Rheumatic Mitral Insufficiency Research Articles

A case report of successful surgical treatment of mitral valve disease 38 years after implantation of ball-valve mechanical prosthesis in aortic position

The application of ball-valve prostheses in clinical practice marked a new age in the treatment of valvular heart pathology. Ball-valve prostheses are made of long-living and hard-wearing materials; however, these properties confer significant disadvantages resulting from the large dimensions and weight, increased pressure gradient and risk of valve thrombosis and systemic embolism. With the advent of more advanced disk structures, the use of ball-valve prostheses was ended.In Russia and other counties, the scientific literature shows an increase in reoperation after implantation of ball-valve prostheses over the long-term, which is associated with the occurrence of another valve defect. The need to replace a functioning ball-valve prosthesis with a modern mechanical or biological prostheses during surgery for another valve is still controversial.We present a case report of a 55-year-old patient with rheumatic mitral stenosis and functional insufficiency of the tricuspid valve, who underwent repeat surgery 38 years after implantation of a ball-valve prosthesis in the aortic position. From the echocardiography findings, the peak transmitral gradient was 16 mm Hg, the average gradient was 5.5 mm Hg, the area was 1.3 cm2 and regurgitation was third-degree. On the tricuspid valve, there was third-degree regurgitation.Adequate hemodynamic parameters of the ball-valve prosthesis (the maximum blood flow rate was 2.65 m/sec, the peak gradient was 30 mm Hg, the average gradient was 18 mm Hg and there was no regurgitation) and the absence of valve-dependent complications enabled us to perform mitral prosthetics and tricuspid valve plastic surgery without replacing the aortic prosthesis, which reduced the operation time and decreased the risk of complications.The patient was examined two years later. The patient’s active lifestyle and adequate hemodynamic parameters proved the rationality of our treatment policy.The reported case indicates that mitral valve defect that develops a long time after aortic valve prosthetics can be treated surgically without the replacement of a ball-valve prosthesis in the case that it has good function.Received 25 July 2021. Revised 22 August 2021. Accepted 23 August 2021.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Contribution of the authors: The authors contributed equally to this article.

Peripheral Artery Embolism as a Complication of Infective Endocarditis in Mitral Insufficiency

Injective endocarditis in a 10 years old boy complicated by left brachial artery emboly in a case of rheumatic mitral insufficiency has been reported. The etiologic microorganism was coagulase positive Staphylococci. Though clinical cure was achieved by a 4 weeks long high dose of antibiotic (Ceftriaxone), peripheral artery emboly, had complicated the disease. Since adequate collateral circulation has already occurred, no specific treatment has been given. A further follow-up and injective endocarditis prophylaxis are still needed.

Childhood Heart Disease in Côte d’Ivoire: Retrospective Multicentric Study about 228 Cases

Introduction: In Cote d’Ivoire, the paediatrician has to face a diagnosis and management problem in front of pediatric heart disease, with consequent a high lethality. Objective: To describe the epidemiological, diagnostic, therapeutic and progressive aspects of childhood cardiopathy for the improvement of prognosis and professional practice. Materials and methods: This was a multicenter retrospective and descriptive study conducted from January 2011 to March 2016 in two main hospitals universities, one located in Abidjan and the other in Bouaké. It concerned children aged 0 to 15 admitted for cardiac disease diagnosed on clinical and/or echocardiographic arguments. The variables studied were the epidemiological, diagnostic, therapeutic and evolutionary aspects. Results: A total of 49.760 admissions including 228 infantile heart disease cases (congenital 113, acquired 51, indeterminate 64) are overall prevalence of 4.6‰. They involved 106 boys and 122 girls. In 74.6% of cases, the age was between 0 and 2 years. Respiratory distress 73.7% was the main reason for consultation. The main congenital heart diseases (CHD) are ventricular septal defect (VSD) (31%), atrial septal defect (ASD) (20.4%), atrioventricular canal (AVSD) (12.4%) and tetralogy of Fallot (TOF) (11.5%). As for acquired forms (AHD), rheumatic mitral insufficiency (41.2%) and tuberculous pericarditis (15.7%) were the two main causes. Treatment progress is marked by stabilization (71.1%) and death (14%). Death was significantly associated with low socioeconomic status (p = 0.01) and with complication (p 0.001). Conclusion: Infantile heart diseases are relatively less frequent and serious in Cote d’Ivoire. To improve the prognosis, close collaboration between the pediatrician and the cardiologist is required for early diagnosis and management.

