Abstract 19570: Diastolic Anterior Leaflet Tethering Contributes to Functional Mitral Stenosis after Restrictive Mitral Valve Annuloplasty

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Philippe B Bertrand ◽  
David Verhaert ◽  
Christophe J Smeets ◽  
Frederik H Verbrugge ◽  
Lars Grieten ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Stenosis ◽  
Gas Analysis ◽  
Peak Exercise ◽  
Opening Angle ◽  
Anterior Leaflet ◽  
Mitral Valve Annuloplasty ◽  
Chamber View ◽  
Secondary Mr ◽  
Bicycle Exercise Test

Introduction: Restrictive mitral valve annuloplasty (RMA) for secondary mitral regurgitation (MR) might cause functional (mitral) stenosis, yet underlying pathophysiological mechanisms remain debated. Hypothesis: Diastolic restriction of the anterior leaflet (AL) opening, due to papillary muscle tethering, plays a key role in the inflow obstruction after RMA. Increasing AL opening during exercise is associated with greater mitral valve area (MVA). Methods: Consecutive RMA patients (n=39, 63±11 years, 77% male) performed a symptom-limited (supine) bicycle exercise test with stepwise Doppler echocardiography and respiratory gas analysis. Diastolic AL opening angle (3-chamber view, Figure A), transmitral flow rate, mean transmitral gradient, and effective MVA were assessed at rest and during peak exercise. Results: At rest, effective MVA (1.5±0.4cm2) correlated moderately to the AL opening angle (68±10°) (r=0.4, p=0.014; Figure B). During exercise, effective MVA increased significantly to 2.0±0.5cm2 (p<0.001), with a stronger correlation to AL opening angle (r=0.6, p<0.001; Figure B). After stratification of the population into tertiles according to increase in AL opening angle during exercise (<=0°, 0-4° and >4° AL angle increase, respectively), a higher increase was significantly associated with greater effective MVA during exercise (p=0.013, Figure C). Patients with AL opening angle <69° at rest (median) and without dynamic AL angle increase of >4° (n=13) had a significantly lower maximal oxygen uptake compared to patients with AL opening angle at rest above the median or a greater dynamic AL angle increase with exercise (n=22) (VO2max 12.5±2.8 versus 16.4±4.7 mL/kg/min, p=0.005). Conclusions: Diastolic restriction of AL opening plays a key role in functional mitral stenosis after RMA for secondary MR. Increasing AL opening at rest, or better AL opening reserve during exercise, are associated with higher MVA and improved exercise capacity.

scholarly journals Randomized, Controlled Trial Comparing Mitral Valve Repair With Leaflet Resection Versus Leaflet Preservation on Functional Mitral Stenosis

Circulation ◽  
2020 ◽  
Vol 142 (14) ◽  
pp. 1342-1350
Author(s):  
Vincent Chan ◽  
C. David Mazer ◽  
Faeez Mohamad Ali ◽  
Adrian Quan ◽  
Marc Ruel ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Mitral Stenosis ◽  
Controlled Trial ◽  
Walking Distance ◽  
Peak Exercise ◽  
Unique Identifier ◽  
Randomized Controlled ◽  
The Mean

Background: Equipoise exists between the use of leaflet resection and preservation for surgical repair of mitral regurgitation caused by prolapse. We therefore performed a randomized, controlled trial comparing these 2 techniques, particularly in regard to functional mitral stenosis. Methods: One hundred four patients with degenerative mitral regurgitation surgically amenable to either leaflet resection or preservation were randomized at 7 specialized cardiac surgical centers. Exclusion criteria included anterior leaflet or commissural prolapse, as well as a mixed cause for mitral valve disease. Using previous data, we determined that a sample size of 88 subjects would provide 90% power to detect a 5–mm Hg difference in mean mitral valve gradient at peak exercise, assuming an SD of 6.7 mm with a 2-sided test with α=5% and 10% patient attrition. The primary end point was the mean mitral gradient at peak exercise 12 months after repair. Results: Patient age, proportion who were female, and Society of Thoracic Surgeons risk score were 63.9±10.4 years, 19%, and 1.4±2.8% for those who were assigned to leaflet resection (n=54), and 66.3±10.8 years, 16%, and 1.9±2.6% for those who underwent leaflet preservation (n=50). There were no perioperative deaths or conversions to replacement. At 12 months, moderate mitral regurgitation was observed in 3 subjects in the leaflet resection group and 2 in the leaflet preservation group. The mean transmitral gradient at 12 months during peak exercise was 9.1±5.2 mm Hg after leaflet resection and 8.3±3.3 mm Hg after leaflet preservation ( P =0.43). The participants had similar resting peak (8.3±4.4 mm Hg versus 8.4±2.6 mm Hg; P =0.96) and mean resting (3.2±1.9 mm Hg versus 3.1±1.1 mm Hg; P =0.67) mitral gradients after leaflet resection and leaflet preservation, respectively. The 6-minute walking distance was 451±147 m for those in the leaflet resection versus 481±95 m for the leaflet preservation group ( P =0.27). Conclusions: In this adequately powered randomized trial, repair of mitral prolapse with either leaflet resection or leaflet preservation was associated with similar transmitral gradients at peak exercise at 12 months postoperatively. These data do not support the hypothesis that a strategy of leaflet resection (versus preservation) is associated with a risk of functional mitral stenosis. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier NCT02552771.

