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Graphical abstract, Highlights • POS is a rare clinical condition. • Symptoms are upright posture dyspnea and arterial desaturation. • Supine and sitting position oxygen saturation levels suggest right-to-left shunt. • First report of uncommon spontaneous tricuspid valve chordal rupture–induced POS.

We present the case of a 48-year-old man referred for a reduced exercise tolerance in whom a bileaflet mitral prolapse (Barlow's disease), associated with flail motion of posterior mitral leaflet and ruptured chordae tendineae and complicated by eccentric severe regurgitation, was incidentally diagnosed. Albeit paucisymptomatic, at echocardiography he showed the signs of LV dysfunction and, accordingly, was underwent surgical mitral valvuloplasty with implantation of the Memo 3D ReChord Ring without complications. We analyzed the changes of echocardiographic parameters of cardiac remodeling from baseline to post operative setting, highlighting the utility of modern imaging tools (strain and myocardial work) in grade to gauge with more sensitivity LV deformation and function in different conditions of pre and afterload and to overcome the limits of ancient ejection fraction. In conclusion, especially LV myocardial work may be a promising and accurate non load dipendent tool to quantify subclinical LV dysfunction, to guide therapeutic decisions and in post-surgical follow up.

A 40-year-old man was transferred to our hospital following an isolated horse kick injury to the anterior chest wall. The case showed bi-fascicular block, severe tricuspid valve regurgitation due to ruptured chordae tendineae of the anterior leaflet, moderate mitral valve regurgitation due to prolapse of mitral anterior leaflet, and hypokinetic motion of the inferior septal wall. Both tricuspid and mitral insufficiency were completely repaired by a surgical operation. Fortunately, these injuries were not fatal in this case, but the comprehensive assessment of cardiac damage and careful observation are important for managing patients with cardiac injury.

Platypnea orthodeoxia syndrome (POS) is a disease which is characterized by hypoxemia and dyspnea in the upright position, but an oxygen saturation level is nearly normal in the supine position. It is a rare disorder which is usually associated with right-to-left shunt through a patent foramen ovale

Preoperative information concerning the severity and etiology of MR is very important for selecting the most appropriate surgical strategy. Ruptured chordae tendineae (RCT) are one of the most important preoperative findings. We compared the diagnostic power of transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) to detect RCT in patients with MR. We studied 61 patients with MR (30 men, 31 women; mean age, 61 ± 12 years) who underwent mitral valve repair or replacement. Both TTE and TEE were performed before the operations, and the sensitivity and specificity of TTE and TEE to detect RCT were determined. In addition, other factors that influenced the detection of RCT by these two methods were investigated. At the time of an operation, RCT was confirmed in 39 of 61 cases. Transesophageal echocardiography had a higher sensitivity than TTE (74% versus 44%; P = 0.006) to detect RCT, although the specificity was not significantly different. In patients with a body mass index (BMI) > 22 (P = 0.023) or MR grade 4 (P = 0.026), TEE had a significantly higher diagnostic sensitivity than TTE, although there was no significant difference in patients with BMI < 22 or MR grade ≤ 3. In the lateral and medial segments of the mitral valve, TEE had a significantly higher diagnostic sensitivity to detect RCT than TTE (P = 0.0012), although there was no significant difference in the middle segments. There was no significant difference between TTE and TEE with respect to the sensitivity to detect RCT in myxomatous mitral valves. Although the sensitivity of TEE was higher than that of TTE to detect RCT, it was affected by BMI, MR grade, the RCT-presenting segments, and the etiology of MR., International Heart Journal, 53(4), pp.225-229; 2012