0538: Rheumatic valvular detected during the medical examination of non-counter-indications to the practice of the high level sport: result of a systematic evaluation

The cardiovascular assessment during the first medical examination of of noncounter-indications to the practice of the high level sport has systematically a heart Doppler ultrasound according to the consensus of National Center for Sport’s Medicine and Science (NCSMS). To study the prevalence of rheumatic valve disease detected during the systematice echocardiographic assessment of Tunisian elite athletes. We retrospectively studied the data of all the TTE carried out in the NCSMS from 1998 to 2009 (4254 heart Doppler ultrasound performed). The study population was composed of 2253 sportsmen including 586 girls (26.1%) and 1667 boys (73.9%). They are of average age of 20.58±4. 2 years. It is composed of national team’s members (31.5%), professional players (9.23%), sporting pupils (50.19%) and arbitrators (9.23%). Results We report 628 cardiac anomalies with good left ventricular function, consistent with the practice of competitive sports, mainly 173 cases of rheumatic valvular disease (27.5%) representing 94% of all valvular abnormalities observed.Rheumatic mitral leak was found in 122 cases (70.5%) with the combination of a moderate dilatation of the LV in 7 cases only. 40 athletes (32.7%) received only their routine annual echocardiographic controls whose data were similar to initial results, with the exception of three cases with valvular heart disease has evolved on a LV moderately dilated. We detected 34 rheumatic aortic insufficiency (19.6%), grade 1 to 2 (mild to moderate).Mitral and aortic valve disease (rheumatic mitral insufficiency grade I and rheumatic aortic insufficiency grade I) were observed in 17 athletes (9.9%). Six of them have benefited from echocardiographic control that was similar to the initial one. Our study therefore to an echo-cardiographic description of the various rheumatic valve disease that can be observed in the athlete population and is compatible with the sport.

Experiência com a técnica de ampliação do folheto posterior para correção da insuficiência mitral reumática na infância

To describe the experience with the technique of posterior leaflet extension in children suffering of rheumatic mitral regurgitation. Between April 2002, and October 2007, 30 children, mean age 11.3 years, underwent correction of mitral insufficiency with the technique of posterior leaflet extension with a pericardial patch. Eight also received a Carpentier ring. Six children had aortic valve disease and were submitted to Ross operation (five cases) or valve replacement with an aortic homograft. All were in functional class III or IV (NYHA classification). There was one death. One child presented severe hemolysis in the postoperative period and was submitted to mitral valve replacement. Clinical evolution in the remaining patients was good. Posterior leaflet extension of the mitral valve seems to be an effective surgical technique for correction of rheumatic mitral insufficiency in children.

Long-Term (29 Years) Results of Reconstructive Surgery in Rheumatic Mitral Valve Insufficiency

Background Results of conservative surgery are well established in degenerative mitral valve (MV) insufficiency. However, there are controversies in rheumatic disease. This study is the evaluation of one center for rheumatic MV insufficiency based on a functional approach. Methods and Results From 1970 to 1994, 951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by Alain Carpentier. Aortic valve diseases were excluded. Mean age was 25.8 years (4 to 75), and sinus rhythm was present in 63%. The functional classification used was type I, normal leaflet motion, 71 patients (7%); type II, prolapsed leaflet, 311 patients (33%); and type III, restricted leaflet motion, 345 patients (36%). The combined lesion of prolapse of the anterior leaflet and restriction of the posterior was present in 224 patients (24%). Surgical techniques used were implantation of a prosthetic ring in 95%, shortening of the chords and leaflet enlargement with autologous pericardium, and commissurotomy. Hospital mortality rate was 2%. The mean follow-up was 12 years (maximum, 29 years): 8618 patients per year. Actuarial survival was 89±19% at 10 years and 82±18% at 20 years. The rate of thromboembolic events was 0.4% patients per year (33 events), with 3 deaths. Freedom from reoperation was 82±19% at 10 years and 55±25% at 20 years. The main cause (83%) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patients per year and was correlated to the degree of preoperative fibrosis. Conclusions Conservative surgery of rheumatic MV insufficiency has a low hospital mortality rate and an acceptable rate of reoperation. The results are excellent regarding the minimal risk of thromboembolic events.