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 A randomized surgical trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis – primary results of the CAMRA CardioLink-2 trial

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
V Chan ◽  
C.D Mazer ◽  
T Mesana ◽  
B.E De Varennes ◽  
A.J Gregory ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Valve Repair ◽  
Mitral Stenosis ◽  
Peak Exercise ◽  
Funding Source ◽  
Posterior Leaflet ◽  
Valve Repair ◽  
Mitral Repair ◽  
The Mean ◽  
Leaflet Prolapse

Abstract Background The gold standard treatment for mitral valve regurgitation due to prolapse involves surgery with annuloplasty and either leaflet resection or leaflet preservation, with placement of artificial neochordae. It has been suggested that leaflet resection may be prone to functional mitral stenosis, whereby a patient may have a higher mitral gradient at peak exercise compared to a leaflet preservation strategy. Although both techniques are widely used, there has been no prospective randomized study conducted to compare these two techniques, particularly in regard to functional mitral stenosis. Methods A total of 104 patients with posterior leaflet prolapse were randomized to undergo mitral repair with either leaflet resection (N=54) or leaflet preservation (N=50) at 7 specialized Canadian cardiac centers. Patient age, proportion of female patients, and mean Society of Thoracic Surgeons risk score was 63.9±10.4 years, 19%, and 1.4% for those who underwent leaflet resection, and 66.3±10.8 years, 16%, and 1.9% for those who underwent leaflet preservation, respectively. The primary endpoint was the mean trans-mitral repair gradient at peak exercise 12-months after repair. Results Baseline characteristics were similar between the groups. At 12-months, the mean trans-mitral repair gradient at peak exercise in patients who underwent leaflet resection and preservation was 9.1±5.2 and 8.3±3.3 mmHg (P=0.4), respectively. The two groups had similar mean mitral valve gradient at rest (3.2±1.9 mmHg following resection and 3.1±1.1 mmHg following leaflet preservation, P=0.7). There was no between-group difference for the 6-minute walk distance (451±147 m and 481±95 m for the resection and preservation groups, respectively, P=0.3). Conclusion We report the first prospective surgical randomized trial to evaluate commonly used mitral valve repair strategies for posterior leaflet prolapse. Leaflet resection and leaflet preservation both yield acceptable results with no difference in postoperative valve gradient and functional status 12-months after surgical mitral valve repair. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Heart and Stroke Foundation of Canada

scholarly journals Effect of Mitral Valve Leaflets Excursion on Mitral Valve area after Percutaneous Trans- Venous Mitral Commissurotomy

2017 ◽  
Vol 10 (1) ◽  
pp. 3-7
Author(s):  
Md Abdul Mannan ◽  
AAS Majumder ◽  
Solaiman Hossain ◽  
Mohammad Ullah ◽  
SNI Kayes
Keyword(s):  
Mitral Valve ◽  
Mitral Stenosis ◽  
Posterior Leaflet ◽  
Anterior Leaflet ◽  
Valve Morphology ◽  
Mitral Valve Area ◽  
A Value ◽  
Percutaneous Transvenous Mitral Commissurotomy ◽  
Mitral Commissurotomy ◽  
Valve Area

