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This report describes a technique for anterior leaflet extension using an autologous pericardial patch in patients suffering from rheumatic mitral regurgitation. The technique has recently evolved and now enables us to correct both vertical and transversal fibrotic leaflet retraction.

Background Identification of mitral regurgitation (MR) mechanism and pathology are crucial for surgical repair. The aim of the present investigation was to evaluate the comparative accuracy of real-time three-dimensional (3D) transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) with two-dimensional (2D) TEE and TTE in diagnosing the mechanism of MR compared with the surgical standard. Methods Forty patients referred for surgical mitral valve repair were studied; 2D and 3D echocardiography with both TTE and TEE were performed preoperatively. Two independent observers reviewed the studies for MR pathology, functional or organic. In organic disease, the presence and localization of leaflet prolapse and/or flail were noted. Surgical findings served as the gold standard. Results There was 100% agreement in identifying functional versus organic MR among all four modalities. Overall, 2D TTE, 2D TEE, and 3D TEE performed similarly in identifying a prolapse or a flail leaflet; 3D TEE had the best agreement in identifying anterior leaflet prolapse, and it also showed an advantage for segmental analysis. Three-dimensional TTE was less sensitive and less accurate in identifying flail segments. Conclusion All modalities were equally reliable in identifying functional MR. Both 2D TEE and 3D TEE were comparable in diagnosing MR mechanism, while 3D TEE had the advantage of better localizing the disease. With current technology, 3D TTE was the least reliable in identifying valve pathology.

Surgical treatment of tricuspid valve endocarditis is challenging especially in intravenous drug users. We present a case of a 30-year-old male active drug user with anterior leaflet endocarditis treated successfully with valve repair. This was achieved through excision of the vegetation with part of the leaflet. Bovine pericardium was used to close the defect. The edges were reinforced with Teflon pledgeted polytetrafluoroethylene Gore-Tex neochordae (W.L. Gore & Associates, Flagstaff, AZ, USA). An annuloplasty ring was used to reinforce the whole annulus. Repair was competent and the patient recovered well. This technique is simple and effective and should be considered for similar cases. (J Card Surg 2010;25:153-155)

A routine chest X-ray in a 78-year-old female patient suggested a retained vascular catheter in the right ventricle (RV). On transthoracic echocardiography, a prominent linear echo was found in the RV and the patient was referred for cardiac computed tomography and magnetic resonance imaging. Although neither of these tests showed evidence of a retained foreign body in the RV, they could not clarify the nature of the linear structure within the RV cavity. Finally, transesophageal echocardiography, using a matrix array three-dimensional probe solved the mystery: the linear structure in question within the RV was a large papillary muscle with attachments to the anterior leaflet of the tricuspid valve and an unusual origin from the interventricular septum.

The mitral valve is a complex, bi-leaflet structure that separates the left atrium (LA) and the left ventricle (LV). It consists of two leaflets, a fibrous annulus, chordae tendinae, two papillary muscles, and their left ventricular attachments (Fig. 3.1).

An appreciation of atrioventricular valve surgical anatomy reveals that they are much more than simple valves, opening and closing in response to pressure changes. The structural interrelationship of the valves of the heart and the dynamic mechanisms involved in their function are fundamental in optimizing valve performance and are dependent upon an intricate, multifaceted central cardiac complex.

The tricuspid valve has three leaflets, the anterior, the septal and the posterior (Fig. 5.1). The anterior leaflet is the largest of the three. As with all cardiac valves there is a free edge and a line of closure, located on the atrial side of the tricuspid valve. There are three commissures separating each leaflet. Each leaflet has chordae tendonae attached to ventricular papillary muscles, which can vary in number. One of the defining characteristics of a tricuspid valve is that the septal leaflet chordae attach directly to the underlying, adjacent ventricular septum.

In this issue of JASE, Magne et al continue their previous work using echocardiography to analyze outcomes of mitral valve repair for ischemic mitral regurgitation, demonstrating that continued adverse left ventricular (LV) remodeling may not be a prerequisite for recurrent mitral valve regurgitation in patients who had undergone initially successful repairs. They observed a group of 26 patients selected from a larger group who had undergone surgical repair for ischemic mitral regurgitation and noted that 10 patients developed recurrent mitral regurgitation within a mean of 18 months after surgery. In those 10 patients, recurrent regurgitation was ascribed to continued adverse LVremodeling in 5 patients, while the other 5 did not have detectable changes in ventricular volumes. The authors did note increased tethering of the anterior leaflet in the latter group of patients and suggested that recurrent regurgitation was due to localized LV remodeling in the vicinity of the papillary muscle. Does this finding represent an advance in our understanding of ischemic mitral valve repair? Have alternate explanations for recurrent regurgitation been excluded? To help put these findings in perspective, it is necessary to review the pathophysiology of ischemic mitral valve regurgitation and to separate the issue of residual or recurrent mitral regurgitation that results from surgical technical failure, as opposed to that due to the progression of the underlying disease process.

