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Mitral annular caseoma is a common incidental finding involving the posterior annulus. It has an innocent nature, with the exception of its endocarditic degeneration and/or a stenotic functional effect when exophytic. We report an exceptionally rare isolated anterior mitral annular caseoma involving also the anterior mitral leaflet and affecting its physiologic systolic movement, thus resulting in a restricting anterior leaflet motion responsible for mitral insufficiency. The case was successfully treated by complex mitral valve repair.

The papillary fibroelastoma (PFE) is a rare and benign primary cardiac tumor, and the most frequently found tumor occurring in the cardiac valves. With the introduction of echocardiography, the diagnosis of these tumors in living patients has been reported sporadically. The PFEs have been found most often on valve leaflets, chordae tendineae, and both ventricles. We describe an interesting case of the PFE originating from the anterior leaflet of the mitral valve mimicking vegetation. The patient underwent successful surgical removal of the PFE.

Secondary mitral regurgitation (MR) is common in patients with dilated or ischaemic cardiomyopathy and conveys an adverse prognosis associated with the degree of MR.1 The principal mechanism underlying the development of secondary MR is related to altered mitral valve geometry resulting from LV remodelling and distortion.1–3 LV dilation causes papillary muscle displacement, which in turn results in leaflet tethering, restricted closure and MR (figure 1).3 Although secondary MR is a common valvular problem, therapy remains problematic. Mitral ring annuloplasty most often performed at the time of coronary artery bypass surgery is the standard surgical therapy. However, the beneficial effects on overall survival of ring annuloplasty for secondary MR are unclear with a relatively high recurrence rate of moderate or greater secondary MR of approximately 30%. There is a need to explore alternate surgical approaches for secondary MR. Figure 1 Mechanism of secondary mitral regurgitation. Spatial relationship between mitral valve apparatus and LV in normal condition (left panel) and pathological condition (ie, secondary mitral regurgitation; right panel). Ao, aorta; LA, left atrium; MR, mitral regurgitation. Adapted from Hung,3 with permission from Elsevier. Tethering of the mitral leaflets, the fundamental mechanism in secondary MR, is effected through the basal chordae that attach to the basal and mid body of the anterior leaflet, often resulting in a bend of the anterior mitral valve leaflet, a sign coined by Alain Carpentier as the ‘seagull wing’.2 This bend in the anterior leaflet represents abnormal tethering by the basal chordae. Limited experimental and clinical studies have demonstrated efficacy in …

After its introduction in the early 90s, the edge-to-edge (EE) technique has been used in patients with mitral regurgitation (MR) due to different etiologies and mechanisms. More than 20 years after its introduction, it is now clear that the best indications for the EE repair are represented by bileaflet prolapse (facing segments), segmental anterior leaflet prolapse/flail and commissural prolapse/flail. In addition this technique does have an important role also in functional mitral regurgitation, and as a “rescue” procedure in case of suboptimal conventional mitral reconstruction (“rescue” EE). Finally it has been used for the prevention/treatment of SAM. In this chapter the results of the EE repair in the most common indications described above will be outlined and discussed.

Many surgical techniques have been described to treat mitral regurgitation (MR) associated with hypertrophic cardiomyopathy (HCM) (sometimes contradictory: i.e., both shortening [1] and elongation [2] of the anterior leaflet), which probably illustrates confusion in the interpretation of the disease. Mitral regurgitation due to HCM is mainly functional (secondary) as a consequence of systolic anterior motion (SAM) of the anterior leaflet. Two dysfunction mechanisms account for SAM (Fig. 8.1): a pulling mechanism due to a Venturi effect in the outflow tract, and a pushing effect due to the force of flow exerted on the distal part of the anterior leaflet. Moreover, an organic MR mechanism is also possible, due to a too long anterior leaflet or abnormal anatomy or position of the papillary muscles. Taken together, these mechanisms are responsible for severe MR in more than 30 % of cases of HCM in surgical series [3].

Partial atrioventricular (AV) canal is also known as ostium primum atrial septal defect (ASD) with a cleft or zone of apposition of the anterior leaflet of the left AV valve. Most anatomists and surgeons use the term “partial AV canal” for this entity, as it aligns with the other forms of AV canal and the ramifications of its repair are quite different from those of other forms of ASD, owing to the unpredictable outcome of left AV valve repair. More recently, the term “zone of apposition” has been substituted for “cleft” and is used preferentially in the literature, although both descriptions can be found.

The edge-to-edge (EE) technique is a method to treat mitral valve (MV) regurgitation by suturing the edges of the leaflets at the site of regurgitation. Although the method is technically simple, its application should follow precise rules to avoid complications and to ensure durable results.

