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Objectives: In patients who require minimally invasive mitral valve repair (MICS-mitral), it is difficult to determine the appropriate length of artificial chordae, position, and number of artificial chordae. The Memo 3D Rechord, a complete prosthetic ring associated with a temporary chordal guide system comprised of yellow loops that function as a reference guide for automatically determining the height of neo-chordae. We sought to evaluate our tips for use of this system., Methods: Five patients (1 male, mean 68 years old) who underwent MICS-mitral using artificial chordae with the Memo 3D Rechord were evaluated. Prior to surgery, we assessed the prolapse position using 3-dimensional( 3D) echocardiography to decide the number and positions of the artificial chordae. Polytetrafluoroethylene (PTFE) sutures were passed through the papillary muscles and the free margin of the prolapsed leaflet, then appropriate positioning of the PTFE chordae was performed using a saline test. The PTFE chordae were passed through the loops and the free margin of the prolapsed leaflet was brought to the posterior annulus. Then, the PTFE sutures were tied and the temporary loop system removed., Results: All patients had posterior leaflet prolapse. The number of the artificial chordae was 2 in 3 patients, and 1 in 2. The base of the artificial chordae was attached to the anterior papillary muscle in 3patients and posterior in 4. Additional indentation closure was required in 1 patient. All mitral valve repairs were performed successfully. Postoperative echocardiography mitral regurgitation( MR) grade was trivial in 5., Conclusions: Using our technique, it was possible to decide the appropriate length and position of the artificial chordae and MICS-mitral for leaflet prolapse with the Memo 3D Rechord is a simple and reproducible method.

Recently, mitral valve repair has been the mainstream of the operation for the treatment of mitral valve regurgitation. In particular, chorda reconstruction with artificial chordae is useful for the anterior leaflet. However, there has been no established method determining the length of chordae. In this report, we performed mitral valve repair using Memo 3D ReChord ring which enables to decide the length of chordae more easily. It is based on the concept of folding leaflet technique by Garcia et al. We used this ring in 7 patients (of which 2 were reoperation) in our institution. There was no postoperative death nor complication. Postoperative transthoracic echocardiography showed class 0~ Ⅰ mitral valve regurgitation in each case at discharge. This ring helps to make the repair more reproducible and we consider that it enables to decide the length of chordae more easily even in reoperative cases.

The entrapment of a circular mapping catheter by chordae tendineae during catheter ablation is a very rare but serious complication requiring, in some cases, surgical treatment. We report a case that required open heart surgery for catheter removal and mitral valve repair. A 79-year-old man underwent catheter ablation for paroxysmal atrial fibrillation in other hospital. During the operation, he moved accidentally, despite circular mapping catheter was in the left atrium. The circular mapping catheter was uncontrolable due to resistance interfering with catheter removal, and the patient was brought to our hospital for open heart surgery to remove catheter. General anesthesia was induced and maintained with midazolam, fentanyl. Transesophageal echocardiography was performed to monitor catheter position and mitral valve condition. Transesophageal echocardiography revealed that circular catheter tip was located adjacent to the posterior mitral leaflet and the presence of moderate mitral valve regurgitation. Circular catheter tip was entraped by chordae tendineae and caused posterior mitral leaflet damage. Intracardiac foreign body removal and posterior mitral leaflet repair were completed uneventfully under cardiopulmonary bypass. The postoperative course was uneventful. It is expected that catheter ablation for atrial fibrillation will increase in number. This rare complication of catheter ablation may become a threat to cardiologist, cardiac surgeon and anesthesiologist.

To achieve optimal long-term result of mitral valve repair, artificial chordae creation has got to be an important technique. Artificial chordae creation can preserve leaflet motion of the posterior mitral leaflet and soft coaptation area. Loop technique is suitable technique for creation of multiple artificial chordae, especially in minimally invasive minithoracotomy setting. Loop-in-loop technique is a new technique to realize easy adjusting of the length of the neochordae using slippery Gore-Tex suture. Loop-in-loop technique helps surgeons to afford variety of mitral valve repair techniques and manage complex mitral valve pathologies.

