing EPS. We included 21 patients with MAD and no history of sustained VAs who underwent EPS for risk stratification. Patients who underwent ablation of any VA during the same procedure were excluded. EPS protocol included programmed ventricular stimulation with up to triple extrastimuli and with burst pacing from 2 ventricular sites. Post-EPS events including sustained VAs, appropriate implantable-cardioverter defibrillator (ICD) shocks, and sudden death, were assessed according to the EPS results. Mean age at the time of EPS was 46±16 years, and 15 (71.4%) patients were female. Mean MAD length was 10±4 mm. 18 (85.7%) patients had MVP (bileaflet MVP in 15 patients and posterior MVP in 3 patients). Non-sustained ventricular tachycardia (NSVT) was induced in 2 (9.5%) patients, sustained monomorphic ventricular tachycardia (VT) in 4 (19%) patients, and ventricular fibrillation (VF) in 9 (42.9%) patients, while six (28.6%) patients had no inducible VAs. 10 (47.6%) patients underwent ICD implantation due to inducible sustained VT (n=4) or VF (n=6), while 5 (23.8%) patients received an implantable loop recorder (ILR). After a median follow-up of 18.9 months, 4 (19%) patients had incident sustained VT or VF, all among patients with an ICD. These events occurred in 2 of the 4 patients with inducible VT and 2 of the 9 with inducible VF, while no events occurred in those with inducible NSVT or no inducible VAs. Inducible sustained VT or VF at EPS did not demonstrate a statistically significant association with incident sustained VAs (p=0.13). No deaths occurred in any patients in this series. More than half of patients with MAD referred for risk stratification EPS had inducible sustained VT or VF. Inducibility of VT/VF was not statistically associated with incident sustained VAs though this analysis is limited by the small sample size. Larger prospective studies are needed to clarify the role of EPS with standardized protocols in the risk stratification of patients with MAD, including investigation of the value of right and left ventricular stimulation.

Comparison of early and late postoperative outcomes between chordal reconstruction and quadrangular resection in patients with posterior mitral valve prolapse: a single-center retrospective study

BackgroundTo compare the early and late postoperative outcomes of chordal reconstruction (CR) and quadrangular resection (QR) in patients with posterior mitral valve prolapse (PMPL).MethodsBetween January 2008 and December 2018, 305 patients with PMPL who underwent mitral valve plasty (MVP) were included in this retrospective analysis. The CR and QR procedures were performed in 169 patients (CR group) and 136 patients (QR group), respectively. Early and late postoperative outcomes were compared between the groups.ResultsFollow-up was complete in 96.4% (294/305) of patients, with a mean follow-up of 81.2 ± 30.4 months. No 30-day mortality was observed in any of the patients. The success rate of the mitral valve repair was similar in both groups (99.4% vs. 98.5%, P = 0.850). The incidence of early postoperative hemolysis was lower in the CR group than in the QR group (0.00% vs. 3.0%, P = 0.024). Postoperative left ventricular end-diastolic diameter (LVEDD) decreased more significantly in the CR group than in the QR group at 3 months (8.15 [1.30,12.65] vs. 3.25 [− 0.05, 8.75] mm, P < 0.001). During follow-up, the overall survival rates were 95.1% and 94.6% in the CR and QR groups, respectively. The incidence of reoperation for moderate or severe mitral regurgitation (MR) was similar in both groups (4.3% vs.5.4%, P = 0.653), but the time interval between the initial operation and reoperation was shorter in the QR group than in the CR group (84.3 ± 36.1 vs. 120.9 ± 27.6 months, P = 0.026). The LVEDD enlargement was more significant in the QR group than in the CR group (4.5 [3.6, 4.5] vs. 2.4 [1.3, 2.8] mm, P < 0.001).ConclusionCR and QR are effective techniques for patients with PMPL. Both techniques resulted in a low incidence of recurrent MR. However, CR can reduce early postoperative hemolysis and LVEDD more significantly. During the long-term follow-up, reoperations due to recurrent MR were performed at a longer interval after the initial operation. LVEDD expansion was better avoided in the CR group.

