Echocardiography of congenital mitral valve disorders: echocardiographic–morphological comparisons

AbstractI surveyed our echocardiographic database of the years between 1998 and 2012 for congenital abnormalities of the mitral valve in patients over 14 years. A total of 249 patients with mitral valve abnormalities were identified. Abnormalities included clefts in the mitral valve in 58 patients, double orifice of the mitral valve in 19, mitral stenosis with two papillary muscles in 72, and mitral stenosis with one papillary muscle in 51 patients. Supravalvar rings were found in 35 patients with a single papillary muscle, and mitral stenoses with two papillary muscles were found in 22 patients. Mitral prolapse occurred in 44 patients and mitral valvar straddle in five patients. The patients were evaluated by all modalities of ultrasound available over the course of time. Although some lesions were isolated, there were many lesions in which more than one mitral deformity presented in the same patient. The patients are presented showing anatomical correlation with autopsy specimens, some of which came from the patients in this series, and others matched to show correlative anatomy. These lesions remain rare as a group and continue to have high morbidity and mortality.

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P365Does papillary muscle ablation affect mitral valve function: a single centre experience

EP Europace ◽

10.1093/europace/euaa162.185 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

J Stassen ◽

D Dilling ◽

J Vijgen ◽

J Schurmans ◽

P Koopman

Keyword(s):

Mitral Valve ◽

Papillary Muscle ◽

Delayed Enhancement ◽

Papillary Muscles ◽

Premature Ventricular Contractions ◽

Valve Function ◽

History Of ◽

Study Population ◽

The Impact

Abstract Introduction Ventricular arrhythmias from papillary muscles (PMs) often require extensive catheter ablation (CA). Not much is known about the mitral valve (MV) function after these extensive catheter ablations. Purpose The goal of this study was to determine the impact of papillary muscle CA on MV function. Methods We retrospectively examined echocardiographic measurements in 21 patients with frequent premature ventricular contractions (PVCs) originating from the mitral PMs who underwent CA, dating from October 2012 till November 2018. We assessed MV function at baseline, 6 month and last follow-up. Degree of mitral regurgitation (MR) was graded as mild (ERO <0,2 cm2, regurgitation volume (RV) <30ml), moderate (ERO 0,2-0,4cm2, RV 30-59ml) or severe (ERO ≥0,4cm2, RV ≥60ml). Significant MR was defined as a 2+ change. Results Mean age of the study population was 59,7 (27-80)years, 52,4% was female. 2 patients were known with ischemic heart disease. There was a family history of sudden cardiac death in 3 patients. Main symptoms at presentation were palpitations (66,7%), fatigue (33,3%), dyspnea (33,3%, all NYHA 2), dizziness (28,6%), angina pectoris (14,3%) and syncope (4,8%). Beta blocker (71,4%), flecaïnide (23,8%), amiodarone (9,5%), sotalol (4,8%) and propafenon (4,8%) were the most frequent medical therapies before CA. Mean burden of PVC before ablation was 15 574 (2000-39700)/24h. In 28,6% non sustained VT was documented, 1 patient suffered a sustained episode of VT. After ablation, mean burden of PVC was reduced to 1331 (0-14200)/24h. Redo ablation was necessary in 28,6% of patients. PVCs orginated from the anterolateral PM in 33,3% and from the posteromedial PM in 66,7%. Mean troponin release was 9.4 ± 5.3 µg/l, mean troponin hs (since 2016) was 1591.0 ±658.6ng/ml. CMR was done in 14/21 (66,7%) patients before CA. In 5 out of 14 patients (35,7%), delayed enhancement at the papillary muscles was noticed. In 5 patients without delayed enhancement, CMR was repeated after CA. In all these 5 patients, delayed enhancement was noticed at the level of the papillary muscles. At baseline, 15/21 had mild, 5/21 moderate and 1/21 severe MR. There was no significant chance in MR at 6m follow-up with 15/21 having mild and 6/21 moderate MR (p 0.58) with 1 patient having a significant MR 2+ change. At last follow-up (23.7 ± 22.6 months) there was also no significant chance in MR with 15/21 having mild and 6/21 moderate MR (p 0.58) without a significant MR 2+ change. Complications occurred in 1 patient (transient AV blok). No patients died during follow up. Conclusions Although PM ablation was associated with time extensive ablation, significant troponine release and documented delayed enhancement on post ablation MRI, there was no risk of additional valvular dysfunction after CA in this study. Larger studies will be necessary to confirm these findings.