Mitral valve edge-to-edge repair (ETER) alters valve mechanics, which may impact efficacy and durability of the repair. The objective of this paper was to quantify stretches in the central region of the anterior leaflet of the mitral valve after ETER with a single suture and 6 mm suture. Sixteen markers, forming a 4×4 array, were attached onto the central region of the mitral valve anterior leaflet. The mitral valve was subjected to ETER with a single suture and 6 mm suture, and mounted in an in vitro flow loop simulating physiological conditions. Images of the marker array were used to calculate marker displacement and stretch. A total of 9 mitral valves were tested. Two peak stretches were observed during a cardiac cycle, one in systole and the other in diastole under mitral valve edge-to-edge repair condition. The major principal (radial) stretch during systole was significantly greater than that during diastole. However, there was no significant difference between the minor principal (circumferential) stretch during diastole and that during systole. In addition, there were no significant differences in the radial and circumferential, or areal stretches and stretch rates during diastole between the single suture and 6 mm suture. The ETER subjects the mitral valve leaflets to double frequency of loading and unloading. Minor change in suture length may not result in a significant load difference in the central region of the anterior leaflet during diastole.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 27-year-old female patient with severe mitral regurgitation due to anterior leaflet prolapse underwent elective mitral repair. Polytetrafluoroethylene sutures were used to reconstruct the anterior

The mitral valve is so named due to its appearance that resembles a bishops’ miter. Transesophageal echocardiography and the mitral valve (that sits only 5–10 cm from the transducer with nothing but blood between them) were made for each other with the spatial and temporal resolution of the technique allowing the valve with its complex structure and motion to be perfectly described. Assessment of the mitral valve (MV) is, therefore, one of the commonest indications for TEE and should be undertaken in all patients being evaluated for (preoperatively) or undergoing (perioperatively) MV surgery. The MV is one of the atrio-ventricular valves (the tricuspid valve being the other one) and has an anterior and a posterior leaflet. The posterior leaflet has clefts that divide it into 3 scallops (P1, P2, and P3); the anterior leaflet has no such scallops, but is described as having three regions that reflect those of the posterior leaflet (A1, A2, and A3 respectively). In addition to the points of apposition along the leaflets, there are anterior (adjacent to A1/P1) and posterior (adjacent to A3/P3) commissures. The nonleaflet apparatus consists of the saddle-shaped mitral annulus, the chordae tendinae (primary chordae attached to the free edges of the leaflets, secondary and tertiary chordae attached to body of leaflets), and papillary muscles (anterior: chordae attached to lateral aspects of leaflets; posterior: chordae attached to medial aspects of leaflets).

Objective: To critically evaluate an initial experience with small-incision mitral valve operation with respect to safety, durability, and effectiveness. Summary Background Data: Mitral valve (MV) surgery is dominated by a sternotomy approach, with MV repair rates which average 60%. Advantages of valvular repair compared with replacement include lower operative and long-term mortality, decreased stroke and infection risks, and superior freedom from reoperation and complications of anticoagulation. Methods: Right chest small-incision MV surgery was performed on 187 consecutive patients. Outcomes including operative mortality and major morbidity were recorded. All patients underwent predismissal echocardiography in a core laboratory. Results: Between 2003 and 2008, 57% (187/327) of isolated MV operations were performed using an anterolateral 6 cm 4th intercostal space small-incision. Operative techniques included femoral arterial and venous plus internal jugular cannulation and direct aortic cross-clamping. Pathology of the anterior leaflet was present in 22%, and PTFE neochordal repairs were used in 36% of cases. The rate of MV repair was 96.3% (180/187) and was 100% for patients with degenerative disease. Median cardiopulmonary bypass and aortic cross-clamp times were 108 and 82 minutes, respectively. There were no deaths, strokes, renal failure, or wound infections. Two patients (1.1%) were re-explored for bleeding, and 27% received blood transfusions. The median hospital stay was 4 days. Clinical core laboratory-assessed freedom from significant (MR > mild) at hospital discharge was 99%. Survival at a median follow-up of 2.5 years was 99%. Conclusions: Direct visualization of the mitral valve through a right chest small-incision enables safe and effective performance of complex MV repair, with repair rates in excess of 95%.

