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Given its complex pathological anatomy, recurrent left atrioventricular valve regurgitation after partial atrioventricular septal defect repair remains a challenge for surgical correction. Here, we introduce a modified bridging technique by shortening the anteroposterior leaflet distance in selected patients with inadequate coaptation to compensate for the short leaflet height, specifically that of the anterior leaflet.

Cone reconstruction for Ebstein’s anomaly, although effective, is challenging in neonatal cases. Very few reports have discussed recurrent regurgitation. Herein, we report a successful redo tricuspid valve repair for recurrent regurgitation 5 years after cone reconstruction. A 5-year-old boy underwent cone reconstruction for Ebstein’s anomaly in the neonatal period. Although tricuspid regurgitation reduced initially, it subsequently worsened. The mechanisms of regurgitation are dilatation of the anteroseptal commissure, indentation in the septal leaflet, and foreshortening of the anterior leaflet. Augmentation of the anterior leaflet using an elliptic autologous pericardium and mending of the gaping commissure and indentation markedly reduced the regurgitation.

A rare case of congenital mitral insufficiency characterized by a fenestration in the anterior leaflet of mitral valve is reported. At operation, the mitral valve was successfully repaired by closure of unusual valvular tissue orifice with bovine pericardium and suture of the free edge between A1 and A2 without a ring annuloplasty.

Background: Tricuspid annuloplasty is the most common surgical approach to correct tricuspid regurgitation (TR). In some patients, however, anterior leaflet patch augmentation may be necessary to optimize tricuspid competence. We reviewed our center cohort over the midterm and long term. Methods: From January 2013 to August 2018, 424 tricuspid valve procedures were performed, of which 420 were repairs and 4 were replacements. Indications were either isolated severe TR or moderate or greater TR, concomitant with other surgery. In the repair cohort, we identified those that had a patch augmentation, and the database was interrogated for preoperative characteristics. The resulting patients had outpatient assessment (clinical and echocardiography) at 6 weeks and at a later interval. Additionally, a comparison was made between those who had good and poor results (moderate or greater TR or cardiac death). Results: In the repair cohort, 19 patients underwent complex tricuspid valve repair with CorMatrix anterior leaflet augmentation. Preoperative characteristics were as follows: age, 65.5 ± 13.5 years; New York Heart Association (NYHA) class, 3.5 ± 0.5; left ventricular ejection fraction, 48.3% ± 5.9%; tricuspid annular plane systolic excursion, 17.1 ± 3.7 mm; right ventricle (good, mild, moderate, poor), 10, 5, 4, 0; annulus size, 40.9 ± 6.9 mm; mean tethering distance, 1.00 ± 0.3 cm; and mean tethering area, 1.53 ± 1.16 cm2. Mean follow-up was 2.1 ± 1.9 years, and survival at 2 years was 73.8%. There were 2 in-hospital deaths. Mean NYHA class was 1.0 ± 0.5 (6 weeks) and 1.5 ± 0.6 (later follow-up); mean residual TR grade was 0.5 ± 0.6 (6 weeks) and 1.3 ± 1.4 (follow-up). Ten of 13 survivors had a good result at last follow-up (TR 0 to 1). We compared the preoperative and operative data of this group versus those with poor results (TR >1 or cardiac mortality). Significant univariate predictors of poor results were larger preoperative tethering area (1.18 ± 0.43 versus 2.4 ± 1.5 cm2; P = .02), longer tethering distance (0.87 ± 0.21 versus 1.2 ± 0.19 cm; P = .007), or the presence of mild or greater TR at 6 weeks (0.2 ± 0.4 vs 1.25 ± 0.5; P = .03). Conclusions: CorMatrix anterior leaflet augmentation produces successful, stable repair in the majority of this complex population. The presence of even mild TR at 6 weeks’ follow-up predicts a poor result. When the tethering area or the tethering distance is significantly high, replacement is probably a better option.

