Abstract 3387: The Effects of Restrictive Annuloplasty on Mitral Leaflet Coaptation and The Mechanism Regulating Functional Mitral Regurgitation: Simplified Echocardiographic Study

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Yasuhiro Shudo ◽  
Kazuhiro Taniguchi ◽  
Koichi Toda ◽  
Hajime Matsue ◽  
Hiroki Hata ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Significant Negative Correlation ◽  
Functional Mitral Regurgitation ◽  
Anterior Leaflet ◽  
Mitral Leaflet ◽  
Diastolic Phase ◽  
Simplified Method ◽  
Leaflet Coaptation ◽  
Lateral Diameter

Objectives: The effects of restrictive annuloplasty on mitral leaflet coaptation in a clinical setting have not been fully elucidated. We developed a novel simplified method for assessing the actual degree of coaptation and investigated changes caused by its use. Based on our findings, we evaluated the direct effects of restrictive annuloplasty on mitral leaflet coaptation and the mechanism regulating mitral regurgitation. Methods and Results: We studied 23 patients (mean 60 years old) with functional mitral regurgitation (grade 3 to 4+) with congestive heart failure (LV ejection fraction 32±10%) due to idiopathic (n=8) or ischemic (n=15) who underwent mitral valve repair with restrictive annuloplasty and 20 normal control subjects. We measured the septal-lateral diameter, tenting height, tenting area, and coaptation length of the mitral valve in 4-chamber, 2-chamber, and long-axis views at mid-systole before and after surgery using transthoracic and transesophageal echocardiography procedures. Coaptation length was calculated with the following formula: Ad-Ac, where Ad equals the whole length of the anterior leaflet during the diastolic phase and Ac equals the length of the non-coaptation free portion of the anterior leaflet at mid-systole. Coaptation length index was defined as the ratio of coaptation length to septal-lateral diameter. Results: Tenting height and tenting area were significantly decreased, while coaptation length and coaptation length index were significantly increased (Table ). In multivariate analysis, coaptation length index showed a statistically significant negative correlation with degree of residual MR (r=0.77, p<0.0001) and was found to be the most reliable predictor of MR grade. Conclusion: Our novel simplified method provided quantitative and morphological descriptions of mitral leaflet coaptation, and can also provide important information for developing a surgical strategy for regulation of MR. Table

Mechanism of Incomplete Mitral Leaflet Coaptation—Interaction of Chordal Restraint and Changes in Mitral Leaflet Coaptation Geometry

2002 ◽  
Vol 124 (5) ◽  
pp. 596-608 ◽  
Author(s):  
Sten Lyager Nielsen ◽  
Hans Nygaard ◽  
Lars Mandrup ◽  
Arnold A. Fontaine ◽  
J. Michael Hasenkam ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Spatial Relations ◽  
Functional Mitral Regurgitation ◽  
Papillary Muscles ◽  
Mitral Leaflet ◽  
Force Components ◽  
Leaflet Coaptation

Clinically observed incomplete mitral leaflet coaptation was reproduced in vitro by altering the balance of the chordal tethering and chordal coapting force components. Mitral leaflet coaptation geometry was distorted by changes of the spatial relations between the papillary muscles and the mitral valve as well as hemodynamics. Mitral leaflet malalignment was accentuated by a redistribution of the chordal tethering and coapting force components. For the overall assessment of systolic mitral leaflet configuration in functional mitral regurgitation it is important to consider the interaction between chordal restraint and an altered mitral leaflet coaptation geometry.

Functional and Degenerative Mitral Regurgitation: One Ring Fits All?

2019 ◽  
Vol 68 (06) ◽  
pp. 470-477
Author(s):  
Konstantinos Sideris ◽  
Johannes Boehm ◽  
Bernhard Voss ◽  
Thomas Guenther ◽  
Ruediger S. Lange ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Three Dimensional ◽  
Cumulative Risk ◽  
Functional Mitral Regurgitation ◽  
Combined Procedures ◽  
Echocardiographic Assessment ◽  
Leaflet Coaptation ◽  
Mid Term Results