The purpose of this study was to examine the usefulness of polytetrafluoroethylene (PTFE) patches as artificial mitral leaflets in complex mitral valve plasty.Nineteen patients (mean age, 66 +/- 9 years) who were in need of mitral valve replacement successfully underwent mitral valve plasty with enlargement of the basal anterior leaflet using a PTFE patch.Operative and in-hospital mortality was 0%. Patients were followed-up by maintaining their history, physical examinations, and echocardiography. The mean follow-up period was 30 +/- 15 months (2 to 52 months) with one late mortality and one reoperation. A thin neointimal layer was observed on the explanted PTFE patch. The PTFE patch maintained its pliability with no signs of calcification, excessive thickening, or perforation for 4 years. Mean motion angle of the patch on echocardiography decreased from 41.1 +/- 10.6 to 35.2 +/- 12.5 degrees (p0.05) during 26.7 +/- 15.5 months of study (range, 6-46 months). The mean mitral valve area was 2.9 +/- 0.7 cm(2) at last follow-up.The PTFE patches may be a promising material for artificial mitral leaflets.

Improvements in mitral valve (MV) treatments are dependent on a complete understanding of the function, mechanical properties, and underlying mechanobiological responses of the MV. While finite element analyses have provided insight into the cooperative interactions of MV components [1], a lack of quantitative information on the dynamic MV boundary conditions and synchronous leaflet deformation limits present modeling efforts [2]. In this work, we utilized high fidelity transducers implanted in the ovine MV annulus and anterior leaflet to quantify the complete 3D MV kinematics in synchrony. Additionally, effects of systolic blood pressure (SBP) variations on annular and leaflet deformation were investigated.Copyright © 2009 by ASME

The anterior leaflet of the mitral valve (MV), viewed traditionally as a passive membrane, is shown to be a highly active structure in the beating heart. Two types of leaflet contractile activity are demonstrated: 1) a brief twitch at the beginning of each beat (reflecting contraction of myocytes in the leaflet in communication with and excited by left atrial muscle) that is relaxed by midsystole and whose contractile activity is eliminated with β-receptor blockade and 2) sustained tone during isovolumic relaxation, insensitive to β-blockade, but doubled by stimulation of the neurally rich region of aortic-mitral continuity. These findings raise the possibility that these leaflets are neurally controlled tissues, with potentially adaptive capabilities to meet the changing physiological demands on the heart. They also provide a basis for a permanent paradigm shift from one viewing the leaflets as passive flaps to one viewing them as active tissues whose complex function and dysfunction must be taken into account when considering not only therapeutic approaches to MV disease, but even the definitions of MV disease itself.

Isolated-congenital mitral regurgitation is infrequently seen in adults. In its mechanism, the entire mitral apparatus or different components separately can play a role [Gallet B. Use of echocardiography in mitral regurgitation for the assessment of its mechanism and aetiology for the morphological analysis of the mitral valve. Ann Cardiol Angeiol 2003;52(2):70-7; Valdes-Cruz LM, O'Cayre R. Echocardiographic Diagnosis of Congenital Heart Disease. Philadelphia, NY: Lippincott-Raven; 1998; Carpentier A, Branchini B, Cour JC, Asfaou E, Villani M, Deloche A et al. Congenital malformations of the mitral valve in children. Pathology and surgical treatment. J Thorac Cardiovasc Surg 1976;72: 854-66]. We report a case of an unusual congenital mitral regurgitation resulting from restriction of the mitral leaflet caused by thick fibrotic tissue connecting left atrial roof and the anterior leaflet precluding sufficient coaptation. To the best of our knowledge, this pathology has never been reported before.

Extensive mitral annular calcification remains a technical challenge in mitral valve surgery. Decalcification and reconstruction of the mitral annulus is an established technique, but it is time consuming and technically demanding. This report presents the case of an 88-year-old diabetic female patient in whom edge-to-edge repair was completed quickly, with good early results thus being obtained.

Between October 1986 and May 1991, 19 patients with acute rheumatic fever who were hospitalized in the Department of Pediatrics at Soroka Medical Center underwent echocardiographic color flow Doppler examination. Five patients had an echocardiographic picture of mitral valve prolapse, with or without leaflet thickening, and one had a flail anterior leaflet. Six had mitral valve thickening without prolapse, and seven patients had an echocardiographically normal appearing mitral valve. All 19 patients had a posterolaterally directed jet of mitral regurgitation demonstrated on color flow Doppler. All patients had echocardiographically normal aortic valves. However, mild aortic regurgitation was noted in eight of them. The posterolateral jet of mitral insufficiency in acute rheumatic fever may be the most common echo-Doppler finding in this condition. (ECHOCARDIOGRAPHY, Volume 8, November 1991) Summary and Conclusions

SummaryMalfunctioning of the left atrioventricular valve has always been, and remains, the major incremental risk factor in the repair of atrioventricular septal defect. Now that the cardiac surgeon has ample time to assess the anatomy and function of the left valve, results have improved, but are still less than ideal. On the presumption that the anterior leaflet of the mitral valve is “cleft” in this anomaly, it used to be common practice to close the “cleft”. Currently, a substantial number of surgeons employ this technique, often irrespective of the individual anatomy, and in the majority of cases with success.

