Anterior Mitral Leaflet Prolapse Research Articles

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.

P161 INCIDENTAL FINDING OF QUADRICUSPID AORTIC VALVE IN A YOUNG ASYMPTOMATIC PATIENT

Abstract Background Quadricuspid aortic valve (QAV) is a rare congenital heart disease, eventually leading to aortic regurgitation (AR) and heart failure. In up to one–third of patients, QAV is associated with other coexisting cardiac defects, particularly aortic dilation and coronary arteries abnormalities. Case Report A 48–years old man without significant past medical history was referred to the Cardiologist for newly diagnosed arterial hypertension. The patient was asymptomatic and no abnormal findings were noticed on physical examination. Transthoracic echocardiography showed normal end–diastolic volume and diameter of the left ventricle and preserved systolic function. However, a mild dilation of the aortic root (40 mm) and ascending aorta (38 mm) with concomitant moderate–to–severe AR were described. Transoesophageal echocardiogram (TOE) was performed to better visualize the aortic valve anatomy and to define the exact mechanism of the AR. 2D–TOE revealed a QAV with equal–sized cusps (type A according to the Hurwitz–Roberts classification), with a central quadrangular coaptation defect and a moderate AR (vena contracta width: 4 mm) [Fig. 1–2]. The regurgitant jet conditioned a pseudo–prolapse of anterior mitral leaflet with consequent mild–to–moderate mitral regurgitation. 3D–TOE allowed a better characterization of valve morphology and the individuation of the sole left coronary artery ostium. A coronary artery computed tomography was requested to investigate a probable abnormal origin of the right coronary artery. The patients was subsequently addressed to a regular clinic and echocardiographic follow–up for the surveillance of AR and aortic dimensions and a prompt management of an eventual symptoms onset. Discussion We describe a rare case of type A QAV with moderate AR, mild dilation of aortic root and ascending aorta and suspected anomalous origin of the right coronary ostium. The broad diffusion of imaging techniques has recently led to an increase of incidental diagnosis, even in asymptomatic patients. The complex valve anatomy, with many possible morphologies of the supernumerary cusp, and the association with other congenital defects, particularly anomalous coronary ostia location, pose many technical issues in case of valve replacement. A multimodality imaging approach is essential for a clear description of valve morphology and coronary anatomy to avoid intraoperative complications in both surgical and percutaneous valve replacement procedures.

Minimally Invasive Mitral Valve Repair Through Right Minithoracotomy - 11-Year Single Institute Experience.

Although minimally invasive mitral valve repair (MIMVR) is increasingly being performed, only a few clinical studies from Japanese institutions have been reported.Methods and Results:From 2006 to 2017, 387 consecutive patients (135 females, mean age 56±13 years) underwent an initial isolated MIMVR through a right minithoracotomy. The mitral etiology was degenerative in 348, functional in 22, and endocarditis in 13 cases. Repair techniques included leaflet resection/plication in 280, chordal reconstruction in 109, and annuloplasty alone in 24 patients, and concomitant procedures included tricuspid valve repair and atrial fibrillation ablation in 70 (18.1%) and 78 (20.2%), respectively. Hospital mortality rate was 0.26%; 2 patients (0.5%) required intraoperative conversion to a median sternotomy. Perioperative morbidity included stroke (1.3%), reoperation for bleeding (0.8%), prolonged ventilation (0.5%), and permanent pacemaker implantation (2.1%). The transfusion rate was 14.7% and median ventilation time was 4 hours. Overall 5-year survival was 96.9%. For patients with degenerative mitral regurgitation (MR), the 5-year freedom from reoperation or severe recurrent MR, and freedom from ≥moderate MR were 94.7% and 82.2%, respectively. Repair for anterior mitral leaflet prolapse and the initial 30 cases were associated with higher occurrence of recurrent MR. MIMVR can be performed safely with low levels of mortality and morbidity, and provides sufficient repair durability. A learning curve exists in terms of repair durability, especially for anterior mitral leaflet repair.