Sinus of Valsalva Aneurysm in Females.

Sinus of Valsalva aneurysm (SVA) is a rare cardiovascular disease with male predominance. Recently, an association with aortic aneurysm and SVA has been revealed in periventricular nodular heterotopia patients with loss-of-function Filamin A (FLNA) mutations, which were located on chromosome X and almost exclusively affect females.Among patients hospitalized for aortic surgery with aortic root diameter over 4.0 cm, next-generation sequencing was performed to investigate 30 candidate genes related to inherited aortic aneurysm syndromes and familial thoracic aortic aneurysm and dissection. The present report reviewed an electronic case database and identified two female cases of unruptured SVA with heterozygous FLNA truncating mutations.Case 1 displaying a rare SVA phenotype involving left and noncoronary sinus harbored a nonsense variant p.Tyr1720Ter/c.5160C > G. Case 2 displayed right and noncoronary SVA with predominantly enlarged right coronary sinus, posterior mitral valve prolapse, and harbored a frameshift variant p.Val1724fs*68/c.5171_5172delTG. Both novel mutations resulted in the premature termination of filamin A with the loss of functional Rod 2 and dimerization region.The present report raised the possibility of the presence of a cardiovascular onset form in the spectrum of FLNA hereditary diseases. The association between SVA and loss-of-function FLNA mutations indicates a unique etiology and pathogenesis among female patients, which requires further investigation to establish the linkage between FLNA variants and a wide spectrum of phenotypes.

Leaflet plication with neochordae implantation: A novel technique for mitral valve repair.

Leaflet plication with neochordae implantation: A novel technique for mitral valve repair.

Clinical impact of the repair technique for posterior mitral leaflet prolapse: Resect or respect?

Leaflet resection and chordal reconstruction are established repair techniques for posterior mitral valve (MV) prolapse. This study aimed to compare the clinical results of the resect and respect approaches, with a particular focus on MV hemodynamics. Overall, 291 patients who underwent elective MV repair for isolated posterior leaflet prolapse between 2012 and 2020 were enrolled. Patients who underwent leaflet resection alone were classified as the "resection" group (n = 166), while patients who underwent neochordal replacement with/without limited leaflet resection were classified as the "respect" group (n = 125). Early postoperative MV hemodynamics and midterm repair durability were compared between the groups. The annuloplasty ring size was significantly larger in the respectgroup than in the resection group (31.0 ± 2.1vs. 30.4 ± 2.0 mm, p = .028). The respectgroup showed significantly lower mean MV gradient (2.6 ± 1.1vs. 3.0 ± 1.4 mmHg, p = .03) and larger effective orifice area (EOA) (1.86 ± 0.48vs. 1.66 ± 0.47 cm2 , p < .001) than the resection group. Multivariable analysis identified the respect approach, younger age, female sex, larger ring size, and partial band as independent determinants of larger EOA. The rate of freedom from moderate or greater recurrent mitral regurgitation 5 years postoperatively was 90.9% in both groups. The respect approach allowed for a lower MV gradient and a larger EOA than the resection approach, which is possibly due to the capability of implanting a larger annuloplasty ring.

Management and outcomes in mitral valve prolapse with ventricular arrhythmias undergoing ablation and/or implantation of ICDs.

While there is an association between isolated mitral valve prolapse (MVP) and sudden cardiac arrest (SCA), the baseline characteristics and outcomes of patients with isolated MVP who experience ventricular arrhythmias (VAs) and then subsequently undergo catheter ablation and/or implantable cardioverter defibrillator (ICD) implantation are unknown. We performed a retrospective review of all patients at the Cleveland Clinic with isolated MVP between 1997 and 2016 who underwent VA catheter ablation or secondary prevention ICD implantation. Of 617 screened patients, we identified 43 patients with isolated MVP and significant VA who underwent ICD placement (n=13, 30%) or catheter ablation (n=30, 70%). Both leaflets were most commonly involved (n=22, 52%) with posterior MVP being next most common (n=15, 36%). The most common foci of VA origin was the left ventricular papillary muscle (n=9, 27%). Ablation was successful in the majority of cases (n=20, 65%). At a mean follow-up of 2.5 years, 11 patients (26%) had recurrent VT. Patients with isolated MVP and VA were more likely to have bileaflet prolapse and at least moderate mitral regurgitation. VA originated more commonly from left-sided foci. While ablation was acutely successful in the majority of cases, there was still a moderate rate of VA recurrence. There is still more study needed on factors that will predict malignant VAs and management of these VAs in the MVP population.