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Echocardiography Diagnosis of a Stenotic Double Orifice Parachute Mitral Valve with a Single Papillary Muscle

Echocardiography ◽

10.1111/j.1540-8175.2000.tb01149.x ◽

2000 ◽

Vol 17 (4) ◽

pp. 349-352 ◽

Cited By ~ 8

Author(s):

DILEK YESILBURSA ◽

ANDREW MILLER ◽

NAVIN C. NANDA ◽

OSMAN MUKHTAR ◽

WEN YING HUANG ◽

...

Keyword(s):

Mitral Valve ◽

Papillary Muscle ◽

Parachute Mitral Valve ◽

Double Orifice

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P1689 Mitral valve prolapse secondary to ischemic cardiomyopathy

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.1052 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

G Babur Guler ◽

A Kilicgedik ◽

H Zencirkiran Agus ◽

G Kahveci

Keyword(s):

Myocardial Infarction ◽

Mitral Valve ◽

Left Ventricle ◽

Mitral Regurgitation ◽

Transesophageal Echocardiography ◽

Papillary Muscle ◽

Mitral Valve Prolapse ◽

Systolic Function ◽

Systolic Pulmonary Artery Pressure ◽

Mitral Prolapse

Abstract Introduction Mitral valve prolapse is the most common form of degenerative mitral valve disease. However, ischemic mitral valve prolapse is a rare cause of mitral regurgitation. The mechanism was initially thought to be papillary muscle dysfunction, but more complex mechanisms were suggested recently. Purpose Try to understand the pathophysiology of ischemic mitral valve prolapse on a case example. Case Report A 42-year-old male with a history of inferoposterior myocardial infarction was admitted from outpatient clinic due to NYHA class 3 heart failure symptoms. On physical examination, a 4/6 holosystolic murmur was heard in the apex. He had a permanent pacemaker implanted for sick sinus syndrome. Transthoracic echocardiography showed 1-global dysfunction of the left ventricle (posterior segment akinetic and thinned), 2- prolapse of the posterior mitral leaflet (suspicion of ruptured chordae) 3-severe mitral regurgitation (with anterior eccentric jet), 4- moderate tricuspid regurgitation and high systolic pulmonary artery pressure (65 mmHg), 5- pacemaker lead in the right heart chambers. 6- normal right ventricular systolic function. Transesophageal echocardiography showed P2 scallop prolapse and chordae were intact, there were no redundant or myxamous components of the leaflets. It was observed that the posteromedial papillary muscle was elongated and did not contract. We commented that these echocardiographic findings represented ischemic mitral valve prolapse. Other echo findings in favour of this hypothesis were the posteromedial papillary muscle prolongation in systole and reduced the free strain of papillary muscle in the the apical long axis view. The patient underwent mitral ring anuloplasty and surgical neocord implantation. Surgery also reported the aetiology as ischemic mitral prolapse secondary to chordal extension in accordance with echocardiography. Conclusion(s): Ischemic mitral prolapse is a complex pathology involving multiple components of the mitral valve apparatus as left ventricle, papillary muscle, chordae, annulus, leaflets. The diagnostic criteria for ischemic mitral valve prolapse and its management are not defined. The presence of myocardial infarction and the exclusion of other possible valve pathologies with transesophageal echocardiography are important steps in the diagnosis. Abstract P1689 Figure.

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In Vitro Measurement of the Coaptation Force Distribution in Normal and Functional Regurgitant Porcine Mitral Valves

Journal of Biomechanical Engineering ◽

10.1115/1.4029746 ◽

2015 ◽

Vol 137 (7) ◽

Cited By ~ 3

Author(s):

John Adams ◽

Malachy J. O'Rourke

Keyword(s):