Background: Aim of our study was to predict the effect of mitral valve leaflets excursion on mitral valve area following percutaneous transvenous mitral commissurotomy PTMC in patients of mitral stenosis.Methods: Total 70 patients with severe mitral stenosis who underwent PTMC were enrolled in the study.Transthoracic echocardiography was done the day before PTMC and 24-48 hours after PTMC. Mitral valve area, anterior and posterior leaflets excursion were recorded. The relation between leaftlet excursion and mitral valve after PTMC was evaluated.Results: Following PTMC there were significant increasein anterior leaflet excursion from 1.9 ± 0.2 to 2.3 ± 0.2cm (p<0.001), posterior leaflet excursion from 1.6±0.2to1.9 ± 0.2cm (p<0.001). Mitral valve areas increased from 0.8 ± 0.1 to1.7 ± 0.2cm²(p<0.001). Both leaflet excursion increased significantly with the increase in mitral valve area till the area reached a value of about 1.5 cm2, after which any further increase in mitral valve area was not associated with any further increase in leaflet excursion.Conclusion: PTMC is associated with immediate significant changes in mitral valve morphology in terms of splitting of fused mitral commissures, increased leaflets excursion and splitting of the subvalvular structures. Post PTMC leaflet excursion increases significantly with the increase in mitral valve area till the area reaches a value of about 1.5 cm2 after which any further increase in mitral valve area is not associated with any further increase in leaflet excursion.Cardiovasc. j. 2017; 10(1): 3-7

scholarly journals P760 Stress echocardiography testing of a novel trans annular mitral bridge implantation for mitral regurgitation

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
M Benesova ◽  
V A Subramanian ◽  
S Cerny
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Arterial Pressure ◽  
Mitral Stenosis ◽  
Functional Mitral Regurgitation ◽  
Peak Exercise ◽  
Valve Repair ◽  
Ergometer Exercise ◽  
Valve Area

Abstract Objectives Indirect reduction of septal- lateral diameter (SLD) by circumferential cinching of the annulus with ring annuloplasty (RA) is the standard part of mitral valve repair surgery. Direct SLD reduction without circumferential annular cinching by a novel trans-annular Mitral Bridge with an infra-annular curvature has been used for functional mitral regurgitation (FMR) as a sole procedure and for mitral valve prolapse (MVP)as a part of valve repair. The aim of this study was to assess the functional and hemodynamic outcomes at rest and exercise at 2 yr. follow up in the patients with this novel type of annuloplasty. Methods 30 of 34 patients with FMR who had trans annular Mitral Bridge as the sole treatment of their MR and 5 of 8 patients with MVP in a prospective trial underwent at 2yr F/U bicycle ergometer exercise echocardiography on a special semi-recumbent bicycle. Mitral regurgitation, mitral peak and mean gradient, mitral valve area, systolic pulmonary arterial pressure, systolic function of the left ventricle were assessed at rest and peak exercise. Results Mitral regurgitation was 0.3 ± 0.5 at rest and 0.4 ± 0.5 at peak exercise (p = 0.264). The resting mean mitral gradient was 2.3 ± 0.9 mmHg and peak 4.6 ± 1.9 mmHg (p &lt;.0001) and valve area was at rest 3.5 ± 0.7cm2 and at peak 3.9 ± 0.9 cm2 (p = 0.026). Pulmonary systolic arterial pressure was 25.8 ± 17 at rest and 36.9 ± 21.8 at peak exercise (P = 0.012). LVEF was 60,4± 10.5 at rest and at peak 66,4± 12.5 (p &lt;.0001). Conclusion Trans annular Mitral Bridge as a alternative to standard annuloplasty ring is effective. At 2 yr follow up there was only trace mitral regurgitation and no mitral stenosis. The stress test verified the durability of the mitral repair both in FMR and MVP. There was no mitral stenosis and no mitral regurgitation at exercise. The raise of the mean mitral gradient was statistically important, but the values remained within the normal range. The raise of gradients is in correlation with the presence of cardiac reserve and increased LVEF. There were no signs of pulmonary hypertension caused by the stress. Abstract P760 Figure. Mitral Bridge

Rare Combination of Pathologies Causing Mitral Stenosis and Mitral Regurgitation: A Case Report

2018 ◽  
Vol 11 (4) ◽  
pp. NP113-NP116
Author(s):  
Anupama K. Nair ◽  
Kuntal Roy Chowdhuri ◽  
Sitaraman Radhakrishnan ◽  
Krishna S. Iyer ◽  
Manish Saxena
Keyword(s):  
Case Report ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Mitral Stenosis ◽  
Surgical Repair ◽  
Heart Defects ◽  
Severe Mitral Regurgitation ◽  
Anterior Leaflet ◽  
Rare Combination ◽  
Congenital Mitral Regurgitation