In patients with mitral regurgitation (MR) secondary to ischemic or non-ischemic dilated cardiomyopathy, valve repair is usually performed by means of an undersized annuloplasty. This procedure leads to symptomatic improvement and reverse left ventricular (LV) remodeling in a substantial proportion of patients. However, the failure rate of undersized annuloplasty is still high and is mainly due to inappropriate patient selection and to technical issues which have been progressively identified. Annuloplasty alone should only be carried out in the early phase of the disease before the occurrence of advanced LV remodeling and echocardiographic predictors of unfavourable outcome should be taken into account. Under certain circumstances, in particular when tethering is more pronounced, surgery should include additional procedures beside annuloplasty to enhance the durability of the repair. The edge-to-edge (EE) technique has been used in our Institution for this purpose. Herein we will report what we have learned over the years by using this method of repair as an adjunct to undersized annuloplasty in patients with functional mitral regurgitation.

s ( p r g a 4 m d m t t n d ( t ( C YSTOLIC ANTERIOR MOTION (SAM) and left ventricular outflow tract obstruction (LVOTO) occur in 2% to 4% of cases of mitral valve repair for myxomatous disease.1,2 he risk of SAM/LVOTO is greater when the excessive mitral eaflet tissues coapt closer to the LVOT during systole.3-5 recardiopulmonary bypass (CPB) echocardiographic meaurements consistent with this include a shorter distance beween the mitral coaptation point and the ventricular septum C-Sept 2.5 cm) and a relatively large coapting posterior eaflet (PL-syst: posterior annulus to the coaptation point) when ompared with the anterior leaflet (AL-syst: anterior annulus to oaptation point), resulting in an AL-syst/PL-syst ratio 1.44,5 Fig 1). Resection of the posterior leaflet, reattachment of the remainng leaflet tissues, and performance of a mitral ring annulolasty reduce the coapting length (systole) of the posterior eaflet.2-5 For patients at high risk for SAM/LVOTO, greater eduction of the posterior leaflet is accomplished by performing posterior sliding leaflet technique2,3,6 (Fig 2). The authors present 2 cases in which the prerepair assessent showed a large prolapsing or flail middle posterior scallop P2) and increased risk of SAM/LVOTO. In the first case, a liding leaflet technique, to prevent SAM/LVOTO, may have ontributed to postrepair mitral incompetence. In a second imilar high-risk case, a sliding leaflet technique was not perormed and the repaired valve was competent.

A fundamental assumption in mitral valve (MV) therapies is that a repaired or replaced valve should mimic the functionality of the native valve as closely as possible. Thus, improvements in valvular treatments are dependent on the establishment of a complete understanding of the function and mechanical properties of the native normal MV. In a recent study [Grashow et al. ABME 34(2), 2006] we demonstrated that the planar biaxial stress-strain relationship of the MV anterior leaflet (MVAL) exhibited minimal hysteresis and a stress-strain response independent of strain rate, suggesting that MVAL could be modeled as a "quasi-elastic" material. The objective of our current study was to expand these results to provide a more complete picture of the time-dependent mechanical properties of the MVAL. To accomplish this, biaxial stress-relaxation and creep studies were performed on porcine MVAL specimens. Our primary finding was that while the MVAL leaflet exhibited significant stress relaxation, it exhibited negligible creep over the 3-h test. These results furthered our assertion that the MVAL functionally behaves not as a linear or non-linear viscoelastic material, but as an anisotropic quasi-elastic material. These results appear to be unique in the soft tissue literature; suggesting that valvular tissues are unequalled in their ability to withstand significant loading without time-dependent material effects. Moreover, insight into these specialized characteristics can help guide and inform efforts directed toward surgical repair and engineered valvular tissue replacements.

Background This study was a long-term Doppler echocardiographic assessment of mitral valve repair for anterior mitral leaflet prolapse using expanded polytetrafluoroethylene sutures. Methods Between April 1992 and December 2003, we performed mitral valve repair using expanded polytetrafluoroethylene sutures in 204 patients (mean age, 54.6 years) with severe mitral regurgitation (MR) having anterior mitral leaflet prolapse. The cause of valve disease was degenerative in 181 patients (88.7%). Postoperative serial transthoracic echocardiographic studies were performed in all hospital survivors. Residual MR flow detected by color Doppler echocardiography was classified according to the maximum regurgitant jet area. Results The 30-day mortality of 204 patients was 1.4% (3 deaths). There were 12 late deaths and 14 reoperations in this series. Kaplan-Meier survival and freedom from reoperation at 12 years were 84.6% ± 4.0% and 89.9% ± 2.9%, respectively. Postoperative transthoracic echocardiographic assessment after discharge (mean follow-up, 4.2 ± 3.0 years) showed less than mild regurgitation (maximum regurgitant jet area 2 ) in 80.9% of the patients. Overall, freedom from severe MR (maximum regurgitant jet area ≥ 7.0 cm 2 ) estimates at 12 years were 88.1% ± 3.1%. Freedom from severe MR at 12 years for 114 patients with no MR (maximum regurgitant jet area=0 cm 2 ) on intraoperative transesophageal echocardiography and 77 patients with MR was 95.3% ± 2.1% and 82.9% ± 5.1%, respectively ( p = 0.033). Conclusions Twelve-year echocardiographic follow-up demonstrates good long-term results of chordal replacement with expanded polytetrafluoroethylene sutures for anterior mitral leaflet prolapse. To avoid recurrence of regurgitation, a significantly high level of competence of the valve is essential in the repair of anterior mitral leaflet prolapse.

