Type Of Mitral Regurgitation Research Articles

Description of the anatomical characteristics of mitral valve apparatus among patients with moderate or severe primary mitral regurgitation using 3D transesophageal echocardiography

Abstract Background/Introduction There are two types of mitral regurgitation (MR); primary, which is characterized by abnormalities of the mitral valve apparatus and secondary or functional, caused by left atrioventricular remodeling. The implementation of 3D transesophageal echocardiography (3D-TEE) has resulted in the precise depiction of the anatomical characteristics of mitral valve apparatus that prompts appropriate treatment. Purpose The aim of this study is to describe the anatomical characteristics of the mitral valve among patients with moderate or severe primary MR by using 3D-TEE. Methods From 2017 to 2023, 333 3D-TEE examinations have been performed in our center to evaluate MR cases. Specifically, 181 cases were classified as primary MR (52 moderate and 129 severe), in which visualization of the mitral apparatus had been performed via 3D-TEE. The recorded 3D data were retrospectively analyzed with specialized software and the pathophysiology of MR was described in each case. Results The median patient age was 63.9 years (SD±13.5), while 58% of patients were men. The left atrium was moderately or severely enlarged in 79% of the cases and the left ventricular ejection fraction was >60% in 61.5% of the patients. Mitral valve prolapse (MVP) with or without flail was found in 109 (61.9%) patients. Furthermore, it was noticed that MVP had been occurred at the anterior leaflet in 45.5% of the cases, at the posterior leaflet in 25% and at both leaflets in 29.5% of the cases. Moreover, in 65.5% of the cases, one or two mitral valve scallops had been affected. In the MR cases where the predominant pathophysiology was flail valve, the posterior mitral leaflet had been involved in 94.8% of the cases with one or two scallops been affected (83.9%). Among patients with both flail valve and MVP, the former was found at the posterior leaflet, while the latter at the anterior leaflet (in 63.9% of the cases). Mitral valve cleft in the absence of another mitral valve pathology was found in 7 patients (4%), while in 8 patients (4.4%) MVP was present and in 4 cases (2.2%) a combination of MVP and flail was found. The mitral cleft was depicted on P1P2 (38.1%) and P2P3 (23.8%) scallops respectively. Bileaflet cleft was found only in 4.8% of the cases. Moreover, calcified mitral lesions as primary cause of MR were found in 37 patients (21%), while rheumatic mitral valve pathology was found in 13 patients (7.4%). Among the rest causes of MR, infective endocarditis was found in 7 patients (4%) and systolic anterior motion of mitral valve in the context of hypertrophic cardiomyopathy in 3 patients (1.7%). Conclusions The description of mitral valve anatomy with the use of 3D-TEE provides useful information regarding morphological features that are used as favorable criteria for mitral valve repair procedures. It is suggested that cardiologists should get familiarized with 3D-TEE aiming at optimal clinical decisions to achieve maximum benefit for the patient.

Overview of the catheter-based methods for treatment of mitralregurgitation

Mitral regurgitation or mitral insuffi ciency is the second most common valve pathology requiring a surgical treatment worldwide. It is characterized by an abnormal return of blood from the left ventricle to the left atrium during the systole. The incidence of mitral regurgitation increases in line with the rise in the life expectancy and the overall aging of the world population. According to the pathoanatomy and the mechanism of development, there are two main types of mitral regurgitation: a primary (degenerative) regurgitation and secondary (functional) regurgitation. In the fi rst type, there is organic damage to the valve and/or the valve apparatus, and in the second type, there is a secondary dysfunction of the mitral valve due to damage to the structure and/or the function of the left ventricle. The treatment of choice for the management of the mitral regurgitation is a surgical intervention. In recent years new high-tech transcatheter methods of treatment have been introduced in clinical practice. The most popular and proven method of treatment in patients who could not undergo classic cardiac surgery is the MitraClip edge-to-edge transcatheter approximation system. Other endovascular methods of treatment are percutaneous plasty device Pascal (Edwards Lifesciences) and Cardioband using transseptal approach, and also NeoChord and Harpoon using transapical approach.

Suture annuloplasty in treatment of different types of mitral regurgitation

Suture annuloplasty in treatment of different types of mitral regurgitation

Abnormal mitral-aortic intervalvular coupling in mitral valve diseases: a study using real-time three-dimensional transesophageal echocardiography.