Abstract 16731: Novel CMR Anatomical Predictors of Mitral Regurgitation Presence and Severity in Mitral Valve Prolapse

Introduction: Mitral valve (MV) prolapse (MVP) is often associated with mitral regurgitation (MR). The determinants of MR in MVP are incompletely understood. Methods: We retrospectively identified 86 consecutive patients with MVP and preserved ejection fraction undergoing CMR with velocity encoding for MR quantification between 2005 and 2017. On 3-chamber cine images we measured, in end-diastole (Figure), end-systole, and their percentage change during the cardiac cycle, the following parameters: basal and mid inferolateral wall thickness, posterior papillary muscle length, annulus diameter, LV diameter and distance from the posterior papillary muscle to anterior and posterior annulus. In addition, we measured anterior and posterior leaflet thickness in diastole and maximal prolapse distance in end-systole. We explored the associations between these parameters and mitral regurgitant fraction (RF) using multivariate linear regression. Results: Median age was 52.6 years and 48% were males. There was posterior MVP in 49 (57%), bileaflet MVP in 35 (41%) patients, and isolated anterior MVP in 2 (2%) patients. MR was present in 73 (85%) and, in these, median RF was 23% (IQR 13-33%). In multivariate analyses, diastolic papillary muscle to posterior annulus distance, maximal prolapse distance, maximal posterior leaflet thickness, and LV basal inferolateral diastolic thickness were independent predictors of mitral RF (p&lt;0.05 for all). Conclusions: Beyond known determinants of MR in MVP such as maximal prolapse and leaflet thickness, we identified novel anatomical predictors of MR severity, namely increased diastolic papillary muscle to posterior annulus distance and LV basal inferolateral thickness. Whether these abnormalities represent secondary changes to MVP (i.e. basal inferolateral “stretch” and compensatory regional LV hypertrophy, respectively) or primary phenotypic features of the MVP syndrome is uncertain.

Echocardiographic Assessment of Young Male Draft-Eligible Elite Hockey Players Invited to the Medical and Fitness Combine by the National Hockey League

The "athletic heart" is characterized by hypertrophy and dilation of the heart, in addition to functional and electrical remodeling. The aim of this study was to provide reference 2-dimensional (2DE) and 3-dimensional (3DE) echocardiographic measurements in a large database on draft-eligible elite ice hockey players and to determine the frequency of occult cardiac anomalies in this cohort of athletes. In this prospective cohort study, we performed a comprehensive cardiac assessment of the 100 top draft picks selected by the National Hockey League. Complete 2DE and 3DE examinations were performed to obtain comprehensive measurements of cardiac structure and function at rest, which were compared with nonathlete controls. A total of 592 athletes were evaluated (mean age 18 ± 0.5years) from 2009 to 2014 at the National Hockey League combine. 2DE and 3DE ventricular, atrial dimensions, and left ventricular mass were significantly greater in the athletes compared with controls. Abnormalities were identified in 15 hockey players (2.5%) consisting of a bicuspid aortic valve in 10 (1.7%), patent ductus arteriosus in 1 (0.2%), low normal left ventricular systolic function in 2 (0.3%), an idiopathic pericardial effusion in 1 (0.2%), and posterior mitral valve prolapse in 1 (0.2%). In conclusion, intense ice hockey training is associated with typical myocardial adaptations and the frequency of cardiac anomalies found in this cohort of young elite hockey players is low and does not differ significantly from the reported incidences in the general population.