Proper leaflet coaptation of the mitral valve is vital for a healthy functioning heart. Chordal tension directly affects leaflet coaptation. The C-shaped transducer used previously to measure chordal tension was too big for tension measurement of multiple chordae and their branches. A new method is needed to measure chordal tension with minimum interference with chord and leaflet motion. The method was to extrapolate longitudinal chordal tension from transverse chordal fibril force measured by inserting a small elliptical AIFP4 sensor from MicroStrain Inc. (Williston, VT) through a chord. Sensitivity of the method has been tested with the sensor implanted in chordae, and error of the method has been estimated at various sensor deviation angles. Intact porcine and ovine hearts were used to measure mitral valve strut and marginal chordal tensions at static transmitral pressures of 120 mm Hg and 160 mm Hg under an in vitro condition. The results obtained from the AIFP4 sensor were similar to the results obtained previously by C-shaped transducers in the porcine mitral valves. The sensor output errors increased with the increase in sensor deviation angle in the chord at a peak systolic tension. Strut chordal tensions of four ovine mitral valves of Edwards ring size M 28 were 0.29+/-0.06 N at the transmitral pressure of 120 mm Hg. The tension of 18 porcine strut chordae of porcine mitral valves of Edwards ring size M 32 was 1.00+/-0.42 N at the transmitral pressures of 120 mm Hg. The tension of 22 anterior leaflet marginal chordae from porcine mitral valves of Edwards ring size M 32 was 0.10+/-0.04 N at the transmitral pressure of 120 mm Hg. A new method using an AIFP4 miniature force sensor to measure mitral valve chordal tension indirectly is successfully developed. This force sensor works well in measuring mitral valve chordal tension at an in vitro hydrostatic transmitral pressure. The size and simple fixation of the sensor make it favorable for chordal tension measurement of multiple chordae and their branches under in vitro or in vivo conditions with minimal interference with chordal geometry and dynamics.

Background Procedures on the subvalvular apparatus are an etiology-based treatment for ischemic mitral regurgitation (IMR). Methods and Results Fifty-nine patients with IMR were divided into 3 groups: mitral annuloplasty (MAP) (M group, n=27), MAP+left ventricular reconstruction (LVR) (LV group, n=18), and MAP+LVR+subvalvular procedure (S group, n=14). Tenting height and area, angle between the annular line and the line connecting leaflet base to the bending- or tip-point of either the anterior or posterior leaflet, and leaflet mobility were measured echocardiographically preoperatively and at immediate- and mid-term postoperative follow-up. The angles at the bending-point of the anterior leaflet in mid-systole remained greater than those at its tip-point in the M and LV groups, but became significantly smaller postoperatively only in the S group (p

Objective: To evaluate the effects of an anterior leaflet ankle-foot orthosis (AFO) on postural stability in stroke patients with hemiplegia. Design: Twenty-one stroke patients with hemiplegia resulting from new-onset stroke and ten normal subjects were included in this study. The SMART balance master system was used to assess the postural stability by measuring the ankle strategy, maximal stability, and velocity of center-of-gravity (COG) movement under the following six conditions: (1) eyes open and fixed support (EOFS), (2) eyes closed and fixed support (ECFS), (3) sway-referenced vision and fixed support (SVFS), (4) eyes open and sway-referenced support (EOSS), (5) eyes closed and sway-referenced support (ECSS), and (6) sway-referenced vision and support (SVSS). Each patient was tested with and without an anterior AFO as compared with normal subjects. Results: When wearing an anterior AFO, patients used ankle strategy more than hip strategy to maintain postural stability in all the six sensory conditions (P < 0.05). An anterior AFO also provided stroke patients with better maximal stability under relatively challenging conditions such as SVFS, EOSS, and ECSS (P < 0.05), but the effect was not apparent in the conditions without external perturbation (EOFS and ECFS) and the most difficult condition (SVSS). The velocity of COG movement was lowered when wearing an anterior AFO in stroke patients, and significant differences existed in the EOFS, ECFS, ECSS, and SVSS conditions (P < 0.05). Conclusions: In the early stage of recovery, the use of an anterior AFO may assist stroke patients with hemiplegia to improve their postural stability.