We report a case of 5-month-old boy with severe mitral regurgitation due to a rupture of chordae tendinae. Cardiac echography showed a prolapse of the anterior cusp of the mitral valve. He was progressively deteriorated despite maximal medical treatment, and a surgical intervention was performed 15 hours after the onset. The operative finding was a rupture of chordae tendinae attached to the anterior cusp of the mitral valve. The infant underwent mitral valve plasty using artificial chordae together with partial annulo-plasty. A rupture of chordae tendineae is extremely rare in infants, and its cause is yet unknown. Chordal reconstruction is feasible even at this early stage of life, although the long-term follow-up is mandatory.

A 61-year-old man was treated medically under a diagnosis of hypertrophic obstructive cardiomyopathy 7 years previously. He was transferred to our hospital because of sudden onset of dyspnea. Chest radiography showed marked pulmonary congestion. Echocardiography revealed hypertrophic obstructive cardiomyopathy, with a left ventricular pressure gradient of 120 mmHg, accompanied by severe mitral regurgitation due to ruptured chordae tendineae. Mitral valve replacement and the Morrow operation were performed. After the operation, no left ventricular outflow pressure gradient was detected by echocardiography and cardiac catheterization. The patient did well and no further cardiac symptoms were detected for 3 years.

The common causes of mitral valve chordae rupture are myxomatous valve disease, infective endocarditis. Acute mitral valve insufficiency from chordae rupture, severe clinical symptoms such as dyspnea and shock are observed. Diagnosis is made with clinical symptoms, chest X-ray and echocardiography. Echocardiography is very useful to evaluate the exact lesions. First, inotropic agents, dilators and intraaortic balloon pumping (IABP) are used to stabilize hemodynamic status. Once hemodynamic status becomes unstable in spite of such therapy, surgical correction of mitral regurgitation (MR) is considered. Mitral valve repair should be the first choice of surgical repair, because it preserves left ventricular function, avoids anti-coagulation therapy. Quadrangular resection and suture, annuloplasty and artificial chordae are reliable surgical techniques. If mitral valve repair is difficult, mitral valve replacement is another option. From 1994 to 2002, there were 12 patients who underwent emergency mitral valve surgery because of chordae rupture. There were 7 men and 5 women with mean age of 52.7+/-14.3 years old. Nine of them received mitral valve repair. Two patients were infective endocarditis. Preoperative MR grade was 4.0+/-0.0. Postoperative MR grade was 0.2+/-0.2. Mean follow-up period was 3.8 years. There were no cardiac events and reoperations. Repair technique is quite reliable even in patients with multiple lesions, and the surgical results were almost same as single lesion patients. Repair technique should be the first choice to treat acute MR caused by chordae rupture.

Serial changes in mitral regurgitation after anterior mitral valve repair were examined by transesophageal echocardiography (TEE) in 34 of 86 consecutive patients with pure mitral regurgitation who underwent anterior mitral valve repair from 1987 to 1996. The patients were divided into two groups: 15 patients undergoing mitral repair with polytetrafluoroethylene (PTFE; PTFE group) and 19 undergoing conventional mitral repair without PTFE (non-PTFE group). The PTFE group included 11 men and 4 women with a mean age of 52.1 years. They were followed for mean 22.8 +/- 12.0 months. The non-PTFE group included 12 men and 7 women with a mean age of 53.9 years. They were followed for mean 33.9 +/- 20.4 months. Mitral regurgitation jet areas were observed at the time of operation, 1 month after mitral valve repair, and in the late follow-up period. Regurgitation jet areas were 0.7 +/- 0.7, 1.1 +/- 0.9 and 2.5 +/- 2.1 cm2 in the PTFE group, and 1.1 +/- 1.3, 2.4 +/- 1.7, 4.7 +/- 2.9 cm2 in the non-PTFE group. The jet area was significantly smaller in the PTFE group than in the non-PTFE group at 1 month after operation and in the late follow-up period. Moderate to severe regurgitation was observed in two patients (13.3%) in the PTFE group, and eight patients (42.1%) in the non-PTFE group. Mitral valve repair with PTFE showed better results than conventional mitral valve repair without PTFE during the mean follow-up period of 23 months.

The long-term results of mitral valve repair using artificial polytetrafluorethylene (PTFE) chordae were assessed in 61 consecutive patients with pure mitral regurgitation who underwent mitral valve repair with replacement of elongated or ruptured chordae tendineae between 1992 and 1996. There were 36 men and 25 women aged from 14 to 73 years (mean 52.1 +/- 13.8 years). The patients were followed up for between 1 to 73 months (mean 29.3 +/- 17.6 months). Fifty-five patients underwent mitral valve repair of the anterior leaflet and 6 repair of the posterior leaflet. There were two hospital and two late deaths. Actual survival rate at 5 years was 93.1%. Freedom from cardiac events at 5 years was 87.8%. Two patients required reoperation due to hemolysis. There were three occurrences of non-fatal thromboembolism. Although further investigation is necessary in a large population, expanded PTFE sutures are excellent for chordal replacement during mitral valve repair.