A Rare Case of Anomalous Original Left Circumflex Artery Stenosis After Artificial Mitral Valve Replacement

A 72-year-old woman was admitted because of progressive 9-year chest tightness. Nine years ago, she underwent mitral valve replacement using a Hancock II porcine mitral valve bioprosthesis (size 27) (Medtronic, Minneapolis, Minnesota) for posterior mitral valve prolapse. Pre-operative coronary

A systematic review and meta-analysis of chordal replacement versus leaflet resection for isolated posterior mitral valve prolapse.

Chordal replacement (Chord MVr) for isolated posterior mitral valve prolapse allows for preservation of the native mitral valve apparatus. The potential benefits of this approach, as compared with leaflet resection (Resection), are not clearly defined. A systematic review and meta-analysis was conducted on operative, clinical, and echocardiographic outcomes. Risk ratios (RR) were calculated by the Mantel-Haenszel method under a fixed or random effects model, as appropriate. Eight studies were included, with a total of 1922 patients (Chord MVr, N.=835; Resection, N.=1087). Baseline characteristics were similar, except for a higher incidence of atrial fibrillation in the Chord MVr group (15.5% versus 9.9%, P=0.03), and a slightly greater mitral regurgitation grade in the Resection group (3.5 versus 3.4, P=0.008). P2 segment prolapse was the most common pathology, however, patients undergoing Chord MVr had a higher incidence of multi-segment prolapse (32.1% versus 13.9%, P=0.0006). There was no difference in operative mortality (1.1% for both) or perioperative complications. At a mean follow-up of 2.9±2.8 years (median=2.8 years, IQR 1.6-4.4), Chord MVr was associated with a lower risk of reoperation (1.1% versus 4.3%; RR 0.26, 95% CI 0.12-0.56, P=0.0007), and similar survival and recurrence of moderate mitral regurgitation, when compared with Resection. Finally, a lower transmitral gradient (2.5 versus 2.8 mmHg, P=0.0004) and larger orifice area (3.2 versus 3.0 cm2, P=0.002) were observed with Chord MVr. At 2.9-year follow-up, Chord MVr for isolated posterior mitral valve prolapse was associated with a lower reoperation rate and favorable valve hemodynamics, when compared with leaflet resection.

P210Long- term outcome of primary mitral valve prolapse: results from a population of 250 patients referred to a tertiary cardiovascular center.

Outcome of Mitral Valve Prolapse (MVP) was controversial for long time. Many studies reported great differences in the incidence of cardiovascular events due, above all, to heterogeneous and small studied populations. Most of theme were also published to late '80 of the last century till early '00. To make a contemporary survey on the incidence of cardiovascular events in a selected population of patients affected by primary MVP referred to a tertiary cardiovascular center for the medical and surgical care of valvular heart disease. We reviewed our MVP database; patients with at least 2 cardiologic evaluations inclusive of echocardiographic examination and at least 6 months follow up were enrolled. A total of 250 patients (126 F) were selected. Their mean age was 52.1 years (ranging from 13 to 88 yo). The average follow-up time was 100 months (8,33 yrs). At the first medical and echocardiographic examination 8 patients (3,2%) had no mitral regurgitation (MR), 104 (41.6%) have a trace/mild MR, 93 (37,2%) a moderate MR and 46 (18,4%) a severe MR. They were widely asymptomatic (NYHA I 205-82%, NYHA II 44-17.60%, NYHA III 1- 0.40%). Most of theme presented a bileaflet (140-55.8%) or a posterior MVP (94 - 37.6%); an isolated anterior MVP was rare (16 - 6,4%). Flail leaflet was present in 8 (3,2%) and 25 (10%) had a chordal rupture. Respectively 165 (65,6%) and 115 (46,1%) patients had thick and redundant leaflets. Mean antero-posterior mitral annulus diameter was 37 mm. During the follow up 7 patients died of non-cardiac cause and 5 (2%) of suspected cardiac cause (2 because of acute coronary syndrome and 3 died suddenly). MR progresses in 43 (17,2%) patients and finally we observed 81 (32,4%) moderate/severe and severe MR. 12 new chordal rupture occurred during the follow up in most cases concerning mitral chordae linked to posterior mitral leaflet (10 cases-83,3%). The worsening of MR provoked an evolution of the clinical condition of 48 patients (19.2%) which developed Dyspnea On Excertion (DOE) with 42 new NYHA II and 6 new NYHA III. At the end of the follow up the amount of patients symptomatic for DOE was 93 (37.2% vs 18% at the initial evaluation). A total of 45 patients (18%) underwent mitral valve surgery. 40 needed in-hospital treatment in most cases due to the development of atrial fibrillation (19 -7.6%) or heart failure ( 8- 3,2%). Endocarditis occurred in 4 patients (1.6%) and cerebrovascular accidents/cardioembolic event in 6 (2.4%). The overall cardiovascular event rate was 4,33/100 patients-year, significantly higher than reported in community based studies. The prognosis of a MVP population referred to a tertiary cardiovascular center is not benign. The most frequent complications are progression of MR and MV surgery. Sudden death is also more frequent than in general population. More studies are needed to identify what patients with MVP are at risk for it.