Mitral Valve ◽

Myocardial Ischemia ◽

Papillary Muscle ◽

Force Distribution ◽

Papillary Muscles ◽

Flow Loop ◽

Static Tests ◽

Mitral Valves ◽

Static Conditions

Closure of the left atrioventricular orifice is achieved when the anterior and posterior leaflets of the mitral valve press together to form a coaptation zone along the free edge of the leaflets. This coaptation zone is critical to valve competency and is maintained by the support of the mitral annulus, chordae tendinae, and papillary muscles. Myocardial ischemia can lead to an altered performance of this mitral complex generating suboptimal mitral leaflet coaptation and a resultant regurgitant orifice. This paper reports on a two-part experiment undertaken to measure the dependence of coaptation force distribution on papillary muscle position in normal and functional regurgitant porcine mitral heart valves. Using a novel load sensor, the local coaptation force was measured in vitro at three locations (A1–P1, A2–P2, and A3–P3) along the coaptation zone. In part 1, the coaptation force was measured under static conditions in ten whole hearts. In part 2, the coaptation force was measured in four explanted mitral valves operating in a flow loop under physiological flow conditions. Here, two series of tests were undertaken corresponding to the normal and functional regurgitant state as determined by the position of the papillary muscles relative to the mitral valve annulus. The functional regurgitant state corresponded to grade 1. The static tests in part 1 revealed that the local force was directly proportional to the transmitral pressure and was nonuniformly distributed across the coaptation zone, been strongest at A1–P1. In part 2, tests of the valve in a normal state showed that the local force was again directly proportional to the transmitral pressure and was again nonuniform across the coaptation zone, been strongest at A1–P1 and weakest at A2–P2. Further tests performed on the same valves in a functional regurgitant state showed that the local force measured in the coaptation zone was directly proportional to the transmitral pressure. However, the force was now observed to be weakest at A1–P1 and strongest at A2–P2. Movement of the anterolateral papillary muscle (APM) away from both the annular and anterior–posterior (AP) planes was seen to contribute significantly to the altered force distribution in the coaptation zone. It was concluded that papillary muscle displacement typical of myocardial ischemia changes the coaptation force locally within the coaptation zone.

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Double orifice mitral valve: A case report

Vojnosanitetski pregled ◽

10.2298/vsp141223036m ◽

2016 ◽

Vol 73 (5) ◽

pp. 496-499

Author(s):

Ljilja Music ◽

Bozidarka Knezevic ◽

Ljiljana Jovovic ◽

Nebojsa Bulatovic

Keyword(s):

Case Report ◽

Mitral Valve ◽

Mitral Stenosis ◽

Fibrous Tissue ◽

Bundle Branch Block ◽

Functional Changes ◽

Mitral Orifice ◽

Sport Activities ◽

Double Orifice

Introduction. Double orifice mitrol valve (DOMV) is a very rare congenital heart defect. Case report. We reported 20-year-old male referred to our center due to evaluation of his cardiologic status. He was operated on shortly after birth for a tracheoesophageal fistula. Accidentally, echocardiography examination at the age of 4 years revealed double orifice mitral valve (DOMV) without the presence of mitral regurgitation, as well as mitral stenosis, with normal dimensions of all cardiac chambers. The patient was asymptomatic, even more he was a kick boxer. His physical finding was normal. Electrocardiography showed regular sinus rhythm, incomplete right bundle branch block. Transthoracic echocardiography (TTE) examination revealed the normal size of the left atrial, mitral leaflets were slightly more redundant. The left and right heart chambers, aorta, tricuspid valve and pulmonary artery valve were normal. During TTE examination on a short axis view two asymmetric mitral orifices were seen as a double mitral orifice through which we registered normal flow, without regurgitation and mitral stenosis. Transesophageal echocardiography (TEE) examination from the transgastric view at the level of mitral valve, showed 2 single asymmetric mitral orifices separated by fibrous tissue, mitral leaflet with a separate insertion of hordes for each orifice. Conclusion. The presented patient with DOMV is the only one recognized in our country. The case is interesting because during 16-year a follow-up period there were no functional changes despite the fact that he performed very demanded sport activities. This is very important because there is no information in the literature about that.

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Effect of Edge-to-Edge Mitral Valve Repair on Chordal Strain: Fluid-Structure Interaction Simulations

Biology ◽

10.3390/biology9070173 ◽

2020 ◽

Vol 9 (7) ◽

pp. 173 ◽

Cited By ~ 2

Author(s):

Milan Toma ◽

Daniel R. Einstein ◽

Keshav Kohli ◽

Sheridan L. Caroll ◽

Charles H. Bloodworth ◽

...