Some health aspects of children born with different types of intrauterine growth restriction during the early neonatal period

Aim. To evaluate some health aspects of children born with different types of intrauterine growth restriction during the early neonatal period.Methods. Clinical and anamnestic, physical, laboratory, electrophysiological, ultrasound and statistical methods were used. Children’s past medical history, development during early neonatal period, physical development, functioning of autonomic nervous system and cardiovascular system were assessed.Results. It was revealed that development of different types of intrauterine growth restriction is related to father and mother’s age at the time of pregnancy, women’s body mass before pregnancy, and time of pregnancy complication development (abortion risk, pre-eclampsia, arterial hypertension, Rh-immunization, edema). Fetuses with asymmetric type of intrauterine growth retardation had survived hypoxia more often (by 4.87 times). Children with symmetrical type of intrauterine growth retardation were more often born by C-section (by 2.66 times), with smaller anthropometric measurements, with more frequent and severe hypotrophy, moderate and severe cerebral ischemia and mild intracranial hemorrhage, cryptorchidism, kidney diseases, atrial septal defects, muscular ventricular septal defects, open arterial duct, and depleted reserves. Children with asymmetric type of intrauterine growth retardation more often had hypoglycemia, jaundice, polycythemia, restricted adaptation reserves, myocardial metabolic disorders, anterior mitral valve leaflet prolapse, posthypoxic changes similar to hypertrophic cardiopathy.Conclusion. Revealed features of past medical history, development during early neonatal period of life, physical development, functioning of autonomic nervous system and cardiovascular system in different types of children’s intrauterine growth restriction can promote formulation of criteria for early diagnosis of adaptive and reserve disorders and identification of dispensary groups.

The Premature Ventricular Contraction-Induced Mitral Valvular Cardiomyopathy Successfully Treated by Radiofrequency Ablation: A Case Report

[Case report] A 70-year-old man referred to our hospital because he suffered from New York Heart Association (NYHA) functional class 2 heart failure symptoms. The electrocardiogram showed frequent monomorphic premature ventricular contractions (PVCs). The echocardiogram showed moderate mitral regurgitation (MR) due to anterior mitral leaflet (AML) prolapse with reduced left ventricular ejection fraction (LVEF)of 48%. Coronary angiography showed 99% stenosis in right coronary artery and 75% stenosis in left anterior descending artery. First, we conducted percutaneous coronary intervention because he refused surgical therapy. Although complete revascularization was achieved, PVCs were not disappeared and heart failure (HF) was not improved. Next, we conducted simultaneous lidocaine challenge test and left ventriculogram showing PVC disappearance and accompanying MR improvement in Sellers classification of 2 from 3. We considered that PVCs caused both HF and MR. PVCs were disappeared and improved MR to 2 from 3. The radiofrequency ablation (RFA) was conducted, and PVCs, which arose from aorto-mitral continuity, was successfully ablated at earliest activation site. PVCs have not recurred after RFA resulting continuous MR improvement and LVEF normalization. He spends free from HF symptoms for 14 months.[Conclusion] We report a rare case of mitral valvular cardiomyopathy, in which both reduced LVEF and moderate AML prolapsing MR were successfully treated by PVC ablation.

0117: Left ventricular mechanics in mitral valve prolapse: a longitudinal strain study

Valve apparatus alterations may influence left ventricular (LV) mechanics in mitral valve prolapse (MVP). To assess LV mechanics and ventriculo-valvular interaction in MVP. A comprehensive echocardiography including 2D speckle tracking myocardial longitudinal strain assessment was carried out in 194 adult patients with MVP (leaflet displacement >2mm above the annulus) and 30 matched controls. In MVP group mitral regurgitation (MR) was not significant in 76 (39%) patients (NoMR-MVP, effective regurgitant orifice <10mm 2 ), mild to moderate in 53 (27%) and severe in 65 (34%) patients. Posterior (PML) and/or anterior (AML) mitral leaflet prolapse were present in 188 (93%) and 85 (42%) patients, respectively. PML and AML positions averaged –6.0±3.4mm and –1.6±3.5mm, respectively. Ventriculo-atrial disjunction was found in 82 (41%) patients and averaged 5.7±1.6mm. Posterior wall thickening was clearly increased in MVP groups with frank wall bulging in 82 patients (41%). Despite the third left chamber (between mitral annulus and prolapsed leaflets) forward stroke volume was preserved in MVP groups, and even increased in NoMR-MVP (44±9mL/m 2 vs 39±9mL/m 2 in Controls, p<0.001). In addition LV EF was improved in NoMR-MVP. Global Longitudinal Strain (GLS) was also improved in NoMR-MVP (–21.5±2.8%) and in the overall MVP group (–21.7±3.0%) compared with Controls (–19.7±1.7%, both P<0.001). In multivariate analysis GLS improvement was associated with the magnitude of PML prolapse (β=0.14, P=0.04), posterior wall thickening (β=–0.16, P=0.004), posterior papillary muscle displacement in systole (β=–0.21, P=0.002) and posterior wall bulging (β=–0.23, P<0.001). MVP and associated abnormalities have a significant impact on LV mechanics. LV systolic function is improved in MVP as assessed by EF and GLS and preserves forward stroke volume. These changes might have significant effect at long-term on LV myocardium.