Abstract Background Three-dimensional saddle-shaped annuloplasty rings have been shown to create a larger surface of leaflet coaptation in mitral valve repair (MVR) for functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR) which may increase repair durability. For the first time, this study reports mid-term results after MVR for DMR and FMR using a rigid three-dimensional ring (Profile 3D, Medtronic). Methods Between June 2009 and June 2012, 369 patients with DMR (n = 326) or FMR (n = 43) underwent MVR (mean age 62.3 ± 12.6 years). A total of 205 patients (55.6%) underwent isolated MVR and 164 patients (44.4%) a combined procedure. Follow-up examinations were performed in 94.9% (mean 4.9 ± 0.9 years). Echocardiographic assessment was complete in 93.2% (mean 4.3 ± 1.2 years). Results The 30-day mortality was 1.5% (5/326) for DMR (1.5% for isolated and 1.6% for combined procedures) and 9.3% (4/43) for FMR (0% for isolated and 10.5% for combined procedures). Survival at 6 years was 92.1 ± 1.9% for DMR (92.9 ± 2.6% for isolated and 90.7 ± 2.7% for combined procedures) and 66.4 ± 7.9% for FMR (80.0 ± 17.9% for isolated and 63.7 ± 8.9% for combined procedures). Cumulative risk for mitral valve-related reoperation at 6 years was 0% for FMR and 7.1 ± 1.5% for DMR. At echocardiographic follow-up, one patient presented with mitral regurgitation (MR) more than moderate. The only predictor of recurrent MR after MVR for DMR was residual mild MR at discharge. Conclusion Repair of FMR with the three-dimensional Profile 3D annuloplasty ring shows excellent mid-term results with regard to recurrence of MR. In cases of DMR, the results are conforming to the current literature.

scholarly journals Influence of Chronic Tethering of the Mitral Valve on Mitral Leaflet Size and Coaptation in Functional Mitral Regurgitation

2012 ◽  
Vol 5 (4) ◽  
pp. 337-345 ◽  
Author(s):  
Ken Saito ◽  
Hiroyuki Okura ◽  
Nozomi Watanabe ◽  
Kikuko Obase ◽  
Tomoko Tamada ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Functional Mitral Regurgitation ◽  
Mitral Leaflet

Repair of the Mitral Valve Anterior Leaflet: Early Results

1996 ◽  
Vol 4 (4) ◽  
pp. 214-216 ◽  
Author(s):  
Taweesak Chotivatanapong ◽  
Pradistchai Chaiseri ◽  
Udom Leelataweewud ◽  
Promporn Petchyungthong
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Mitral Stenosis ◽  
Anterior Leaflet ◽  
Mitral Leaflet ◽  
Anterior Mitral Leaflet ◽  
Early Results ◽  
Hospital Deaths ◽  
Prosthetic Ring

Between March 1994 and December 1995 a total of 27 cases of mitral valve anterior leaflet repair were undertaken at our institution. Five of the patients were excluded from the study; 3 with predominant mitral stenosis and 2 with atrial septal defect primum type. Of the 22 anterior mitral leaflet repair patients, there were 12 males and 10 females with a mean age of 41.5 years. Follow-up was complete in all patients and ranged from 2 to 22 months with a mean of 8.6 months. Mitral valve disease was attributed to rheumatic disease in the majority of cases (12). Other causes included degenerative (5), endocarditis (2), ischemic (2), and congenital conditions (1). Preoperatively there, were 18 cases of mitral regurgitation, and 4 of mixed mitral stenosis and regurgitation. The most commonly used surgical procedures were prosthetic ring implantation, chordal shortening and chordal transposition. Most of the patients required multiple procedures to accomplish the repair with an average of 3.4 procedures per patient. Neochordal implantation with polytetrafluoroethylene was performed in 4 cases. Reconstruction of the anterior mitral leaflet using autologous glutaraldehyde-treated pericardium was completed in 2 patients who had bacterial endocarditis. There were no hospital deaths nor late mortality in this series. None of the patients required reoperation during the follow-up. The patients' functional status as well as the severity of the mitral regurgitation improved markedly after the operation. We conclude from our study that repair of the mitral valve anterior leaflet is possible in selected patients with good early results.

scholarly journals MitraClip procedure with two MitraClips after indirect annuloplasty with the MONARC device

2014 ◽  
Vol 0 (0) ◽  
pp. 1-3
Author(s):  
Susanne Rutschow ◽  
Sebastian Jäger ◽  
Michael C. Gross
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Heart Surgery ◽  
Functional Mitral Regurgitation ◽  
Anterior Leaflet ◽  
Mitral Valve Reconstruction ◽  
Heart Lung Machine ◽  
Valve Reconstruction ◽  
High Comorbidity ◽  
Lung Machine