Background We evaluated a novel formula using preoperative transesophageal echocardiographic measurements to determine neochordae length for repair of degenerative mitral regurgitation (MR). Methods The formula is based on measuring the distance from the adjacent papillary head to the intended coaptation zone of the flail/prolapsing leaflet segment and subtracting the redundant leaflet length. Between 2008 and 2017, 264 consecutive patients underwent mitral valve repair (82.2% endoscopic, minimally invasive approach and 17.8% sternotomy) with neochordae loop reconstruction (68.6% posterior, 6.4% anterior, and 25% bileaflet repair). Mean patient age was 63 ± 13.6 years, 73.5% were men, and mean left ventricular ejection fraction was 63.1% ± 6.7%. Results Mitral valve repair was successful in 100% of patients, with no patient requiring conversion to replacement. Neochordae length measurement was accurate in 259 patients (98%), with 4 patients requiring conversion to resection and 1 patient requiring longer anterior leaflet neochordae. Median anterior and posterior neochordae lengths were 27 mm (range, 18-32) and 17 mm (range, 9-27), respectively. Intraoperative transesophageal echocardiography demonstrated no or trace residual MR in 254 patients and mild residual MR in 10 patients. In-hospital mortality occurred in 1 patient, and complications included respiratory failure (2.7%) and renal failure (1.8%). At the median follow-up of 12.6 months (interquartile range, 11.1), 98.9% of patients remained free from ≥2+ MR, whereas freedom from reoperation was 100%. Conclusions Preoperative transesophageal echocardiographic measurements can accurately and reproducibly predict the required length of neochordae loop reconstruction for degenerative mitral valve repair with good results. Longer-term follow-up is necessary.

Mitral valve (MV) repair for infective endocarditis (IE) is sometimes challenging. We investigated the durability of repair associated with the location of the infected lesion.The study comprised 83 patients (55 ± 18 years; active, 66; healed, 17) who underwent MV repair at our institution. Patients were categorized into 5 types based on the location of the main lesion: type I, posterior leaflet (n = 36); type IIC, clear zone of anterior leaflet (n = 12); type IIR, rough zone of anterior leaflet (n = 28); and type III, annulus (n = 7). Type IIR was divided into 2 subgroups: IIR-large (1 segment involvement, n = 9) and IIR-small (1 segment, n = 19).Follow-up was 95.2% completed for 7.2 ± 5.2 years. The rate of recurrent moderate or severe mitral regurgitation (MR) was 2.8% in type I, 0% in type IIC, 28.6% in type IIR, and 14.3% in type III. The freedom from recurrent moderate or severe MR was significantly lower in type IIR compared with the other types (63.1% ± 10.6% vs 96.8 ± 3.2% at 5 years, P .001). Moreover, the recurrence rate was higher in type IIR-large (55.6%) than in type IIR-small (15.8%, P = .068). Type IIR was an independent predictor of recurrent MR (hazard ratio, 11.1, 95% confidence interval, 2.52-78.2; P = .001).The durability of MV repair for IE was satisfactory in posterior leaflet infection without annulus invasion and in clear zone infection of the anterior leaflet. However, rough zone infection of the anterior leaflet, especially with more than 1 segment involvement, was associated with a high risk of recurrent MR.

Background and aim Second-order chord tethering of the anterior leaflet is a risk factor for failure of posterior leaflet prolapse repair. Materials and methods We describe two cases of second-order chord tethering of the anterior leaflet associated with severe mitral regurgitation due to prolapse or chordal rupture of the anterior leaflet, causing early and late failure of repair. Results We described two cases where this phenomenon happened. Conclusions Our cases demonstrate that the second-order chords of the prolapsing AL can be tethered and that this aspect should be carefully evaluated before surgery, as it can progress over time, affecting the results of surgical repair.

Mitral valve systolic anterior motion and associated regurgitation remain a challenging problem in mitral valve plasty. A simple procedure to correct intraoperative systolic anterior motion using sutures applied between the tip of the anterior leaflet and the posterior annulus is presented. This technique reduces the movement of the anterior leaflet toward the septum while maintaining sufficient valve orifice area.