Long-term (29 years) results of reconstructive surgery in rheumatic mitral valve insufficiency.

Results of conservative surgery are well established in degenerative mitral valve (MV) insufficiency. However, there are controversies in rheumatic disease. This study is the evaluation of one center for rheumatic MV insufficiency based on a functional approach. From 1970 to 1994, 951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by Alain Carpentier. Aortic valve diseases were excluded. Mean age was 25.8 years (4 to 75), and sinus rhythm was present in 63%. The functional classification used was type I, normal leaflet motion, 71 patients (7%); type II, prolapsed leaflet, 311 patients (33%); and type III, restricted leaflet motion, 345 patients (36%). The combined lesion of prolapse of the anterior leaflet and restriction of the posterior was present in 224 patients (24%). Surgical techniques used were implantation of a prosthetic ring in 95%, shortening of the chords and leaflet enlargement with autologous pericardium, and commissurotomy. Hospital mortality rate was 2%. The mean follow-up was 12 years (maximum, 29 years): 8618 patients per year. Actuarial survival was 89+/-19% at 10 years and 82+/-18% at 20 years. The rate of thromboembolic events was 0.4% patients per year (33 events), with 3 deaths. Freedom from reoperation was 82+/-19% at 10 years and 55+/-25% at 20 years. The main cause (83%) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patients per year and was correlated to the degree of preoperative fibrosis. Conservative surgery of rheumatic MV insufficiency has a low hospital mortality rate and an acceptable rate of reoperation. The results are excellent regarding the minimal risk of thromboembolic events.

Is posterior leaflet preservation in the surgical treatment of rheumatic mitral insufficiency without left ventricular dysfunction necessary?

Preservation of the mitral valve leaflet and tensor apparatus during valve replacement is believed to maintain left ventricular performance. To determine the effect of posterior leaflet preservation in pure severe mitral insufficiency without left ventricular dysfunction 56 patients were operated on between 1993 and 2000. Twenty-three patients underwent mitral valve replacement with posterior chordal preservation and 33 patients underwent mitral valve replacement with chordal transection. Preoperative data in the both groups were similar. After 30 days there were no mortalities observed. Dimensions of the left ventricle had significantly decreased within one group, but there was no difference in the other group. The improvement of the functional and cardiac performance in all patients was significant without any difference between the two groups. Actuarial freedom from death was not significantly different at 6 yr ( P=0.23). To preserve left ventricular function in pure severe mitral regurgitation without left ventricular dysfunction, mitral valve replacement is very effective with or without posterior leaflet preservation. But, it is difficult to suggest that posterior leaflet preservation alone can increase cardiac performance.

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency

Background. This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children.Methods. From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism.Results. All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair.Conclusions. Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.

Resultados a médio prazo de anuloplastia com órtese maleável de pericárdio bovino na insuficiência mitral reumática