The patient, who had an aortic stenosis, suddenly complicated with severe acute cardiac failure. The rupture of the mitral chordae tendineae was detected by the echocardiogram. Double replacements (aortic and mitral) were done immediately after the onset of chordae rupture. This condition, combination of aortic stenosis and sudden onset of chordae rupture, always results in severe heart failure which is explained by the combination of pressure and volume loading. Finally the emergent operation is believed to be an only solution for this situation.

A 70-year-old woman was found to have new heart systolic murmur and was transferred to our hospital for the treatment of high fever and dyspnea. The chest X ray showed cardiomegaly (CTR 63%) and marked pulmonary congestion. The UCG revealed that there was no evidence of infective endocarditis, but there was hypertrophic obstructive cardiomyopathy with the left ventricular pressure gradient of 90 mmHg accompanied by mitral regurgitation (grade 3/4). Two weeks after the admission, mitral regurgitation progressed due to chordae rupture confirmed by UCG. Transaortic subvalvular myectomy and mitral valve replacement were underwent. Post-operative electrocardiogram demonstrated right and left anterior bandle branch block. Eleven months after the operation left ventricular outflow pressure gradient was not detected by echocardiogram and she has been in I/IV NYHA functional class.

The results of anterior mitral leaflet repair were evaluated by the serial change of mitral regurgitation (MR) using transesophageal echocardiography (TEE) in 24 patients undergoing mitral valve repair for anterior leaflet prolapse during 1988 to 1994, who were examined by TEE immediately after operation, 1 month after operation, and late after operation (mean 15 months). Chordal replacement using polytetra-fluorethylene chordae was performed in 15 patients (PTFE group), and not performed in 9 patients (non-PTFE group). MR jet area late after operation was significantly smaller in the PTFE group than in the non-PTFE group (2.2 +/- 2.3 vs. 4.6 +/- 2.3 cm2, p < 0.05). Moderate to severe MR was observed in four patients (27%) in the PTFE group, and six (67%) in the non-PTFE group late after operation. The thickness of the mitral leaflet before operation was more than 5 mm in all patients with more than moderate MR late after operation in the PTFE group. Chordal replacement using polytetrafluorethylene chordae showed better results compared with conventional mitral valve repair without polytetrafluorethylene chordae over the follow-up period of 15 months.

A 61-year-old man with hypertrophic obstructive cardiomyopathy and ruptured chordae tendineae but subsequent disappearance of the obstruction received mitral valve replacement 4 years after the diagnosis of ruptured chordae tendineae. Chordal rupture should be recognized as one of the important causes of mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy.

A 47-year-old woman, who has mitral regurgitation previously diagnosed in another hospital, was transferred to our intensive care unit for acute congestive heart failure. Just after admission, her respiratory state became worse and she suddenly fell into cardiac arrest. Five minutes later she recovered through cardiopulmonary resuscitation. The pulmonary artery pressure, however, which reached 85/43 mmHg with a Swan-Ganz catheter, had been exceeding systemic pressure. On echocardiography ruptured chordae tendineae of the mitral anterior leaflet was most suspected. Five days after the intensive treatment with a use of IABP, we operated upon her. On the operative findings most rough zone chordae of both leaflets including two strut chordae were ruptured with severe prolapsing. Thus we chose prosthetic valve replacement rather than mitral valve repair. We replaced the mitral valve with a Carbomedix 25 mm. Postoperatively the mean pulmonary artery pressure remained still high as 40 mmHg. With a continuous intravenous administration of prostaglandin E1, the pulmonary artery pressure became lower gradually. The patient was able to wean from respirator on the 18th postoperative day. The patient was discharged on the 49th postoperative day. The mitral valve removed at operation showed myxomatous degeneration and idiopathic ruptured chordae tendineae on the pathological examination. In summary a 47-year-old woman underwent mitral valve replacement 5 days after cardiac arrest from acute severe mitral regurgitation due to widely ruptured chordae tendineae of both leaflets. She survived the operation and got well. The mitral valve showed myxomatous degeneration on pathological examination.