Because mitral valve dysfunction in adults with Marfan syndrome is poorly characterized, this study compares mitral valve pathophysiology and morphology with that of myxomatous mitral disease, documents types of mitral valve operations, and assesses long-term survival and durability of mitral valve surgery in Marfan patients.From May 1975 to June 2000, 27 adults with Marfan syndrome underwent mitral valve surgery. Their valve pathophysiology and morphology was compared with that of 119 patients with myxomatous mitral disease undergoing surgery from September 1995 to March 1999. Survival and repair durability were assessed at follow-up.Compared with myxomatous disease patients, Marfan patients had less posterior leaflet prolapse (44% versus 70%, p = 0.01), more bileaflet (44% versus 28%, p = 0.09) and anterior leaflet prolapse (11% versus 3%, p = 0.07), and presented earlier for surgery (age 41 +/- 12 years versus 57 +/- 13, p0.0001). Marfan patients had longer and thinner leaflets. Mitral valve repair was performed less frequently in Marfan (16 of 27, 59%) than myxomatous disease patients (112 of 119, 94%). There were no hospital deaths; at 10 years, survival was 80% and freedom from reoperation 96%, with only 1 reoperation among the 16 repairs.Mitral valve pathophysiology and morphology differ between Marfan and myxomatous mitral valve diseases. Valve repair in Marfan patients is durable and gives acceptable long-term results, even in adults who present with advanced mitral valve pathology. With increasing use of the modified David reimplantation operation and sparing of the aortic valve, mitral valve repair is a greater imperative, particularly since we have not had to reoperate on any Marfan patients with reimplantations.

MitraClip is an attractive and less invasive alternative to mitral valve surgery in serve mitral regurgitation in patients with moderate or severe risk for operation. It has been described to be effective and safe in functional as well as in degenerative mitral regurgitation. We report a case of MitraClip procedure with the pull out of the anterior leaflet during the intervention. The patient underwent cardiopulmonary support and surgical intervention with a good outcome. With this report we illustrated the etiology and management of this complication.

Secondary mitral regurgitation (SMR) is a heterogeneous disorder that includes ischemic and non ischemic valve regurgitation. It both scenarios, SMR is the result of incomplete mitral leaflets coaptation, due to tethering forces generated by left ventricle (LV) dysfunction and dilatation, with or without annular dilatation (Fig. 2.1).

Objective We developed a repair technique for an excessively high posterior leaflet of the mitral valve. This is an improvement of the folding plasty. Methods The resection shape is that of an hourglass rather than a quadrangle. The vertical sides of the quadrangle curve inward, which helps to prevent the curtain effect or restriction that is common in the large triangular resection or folding plasty. We used hourglass resection for 26 tall posterior leaflets (53.8% were Barlow disease) and triangular resection for 23 posterior leaflets of normal height (without Barlow disease). Results All surgeries were performed successfully. There was no mortality, no mitral regurgitation greater than moderate, and no systolic anterior motion of the anterior leaflet in the early postoperative period. One patient required a second pump run, and another required a second repair procedure. The mean follow-up period was 2.3 years (0.3-4.9 years) for the hourglass resection and 2.8 years (0.1-4.9 years) for the triangular resection. One patient in the triangular resection group died of rectal cancer. One patient treated with the hourglass resection via minithoracotomy required re-repair 1 month postoperatively due to suture dehiscence. For the hourglass and triangular resection groups, the most recent postoperative echocardiogram revealed no mitral regurgitation in 18 and 20 cases, respectively; mild mitral regurgitation in 7 and 3 cases, respectively; and moderate mitral regurgitation in 1 and 0 cases, respectively. Conclusions The short-term results of our strategy for posterior leaflet repair appear promising.

Quadrangular resection is the gold standard technique for correction of the posterior leaflet prolapse in mitral valve disease. Prompted by the idea that the anterior leaflet of the tricuspid valve corresponds to the posterior leaflet of the mitral valve in its structure and function, we conducted a quadrangular resection of the anterior leaflet of the tricuspid valve in a case of tricuspid endocarditis. Tricuspid regurgitation was well corrected, and the durability of the repair was proven by the patient's freedom from cardiac events for the following 8 years.