We measured leaflet displacements and used inverse finite-element analysis to define, for the first time, the material properties of mitral valve (MV) leaflets in vivo. Sixteen miniature radiopaque markers were sewn to the MV annulus, 16 to the anterior MV leaflet, and 1 on each papillary muscle tip in 17 sheep. Four-dimensional coordinates were obtained from biplane videofluoroscopic marker images (60 frames/s) during three complete cardiac cycles. A finite-element model of the anterior MV leaflet was developed using marker coordinates at the end of isovolumic relaxation (IVR; when the pressure difference across the valve is ∼0), as the minimum stress reference state. Leaflet displacements were simulated during IVR using measured left ventricular and atrial pressures. The leaflet shear modulus ( Gcirc-rad) and elastic moduli in both the commisure-commisure ( Ecirc) and radial ( Erad) directions were obtained using the method of feasible directions to minimize the difference between simulated and measured displacements. Group mean (±SD) values (17 animals, 3 heartbeats each, i.e., 51 cardiac cycles) were as follows: Gcirc-rad= 121 ± 22 N/mm2, Ecirc= 43 ± 18 N/mm2, and Erad= 11 ± 3 N/mm2( Ecirc> Erad, P < 0.01). These values, much greater than those previously reported from in vitro studies, may result from activated neurally controlled contractile tissue within the leaflet that is inactive in excised tissues. This could have important implications, not only to our understanding of mitral valve physiology in the beating heart but for providing additional information to aid the development of more durable tissue-engineered bioprosthetic valves.

Objective The aims of this work were to employ functional imaging capabilities of the Visible Heart laboratory and endoscopic visualization of mitral valves in perfusion-fixed specimens to better characterize variability in mitral valve leaflet anatomy and to provide a method to classify mitral leaflets that varies from the current nomenclature. Methods We gathered functional endoscopic video footage (11 isolated reanimated human hearts) and static endoscopic anatomical images (38 perfusion-fixed specimens) of mitral leaflets. Commissure and cleft locations were charted using Carpentier's accepted description. Results All hearts had 2 commissures separating anterior and posterior leaflets. "Standard" clefts separating P1/P2 were found in 66% of hearts (n = 25), and standard clefts separating P2/P3 were present in 71% of hearts (n = 27). "Deviant" clefts occurred in each region of the anterior leaflet (A1, A2, A3), and their relative occurrences were 5%, 8%, and 13% (n = 2, 3, 5), respectively. Deviant clefts were found in posterior leaflets: 13.2% in P1 (n = 5), 32% in P2 (n = 12), and 21% in P3 (n = 8). Conclusions Humans elicit complex and highly variable mitral valve anatomy. We suggest a complementary, yet simple nomenclature to address variation in mitral valve anatomy by describing clefts as either standard or deviant and locating regions in which they occur (A1 to A3 or P1 to P3).

Background: Different techniques have been proposed to measure the correct length of artificial chordae. We herein describe a new simple method to measure the chordal length in complex chordal replacement. Method: Chordal replacement was used by us for two different purposes: (1) to maintain the correct chordal length for the anterior leaflet (AL) and (2) to eliminate any movement of the posterior leaflet (PL) to fix it. To reach this goal, the AL is pulled up to the maximum extent and the new chordae are tied 5 mm higher than the related border. On the contrary, in the PL the new chordae are tied at the level of the related border. Results: From March 2006 to March 2007, at the University of Catania, this technique was used in 32 patients (16 for correction of PL prolapse, 6 patients for correction of AL prolapse, and in 10 patients for correction of both leaflets prolapse). The number of chordae per patients was 8.6 for the PL and 6.8 for the AL. No patient died or had major complications. After a mean follow-up of 5 ± 2 months, two-dimensional echocardiography showed that all the patients had no or trivial mitral regurgitation (MR). The echocardiogram showed a correct movement of the new chordae. Conclusions: This technique allows to easily establish the length of the new chordae of the AL and, if necessary, of the PL in complex mitral valve repair.

A rare case of a 14-year-old child with congenital mitral insufficiency secondary to hypoplasia of the posterior leaflet is reported. Echocardiography revealed the almost complete absence of the posterior mitral leaflet, which determined massive regurgitation. At surgical inspection the posterior leaflet was almost completely absent, represented only by tags of fibrous tissue that strictly adhered to the posterior annulus with a total absence of chordae inserting into the hypoplastic leaflet. The mitral valve was successfully repaired by restrictive annuloplasty, which gained a satisfactory surface of coaptation between the anterior leaflet and the primordial posterior structure, resulting in stable valve continence.

In this chapter of the MMCTS, Malaisrie and coworkers describe a very interesting case of severe post-traumatic tricuspid regurgitation which was successfully corrected by resecting a flail segment of the anterior leaflet of the tricuspid valve w1x. A tricuspid annuloplasty ring (Edwards MC3) was used to treat the associated annular dilatation and stabilize the repair. No residual tricuspid regurgitation was present at the trans-esophageal exam performed before leaving the operating room. Although long-term echocardiographic follow-up is mandatory to confirm the durability of the repair, the Authors have to be congratulated for the excellent early result obtained in this patient in whom, in addition, they used a minimally invasive approach rather than a standard median sternotomy. Surgical correction of traumatic tricuspid regurgitation can be unpredictable and challenging. At the time of surgery it is not unusual to find multiple and different lesions involving the leaflets and the subvalvular apparatus, together with some degree of right ventricular dilatation and dysfunction. The leaflet resection technique, adopted in this case, was certainly a reasonable solution considering that the lesion encountered was represented by an isolated flail of the anterior leaflet. Nevertheless, in the presence of severe right ventricular dilatation, the application of this method can lead to significant residual regurgitation. In fact, in longstanding undiagnosed tricuspid insufficiency, the segmental flail initially caused by the blunt chest trauma is gradually followed by the development of tethering defects of the remaining portions of the valve due to the progressive enlargement of the right ventricular chamber. When this stage has been reached, resection of the flailing segment

