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Duvall LR, Korol Y, Wigand KE, Mace JE, Pagel PS, Boettcher BT. Mitral Regurgitation During Chronic Type A Aortic Dissection Repair: The Usual Suspects or Something Entirely Unsuspected? J Cardiothorac Vasc Anesth 2024; 38:849-851. [PMID: 38148267 DOI: 10.1053/j.jvca.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Lydia R Duvall
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI
| | - Yekaterina Korol
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI
| | - Kelsey E Wigand
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI
| | - James E Mace
- Division of Cardiothoracic Surgery, the Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesiology service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Brent T Boettcher
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI.
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2
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Bornaun H, Katipoğlu Ç, Dedeoğlu S. Revealing Mitral Valve Cleft Using Real-Time 3-Dimensional Echocardiography in Children with Mitral Regurgitation. Pediatr Cardiol 2024; 45:660-665. [PMID: 37020140 DOI: 10.1007/s00246-023-03155-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/27/2023] [Indexed: 04/07/2023]
Abstract
Mitral valve cleft (MVC) is the most common cause of congenital mitral regurgitation (MR). MVC may be located on the anterior or posterior leaflets. We evaluated children with moderate-to-severe MR using 3D transthoracic echocardiography (3DTTE) to diagnose MVC and determine the location, shape and size of MVC. Twenty-one patients under 18 years of age with moderate-to-severe MR without symptoms who were suspected of having MVC were included in the study. The patients' history and clinical data were obtained from the medical records. 2D and 3D imaging were performed with a high-quality machine (EPIQ CVx). A vena contracta (VC) of colour Doppler regurgitated jet 3-7 and ≥ 7 mm defined moderate-to-severe regurgitation. An isolated anterior leaflet cleft (ALC) was detected in four patients, an isolated posterior leaflet cleft (PLC) in 12 patients, and both an ALC and PLC in five patients. VC was larger in patients with ALCs than PLCs (8.85 mm vs. 6.64 mm). Global LV longitudinal strain was better in the ALC group than in the PLC and both-posterior-and anterior MVC groups (- 24.7, - 24.3, and - 24%, respectively). Global circumferential strain was better in the ALC group (- 28.9%) and reduced in the bi-leaflet MVC group (- 28.6%). 3DTTE for visualisation of the MV can be successfully implemented in children and should be proposed during follow-up. AMVC and bi-leaflet MVC results in severe regurgitation and bi-leaflet MVC may be the reason for systolic dysfunction determined before clinically proven symptoms in the future.
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Affiliation(s)
- Helen Bornaun
- Department of Pediatric Cardiology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey.
| | - Çağlanur Katipoğlu
- Department of Pediatric Cardiology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Savas Dedeoğlu
- Department of Pediatrics, Uskudar University Medical Faculty, Istanbul, Turkey
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3
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Gupta S, Karamlou T, Salim Hammoud M, Ghobrial J, Aziz P, Najm HK. Concomitant Mitral Valve Re-Repair for Mixed Congenital and Degenerative Mitral Disease, Tricuspid Repair, and Cox-Maze Procedure in a College Athlete. World J Pediatr Congenit Heart Surg 2023; 14:77-80. [PMID: 35770311 DOI: 10.1177/21501351221102891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A significant proportion of patients undergoing repair of congenital mitral valve disease will require a subsequent reoperation. During somatic growth, mitral valve repair is preferable to replacement as it allows for annular growth, preservation of ventricular function, and avoidance of lifelong anticoagulation. Techniques to facilitate successful re-repairs for congenital and non-rheumatic mixed degenerative mitral valve disease are not well-described in the literature. Description of the encountered pathology and surgical maneuvers utilized in this case provides real-world tools to help surgeons deal with limited orifice availability, fibrosis, and multilevel lesions. We describe a mitral valve re-repair in a young athlete for a rare cleft posterior mitral leaflet, with a simultaneous tricuspid valve repair and Cox-Maze procedure. We focus on technical pearls that address specific anatomic challenges within our surgical approach.
