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Background and Objectives: The anatomical characteristics of patients with mitral valve prolapse (MVP) and mitral regurgitation (MR) have rarely been investigated demographically to determine the applicability of transcatheter intervention. Therefore, the study objective was to analyze potential candidates and their prognosis. Predictors determining the prognosis were also investigated. Methods: Patients diagnosed with MVP and MR severity of ≥2+ were screened from our echocardiography database from 2010 to 2012. All clinical and echocardiogram information was retrieved from electronic medical records. The endpoint was all-cause mortality analyzed by a proportional hazards model. Results: A total of 1268 patients (mean age 57.50 ± 14.88 years, 47.16% female) with MVP and MR severity of ≥ 2+ were included. Isolated P2 (n = 239, 18.85%) appeared as the most common site of leaflet prolapse. The incidence of MR jet solely from middle scallop (A2 and/or P2) was 31.07% (n = 394). If a nonsignificant jet from other locations was also accepted, the incidence of MR jet derived from mainly the middle scallop (A2 and/or P2) was 52.10% (n = 659). For MVP patients with MR R + 3, the conservative therapy group had higher mortality than the early surgery group (31.45% vs. 5.25%, P < 0.001) after 4.5 ± 1.0 years of follow-up, multiple analysis showed that surgical treatment (hazard ratio [HR]: 0.202, P < 0.001), systolic pulmonary artery pressure of o60 mmHg (HR: 6.816, P < 0.001), age of ≥ 60 years (HR: 3.838, P < 0.001), and pericardial effusion (HR: 1.915, P = 0.003) were independent predictors of all-cause mortality. Conclusions: In patients with MVP, one-fifth leaflet prolapse located solely in P2 and one-half of MR jet derived from the middle scallop were anatomically eligible for transcatheter chordal repair and edge-to-edge repair therapy, respectively. Initial conservative therapy, pericardial effusion, pulmonary hypertension, and advanced age were independent predictors of a higher mortality rate in MVP patients with MR severity of ≥ 3+.

LifeTec Group has developed a Cardiac Biosimulator where a dead porcine heart is used to mimic a beating heart in a simulated environment. This is useful for assessment of medical devices or as a training platform for medical professionals. The research presented aims at extending this simulator by designing feedback controllers for the time-averaged relevant pressures and flow, which reduces the startup time and potentially increases stability of the simulator. To achieve this, both the continuous and time-averaged models of the simulator are presented together with their state-space representations. The proposed controller consists of three independent PI controllers, which are presented along with simulation and measurement results and show promising system performance. Lastly, the controller implementation was tested on the Biosimulator with a pathological heart (Mitral prolapse), which showed no significant decrease in performance compared to the physiological heart.

The association between the mitral valve prolapse and the sudden Cardiac Death remains controversial, the high prevalence of this valvulopathy contrasting with the low incidence of sudden death in this population. We report the case of a 54-year-old woman admitted for a sudden cardiac death, revealing a bi-prolapse with low-grade leakage, leading to the implantation of a subcutaneous automatic defibrillator. Combined echocardiography and cardiac MRI can identify the mitral annular disjunction, the rolling motion of the posterior face of the mitral annulus towards the myocardium, and the myocardial fibrosis of the inferolateral wall induced by streching forces of the sub valvular apparatus, that may lead to ventricular arrhythmias. More than the conventional clinical parameters (young woman, ventricular premature beats with a right bundle branch block morphology, mitral bi-prolapse), mitral annular disjunction and myocardial fibrosis are to be considered as powerful markers of the rhythmic risk of mitral prolapse and must be systematically sought and integrated into the prognostic evaluation of these patients. In the absence of randomised trials, therapeutic management is difficult especially in primary prevention, and needs Heart Team advice.