In Part I of this article, several aspects of valve structure and function and their possible clinical relevance were discussed. We now review the clinical evolution and application for various forms of valve repair and outline some of the factors relating to the timing and choice of particular types of repair or replacement and, whenever appropriate, repair versus replacement. In addition, future prospects of valve repair based on understanding of the sophisticated function and structure of valves and the possible future contribution of tissue engineering are discussed. The very first attempts at surgical treatment of heart valve disease were directed toward repair of mitral stenosis in the early 1920s by Elliot Carr Cutler1 in Boston and Sir Henry Souttar2 in London. Although some of these operations were successful, it was approximately 30 years before mitral valvotomy was established by Bailey in the United States and Lord Brock and O.S. Tubbs in the United Kingdom. The next heart valve operation to be attempted was repair of mitral regurgitation by Lillehei et al,3 who in 1957 reported “surgical correction of pure mitral regurgitation by annuloplasty under direct vision.” Shortly after that, Dwight McGoon,4 at the Mayo Clinic, introduced “repair of mitral regurgitation for ruptured chordae tendineae by triangular resection of the prolapsing segment,” a major contribution. With the introduction of mechanical valve replacement by Harken, Starr, and others and biological valves (homografts) by Donald Ross and Brian Barratt-Boyes in the early 1960s, there was a swing toward valve replacement. More recently, however, there has been a gradual realization that the ideal operation may be a restorative (repair) operation attempting to reproduce some of the sophisticated functions of a normal valve. This was accompanied by refining and evolving new techniques for repair of different valves by Carpentier5 and …

Background Three-dimensional transesophageal echocardiography (3DTEE) has been demonstrated to provide more accurate information than two-dimensional transesophageal echocardiography (2DTEE) in the localization of mitral valve prolapse (MVP). However, most studies have been single-rater studies. Few results were tested for inter-observer variability with a single second rater. This multicenter study aimed to determine reliability of 2D and 3DTEE mitral valve evaluations by calculating inter-observer agreement between various echocardiographers. Methods Fifteen observers from 4 institutions in Germany and Switzerland interpreted 2D and 3DTEE images from 6 patients selected to represent a large spectrum of MVP diversity. Surgical findings served as reference. Individual assessments of MVP and ruptured chordae tendineae (ChR) pathology were compared by calculating Randolph's free-marginal multirater kappa coefficient. Results Accuracy of MVP evaluation with 3DTEE was 83.9%, CI [81.0%; 86.8%] and 78.7% CI [76.6% 80.8%] with 2DTEE. Flail leaflets with chordal ruptures were described correctly in 91.1%, CI [85.8, 96.4] with 3D compared to 71.1%, CI [65.0, 77.2] with 2DTEE. The multirater kappa coefficient of inter-observer agreement among all 15 observers was κ = 0.65/0.58 for 3D/2D evaluation of MVP and κ = 0.70/0.54 for detection of ChR. Conclusion Three-dimensional assessment of MVP was superior to 2DTEE, although the accuracy of both 3DTEE and 2DTEE was found to be lower than previously published. 3D MVP assessment is less operator dependent than 2DTEE evaluation. Although validity has been demonstrated before, we provide evidence that 3DTEE is reproducible among 15 observers and is a reliable method for MVP evaluation.

Background Three-dimensional (3D) transesophageal echocardiography (TEE) has been claimed to provide more information than two-dimensional (2D) TEE in the localization of mitral valve prolapse (MVP). However, most studies have been performed by experts in echocardiography, without accounting for differences in training or expertise. This multicenter study was designed to assess the differences between experts and inexperienced echocardiographers in localizing MVP and ruptured chordae tendineae using 2D and real-time 3D TEE. Methods Thirty-six observers from 10 institutions in Germany and Switzerland interpreted 2D and 3D transesophageal echocardiographic images from six patients selected to represent a large spectrum of MVP diversity. Surgical findings served as a reference. Individual performance in the prediction of pathology was scored. Differences between 15 experts and 21 beginners in TEE were assessed, and the benefits conferred by 3D TEE were compared. Results Both study groups scored significantly higher when interpreting 3D transesophageal echocardiographic images ( P ≤ .001). The experts were superior in 2D MVP localization (14.8%; P ≤ .001), a difference that diminished with 3D TEE (1.4%; P = .41). The benefit of access to 3D information for MVP localization was greater for inexperienced echocardiographers compared with experts ( P Conclusions The reported diagnostic advantage of 3D TEE over 2D TEE in MVP assessment for expert echocardiographers can be transferred to inexperienced echocardiographers. Inexperienced echocardiographers benefit from the technology to a greater extent than their expert colleagues.