There is a wide range of annuloplasty systems available now. However, controversy concerning the choice of annuloplasty device persists. We analyzed our preliminary experience in mitral valve repair using the Cosgrove-Edwards annuloplasty ring. To correct their mitral insufficiency (MI), 118 consecutive patients (mean age, 60.4+/-15.1 years) underwent mitral repair using this annuloplasty device. NYHA functional class 3 or 4 were present in 86.4%. Degenerative heart disease was the cause of MI in 36.6% of the patients, ischemic heart disease in 25.4%, Barlow's disease in 17.8%, and idiopathic dilated cardiomyopathy in 7.6%. Mitral surgical procedures included quadrangular resection and sliding of the posterior leaflet, posterior leaflet decalcification, anterior leaflet repair, the edge-to-edge technique, and chordal repair. Mean follow-up was 25.1+/-14.0 months. There were four in-hospital non-valve-related cardiac deaths, and one in-hospital non-cardiac death. No cases of systolic anterior motion were observed. NYHA functional class improved from 3.3+/-0.7, before repair, to 1.3+/-0.6, at follow-up (P=0.00012), MI from 3.6+/-0.5 to 0.5+/-0.6 (P=0.0096), and left ventricular ejection fraction from 52.0+/-12.2% to 55.4+/-12.0% (P=0.044). Three-year actuarial rates of survival, freedom from thromboembolism, and freedom from mitral reoperation were 96.9, 97.9, and 96.4%, respectively. The Cosgrove-Edwards annuloplasty ring does not combine with systolic anterior motion. It minimizes MI secondary to all causes, and preserves left ventricular function.

We present a case of a 75-year-old male with a worsening dyspnea during the last month. Transthoracic echocardiography revealed a severe mitral regurgitation. Transesophageal echocardiography was evident of a 6 mm defect of the mitral anterior leaflet at the region of the anteromedial A1 and medial A2 scallops probably due to perforation, which caused a significant regurgitant jet as documented by the presence of a convergence flow over the ‘hole’. As the patient had a prolonged fever of undetermined origin one and a half months ago, perforation of the mitral anterior leaflet must at least be considered to be of an infective origin.

Pacemaker leads may impair tricuspid valve coaptation and they are a well-known cause of mild tricuspid regurgitation. Occasionally, right ventricular leads worsen tricuspid regurgitation over time and patients develop late-onset symptoms of right-sided heart failure. The exact mechanism of this clinical entity is rarely identifiable by 2D-echocardiography only. This case report details a patient with severe tricuspid regurgitation secondary to immobilization of the anterior leaflet of the tricuspid valve by a permanent ventricular pacing lead. The mechanism of regurgitation was clarified by real time three-dimensional echocardiography that showed the location of the ventricular lead and its interference with the tricuspid valve.

BACKGROUND This paper reports on the mid-term clinical and echocardiographic results of mitral valve repair with chordal replacement. METHODS Sixty-nine patients (mean age 61 +/- 14 years) underwent mitral valve repair with chordal replacement. The etiology was degenerative in 53 (77 %), rheumatic in 7 (10 %), ischemic in 6 (9 %) and infective in 3 (4 %). Mean ejection fraction was 58 +/- 14. In 35 patients (51 %), a minimally invasive approach was used. Mean follow-up time was 45 +/- 27 months. RESULTS Anterior leaflet chordae were replaced in 58 (84 %) patients. There were 3 operative deaths. Freedom from non-trivial recurrent mitral regurgitation (MR) was 81.3 +/- 8.7 % at 97 months. Follow-up echocardiographic controls showed mild recurrent MR in 5 (8 %) patients and moderate in 2 (3.2 %). These two patients required reoperation due to mitral annulus redilation after suture annuloplasty. Competent neochordae were found at reoperation. Freedom from reoperation at 97 months was 96.6 +/- 2.4 %. Four patients died during follow-up resulting in an actuarial survival of 87 +/- 6.2 %. CONCLUSION The replacement of chordae tendineae with ePTFE sutures during mitral valve repair has shown good mid-term results. The implantation of the neochordae can be also performed safely using minimally invasive procedures.