To obtain 3D CT measurements of mitral annulus throughout cardiac cycle using prototype mitral modeling software, assess interobserver agreement, and compare among patients with mitral prolapse (MP) and control group.Pre-procedural imaging is critical for planning of transcatheter mitral valve (MV) replacement. However, there is limited data regarding reliable CT-based measurements to accurately characterize the dynamic geometry of the mitral annulus in patients with MV disease.Patients with MP and control subjects without any MV disease who underwent ECG-gated cardiac CT were retrospectively identified. Multiphasic CT data was loaded into a prototype mitral modeling software. Multiple anatomical parameters in 3D space were recorded throughout the cardiac cycle (0-95%): annular circumference, planar-surface-area (PSA), anterior-posterior (A-P) distance, and anterolateral-posteromedial (AL-PM) distance. Comparisons were made among the two groups, with p 0.05 considered statistically significant. Interobserver agreement was assessed on ten patients using intraclass correlation coefficient (ICC) among 4 experienced readers.A total of 100 subjects were included: 50 with MP and 50 control. Annular dimensions were significantly higher in the MP group than control group, with circumference (144 ± 11 vs. 117±8 mm), PSA (1533 ± 247 vs. 1005 ± 142 mmA significant variation in the mitral annular measures between different cardiac phases and two groups was observed with excellent interobserver agreement.

most frequent valvular heart diseases. The most common etiology of primary MR is the myxomatous degeneration of the mitral valve, encompassing fibroelastic deficiency and Barlow's disease. In severe chronic primary MR, the presence of symptoms, reduced left ventricular ejection fraction (LVEF) #60%, and increased left ventricular (LV) end-systolic diameter are indications for mitral valve repair (1,2). In asymptomatic patients, surgery should be considered if there is a high likelihood of durable mitral valve repair; low operative risk; and atrial fibrillation, pulmonary hypertension, flail leaflet, or dilated left atrium at sinus rhythm (1,2). The evidence showing the benefits of early surgery is accumulating. Data from a large cohort of 1,512 patients undergoing mitral valve surgery for isolated primary MR revealed that patients who were operated based only on high likelihood of successful mitral valve repair had the best outcome (3). The rationale for an early intervention is that the longstanding volume overload caused by severe MR may lead to irreversible LV dysfunction. LVEF is considered the parameter of reference to define LV function and to

Mitral valve prolapse (MVP) is the most common valvular heart disease, affecting 2–3% of the general population. Barlow’s disease is a clinical syndrome characterised by MVP. Initially thought a benign condition, MVP is now recognised as a cause of sudden cardiac death and ventricular arrhythmias. The development of new imaging techniques has contributed recently to the identification of novel risk factors. Catheter ablation of ventricular arrhythmias in patients affected by MVP is traditionally considered challenging. In this review, the authors summarise the evidence on arrhythmogenesis in the context of MVP, along with risk stratification of sudden cardiac death and the available treatment options, including new catheter ablation techniques.

Introduction: Asymptomatic patients on active surveillance for degenerative mitral regurgitation are at risk of ventricular arrhythmia and sudden death. Hypothesis: Abnormal myocardial mechanics may precede ventricular remodeling and may help identify at-risk patients. Methods: Multi-directional myocardial mechanics and LV dyssynchrony were assessed in 204 consecutive patients awaiting surgical mitral repair for severe degenerative MR in a quaternary mitral reference center. Results: The mean age was 58 ±12.5 years and 40% were females. The mean EF was 63% ± 6% and 92% had compensated LV function (EF>60% and LVESD2 ). The median LV mechanical dispersion was 40msec (IQR 30.7-56.5) but increased significantly with ventricular ectopy (65msec, P Conclusions: Left ventricular dyssynchrony manifested by increased mechanical dispersion and imbalanced interpapillary mechanics are observed prior to overt chamber remodeling in significant degenerative MR and is associated with ventricular ectopy. Further studies are needed to assess the related clinical implications and potential impact on risk stratification in this patient group.