The advantages of mitral valve repair for pure mitral incompetence are established. It is necessary for us to describe suture points more detailed. This article presents our standardized maneuver for mitral regurgitation due to ruptured chordae to the posteromedial commissural scallop. The first step in the repair is placement of a temporary suture in the annulus at attachment of posterior commissural chordae and one of posterior cleft chordae. After measuring the annular diameter and estimating coaptation, this suture is removed. Secondary, rupture of chordae tendinease and adjacent margin of posteromedial commissural scallop are resected. Then, one end of a thread is passed through the margin at end of this untethered segment of leaflet, and another end is passed through the margin of leaflet at opposite end of this segment. Finally, a mattress suture using 3-0 Prolene with pledget is placed as a temporary suture. Between April 1993 and December 1994, four patients underwent reconstruction of mitral regurgitation with ruptured chordae to the posteromedial commissural scallop. Left ventriculogram 4 weeks postoperatively showed no regurgitant jet in all patients.

A 66-year-old man admitted to our hospital complaining of severe dyspnea. Echocardiography demonstrated severe mitral regurgitation and an abnormal echo at the anterior leaflet of the mitral valve. It was a persistent bulge that protruded toward the left atrium throughout systole and diastole. Left ventriculography also demonstrated the same abnormal shadow of the mitral valve. At the operation, it was seen that two of the chordae tendineae of the anterior leaflet had ruptured and a small aneurysm, approximately 10 mm in length, originated from the lateral part of the leaflet. The aneurysm protruded into the left atrium and had neither rupture nor perforation. Because the aneurysm of the mitral valve was too large to resect and repair the valve, it was replaced with St. Jude Medical Valve (29 M). IABP was needed at the weaning from cardiopulmonary bypass, but he recovered gradually well afterwards. The excised anterior leaflet showed myxomatous degeneration, but had no vegetation and rheumatic change. Microscopic examination of the valve aslo revealed myxomatous degeneration and no signs of the inflammation.

Two cases of nonpenetrating traumatic tricuspid regurgitation were reported. The first case, a 46-year-old man who had an episode of traffic accident 21 years ago, was admitted with complaints of peripheral edema and dyspnea on exertion. The second case was a 16-year-old man who noted to have cardiac murmur and cardiomegaly after 4 years of a traffic accident. In both cases, cardiac catheterization showed increased right atrial pressure with high v wave, and echocardiogram showed severe tricuspid regurgitation with ruptured chordae tendineae of the anterior leaflet. Tricuspid valve replacement was performed successfully in both the cases. Twenty-two operated cases of traumatic tricuspid regurgitation have been reported in Japan; 17 of ruptured chordae tendineae, 3 of ruptured papillary muscle, and 2 of primary laceration of anterior leaflet. The patients with ruptured papillary muscle were operated from 2 months to 7 years (average 4 years) after trauma, while those with ruptured chordae tendineae were operated from 5 months to 25 years (average 10 years) after trauma. Tricuspid valve replacement was performed in 17 of 22 cases. From the review of 22 cases, tricuspid valve replacement should be indicated for traumatic tricuspid regurgitation in consideration of the severity of valve destruction regardless of the interval after trauma.

We reported a successful surgical treatment of mitral regurgitation (MR) due to ruptured chordae tendineae in a 44-year-old man with systemic lupus erythematosus (SLE) who had received the steroid therapy. He had signs of acute congestive heart failure with severe pulmonary hypertension due to MR, and underwent urgent mitral valve replacement. The postoperative course was uneventful. When replacing valve in SLE, a careful manipulation should be taken because of friability of cardiovascular tissue. Patients are usually administered steroid agents, and the agents ought to be discontinued in perioperative period, but it seems to be better to resume as soon as possible. We conclude that the surgical treatment for valvular diseases should be considered, even in the patient with SLE.

A 66-year-old woman with double mitral valve (bridge type) and severe mitral regurgitation by spontaneous ruptured chordas is reported. The case with this combination has not been reported in the literature. She had not any other congenital heart diseases. The mitral valve was clearly shown by two-dimensional Doppler transesophageal echocardiography. Mitral valve replacement with Medtronic-Hall valve was carried out successfully.