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Affiliation(s)
- Sohini Gupta
- 2546Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tara Karamlou
- Department of Pediatric and Congenital Heart Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Miza Salim Hammoud
- Department of Pediatric and Congenital Heart Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joanna Ghobrial
- Department of Pediatric Cardiology, 2569Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Peter Aziz
- Department of Pediatric Cardiology, 2569Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Hani K Najm
- Department of Pediatric and Congenital Heart Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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4
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Ishikawa N, Watanabe G, Miyata K, Shigematsu S, Horikawa T, Seguchi R, Kiuchi R, Tomita S, Ohtsuka T. Robotic mitral valve plasty for isolated clefts of mitral valve leaflets. Asian J Endosc Surg 2022; 15:809-811. [PMID: 35488502 DOI: 10.1111/ases.13070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 11/26/2022]
Abstract
A 21-year-old female patient referred to our institute had been suffering from severe mitral valve regurgitation due to a rare anomaly: a typical cleft at the posterior mitral leaflet and the other partial one at the anterior leaflet. We successfully fixed the mitral valve using the robot-assisted totally endoscopic technique which could perform suture closure of both leaflets and annuloplasty. This communication is the first report of the robotic and totally endoscopic procedure which could treat this rare mitral anomaly.
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Affiliation(s)
- Norihiko Ishikawa
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Japan
| | - Go Watanabe
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Japan
| | - Kazuto Miyata
- Department of Anesthesia, NewHeart Watanabe Institute, Japan
| | | | - Takafumi Horikawa
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Japan
| | - Ryuta Seguchi
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Japan
| | - Ryuta Kiuchi
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Japan
| | - Shigeyuki Tomita
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Japan
| | - Toshiya Ohtsuka
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Japan
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5
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Rizk J, Abdel-Hay MA. Cleft posterior mitral valve leaflet: The added value of 3-dimensional echocardiography. Echocardiography 2022; 39:404-406. [PMID: 35014733 DOI: 10.1111/echo.15273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/13/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022] Open
Abstract
A 65-year-old female patient diagnosed with degenerative aortic valve disease and severe regurgitation on transthoracic echocardiography (TTE) also had severe mitral regurgitation (MR), but the exact mechanism of MR could not be determined. Transesophageal echocardiography (TEE) showed limited leaflet coaptation and a severe central MR jet. Further three-dimensional (3D) imaging revealed an indentation in the middle of P2 scallop almost reaching the annulus. This was consistent with the diagnosis of cleft posterior mitral valve leaflet. Unlike cleft anterior leaflet which can be clear on TTE short-axis images, cleft posterior leaflet may only be visible using 3D TEE. The identification of cleft posterior leaflet is essential in guiding surgical valve repair.
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Affiliation(s)
- Judy Rizk
- Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Honda T, Tsunoda R, Ito T, Ikemoto T, Yoshimura H. Isolated posterior mitral valve leaflet cleft with mitral regurgitation. J Echocardiogr 2021; 20:245-246. [PMID: 34120325 DOI: 10.1007/s12574-021-00534-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/17/2021] [Accepted: 06/07/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Tsuyoshi Honda
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine minami, Higashi-ku, Kumamoto, 862-8520, Japan.
