scholarly journals Anterior mitral leaflet length and mitral annulus diameter impact the echocardiographic outcome after isolated myectomy

2019 ◽  
Vol 14 (1) ◽  
Author(s):  
Mateusz Kuć ◽  
Magdalena Kumor ◽  
Mariusz Kłopotowski ◽  
Maciej Dąbrowski ◽  
Natalia Kopyłowska-Kuć ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Nyha Class ◽  
Mitral Annulus ◽  
Outflow Tract ◽  
Mitral Leaflet ◽  
Anterior Mitral Leaflet ◽  
Anterior Posterior ◽  
Annulus Diameter

Abstract Background Myectomy remains the standard surgical treatment of patients with hypertrophic cardiomyopathy (HOCM). New surgical methods developed in the last decades mainly address the mitral valve and are controversial because of their conflicting assumptions. This study assesses the influence of anterior mitral valve leaflet (AML) length and the anterior-posterior diameter of the mitral annulus (MAD) on dynamic left ventricle outflow tract obstruction and mitral regurgitation (MR) after extended myectomy. Methods We retrospectively analysed the transthoracic echocardiograms (TTE) of 36 patients. AML length and MAD were obtained from TTE performed before the operation. The greatest maximal left ventricle outflow tract (LVOT) gradient and MR registered in follow-up were analysed. After surgery, patients were divided into two groups; those with moderate or milder MR and/or an LVOT gradient < 30 mmHg (responders), and those with more than moderate MR and/or an LVOT gradient ≥30 mmHg (non-responders). Results Patients in responders group had significantly longer AML: 32.3 ± 2.3 mm vs 30.0 ± 3.8 mm (p = 0.03) [parasternal long axis view – PLAX view], 25.9 ± 2.3 mm vs 23.5 ± 2.7 mm (p = 0.008) [four chamber view - 4CH view] and larger anterior-posterior mitral annulus diameter 28.1 ± 2.8 mm vs 25.4 ± 3.2 mm (p = 0.011) than those in non-responders group. Among all analysed patients longer anterior mitral leaflet was correlated with lower postoperative LVOT gradient when measured in PLAX view (p = 0.02) and lower degree of MR due to systolic anterior motion (SAM) when measured in 4CH view (p = 0.009). Greater [AML x mitral annulus] ratio correlated with lower postoperative LVOT gradient in both projections: 4CH (p = 0.025), PLAX (p = 0.012). There was significant reduction in NYHA Class after surgery (p = 0.000). There were no significant differences in NYHA class after surgery (p = 0.633) neither in NYHA class reduction (p = 0.475) between patients divided into responders and non-responders group according to echocardiographic parameters. Conclusions Patients with a longer AML and a greater diameter of the mitral annulus are less likely to have mitral regurgitation due to residual SAM and increased LVOT gradient after an extended myectomy. Division of patients according to echocardiographic criteria into responders and non-responders was not in concordance with clinical improvement. Trial registration Retrospective study. Approved by ethics committee (IK-NPIA-0021-21/1763/19) at 16.01.2019.

scholarly journals Systematic cutting of selected secondary mitral valve chordae, in association with a shallow myectomy, in obstructive hypertrophic cardiomyopathy:impact on mitral valve function and patient management

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
D Margonato ◽  
R Abete ◽  
A Zyrianov ◽  
A Sorropago ◽  
M Chioffi ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Septal Defect ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Anterior Leaflet ◽  
Mitral Leaflet ◽  
Access To Treatment ◽  
Anterior Mitral Leaflet ◽  
Septal Myectomy ◽  
Number Of Patients