Very long-term durability of the edge-to-edge repair for isolated anterior mitral leaflet prolapse: Up to 21 years of clinical and echocardiographic results

To assess the very long-term clinical and echocardiographic results of the edge-to-edge repair for mitral regurgitation (MR) due to isolated prolapse or flail of the anterior leaflet. From 1991 to 2004, 139 patients (age, 54±14.4 years; left ventricular ejection fraction 56%±7.8%, New York Heart Association class I-II in 68.9%, atrial fibrillation in 20.1%) with severe degenerative MR due to isolated segmental prolapse or flail of the anterior leaflet were treated with the EE technique combined with annuloplasty. MR had resulted from prolapse or flail of the central scallop of the anterior leaflet (A2) in 105 patients (75.5%) and scallops A1 or A3 in 34 (24.4%). No hospital deaths occurred. At hospital discharge, MR was absent or mild in 130 patients (93.5%) and moderate (2+/4+) in 9 (6.4%). The clinical and echocardiographic follow-up data were 97.1% complete (mean length, 11.5±3.73 years; median, 11; longest duration, 21.5). At 17 years, the actuarial survival was 72.4%±7.89%, freedom from cardiac death was 90.8%±4.77%, and freedom from reoperation was 89.6%±2.74%. At the last echocardiographic examination, recurrence of MR grade≥3+ was documented in 17 patients (17 of 135, 12.5%). Freedom from MR grade≥3+ at 17 years was 80.2%±5.86%. At multivariate analysis, the predictors of MR recurrence grade≥3+ were residual MR greater than mild at hospital discharge (hazard ratio, 7.4; 95% confidence interval, 2.5-21.2; P=.0001) and the use of posterior pericardial rather than prosthetic ring annuloplasty, which was very close to statistical significance (hazard ratio, 2.8; 95% confidence interval, 0.9-8.7; P=.06). In patients with MR due to segmental anterior leaflet prolapse, the very long-term results of the edge-to-edge repair combined with annuloplasty were excellent.

Bilateral branch pulmonary artery stenosis and Mitral valve prolapse in a patient with Noonan syndrome: A case report

Rasopathy syndromes are a class of phenotypically similar, but genetically distinct multiple anomaly syndromes caused by germ line mutations in genes that encode protein components of the Ras/mitogen activated protein kinase (MAPK) pathway. Noonan syndrome, cardiofaciocutaneous syndrome and Costello syndrome are part of this group of developmental syndromes and have similar cardiac abnormalities. A 19-year-old male presented with complaints of exertional breathlessness class I for 6 months. Clinical examination revealed characteristic facial features, skeletal abnormalities, growth and neurocognitive problems reported in patients with Noonan syndrome. There was evidence of severe pulmonary hypertension. Trans-thoracic echocardiography revealed right atrial and right ventricular enlargement, severe pulmonary hypertension, no intra cardiac shunt, prolapse of anterior mitral leaflet with mild mitral regurgitation. CT pulmonary angiogram revealed bilateral branch pulmonary artery stenosis. A final diagnosis of Noonan syndrome was made.

Repair of Anterior Mitral Leaflet Prolapse: Comparison of Midterm Outcomes With Chordal Transposition and Chordal Replacement Techniques

Mitral valve surgery for anterior leaflet prolapse is considered more difficult than repair of the posterior leaflet. Most used techniques consist in chordal transposition from the posterior to the anterior leaflet, and chordal replacement using expanded polytetrafluoroethylene sutures. The aim of this study was to compare the midterm outcomes of anterior leaflet repair using chordal transposition and chordal replacement techniques.