| | - Ryusuke Tsunoda
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine minami, Higashi-ku, Kumamoto, 862-8520, Japan
| | - Teruhiko Ito
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine minami, Higashi-ku, Kumamoto, 862-8520, Japan
| | - Tomokazu Ikemoto
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine minami, Higashi-ku, Kumamoto, 862-8520, Japan
| | - Hiromi Yoshimura
- Department of Cardiovascular Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine minami, Higashi-ku, Kumamoto, 862-8520, Japan
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Bahrami MH, Ansari HZ, Guglin M, Ephrem G, Revtyak GE. Isolated congenital cleft mitral valve leaflet: a rare cause of refractory cardiogenic shock complicating acute myocardial infarction. JOURNAL OF CONGENITAL CARDIOLOGY 2021. [DOI: 10.1186/s40949-021-00062-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractWe report a unique presentation of isolated congenital cleft mitral valve complicating cardiogenic shock from acute myocardial infarction. Isolated cleft mitral valve is an uncommon diagnosis that can have significant clinical implications, especially if not recognized in patients presenting to the catheterization lab with acute myocardial infarction and cardiogenic shock. A review of this rare diagnosis including the options and timing of therapeutic interventions, which can include MitraClip, is important for publication.The case is of a patient who presented with an anterior acute ST elevation myocardial infarction. Despite early coronary revascularization and conventional support, refractory cardiogenic shock ensued requiring mechanical circulatory support escalation to Veno-arterial extracorporeal membrane oxygenation. Subsequently, left ventriculography revealed a massively dilated left atrium and severe mitral regurgitation raising concerns for a mechanical mitral valve complication. The patient was taken to the operating room for possible mitral valve surgery, but a preoperative transesophageal echocardiogram revealed an isolated posterior cleft mitral valve. Since the patient had stabilized on mechanical circulatory support, emergent surgery was deferred. The patient successfully recovered during index hospitalization with mechanical circulatory support and discharged on guideline directed medical therapy.In conclusion, isolated cleft mitral valve is a rare diagnosis that can often be underrecognized without comprehensive 3-dimensional transesophageal echocardiography evaluation. If diagnosed early with significant regurgitation, surgical treatment results in good outcomes and preservation of LV systolic function. Percutaneous correction of a CMVL with MitraClip has been described and may offer an alternative approach for high risk surgical patients.
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Hunter LD, Monaghan M, Lloyd G, Lombard C, Pecoraro AJK, Doubell AF, Herbst PG. Interscallop separations of the posterior mitral valve leaflet: a solution to the 'borderline RHD' conundrum? Open Heart 2020; 7:openhrt-2020-001452. [PMID: 33154146 PMCID: PMC7646362 DOI: 10.1136/openhrt-2020-001452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/02/2022] Open
Abstract
Objective The World Heart Federation (WHF) criteria incorporate a Doppler-based system to differentiate between ‘physiological’ and ‘pathological’ mitral regurgitation (MR)—a sole criterion sufficient for the diagnosis of WHF ‘borderline’ rheumatic heart disease (RHD). We have identified that interscallop separations (ISS) of the posterior mitral valve (MV) leaflet, can give rise to pathological MR in an otherwise-normal MV. We aimed to establish and compare the prevalence of ISS-related MR among South African children at high and low risk for RHD. Methods A prospective cross-sectional echocardiographic study of 759 school children (aged 13–18) was performed. Cases with MR≥1.5 cm underwent a second comprehensive study to determine the prevalence of RHD according to the WHF guideline and establish the underlying mechanism of MR. Results Of 400 high-risk children, two met criteria for ‘definite RHD’ (5 per 1000 (95% CI 1.4 to 18.0); p=0.5) and 11 for ‘borderline RHD’ (27.5 per 1000 (95% CI 15.4 to 48.6)). Of 359 low-risk children, 14 met criteria for borderline RHD (39 per 1000 (95% CI 23.4 to 64.4)). Comprehensive echocardiography identified an underlying ISS as the mechanism of isolated pathological MR in 10 (83.3%) high-risk children and 11 low-risk children (78.5%; p>0.99). Conclusions ISS are a ubiquitous finding among South African schoolchildren from all risk profiles and are regularly identified as the underlying mechanism of WHF pathological MR in borderline RHD cases. A detailed MV assessment with an emphasis on ascertaining the underlying mechanism of dysfunction could reduce the reported numbers of screened cases misclassified as borderline RHD.