Keyword(s):

Mitral Valve ◽

Papillary Muscle ◽

Fold Increase ◽

Mitral Valve Regurgitation ◽

Functional Mitral Regurgitation ◽

Papillary Muscles ◽

Risk Patients ◽

Procedural Complications ◽

Regurgitant Orifice Area ◽

Normal Mitral Valve

Edge-to-edge repair for mitral valve regurgitation is being increasingly performed in high-surgical risk patients using minimally invasive mitral clipping devices. Known procedural complications include chordal rupture and mitral leaflet perforation. Hence, it is important to quantitatively evaluate the effect of edge-to-edge repair on chordal integrity. in this study, we employ a computational mitral valve model to simulate functional mitral regurgitation (FMR) by creating papillary muscle displacement. Edge-to-edge repair is then modeled by simulated coaptation of the mid portion of the mitral leaflets. in the setting of simulated FMR, edge-to-edge repair was shown to sustain low regurgitant orifice area, until a two fold increase in the inter-papillary muscle distance as compared to the normal mitral valve. Strain in the chordae was evaluated near the papillary muscles and the leaflets. Following edge-to-edge repair, strain near the papillary muscles did not significantly change relative to the unrepaired valve, while strain near the leaflets increased significantly relative to the unrepaired valve. These data demonstrate the potential for computational simulations to aid in the pre-procedural evaluation of possible complications such as chordal rupture and leaflet perforation following percutaneous edge-to-edge repair.

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P1720 Hammock mitral valve, a challenging echocardiographic diagnosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.1082 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

D Rodrigo Carbonero ◽

U Estandia ◽

C Perez ◽

R Voces ◽

P Perez ◽

...

Keyword(s):

Mitral Valve ◽

Left Ventricle ◽

Papillary Muscle ◽

Tricuspid Regurgitation ◽

Pulmonary Veins ◽

Left Ventricular ◽

Valve Disease ◽

Valve Prosthesis ◽

Papillary Muscles ◽

Rheumatic Valve Disease

Abstract We report a 43 year-old female with a past TTE echocardiography of rheumatic valve disease performed in her district hospital , ( No clear symptomatology of rheumatic fever in the past). She was transferred to our tertiary hospital for elective cardiac surgery. Preoperative echocardiogram showed a non-dilated left ventricle with preserved contractility, mild-moderate left atrium enlargement with severe mitral regurgitation and basal displacement of papillary muscles and severe tricuspid regurgitation.All of it resembling a hammock mitral valve instead of former echocardiogram described as rheumatic valve disease. Preoperative cardiac study showed severe pulmonary hypertension with increased pulmonary vascular resistances. Preserved biventricular cardiac output and increased proto and telesystolic pressures. During surgery , ifindings were described as a mitral valve with a large papillary muscle inserted in the distal third of the left ventricle with none tendinous cords at the anterior leaflet and without cords in the posterior leaflet with an isolated papillary muscle with cords at A3 and P3 scallops, compatible with hammock mitral valve. A tendinous muscle/fibrous or fibromuscular band connecting the septum to the posterior wall of the left ventricle was described. Moreover over, there was an enlarged tricuspid ring with very short tendinous cords on the septal leaflet, although the leaflet was bigger than usual. Surgery consisted of resection of the mitral valve preserving A3 and P3 scallops with a 29mm Bicarbon Sorin mechanical mitral prosthesis and a 32mm Carpentier tricuspid ring implantation and pulmonary veins ablation combined with occlusion of left atrial appendage. After 112 minutes of cross-clamping time, the patient was weaned from cardiopulmonary bypass. She had important left ventricle dysfunction which improved with dobutamine and AAI pacemaker at 90lpm. Postoperative TEE showed moderate dysfunction of right ventricle, mild left ventricular dysfunction, moderate tricuspid regurgitation and a good functioning of the prosthesis. TTE before discharge showed good function of mitral valve prosthesis, good left ventricle function, mild tricuspid regurgitation, mild-moderate right ventricular enlargement, although less than preoperatively. Conclusion Congenital mitral valulophaty is a rare condition in the adulthood. The estimated prevalence is 0,5%. The hammock mitral valve is a more uncommon pathology which affects the mitral valve and subvalvular apparatus. This anomaly, was first described in 1967 and it is characterised by anomalous papillary muscles directly connected to the anterior mitral valve by a fibrous bridge without chordae tendineae in between them. This fibrous bridge hampers the opening and closure of the mitral valve. Diagnosis requires a high index of suspicion, both ultrasound studies and medical history, to avoid misdiagnosis. Abstract P1720 Figure.