Mitral and aortic valves are coupled via fibrous tissue. This coupling is considered to be important for cardiac function before and after mitral valve surgery. The relationship between mitral-aortic coupling and different types of mitral regurgitation (MR) is not completely understood. Real-time three-dimensional transesophageal echocardiography (RT3D-TEE) was performed in 133 subjects: 30 normal subjects, 15 patients with Carpentier type I MR (annular dilatation and congenital cleft), 40 type II (mitral valve prolapse), 20 type IIIa (rheumatic) and 28 type IIIb (ischemic mitral regurgitation). Custom software was used to track mitral (MA) and aortic annuli (AoA) in 3D space throughout cardiac cycle, allowing measurement of changes in mitral and aortic valve morphology. Normal mitral-aortic coupling is characterized by reciprocal changes in the annular areas throughout cardiac cycle, with systolic reduction of the angle between the two annular planes. In Carpentier type II patients, not only MA but also AoA areas were increased (P<0.05 vs normal), but the reciprocal pattern of mitral-aortic coupling was preserved. In both type I IMR and IIIb patients, MA and AoA areas were both increased (P<0.05 vs normal) and the reciprocal behavior of mitral-aortic coupling was lost. Only MA area was increased in type IIIa patients. The extent of mitral-aortic angle reduction during systole was diminished in all 4 Carpentier groups (P<0.05 vs normal). Mitral valve diseases may affect normal mitral-aortic coupling and aortic valve function. Different patterns of abnormal mitral-aortic coupling are associated with different Carpentier types of MR.

Changes in mitral annulus and leaflets size are related to regurgitation severity in organic mitral regurgitation: a three-dimensional transthoracic study

Background: Until recently, quantitative analysis of mitral valve annulus (MVA) dimensions in different types of mitral regurgitation (MR) was feasible only by transesophageal 3D echocardiography (3DE); data about the relationship of these quantitative parameters to MR severity are scarce. Objectives: Our aim was to assess if the changes in mitral annulus and leaflets of patients with organic MR are related to MR severity. Methods: 30 pts with moderate-severe organic MR (OMR) due to MV prolapse (57±14 yrs, 21 men, 28 pts with posterior leaflet prolapse) underwent 3D full-volume acquisition of the MV (32±2 fps) using Vivid E9 (BT 12, GE Healthcare, Horten, N). MR severity was quantitatively assessed according to current guidelines: vena contracta (VC), PISA radius (PISArad), effective regurgitant orifice (ERO), and MR volume (MRvol). Left atrial biplane volume was also measured. Several MV geometry parameters were measured at mid-systole with prototype software for 3DTTE (TomTec MV assessment 2.0, Unterschleissheim, D): antero-posterior annulus diameter (A-P diameter), anterolateral-posteromedial annulus diameter (AL-PM diameter), commissural diameter, 3D annulus circumference and area, anterior and posterior leaflet areas (ALA, PLA). Results: 3D annulus area and circumference correlated to PISArad (r=0.455, p=0.027; r=0.477, p=0.027), and MRvol (r=0.610, p=0.009; r=0.584, p=0.014) (Figure). Due to dominance of posterior leaflet prolapse, PLA was also related to MRvol (r=0.526, p=0.003). Moreover, a positive relationship was found between biplane LA volume and MVA area (r=0.630, p=0.001). ![Figure][1] Correlation for MVA size and MR severity Conclusion: In organic MR, quantitative analysis of MVA geometry by 3D TTE revealed that increased dimensions of MV leaflets and annulus, in addition to MV morphology, contribute to MR severity and LA volume. [1]: pending:yes

Clinical outcomes of mitral valve repair in mitral regurgitation: a prospective analysis of 100 consecutive patients