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Affiliation(s)
- Luke David Hunter
- Division of Cardiology, Department of Medicine, Tygerberg Academic Hospital, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Mark Monaghan
- Cardiology, King's College London School of Medical Education, London, United Kingdom
| | - Guy Lloyd
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom.,Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom.,Institute of Cardiovascular Sciences, University College London, London, United Kingdom.,William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Carl Lombard
- Division of Epidemiology and Biostatistics, University of Stellenbosch, Cape Town, Western Cape, South Africa
| | - Alfonso Jan Kemp Pecoraro
- Division of Cardiology, Department of Medicine, Tygerberg Academic Hospital, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Anton Frans Doubell
- Division of Cardiology, Department of Medicine, Tygerberg Academic Hospital, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Philipus George Herbst
- Division of Cardiology, Department of Medicine, Tygerberg Academic Hospital, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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Miyata K, Shigematsu S. Additional cleft mitral valve diagnosed by a combination of 2-D and 3-D echocardiography using transesophageal echocardiography during mitral valve prolapse: a case report. JA Clin Rep 2020; 6:30. [PMID: 32358644 PMCID: PMC7195506 DOI: 10.1186/s40981-020-00337-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/22/2020] [Indexed: 11/15/2022] Open
Abstract
Background A mitral cleft may be an important etiological factor for significant mitral regurgitation. We diagnose an additional cleft mitral valve by a combination of 2-dimensional (2-D) and 3-dimensional (3-D) echocardiography. Case presentation We describe the case of a severe mitral regurgitation due to posterior leaflet prolapse (P2). In the 2-D view, which is obtained after turning the probe clockwise from the mid-esophageal long-axis view, TEE showed a moderate central regurgitation jet. In the 3-D en face view, a cleft between P2 and P3 was identified, and we found that the cause of mitral regurgitation was not only P2 prolapse but also a cleft between P2 and P3. Conclusion A complex mitral valve lesion was detected by a combination of 2-D and 3-D TEE. The presence of a cleft could affect the surgical procedure because of the possibility that an enlarged cleft would increase with leaflet resection.
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Affiliation(s)
- Kazuto Miyata
- Department of Anesthesia, New Heart Watanabe Institute, Hamadayama 3-19-11, Suginami-ku, Tokyo, 168-0065, Japan.
| | - Sayaka Shigematsu
- Department of Anesthesia, New Heart Watanabe Institute, Hamadayama 3-19-11, Suginami-ku, Tokyo, 168-0065, Japan
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de Groot-de Laat LE, McGhie J, Ren B, Frowijn R, Oei FB, Geleijnse ML. A Modified Echocardiographic Classification of Mitral Valve Regurgitation Mechanism: The Role of Three-dimensional Echocardiography. J Cardiovasc Imaging 2019; 27:187-199. [PMID: 31161753 PMCID: PMC6669177 DOI: 10.4250/jcvi.2019.27.e29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/27/2019] [Accepted: 04/08/2019] [Indexed: 12/22/2022] Open
Abstract
In this report, we provide an overview of a new, updated echocardiographic classification of mitral regurgitation mechanisms to provide a more comprehensive and detailed assessment of mitral valve disorders. This is relevant to modern mitral valve repair techniques, with special attention to the added value of 3D-echocardiography.
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Affiliation(s)
- Lotte E de Groot-de Laat
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Cardiothoracic Surgery, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Jackie McGhie
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ben Ren
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - René Frowijn
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frans B Oei
- Department of Cardiothoracic Surgery, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marcel L Geleijnse
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
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11
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Moura-Ferreira S, Sampaio F, Ribeiro J, Fontes-Carvalho R. A rare case series of mitral valve clefts diagnosed by 3D echocardiography and mini-review of the literature. Echocardiography 2019; 36:1203-1207. [PMID: 31025775 DOI: 10.1111/echo.14353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 03/27/2019] [Indexed: 11/28/2022] Open
Abstract
Mitral valve cleft is a rare entity. However, it must be recognized as a differential mechanism for mitral valve regurgitation. 3D transesophageal echocardiography plays an essential role in the evaluation of single and multiple mitral valve clefts, improving morphological and functional assessment of the valve, with potential implications on surgical planning. The authors present four rare cases of mitral valve cleft presenting during adulthood, followed by a mini-review about the role of 3D echocardiography, as well as its pitfalls, in the assessment of this complex congenital mitral valve disease.
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Affiliation(s)
- Sara Moura-Ferreira
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal.,Cardiology Department, Divino Espírito Santo Hospital, Ponta Delgada, Azores, Portugal
| | - Francisco Sampaio
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal.,Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research & Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - José Ribeiro
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal.,Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research & Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
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12
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Ramsdell G, Davies S, Ailawadi G, Singh KE. An unusual appearance of a large mitral valve cleft within a prolapsing segment diagnosed by three-dimensional transesophageal echocardiography. Echocardiography 2018; 35:2124-2126. [PMID: 30324625 DOI: 10.1111/echo.14159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/12/2018] [Indexed: 11/27/2022] Open
Abstract
Eighty-year-old woman presented for minimally invasive mitral valve repair for severe mitral regurgitation. Intraoperative two-dimensional transesophageal echocardiography (2DTEE) and subsequent three-dimensional transesophageal echocardiography examination showed severe mitral valve regurgitation with a bidirectional jet caused by both P2 segment prolapse and a large cleft within the P2 segment. The preoperative diagnosis of this complex pathology was challenging by 2DTEE, and a 3D examination of the mitral valve was helpful to confirm the presence of a cleft within the prolapsing segment.