Equivalent Short-term Outcomes for Minimally Invasive Repair of Anterior, Posterior and Bi-Leaflet Mitral Valve Prolapse

Equivalent Short-term Outcomes for Minimally Invasive Repair of Anterior, Posterior and Bi-Leaflet Mitral Valve Prolapse

Evolution of Mitral Valve Prolapse: Insights From the Framingham Heart Study.

Longitudinal studies of mitral valve prolapse (MVP) progression among unselected individuals in the community, including those with nondiagnostic MVP morphologies (NDMs), are lacking. We measured longitudinal changes in annular diameter, leaflet displacement, thickness, anterior/posterior leaflet projections onto the annulus, coaptation height, and mitral regurgitation jet height in 261 Framingham Offspring participants at examination 5 who had available follow-up imaging 3 to 16 years later. Study participants included MVP (n=63); NDMs, minimal systolic displacement (n=50) and the abnormal anterior coaptation phenotype (n=10, with coaptation height >40% of the annulus similar to posterior MVP); plus 138 healthy referents without MVP or NDMs. At follow-up, individuals with MVP (52% women, 57±11 years) had greater increases of leaflet displacement, thickness, and jet height than referents (all P<0.05). Eleven participants with MVP (17%) had moderate or more severe mitral regurgitation (jet height ≥5 mm) and 5 others (8%) underwent mitral valve repair. Of the individuals with NDM, 8 (80%) participants with abnormal anterior coaptation progressed to posterior MVP; 17 (34%) subjects with minimal systolic displacement were reclassified as either posterior MVP (12) or abnormal anterior coaptation (5). In comparison with the 33 participants with minimal systolic displacement who did not progress, the 17 who progressed had greater leaflet displacement, thickness, coaptation height, and mitral regurgitation jet height (all P<0.05). NDM may evolve into MVP, highlighting the clinical significance of mild MVP expression. MVP progresses to significant mitral regurgitation over a period of 3 to 16 years in one-fourth of individuals in the community. Changes in mitral leaflet morphology are associated with both NDM and MVP progression.

Interactions between mitral valve and left ventricle analysed by 2D speckle tracking in patients with mitral valve prolapse: one more piece to the puzzle.

Two-dimensional echocardiography often reveals abnormal left ventricle (LV) lateral wall kinetics in patients presenting with mitral valve prolapse (MVP). However, relations between MVP and LV deformation are not clearly established. The aim of this study was to assess and quantify mitral valve chordae, leaflets, and LV myocardial interactions using speckle tracking echocardiography (STE). Using STE-derived longitudinal strain curves, LV peak longitudinal strain (PLS, %), post-systolic index (PSI), and pre-stretch index (PST) were analysed in 100 patients with MVP and normal LV ejection fraction. Global, regional, and segmental values were compared according to mitral regurgitation severity and MVP location. Twenty healthy subjects served as control patients. There was no significant difference among control and MVP group for global and regional PLS (-23.7 ± 3.2 vs. -23.1 ± 2.2). In contrast, patients with MVP had significantly higher values of global PST (3.2 ± 4.1 vs. 1.3 ± 1.2; P = 0.01) and global PSI (3.2 ± 0.4 vs. 1.7 ± 1.1; P = 0.05) compared with controls, located mainly in the lateral wall and basal segments. Both anterior and posterior MVPs were responsible for PSI in basal inferior segments and PST in anterior ones. Mid-wall segmental deformation pattern changes were mainly observed at the level of the segments adjacent to the papillary muscle. This study supports the hypothesis that pathological early-systolic shortening and late systolic, post-systolic deformation are attributed to an increased interaction between wall deformation and mitral valve events in patients with MVP. STE is a useful tool in the assessment of interplays between MV leaflets and myocardium and helps to demonstrate changes in temporal pattern of myocardial deformation.