Objectives The aim of this study was to quantitate patient-specific mitral valve (MV) strain in normal valves and in patients with mitral valve prolapse with and without significant mitral regurgitation (MR) and assess the determinants of MV strain. Background Few data exist on MV deformation during systole in humans. Three-dimensional echocardiography allows for dynamic MV imaging, enabling digital modeling of MV function in health and disease. Methods Three-dimensional transesophageal echocardiography was performed in 82 patients, 32 with normal MV and 50 with mitral valve prolapse (MVP): 12 with mild mitral regurgitation or less (MVP − MR) and 38 with moderate MR or greater (MVP + MR). Three-dimensional MV models were generated, and the peak systolic strain of MV leaflets was computed on proprietary software. Results Left ventricular ejection fraction was normal in all groups. MV annular dimensions were largest in MVP + MR (annular area: 13.8 ± 0.7 cm2) and comparable in MVP − MR (10.6 ± 1 cm2) and normal valves (10.5 ± 0.3 cm2; analysis of variance: p Conclusions MVs that exhibit prolapse have higher strain compared to normal valves, particularly in the posterior leaflet. Although higher strain is observed with worsening MR and larger valves and annuli, mitral valve leaflet thickness—and, thus, underlying MV pathology—is the most significant independent determinant of valve deformation. Future studies are needed to assess the impact of MV strain determination on clinical outcome.

Objective: Surgical repair remains the standard treatment for severe mitral regurgitation (MR) due to mitral prolapse. Minimally-invasive mitral valve surgery (MIMVS) has been increasingly performe...

Degenerative mitral valve (MV) disease involving mitral prolapse is one of the most prevalent MV pathologies. Quadrangular leaflet resection and neochordoplasty demonstrate excellent clinical outcomes for the treatment of posterior leaflet prolapse. We evaluated the functional and biomechanical characteristics of a virtual pathologic MV model suffering from chordal rupture, performed virtual neochordoplasty and quadrangular leaflet resection, and compared the two post-repair MV functions. The pre-repair MV demonstrated severe posterior leaflet prolapse due to the ruptured P2 chordae and excessive stress concentration. Both repair techniques revealed reduced leaflet prolapse, decreased stress concentration, and restored leaflet coaptation. While neochordoplasty demonstrated further improved leaflet coaptation and superior posterior leaflet mobility, leaflet resection showed more uniform leaflet stress distributions. Virtual MV repair simulation has the ability to predict and quantitate biomechanical and functional improvement following MV repair. This strategy has the potential to help determine the most effective repair technique to restore MV function.

Objective: The Mitral Butterfly is a novel transcatheter mitral stent device. A polymer matrix spreads from nitinol wings along the annulus of the mitral valve towards a swing arm covering a prolap...

Objectives To identify the risk factors causing misdiagnosis by echocardiography and missed diagnosis of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Materials and methods Echocardiographic results of 16 patients with ALCAPA confirmed by surgery in Union Hospital, Wuhan, were analyzed retrospectively. The influencing factors leading to echocardiographic misdiagnosis were analyzed from the aspects of confusing image characteristics, special pathological anatomy of the left coronary artery (LCA), and operators' working years. Results Echocardiography diagnosed 11 cases with an accuracy rate of 68.8%. Five cases were misdiagnosed, three cases as endocardial fibroelastosis, one case as mitral prolapse with severe insufficiency, and one case as coronary-pulmonary artery fistula. Display rate of the specific echocardiographic features for confirmed group and misdiagnosed group was statistically significantly different（P = .014）. But the working years of the operator for confirmed group and misdiagnosed group were not statistically significantly different（P = .267）. Some special pathological anatomy and pathophysiological features could be also the cause of misdiagnosis. Conclusions Echocardiography is the first diagnostic choice of the ALCAPA in China. It is essential for the operator to have the knowledge, diagnostic awareness, and proficiency in manipulation in the accurate interpretation of echocardiography results.

Hypertrophic cardiomyopathy is the most common genetic heart disease. Once considered relentless, untreatable, and deadly, it has become a highly treatable disease with contemporary management. Hypertrophic cardiomyopathy is one of cardiology's "great masqueraders." Mistakes and delays in diagnosis abound. Hypertrophic cardiomyopathy commonly "masquerades" as asthma, anxiety, mitral prolapse, and coronary artery disease. However, once properly diagnosed, patients with hypertrophic cardiomyopathy can be effectively managed to improve both symptoms and survival. This review highlights some of the misconceptions about hypertrophic cardiomyopathy. Providers at all levels should have awareness of hypertrophic cardiomyopathy to promptly diagnose and properly manage these individuals.