Objetivo: Os procedimentos conservadores sobre a valva mitral têm vantagens sobre a troca da mesma, mas a durabilidade destes procedimentos e das técnicas empregadas variam conforme a lesão. Nós avaliamos os resultados a médio prazo em pacientes com insuficiência mitral de etiologia reumática quanto às variáveis clínicas e ecocardiográficas. Material e Métodos: De janeiro de 1995 a fevereiro de 1997, 23 pacientes foram submetidos a procedimentos conservadores sobre a valva mitral de etiologia reumática. Dezessete (73,9%) pacientes eram do sexo feminino e 6 (26,1%) do masculino. Todos os pacientes apresentavam insuficiência mitral pura ou dupla disfunção. Nenhum paciente apresentava reativação da doença no momento da cirurgia. A idade média dos pacientes foi de 32,39 ± 15,35 anos. Onze (47,8%) pacientes estavam em classe funcional III ou IV no pré-operatório. Todos os pacientes foram submetidos a anuloplastia com anel maleável de pericárdio. Os pacientes foram avaliados com ecocardiografia transtorácica pré-operatória e repetida a cada 6 meses. Resultados: Não houve óbito hospitalar. O tempo de seguimento médio foi de 25,8 ± 7,8 meses, ficaram livres de reoperação 83,95% dos pacientes em um período de 36,09 ± 1,21 meses (intervalo de confiança 33,73 a 38,46 meses). Utilizando o teste T de Student para dados pareados, observamos que houve melhora quanto ao volume diastólico final do ventrículo esquerdo de 58,52 ± 12,87 mm para 53,00 ± 12,15 mm (p = 0,001), tamanho do átrio esquerdo de 53,47 ± 10,05 mm para 46,26 ± 7,20 mm (p < 0,0001). Não houve melhora estatística para o diâmetro sistólico do ventrículo esquerdo e fração de ejeção. Houve melhora significativa quanto à classe funcional (p = 0,0001). Houve duas reoperações com 22,7 meses e 28,5 meses de seguimento. Insuficiência mitral moderada pós-operatória foi observada em 1 paciente, leve ou ausente nos restantes. Conclusão: A anuloplastia da valva mitral a médio prazo proporciona bons resultados com melhora de parâmetros ecocardiográficos e clínicos. A incidência de reoperação nesta série foi baixa, compatível com os dados da literatura.

Plástica da valva mitral em portadores de febre reumática

Purpose: To analyze the late results of mitral valve repair in rheumatic patients. Material and Methods: Between March 1980 and December 1997, 201 rheumatic patients underwent mitral valve repair in the Heart Institute of HCFMUSP. Average age was 26.9 ± 15.4 years and 59.6% were female. Other diagnoses were present in 67.7% of patients and the most common was tricuspid regurgitation (31.3%). The techniques of repair were: Carpentier ring annuloplasty in 75 (37.3%), posterior annuloplasty with pericardial sling in 68 (33.8%), posterior segmental annuloplasty in 16 (7.9%), quadrangular resection of the posterior leaflet in 11 (5.5%), partial resection of the anterior leaflet in 6 (3%), De Vega type annuloplasty in 6 (3%), Kay in 5 (2.5%), Reed in 4 (2%) and others in 10 patients. Associated techniques were employed in 94 patients (46.8%), the most frequent was chordal shortening (48 patients - 23.9%). Associated procedures were performed in 113 patients (56.2%). The actuarial curves (Kaplan-Meier) were compared through linear regression analysis. Results: Hospital mortality was 4 patients (2.0%) and the causes were multiorgan failure in 2 (50%) and low cardiac output in 2 (50%). In the late postoperative period, 83.9% of the patients were in functional class I (NYHA). The actuarial survival was 93.9 ± 1.9% in 125 months. Twenty three patients were reoperated in the post-operative period with a mean interval of 35.7 months. The actuarial freedom from reoperation was 43.3 ± 13.7% in 125 months. Comparing the patients according to age, in the group over 16 years (group 1), the actuarial survival was 91.3 ± 3.8%, against 95.6 ± 2.7% in the group with more than 16 years (group 2), with a statistic difference (p < 0.0001). Freedom from reoperation was 50.8 ± 16.9% in group 1 and 47.0 ± 14.9% in group 2 (p < 0.0001). Conclusions: Late results with mitral valve repair in rheumatic mitral insufficiency were satisfactory.

Correção cirúrgica simultânea da fibrilação atrial e da insuficiência mitral em criança

Plastia valvar mitral combinada com cirurgia de COX (labirinto) foi realizada em uma paciente de 12 anos, para correção de insuficiência mitral reumática e fibrilação atrial crônica. Um ano após a cirurgia, a paciente encontra-se assintomática e em ritmo sinusal. O ecodopplercardiograma mostrou redução importante do átrio esquerdo e o cateterismo, assim como o ecodopplercardiograma confirmaram sístole atrial efetiva.

