Morphometric Study of Mitral Valve in South Odisha - A Cadaveric Study

BACKGROUND The heart is a pair of valved muscular pumps combined in a single organ. For the proper functioning of the heart, all valves should be intact. Mitral valve (MV) prolapse and regurgitation is the main cause of MV replacement. The dimensions of mitral valve and the cusps vary from person to person. We wanted to measure the average size of the valve components with respect to the annulus in the cadavers of South Odisha region, which would help in the selection of prosthetic valve in cardiac surgery. METHODS This comparative study was carried out on 58 adult cadaveric human hearts. Left atrium was opened along the left border of heart so as to expose the mitral orifice. Parameters of different components ofthe valve were measured by using appropriate instruments. RESULTS The mean annular circumference of the mitral valve was found to be 8.84 ± 1.24 cm; The annular attachment and height of anterior cusp were 2.94 ± .81 cm and 2.55 ± 0.27 cm respectively. The annular attachment and height of posterior cusp were 4.52 ± 0.78 cm and 1.2 ± 0.17 respectively. The annular area was found to be 5.22 ± 1.13 cm2. The combined cusp area was found to be 9.38 ± 2.32 cm. CONCLUSIONS The size of mitral valve parameters in the South Odisha region were found to be less compared to other studies. This study might help cardio-thoracic surgeons as well as the prosthetic valve manufacturing companies for the rough estimation of the mitral valve size. KEY WORDS Mitral Valve, Anterior Cusp, Posterior Cusp, Annular Circumference, Annular Valve Area and Combined Cusp Area

P1244 Mitral valve abscess caused by Klebsiella pneumoniae in a patient with diabetes melitus

Introduction Infective endocarditis (IE) still leads to high mortality, despite the achievements of modern medicine. Particular attention should be paid to the group of patients in whom the occurence of IE is caused by rare atypical bacteria, such as Klebsiella pneumoniae. It is known that Klebsiella is the cause of IE in only 1.2% of cases in patients with native valves (Anderson MJ, Janoff EN, 1998), at the same time disease proceeds extremely aggressive. Case presentation Patient M., 47 years old, complained of shortness of breath, fever up to 40 degrees Celcius and general weakness. In medical history patient had diabetes melitus (DM) for a 15 years. 10 days before hospitalization the patient was subjected to hypothermia, after that he noted the appearance of fever, chills and general weakness. 4 days after the symptoms appears he turned to a general practitioner and was diagnosed with acute respiratory viral infection. Since the patient did not notice the effect of treatment for 5 days (general weakness and fever persisted, shortness of breath appeared), he called an ambulance and was taken to our clinic with suspected pneumonia. Conducted computer tomography (CT) revealed no signs of pneumonia. During hospitalization, transthoracic echocardiography (TTE) was performed. There was no heart disease in the patient"s medical history. TTE revealed the hyperechoic mobile mass (15x15 mm) on the posterior cusp of a mitral valve. Mitral regurgitation was within physiological range. For the verification, patient was recommended to undergo transesophageal echocardiography (TEE), but he categorically refused this examination. Against the background of ongoing antibiotic therapy fever persisted. Subsequently, the patient was consulted by a neurologist about a complaint of double vision, and a brain CT was performed and revealed acute infarction in the right occipital lobe. Stroke was regarded as cardioembolic. The patient"s condition progressively worsened, miltiple organ failure was increasing, he was intubated and transferred to the intensive care unit. We performed an ultrasound as heart murmur appeared. TEE revealed a large hyperechoic formation 30x30 mm with anechoic collapsing cavity in the center and defect in the posterior cusp up to 20 mm, mitral regurgitation reached 4 degrees. Despite adequate therapy the patient"s condition progressively worsened, and the next morning biological death was diagnosed. The autopsy results confirmed IE caused by Klebsiella pneuminiae. Conclusion Our clinical case shows that we cannot neglect a small percentage of cases of IE caused by such atypical bacteria as Klebsiella. The disease in this case was extremely severe and difficult to treat, which can be explained by the tendency of patients with DM to the occurence of infections. Abstract P1244 Figure.