In the mitral valve, regional variations in structure and material properties combine to affect the biomechanics of the entire valve. Previous biaxial testing has shown that mitral valve leaflet tissue is highly extensible, and exhibits nonlinear, anisotropic material properties. In this study, experimental measurements of mitral valve leaflet deformation under quasi-static pressure loading were performed on isolated porcine hearts. Biplane video images of markers placed on the anterior leaflet surface were used to reconstruct the 3D position of the markers at several pressure levels over the physiological range. A least-squares finite-element method was used to fit parametric models to the markers and to calculate the deformation over the surface. The results showed that the leaflet deformations were anisotropic, exhibiting a large nonhomogeneous radial stretch and a small circumferential stretch. This information can be used to better understand how the valve deforms under physiological loading, and to help design treatments for valve problems, such as mitral regurgitation.

Background Satisfactory results of bileaflet preserving mitral valve replacement (MVR) had forced several institutes to preserve both leaflets during MVR. Modifications were required to prevent the preserved tissue from interfering with prosthetic valve function, to implant an adequate size of valve and to prevent left ventricle outflow tract (LVOT) obstruction. Materials and methods Conventional MVR was performed to 51 patients (group 1) and bileaflet preserving MVR was performed to 43 patients (group 2). Mitral anterior leaflet incised from the middle of the leaflet to mitral annulus without chordal injury in group 2 patients. Sutures were placed through the mitral annulus first and then passed from the bottom to the tip of anterior leaflet. Posterior leaflet was also preserved. Prosthetic valve was put down into the mitral annulus and sutures were ligated. Excessive anterior leaflet tissue was attached to left atrial wall. Results Cross-clamping time was 45 +/- 5.33 minutes versus 61.32 +/- 4.43 minutes (p = 0.0001) and total cardiopulmonary bypass time was 60.80 +/- 4.44 minutes versus 80.55 +/- 3.65 minutes (p = 0.0001) in groups 1 and 2, respectively. Inotropy requirement was higher in group 1 (p = 0.0058). When compared with preoperative values postoperative left ventricle ejection fraction (LVEF) increased both at rest (from 52.74% +/- 3.88% to 62.86% +/- 3.18%, p = 0.0001) and during exercise (from 53.16% +/- 3.16% to 64.11% +/- 2.46%, p = 0.0001) in bileaflet preserving MVR group. But in conventional MVR group LVEF decreased postoperatively both at rest (from 51.45% +/- 4.27% to 48.27% +/- 3.35%, p = 0.0001) and during exercise (from 54.47% +/- 7.36% to 42.96% +/- 3.58%, p = 0.0001). Conclusion Leaflet preserving MVR operation not only improves the left ventricular performance but also reduces the mortality and morbidity after MVR. LVEF increases both at rest and during exercise. Risk of LVOT obstruction can be completely eliminated with our simple technique.

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. …

Triangular resection is a reconstructive option for treatment of anterior leaflet mitral disease with segmental prolapse. In our experience, it is a safe and reproducible technique, associated with low rates of recurrent MR or need for reoperation, as well as decreased likelihood for systolic anterior motion after mitral repair. We review our experience with this technique over a 25-year experience with mitral valve reconstruction.

Postoperatively, posterior leaflet tethering tended to be ameliorated, just as was the anterior leaflet tethering. AML, Anterior mitral leaflet; PML, posterior mitral leaflet; LA, left atrium; LV, left ventricular; LVDd, left ventricular diastolic diameter; LVEF, left ventricular ejection fraction;MR,mitral regurgitation; NS, not significant; PA, pulmonary artery; PG, pressure gradient. Surgical Techniques

We describe a case of hammock mitral valve in an adult. A 38-year-old woman presented with recently acquired dyspnea. Echocardiography showed severe mitral stenosis related to a hammock mitral valve characterized by the presence of an overdeveloped papillary muscle that gives short chordae to both mitral leaflets. No other valve insufficiency was noted. At operation, we observed direct continuity accompanying several fenestrations between both leaflets and the huge abnormal muscular band just underneath the mural leaflet. Resection of the anterior leaflet and was successfully replaced with a bioprosthetic valve. Her postoperative course was unremarkable.