Degenerative mitral regurgitation repair using a measured algorithm could increase the precision and reproducibility of repair outcomes.Direct and echocardiographic measurements guide the repair to achieve a coaptation length of 5 to 10 mm and minimize the risk of systolic anterior motion. Leaflet reconstruction restored the normal 2 to 1 ratio of anterior to posterior leaflet length without residual prolapse or restriction. The choice of ring size was based on anterior leaflet length, the distance from the leaflet coaptation point to the septum, and the anterior-posterior ring dimension. Freedom from reoperation and mitral regurgitation recurrence were based on multistate models.One thousand fifty-one patients had mitral surgery and 1026 (97.6%) were repaired. A2 length was 27.2 ± 4.5 mm; and the reconstructed posterior leaflet was 13.9 ± 2.3 mm. Median ring size was 34 mm and strongly correlated to A2 length (R = 0.76; P .001). The coaptation length at P2 after repair was 6.4 ± 1.7 mm and 87% of measurements were between 5 and 10 mm. Results at predischarge and 10 years, respectively, included mild regurgitation (7.5% and 26.1%), moderate (0.7% and 15.6%), moderate to severe (0% and 1.4%), and severe (0% and 0%), with mean mitral gradient values 3.5 ± 1.5 and 2.9 ± 1.2 mm Hg, respectively. Systolic anterior motion at discharge and last follow-up were 0.2% and 1.1%, respectively. Ten-year freedom from mitral valve reoperation was 99.7%.A simple, reproducible, measured algorithm for degenerative mitral valve repair provides excellent early and late results and is a useful adjunct to established surgical techniques.

Aims To characterize the dynamic nature of the left ventricular outflow tract (LVOT) geometry and flow rate in patients following transcatheter mitral valve replacement (TMVR) with anterior leaflet laceration (LAMPOON) and derive insights to help guide future patient selection. Methods and results Time-resolved LVOT geometry and haemodynamics were analysed with post-procedure computed tomography and echocardiography in subjects (N = 19) from the LAMPOON investigational device exemption trial. A novel post hoc definition for LVOT obstruction was employed to account for systolic flow rate and quality of life improvement [obstruction was defined as LVOT gradient >30 mmHg or LVOT effective orifice area (EOA) ≤1.15 cm2]. The neo-LVOT and skirt neo-LVOT were observed to vary substantially in area throughout systole (64 ± 27% and 25 ± 14% change in area, respectively). The peak systolic flow rate occurred most commonly just prior to mid-systole, while minimum neo-LVOT (and skirt neo-LVOT) area occurred most commonly in early-diastole. Subjects with LVOT obstruction (n = 5) had smaller skirt neo-LVOT values across systole. Optimal thresholds for skirt neo-LVOT area were phase-specific (260, 210, 200, and 180 mm2 for early-systole, peak flow, mid-systole, and end-systole, respectively). Conclusion The LVOT geometry and flow rate exhibit dynamic characteristics following TMVR with LAMPOON. Subjects with LVOT obstruction had smaller skirt neo-LVOT areas across systole. The authors recommend the use of phase-specific threshold values for skirt neo-LVOT area to guide future patient selection for this procedure. LVOT EOA is a ‘flow-independent’ metric which has the potential to aid in characterizing LVOT obstruction severity.

BACKGROUND: Left ventricular outflow tract (LVOT) obstruction is a leading cause of mortality and exclusion from transcatheter mitral valve replacement (TMVR). Intentional laceration of the anterior mitral valve leaflet to prevent LVOT obstruction (LAMPOON) is a transcatheter mimic of surgical chord-sparing leaflet resection. OBJECTIVES: The purpose of this prospective multicenter trial was to study LAMPOON with transseptal (Edwards Lifesciences, Irvine, California) TMVR in annuloplasty rings or native mitral annular calcification (MAC). METHODS: Subjects at high or extreme surgical risk and prohibitive risk of LVOT obstruction from TMVR were included. Eligibility was modified midtrial to exclude subjects with threatened LVOT obstruction from a Sapien 3 valve fabric skirt. The primary endpoint was procedure survival with successful LAMPOON, with successful TMVR, without reintervention, and with LVOT gradient