Abstract Introduction Few centers worldwide have large experience with performing an extended septal myectomy in patients with obstructive hypertrophic cardiomyopathy (HCM). Therefore, many HCM patients eligible for surgical relief of left ventricular (LV) outflow gradient do not have access to treatment. In a previous study, cutting fibrotic anterior mitral leaflet secondary chordae, in association with only a shallow myectomy, proved highly effective in moving the mitral valve (MV) apparatus away from the LV outflow tract and relieving the outflow gradient in our HCM patients with mild hypertrophy (&lt;19 mm), a surgical approach that simplifies the operation. Purpose To assess whether chordal cutting is equally effective in improving MV geometry and relieving LV outflow gradient and heart failure symptoms in HCM patients with more marked hypertrophy. Methods Surgical outcome and MV geometry and function were assessed in 226 consecutive HCM patients who underwent systematic cutting of fibrotic anterior mitral leaflet secondary chordae, in association with a shallow myectomy and independently of magnitude of septal thickness, at our center from January 2015 to December 2018. Results Of 226 study patients, 1 (0.4%) died perioperatively. None had iatrogenic septal defect. Postoperatively, LV outflow gradient at rest decreased from 70±36 to 10±2 mmHg (P&lt;0.001). In the 77 patients in whom data on the outflow gradient provoked with physiologic maneuvers after surgery were available, the provocable gradient was 16±10 mmHg. NYHA functional class improved significantly (P&lt;0.001), with the number of patients in class III-IV decreasing from 178 (79%) to 2 (0.9%). No patient had residual severe MV regurgitation and only 4 (1.7%) had moderate-to-severe regurgitation. Quality of the echocardiogram allowed assessment of MV geometry in 212 (94%) patients. In the 62 patients with mild hypertrophy, anterior leaflet-annulus ratio increased 27% postoperatively, from 0.43+0.06 to 0.55+0.06 and MV tenting area decreased 34% from 2.9+0.6 to 1.9+0.4 cm2 (P&lt;0.001), indicating repositioning of MV coaptation away from the outflow tract (with increased outflow tract dimension). Similarly, in 150 patients with marked hypertrophy, anterior leaflet-annulus ratio increased 27% from 0.43+0.05 to 0.55+0.06 and tenting area decreased 28% from 2.9+0.6 to 2.1+0.4 cm2 (P&lt;0.001). Conclusions Our results show that cutting fibrotic anterior mitral leaflet secondary chordae, by moving the MV apparatus away from the LV outflow tract and independently of the magnitude of septal hypertrophy, contributes to improve the results of septal myectomy and reduces the need for a deep septal excision (and associated risk of iatrogenic septal defect) in patients with obstructive HCM. Therefore, chordal cutting could make the myectomy operation more accessible to surgeons, increasing the availability of surgical treatment for HCM patients eligible for invasive abolition of LV outflow obstruction. Funding Acknowledgement Type of funding source: None

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 Selected Abstracts of the TEEPGI 2014 Workshop

2014 ◽  
Vol 2 (1) ◽  
pp. 42-48
Keyword(s):  
Mitral Valve ◽  
Aortic Valve ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Mitral Leaflet ◽  
Axis View

ABSTRACT Mitral valve perforation is most commonly due to infective endocarditis. Iatrogenic mitral valve perforation following aortic valve replacement has not been described previously. A 57 years male patient presented with complaints of progressive dyspnea on exertion and occasional palpitations. A preoperative diagnosis of severe aortic stenosis, sclerodegenerative aortic valve with normal left ventricle function was made on transthoracic echocardiography. A coronary angiogram showed single vessel disease involving proximal left anterior descending artery causing 80% stenosis. The patient was planned for aortic valve replacement (AVR) and CABG. Pre bypass TEE showed bicuspid aortic valve, thick, calcified, severe aortic stenosis and normal left ventricle systolic function. Mitral valve was morphologically normal with mild central mitral regurgitation jet. Patient underwent CABG and AVR under cardiopulmonary bypass support. Post CPB TEE examination showed 2 jets of mitral regurgitation in midesophageal aortic long-axis view (Fig. 1). There was a mild central MR jet and an additional mild MR jet from the body of anterior mitral leaflet. Transgastric short axis view showed turbulence in the region of A1 scallop of anterior mitral leaflet. We present the intraoperative TEE images of the patient with a discussion on the role of TEE in detection of mitral valve perforation and surgical decision making.

scholarly journals Mitral annulus disjunction: is it a marker of ominous prognosis?

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
NPD Cunha ◽  
J Rigueira ◽  
R Santos ◽  
A Nunes-Ferreira ◽  
T Rodrigues ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Sinus Rhythm ◽  
Univariate Analysis ◽  
Interventricular Septum ◽  
Maximum Velocity ◽  
Mitral Annulus ◽  
Maximum Diameter