A 70-year-old man with severe mitral regurgitation (MR) was referred to our institution for percutaneous mitral valve repair. A Mitraclip (Abbott Vascular, Santa Clara, California) was implanted but did not correctly tether the posterior leaflet and was solely attached to the anterior leaflet. A

Mitral valve repair in patients with mitral valve billowing and prolapse (Barlow) can be a demanding surgical procedure. A mitral valve repair method, which incorporates the complete resection of the middle scallop of the posterior leaflet, a sliding and folding plasty with the remaining lateral scallops combined with a triangular resection of the anterior leaflet and a ring-annuloplasty was developed, which maximizes predictable anatomic and physiologic efficacy of this repair and minimizes unpredictable results. A total of 37 consecutive patients underwent mitral repair with this method from 1996 to 1998, with consistently excellent results. Short-term follow-up information collected after 22.7 +/- 8.6 months showed one late death and 93.0% of all surviving patients in New York Heart Association functional class I or II. There were no late reoperations and no thromboembolic, bleeding, or other complications. No patient had recurrent mitral regurgitation.

Literature has been limited in regard to the mechanisms of tricuspid regurgitation (TR) in patients with paramembranous (perimembranous) ventricular septal defect (VSD). Most observations have noted tricuspid valve clefts or dysplasia. We describe another mechanism for production of TR in association with paramembranous VSD. In 8 patients, we found significant TR produced by the VSD jet pushing the tricuspid anterior leaflet forward to open the tricuspid valve orifice. In these patients, a moderate paramembranous VSD extended slightly below the septal tricuspid leaflet with only partial obstruction of the VSD jet. All patients had restrictive VSD with low right ventricular pressure. This mechanism to produce TR was best defined by intraoperative transesophageal echocardiography, but current higher resolution imaging should allow correct diagnosis. We believe that when this mechanism for TR is found in association with a moderate VSD, surgical VSD closure is warranted.

We describe a technique for treating severe functional tricuspid regurgitation (TR) when residual regurgitation cannot be eliminated with ring annuloplasty alone. The anterior leaflet and the anterior half of the posterior leaflet are augmented with an elliptic pericardial patch before implantation of a rigid annuloplasty ring. We successfully performed this procedure in 9 patients with severe TR due to severe leaflet tethering or short coaptation length and achieved complete elimination of TR with sufficient coaptation length in tricuspid valve leaflets for all patients.

Mitral valvuloplasty using Gore-Tex (W.L. Gore & Associates, Inc, Flagstaff, AZ) as artificial chordae is often associated with difficulties in determining the length of the artificial chordae, as well as preventing knot slippage, especially for patients with broad anterior leaflet prolapse. We describe a simple technique that enables surgeons to easily determine the correct length of the artificial chordae and tie slippery knots without using a specific device.

Background The objectives of this study were twofold: to assess the diagnostic utility of three-dimensional (3D) multiplanar reconstruction (MPR) in identifying prolapsing mitral valve (MV) scallops, and (2) to compare two-dimensional (2D) transthoracic echocardiography (TTE) and 3DMPR to (2D) transesophageal echocardiography (TEE) approaches among patients with mitral valve prolapse (MVP). Methods Fifty-five patients with MVP who underwent MV repair or replacement were retrospectively analyzed using 3 types of echocardiographic studies (2DTEE, 2DTTE, 3DMPR). The operative (OR) findings were considered the gold standard. Results When 3DMPR was combined with 2DTTE, the agreement with the OR findings was moderately strong for the A2 scallop (P

Background In this study, advanced postprocessing of three-dimensional echocardiographic (3DE) data sets was used to identify tricuspid valve (TV) leaflets in two-dimensional echocardiographic (2DE) views, and the feasibility of the subcostal view to obtain 2DE en face views of the TV, as an alternative imaging option to image reconstruction from 3DE imaging, was also tested. Methods In 155 consecutive patients, attempts were made to obtain the en face view of the TV by 2DE imaging (from the subcostal window) and by reconstruction from 3DE imaging. Using both in-house-developed and commercially available software for postprocessing of 3DE data, image planes from the standard 2DE views were reconstructed and TV leaflets identified in each view. Results With 2DE imaging, all TV leaflets could be visualized in 58% of patients, compared with 56% using 3DE imaging. In 30 patients (19%), en face views of the TV could be obtained only by 3DE imaging. The anterior leaflet was the largest one in 90% of patients, and the smallest leaflet was either the posterior (49%) or septal (41%) leaflet. In 12% of patients, the TV was either bicuspid or quadricuspid. In patients with pacemakers, the position of the right ventricular lead relative to the TV leaflets was readily determined using both imaging techniques. Visible TV leaflets varied in all standard 2DE views because of variability in image planes and leaflet morphology. Conclusions High variability in TV leaflet anatomy and the dependence on transducer position do not allow schematic leaflet identification. All existing TV leaflet identification schemes are therefore only partially correct, and if correct leaflet identification is needed, the use of an en face view is recommended.