All anterior and bileaflet mitral valve prolapses are repairable in the modern era of reconstructive surgery

Although mitral valve repair is the preferred treatment for degenerative mitral valve disease, valve replacement still remains prevalent, particularly in the setting of anterior leaflet prolapse. We sought to determine the feasibility and mid-term durability of a lesion-based surgical strategy applied systematically in a consecutive and nonexclusionary (all comers) series of patients with degenerative mitral valve disease and either isolated anterior leaflet or bileaflet prolapse. From January 2002 to December 2010, 188 consecutive patients [mean age 56 ± 14 years (range 12-86), 31% female, mean left ventricular ejection fraction 55 ± 9%] underwent surgery for degenerative anterior mitral leaflet prolapse [isolated (n = 42, 22%) or bileaflet prolapse (n = 146, 78%)]. Degenerative aetiology was Barlow's disease in 110 (58%) patients and fibroelastic deficiency in 78 (42%). Patients with anterior leaflet prolapse were significantly more symptomatic (New York Heart Association functional Class III-IV) than those with bileaflet prolapse (28.6 vs 9.6%; P = 0.003) at the time of surgery. All patients underwent mitral valve repair and ring annuloplasty. There was 1 immediate valve replacement due to atrioventricular groove bleeding and consequent haematoma in an elderly female patient (99.5% repair rate). Predominant repair techniques were polytetrafluoroethylene neochordoplasty (or loop technique) in 93 (49%) patients, chordal transfer in 86 (46%) and posterior leaflet flip technique in 21 (11%). Median length of stay was 6 (interquartile 5-8) days. In-hospital mortality was 1% (n = 2). Predischarge transthoracic echocardiography showed none to trace mitral regurgitation in 91% of the patients and mild mitral regurgitation in 9%. The Kaplan-Meier estimates for cumulative survival at 1 and 7 years were 98.4 ± 0.9 and 88.7 ± 2.2%, respectively. Freedom from ≥ moderate mitral regurgitation was 100% at 1 year, 93.7 ± 2.2% at 4 years and 90.3 ± 3.7% at 7 years. When the interval-censored estimator was used, freedom from ≥ moderate mitral regurgitation at 1, 4 and 7 years was 100, 96 and 92%, respectively. A lesion-based surgical approach with an intention to repair all degenerative valves with anterior leaflet prolapse was applied to a consecutive series of patients with degenerative mitral valve disease. We were able to achieve a near-100% repair rate. Repair of all degenerative valves may be feasible with good mid-term durability, regardless of valve morphology, patient age or comorbidities.

Three-dimensional echocardiography and operative imaging of a false tendon connecting the left atrial wall to the anterior mitral leaflet

A 55-year-old woman was referred to our hospital for mitral valve regurgitation. An echocardiogram showed an anterior mitral leaflet prolapse and moderate mitral regurgitation, but neither elongation nor chordae cutting was observed. A tendon-like structure from the left atrial side of the foramen ovale to the anterior mitral leaflet …

The use of a functional technique for neo-chords’ length determination during reconstructive operations for degenerative mitral regurgitation

Aim. To evaluate to effectiveness and safety of the functional technique of measuring the length neo-chords during reconstructive operations on the mitral valve for degenerative mitral regurgitation. Methods. The study included 34 patients, in whom the method of chord prosthesis with polytetrafluoroethylene sutures was used for correction of the anterior and/or posterior mitral valve leaflet prolapse. In order to determine the length of the chords a technique of functional hydraulic tests with a sliding suture knot was used by pressure infusion of a cold isotonic sodium chloride solution into the left ventricle until optimal geometry and competence of the valve leaflets was achieved. Results. No perioperative deaths were registered. The average postoperative length of hospital stay was 10±3.1 days. In 97% of the cases this technique made it possible to obtain immediate satisfactory hemodynamic results of the reconstruction. In long-term follow-up (13 months) 1 (3%) patient was re-operated for severe mitral regurgitation that was associated with the detachment of a native anterior leaflet chord, which was discovered during the operation. The two neo-chords epithelialized, became macroscopically indistinguishable from the native chords, and could be identified by the knots on the atrial side of the leaflet, their integrity was not compromised. In all other cases long-term follow-up after the operation showed a satisfactory hemodynamic functionality of the mitral valve. 76% of the operated patients had postoperative echocardiographic examination performed in our center. In 42% of patients there was no insufficiency, 44% of the patients had 1st degree regurgitation, in 14% of patients the regurgitation was classified as 1-2 degree with no signs of left atrium volume overload, left ventricular dysfunction or symptoms of heart failure. Conclusion. The functional technique for determining the length of neo-chords is an effective and safe method that makes it possible to successfully perform reconstructive operations for degenerative mitral regurgitation.