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Rheumatic mitral stenosis simulating double-orifice mitral valve

BMJ Case Reports ◽

10.1136/bcr-2013-200090 ◽

2013 ◽

Vol 2013 (sep02 1) ◽

pp. bcr2013200090-bcr2013200090

Author(s):

H. Mahla ◽

S. Bhairappa ◽

P. Bhat ◽

C. N. Manjunath

Keyword(s):

Mitral Valve ◽

Mitral Stenosis ◽

Rheumatic Mitral Stenosis ◽

Double Orifice

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Successful Treatment of Double-Orifice Mitral Stenosis with Percutaneous Balloon Mitral Commissurotomy

Case Reports in Cardiology ◽

10.1155/2012/315175 ◽

2012 ◽

Vol 2012 ◽

pp. 1-4 ◽

Cited By ~ 2

Author(s):

Suresh V. Patted ◽

Prabhu C. Halkati ◽

Sameer S. Ambar ◽

Ameet G. Sattur

Keyword(s):

Congenital Anomaly ◽

Mitral Valve ◽

General Population ◽

Left Ventricle ◽

Successful Treatment ◽

Mitral Stenosis ◽

Rare Case ◽

Percutaneous Balloon ◽

Mitral Commissurotomy ◽

Double Orifice

Double-orifice mitral valve (DOMV) is an uncommon congenital anomaly, being present in 0.05% of the general population. The isolated occurrence of this anomaly is very rare and, to our knowledge, no data are currently available on the incidence of an isolated DOMV. A DOMV is characterized by a mitral valve with a single fibrous annulus with 2 orifices opening into the left ventricle (LV). Subvalvular structures, especially the tensor apparatus, invariably show various degrees of abnormality. It can substantially obstruct mitral valve inflow or cause mitral valve incompetence. We present a rare case of nineteen-year-old male who underwent percutaneous mitral balloon commissurotomy in stenotic DOMV.

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Mid-term results of papillary muscles approximation: a retrospective single-center study

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2018-4-54-63 ◽

2018 ◽

Vol 22 (4) ◽

pp. 54

Author(s):

V. V. Bazylev ◽

A. I. Mikulyak ◽

R. M. Babukov ◽

V. A. Karnakhin

Keyword(s):

Mitral Valve ◽

Mitral Regurgitation ◽

Papillary Muscle ◽

Ischemic Cardiomyopathy ◽

Left Ventricular ◽

Rank Test ◽

Mitral Insufficiency ◽

Papillary Muscles ◽

Mitral Annuloplasty ◽

Mid Term Results

Background. Enlargement of the left ventricular chamber and displacement of papillary muscles in the apical and lateral directions increase the tethering forces. Left ventricular and papillary muscle desynchrony and reduced myocardial contractility reduce the closing forces, thus leading to impaired leaflet coaptation and appearance of mitral regurgitation. Therefore, treatment of mitral insufficiency requires an integrated approach, affecting all aspects of the pathogenesis of mitral regurgitation recurrence. Recent publications show that adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation is effective in preventing recurrent regurgitation. One of these procedures is papillary muscle approximation. However, the safety and the positive impact of this method are still open to question. Aim. This study focused on the assessment of mid-term results of papillary muscles approximation and comparison of the obtained results with those of isolated mitral annuloplasty. Methods. Two hundred and twelve patients with ischemic cardiomyopathy and ischemic mitral regurgitation were enrolled in this retrospective single-center study. The patients were randomised to 2 groups by using propensity score matching (a “neighbor” method) according to the following parameters: end diastolic volume, end systolic volume, stroke volume and ejection fraction. The first group included 112 patients with ischemic cardiomyopathy and mitral regurgitation, who underwent coronary artery bypass grafting, mitral annuloplasty and papillary muscle approximation. The second group included 112 patients with ischemic cardiomyopathy who underwent coronary artery bypass grafting and mitral valve annuloplasty. We evaluated early and mid-term results. Results. Two patients in group 1 and three patients in group 2 died of heart failure progression during 31.3±10.4 month follow-up. According to the Kaplan-Meier analysis, no statistically significant differences were noted between the groups (log-rank test = 0.8). Approximation of papillary muscles in patients with ischemic mitral regurgitation improved mitral valve leaflet coaptation as evidenced by the values of coaptation depth, coaptation line and tenting area (p>0.05). During follow-up, 3 cases (2.7%) of mitral insufficiency recurrence were recorded in group 1 and 16 (14.3%) in group 2. The Kaplan-Meier analysis of cumulative probability showed a significant difference in freedom from recurrence of mitral regurgitation ≥2 between groups in the mid-term postoperative period (log-rank test = 0.041). Conclusion. Adjunctive papillary muscle approximation performed at the time of mitral annuloplasty improves the durability of mitral valve repair.Received 18 April 2018. Revised 12 October 2018. Accepted 18 October 2018.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

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