Bioprosthetic valve obstruction is a feared complication associated with considerable morbidity and mortality. High clinical suspicion is needed for prompt recognition and treatment. A 70-year-old female with a bioprosthetic valve for mitral prolapse placed nine years prior presented in atrial

Papillary fibroelastoma (PFE) is a benign cardiac tumor usually unique and involving left valves. Multiple tumors including the tricuspid valve are very rare. Thrombosis of mechanical prosthetic valve is a high mortality complication that requires rapid assessment and treatment. A 42 years old

Objective We sought to develop an instrument that would enable the delivery of artificial chordae tendineae (ACT) using optical visualization of the leaflet inside the beating heart. Methods A delivery instrument was developed together with an ACT anchor system. The instrument incorporates an optically clear silicone grasping surface in which are embedded a camera and LED for direct leaflet visualization during localization, grasping, and chordal delivery. ACTs, comprised of T-shaped anchors and an expanded polytetrafluoroethylene chordae, were fabricated to enable testing in a porcine model. Ex vivo experiments were used to measure the anchor tear-out force from the mitral leaflets. In vivo experiments were performed in which the mitral leaflets were accessed transapically using only optical guidance and ACTs were deployed in the posterior and anterior leaflets (P2 and A2 segments). Results In 5 porcine ex vivo experiments, the mean force required to tear the anchors from the leaflets was 3.8 ± 1.2 N. In 5 porcine in vivo nonsurvival procedures, 14 ACTs were successfully placed in the leaflets (9 in P2 and 5 in A2). ACT implantation took an average of 3.22 ± 0.83 minutes from entry to exit through the apex. Conclusions Optical visualization of the mitral leaflet during chordal placement is feasible and provides direct feedback to the operator throughout the deployment sequence. This enables visual confirmation of the targeted leaflet location, distance from the free edge, and successful deployment of the chordal anchor. Further studies are needed to refine and assess the device for clinical use.

Introducción. La insuficiencia mitral es la valvulopatía más prevalente en la población occidental, siendo una de sus principales causas el prolapso valvular. Actualmente, la técnica más utilizada para determinar su severidad es la ecocadiografía Doppler, mediante la cuantificación del EROA y volumen regurgitante mediante el método PISA. Sin embargo, este método considera un único punto de la sístole, y, por otra parte, faltan datos cuantitativos sobre el comportamiento dinámico de la IM por prolapso en la práctica clínica diaria. Objetivos. El objetivo de este trabajo es evaluar y cuantificar el comportamiento dinámico de la IM orgánica por prolapso. Métodos. Se analizó, mediante ecocardiografía tridimensional transesofágica, el comportamiento dinámico del PISA a lo largo de la sístole en 30 pacientes consecutivos con IM primaria por prolapso.Resultados. Únicamente el 23% de los pacientes presentó un comportamiento estable, mientras que un 77% mostró una variación dinámica significativa de su IM. Con respecto al comportamiento dinámico, éste era creciente en un 43%, decreciente en un 35% y bifásico en un 22%. Conclusiones. La mayoría de las IM primarias por prolapso presentan un marcado carácter dinámico, con diversos patrones de comportamiento. Esto implica que el método PISA, tal como se aplica en la actualidad -en un punto único de la sístole- puede resultar en una cuantificación errónea en la mayor parte de los casos (77%) Introduction. Mitral regurgitation is the most prevalent valvulopathy in the western population and one of its main causes is valvular prolapse. Currently, the most used technique to determine its severity is Doppler echocardiography quantitating the EROA and the regurgitant volume by the PISA method. However, this method only considers a single point of systole and quantitative data about the dynamic behavior in mitral regurgitation are lacking in daily clinical practice. Objectives. The objective of this work is to evaluate and quantify the dynamic behavior of organic mitral regurgitation due to prolapse. Methods. In 30 consecutive patients with primary mitral regurgitation due to prolapse, we analyzed the dynamic behavior of the PISA throughout systole by three-dimensional transesophageal echocardiography.Results. Only 23% of the patients presented a stable regurgitation pattern, while 77% showed a significant variation of their regurgitation. With regard to the dynamic regurgitation pattern, the behavior was increasing in 43% cases, decreasing 35% and biphasic in 22%. Conclusions. Most primary mitral regurgitations due to prolapse presented a dynamic variation with diverse behavior patterns. This implies that the PISA method, as currently applied -in a single systolic point- may result in an inaccurate quantitation in most cases (77%). Grado en Medicina