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Affiliation(s)
- Geoffrey Ramsdell
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Stephen Davies
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Karen E Singh
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Narang A, Addetia K, Weinert L, Yamat M, Shah AP, Blair JE, Mor-Avi V, Lang RM. Diagnosis of Isolated Cleft Mitral Valve Using Three-Dimensional Echocardiography. J Am Soc Echocardiogr 2018; 31:1161-1167. [PMID: 30097300 DOI: 10.1016/j.echo.2018.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The prevalence of isolated cleft mitral valve (MV; no concomitant congenital heart disease or degenerative MV disease) with significant mitral regurgitation (MR) diagnosed using two-dimensional echocardiography (2DE) has been reported to be very low. Three-dimensional echocardiography (3DE) has enabled a more comprehensive visualization of the MV and detailed understanding of the mechanisms of MR and can potentially reveal isolated cleft MV that is not recognized with 2DE. The aim of this study was to determine, using 3DE, the prevalence, location, and associated MV annular and left ventricular characteristics of isolated cleft MV, in the absence of associated congenital heart disease, in patients with significant MR. METHODS A total of 1,092 patients with unexplained moderate or greater MR on two-dimensional transthoracic echocardiography who were referred for three-dimensional transesophageal echocardiography between 2005 and 2017 (n = 626) were retrospectively studied. Left ventricular dimensions and function were determined, and quantitative MR assessment and three-dimensional analysis of the MV annulus was performed. RESULTS Twenty-one patients (prevalence 3.3%) were diagnosed with isolated cleft MV using three-dimensional transesophageal echocardiography but not 2DE. The majority of these patients (n = 16) were noted to have anterior cleft MVs, with most located in the mid-A1 (n = 10) or mid-A3 (n = 5) scallops. Posterior clefts were less common (n = 5) and occurred at the site of the natural scallop indentations (three between P1 and P2 and two between P2 and P3). Among patients with either anterior or posterior MV cleft, there were no differences in left ventricular ejection fraction or three-dimensional MV geometry (annular distance, height, circumference, and area). There was a trend toward worse MR severity in patients with anterior cleft MV. CONCLUSIONS In patients with otherwise unexplained significant MR referred for transesophageal echocardiography, 3DE uncovered a considerably higher prevalence of isolated cleft MV than previously reported by 2DE, with the majority located in the anterior MV. Although the annular geometry was similar between patients with anterior and posterior cleft MVs, a trend toward more severe MR in anterior clefts may reflect underlying abnormalities in the embryologic development of the anterior MV leaflet. Evaluation of MV pathology is improved by 3DE, which should be used routinely in the setting significant MR.