A supramitral ring is a rare cause of mitral stenosis, while an isolated mitral valve cleft is a rare cause of congenital mitral regurgitation. Fortunately, both the lesions are known to have good outcomes after surgical correction. Although each is known to be associated with a variety of other structural heart defects, their coexistence has not been reported previously. We report a case of a three- and half-year-old boy detected to have a rare combination of supramitral ring producing severe mitral stenosis with a coexisting cleft in the anterior leaflet of mitral valve causing severe mitral regurgitation. The patient underwent successful surgical repair with resolution of both mitral stenosis and regurgitation.

Outcome and durability of mitral valve annuloplasty in atrial secondary mitral regurgitation

Heart ◽  
2021 ◽  
pp. heartjnl-2021-319045
Author(s):  
Sébastien Deferm ◽  
Philippe B Bertrand ◽  
David Verhaert ◽  
Jeroen Dauw ◽  
Jan M Van Keer ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Patient Characteristics ◽  
Left Ventricular ◽  
Type I ◽  
Therapeutic Implications ◽  
Mitral Valve Annuloplasty ◽  
All Cause Mortality ◽  
Secondary Mitral Regurgitation ◽  
Secondary Mr

ObjectivesAtrial secondary mitral regurgitation (ASMR) is a clinically distinct form of Carpentier type I mitral regurgitation (MR), rooted in excessive atrial and mitral annular dilation in the absence of left ventricular dysfunction. Mitral valve annuloplasty (MVA) is expected to provide a more durable solution for ASMR than for ventricular secondary MR (VSMR). Yet data on MR recurrence and outcome after MVA for ASMR are scarce. This study sought to investigate surgical outcomes and repair durability in patients with ASMR, as compared with a contemporary group of patients with VSMR.MethodsClinical and echocardiographic data from consecutive patients who underwent MVA to treat ASMR or VSMR in an academic centre were retrospectively analysed. Patient characteristics, operative outcomes, time to recurrence of ≥moderate MR and all-cause mortality were compared between patients with ASMR versus VSMR.ResultsOf the 216 patients analysed, 97 had ASMR opposed to 119 with VSMR and subvalvular leaflet tethering. Patients with ASMR were typically female (68.0% vs 33.6% in VSMR, p<0.001), with a history of atrial fibrillation (76.3% vs 33.6% in VSMR, p<0.001), paralleling a larger left atrial size (p<0.033). At a median follow-up of 3.3 (IQR 1.0–7.3) years, recurrence of ≥moderate MR was significantly lower in ASMR versus VSMR (7% vs 25% at 2 years, overall log-rank p=0.001), also when accounting for all-cause death as competing risk (subdistribution HR 0.50 in ASMR, 95% CI 0.29 to 0.88, p=0.016). Moreover, ASMR was associated with better overall survival compared with VSMR (adjusted HR 0.43 95% CI 0.22 to 0.82, p=0.011), independent from baseline European System for Cardiac Operative Risk Evaluation II surgical risk score.ConclusionPrognosis following MVA to treat ASMR is better, compared with VSMR as reflected by lower all-cause mortality and MR recurrence. Early distinction of secondary MR towards underlying ventricular versus atrial disease has important therapeutic implications.

A three-step technique for repair of rheumatic disease of the mitral valve

2014 ◽  
Vol 24 (6) ◽  
pp. 1104-1107 ◽  
Author(s):  
Matthew P. Thomas ◽  
Vinay Badhwar
Keyword(s):  
Mitral Valve ◽  
Rheumatic Disease ◽  
Mitral Valve Repair ◽  
Mitral Stenosis ◽  
Systolic Anterior Motion ◽  
Anterior Leaflet ◽  
Valve Repair ◽  
Rheumatic Mitral Stenosis

Abstract:This manuscript presents a technically straightforward technique to allow for mitral valve repair in the patient with rheumatic mitral stenosis. This non-resection technique allows for the correction of both mitral stenosis and regurgitation without requiring complex subvalvar procedures and eliminates the concerns for postoperative systolic anterior motion. The authors feel this three-part technique of bi-commissural release, anterior leaflet augmentation, and oversized annuloplasty may allow for a more reproducible approach to repair of the rheumatic mitral valve.

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