OBJECTIVE: Mitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior vs. posterior leaflet repair remain poorly-defined. We propensity-matched anterior and posterior repairs to compare long-term outcomes. METHODS: Patients undergoing first-time degenerative mitral repair between 1992–2018 were identified. Primary outcome was overall survival. Secondary outcomes were post-procedural residual mitral regurgitation (MR) and reoperation. From 1025 patients, 1:1 propensity score matching was performed, yielding 309 anterior (isolated anterior=85, bileaflet=224) and 309 isolated posterior repairs. RESULTS: Age was 58±15 years, ejection fraction was 57±10%, and matched groups were well-balanced. Anterior repairs had longer bypass (122±53 vs. 109±43 minutes, p=0.001) and cross-clamp (94±44 vs. 85±62 minutes, p=0.033) times. Mean residual MR grade was 0.44 (95% CI 0.24–0.65) for anterior and 0.30 (95% CI 0.13–0.47) for posterior repair (p=0.31). Overall 92% (569/618) of matched patients had no residual MR, with no differences in MR grade between groups (p=0.77). Survival did not differ between anterior (10-year: 72±7%; 15-year: 63±7%) and posterior (10-year: 74±7%; 15-year: 60±8%) groups (log-rank p=0.93). Linearized incidence of reoperation was 0.62% per patient-year, including 0.74% for anterior and 0.48% for posterior repairs. Cumulative incidence of reoperation at 15 years was 7.5% after anterior and 4.9% after posterior repair (Gray’s test p=0.26). CONCLUSIONS: No long-term survival or reoperation difference was found between posterior and anterior repair. Based on these findings, surgeons at centers of excellence should aim for repair of both anterior and posterior leaflet pathology with the same decision-making threshold over valve replacement for degenerative mitral disease.

BACKGROUND Complete atrioventricular septal defects (CAVSD) include a variable spectrum of congenital malformations with different forms of clinical findings. We examined early and midterm outcomes, the need for reoperation, postoperative residual AV valve regurgitation, and other risk factors after various CAVSD repairs. METHODS Between 2014 and 2018, we have performed 89 isolated CAVSD repairs. We retrospectively reviewed the patients' medical records. Patients were divided into three groups according to their repair techniques modified one patch repair (MP) (n = 16); two patch repair (TP) (n = 49); and left anterior leaflet augmentation (ALA) technique (n = 24). RESULTS Eighty patients (89.8%) survived hospital discharge. Early mortality rates were three (18.8%) in the group MP, five (10.2%) in the group TP, and one (4.2%) in the group ALA. Thirteen patients died during the follow-up period. Late mortality rates were three (18.8%) in the group MP, four (16.6%) in the group ALA, and six (12.2%) in the group TP. The mean follow-up time was 35.9 ± 22.97 months (range: 0.3-77 months). The morbidity and mortality results were similar between-group TP and ALA but worse in the MP group. Low body weight (

The advantages of mitral valve repair are lower morbidity and mortality, reduced risk of thromboembolism and endocarditis, improved survival, and better preservation of left ventricular function. The most common cause of degenerative mitral regurgitation is a myxomatous valve with segmental prolapse of the posterior leaflet, a lesion that can be corrected by classical techniques such as quadrangular resection, but other lesions may require more complex surgical techniques, for instance, correction of anterior leaflet prolapse or Barlow disease. Mitral valve repair [...]

We present the case of a previously healthy 2-year-old boy with extensive infective mitral valve endocarditis, with 2 huge, mobile vegetations attached to the anterior leaflet of the mitral valve and to the left ventricular outflow tract, and interventricular septal abscesses extending into the left ventricular outflow tract without any septal defects. He underwent mitral valve repair and simultaneous drainage of the interventricular septal abscesses excluding the inlet portion to avoid postoperative complications.