Reverse remodeling of left heart following mitral valve repair in case of mesenchimal dysplasia

Objectives. Volume overload in mitral regurgitation leads to compensatory dilation of the left heart chambers. Surgical correction promotes reverse remodeling of the heart. In this study, focus was placed on the changes in the left heart resulted from mitral regurgitation correction by using two different surgical techniques for mitral valve repair. Methods. 94 patients with posterior mitral valve prolapse were randomized in two groups. The first group patients underwent artificial chordal replacement, while a leaflet resection technique was used for the patients of the second group. Preoperative transthoracic and intraoperative transesophageal echocardiography was performed for all patients and data were obtained at 10-12 days after surgery and during long-term follow up. Results. In the early postoperative period, significant reverse remodeling of the left heart chambers was observed (LA 5.4-4.6, p <0.05; LVEDD 5.8-4.9 p <0.05; LVESD 3.6 - 3.1 p <0.05) - LA 5.2 - 4.5 p <0.05; LVEDD 5.8 - 4.8 p <0.05; LVESD 3.5 - 3.2 p <0.05. The mitral valve orifice area in the groups was 3.3 - 3.3 - 3.2 when replacing chords and 3.5 - 3.4 - 3.2 when doing resection, with p being equal to 0.32, 0.36 and 0.51 respectively. The mean diastolic gradient in the first group was 2.0 - 3.0 - 3.0 mm Hg, while in the second one it amounted to 2.3 - 3.2 - 3.3 mmHg, with p <0.05. Conclusion. The authors conclude that significant remodeling of the left heart occurs in the early postoperative period. In the immediate postoperative period, the mitral valve area tends to decrease and the gradient has a tendency to increase in both groups, with no significant changes observed in the late postoperative period.

Strain balance of papillary muscles as a prerequisite for successful mitral valve repair in patients with mitral valve prolapse due to fibroelastic deficiency

The aim of this study was to assess the papillary muscle strain as a contributor to recurrent mitral regurgitation (MR) after mitral valve repair for fibroelastic deficiency. Sixty-four patients with isolated posterior mitral valve prolapse and severe MR referred for surgery were prospectively recruited between 2008 and 2012. Two- and three-dimensional echocardiography and speckle tracking were performed in all patients. The longitudinal strain of the anterolateral (AL) and posteromedial (PM) papillary muscles was individually calculated as well as the global longitudinal strain of both papillary muscles was measured before and after mitral repair and normalized to left ventricle end-diastolic volume. Eight patients (12.5%) had at least moderate MR 6 months after mitral repair. The longitudinal strain of the AL (preop -4.94 ± 2.2 vs. postop -3.28 ± 1.3, P < 0.001) and the PM papillary muscles (preop -12.64 ± 5.3 vs. postop -4.12 ± 6.77, P < 0.001) as well as the global strain of both papillary muscles (preop -7.59 ± 3.48 vs. postop -1.07 ± 6, P < 0.001) were all reduced after surgical repair. The longitudinal strain of the PM papillary muscle was the strongest predictor of recurrent MR (when less than or equal to -14.78). The global preoperative papillary muscle strain was also a determinant of recurrent MR when the global strain was greater than -9.05% (area under the curve: 0.895, sensitivity: 100%, and specificity: 76.8%). Patients with isolated posterior mitral leaflet prolapse are less likely having any residual MR post repair when the global papillary muscle strain of both papillary muscles is close or equal to zero. Strain of the papillary muscles may be an important determinant in predicting residual MR in patients who undergo mitral valve repair.