Minimally invasive mitral valve repair for anterior leaflet prolapse

Mitral valve repair for anterior mitral leaflet prolapse is technically challenging. We report here our experience with minimally invasive anterior mitral leaflet repair. Our institutional database for minimally invasive mitral valve surgery was screened for patients with mitral regurgitation caused by isolated prolapse of the anterior mitral leaflet. Patient characteristics, intraoperative data, and short- and long-term outcomes are analyzed and reported. A total of 180 patients presented with mitral regurgitation caused by isolated anterior mitral leaflet prolapse. All patients underwent minimally invasive surgery at our institution between 1999 and 2010. Mitral valve repair was performed in 170 cases (94.4%), and these patients form the focus of this study. The mean age of the patients was 59.7±14.8, and their mean log EuroSCORE was 4.9±5.1. Mean aortic crossclamp time (cardiopulmonary bypass time) was 82±25 minutes (130±40 minutes). Mitral valve repair techniques were neochordal replacement with the loop technique in 68.2% of patients, chordal transfer in 14.7%, anterior mitral leaflet resection in 7.1%, and edge-to-edge repair in 5.9%. Thirty-day mortality was 1.8%. Kaplan-Meier estimates showed 86.7%±3.2% survival and 95.7%±1.6% freedom from mitral valve reoperation at 5 years. This large series demonstrates good results for anterior mitral leaflet repair with the minimally invasive approach.

Chordal transfer in rheumatic mitral regurgitation: early experience

Chordal transfer and chordal replacement techniques have been quite successful for repair of anterior mitral leaflet prolapse in degenerative disease, but largely unexplored in rheumatic patients. To extend the scope of valve repair, we assessed the chordal transfer technique for correction of anterior mitral leaflet prolapse in 57 patients with rheumatic mitral regurgitation, who were treated between October 2008 and March 2010. There were 36 women and 21 men with a mean age of 25 ± 7.4 years. Normal chordae and a strip of leaflet tissue were transferred from the posterior leaflet to the free edge of the anterior leaflet; the posterior leaflet was repaired in the same manner as after quadrangular resection. Additional procedures were commissurotomy in 19 patients, aortic valve replacement in 1, tricuspid repair in 5, and cryo maze operations in 21. There was no hospital mortality. One (1.7%) patient had acute renal failure but recovered fully. There was moderate regurgitation in one patient who had undergone simultaneous aortic valve replacement. At a mean follow-up of 6.2 ± 2 months, 56/57 (98.2%) patients were asymptomatic with no significant mitral regurgitation.

Mitral Valve Growth After Posterior Annular Stabilization With Untreated Autologous Pericardial Strip in Children With Mitral Valve Insufficiency

Mitral valve (MV) reconstruction is the technique of choice for MV disease in infants and children. We evaluated whether our technique of posterior annulus stabilization with untreated autologous pericardial strip allows growth of anterior MV leaflet and its annulus. Seventeen children (mean age, 9.43 ± 6.03 years; range, 1 to 17) were prospectively followed up after MV repair for mitral insufficiency with severe annular dilation and anterior mitral leaflet prolapse. The MV repair techniques were Paneth posterior annuloplasty (n = 14) and Gerbode plication plasty (n = 3), both modified with pericardial strip stabilization of the posterior annulus (Hetzer's modification). Echocardiograms were taken perioperatively and serially during follow-up. Serial Doppler echocardiography showed good valve function at mean follow-up of 13.62 ± 2.37 years. Left ventricular function was significantly improved, and mitral insufficiency was either absent or significantly decreased. Diameter of anterior MV leaflet and its annulus increased linearly in relation to body size. These findings were consistent in all patients except 3 who required reoperation 1 and 2 years postoperatively, respectively, for recurrent and progressive insufficiency. On reoperation, the pericardial strip was perfectly attached to the posterior annulus and covered by a fibrous tissues without calcification. Stabilization of the posterior annulus with pericardial strip prevents further posterior annular dilation and allows anterior MV leaflet and its annulus to grow in relation to body size over time, as well as preserving flexible properties of the MV orifice.