OBJECTIVES Echocardiography is used routinely to assess mitral regurgitation severity, but echocardiographic measures of mitral regurgitation in dogs have not been compared with other quantitative methods. The study aim was to compare echocardiographic measures of mitral regurgitation with cardiac magnetic resonance imaging-derived mitral regurgitant fraction in small-breed dogs. METHODS Dogs with myxomatous mitral valve disease scheduled for magnetic resonance imaging assessment of neurological disease were recruited. Correlations were tested between cardiac magnetic resonance imaging-derived mitral regurgitant fraction and the following echocardiographic measures: vena contracta/aortic diameter, transmitral E-wave velocity, amplitude of mitral prolapse/aortic diameter, diastolic left ventricular diameter:aortic diameter, left atrium:aortic diameter, mitral regurgitation jet area ratio and regurgitant fraction calculated using the proximal isovelocity surface area method. RESULTS Measurement of cardiac magnetic resonance imaging-derived mitral regurgitant fraction was attempted in 21 dogs. Twelve consecutive, complete studies were obtained and 10 dogs were included in the final analysis: vena contracta/aortic diameter (r = 0 · 89, p = 0 · 001) and E-wave velocity (r = 0 · 86, p = 0 · 001) had the strongest correlations with cardiac magnetic resonance imaging-derived mitral regurgitant fraction. E velocity had superior repeatability and could be measured in all dogs. The presence of multiple jets precluded vena contracta/aortic diameter measurement in one dog. CLINICAL SIGNIFICANCE Measurement of cardiac magnetic resonance imaging-derived mitral regurgitant fraction is feasible but technically demanding. The echocardiographic measures that correlated most closely with cardiac magnetic resonance imaging-derived mitral regurgitant fraction were vena contracta/aortic diameter and E-wave velocity.

To investigate the feasibility and diagnostic value of a preoperative transthoracic echocardiography-guided three-dimensional printed model (TTE-guided 3DPM) for the assessment of structural heart disease (SHD).Fourty-four patients underwent cardiac surgery at Tianjin Chest Hospital. The patients were preoperatively assessed using TTE-guided 3DPM, which was compared to conventional three-dimensional transthoracic echocardiography (3DTTE) along with direct intraoperative findings, which were considered the "gold standard." Twelve patients had SHD, including four with mitral prolapse, two with partial endocardial cushion defects, two with secondary atrial septal defects, two with rheumatic mitral stenosis, one with tetralogy of Fallot, and one with a ventricular septal defect (VSD). Thirty-two patients who did not have SHDs were designated as the negative control group.The sensitivity and specificity of the TTE-guided 3DPM were greater than or equal to those of the 3DTTE. The P-value of the McNemar test of 3DTTE was.05, which indicates that the difference was not statistically significant (Kappa = 0.745, P .001). The P-value of the McNemar test of TTE-guided 3DPM was.05, which indicates that the difference was not statistically significant (Kappa = 0.955, P .001). A comparison of 3DTTE and TTE-guided 3DPM resulted in a P-value.05, which indicates that the difference was not statistically significant (Kappa = 0.879, P .001). TTE-guided 3DPM displayed the 3D structure of SHDs and cardiac lesions clearly and was consistent with the intra-operative findings.Transthoracic echocardiography-guided three-dimensional printed model (TTE-guided 3DPM) provides essential information for preoperative evaluation and decision making for patients with SHDs.