To determine the additional diagnostic value of biplane transesophageal echocardiography (TEE) in patients undergoing mitral valve surgery, we studied 48 patients with severe mitral regurgitation. Transesophageal echocardiographic video recordings were reorganized in separate transverse and longitudinal sections to allow independent evaluation. Mechanism of mitral regurgitation and anatomic abnormalities of the mitral valve were assessed by all 3 transesophageal echocardiographic modalities and were related to surgical findings. Biplane TEE detected increased leaflet mobility with a sensitivity of 91% and a specificity of 84%, and restricted leaflet mobility with a sensitivity of 100% and a specificity of 97%. Biplane TEE was accurate in the diagnosis of most of the anatomic abnormalities associated with these mechanisms. However, the sensitivity for detecting subvalvular abnormalities (including papillary muscle abnormalities) was poor, and measurement of the annular diameter had a poor correlation with annular dilatation. Although the yield of biplane TEE was better than either transverse or longitudinal TEE alone, the differences did not reach statistical significance, because of the size of the patient group. The surgical procedure (either valve repair or replacement) was correctly predicted with transverse TEE in 71%, with longitudinal TEE in 69%, and with biplane TEE in 79% of the patients. All 3 transesophageal echocardiographic modalities are very capable of assessing the anatomic abnormalities and mechanism of mitral regurgitation, as well as predicting the feasibility of valve repair.

僧帽弁逸脱症は腱索断裂を比較的高頻度に合併するが,感染性心内膜炎やMarfan症候群の合併なく急激に僧帽弁閉鎖不全を発症し,急性左心不全さらに,心停止にいたることは希である.今回,突然の急性左心不全にて発症し,救急外来受診直後心停止をきたした僧帽弁腱索断裂を伴う急性僧帽弁閉鎖不全症の43歳男性に対し,緊急手術を施行し良好な結果を得た.本症例では術中に先天性大動脈二尖弁による高度の閉鎖不全症の合併が判明し,これによる慢性左室容量負荷増大に加え,急性の腱索断裂が心停止をきたすほどの急性左心不全を招来した一因と考えられた.

Degenerative mitral valve disease is frequently represented by elongated and/or ruptured chordae tendineae which leads to prolapse of the mitral valve (MV) and, thus, to mitral regurgitation (MR). In such cases, MV surgery provides a curative treatment. A simple surgical procedure to address MV prolapse is to replace the diseased chordae tendineae by polytetrafluoroethylene (PTFE) sutures. This idea of chordae replacement was introduced by Frater and colleagues. They followed the attempt of completely replacing diseased chordae with PTFE sutures, a material very similar to native chordae in terms of biomechanical characteristics. Until today, several different techniques for implantation of neochordae in MV repair have been described with a very high rate of success and good long-term durability. Despite these promising results, the question remains whether chordal insertion is the procedure of choice in mitral valve repair?

Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid-and long-term results.

To compare the accuracy of transesophageal echocardiography (TEE) with that of transthoracic echocardiography (TTE) in the detection of morphologic characteristics and in the quantitative assessment of the severity of mitral regurgitation with ruptured chordae tendineae, 40 patients with ruptured chordae tendineae (group 1) and 20 patients with moderate or severe mitral regurgitation due to other causes (group 2) were studied. All echocardiograms were recorded before cardiac surgery. Cardiac catheterization was performed in 55 patients (92%). TEE showed greater sensitivity and negative predictive value than TTE (100 vs 65%, and 100 vs 56%, respectively; p0.005) in the diagnosis of ruptured chordae tendineae. Visualization of the ruptured chordae (termed snake-tongue sign) was highly sensitive and specific (93 and 95%, respectively) for establishing the diagnosis of ruptured chordae tendineae. The severity of mitral regurgitation in group 1 patients evaluated by TTE color flow mapping was underestimated by 2 grades in 1 patient and by 1 grade in 6 patients, and overestimated by 1 grade in 1 patient, compared with left ventriculography. In contrast, by TEE color flow mapping it was underestimated by 1 grade in 1 and overestimated by 1 grade in 1 patient. TEE color flow mapping showed better correlation with angiography than did TTE color flow mapping (r = 0.82 vs r = 0.49).