Rheumatic mitral valve disease often manifests with leaflet fibrosis, commissural fusion and early calcific degeneration. The thickening and fibrosis of the valvular and subvalvular apparatus has made prosthetic mitral replacement the traditional surgical solution. However, favourable valve morphology in some patients may permit a durable mitral repair rather than replacement. There is growing interest in reparative techniques that durably improve the mitral orifice while preserving the subvalvular apparatus. Many of these techniques are technically challenging and require complex resections with intricate chordal adjustments, which may have limited their global acceptance. In this report, we outline a three-step technique that does not require significant resection or involve the use of neochords. This offers a potentially simplified approach to the repair of rheumatic mitral stenosis.

Idiopatic hypertrophic subaortic stenosis (IHSS) is a type of obstructive cardiomyopathy that causes aortic outflow tract obstruction during systole. Moreover, the anterior leaflet can be shifted toward the hypertrophied septum creating, more outflow obstruction and concomitant mitral insufficiency. Traditional IHSS has been treated surgically through the aortic valve. In this chapter, we describe a robotic trans-atrial left approach to perform a large septal myectomy with concomitant mobilization of anterior papillary muscle and mitral valve reconstruction. Robotic methods provide ideal septal and valve exposure as well as superior visualization and ergonomic access.

Firstly described by W. Ebstein in 1866, the Ebstein anomaly (EA) is composed of a wide spectrum of malformations, so that every valve taken into consideration is a unique valve. EA is rare, accounting for approximately 1-5 cases every 200,000 live births and representing less than 1 % of all CHD, but is the most frequent congenital lesion of the tricuspid valve (TV). Natural history of patients with EA is poor. Early presentation in life is associated with high percentage of mortality, while patients who survived the neonatal period have a limited life expectancy. Deaths usually occur for arrhythmic events and heart failure. From the embryological point of view, the anomaly is related to a failure of delamination of the TV leaflets which reflects with a characteristic pattern of morphological anomalies involving the TV and the right ventricle (RV). This cohort of abnormalities could be associated with rhythm disturbances and other cardiac defects. The disease may have a clinical neonatal presentation which corresponds to a severe RV and TV dysfunction or may present later in life, concurrently with an increasing degree of TV regurgitation and RV dilatation. Since the pioneer period of cardiac surgery, many techniques have been described to address the TV and RV anomalies including TV replacement which is still an option, despite reconstructive techniques being now preferred due to the improvement of the early and long-term results. The aim of the repairing techniques is to restore a normal tricuspid valve function, to preserve the right ventricular contractility, and to decrease the risk of rhythm disturbances. Results are associated with the severity of the disease, the surgeon experience, and the perioperative care of the patient.

Mitral repairs should be directed toward re-establishing the normal annular geometry with adequate posterior and anterior leaflet coaptation during systole. In the majority of insufficient degenerative (i.e. myxomatous valves), a leaflet segment is flail either from ruptured or elongated chords. Previously, most mitral valve repairs were done by resecting a large leaflet segment with suture reconstruction and performing an annular plication. Many of these repairs were complex and not embraced by all cardiac surgeons, leading to a prosthetic valve replacement. Moreover, others found results varied in reproducibility. Herein, we describe a technique, developed at the Leipzig Heart Center, that simplifies reduction of the involved segment to an appropriate level. The technique is very reproducible and is the mainstay of our repair strategy. Using PTFE material, multiple “neochord” loops are measured and fabricated into cluster. The base of this cluster is attached to the correct papillary muscle, and each loop is sutured along the effected leaflet segment, establishing a generous area of systolic coaptation. Thus, reduction of prolapsed leaflets (Type II, Carpentier) has become simplified, and this method can be reproduced by most cardiac surgeons.

A 91-year-old man was referred following congestive heart failure with acute pulmonary edema that was medically treated. Echocardiography revealed the presence of severe mitral regurgitation (MR) as a result of chordal rupture on the anterior leaflet at the level of the A2 segment ([Figures 1A to

The standard of care for mitral regurgitation secondary to degenerative valvular disease is mitral valve repair whenever possible. Mitral valve repair is associated with better left ventricular function preservation, fewer complications, and improved survival as compared with mitral valve replacement. Most of the mitral valve pathology involves the posterior leaflet or annulus and usually can be repaired by using standard valve repair techniques. Difficulties may arise when trying to repair the somewhat uncommon anterior leaflet prolapse or calcified mitral annulus. This article reviews these more complex mitral valve repair techniques and their outcomes.

Isolated cleft of the mitral valve is an uncommon congenital cause of mitral regurgitation. Most of the clefts involve the anterior leaflet and isolated clefts of the posterior leaflet have been anecdotally identified. We report a case of Marfan syndrome in whom an echocardiographic examination revealed a cleft in the posterior mitral leaflet. Marfan syndrome frequently involves the mitral valve causing mitral valve prolapse. Occurrence of a cleft may be an extension of its mitral valve involvement.