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Affiliation(s)
- Akhil Narang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Karima Addetia
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Lynn Weinert
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Megan Yamat
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Atman P Shah
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - John E Blair
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Roberto M Lang
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
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14
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Fernando RJ, Johnson SD, Patel PA, Gutsche JT, Lauter D, Feinman JW, Guelaff E, Weiss SJ, Richardson KM, Boisen ML, Gelzinis TA, Augoustides JG. Unexpected Mitral Regurgitation During Coronary Artery Bypass Graft Surgery: The Multidisciplinary Management of a Mitral Valve Cleft. J Cardiothorac Vasc Anesth 2018; 32:1480-1486. [DOI: 10.1053/j.jvca.2017.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Indexed: 12/23/2022]
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15
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Ma W, Shi W, Zhang W, Wu W, Ye W, Kong Y. Management of Incomplete Initial Repair in the Treatment of Degenerative Mitral Insufficiency. Int Heart J 2018; 59:510-517. [PMID: 29743415 DOI: 10.1536/ihj.17-287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We sought to present our institutional protocol to manage incomplete initial repair of degenerative mitral regurgitation and to evaluate its mid-term outcomes. Eight hundred and fifteen patients with degenerative mitral insufficiency undergoing mitral valve repair were investigated in this study. The initial repair attempt was incomplete in 48 patients, leaving a degree of residual regurgitation > mild, and an elevated transmitral gradient or systolic anterior motion (SAM). These patients were further treated with medication or mitral valve re-repair or replacement under reinstituted cardiopulmonary bypass. Transesophageal echocardiographic reports and operational records were reviewed to identify morphological causes and establish management of incomplete initial repair. Mid-term outcomes of patients with re-repair and complete initial repair were evaluated and compared. Residual mitral regurgitation > mild was detected in 25 patients, an elevated transmitral gradient was detected in seven patients, and SAM was detected in 16 patients. The condition of eight patients with SAM was resolved with medication only. Mitral valve re-repair was performed in 23 patients and replacement was performed in 17, with comparable early mortality and morbidity. At 60.3 ± 25.5 months after surgery, late mitral stenosis and reoperation rate were significantly higher in re-repair patients than in patients with complete initial repair, despite comparable survival, left chamber reverse remodeling, and degree of residual regurgitation. Based on our institutional protocol, acceptable outcomes can be achieved for patients with incomplete initial mitral valve repair. Management should be tailored based on the characteristics of the mitral valve complex, expected repair durability, and operative risk.
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Affiliation(s)
- Wenrui Ma
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University
| | - Wei Shi
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University
| | - Wei Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University
| | - Weihua Wu
- Department of Echocardiography, Shanghai Chest Hospital, Shanghai Jiao Tong University
| | - Wei Ye
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University
| | - Ye Kong
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University
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16
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Hunter LD, Monaghan M, Lloyd G, Pecoraro AJK, Doubell AF, Herbst PG. Prominent inter-scallop separations of the posterior leaflet of the mitral valve: an important cause of 'pathological' mitral regurgitation. Echo Res Pract 2018; 5:ERP-18-0010. [PMID: 29572293 PMCID: PMC5900448 DOI: 10.1530/erp-18-0010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/23/2018] [Indexed: 01/22/2023] Open
Abstract
The 2012 World Heart Federation (WHF) criteria for echocardiographic diagnosis of rheumatic heart disease (RHD) identify that the finding of 'pathological' mitral regurgitation (MR) in a screened individual increases the likelihood of detecting underlying RHD. Cases of isolated "pathological MR are thus identified as 'borderline RHD'. A large-scale echocardiographic screening program (Echo in Africa) in South Africa has identified that inter-scallop separations of the posterior mitral valve leaflet (PMVL) can give rise to 'pathological' MR. The authors propose that this finding when associated with isolated 'pathological' MR is unrelated to the rheumatic disease process. In this case report, we present two examples of 'pathological' MR related to inter-scallop separation from the Echo in Africa image database. We provide additional screening tips to accurately identify this entity.
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Affiliation(s)
- L D Hunter
- Division of Cardiology, Tygerberg Hospital and University of Stellenbosch, Cape Town, South Africa
| | - M Monaghan
- Barts Heart Centre, St Bartholomew’s Hospital, London, UK
| | - G Lloyd
- Kings College Hospital, London, UK
| | - A J K Pecoraro
- Division of Cardiology, Tygerberg Hospital and University of Stellenbosch, Cape Town, South Africa
| | - A F Doubell
- Division of Cardiology, Tygerberg Hospital and University of Stellenbosch, Cape Town, South Africa
| | - P G Herbst
- Division of Cardiology, Tygerberg Hospital and University of Stellenbosch, Cape Town, South Africa
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17
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Abstract
With the advent of 3-dimensional echocardiography, visualization of the mitral valve has greatly improved. Recently, there has been an increase in reporting of a distinct entity called the "trileaflet mitral valve" using 3-dimensional echocardiography. It is controversial whether this is a new entity or an improved visualization of isolated mitral valve clefts or trifoliate left atrioventricular valve in the setting of an atrioventricular septal defect (AVSD) with intact septum. We present a case of a trifoliate valve, interpreting our findings based on a systematic review of previous publication on trileaflet mitral valves, isolated clefts in the mural (posterior) leaflet of the mitral valve, and trifoliate left atrioventricular valves with AVSD and intact septal structures. We describe the latter entity as a left atrioventricular valve because it never achieves the features of a normal mitral valve. We compare the features of isolated clefts of the mural leaflet of the mitral valve with trifoliate left atrioventricular valve found in the setting of AVSDs with intact septal structures to illustrate the current controversy regarding these conditions. In conclusion, our review suggested the reported trileaflet left atrioventricular valves is likely a misnomer because of a lack of consideration of embryologic development and nomenclature, rather than a greater appreciation and identification of a new distinct disease entity.