Abstract Mitral regurgitation is associated with a worsened prognosis in dilated cardiomyopathy. First standard therapy consists of a mitral valve reconstruction through heart surgery including the heart–lung machine. In patients with high comorbidity, catheter-based techniques have been developed. In the Evolution I study, the MONARC system was implanted in the coronary sinus in the functional mitral regurgitation. A reduction in regurgitation by >1 grade was documented in 50% of the patients. MitraClip is an alternative, edge-to-edge technique, which joined the posterior and anterior leaflet by implanting a clip. It can be used for both functional and degenerative mitral regurgitations. We reported a case of MitraClip procedure with the use of two clips and a reduction of mitral regurgitation to grade 0–1 after implanting a MONARC device four years ago with missing relevant reduction in mitral regurgitation. With this report, we illustrated the management of Mitraclip in a patient with an implanted MONARC device and technical difficulties through the bowing of the posterior annulus.

scholarly journals Prognostic value of mitral valve tenting area in patients with functional mitral regurgitation

2019 ◽  
Vol 30 (3) ◽  
pp. 431-438
Author(s):  
Maria von Stumm ◽  
Florian Dudde ◽  
Simone Gasser ◽  
Tatiana Sequeira-Gross ◽  
Jonas Pausch ◽  
...  
Keyword(s):  
Survival Rate ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Functional Mitral Regurgitation ◽  
Primary Study ◽  
Mitral Leaflet ◽  
Cardiac Events ◽  
End Point ◽  
Increased Risk ◽  
Adverse Cardiac Events

Abstract OBJECTIVES Mitral valve (MV) repair in functional mitral regurgitation is still associated with suboptimal outcomes. Our goal was to determine whether the clinical outcome following MV repair correlates with preoperative tenting parameters. METHODS We retrospectively identified consecutive patients with functional mitral regurgitation who underwent an isolated MV annuloplasty during a 7-year period (2010–2016) from our institutional database. Preoperative tenting parameters (i.e. tenting height, coaptation length, tenting area, posterior mitral leaflet and anterior mitral leaflet angles and interpapillary muscle distance) were systematically measured. The primary end point was the composite of survival and freedom from adverse cardiac events. The follow-up protocol consisted of a structured clinical questionnaire and an analysis of the echocardiographic data. RESULTS A total of 240 patients (mean age 67.8 ± 9.8 years, 57% of men) were analysed. The overall 5-year survival rate for the whole study cohort was 74.7 ± 4.2%, and freedom from adverse cardiac events was 84.8 ± 3.4%. A tenting area ≥2.4 cm2 was identified as a cut-off value, independently predicting the composite primary study end point (hazard ratio 2.0; P = 0.03). Furthermore, a Kaplan–Meier analysis revealed a strong tendency towards worse 5-year outcomes in patients with a tenting area ≥2.4 cm2 (n = 153) versus patients with a tenting area &lt;2.4 cm2 (n = 87) (65.3 ± 5.5% vs 77.1 ± 6.3%; P = 0.06). CONCLUSIONS MV annuloplasty is associated with acceptable clinical and echocardiographic outcomes in patients with functional mitral regurgitation 5 years postoperatively. A preoperative tenting area ≥2.4 cm2 showed a strong trend towards a worse 5-year survival rate and an increased risk of adverse cardiac events after an isolated MV annuloplasty.

scholarly journals 1634 3D transoesofageal echocardiography in detection of anterior leaflet laceration during mitraclip implantation

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
M Mariani ◽  
A G Cerillo ◽  
S Maffei ◽  
F Marchi ◽  
G Benedetti ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Color Doppler ◽  
Intraoperative Complications ◽  
The Body ◽  
Functional Mitral Regurgitation ◽  
Anterior Leaflet ◽  
Percutaneous Mitral Valve Repair ◽  
Annular Dilatation ◽  
Determinant Factor