Sixteen-six patients treated surgically for ruptured mitral valve chordae tendineae were investigated to clarify usefullness of mitral valvuloplasty. Of the 16 patients 6 underwent MVP (group MVP) and 10, underwent valve replacement (group MVR). The causes of chordal rupture were idiopathic in 10 (63%), rheumatic in 4 (25%) and infective endocarditis in 2 patients (12%). All cases of group MVP were males and were diagnosed as idiopathic because of mucous degeneration and unknown cause. In idiopathic cases, the interval from onset of heart failure to operation was significantly shorter than that in rheumatic cases (6±7 months versus 52±15 months, p

OBJECTIVE: The objective of this study was to evaluate, using echocardiography, the functioning of the mitral valve apparatus in patients submitted to standardized bovine pericardium chordae implantation to substitute ruptured chordae tendineae or elongated chordae with a significant degree of thinning. METHOD: Standardized bovine pericardium chordae were implanted in 23 patients with mitral valve insufficiency due to ruptured or elongated chordae with significant thinning. The ages of the patients varied from 23 to 84 years old (mean 62 years old). The most common cause was fibroelastic degeneration affecting 20 (87.0%) patients. The standardized bovine pericardium chordae were manufactured in sets connected at both ends by two polyester-reinforced rods thereby forming a single block. The bovine pericardium chordae measure 2 mm wide with 3 mm between the chordae. The sets of bovine pericardium chordae are produced in lengths varying from 20 to 35 mm. In 17 (73.9%) patients bovine pericardium chordae were implanted in the posterior cusp and in 6 (26.1%) in the anterior cusp. All the patients were evaluated in the postoperative period by echocardiography after a mean follow-up of six months. RESULTS: The echocardiography in the postoperative period demonstrated an absence of reflux in 11 (47.8%) patients, slight reflux in 8 (34.8%) and slight to moderate reflux in 3 (13.0%). The opening and mobility of the mitral valve was normal in the 22 surviving patients. CONCLUSION: The echocardiography demonstrated good functioning of the mitral valve apparatus in patients submitted to the implantation of standardized bovine pericardium chordae to substitute ruptured chordae tendineae or elongated chordae with a significant degree of thinning.

Traumatic tricuspid regurgitation is a fairly rare complication following blunt chest trauma but not as uncommon as it was believed to be before the advent of transthoracic echocardiography. We report a case of severe tricuspid regurgitation with ruptured chordae tendineae 10 years after blunt chest trauma that was successfully repaired with a simple method. The operative technique consisted of plication of the anteroposterior commissure to create a bicuspid valve, along with ring annuloplasty.

A case of severe tricuspid valve regurgitation caused by ruptured chordae tendineae secondary to blunt chest trauma from a motor vehicle accident is described. A transthoracic echocardiogram did not demonstrate these findings, which were clearly visualized on a transesophageal echocardiogram. We propose that patients with blunt chest trauma be considered for transesophageal echocardiography (unless surface images are of high quality) to evaluate not only the tricuspid valve apparatus but to examine other cardiac structures as early (ie, presymptomatic) treatment is preferable.