Tooth wear in captive rhinoceroses (Diceros, Rhinoceros, Ceratotherium: Perissodactyla) differs from that of free-ranging conspecifics

Tooth wear can affect body condition, reproductive success and life expectancy. Poor dental health is frequently reported in the zoo literature, and abrasion-dominated tooth wear, which is typical for grazers, has been reported in captive browsing ruminants. The aim of this study was to test if a similar effect is evident in captive rhinoceros species. Dental casts of maxillary cheek teeth of museum specimens of captive black (Diceros bicornis; browser), greater one-horned (Rhinoceros unicornis; intermediate feeder) and white rhinoceroses (Ceratotherium simum; grazer) were analysed using the recently developed extended mesowear method for rhinoceroses. Captive D. bicornis exhibited significantly more abrasion-dominated tooth wear than their free-ranging conspecifics (p<0.001), whereas captive C. simum exhibited significantly less abrasion-dominated tooth wear, particularly in the posterior cusp of the second molar (p=0.005). In R. unicornis, fewer differences were exhibited between free-ranging and captive animals, but tooth wear was highly variable in this species. In both free-ranging and captive D. bicornis, anterior cusps were significantly more abrasiondominated than posterior cusps (p<0.05), which indicates morphological differences between cusps that may represent functional adaptations. By contrast, tooth wear gradients between free-ranging and captive animals differed, which indicates ingesta- specific influences responsible for inter-tooth wear differences. Captive D. bicornis exhibited more homogenous tooth wear than their free-ranging conspecifics, which may be caused by an increase in the absolute dietary abrasiveness and a decrease in relative environmental abrasiveness compared to their freeranging conspecifics. The opposite occurred in C. simum. The results of this study suggest that diets fed to captive browsers are too abrasive, which could result in the premature loss of tooth functionality, leading to reduced food acquisition and processing ability and, consequently, malnourishment.

Posterior cusp enlargement in mitral valve reconstructive surgery for restrictive valve insufficiency: Case report

Introduction According to Carpentier classification, group III of mitral insufficiency is caused by the restrictive motion of the mitral valve. A rheumatic process and a coronary disease are the main causes. It is very important to examine the valve precisely, to define deformities and aetiology in order to make such a valve functional. In rheumatic disease, fibrosis and degeneration deform the entire mitral apparatus. A surgical principle is to re-establish mobility and pliability of the apparatus taking care of the functional anatomy at the same time. Cusp enlargement, chordal mobilization and ring remodeling are just some of the numerous surgical techniques that could be performed in these patients. Case outlineA 55-year old female patient was admitted to hospital with severe mitral regurgitaion. She belonged to NYHA, functional stage 2. Echocardiography revealed that both cusps, mostly posterior, were of reduced size and mobility, resulting in grade 3 regurgitation. We performed posterior cusp enlargement by using autologous pericardium treated in 0.6% of glutaraldehyde solution. Annulus remodeling was done using size 27 flexible Duran ring. Control echocardiography found trivial regurgitation. The patient was discharged on 12th postoperative day in sinus rhythm. Conclusion Surgical reconstruction of the rheumatic mitral valve back to the functional state is a demanding procedure, which, however, provides certain benefit for the successfully treated patient.

Motion of both mitral valve leaflets: a cineroentgenographic study in intact dogs

Motion and position of both mitral leaflets were studied in five normal dogs 1–11 wk after radiopaque markers were sutured on the valve cusps and on the mitral annulus. Cinefluorograms and cineangiograms (100–120 frames/s) of left atrium and left ventricle were used to study cusp motion and intraventricular flow patterns, and to detect mitral regurgitation during sinus rhythm (42–184 beats/min) and during isolated atrial or ventricular contractions. Time-motion of both leaflets was similar throughout diastole with the exception of delayed posterior cusp opening. Peak opening and closing speeds, opening and closing times, and time of complete closure, measured from the Q wave of the ECG, were not significantly affected by the variations in heart rate. Diastolic leaflet closure began immediately after opening, while the ventricular cavity was small, and was caused by flow eddies behind the cusps. Isolated ventricular contractions closed the valve leaflets completely and symmetric valve closure was ensured by the different rates of leaflet edge approximation. In contrast, atrial closure was slow, partial, and of very short duration.