Background and aim of the study The outcome of mitral valve (MV) repair for chronic ischemic mitral regurgitation (IMR) is suboptimal, due to the high recurrence rate of moderate or severe mitral regurgitation (MR) during follow-up. The MV adapts to new MR increasing its area to cover the enlarged annular area (mitral plasticity). As this process is often incomplete, we aimed to evaluate if augmenting the anterior leaflet (AL) and cutting the second-order chords (CC) together with restrictive mitral annuloplasty, a strategy we call "surgical mitral plasticity," could improve the midterm results of MV repair for IMR. Materials and methods From November 2017 to October 2019, 22 patients with chronic IMR underwent surgical mitral plasticity. Mean age was 73 ± 7 years and six were female. Mean ejection fraction was 32% ± 11%, IMR grade was moderate in 10 and severe in 12. Mean clinical and echocardiographic follow-up was 12 ± 6 months. Results There was no early death, and one patient died 6 months after surgery. Ejection fraction improved from 32% ± 15% to 40% ± 6% (P = .031). IMR was absent or mild in all patients, and none showed recurrent moderate or more IMR. Tenting area decreased significantly from 2.5 ± 0.5 to 0.5 ± 0.3 cm² and coaptation length increased from 1.9 ± 0.7 to 7.8 ± 1.6 mm. All patients were in New York Heart Association class I or II. Conclusions Mitral plasticity, if uncomplete, is ineffective in preventing IMR to become significant. Surgical mitral plasticity, by completing incomplete process of MV adaptation, has a strong rationale, which however needs to be validated with longer follow-up.

Background and aim Mitral regurgitation (MR) in Barlow's disease is complicated because of its mixed pathophysiology, leaflet billowing with or without organic prolapse, and abnormal annular dynamics that cause functional prolapse. Complex repair techniques, including aggressive leaflet resection and implantation of multiple artificial chordae, are conventionally performed; nevertheless, these are technically demanding, especially when performed using a minimally invasive approach. We aimed to standardize the repair technique for Barlow's disease and developed stepwise repair techniques. Methods Of 292 patients who underwent isolated minimally invasive mitral valve repair for MR, 29 patients (seven females, age 49 ± 10 years) were found to have Barlow's disease. Our repair technique consists of the following three steps: (a) stabilization of the mitral annulus by placing annuloplasty ring sutures; (b) distinction between organic and functional prolapse by a saline injection test; and (c) targeted repair for organic prolapse by leaflet resection or chordal replacement. Results Surgical techniques included leaflet resection in 22 patients, chordal replacement in 19 patients, and ring annuloplasty only in one patient. These procedures were applied to the anterior leaflet in one, posterior leaflet in eight, and both leaflets in 19 patients. The median annuloplasty ring size was 34 mm. The repair success rate was 100%. No patients developed moderate or greater MR during a mean follow-up period of 36 ± 21 months. Conclusions A stepwise repair strategy facilitates mitral valve repair in patients with Barlow's disease and provides excellent outcomes even via a minimally invasive approach.

Background: The aim of this study is to evaluate severe mitral regurgitation caused by so called atrial leaflet “pseudoprolapse” and verify the effect of simple annular stabilization. Methods: One-hundred-twenty-two patients underwent surgery for severe mitral regurgitation at our institute between January 2015 to July 2018. Of those, 32 cases diagnosed as anterior leaflet prolapse that underwent mitral repair were analyzed. Ten cases with pseudoprolapse, which is defined as anterior leaflet prolapse without dropping into the left atrium beyond the annular line causing eccentric regurgitation flow directed to the posterior atrium, were classified as the Pseudoprolapse Group. The other 22 cases had obvious anterior leaflet prolapse dropping into the left atrium; these cases were classified as the True Prolapse Group. We compared clinical findings between the 2 groups and reviewed pseudoprolapse cases. Results: Patients in the Pseudoprolapse Group had lower ejection fraction and lower regurgitation volume than those in the True Prolapse Group. A2 lesion as main inflow of regurgitation was more included in the Pseudoprolapse Group. All but one patient in the Pseudoprolapse Group received only simple annuloplasty, and all patients in the True Prolapse Group received leaflet repair and annuloplasty. In both groups, mid-term regurgitation grade and the reoperation rate were satisfactory. In the Pseudoprolapse Group, 6 cases were clarified as atrial functional mitral regurgitation, and 4 cases were considered to have focal posterior leaflet tethering. Conclusions: Pseudoprolapse cases could be characterized by low ejection fraction, low regurgitation volume, and A2 prolapse. For most cases with pseudoprolapse, simple annuloplasty may be enough, however further study is needed.

International audience; No abstract available

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.