Background: Mitral valve repair is probably the procedure of choice for the surgical treatment of degenerative mitral insufficiency. Aim: To evaluate the late results of mitral valve repair in degenerative mitral insufficiency. Patients and method: The records of 88 patients who underwent mitral valve repair for degenerative mitral insufficiency from December 1991 through June 2002 were reviewed. Mean age was 59.9 years (range 22 to 82). At least moderate mitral insufficiency was present in every patient. Mean left atrial diameter was 55 mm and mean end diastolic and end systolic left ventricular diameters were 61 and 37 mm respectively. Results: The most common underlying lesion was ruptured chordae tendineae (66%) and posterior leaflet prolapse (68%). The surgical procedure most frecuently performed was quadrilateral resection of the posterior leaflet (68%). A Carpentier-Edwards ring was placed in 97% of patients. An associated procedure was performed in 34%. Operative mortality was 2.3%. A complete follow up was obtained in 93% of cases with a mean of 54±36 months. Overall survival rate was 98% at one year, 88% at 5 and 82% at 10 years. Free of cardiac death rates were 94% at 5 and 89% at 10 years. Only 2 patients were reoperated during follow up, resulting in a 98% reoperation free rate follow up. Functional class improved in all patients at the end of follow up. Late echocardiographic evaluation showed absent or minimal mitral regurgitation in 83% and mild mitral regurgitation in 17%. Conclusion: Good late results have been obtained with mitral valve repair, avoiding the inconveniencies of prosthetic replacement. Therefore, mitral valve repair should be the procedure of choice to treat degenerative mitral insufficiency (Rev Med Chile 2003; 131: 1355-64). (Key Words: Mitral valve insufficiency)

Tricuspid regurgitation (TR) due to chordal rupture is a rare condition in newborns. We present a newborn with critical TR. Cross-sectional echocardiography demonstrated a dense, mobile mass localized at the tricuspid valve and resembling an atrial thrombus or myxoma. At operation, ruptured chordae tendineae of the tricuspid valve were found, forming a tangled mass. Histopathologic examination revealed collagen degeneration and calcification in the ruptured chordae, producing the hyperechoic image. It should be emphasized that ruptured chordae of the tricuspid valve might mimic a tricuspid valve myxoma or a thrombus on cross-sectional echocardiography.

We report a case of systolic anterior motion of the mitral valve after mitral reconstruction without a semirigid mitral annular ring. A 56-year-old man with mitral regurgitation due to ruptured chordae tendineae underwent mitral valve reconstruction by replacement of chordae tendineae, leaflet excision, and suture annuloplasty without an annular ring. Postoperatively, left ventricular outflow tract obstruction developed and echocardiography revealed systolic anterior motion of the mitral valve. These findings disappeared after medication with a beta-blocking drug.

The accuracy of transesophageal echocardiography was compared with that of transthoracic echocardiography in the detection of ruptured chordae tendineae (flail mitral leaflet) in 27 patients with mitral valve prolapse (MVP) who underwent valve repair or replacement for mitral regurgitation. Confirmation of the presence of ruptured chordae resulting in a flail leaflet was available at surgery in all cases. The echocardiographic studies were read blindly by 2 independent observers with any differences resolved by a third. Mean (+/- standard deviation) age was 63 +/- 13 years. Men (n = 20) outnumbered women (n = 7) (p less than 0.02), and tended to be younger (p = 0.06). Flail leaflets were identified in 20 of 27 patients. In 1 patient, both leaflets were involved and in the remaining 19 patients posterior leaflets (15 patients) were more frequently affected than anterior leaflets (4 patients). Transesophageal echocardiography correctly identified all 20 patients with flail leaflets, but 1 false positive study occurred among the 7 patients without a flail leaflet. In contrast, transthoracic echocardiography identified only 12 of 20 patients with flail leaflets, with no false positive studies. Transesophageal echocardiography was more accurate, correctly classifying 26 of 27 (96%) cases versus 19 of 27 (70%) by the transthoracic approach (p less than 0.01). This study suggests a higher incidence of chordal rupture to the posterior leaflet in patients with MVP and demonstrates improved accuracy of transesophageal over transthoracic echocardiography in the detection of flail leaflets.

Acute mitral regurgitation due to ruptured chordae tendineae is a dramatic and life-threatening clinical situation. Rarely does this complication occur during pregnancy. We present a case of a 30-year-old woman in week 31 of her pregnancy who developed acute mitral regurgitation, secondary to bacterial endocarditis and ruptured chordae tendineae. This acute event resulted in preterm labor a few hours later. Delivery was uneventful and successful and was followed by open heart surgery 5 days later. A review of the literature on chordae tendineae rupture and resulting mitral regurgitation during pregnancy is presented.