A 67-year-old female patient underwent mitral valvuloplasty for mitral regurgitation due to the chordal rupture at the posterior commissure. Sliding commissuroplasty was made to avoid large annular plication. Carpentier's prosthetic ring (30 mm) was sutured to remodel the annulus and to reinforce repair. Postoperative Left ventriculogram revealed no regurgitation. Sliding commissuroplasty is effective for mitral regurgitation due to commissural chordal rupture.

We have performed a mitral valve reconstruction on a 31-year-old man who suffered from infective endocarditis four years ago. Severe mitral regurgitation and posterior commissural chordal rupture were noted. The mitral valve was repaired by Carpentier's sliding commissuroplasty and ring annuloplasty. The postoperative course was uneventful, and mitral regurgitation completely disappeared. It appears that Carpentier's sliding commissuroplasty is a superior new reconstructive technique for mitral regurgitation due to commissural chordal rupture.

The patient was a 62 year old woman complaining of severe exertional dyspnea. Preoperative echocardiogram demonstrated the abnormal uniform echo of the anterior leaflet of the mitral valve which protruded toward the left atrium in systole as well as in diastole. Severe mitral regurgitation was also detected. The aneurysm of the anterior leaflet of the mitral valve was confirmed during the operation and mitral valve replacement was performed. The postoperative course was uneventful. Pathological examination of the resected aneurysm showed myxomatous degeneration. There were no signs of the inflammatory processes. The aneurysm formation in this case was considered to be due to the myxomatous degenerative changes of the anterior leaflet of the mitral valve. Fifteen cases of true aneurysm of the mitral valve reported in Japan were reviewed.

A 67-year-old female with mitral regurgitation associated with acromegaly was admitted to our hospital. The cause of MR was torn chordae of posterior leaflet of the mitral valve. A prolapse part of the posterior leaflet was resected and sutured by McGoon's method. Annuloplasty was performed by Kay's method. Postoperative course was uneventful. She recovered well after the operation.

A 57-year-old man was admitted with dyspnea and bloody sputum. The chest X-ray showed unilateral alveolar infiltration, and alveolar cell carcinoma was suspected. Physical examination showed orthopnea and a loud systolic murmur, and the echocardiogram showed mitral valve prolapse. A chest X-ray 4 days later revealed bilateral infiltration. The cardiac catheterization showed pulmonary congestion and the capillary wedge pressure revealed a prominent V wave. Papanicolaou's test of sputum was negative. These findings suggested heart failure due to mitral regurgitation rather than lung carcinoma. The patient underwent mitral valve replacement because of his refractoriness to the medical treatment. During the operation, the chordae tendineae of the anterior mitral leaflet was found to be completely ruptured. The mechanisms of unilateral pulmonary edema could not be ascertained, but the effect of posture and gravity was thought to be a possible mechanism.

A 33-year-old female who had undergone closure of VSD 20 years before, was hospitalized for sudden onset of dyspnea without history of febrile or traumatic disorder. On admission, she had cyanotic lips and nailbeds but no clubbed finger. Chest x-ray film showed neither lung congestion nor cardiomegaly. Arterial blood gas analysis revealed deep hypoxia (PaO2 = 49.6 mmHg). Echocardiogram clarified massive tricuspid regurgitation (TR) due to chordal rupture of anterior leaflet, small VSD jet stream through the membranous aneurysm and a great deal of R-L shunt on the atrial level through a persistent foramen ovale. Cardiac catheterization data confirmed 35% of R-L shunt. At operation, a torn chordal tendon of anterior leaflet and an adhered septal leaflet to aneurysm of membranous portion of ventricular septum were seen. There were two pledgets, used at the first surgery, at the base of the aneurysm and a couple of tiny holes (VSDs) above and below the pledgets were recognized. Following resection of anterior and posterior leaflet, plication of septal leaflet and closure of VSD, a Xenograft valve (Carpentier-Edwards 29-M) was implanted. Then persistent foramen ovale, 20 x 20 mm in large, was closed directly. Her postoperative course was excellent with disappearance of cyanosis, normalized oxygen saturation in arterial blood and improved activity without dyspnea.