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18
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Nair AK, Chowdhuri KR, Radhakrishnan S, Iyer KS, Saxena M. Rare Combination of Pathologies Causing Mitral Stenosis and Mitral Regurgitation: A Case Report. World J Pediatr Congenit Heart Surg 2018; 11:NP113-NP116. [PMID: 29334829 DOI: 10.1177/2150135117743224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A supramitral ring is a rare cause of mitral stenosis, while an isolated mitral valve cleft is a rare cause of congenital mitral regurgitation. Fortunately, both the lesions are known to have good outcomes after surgical correction. Although each is known to be associated with a variety of other structural heart defects, their coexistence has not been reported previously. We report a case of a three- and half-year-old boy detected to have a rare combination of supramitral ring producing severe mitral stenosis with a coexisting cleft in the anterior leaflet of mitral valve causing severe mitral regurgitation. The patient underwent successful surgical repair with resolution of both mitral stenosis and regurgitation.
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Affiliation(s)
- Anupama K Nair
- Department of Pediatric Cardiology, Fortis-ESCORT Heart Institute, New Delhi, India
| | - Kuntal Roy Chowdhuri
- Department of Pediatric Cardiac Surgery, Fortis-ESCORT Heart Institute, New Delhi, India
| | | | - Krishna S Iyer
- Department of Pediatric Cardiac Surgery, Fortis-ESCORT Heart Institute, New Delhi, India
| | - Manish Saxena
- Department of Pediatric Cardiology, Fortis-ESCORT Heart Institute, New Delhi, India
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19
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Freixa X, Hayami D, Basmadjian A, Asgar AW. MitraClip repair of a "trileaflet" regurgitant mitral valve. EUROINTERVENTION 2016; 11:355. [PMID: 25022225 DOI: 10.4244/eijy14m07_05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Xavier Freixa
- Department of Interventional Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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20
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Mantovani F, Clavel MA, Vatury O, Suri RM, Mankad SV, Malouf J, Michelena HI, Jain S, Badano LP, Enriquez-Sarano M. Cleft-like indentations in myxomatous mitral valves by three-dimensional echocardiographic imaging. Heart 2015; 101:1111-7. [DOI: 10.1136/heartjnl-2014-307016] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/27/2015] [Indexed: 11/03/2022] Open
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21
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Maslow A. Mitral Valve Repair: An Echocardiographic Review: Part 2. J Cardiothorac Vasc Anesth 2015; 29:439-71. [DOI: 10.1053/j.jvca.2014.03.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Indexed: 12/12/2022]
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22
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Rice K, Simpson J. Three-dimensional echocardiography of congenital abnormalities of the left atrioventricular valve. Echo Res Pract 2015; 2:R13-24. [PMID: 26693328 PMCID: PMC4676473 DOI: 10.1530/erp-15-0003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 01/16/2015] [Indexed: 01/01/2023] Open
Abstract
Congenital abnormalities of the left atrioventricular (AV) valve are a significant diagnostic challenge. Traditionally, reliance has been placed on two-dimensional echocardiographic (2DE) imaging to guide recognition of the specific morphological features. Real-time 3DE can provide unique views of the left AV valve with the potential to improve understanding of valve morphology and function to facilitate surgical planning. This review illustrates the features of congenital abnormalities of the left AV valve assessed by 3DE. The similarities and differences in morphology between different lesions are described, both with respect to the valve itself and supporting chordal apparatus. The potential advantages as well as limitations of this technique in clinical practice are outlined.