Background Recent awareness of the importance of the mitral valve's basal chordae stimulated a comparative anatomic study of these chordae in 11 human, 10 ovine, and 10 porcine hearts. Methods The basal chordae were defined as the chordae that arise from the papillary muscles and insert into the ventricular aspect of the leaflets. Results All leaflet insertions of the basal chordae were close to the annulus, except at the anterior mitral leaflet, where insertion was at the junction of the smooth and rough zones. The number of basal chordae was 24.6 ± 4.21 in the porcine, 19.7 ± 2.90 in ovine, and 18.81 ± 3.54 in the human hearts. At least two anterior basal chordae were present in each half of the anterior leaflet in 70% of ovine and porcine and in 100% of human hearts. At least two basal chordae were present in each half of the middle scallop of the posterior mitral leaflet in 80% of ovine, 70% of porcine, and 63.6% of humans. Among them, only the two principal or strut chordae were identified as the longest and thickest. Conclusions The basal chordae of the mitral valve follow a definite pattern in each of the three species studied. A new and logical terminology that should facilitate identification of specific basal chordae is suggested.

Objectives Despite Class 1 evidence that mitral repair is better than replacement, in the USA the repair rate is only just over 50% in degenerative mitral valve disease. A majority of surgeons do five or less mitral operations per year. We looked at our results over a ten year period and in particular we looked at the anatomy of our failed repairs and our re repairs to establish if using a different technique or strategy could bring the repair rate towards 100%. Methods Valves were repaired using classical Carpentier repair techniques but also with wide use of PTFE neochordal implantation and pericardial patches. Much of the data was collected using the UK and Ireland Cardiac Surgical Dataset. Results Between January 2005 and December 2014, 545 consecutive patients underwent surgery for degenerative mitral regurgitation. The overall inhospital mortality and rate of repair were respectively 1.1% and 95.2% for the whole cohort and 0.4% and 99.6% for elective non rheumatic (non calcified valve) operations. The rate of re operation for residual recurrent mitral regurgitation was 0.5% with a mean follow up of 40 months. 68% of patients were male, 15% in NYHA 1 and 38% in NYHA III/IV. 36% had evidence of atrial fibrillation preoperatively. 3.6% had echocardiographic evidence of moderate or severe MR at a mean follow up of 24 months postoperatively. Of the 20 patients with failed repairs, 12 had endocarditis and grossly destroyed valves. Seven had partially calcified leaflets leading to SAM after repair and had to be replaced. The one degenerative valve had a very unusual posterior leaflet in that it was very enlarged and wrapped around a non enlarged anterior leaflet. PTFE neochordal did not produce a competent repair, and resection of redundant tissue equally was not satisfactory, so the valve was replaced. Of the three patients attending for re repair two had dehiscence of the annuloplasty ring, three and four years after initial surgery and one had further chordal rupture. Conclusions High volume units can produce very high rates of repair for mitral regurgitation. Endocarditis, and partially calcified leaflets still preclude some valves from being repaired. Very close to 100% repair rate can be achieved for other degenerative mitral regurgitation.

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.

The use of conservative surgical techniques to treat mitral valve regurgitation secondary to acute endocarditis is controversial. Reconstruction of the anterior leaflet may represent an additional challenge in such a setting. We report a case of mitral valve repair where extensive excision of the anterior leaflet and related chordae tendinea was necessary because of large vegetation secondary to acute endocarditis. The “double-orifice” technique was performed and allowed the salvage of the native valve. There was no recurrent infection at 6 months from surgery, with optimal hemodynamic results. (J Card Surg 7998; 73:24–26)

An 83-year-old man presented with a large intracavitatory metastatic malignant melanoma, infiltrating the anterior leaflet of the tricuspid valve. The tumour was excised completely along with the anterior leaflet of the tricuspid valve which was replaced. The patient was well 2 months after surgery.

Repair of the anterior mitral leaflet or bi-leaflet prolapse is technically more demanding than repair of the posterior mitral leaflet. Although several techniques have been proposed for the repair of anterior mitral leaflet prolapse during bi-leaflet repair, practical challenges remain, including the determination of the appropriate length for artificial chords. Herein we describe a novel and reproducible technique for bi-leaflet mitral valve repair, including those with extensive anterior mitral leaflet prolapse.

A repair technique is reported for Ebstein's anomaly associated with partial atrioventricular canal. When there is inadequate size of the anterior leaflet of the tricuspid valve, pericardial patch augmentation of the anterior leaflet may result in a well functioning monocusp tricuspid valve.

Left ventricular outflow obstruction may result from preserving the anterior leaflet after mitral valve replacement. A 79-year-old woman, who had a mitral valve replacement with the native mitral leaflets left intact 16 years before, was admitted to our hospital with severe dyspnea due to heart failure. Echocardiography showed systolic anterior motion of preserved anterior mitral leaflet, and continuous wave Doppler detected severe left ventricular outflow tract jets during systole without mitral chordal rupture. Surgical incising of the anterior mitral leaflet through the aortic root relieved the obstruction without removing the prosthetic mitral valve.