Mitral valve repair has become the procedure of choice for almost every type of mitral regurgitation (MR) in the current surgical era. We assessed clinical outcomes of mitral valve repair in severe MR. In this prospective cohort study, 103 patients (61 male, 42 female, mean age 53.2±14.8 years), who were planned to undergo valve repair were included. Mitral valve pathology was regurgitant in 86% and mixed in 14% of patients. The intention to perform mitral repair was successful in 100 (97.1%) of patients. Concomitant procedures were performed in 57 (57%) patients including 31 coronary artery bypass grafting and 13 tricuspid valve repairs. After surgery, early (<30 days) and late (>30 days) complications were recorded. Postoperative echocardiography was performed in all patients at discharge and during clinical follow-up. Late survival and freedom from adverse events including thromboembolism, endocarditis, reoperation, and residual severe MR were estimated by using the Kaplan-Meier survival analysis. There was no early mortality. Echocardiographic assessment of patients at discharge revealed no/trivial regurgitation in 89% and mild (1+) MR in 11% of all patients. Late mortality occurred in only one patient at 14 months because of renal failure. The mean follow-up period of patients was 21.2±10.3 months. Echocardiographic examination during follow-up revealed that mitral insufficiency was none or mild in 96% of patients. Three (3%) patients had moderate (2+) MR and were treated medically. Mitral insufficiency recurrence with severe (3+) regurgitation occurred in one (1%) patient undergoing coronary artery revascularization and concomitant left ventricular aneurysmectomy. Re-operation was needed in only one (1%) case because of infective endocarditis that was treated with mechanical valve replacement. Kaplan-Meier estimates were 99±2.7% for late survival and 98±2.2%, 99±2.7%, 99±2.7% and 99±0.9% for freedom from thromboembolism, endocarditis, reoperation, and residual severe MR, respectively. This study showed that mitral valve repair provides excellent surgical outcomes. Repair procedures are safe, and highly effective, but operations require a considerable surgical experience.

Effect of local annular interventions on annular and left ventricular geometry☆☆☆

Etiology-specific annular interventions and annuloplasty rings are now commercially available for the treatment of different types of mitral regurgitation; however, knowledge concerning the effects of local annular alterations on annular and left ventricular (LV) geometry is limited. Seven adult sheep underwent implantation of eight radiopaque markers around the mitral annulus (MA) and eight markers on the LV (four each on two levels: basal and apical), and one on each papillary muscle tip. Trans-annular septal-lateral (SL) sutures were placed between the corresponding markers on the septal and lateral annulus at valve center (CENT) and near anterior (ACOM) and posterior (PCOM) commissures and externalized. Hemodynamic parameters and 4D marker coordinates were measured before and during SL annular cinching ('SLAC'; suture tightening 3-5 mm for 20s) at each suture location. Mitral annular SL diameter, annular area (MAA), and distance from the mid-septal annulus to the LV markers and papillary muscle tips were determined from marker coordinates every 17ms. End-systolic MAA decreased from 5.93+/-1.27 to 5.23+/-1.29(*)cm(2), 5.98+/-1.16 to 5.33+/-1.31(*)cm(2), and 6.30+/-1.65 to 5.61+/-1.37(*)cm(2) for SLAC(ACOM), SLAC(CENT), and SLAC(PCOM), respectively ((*)p<0.05 vs pre-cinching). Each SLAC intervention reduced the SL diameter at all three locations, while both SLAC(ACOM) and SLAC(CENT) affected ventricular geometry, and SLAC(PCOM) only slightly altered valvular-subvalvular distance. Only SLAC(CENT) altered papillary muscle position. Local annular SL reduction influences remote annular SL dimensions and affects LV geometry. The effect of local annular interventions on global annular geometry and LV remodeling should be considered in surgical or interventional approaches to mitral regurgitation and the design of new annular prostheses as well as supra-annular and sub-annular catheter interventions.

Color doppler echocardiographic assessment of the change in the mitral regurgitant volume

We studied the possibility that a mitral regurgitant Doppler signal area on a two-dimensional color Doppler echocardiogram can reflect changes in mitral regurgitant volume in 24 patients with several types of mitral regurgitation. In 20 patients, mitral regurgitant Doppler signal areas were clear enough to measure. Injections of phenylephrine were given to these patients during the recording of the mitral regurgitant Doppler signal area in the same views and with the same Doppler gains. The mitral regurgitant Doppler signal area, blood pressure, and heart rate were measured before and after phenylephrine provocation. In addition, inhalation of amyl nitrite was performed during the recording of the mitral regurgitant Doppler signal area in the same way. Injection of phenylephrine resulted in an increase in the mitral regurgitant Doppler signal area accompanied by an increase in blood pressure and a decrease in heart rate. On the other hand, inhalation of amyl nitrite resulted in a decrease in the mitral regurgitant Doppler signal area, a decrease in blood pressure, and an increase in heart rate. A positive correlation between the change in blood pressure and that in the mitral regurgitant Doppler signal area was observed. In conclusion, two-dimensional color Doppler echocardiography may be useful in the assessment of the acute change in regurgitant volume in the patient with mitral regurgitation.