Background Leaflet resection represents the reference standard for surgical treatment of mitral valve (MV) regurgitation. New approaches recently proposed place emphasis on respecting, rather than resecting, the leaflet tissue to avoid the drawbacks of the 'resection' approach. Objectives The lateral dislocation of mid portion of mitral posterior leaflet (P2) technique for MV repair is a nonresectional technique in which the prolapsed P2 segment is sutured to normal P1 segment. Our study evaluates the effectiveness of this technique. Patients and methods We performed the procedure on seven patients. Once ring annular sutures were placed, the prolapsed P2 segment was dislocated toward the normal P1 segment with a rotation of 90° and without any resection. If present, residual clefts between P2 and P3 segments were closed. Once the absence of residual mitral regurgitation is confirmed by saline pressure test, ring annuloplasty was completed. The valve was evaluated using transesophageal echocardiography in the operating room and by transthoracic echocardiography before discharge. Results At the last follow-up visit, transthoracic echocardiography revealed no mitral regurgitation and normal TRANSVALVULAR gradients. Conclusion The lateral dislocation of P2 is an easily fine-tuned technique for isolated P2 prolapse, with the advantage of short aortic cross-clamp and cardiopulmonary bypass times. We think it might be very favorable in older and frail patients. Long-term follow-up is necessary to assess the durability of this technique.

I surveyed our echocardiographic database of the years between 1998 and 2012 for congenital abnormalities of the mitral valve in patients over 14 years. A total of 249 patients with mitral valve abnormalities were identified. Abnormalities included clefts in the mitral valve in 58 patients, double orifice of the mitral valve in 19, mitral stenosis with two papillary muscles in 72, and mitral stenosis with one papillary muscle in 51 patients. Supravalvar rings were found in 35 patients with a single papillary muscle, and mitral stenoses with two papillary muscles were found in 22 patients. Mitral prolapse occurred in 44 patients and mitral valvar straddle in five patients. The patients were evaluated by all modalities of ultrasound available over the course of time. Although some lesions were isolated, there were many lesions in which more than one mitral deformity presented in the same patient. The patients are presented showing anatomical correlation with autopsy specimens, some of which came from the patients in this series, and others matched to show correlative anatomy. These lesions remain rare as a group and continue to have high morbidity and mortality.

Ischemic mitral prolapse (IMP) is a pathologic entity encountered in about one-third among the patients undergoing surgery for ischemic mitral regurgitation (IMR). IMP is generally the result of a papillary muscle injury consequent to myocardial, but the recent literature is progressively unveiling a more complex pathogenesis. The mechanisms underlying its development regards the impairment of one or more components of the mitral apparatus, which comprises the annulus, the chordae tendineae, the papillary muscle and the left ventricular wall. IMP is not only a disorder of valvular function, but also entails coexistent aspects of a geometric disturbance of the mitral valve configuration and of the left ventricular function and dimension and a correct understanding of all these aspects is crucial to guide and tailor the correct therapeutic strategy to be adopted. Localization of prolapse, anatomic features of the prolapsed leaflets and the subvalvular apparatus should be carefully evaluated as also constituting the major determinants defining patient's outcomes. This review will summarize our current understanding of the pathophysiology and clinical evidence on IMP with a particular focus on the surgical treatment.

Background— Longitudinal studies of mitral valve prolapse (MVP) progression among unselected individuals in the community, including those with nondiagnostic MVP morphologies (NDMs), are lacking. Methods and Results— We measured longitudinal changes in annular diameter, leaflet displacement, thickness, anterior/posterior leaflet projections onto the annulus, coaptation height, and mitral regurgitation jet height in 261 Framingham Offspring participants at examination 5 who had available follow-up imaging 3 to 16 years later. Study participants included MVP (n=63); NDMs, minimal systolic displacement (n=50) and the abnormal anterior coaptation phenotype (n=10, with coaptation height >40% of the annulus similar to posterior MVP); plus 138 healthy referents without MVP or NDMs. At follow-up, individuals with MVP (52% women, 57±11 years) had greater increases of leaflet displacement, thickness, and jet height than referents (all P P Conclusions— NDM may evolve into MVP, highlighting the clinical significance of mild MVP expression. MVP progresses to significant mitral regurgitation over a period of 3 to 16 years in one-fourth of individuals in the community. Changes in mitral leaflet morphology are associated with both NDM and MVP progression.