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Affiliation(s)
- Kathryn Rice
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas NHS Foundation Trust , Westminster Bridge Road, London, SE1 7EH , UK
| | - John Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas NHS Foundation Trust , Westminster Bridge Road, London, SE1 7EH , UK
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23
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Abstract
Valvular heart disease is a multifactorial disorder. Twin studies may help to better understand both genetic and environmental determinants contributing to the development of valve lesions. We describe the case of a 45-year-old female asymptomatic triplet with multiple valvular heart lesions, with a somewhat different pattern between the dizygotic twin pairs compared with the monozygotic twin pair. After thorough assessment of medical history and physical examination, the triplet underwent two- and three-dimensional transthoracic and transesophageal echocardiographic examinations to assess the pathomechanism and severity of their heart valve lesions. The monozygotic twin pair (second-born twin B and third-born twin C) showed the same pattern of valvular lesions: mild mitral, tricuspidal, and aortic regurgitation of the same pathomechanism (posterior mitral valve cleft and aortosclerosis). Interestingly, the examination of first-born twin (twin A), who was dizygotic to twins B and C, revealed mild protosystolic mitral and mild tricuspidal regurgitation, but neither aortic insufficiency nor mitral cleft or indentation could be detected. Beyond the genetic effect, we presume that the intrauterine twinning process might also play a role in the development of congenital valvular heart disease. In order to verify this, further investigation should be performed on larger twin populations. Nevertheless, when one twin is affected, the other asymptomatic twin should also be examined for valvular heart disease.
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Intraoperative Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation. J Am Soc Echocardiogr 2014; 27:345-66. [DOI: 10.1016/j.echo.2014.01.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Indexed: 12/14/2022]
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25
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Ring L, Rana BS, Ho SY, Wells FC. The prevalence and impact of deep clefts in the mitral leaflets in mitral valve prolapse. Eur Heart J Cardiovasc Imaging 2013; 14:595-602. [DOI: 10.1093/ehjci/jes310] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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26
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Negrea SL, Alexandrescu C, Sabatier M, Dreyfus GD. Cleft posterior mitral valve leaflet in an adult with Turner syndrome diagnosed with the use of 3-dimensional transesophageal echocardiography. Tex Heart Inst J 2012; 39:547-549. [PMID: 22949775 PMCID: PMC3423270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Turner syndrome is a monosomy (45,X karyotype) in which the prevalence of cardiovascular anomalies is high. However, this aspect of Turner syndrome has received little attention outside of the pediatric medical literature, and the entire spectrum of cardiovascular conditions in adults remains unknown. We present the case of a 34-year-old woman who had Turner syndrome. When she was a teenager, her native bicuspid aortic valve was replaced with a mechanical prosthesis. Fifteen years later, during preoperative examination for prosthesis-patient mismatch, severe mitral regurgitation was detected, and a congenital cleft in the posterior leaflet of the mitral valve was diagnosed with use of 3-dimensional transesophageal echocardiography. The patient underwent concurrent mitral valve repair and aortic valve replacement. To our knowledge, this is the first report of a cleft in the posterior mitral valve leaflet as a cardiovascular defect observed in Turner syndrome, and the first such instance to have been diagnosed with the use of 3-dimensional echocardiography.
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27
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Séguéla PE, Houyel L, Acar P. Congenital malformations of the mitral valve. Arch Cardiovasc Dis 2011; 104:465-79. [PMID: 21944149 DOI: 10.1016/j.acvd.2011.06.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/08/2011] [Accepted: 06/09/2011] [Indexed: 11/20/2022]
Abstract
Congenital 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.
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28
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Current world literature. Curr Opin Cardiol 2011; 26:165-73. [PMID: 21307667 DOI: 10.1097/hco.0b013e328344b569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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30
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Biaggi P, Greutmann M, Crean A. Utility of Three-Dimensional Transesophageal Echocardiography: Anatomy, Mechanism, and Severity of Regurgitation in a Patient with an Isolated Cleft Posterior Mitral Valve. J Am Soc Echocardiogr 2010; 23:1114.e1-4. [DOI: 10.1016/j.echo.2010.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Indexed: 11/15/2022]
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