Summary A new finding of fine systolic fluttering of the mitral leaflet is described in two patients with ruptured chordae tendineae and severe mitral regurgitation. The flutter is caused by the action of high-velocity blood flow upon the leaflet margin that has lost its support. The jet stream of blood evokes a high-frequency vibratory motion of the tensed leaflet as opposed to the previously described, lower frequency, less specific, diastolic flutter. This finding was not seen in the echocardiograms of 75 patients with other forms of mitral regurgitation. Systolic flutter appears to be specific for ruptured chordae tendineae.

To assess the reliability of M-mode echocardiographic patterns of mitral valve prolapse (MVP) (echo MVP) in detection of morphologic evidence of MVP (morphologic MVP), operatively excised mitral valves and corresponding M-mode echocardiograms from 65 patients with chronic, severe, isolated, pure mitral regurgitation (MR) were studied. Of the 65 patients, 45 (69%) had echo MVP (either holosystolic or mid-to-late systolic prolapse patterns on preoperative M-mode echograms) and 42 (93%) of them had morphologic MVP;of the 3 without morphologic MVP, 2 had ruptured chordae tendineae from infective endocarditis and 1 had papillary muscle dysfunction from atherosclerotic coronary heart disease. Of the 20 patients without echo MVP, 14 (70%) had no morphologic MVP (9 had papillary muscle dysfunction from coronary heart disease, 4 had infective endocarditis on previous normal valves and 1 had rheumatic heart disease). Of the 48 patients with morphologic MVP, 42 (88% ) had echo MVP and most had considerably dilated mitral anulae;the other 6 had ruptured chordae tendineae with less degrees of anular dilatation. Of the 17 patients without morphologic MVP, 3 had echo MVP (coronary artery disease in 1 and infective endocarditis on a previous normal valve in 2);of the 14 with neither echo nor morphologic MVP, 9 had papillary muscle dysfunction from coronary artery disease, 4 had infective endocarditis on previously normal valves and 1 had rheumatic heart disease. The patients with very dilated mitral anuli and leaflet areas generally had holosystolic (hammocking) patterns on echo;the patients with small anuli and leaflet areas usually had mid-to-late systolic (buckling) prolapse patterns.

A 47-year-old man experienced palpitations and shortness of breath following push-up exercises. Because of paroxysmal atrial fibrillation and fatigue, the patient underwent investigation. Echocardiography and cardiac catheterization indicated the diagnoses of mitral valve prolapse and rupture of the chordae tendineae. This report represents the first description of such a sequence of events.

The clinical, hemodynamic, and electrocardiographic findings in 11 patients with mitral regurgitation secondary to ruptured chordae tendineae are presented. Left atrial overloading, as manifested by a large terminal negative force in the P wave of lead V1, was present in 8 of the 11 patients. Six of the eight patients with this atrial abnormality had a normal size or minimally enlarged left atrium on chest x-ray films and angiography. Left ventricular hypertrohpy was present in 7 of the 11 patients and appeared to be related to the duration of cardiac symptoms. It is concluded that a large terminal negative force in the P wave in lead V1 is a useful clinical indicator of increased left atrial pressure in mitral regurgitation of recent onset. The electrocardiographic finding of left atrial overloading is to be expected in most cases of mitral regurgitation secondary to rupture of the chordae tendineae.

The variety of echographic features associated with the mitral valve prolapse syndrome (MVPS) is not yet completely understood. Therefore, ultrasound recordings were obtained in 33 patients in whom mitral prolapse had been documented by biplane left ventricular cineangiography. Echographic abnormailities of the mitral leaflets during systole were recorded in 26/27 MVPS patients and 6/6 with ruptured chordae tendineae. In MVPS, the midsystolic mitral buckling, emphasized in early echocardiographic studies, was observed in only 12 patients. In our study, the most common aberrancy was abnormal pansystolic mitral motion in 14 patients, which in 12 was similar to the pansystolic bowing observed in all six patients with torn chordae. An additional echographic abnormality in MVPS was localized mitral collapse throughout systole in 10/14 patients with pansystolic prolapse; this finding was the most striking defect noted in five, in two of whom it was the only disturbance. Phonocardiography in MVPS showed typical midsystolic click and/or late systolic murmur in only 15/26 patients of whom ten had midsystolic mitral buckling. A variety of systolic clicks and/or murmurs occurred in the 14 patients with generalized bowing and/or localized collapse throughout systole on echocardiography. Thus, the mitral echographic spectrum of MVPS is comprised of three different abnormal patterns of systolic prolapse: buckling in midsystole, pansystolic bowing, and pansystolic collapse. These echocardiographic disorders commonly occur in the absence of classical auscultatory findings in MVPS and the most frequent abnormality on ultrasound is pansystolic bowing of both mitral leaflets.