The current surgical technique of using an artificial chord (composed of expanded polytetrafluoroethylene [ePTFE] sutures) to repair mitral prolapse is technically difficult to perform. Slippery knot tying and the difficulty of changing the chordae length after the hydrostatic test are frustrating problems. The loop technique solves the problem of slippery knot tying but not the problem of changing the chordae length. Our "loop with anchor" technique consists of the following elements: construction of an anchor at the papillary muscle; determining the loop length; tying the loop to the anchor; suturing the loop to the mitral valve; the hydrostatic test; and re-suturing or changing the loop, if needed. Adjustments can be made for the entire procedure or for a portion of the procedure.

SummaryCongenital malformations of the mitral valve may be encountered in isolation or in association with other congenital heart defects. Each level of the mitral valve complex may be affected, according to the embryological development, explaining the fact that these lesions are sometimes associated with each other. As a perfect preoperative assessment is of importance, good knowledge of both normal and abnormal anatomy is required in order to guide the surgeon accurately. This review presents the different embryological, anatomical and echocardiographic aspects of the congenital mitral anomalies.

Artificial chordal replacement (ACR) has emerged as a superior method of mitral valve repair with excellent early and late efficacy. It is also ideal to combine with robotic techniques for correction of mitral prolapse, and this article presents a current method of robotic Gore-Tex ACR. Patients with isolated posterior leaflet prolapse are approached with the fourth-generation DaVinci robotic system and endoaortic balloon occlusion. A pledgetted anchor stitch is placed in a papillary muscle, and a 2-o Gore-Tex suture is passed through the anchor pledget. After full annuloplasty ring placement, the Gore-Tex suture is woven into the prolapsing segment and positioned temporarily with robotic forceps. Chordal length is then “adjusted” by lengthening or shortening the temporary knot over 1-cm increments as the valve is tested by injection of cold saline into the ventricle. After achieving good leaflet position and valve competence, the chord is tied permanently. The “adjustable” ACR procedure preserves leaflet surface area and produces a competent valve in the majority of patients. Postoperative transesophageal echo shows a large surface area of coaptation. Patient recovery is facilitated by the minimally invasive approach, while long-term stability of similar open ACR techniques have been excellent with a 2% to 3% failure rate over 10 years of follow-up. Robotic Gore-Tex ACR without leaflet resection is a reproducible procedure that simplifies mitral repair for prolapse. The outcomes observed in early robotic applications have been excellent. It is suggested that most patients with simple prolapse might validly be approached in this manner.

BACKGROUND Segmental analysis in mitral prolapse is important to decide the chances of valvular repair. Multiplane transesophageal echocardiography (TEE) is the only echocardiographic tool validated for this aim hitherto. The aim of the study was to assess if segmental analysis can be performed with transthoracic real-time 3-dimensional (3D) echocardiography as accurately as with TEE, hence representing a valid alternative to TEE. METHODS Forty-one consecutive patients diagnosed with mitral prolapse underwent TEE and a complete 3D echocardiography study, including parasternal and apical real-time; apical full-volume; and 3D color full-volume. Investigators performing TEE were blinded to the 3D results. RESULTS Three-dimensional echocardiogram was feasible in 40 to 41 patients (97.7%). Ages ranged from 15 to 92 years, and all possible anatomical patterns of prolapse were represented. Thirty-seven patients (90.2%) had mitral regurgitation of any degree. The level of agreement was k = 0.93 (P < or = .0001), sensitivity of 96.7%, specificity of 96.7%, likelihood ratio for a positive result of 29.0%, and likelihood ratio for a negative result of 0.03%. Four false positives were found, corresponding to scallops A2 (1), A3 (2), and P3 (1). Four false negatives were found, corresponding to scallops A1 (2) and P1 (2). Sensitivity and specificity in the scallop P2 were 100%. CONCLUSION Segmental analysis in mitral prolapse can be performed with transthoracic real-time 3D echocardiography as accurately as with TEE. False negatives tend to appear around the anterolateral commissure, whereas false positives tend to appear around the posteromedial commissure. Highest accuracy was reached in central scallops.