Isolated congenital tricuspid regurgitation without downward displacement of the leaflet is uncommon in adults, and repair of such valves often requires a procedure that is more complex than simple tricuspid annuloplasty. We describe a technique of tricuspid valvoplasty using the neo-papillary loop technique to reconstruct multiple artificial chords for isolated congenital tricuspid regurgitation associated with a dysplastic anterior leaflet with agenesis of the chordae tendineae and a hypoplastic anterior papillary muscle. This technique provides a simple and valuable option for the repair of dysplastic valves lacking chordae, even those with a hypoplastic papillary muscle.

We report an asymptomatic case of a papillary fibroelastoma adherent to the mitral anterior leaflet. Transthoracic echocardiography of an 85-year-old man with chronic atrial fibrillation and no thromboembolic episodes, revealed a cardiac tumor on the mitral valve. Transesophageal echocardiography demonstrated typical findings for a papillary fibroelastoma. The tumor was successfully removed using a shave excision technique. Currently, these tumors are found incidentally in asymptomatic patients by advanced diagnostic modalities.

We report a case of isolated cleft mitral valve with two clefts in the posterior and one in the anterior leaflet. Our case adds to the few reports of posterior and multiple mitral valve clefts and to our knowledge is the first using real-time transoesophageal three-dimensional echocardiography (3DE) for assessment of isolated cleft mitral valve. (Echocardiography 2010;27:E50-E52).

The case of a 50-year-old woman with an occasional diagnosis of cardiac tumor of the tricuspid valve is reported. At surgery, a single 2 cm x 2 cm polypoid gelatinous neoplasm infiltrating the anterior leaflet of the valve was resected and a tricuspid valve reconstruction along with annuloplasty was accomplished. The postoperative period was uneventful. A diagnosis of papillary fibroelastoma was made at pathology. This neoplasm, which represents a rare pathological entity, is more frequently localized on the mitral valve and usually stays asymptomatic for a long time. Only a few cases involving the tricuspid and pulmonary valves have been reported. Indication for surgery is related to a certain incidence of pulmonary embolism. Surgical removal of papillary fibroelastoma is a low-risk and definitive operation, as only one case of recurrence of the tumor has been reported so far in the literature.

Posterior mitral valve (MV) leaflet aneurysms are extremely rare complications of infective endocarditis (IE). When MV aneurysms occur, they usually involve the anterior leaflet. Real time three-dimensional transesophageal echocardiography (RT3D TEE) has been recently developed and provides views of unparalleled quality by optimizing visualization of spatial relationships. We present a rare case of a posterior MV leaflet aneurysm due to IE in a 64-year-old woman, best visualized by RT3D TEE.

Modes of failure of Hancock and Carpentier-Edwards (C-E) porcine bioprosthetic valves placed in the mitral position are not completely understood. We reviewed transesophageal echocardiographic (n = 19) and pathologic features of failed Hancock (n = 22) and C-E (n = 8) porcine mitral valves in 30 patients (mean age 70 +/- 13 years). Age at implantation (59 +/- 14 vs 58 +/-14 years, p = 0.9), time to implanted valve degeneration (13 +/- 5 vs 11 +/- 2 years, p = 0.3), and size of bioprosthesis (30 +/- 2 vs 31 +/- 2 mm, p = 0.14) of the implanted Hancock and C-E valves were similar. Anterior leaflet was flail in 15 versus flail posterior leaflet in 5 patients (p = 0.0004). Eccentric posterior mitral regurgitation jet was present in 12, eccentric anterior jet in 2, central jet in 2, and paravalvular jet in 3 patients. Stenosis of bioprosthesis was present in 1 1 Hancock versus 1 C-E valve (p = 0.06). Stent creep at any stent post was present in 14 Hancock versus no C-E valve (p = 0.0013). Large commissural dehiscence was present in 5 C-E versus 1 Hancock valve (p = 0.0006). Ring margin perforation was the most common perforation in Hancock valves (p