From 1958 through 1980, 131 patients had repair of ruptured chordae tendineae of the mitral valve; 62% were men. Ages ranged from 5 to 70 years (median 57). Chordae to the anterior mitral leaflet were ruptured in 44 patients (34%), to the posterior mitral leaflet in 85 (65%), and to both leaflets in two patients (1%). The mitral valve was repaired by leaflet plication without resection in 116 patients, plication after wedge resection of the unsupported leaflet in six, Ivalon sponge buttress of the posterior leaflet in three, resuspension of chordae in two, and annuloplasty alone in the remaining four. Mitral valve annuloplasty was performed in addition to leaflet repair in 115 patients (88%). Operative (

A flow probe for direct measurement of blood flow of the mitral valve was devised. It was useful for acute experiment, particularly concerning pathophysiology of the mitral valve function. Insertion of the probe into the left atrium and fixation to the left atrial wall and thus to the mitral orifice were readily and satisfactorily performed without disturbance of blood flow and valvular function. It must also be emphasized that support with cardiopulmonary bypass was not necessary at the time of insertion of the probe. Effectiveness of the procedure has been confirmed through simultaneous observation of echocardiogram and mitral blood flow of the dog's heart with ruptured chordae tendineae.

One hundred forty patients with clinical mitral insufficiency were studied with two dimensional echocardiography. Cardiac catheterization was performed in 51 patients; all had mitral insufficiency. Thirty-three patients were surgically treated. An etiologic diagnosis was made in 133 patients. Mitral valve prolapse (41 patients) was the most common cause of mitral insufficiency; the amount of valve insufficiency did not correlate with the leaflet involved or the severity of the prolapse. Patients with rheumatic disease either had combined mitral stenosis and insufficiency (27 patients) or pure mitral insufficiency (10 patients). Echocardiographic measurement of the mitral valve area separated patients with combined lesions from those with pure insufficiency. Fourteen patients had ruptured chordae tendineae; surgical findings were confirmatory in each patient who had valve replacement. Nineteen patients had left ventricular dysfunction; angiographie findings were confirmatory in each patient who underwent cardiac catheterization. Two dimensional echocardiographic findings reliably differentiated mitral insufficiency secondary to valve disease from that secondary to ventricular or papillary muscle dysfunction. Other causes of mitral insufficiency included mitral anular calcification (11 patients), idiopathic hypertrophic subaortic stenosis (5 patients), cleft anterior mitral leaflet (5 patients) and atrial myxoma (1 patient).

Left parasternal cardiograms were recorded at the fifth intercostal space in 30 patients with mitral regurgitation. Early systolic outward movements (E), late systolic outward movements (LOM), and the ratio of the LOM area to the total area occupied by the left parasternal cardiogram (LPC area) were examined. Thirteen patients had pure mitral regurgitation due to ruptured chordae tendineae (ten patients) or "floppy mitral valve" (three patients). In these patients LOM/E correlated significantly with the regurgitation volume determined by the difference between angiographic and Fick stroke volumes, ( r = 0.93, P < 0.01), and with the height of the "v" wave in the pulmonary artery wedge pressure tracings ( r = 0.79; P < 0.01). Simultaneous recordings of left parasternal movements and pulmonary wedge pressures in eight patients in this group showed a close relationship between LOM and "v" waves. Fourteen patients had rheumatic heart disease and mitral regurgitation associated with mitral stenosis of varying degrees of severity. In this group there was no significant correlation between LOM/E or LOM area/LPC area and the regurgitation volume or the height of the "v" wave. Of three patients who had congenital atrial septal defect in addition to mitral regurgitation, none had prominent LOM in the left parasternal cardiogram. This study suggests that if mitral stenosis and atrial septal defect can be excluded on clinical evidence, the left parasternal cardiogram may be used to obtain a noninvasive assessment of the severity of mitral regurgitation, particularly in patients with recent onset of the disease.