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Mitral annulus disjunction (MAD) has been proposed as a contributing factor for arrythmias and mitral regurgitation in patients with mitral valve prolapse (MVP), however its clinical relevance is still under investigation. Objective To evaluate the frequency of MAD in MVP patients, to characterize clinically patients with MAD and assess potential markers for events. Methods Single-center retrospective study of consecutive patients with MVP documented in transthoracic echocardiogram between January 2014 and October 2019. MVP was defined according to the 2017 AHA recommendations; MAD was defined as a separation between mitral valve annulus and the left ventricle free wall. Demographic, clinical, echocardiographic, electrocardiographic data were collected. The results were obtained using Chi-square and Mann-Whitney tests; logistic regression was used to find predictors of events. Results 247 patients were included (mean age 62.9 ± 18 years, 61% males), of these 23 (9.3%) had MAD (mean age 56 ± 20 years, 56.5% males). The maximum diameter of MAD was 10 ± 3mm (range 5-18). 21 patients (92.3%) had mitral regurgitation, and it was at least of moderate severity in 65.2% of patients. Most of the patients (91.3, n = 21) were in sinus rhythm (SR). During follow-up (FUP) of 29 ± 19 months, 39% (n = 9) of the patients developed symptoms, 22% (n = 5) had atrial fibrillation (AF), 4.3% (n = 1) had acute aortic syndrome (AAS), 4.3% (n = 1) needed ICD, 22% (n = 5) were submitted to mitral valve intervention, 8.7% (n = 2) were admitted to hospital and 8.7% (n = 2) died. None of the patients presented sustained ventricular arrhythmias (SVA) as assessed in regular Holter monitoring. These patients had more AAS and needed more ICD in FUP compared to patients without MAD (p = 0.007 and p = 0.006, respectively) Mitral cord rupture (p = 0.04), age (p = 0.044), maximum velocity of tricuspid regurgitation (p = 0.04) and IVS thickness (p = 0.017) were associated with AF in MAD patients. in univariate analysis, interventricular septum thickness was a predictor of AF in this subgroup (OR 4.0, 95%CI 1.1-14.3, p = 0-032) The presence of SR was associated with survival (p = 0.03). There were no predictors of hospital admission or mitral intervention. Conclusion Patients with MAD had a relatively benign prognosis with few events during follow-up, although with more AAS and ICD in FUP. In our sample, AF was more common than SVA. Left ventricle hypertrophy was a predictor of AF and sinus rhythm was associated with survival. Larger studies with more patients and other methods of imaging are needed to confirm our results.

scholarly journals P1714 When the mechanism of mitral regurgitation is unclear, 3D Trans-esophageal echocardiography is the solution

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
N Thabet ◽  
D Labib ◽  
S Nagy ◽  
H Mahmoud-Elsayed
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Imaging Techniques ◽  
Nyha Class ◽  
Mitral Annulus ◽  
Left Ventricular ◽  
Added Value ◽  
Unknown Mechanism ◽  
Arrow Head

Abstract Introduction Assessment of mitral regurgitation (MR) mechanism is not always easy and may require advanced imaging techniques. A 28-year-old male presented with significant MR three years following surgical mitral valve repair for severe MR due to mitral valve prolapse. During surgery, he underwent artificial chordal implantation on A2 scallop and Gore-Tex posterior band annuloplasty. Early post-operative transthoracic echocardiography (TTE) showed mild to moderate eccentric, posteriorly directed MR of unknown mechanism. Since the patient was asymptomatic, only regular follow-up was advised. He missed his follow-up for three years after which presented complaining of exertional dyspnea NYHA class II. TTE showed dilated left ventricular dimensions with moderate to severe MR of unknown mechanism. 2D trans-esophageal echocardiography (TEE) (figure 1, panel A& B) showed severe, posteriorly directed mitral regurgitation, with a mass (arrow head) at the level of the mitral annulus. 3D TEE (figure 1,panel C, 3D zoom mode and panel D, true view mode) showed dehiscence (arrow head) of the annuloplasty band from the posterior mitral annulus with a wide gap measuring 83 mm² in 3D planimetred area. The patient was referred for re-do surgery. Conclusion 3D TEE has a great added value in elucidating the mechanism of MR in obscure cases and guiding the proper management strategy. Abstract P1714 Figure 1

scholarly journals Morphological features of mitral annular calcification leading to systolic anterior motion of the mitral valve

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
E J Friend ◽  
P C Wiener ◽  
K Murthy ◽  
G S Pressman
Keyword(s):  
Mitral Valve ◽  
Interventricular Septum ◽  
Mitral Annulus ◽  
Ventricular Outflow Tract ◽  
Left Ventricular ◽  
Systolic Anterior Motion ◽  
Mitral Leaflet ◽  
Mitral Annular Calcification ◽  
Anterior Mitral Leaflet ◽  
Annular Calcification