We report a case of Marfan's syndrome with acute heart failure caused by a ruptured mitral chorda that was successfully treated by one operation of combined composite valve graft replacement of aortic root and mitral valve replacement (MVR). A 23-year-old man was admitted to our hospital presenting severe dyspnea and chest pain. Echocardiography and cardiac catheterization studies demonstrated marked annulo-aortic ectasia, aortic regurgitation and significant mitral regurgitation due to a ruptured chorda. In operation, it was found that a chorda of the mitral posterior leaflet had been torn, with the leaflet completely prolapsed to the left atrium, and that the aortic root was dilated to 90 mm in diameter. The ascending aorta was extensively resected leaving those areas of aortic tissue involving the coronary ostia. Then the mobilized coronary arteries were reattached to the composite graft. MVR was performed with preservation of the whole anterior and posterior mitral valve apparatus except for that small part with the torn chorda. Histopathological findings of the aortic wall and mitral valve were compatible with those of Marfan's syndrome.

It has been reported that the incidence of mitral valve prolapse was remarkably increased in patients with Klinefelter's syndrome. Some cases which have been previously reported were associated with hemodynamically significant transvalvular regurgitation, however, none of them underwent a surgical treatment such as valvular replacement. Here we report a case of Klinefelter's syndrome which underwent MVR for mitral regurgitation caused by idiopathic chordal rupture. Pathological microscopic examination showed topical and minor myxomatous changes on the free edge of the leaflet and no inflammatory changes such as in infectious endocarditis. It is, therefore, suggested that an echocardiographic follow-up should be carried out in case of Klinefelter's syndrome during its life and also in the case treated by a prophylactic therapy for endocarditis with antibiotics. And when, unfortunately, surgical treatment is required, valve replacement would be preferable to valvuloplasty because of a fragility of leaflet.

A rare case of left atrial myxoma associated with ruptured chordae tendineae is presented. The patient was 70-year-old woman, and was diagnosed to have a left atrial myxoma. The myxoma was extirpated together with the atrial septum from which tumor developed. After removal of the myxoma, a ruptured strut chordae tendineae of anterior leaflet was also detected and resutured to the original papillary muscle. The cause of the torn chordae is presumed to be so-called "wrecking ball effect", and to be myxomatous degeneration of the valve.

To evaluate the difference in the frequency of complication of mitral valve prolapse (MVP) according to sex in subjects aged 60 years and older, 543 patients (218 men and 325 women) who were diagnosed as having MVP by echocardiography at the Lahey Clinic Medical Center were studied. Three hundred and fourty eight patients had no complication of MVP (male vs female = 129:219). Infective endocarditis occurred in 20 patients (male vs female = 13:7). Rupture of chordae tendineae occurred spontaneously in 29 patients (male vs female = 20:9) and were associated with infective endocarditis in 8 other patients (male vs female = 6:2). Eighteen patients required mitral valve surgery for severe mitral regurgitation. The frequencies of these complications were higher in males than those in females. Cerebral ischemic events were encountered in 54 patients. There was no significant difference in the frequency between male and female. In conclusion, MVP in elderly men might be at for cardiac complication.

We studied the prevalence and clinical features of pathologically abnormal mitral valve leaflets (myxomatous mitral valve: MMV) in consecutive 142 patients with the mitral valve prolapse syndrome (MVP). Our echocardiographic criteria for MMV were 1) thick leaflets 3 mm or greater, 2) redundant leaflet-motion, and 3) echo-density lower than that of the aortic walls. The echocardiographic measurements of left ventricular diastolic dimensions (LVDd), percent fractional shortening (%FS), mitral annular diameter (MAD), and LV mass were compared between MMV and non-MMV groups. Twelve patients (8%) were referred for surgery because of congestive heart failure, and two patients died during the observation periods. Gross morphology of the MMV was characterized by increased surface area, dome formation of the leaflet-body, and non-uniform leaflets in thickness, and histologic findings of the MMV were the infiltration of spongiosa layer into the fibrosa layer. The diagnostic accuracy of echocardiography for the MMV was examined in 14 patients underwent either surgery or autopsy, and it was high (78% in sensitivity and 80% in specificity). The progression of mitral regurgitation (MR) from mild to moderate grade or mild to severe grade was found in five of 26 patients during follow-up studies over 12 months (mean = 36 months). All of the five patients were aged 50 years and older. While, MR completely disappeared in a 17-year-old boy with marked physical development within three years of the observation period. Mitral annular diameter significantly increased in MMV with MR when compared to non-MMV with MR (4.1 +/- 0.7 vs 3.5 +/- 0.4). But no significant changes were noted in LVDd and LV mass between non-MMV with MR and MMV with MR. Of the 142 patients with MVP, 96 patients were non-MMV and 46 patients were MMV. Ruptured chordae tendineae were associated in 5/96 patients (5%) with non-MMV and 22/46 patients (48%) with MMV. Intracardiac vegetations were seen in four of the 96 patients (4%) with non-MMV. The prevalence of MMV in MVP was greater in older patients, and it reached nearly as high as 50% of MVP patients aged 60 years and older. In conclusion, the echocardiographic diagnostic criteria for MMV are reliable with high sensitivity and specificity, and are useful to predict the high risk patients in the MVP syndrome. MMV may be a potential etiology causing aggravation of mitral regurgitation and/or ruptured chordae tendineae.

