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

OBJECTIVES Saline testing is used in mitral valve (MV) surgery to evaluate the repair intra-operatively. Sometimes, saline testing shows a prolapse of the anterior leaflet, not seen on preoperative echocardiography. Our objective was to investigate the incidence, predisposing factors and consequences of this phenomenon.METHODS We retrospectively reviewed all consecutive patients undergoing surgery for posterior leaflet prolapse between 2013 and 2017. All data, including intraoperative video recordings of the repair and saline testing, were collected prospectively.RESULTS Isolated posterior leaflet repair was performed in 91 patients. In 17 patients (18.7%), saline testing showed an unexpected anterior leaflet prolapse. Patients with unexpected prolapse presented with higher body mass index (BMI) compared to the reference group (27.52.3 vs 25.0 +/- 4.2, P=0.01). Binomial logistic regression analysis showed BMI, surgical approach, number of prolapsing segments, left ventricular ejection fraction, left ventricular end systolic diameter and left atrial diameter to be predictive for unexpected anterior leaflet prolapse. In patients with unexpected anterior leaflet prolapse, no adequate saline testing was possible and repair was accomplished based on correction of the prolapse as seen on a preoperative echocardiogram. In both groups, 100% repair rate was achieved. Predischarge mitral regurgitation grading showed mild or less mitral regurgitation in all the patients in the unexpected prolapse group in comparison with 98.6% of patients in the reference group.CONCLUSIONS When saline testing shows an unexpected prolapse of the anterior leaflet, not present on preoperative echocardiography, no additional surgical techniques should be performed in order to achieve an excellent postoperative result. Further research is warranted to predict unexpected anterior leaflet prolapse preoperatively.

Please see page 326 for the article by Agricola et al. (doi:10.1016/j.euje.2004.03.001) to which this editorial pertains. Echocardiographic observations of leaflet motion have taught us volumes about the mechanism of valvular heart disease. Identifying excessive versus restricted mitral leaflet motion, as in Carpentier's classification, has become the foundation of repair techniques tailored to the individual patient.1 Ischemic mitral regurgitation (MR) has nevertheless remained a therapeutic challenge,2–6 with important failure and recurrence rates after standard annular ring reduction,7,8 and a higher peri-operative mortality than with degenerative MR.2–5 In ischemic MR as well, echocardiography has firmly established that restricted leaflet motion is the fundamental mechanism in the vast majority of patients,9,10 confirming the proposal that displacement of the papillary muscles (PMs) in the remodeling heart tethers the leaflets into the ventricular cavity.11–17 Echocardiography has provided further mechanistic clues: the anterior leaflet is deformed, with a sharp bend created near its base, at a point where intermediate (basal, secondary, or strut) chords insert;18 this particularly limits the ability of the distal anterior leaflet to coapt with the posterior, and has suggested the therapeutic maneuver of selective chordal cutting to relieve this tethering and reduce MR, while maintaining intact chords to the leaflet margins that prevent prolapse.19 In this issue of the Journal, we learn of a new echocardiographic observation that not all ischemic MR is alike. Agricola, Alfieri and colleagues found two distinct leaflet patterns in 92 consecutive patients considered for surgery with chronic ischemic MR due to restricted leaflet motion.20 These patterns relate specifically to the critical zone of conjunction, where normally the distal leaflets are apposed over a surface of coaptation that ensures an effective seal. …

We report the case of a 26-year old woman who underwent successful tricuspid valve repair for the absence of the anterior papillary of the tricuspid valve. Preoperative echocardiography revealed grade IV tricuspid valve regurgitation, caused by congenital absence of the anterior papillary muscle and prolapse of the anterior leaflet. Tricuspid valve repair was performed using artificial chords consisting of two polytetrafluoroethylene sutures and a concomitant ring annuloplasty. Postoperative echocardiography revealed mild tricuspid valve regurgitation. This approach represented a safe and effective technique for tricuspid valve repair in congenital absence of papillary muscle.

A case is described of sharp incision of the anterior leaflet of the mitral valve, due to penetrating trauma to the chest with a knife. The lesion of the mitral leaflet was diagnosed with echocardiography and successfully repaired with autologous pericardial tissue. Follow up after 15 years showed normal mitral valve function.