Background: Mitral annuloplasty is an important element of most mitral repairs, yet the effects of various types of annuloplasty rings on mitral annular dynamics are still debated. Recent studies suggest that flexible rings preserve physiologic mitral annular area change during the cardiac cycle, while rigid rings do not. Methods: To clarify the effects of mitral ring annuloplasty on mitral annular dynamic geometry, we sutured 8 radiopaque markers equidistantly around the mitral anulus in 3 groups of sheep (n = 7 each: no ring, Carpentier-Edwards semi-rigid Physio-Ring [Baxter Healthcare Corp, Edwards Division, Santa Ana, Calif], and Duran flexible ring [Medtronic, Inc, Minneapolis, Minn]). Ring sizes were selected according to anterior leaflet area and inter-trigonal distance (Physio-Ring 28 mm, n=7; Duran ring 31 mm, n=5, and 29 mm, n=2). After 8 ± 1 days of recovery, the sheep were sedated and studied by means of biplane videofluoroscopy. Mitral annular area was calculated from 3-dimensional marker coordinates without assuming circular or planar geometry. Results: In the no ring group, mitral annular area varied during the cardiac cycle by 11% ± 2% (mean ± SEM; maximum=7.6 ± 0.2, minimum=6.8 ± 0.2 cm 2 ; P ≤ .001). Mitral annular area was fixed in the Physio-Ring group (4.6 ± 0.1 cm 2 ) and, surprisingly, also static in the Duran ring group (4.8 ± 0.1 cm 2 ; P = .26 vs Physio-Ring). Furthermore, mitral annular 3-dimensional shape changed in the no-ring group during the cardiac cycle, but not in the Physio-Ring or Duran groups. Conclusions: Mitral annular area and shape did not change during the cardiac cycle after ring annuloplasty, regardless of ring type. Thus mitral annular area reduction, independent of intrinsic ring flexibility, is the chief mechanism responsible for the salutary effects of mitral ring annuloplasty. (J Thorac Cardiovasc Surg 1999;117:302-9)

Extensive calcification of mitral apparatus may preclude optimal valve repair, thus requiring debridement. We performed mitral valve replacement in a 55-year-old woman with a modified bileaflet preservation technique to avoid complications related to extensive debridement. Posterior transposition of the anterior leaflet as a buttress over the posterior ventricular wall provided extra support for the weakened tissues and covered the decalcified areas, which protected against debris embolism. This technique is safe and reproducible, especially for elderly patients who have complex calcification that requires extensive debridement, enables better preservation of ventricular function, and avoids disruption of the mechanical left ventricular wall.

We are describing two-dimensional and live/real time three-dimensional transthoracic as well as two-dimensional transesophageal echocardiographic findings in an elderly patient with epithelioid hemangioma involving the anterior leaflet of the mitral valve.

There is growing interest in the application of artificial chordae to correct mitral valve regurgitation caused by prolapse. Application of pre-measured artificial chordae facilitates creation of chordae of appropriate length. Herein we illustrate the technique for creation of pre-measured artificial chordae, documenting neo-chordal length and number in 50 patients with anterior leaflet prolapse, highlighting the need for chordae of more than one length in 14% of patients.

In mitral valve regurgitation due to anterior leaflet prolapse and other complicated lesions, chordal replacement with expanded polytetrafluoroethylene is widely practiced. The most troublesome aspects of this procedure are the determination of the necessary length of the artificial chorda and the tying of the knot. We describe a simple technique for artificial chordal replacement using an Alfieri stitch, that has been successfully applied to 10 patients with anterior leaflet prolapse.

Mitral valve regurgitation caused by an isolated cleft of the anterior leaflet of the mitral valve is a rare condition, usually corrected early in life. We report the case of a 66 year old patient with an isolated cleft, which was successfully corrected through a minimally-invasive approach, demonstrating good visibility and direct closure of the cleft.

Background —In hypertrophic cardiomyopathy, a spectrum of mitral leaflet abnormalities has been related to the mechanism of mitral systolic anterior motion (SAM), which causes both subaortic obstruction and mitral regurgitation. In the individual patient, SAM and regurgitation vary in parallel; clinically, however, great interindividual differences in mitral regurgitation can occur for comparable degrees of SAM. We hypothesized that these differences relate to variations in posterior leaflet length and mobility, restricting its ability to follow the anterior leaflet (participate in SAM) and coapt effectively. Methods and Results —Different mitral geometries produced surgically in porcine valves were studied in vitro. Comparable degrees of SAM resulted in more severe mitral regurgitation for geometries characterized by limited posterior leaflet excursion. Mitral geometry was also analyzed in 23 patients with hypertrophic cardiomyopathy by intraoperative transesophageal echocardiography. All had typical anterior leaflet SAM with significant outflow tract gradients but considerably more variable mitral regurgitation; therefore, regurgitation did not correlate with obstruction. In contrast, mitral regurgitation correlated inversely with the length over which the leaflets coapted ( r =−0.89), the most severe regurgitation occurring with a visible gap. Regurgitation increased with increasing mismatch of anterior to posterior leaflet length ( r =0.77) and decreasing posterior leaflet mobility ( r =−0.79). Conclusions —SAM produces greater mitral regurgitation if the posterior leaflet is limited in its ability to move anteriorly, participate in SAM, and coapt effectively. This can explain interindividual differences in regurgitation for comparable degrees of SAM. Thus, the spectrum of leaflet length and mobility that affects subaortic obstruction also influences mitral regurgitation in patients with SAM.