Experience with twenty-eight cases of systolic anterior motion after mitral valve reconstruction by the Carpentier technique

Systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction after Carpentier-type mitral reconstruction with ring annuloplasty has led some surgeons to abandon an otherwise successful repair or to avoid use of a rigid ring. To assess the long-term significance of such motion, we studied 439 patients undergoing Carpenter mitral reconstruction at our institution between March 1981 and June 1990. The hospital mortality rate was 4.8% (21/439) overall and 3.7% (9/243) for isolated mitral reconstruction. Systolic anterior motion was found in 6.4% (28/438) after the operation, and 2.3% (10/438) had a coexisting left ventricular outflow tract gradient (mean 53 mm Hg). Of the 28 patients with systolic anterior motion, 27 (96.4%) had leaflet prolapse, 17 (60.7%) had undergone more than a 3 cm resection of the posterior leaflet, and two (7.1%) had preexisting idiopathic hypertrophic subaortic stenosis. All patients were treated medically, 14 with negative inotropic agents. Follow-up echocardiograms at a mean of 32 months demonstrated the disappearance of systolic anterior motion in 13 of 28 patients (46.4%) and resolution of the outflow tract gradient in 10 of 10 (100%). At follow-up only one patient was in New York Heart Association class III or IV and required reoperation for rheumatic mitral insufficiency. These data demonstrate that systolic anterior motion after Carpentier mitral reconstruction with ring annuloplasty is not prevalent and should be managed medically in most cases. Associated left ventricular outflow tract obstruction resolves with medical treatment.

Specificity of persistence of antibody to the streptococcal group A carbohydrate in rheumatic valvular heart disease.

The specificity of the persistence of antibody to the streptococcal group A carbohydrate for mitral valve disease induced by rheumatic fever was examined. Levels of the antibody were determined in serum samples of 30 patients with rheumatic mitral insufficiency, 30 patients with mitral valve prolapse, and an equal number of normal individuals and patients with congenital heart disease. Antistreptolysin titers and anti-deoxyribonuclease B titers were also assayed in all sera. There were no differences in the incidence of elevated antibody titers or in the geometric means of the antibody titers for the normal individuals, the patients with congenital heart disease, and the patients with mitral valve prolapse. In contrast, the frequency of elevated anti-streptococcal group A carbohydrate titers and the geometric means of these titers were significantly higher in the patients with rheumatic mitral valve disease than in patients with mitral valve prolapse. This confirms the specificity of the persistent elevation of anti-streptococcal group A carbohydrate to patients with mitral valve disease induced by rheumatic fever and also suggests that the persistence of this antibody in patients with rheumatic valvular disease is not a result of a functional abnormality of the mitral valve.

Endomyocardial fibrosis masquerading as rheumatic mitral incompetence: A report of six surgical cases

This report presents six cases (among 43 surgical cases) of left ventricular EMF presenting as pure mitral insufficiency without any echocardiographic or hemodynamic signs of left ventricular EMF (except apical diverticulum in two cases). Five of these cases were diagnosed at operation, and the sixth was diagnosed on the basis of a characteristic right ventricular angiogram. At operation a fibrotic lesion localized to the level of the anteropapillary muscle, with severe mitral insufficiency, was found. Five patients underwent successful mitral valve replacement and one a successful conservative mitral valve procedure. Postoperative angiograms, done in two patients, showed a normal contour of the left ventricle. A review of the literature did not reveal any previous descriptions of this type of limited left ventricular EMF, mimicking rheumatic mitral insufficiency. In our surgical experience, we have encountered three types of left ventricular EMF: obliterative, extensive, and limited. We emphasize EMF as a possible cause of mitral insufficiency in African children.