Background This study investigated the consequences of recurrent mitral regurgitation (MR) after mitral valve (MV) repair in patients with degenerative MR and risk factors for recurrence.Methods and Results:From January 1990 to December 2015, 792 patients underwent MV repair due to degenerative MR. Recurrent MR was defined as moderate-to-severe MR on follow-up echocardiography. Mean follow-up duration was 8.71±5.58 years. During the follow-up period, MR recurred in 133 (16.8%) patients, and the MR recurrence-free rate at 20 years was 77.5±2.0%. In the recurrence group, the degree of MR decreased in 8 (6.0%) patients and was aggravated in 46 (34.6%) patients. Recurrent MR was associated with increased mortality and adverse left ventricular (LV) remodeling. Independent risk factors for MR recurrence were MV repair performed before 2000, preoperative atrial fibrillation, high LV end-diastolic dimension (LVEDD), prolapse of the isolated anterior leaflet or multiple segments, and absence of ring annuloplasty. Predictors of MR progression were high LVEDD and repair without artificial chordae implantation. Conclusions Recurrent MR after MV repair in patients with degenerative MR showed a tendency to progress and was associated with increased mortality and adverse LV remodeling. Early referral for MV repair before development of atrial fibrillation and LV enlargement may reduce the risk of MR recurrence. Moreover, artificial chordae implantation and ring annuloplasty may assure the long-term durability of MV repair.

Suture-related injuries of the left circumflex branch are a serious and well-known complication of mitral valve surgery. Avoiding this complication is challenging, especially in an unexpected course of coronary arteries. We present a case of minimally invasive mitral valve repair in a patient with a rare anatomical variant of the main stem in direct proximity to the whole anterior leaflet.

BACKGROUND Mitral valve prolapse (MVP) is often identified in patients with atrial septal defect (ASD), which occasionally require surgical intervention at the time of ASD closure or even long after the surgery. Ventricular and valvular geometric characteristics in preoperative ASD patients were evaluated by three-dimensional (3D) transesophageal echocardiography. METHODS AND RESULTS Mitral valve (MV) complex geometry was quantitatively measured by 3D transesophageal echocardiography in 11 ASD patients (Qp/Qs > 1.5) and 11 controls. The ASD group had a significantly larger indexed prolapse volume and height, with a larger anterior mitral leaflet than controls (0.53 [0.33-0.75] vs 0.057 [0.027-0.11] mL/m2 , P = .0001; 2.89 [2.13-3.50] vs 0.92 [0.48-1.32] mm/m2 , P

Bulging subaortic septum in hypertrophic cardiomyopathy is a potential risk factor for systolic anterior motion after mitral valve repair. Systolic anterior motion may cause postoperative mitral regurgitation and left ventricular outflow tract obstruction despite conservative management. During “minimally invasive endoscopic” and “robotic” mitral repair procedures, systolic anterior motion is prevented with concomitant septal myectomy through the mitral valve orifice. Technically, the exposure of the bulging subaortic septum is traditionally done with detachment of the anterior mitral leaflet from its annulus, leaving a 2-mm rim of leaflet attached to the annulus. The leaflet is then sutured after myectomy. As an alternative technique in robotic surgery, the exposure of the subaortic septum is feasible without anterior leaflet incision with the use of dynamic atrial retractor in mitral repair procedures. Here, we present a patient who underwent concomitant robotic mitral valve repair with posterior chordal implantation, ring annuloplasty, and septal myectomy without anterior leaflet incision using the da Vinci surgical system.

BACKGROUND The ideal surgical technique for ischemic mitral regurgitation (MR) is controversial. We introduced an extended posterior mitral leaflet (PML) augmentation technique for functional MR with severe tethering, which detached the PML from the annulus almost completely and augmented it with a large 3×6-cm oval pericardial patch. Methods and Results: A total of 17 mitral repairs using the new technique were performed for ischemic MR with no 30-day mortality and 2 hospital deaths. The NYHA class was III in 47% and IV in 13%. The EuroSCORE II was 9.7±4.9. The ring size was 32±1.4 mm. Concomitant coronary bypass was performed in 67% and left ventricular repair in 28%. The mechanism of leaflet closure was evaluated using transthoracic echocardiography in 15 survivors. MR decreased to none or trivial with a significant increase in coaptation length (Pre: 4.6±0.8 mm vs. Post: 9.8±2.5 mm; P