A 54 year-old man was admitted to our hospital with a compliant of high fever following the dental treatment. He had the straight thoracic spine with absence of physiological kyphosis. Blood culture was positive for Streptococcus sanguis I. Echocardiography revealed the mitral valve regurgitation with some vegetation at the ruptured chordae tendinae of the posterior leaflet. The operation was performed after the sign of the inflammation was disappeared. We performed the mitral valve reconstruction following the Carpentier's technique. The half of the posterior leaflet was excised, and the annuloplasty and valvuloplasty was done with ease.

Four patients with mitral regurgitation due to torn chordae of the mitral posterior leaflet underwent mitral valvuloplasty. Standard operation was McGoon's procedure which was sometimes combined with Kay's annulorrhaphy. There were no sign of mitral insufficiency and/or stenosis in all patients revealed by the post-operative cardiac catheterization and all of them are on good health. Then, our plans of mitral posterior valvuloplasty for mitral regurgitation are as follows: A resected area is not beyond 33% of the posterior leaflet and the target mitral valve area after valvuloplasty is 2.8 cm2.

A 66-year-old female was admitted to our hospital with acute heart failure (NYHA III), and diagnosed as an MR + Tr. The cause of MR was torn chordae of the posterior leaflet of the mitral valve. A prolapse part of the posterior leaflet was resected and sutured by McGoon's method. Valvuloplasty was performed by using a Carpentier ring. Postoperative course was uneventful. She recovered well after the operation. Histological examination of the valve showed myxomatous degeneration.

Twenty-three cases with ruptured chordae tendineae (RCT) of the mitral valve and 9 normal control cases were studied by two-dimensional echocardiography. Mitral valve replacement (MVR) was performed in 13 of the 23 cases. The preoperative diagnosis of RCT was proven accurately at operation in all except 2 cases with bacterial endocarditis. Whether RCT occurred in the antero-lateral or in the postero-medial commissural side could be determined perfectly. RCT was observed in the postero-medial side more often than in the anterolateral side, i.e., postero-medial side in 16 (9 operated) and antero-lateral side in 5 (2 operated). This tendency has also been noted in other Japanese reports regardless of the cause of RCT. In the short axis view at the level of the papillary muscles, the area of the posterior papillary muscles was smaller than the area of the anterior papillary muscles in the RCT cases. It is speculated that the smaller size of the posterior papillary muscles has a certain relation with the more frequent RCT in the postero-medial commissural side.

The sensitivity and specificity of the two-dimensional (2D) echocardiographic criteria for diagnosing ruptured mitral chordae tendineae (RCT) were assessed in 52 cases with non-rheumatic mitral regurgitation undergoing mitral valve prostheses. At surgery, chordal rupture was confirmed in 38 cases (RCT group), but not in 14 cases (non-RCT group). Four presumptive and three definite findings for diagnosing mitral chordal rupture using 2D echo were evaluated. Mitral valve prolapse with incomplete coaptation of the mitral leaflets in the long-axis view was observed in 32 cases in the RCT group and in four cases in the non-RCT group (sensitivity 84%, specificity 80%). In the short-axis view at the level of the mitral orifice, delayed closure of the involved mitral leaflet was observed in four cases in the RCT group but in none of the non-RCT group (sensitivity 11%, specificity 100%), delayed protodiastolic opening of the involved leaflet in 15 cases of the RCT group and in one of the non-RCT group (sensitivity 39%, specificity 92%), and finally, increased excursion of the involved valve in 27 cases of the RCT group and in three cases of the non-RCT group (sensitivity 71%, specificity 79%). The following three echocardiographic findings were regarded as direct evidence of mitral chordal rupture: Fine echoes with abnormally rapid transverse and/or oblique motion around the mitral orifice in the short-axis view were observed in 13 cases of the RCT group (sensitivity 34%, specificity 100%); echoes with abnormal whip-like motion in the long-axis view in 10 cases (sensitivity 26%, specificity 100%).(ABSTRACT TRUNCATED AT 250 WORDS)