Left Ventricular Myotomy: Physiologic Approach to Surgical Therapy for IHSS

Twenty patients were operated on for idiopathic hypertrophic subaortic stenosis (IHSS) between 1966 and 1980. All were in New York Heart Association functional class 3 or 4, and 17 had overt congestive failure. The mean resting gradient across the left ventricular (LV) outflow tract preoperatively was 78 mm Hg. Seventeen patients underwent transaortic LV myotomy, one had mitral valve replacement (MVR), and two patients with rheumatic mitral insufficiency (MI) and IHSS underwent myotomy and MVR. There was one operative death (5 percent). Mean follow-up was 5.8 years. Eighteen of 19 survivors were improved to class 1 or 2. One patient whose gradient and symptoms were not relieved by myotomy was improved by myectomy and MVR. The MI was abolished or reduced by myotomy in ten of 13 patients. There were six late deaths, five of which are known or assumed to be cardiac related. We concluded that LV myotomy is a safe and effective technique for surgical management of IHSS. Left ventricular myectomy, MVR, or both are indicated in selected cases.

Granulomatous myocarditis secondary to cornstarch

A 44-year-old white female with chronic rheumatic heart disease and mitral insufficiency was admitted to the hospital for cardiac catheterization and mitral valve replacement. On the ninth postoperative day the patient experienced a sudden onset of chest pain, hypotension, and died shortly therafter. Autopsy revealed multiple mural thrombi of the left atrium, one of which occluded the mitral orifice. Histologic examination showed a granulomatous and non-specific interstitial myocarditis involving all chambers of the heart. In the granulomas, both inside and outside giant cells, rounded foreign bodies were noted which stained light blue with hematoxylin and eosin, red with the periodic acid Schiff reagent, dark bluish-black with Gram's iodine, and showed Maltese cross birefringence under polarized light. These particles were identical with starch granules from surgical glove powder. The cause of death was acute mitral occlusion form a flapping mural thrombus.

COMPARISON OF RHEUMATIC MITRAL VALVE INSUFFICIENCY WITH THE “CLICK-MURMUR” SYNDROME BY ECHOCARDIOGRAPHY

To study the usefulness of echocardiography in determining the etiology of mitral insufficiency, echocardiograms from 17 children with documented rheumatic mitral valve insufficiency (RMVI) and 27 children with the mitral “click-murmur” syndrome (CMS) were compared with studies from 130 normal children.Mitral valve excursion was increased in 11 of 17 patients with RMVI and 16 of 27 patients with CMS. The rate of early diastolic closure (E-F slope) was increased in both groups. Aortic root diameter was normal in all patients with RMVI but was increased in 9 of 27 patients with CMS. Mitral valve prolapse was present, as expected, in the patients with CMS. However, prolapse also was present in 6 of 17 patients with RMVI.Thus, the echocardiographic pattern of mitral valve motion was similar in children with RMVI and those with CMS. In the absence of aortic root dilatation there were no echocardlographic features which clearly separated the two groups of patients. In particular, the demonstration of mitral prolapse did not exclude rheumatic fever as the cause of mitral insufficiency.

Persistence of the Third Heart Sound after Resection of the Native Mitral and Tricuspid Valves: Evidence Against the Valvular Theory of Third Sound Origin

A patient is described with severe rheumatic mitral and tricuspid insufficiency in whom both atrioventricular valves with their chordae tendineae and papillary muscles were resected and replaced with Hancock porcine grafts. This would appear to be the second such patient reported and the first described in detail in whom the third heart sound persisted postoperation. This occurrence documents the fact that a third heart sound can occur in the absence of native atrioventricular valve leaflets and the major portions of the subvalvular supporting apparatus, and argues against the theory that the third heart sound is generated by either the valvular leaflets of the subvalvular apparatus.

Prophylaxis in rheumatic and nonrheumatic mitral insufficiency.

Clinical, epidemologic, and experimental findings suggest that acquired mitral insufficiency should not invariably the attributed to rheumatic fever. In this series of childhood cases, more than 50 per cent of the instances of "pure" mitral insufficiency did not have an acceptable past history of rheumatic fever in terms of the Jones Criteria for the diagnosis of rheumatic fever. The authors therefore recommend that daily antibacterial prophylaxis should be limited to those children with valvular heart disease who have had at least one of the major manifestations of the Jones Criteria. But all cases or acquired valvular heart disease should remain under continued clinical observation, and be given antibacterial therapy to prevent bacterial endocarditis of the damaged valves whenever indicated.