WOS: 000475389300005, PubMed: 31237550, Background: The aim of our study was to compare the outcome of patients who underwent mitral valve anterior leaflet repair with and without chordal replacement for degenerative mitral valve insufficiency. Methods: This study was conducted at our center between May 2006 and May 2013. The study included 125 patients with degenerative mitral valve insufficiency (64 males, 61 females; mean age 47 years, age range 16-78 years) who underwent mitral valve repair with anterior leaflet procedures. The patients were divided into 2 groups. Group A consisted of 56 patients with chordal replacement, and group B consisted of 69 patients with other repair techniques performed. Results: No significant difference was determined between the 2 groups in mortality, recurrence, and reoperation rates. The mortality rate was 3.6% in group A and 1.4% in group B. During the follow-up period, 3 patients were reoperated on (mitral valve replacement) because of severe mitral valve insufficiency. Two of these patients were from group A (3.6%), and the other was from group B (1.4%). One patient in group A underwent intraoperative mitral valve replacement after unsuccessful chordal replacement. Fifty patients (89.3%) in group A and 65 patients (94.2%) in group B exhibited no or mild recurrence of mitral valve insufficiency. Conclusion: Mitral valve repair in patients with degenerative mitral valve insufficiency resulting from anterior leaflet pathology is a safe procedure because of its durability and good long-term results. Despite the difficulty of the chordal replacement procedure, it may be used as an alternative technique for anterior mitral valve leaflet repair.

A 13-year-old boy presented with right atrial aneurysm and downward displacement of the anterior leaflet in the tricuspid valve into the right ventricle, without tricuspid valve regurgitation. Paroxysmal atrial flutter was caused by an abnormal electrical re-entry circuit, which could not be treated using catheter radiofrequency ablation. Therefore, the patient underwent surgical ablation and resection of the enlarged right atrial wall. The anterior leaflet of the tricuspid valve was plastered and displaced downward into the right ventricle, which resembled Ebstein's anomaly. Pathological evaluation revealed a thin wall that contained fibrous tissue with lipomatous degeneration and few muscular elements. No postoperative arrhythmia was observed.

Traumatic tricuspid regurgitation is a rare and progressive disease. Early diagnosis and surgical valve repair are very important. A 57-year-old male was referred to our hospital with a history of blunt chest trauma. Three-dimensional echocardiography showed severe tricuspid regurgitation and demonstrated two main anterior leaflet chordaes of the tricuspid valve rupture and the whole anterior leaflet prolapsed. The diagnosis was severe tricuspid regurgitation due to leaflet chordae rupture secondary to blunt chest trauma. Surgical repair of the tricuspid valve was performed in this patient. At 3-month follow-up, the right ventricle was decreased in size with significantly improved right ventricular function. The signs and symptoms of right heart failure were relieved. In this case, 3-dimensional transthoracic echocardiography enabled fast and non-invasive evaluation of the spatial destruction of the tricuspid valve and subvalvular apparatus to assist in the planning of valve repair.

Left ventricular outflow tract (LVOT) obstruction is a major complication of transcatheter mitral valve replacement (TMVR) and anterior mitral leaflet (AML) laceration has been shown to reduce the risk of this obstruction. Understanding neo-LVOT geometry is critical for determining risk of LVOT

Objective: Transcatheter anterior leaflet laceration is thought to mitigate the risk of left ventricular outflow tract (LVOT) obstruction and valve thrombosis (due to flow stasis) following transca...

We report a symptomatic case of a papillary fibroelastoma originating from the anterior leaflet of the mitral valve. Transthoracic echocardiography of a 37-year-old man with normal coronary angiogram, revealed a fibroelastoma on the mitral valve. The tumour was successfully removed using a shave excision technique.

Symptomatic cardiac rheumatoid nodules are a rare but recognized manifestation of rheumatoid arthritis. We describe the surgical management of a rheumatic nodule involving the anterior leaflet of the mitral valve.