Abstract Background Systolic anterior motion (SAM) of the mitral valve (MV) can develop after mitral valve repair with placement of an annuloplasty ring. It is occasionally seen in patients with mitral annular calcification (MAC) but mechanisms have not been carefully delineated. Using 2-dimensional echocardiography we explored morphologic parameters which may contribute to SAM in patients with MAC. Hypothesis We hypothesized that in cases of MAC where SAM is present there would be anterior displacement of the valve by the posterior annular calcification. Methods From our echocardiographic database we identified 20 patients with severe MAC who also had SAM with definite septal contact. Each subject was paired with 2 controls free of MAC and 1 control with severe MAC but no SAM. All controls were matched for age, sex, BSA, and septal wall thickness (±1.5 mm). 2-D echocardiographic measurements were taken from the parasternal long-axis (PLAX), apical 3-chamber and apical 4-chamber views. Results MAC+SAM vs MAC no-SAM. Three notable differences were observed: MAC+SAM patients, as compared with MAC no-SAM, had a smaller left ventricular outflow tract (LVOT), longer anterior mitral leaflet, and greater displacement of the MV coaptation point towards the interventricular septum (Figure 1). Median values for these 3 factors were determined using the no-MAC controls; each MAC subject was then scored for number of factors exceeding those values. MAC+SAM patients had a mean score of 2.7 vs 1.1 for MAC no-SAM patients. By combining anterior mitral leaflet length and coaptation point-septal distance as a ratio we could effectively separate MAC+SAM vs MAC no-SAM when &gt;0.9 with one exception (Figure 2). We also observed a smaller anteroposterior annular dimension in the MAC+SAM group. MAC no-SAM vs no-MAC. Comparing these groups there were no differences in LVOT diameter or coaptation-septal distance; effective anterior mitral leaflet length was smaller in MAC no-SAM subjects vs no-MAC controls while anteroposterior dimension of the annulus was larger. Conclusions SAM develops in a subset of patients with severe calcification of the mitral annulus. These patients have a smaller anteroposterior annular dimension, possibly due to severe MAC. Other notable differences characterize MAC patients with SAM from those without. The LVOT is smaller, the effective anterior mitral leaflet length is longer, and the point of leaflet coaptation is displaced towards the septum. Using the ratio of anterior mitral leaflet length/coaptation point-septal distance in this study sample effectively separated those MAC patients with SAM from those without. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

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>

Abstract 2068: Systematic Undersized Rigid Ring Decreases Recurrence Rate Following Repair of Ischemic Mitral Valve

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Raphaël Fontaine ◽  
Denis Bouchard ◽  
Philippe Demers ◽  
Raymond Cartier ◽  
Michel Carrier ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Recurrence Rate ◽  
Nyha Class ◽  
High Recurrence Rate ◽  
Class Iii ◽  
Term Survival ◽  
Rigid Ring

Introduction: Chronic ischemic mitral regurgitation (MR) has been associated with poor long-term survival. Suboptimal midterm results have been a growing concern in the surgical community. In recent years, our approach to repair those valves has evolved to a standardized technique using complete, rigid and small annuloplasty rings. This study aims to compare this systematic approach with our prior experience from 1996 –2001 where recurrent MR rate was high. Methods: 129 patients underwent repair for pure ischemic mitral valve regurgitation between 2002 and 2005 at our institution. Of these patients, 99 had clinical and echographic follow-up. These patients were compared to the 1996 –2001 cohort of 73 patients. Results: Preoperatively, 84% of patients were in NYHA class III or IV, 17% had moderate MR, 83% had moderate-severe to severe MR. Sixteen were redo operations, mostly of previous CABG. All patients except one were treated with a complete rigid ring (Annuloflo 46.5%, Physioring 34.9%, Etlogix 13.9%, others 3.8%). Ring size was: 24 (0.8%); 26 (55.8%); 28 (38%); or 30 (4.5%). Mortality was 8.5% at 30 days, 14.7% at 1 year and 17.8% at 2 years. Immediate postoperative regurgitation was absent or trace in all patients. Freedom from reoperation was 97%. Mean postoperative NYHA class was 1.15 at a mean follow-up of 28 months. Recurrent moderate mitral regurgitation (2+) was 15.34%, severe mitral regurgitation (3+ to 4+) was 13.4% at a mean follow-up of 16 months. In the 73 patients from the period 1996 –2001 at the same echo follow-up time, the moderate and severe recurrence were: 37% and 21%. The decrease in the recurrence rate was highly significant (p=0.001). Conclusion: A more standardized approach to ischemic mitral valve repair has improved the high recurrence rate previously reported by our group. Long-term follow-up is necessary to confirm these findings.

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