Surgical Techniques for the Repair of Anterior Mitral Leaflet Prolapse

Myxomatous disease is the leading cause of mitral valve regurgitation in the developed world. Although posterior mitral leaflet (PML) prolapse is the most common cause of regurgitation and of repair, lesions of the anterior mitral leaflet (AML) are often considered beyond the possibilities of repair. The surgical anatomy and pathology of the AML and a precise terminology for the location of the lesions are described. The surgical maneuvers for commissural prolapse, chordal shortening, chordal replacement, leaflet resection, and annuloplasty are also described. The advantages and limitations of each maneuver are discussed. It is concluded that a flexible approach to the repair of the AML is necessary to adapt the best technique for each type of lesion. No particular technique can be applied systematically to all lesions. It is the author's contention that the majority of AML lesions can be repaired safely.

An Effective Technique to Correct Anterior Mitral Leaflet Prolapse

Up to one-third of the patients with degenerative mitral valve disease and severe mitral regurgitation have anterior mitral valve prolapse due to chordal rupture or elongation. Surgical treatment of such a condition is often technically demanding and not infrequently associated with suboptimal results. Techniques used to treat anterior leaflet prolapse include chordal transfer, chordal shortening, artificial chordae, and anterior leaflet resection or plication. Each of these strategies has potential shortcomings, and there is considerable controversy concerning the durability of anterior leaflet prolapse repairs using these techniques. The "edge-to-edge" technique, a simple and effective method of correcting anterior mitral leaflet prolapse is described.

Novel Techniques in Mitral Repair Extended and Rotational Chordal Transfer

Mitral valve repair is preferable to mitral valve replacement because of low rate of thromboembolism, resistance to endocarditis, excellent late durability, and no need for anticoagulation in the majority of patients. This article describes 2 novel techniques for repairing the anterior mitral leaflet prolapse. The extended chordal transfer is achieved by transferring an extended segment of posterior mitral leaflet and, rotational chordal transfer, by rotating the transferred segment either vertical or horizontal. Both techniques are simple and reproducible. It uses patient's own natural chorda and eliminates the problem of knotting and determination of appropriate chordal length faced with other techniques.

Quadricuspid aortic valve in a patient with mitral valve prolapse

A 72-year-old man was admitted to Yuksek Ihtisas Hospital, Ankara, Turkey, with dyspnea. His medical history was remarkable only for hypertension. On physical examination, his blood pressure was 120/70 mmHg and his pulse rate was 86 beats/min. Cardiac auscultation revealed a grade 3/6 systolic murmur at the apex, and auscultation of the lungs revealed bilateral rales. A 12-lead electrocardiogram showed a normal sinus rhythm. Transthoracic echocardiography demonstrated anterior mitral valve leaflet prolapse with severe mitral regurgitation and a quadricuspid aortic valve with four equal-sized cusps, causing moderate aortic regurgitation, with an X-shaped commissural aspect in diastole. Transesophageal echocardiography demonstrated a quadricuspid aortic valve (Figures 1A and ​and1B)1B) with central moderate aortic regurgitation and a flail segment on the anterior mitral valve leaflet with severe mitral regurgitation. The patient underwent elective mitral valve replacement. Figure 1) A Transesophageal echocardiographic view in the aortic valve plane in diastole. The aortic valve demonstrated a characteristic X pattern with equal-sized cusps. B Transesophageal echocardiographic view in the aortic valve plane in systole. The aortic ... Mitral valve prolapse is a common valvular abnormality. Although the overall prognosis of patients with mitral valve prolapse is excellent, it may cause serious complications, including infective endocarditis, sudden cardiac death, cerebrovascular ischemic events and severe mitral regurgitation (1). The most important complication of mitral valve prolapse is severe mitral regurgitation, which may result from progressive myxomatous degeneration or chordal rupture (1). A quadricuspid aortic valve is a rare congenital malformation of the aortic valve. The main functional abnormality of a quadricuspid aortic valve is insufficiency (2). The structure of a quadricuspid aortic valve varies according to the dimension of each individual valve cusp: four equal cusps, three equal cusps with one minor cusp, or two large cusps with two small cusps (2). In the present case, we presented this rare condition again.