Background Carpentier's techniques for degenerative posterior mitral leaflet prolapse have been established with excellent long‐term results reported. However, residual mitral regurgitation ( MR ) occasionally occurs even after a straightforward repair, though the involved mechanisms are not fully understood. We sought to identify specific preoperative echocardiographic findings associated with residual MR after a posterior mitral leaflet repair. Methods and Results We retrospectively studied 117 consecutive patients who underwent a primary mitral valve repair for isolated posterior mitral leaflet prolapse including a preoperative 3‐dimensional transesophageal echocardiography examination. Twelve had residual MR after the initial repair, of whom 7 required a corrective second pump run, 4 underwent conversion to mitral valve replacement, and 1 developed moderate MR within 1 month. Their preoperative parameters were compared with those of 105 patients who had an uneventful mitral valve repair. There were no hospital deaths. Multivariate analysis identified preoperative anterior mitral leaflet tethering angle as a significant predictor for residual MR (odds ratio, 6.82; 95% confidence interval, 1.8–33.8; P =0.0049). Receiver operator characteristics curve analysis revealed a cut‐off value of 24.3° (area under the curve, 0.77), indicating that anterior mitral leaflet angle predicts residual MR . In multivariate regression analysis, smaller anteroposterior mitral annular diameter ( P P =0.002) were significantly associated with higher anterior mitral leaflet angle, whereas left ventricular and left atrial dimension had no significant correlation. Conclusions Anterior mitral leaflet tethering in cases of posterior mitral leaflet prolapse has an adverse impact on early results following mitral valve repair. The findings of preoperative 3‐dimensional transesophageal echocardiography are important for consideration of a careful surgical strategy.

Aims We compared the diagnostic accuracy of cardiac computed tomography (CT) with that of echocardiography for the detection of mitral valve prolapse (MVP) on a scallop-by-scallop basis, using surgical inspection as a reference standard. Methods and results This retrospective study included 145 patients (mean age 53 years; 94 men) who underwent surgical MVP repair or replacement and preoperative cardiac CT between May 2011 and October 2013. The prolapsed scallop was localized using cardiac CT and echocardiography according to the Carpentier method (anterior leaflet: from lateral to medial A1, A2, A3; posterior leaflet: P1, P2, P3). The per-scallop sensitivity and specificity of each method were compared, using surgical inspection as a reference standard. Interobserver agreement for the CT analysis was tested between three independent readers. Surgically, MVP was confirmed in 26% (226/870) scallops, with 56% (81/145) of the patients showing a single-scallop prolapse. The per-scallop sensitivity of cardiac CT was lower than that of echocardiography (80% vs. 87%, P = 0.004), with similar specificity (both 95%). For single-scallop lesions, cardiac CT showed good sensitivity (94%) and specificity (95%), with no significant difference to echocardiography. For the 64 patients with multiple scallop prolapse, CT underestimated the extent of MVP in 31 (49%) patients and echocardiography in 22 (34%) patients. Interobserver agreement was good, with kappa = 0.72-0.74. Conclusion Cardiac CT provides a feasible method for localizing MVP on a per-scallop basis, but it may underestimate the extent of prolapsed scallop compared with echocardiography, particularly in patients with multiple-scallop lesions.

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.

Pulmonary valvular stenosis is a relatively common disorder, accounting for approximately 10% of all CHDs. Pulmonic valvular disease can get clinically detected at different ages of life. The more severe the obstruction, the earlier detected the valvular abnormality. Surgical pulmonary valvotomy has been available as a treatment since 1956. This article is about a case of pulmonary annular and valvular stenosis in a 1-year-old child, and it also explores surgical operation of this condition. Transannular patches are usually used within the 1st year of age in pulmonary annular and valvular stenosis. In recent years, anterior leaflet augmentation has been preferred for annulus enlargements. In our 1-year-old case, we expanded the annulus by the anterior leaflet expansion technique and we also augmented other leaflets by polytetrafluoroethylene patch.

An 84-year-old male patient with ischemic heart disease was referred to transesophageal echocardiography evaluation of mitral regurgitation. He previously underwent multiple percutaneous coronary interventions (PCI) in another hospital, the last intervention 3 years ago. Flail anterior leaflet of