Mitral valve prolapse and infective endocarditis.

In a review of 350 consecutive patients with infective endocarditis (IE) 14 patients were found to have mitral valve prolapse (MVP) and mitral IE between 1970 and 1982 in our institution. We first describe the clinical features, laboratory findings and follow up of this group; then we compare it with the data obtained in patients with IE with other types of mitral regurgitation (MR). All patients with MVP had a murmur or a click with a murmur before the acute episode of IE, the most frequent consecutive organism was Streptococcus (nine cases) and the response to antimicrobial therapy was good; only one patient died and three others needed a mitral valve replacement from one month to 12 years later. The comparison with other types of mitral regurgitation with IE was done by sex, age, duration of symptoms before IE diagnosis, frequency of atrial fibrillation, number of congestive heart failures, heart volume on chest X-ray, number of echographic vegetations and echographic left ventricle size, and number of mitral valve replacements and deaths. None of these items differed significantly, but the duration of symptoms before diagnosis was shorter in the group of patients with MVP.

Abbreviation of systolic time intervals in acute mitral regurgitation: Effect of prosthetic mitral valve replacement

Systolic time intervals were measured in 26 patients with mitral regurgitation (acute in 14 and chronic in 12). In 13 of these patients (7 with acute and 6 with chronic mitral regurgitation) systolic time intervals were also measured after mitral valve replacement. Total electromechanical systole corrected for heart rate (Q-S 2I) was of much shorter duration in the group with acute mitral regurgitation (472 ± 9 msec [mean ± standard error of the mean]) than in the group with chronic mitral regurgitation (516 ± 4.6 msec, P < 0.01). Before operation, the ratio of the preejection period (PEP) to left ventricular ejection time (LVET) and the angiographic ejection fraction did not differ in the groups with acute and chronic mitral regurgitation. The correlation between the PEP LVET ratio and ejection fraction was r = − 0.84, P < 0.01. Two weeks after operation, the PEP LVET ratio increased in all patients, but the increase was greater in those with lower preoperative values for this ratio. The mechanism of the early postoperative increase in the PEP LVET ratio is not clear, but serial studies performed over 6 months showed a return toward the preoperative value. It is concluded that preoperative systolic time intervals are useful for assessing left ventricular performance in all types of mitral regurgitation, but are especially useful for distinguishing between the acute and chronic varieties.

Echocardiographic findings in different types of mitral regurgitation.

Forty-eight patients with mitral regurgitation were studied by echocardiography to establish differential diagnostic features. Six patients with rheumatic mitral insufficiency manifested broad and bright echoes from the anterior mitral leaflets and slowed EF slopes. In the majority of patients with prolapse of the mitral valve leaflets due to rupture or redundancy of the chordae tendineae, a posterior sagging of the CD portion of the thin mitral leaflet echoes was evident. Cases with anterior leaflet rupture revealed increased rate and amplitude of anterior cusp opening with a spiked E point. Eight patients with posterior ruptured chordae tendineae were noted to have a paradoxical diastolic anterior motion of the posterior mitral leaflet. Eight instances of mitral insufficiency due to papillary muscle dysfunction manifested a flat CD segment and characteristic double diamond-shaped pattern of the leaflets, lying within an enlarged left ventricular cavity. In two patients with mitral insufficiency associated with calcification of the mitral annulus, a thickened, intense echo was seen posterior to the leaflets. Echocardiograms taken in the patients with severe mitral insufficiency also demonstrated enlarged left ventricular end-diastolic dimensions, increased stroke volume, and increased amplitude of septal motion. The ejection fraction was usually normal, but in 11 it was reduced, suggesting impaired left ventricular function. Echocardiography is an extremely useful technique in evaluating patients with mitral insufficiency, delineating the etiology and severity of the disease, and aiding in grossly assessing left ventricular function.