Abstract Background MitraClip is a percutaneous way of treatment of mitral regurgitation. Recent trials demonstrate its value in modifying prognosis of patients with functional mitral regurgitation. During MitraClip implant imaging with 3D TEE is mandatory to guide the procedure and monitoring the results. Unfortunately, laceration of mitral leaflets is a well-described complication of Percutaneous Mitral valve repair by implantation of MitraClip. 3D TEE can be useful even to detect complication of the procedure and in particular leaflets lacerations. Here we describe a case where 3D TEE was capable to recognize and visualize a laceration in the anterior leaflet (AL) and we assume some mechanisms leading to this complication. Methods An 83 years old man with post-ischemic severe functional mitral regurgitation underwent to MitraClip implantation. The mitral valve shows a severe tenting and annulus was deformed and dilated. The procedure was performed under fluoroscopic and 3D TEE guidance (Philips iE33). Due to the large central regurgitation and large coaptation gap, we decide to implant MitraClip XTR, this is the larger device 5 mm longer. Results A single MitraClip XTR was implanted in the central scallop (A2-P2) in the region of the larger jet, after device positioning a further jet was detected in the region of implant and the original jet was unchanged. Using 3D color complete volume and X-plane reconstructions we recognize that the jet originates between the clip and the basal aspects of AL. Without color Doppler in 3D zoom and X plane reconstruction, a continuum solution was suspected in the body of AL but the shadow of the delivery system partially masked the region. After removal of the device, perforation of AL was clearly depicted also with 3D zoom without color Doppler. The patient was surgically treated and inspection confirmed the laceration and shows a worn thin AL. The laceration of AL can be caused by the tension on a thinned tissue carried out by the large device. The severe tethering and annular dilatation with a marked distance between anterior and posterior leaflet at the tip of the device may have been a determinant factor in the tear occurrence. Conclusion 3D TEE can clearly depict lacerations of leaflets during MitraClip implantation. Preoperative extensive analysis of valve geometry and inspection of leaflets searching for a thinned region can avoid intraoperative complications. The distance between leaflets at the expected tips of the MitraClip can be a predictive parameter of tension applied on the leaflets and of the risk of tearing. Abstract 1634 Figure. Image 1

Extended Myectomy for Hypertrophic Obstructive Cardiomyopathy

2012 ◽  
Vol 15 (5) ◽  
pp. 251
Author(s):  
Changqing Gao ◽  
Chonglei Ren ◽  
Cangsong Xiao ◽  
Yang Wu ◽  
Gang Wang ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Surgical Procedures ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Systolic Anterior Motion ◽  
Anterior Leaflet ◽  
Septal Myectomy ◽  
The Mean

<p><b>Background:</b> The purpose of this study was to summarize our experience of extended ventricular septal myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM).</p><p><b>Methods:</b> Thirty-eight patients (26 men, 12 women) with HOCM underwent extended ventricular septal myectomy. The mean age was 36.3 years (range, 18-64 years). Diagnosis was made by echocardiography. The mean (mean � SE) systolic gradient between the left ventricle (LV) and the aorta was 89.3 � 31.1 mm Hg (range, 50-184 mm Hg) according to echocardiographic assessments before the operations. Moderate or severe systolic anterior motion (SAM) of the anterior leaflet of the mitral valve was found in 38 cases, and mitral regurgitation was present in 29 cases. Extended ventricular septal myectomy was performed in all 38 cases. The results of the surgical procedures were evaluated intraoperatively with transesophageal echocardiography (TEE) and with transthoracic echocardiography (TTE) at 1 to 2 weeks after the operation. All patients were followed up with TTE after their operation.</p><p><b>Results:</b> All patients were discharged without complications. The TEE evaluations showed that the mean systolic gradient between the LV and the aorta decreased from 94.8 � 35.6 mm Hg preoperatively to 13.6 � 10.8 mm Hg postoperatively (<i>P</i> = .0000) and that the mean thickness of the ventricular septum decreased from 28.3 � 7.9 mm to 11.8 � 3.2 mm (<i>P</i> = .0000). Mitral regurgitation and SAM were significantly reduced or eliminated. During the follow-up, all patients promptly became completely asymptomatic or complained of mild effort dyspnea only, and syncope was abolished. TTE examinations showed that the postoperative pressure gradient either remained the same or diminished.</p><p><b>Conclusions:</b> Extended ventricular septal myectomy is mostly an effective method for patients with HOCM, and good surgical exposure and thorough excision of the hypertrophic septum are of paramount importance for a successful surgery.</p>

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