A 66-year-old man with a history of smoke, hypertension, and dyslipidaemia was referred for chest pain. Baseline ECG and chest X-ray were normal. Transthoracic echocardiography revealed a long, mobile, thick fibrous structure in the left ventricular (LV) cavity which originated from the mitral valve (MV) anterior leaflet and protruded into the LV outflow tract (LVOT) during systole, not associated with MV prolapse or regurgitation. No resting outflow gradient was demonstrated, and a mild …

We would like to congratulate Purvis et al. on their marvellous images of a dysplastic tricuspid valve apparatus1 and thank them for their interest in our own case report on an unusual anterior papillary muscle of the tricuspid valve.2 Before discussing their proposed label ‘parachute-like asymmetric tricuspid valve’ for both our cases, it is worth reflecting on the normal anatomy of the tricuspid valve apparatus. As the name implies, the tricuspid valve consists of three leaflets, named according to their location: septal, posterior (often the smallest), and anterior (mostly the largest) leaflet. From an anatomical study published in 1971, we know the anterior leaflet often shows a notch close to the anteroseptal commissure, which in three-dimensional …

We read with great interest Shin’s manuscript: ‘Reconstruction of the free margin of the anterior mitral leaflet with autologous pericardium in active infected endocarditis’ [1] The partial resection of the anterior leaflet of the mitral valve reported is similar in principle to the one we described to replace the anterior leaflet of the tricuspid valve in cases of active endocarditis [2]. Both techniques employ the use of autologous pericardium and the construction of PTFE neo-chordae to restore valvular competency of the affected valve. The tricuspid repair is effective and durable. Although both techniques are technically challenging, they provide an excellent method of treating valvular endocarditis while conserving the majority of the native valve. We congratulate the authors for their manuscript.

An anomalous mitral chord determining prolapse of the anterior leaflet and severe regurgitation (Figs. 1 and 2) was found in a 58-year-old woman with no history of endocarditis. This abnormality is extremely rare and its rarity can lead to a misdiagnosis. Valve repair was feasible and effective, which allowed us to avoid prosthetic replacement. www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 38 (2010) 387

A 73-year-old female patient was referred for evaluation after suffering an atypical chest pain. Physical examination and ECG were normal. The echocardiogram showed a normal ventricular function. Attached to the anterior leaflet an accessory mitral valve tissue was identified. In systole, this mitral tissue creates an image that looks like the 'number 2'.

[1] Myers PO, Panos A, Cikirikcioglu M, Kalangos A. Anterior leaflet augmentation to address tethering-induced functional tricuspid regurgitation. Eur J Cardiothorac Surg 2009;35:194. [2] Dreyfus GD, Raja SG, John Chan KM. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. Eur J Cardiothorac Surg 2008;34:908—10. [3] Anderson RH, Wilcox BR. The anatomy of the mitral valve. In: Wells FC, Shapiro LM, editors. Mitral valve disease. Oxford: Butterworth-Heinemann; 1996. p. 4.

A 25-year-old male presented with severe anterior mitral leaflet prolapse secondary to a torn cord. The mitral annulus measured 45 mm. A 33-mm St. Jude’s bileaflet mechanical prosthesis was placed with preservation of the native anterior and posterior leaflets; however, a large intravalvular regurgitant jet was subsequently noted on TEE, associated with loitering of the medial aspect of the native anterior leaflet within the valvular apparatus. The jet resolved following resection of the putative valvular tissue (Figs. 1 and 2). European Journal of Cardio-thoracic Surgery 24 (2003) 298 www.elsevier.com/locate/ejcts

Muscle tissue in atrioventricular (A-V) cardiac valve leaflets was studied in 35 human hearts and was found to be more prominent in the anterior leaflet of the mitral (MAL) than in the other valve leaflets. From serial sectioning and wax model reconstruction, the anatomic arrangement of the muscle in the MAL indicates bundles passing from the two commissural regions towards the mid-zone of the valve. Age did not appear to reduce the mass of muscle tissue in the MAL. The possibility of muscle contraction in the MAL increasing leaflet tension and accelerating post-artial movements received support by comparisons of the anterior and posterior leaflets of the mitral valve in their movements towards closure.

Summary A case of Streptococcus milleri endocarditis which caused an aneurysm of the anterior leaflet of the mitral valve is reported. There is only one previous report of a mitral valve aneurysm secondary to infective endocarditis demonstrated by angiography. Streptococcus milleri normally causes endocarditis in an older age group than the patient we describe. Some salient features of this increasingly recognized human pathogen are emphasized.