Insertion of artificial chordae or shortening of native ones on the mitral valve with precise determination of their length can be done through the aortic annulus. This route was used to correct a prolapse of the anterior leaflet in 7 patients and resulted in stable repair with no residual insufficiency (4 patients) or trivial residual insufficiency (3 patients).

Characterization of the mechanical properties of the native mitral valve leaflets at physiological strain rates is a critical step in improving our understanding of MV function and providing experimental data for dynamic constitutive models. We explored, for the first time, the effects of strain rate (from quasi-static to physiologic) on the biaxial mechanical properties of the native mitral valve anterior leaflet (MVAL). A novel high-speed biaxial testing device was developed, capable of achieving in vitro strain rates reported for the MVAL (Sacks et al., Ann. Biomed. Eng. 30(10):1280-1290, 2002). Porcine MVAL specimens were loaded to physiological load levels with cycle periods of 15, 1, 0.5, 0.1, and 0.05 s. The resulting loading stress-strain responses were found to be remarkably independent of strain rate. The hysteresis, defined as the fraction of the membrane strain energy between the loading and unloading curves tension-areal stretch curves, was low (approximately 12%) and did not vary with strain rate. The results of the present work indicated that MVAL tissues exhibit complete strain rate insensitivity at and below physiological strain rates under physiological loading conditions. These novel results suggest that experimental tests utilizing quasi-static strain rates are appropriate for constitutive model development for mitral valve tissues. The mechanisms underlying this quasi-elastic behavior are as yet unknown, but are likely an important functional aspect of native mitral valve tissues and clearly warrant further study.

Chordal transfer is a reliable technique for correction of anterior leaflet prolapse. In most cases, normal chordae and a strip of leaflet tissue are transferred from the posterior leaflet to the free edge of unsupported anterior leaflet; the posterior leaflet is repaired as after a quadrangular resection with either a sliding repair or a standard repair. Occasionally, secondary anterior leaflet chordae may be transferred from the undersurface of the anterior leaflet to its unsupported free edge, effecting a rapid and effective repair. After chordal transfer, annuloplasty completes the mitral valve repair.

Radiotherapy-induced cardiac disease is a progressive condition with symptoms beginning several years after treatment. The following article reports the case of a 48-year-old woman who had undergone mediastinal radiation therapy for Hodgkin's lymphoma at age of 15 and, more than thirty years later, suffered from congestive heart failure due to fibrotic thickening of the mitral valve. She successfully underwent mitral valve repair with patch augmentation of the anterior leaflet. Long-term cardiac follow-up of patients treated by mediastinal radiation therapy is warranted.

Between March 1994 and December 1995 a total of 27 cases of mitral valve anterior leaflet repair were undertaken at our institution. Five of the patients were excluded from the study; 3 with predominant mitral stenosis and 2 with atrial septal defect primum type. Of the 22 anterior mitral leaflet repair patients, there were 12 males and 10 females with a mean age of 41.5 years. Follow-up was complete in all patients and ranged from 2 to 22 months with a mean of 8.6 months. Mitral valve disease was attributed to rheumatic disease in the majority of cases (12). Other causes included degenerative (5), endocarditis (2), ischemic (2), and congenital conditions (1). Preoperatively there, were 18 cases of mitral regurgitation, and 4 of mixed mitral stenosis and regurgitation. The most commonly used surgical procedures were prosthetic ring implantation, chordal shortening and chordal transposition. Most of the patients required multiple procedures to accomplish the repair with an average of 3.4 procedures per patient. Neochordal implantation with polytetrafluoroethylene was performed in 4 cases. Reconstruction of the anterior mitral leaflet using autologous glutaraldehyde-treated pericardium was completed in 2 patients who had bacterial endocarditis. There were no hospital deaths nor late mortality in this series. None of the patients required reoperation during the follow-up. The patients' functional status as well as the severity of the mitral regurgitation improved markedly after the operation. We conclude from our study that repair of the mitral valve anterior leaflet is possible in selected patients with good early results.

A 4-month-old boy with ventricular septal defect was found to have accessory mitral valve tissue attached to the anterior leaflet of the mitral valve. Operation was successfully performed to excise the accessory mitral tissue in the left ventricular outflow tract and close the ventricular septal defect. Most previously reported cases with accessory mitral valve tissue were associated with left ventricular outflow tract obstruction. This boy had no pressure gradient across the left ventricular outflow tract. The indications for prophylactic excision of nonobstructing accessory mitral valve tissue in a patient with other forms of congenital cardiac disease are discussed.