In the present study, the ballooning pattern of the anterior mitral valve (AMV) in mitral valve prolapse (MVP) was investigated, and new diagnostic criteria for MVP were established using two-dimensional and Doppler echocardiography. The study population consisted of 164 patients with prolapse of the AMV alone, including 86 patients with idiopathic MVP, 52 associated with atrial septal defect (ASD), 17 having chordal rupture and nine associated with connective tissue disorders. There were 60 normal controls. The results were as follows: 1. The AMV was divided into two zones, clear and rough (CZ and RZ), according to the point of insertion of the strut chordae based on two-dimensional long-axis echocardiograms of the left ventricle. The severity of AMV prolapse was determined by an angle between the posterior aortic wall (PAO)-CZ and the CZ-RZ. a) Type A: Apparently there was a transitional point between CZ and RZ, despite normal PAO-CZ and CZ-RZ angles. The RZ showed mild ballooning or prolapse into the left atrium. b) Type B: Although the PAO-CZ angle was normal, the CZ-RZ angle was markedly narrowed. Therefore, prolapse of the RZ was more severe compared with that of type A. c) Type C: An overall zone of the AMV showed ballooning or prolapse into the left atrium due to a narrowed PAO-CZ angle. 2. Type B prolapse was frequently observed in idiopathic MVP (58%), the ASD group (71%) and the chordal rupture group (71%), and type C prolapse in MVP of connective tissue disorders (89%). 3. All of 18 patients (100%) with type A, 48 of 99 (48%) with type B, and 10 of 47 (21%) with type C could not be diagnosed as MVP using Gilbert's criterion. 4. Doppler mitral regurgitation (MR) was detected in 40 of the 47 patients (85%) with type C in 56 of the 99 (59%) with type B, and in seven of the 18 (39%) with type A. These results suggested that classification of the two-dimensional echocardiography of the AMV into two zones, clear and rough (CZ and RZ), could contribute to determining not only the severity of AMV prolapse, but also to the extent of myxomatous changes of the AMV and to evaluating the correlations between the degree of MVP and the incidence of MR.

To evaluate the early and late results of mitral valve replacement and reconstruction for mitral insufficiency due to ruptured chordae tendineae respectively, 74 consecutive cases were analyzed. Fifty-five (74.3%) of the patients were men, and the mean age was 48 +/- 12 years old (range 16 to 76). The causes of the mitral disease were idiopathic in 50 (67.6%), rheumatic in 7 (9.4%) and infective endocarditis in 11 (14.9%) patients. In idiopathic 50 cases, 24 had mitral valve prolapse and 16 had both mitral valve prolapse and hypertension. Forty-one (55.4%) of the patients were in NYHA functional class III or IV preoperatively. Thirty (40.5%) cases underwent surgery within one year after their initial symptoms of heart failure onsets including six emergency operation cases due to uncontrollable acute lung edema. Chordae to anterior mitral leaflet were ruptured in 31 (a5, m16, p10)[41%] patients, to the posterior mitral leaflet in 45 (a4, m23, p18)[59%], and to both leaflets in one patient. Mitral valve replacement was performed in 68 patients (91.9%) and 6 patients (8.1%) underwent mitral valve repairs. Twenty cases underwent associated procedures that included tricuspid valve annuloplasty in 8, aortic valve replacement in 5 and myocardial revascularization in 4 cases. There were two operative deaths (2.4%); both occurred after replacement, left ventricular rupture in one and DIC in one. Mean follow-up period was 4.5 years (range 1 to 17) in 67 cases. There were four late deaths; all occurred after replacement. However five patients sustained mild mitral insufficiency after mitral valve repair including one that became worse of regurgitation three years after isolated Kay's annuloplasty, there were no cases that had needed reoperation and no late death after reconstruction. Left ventricular function and pulmonary arterial pressure were almost normalized in more than 90% cases postoperatively. Our data indicated that mitral valve reconstruction (McGoon's plus Kay's method as standardized maneuver) was the procedure of choice for selected patients with mitral insufficiency owing to ruptured chordae tendineae to the posterior mitral leaflet, including more limited patients with ruptured chordae to the anterior mitral leaflet.