Summary A murmur of mitral regurgitation in patients with congestive heart failure after an acute myocardial infarction suggests a surgically correctable cause of the heart failure. Six patients who presented in this manner and who later underwent surgery have been evaluated by two-dimensional echocardiography (2DE). The underlying anatomical cause of the mitral regurgitation was correctly identified as papillary muscle rupture (2 cases), ruptured chordae tendineae (1 case) and papillary muscle fibrosis (3 cases). Two-dimensional echocardiography is useful in evaluating patients with congestive heart failure who develop a systolic murmur after acute infarction, as it can detect surgically correctable structural defects.

The aim of the present study is to perform a detailed analysis of the spot echoes which show chaotic motion of the left ventricular cavity of patients with ruptured chordae tendineae. The subjects were 12 patients with surgically documented ruptured chordae tendineae. They were carefully examined preoperatively by real-time two-dimensional echocardiography with a commercially available wide-angle phased array system (Toshiba SSH-11A).An abnormal moving spot echo was often seen instantaneously in the left ventricle. Its motion was chaotic, and it moved both longitudinally and laterally. Lateral movements were seen in 10 of the 12 subjects and were not found in any of 10 controls. The site of this echo in the left ventricle was identical with the site of the rupture of the mitral chordae confirmed during surgery. Therefore, it was concluded that the spot echo with chaotic motion represents a direct visualization of ruptured chordae.This chaotic motion is considered to be a useful clue in diagnosis. The lateral component (left to right) of the movement is especially important. However, one must carefully examine the left ventricular cavity with moving pictures over a period of many heart beats in order to detect these chaotic movements of spot echoes.

appearances ofthemitral valve after reconstructive surgery fornon-rheumatic mitral regurgitation havebeen studied. Twenty-two patients, divided into 3groups, were studied. Ingroup 1there were12patients with ruptured chordae tendineae and/or anterior mitral leaflet perforation, whounderwent chordal reattachment andplication ofleaflets orcommissures. After operation common abnormalities were slow(

To determine the causes of ruptured chordae tendineae and a suspected etiologic role for mitral valve prolapse (MVP), the mitral valve in 25 consecutive and surgically proved cases of chordal rupture were examined. The diagnosis of MVP was made on the basis of redundancy and marked hooding of the mitral leaflets and on histologic changes. MVP was the underlying morphologic abnormality in 23 patients, only 1 of whom had infective endocarditis that was responsible for the rupture. Thus MVP was the only underlying morphologic abnormality in 22 of 25 patients (88%). Another finding in this study was the demonstration of auscultatory and angiographic or echocardiographic evidence of MVP in 4 patients, aged 4 to 11 years (mean 7), before chordal rupture; no patient had had endocarditis. The morphologic and historical evidence would indicate that MVP is probably the most common cause of so-called spontaneous chordal rupture.

Real-time, phased-array, two-dimensional echocardiographic studies identified ruptured chordae tendineae in five patients: four patients had a flail mitral valve and one had flail mitral and tricuspid valves. The characteristic abnormality was a rapid systolic motion of the involved leaflet beyond the line of valve closure into the atrium. The maximal abnormal systolic motion was greatest at the tip of the leaflet with a loss of the normal coaptation point. By contrast, the two-dimensional echocardiographic feature of mitral valve prolapse is an abnormal systolic motion that is maximal in the body of the leaflet with intact leaflet coaptation. Thus, two-dimensional echocardiography can identify flail mitral and tricuspid valves and is useful in distinguishing ruptured chorade from valvular prolapse.