Acute rupture of chordae tendineae of the mitral valve in infants: a nationwide survey in Japan exploring a new syndrome

Exploring Unusual Cardiac Complications: Chorda Tendinea Rupture and Pulmonary Valve Vegetation in Infective Endocarditis-A Comprehensive Review

Infective endocarditis (IE) is a severe infection of the endocardium, frequently involving heart valves, and is associated with significant morbidity and mortality. At the same time, traditional complications of IE, such as valvular dysfunction and embolic events, are well-documented, and uncommon cardiac manifestations, such as chorda tendinea rupture and pulmonary valve vegetation, present unique diagnostic and management challenges. This comprehensive review explores the pathophysiology, clinical presentation, diagnostic strategies, and management approaches for IE's chorda tendinea rupture and pulmonary valve vegetation. Through a detailed examination of the literature and discussion of clinical scenarios, we highlight the importance of recognizing these rare complications and discuss the implications for clinical practice. Additionally, we identify knowledge gaps and propose areas for future research to enhance further our understanding and management of these unusual cardiac complications in IE. This review aims to provide clinicians with valuable insights to improve patient care and outcomes in the challenging setting of infective endocarditis.

Acute mitral regurgitation with and without acute heart failure

Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized.

Congenital Mitral Regurgitation Repair Based on Carpentier's Classification: Long-Term Outcomes

BACKGROUND

There are few reports of the outcomes of standardized surgical management addressing the etiologic and morphologic aspects of mitral valve malformation according to Carpentier's classification. This study aimed to evaluate the long-term outcomes of mitral valve repair in children according to Carpentier's classification.

METHODS

Patients who underwent mitral valve repair at our institution between 2000 and 2021 were retrospectively reviewed. Preoperative data, surgical techniques, and outcomes were analyzed according to Carpentier's classification. The proportion of patients free of mitral valve replacement and reoperation was estimated using Kaplan-Meier analysis.

RESULTS

Twenty-three patients (median operative age, four months) were followed up for 10 (range, 2-21) years. Preoperative mitral regurgitation was severe in 12 patients and moderate in 11 patients. Eight, five, seven, and three patients had Carpentier's type 1, 2, 3, and 4 lesions, respectively. Ventricular septal defect (N = 9) and double outlet of the great arteries from the right ventricle (N = 3) were the most commonly associated cardiac malformations. There were no cases of operative mortality or deaths during the follow-up. The overall five-year rate of freedom from mitral valve replacement was 91%, whereas the five-year rates of freedom from reoperation were 74%, 80%, 71%, and 67% in type 1, 2, 3, and 4 lesions, respectively. Postoperative mitral regurgitation at the last follow-up was moderate in three patients and less than mild in 20 patients.

CONCLUSIONS

Current surgical management of congenital mitral regurgitation is generally considered adequate; however, more complicated cases required a combination of various surgical techniques.

Endocardial Fibroelastosis as an Independent Predictor of Atrioventricular Valve Rupture in Maternal Autoimmune Antibody Exposed Fetus: A Systematic Review with Clinicopathologic Analysis

BACKGROUND

Neonatal lupus (NL) is a clinical syndrome that develops in the fetus as a result of maternal autoimmune antibodies. Congenital complete heart block (CHB) is the most common manifestation, while extranodal cardiac manifestations of NL, such as endocardial fibroelastosis (EFE) and myocarditis, are rare but more serious. Less is known about this atrioventricular valve rupture due to valvulitis as a consequence of maternal autoantibodies. We have described a case of cardiac neonatal lupus with an antenatally detected CHB patient who developed mitral and tricuspid valve chordal rupture at 45 days of age. We compared the cardiac histopathology and the fetal cardiac echocardiographic findings of this case with another fetus that was aborted after being antenatally diagnosed with CHB but without valvar rupture. A narrative analysis after a systematic review of the literature regarding atrioventricular valve apparatus rupture due to autoimmune etiology along with maternal characteristics, presentation, treatment, and outcome have been discussed in this article.

OBJECTIVES

To describe published data on atrioventricular valve rupture in neonatal lupus, including clinical presentation, diagnostic evaluation, management, and outcomes.

METHODS

We conducted a PRISMA-compliant descriptive systematic examination of case reports that included accounts of lupus during pregnancy or in the newborn period that resulted in an atrioventricular valve rupture. We gathered information on the patient's demographics, the details of the valve rupture and other comorbidities, the maternal therapy, the clinical course, and the results. We also used a standardized method to evaluate the cases' quality. A total of 12 cases were investigated, with 11 cases drawn from 10 case reports or case series and 1 from our own experience.

RESULTS

Tricuspid valve rupture (50%) is more common than mitral valve rupture (17%). Unlike mitral valve rupture, which occurs postnatally, the timing of tricuspid valve rupture is perinatal. A total of 33% of the patients had concomitant complete heart block, while 75% of the patients had endocardial fibroelastosis on an antenatal ultrasound. Antenatal changes pertaining to endocardial fibroelastosis can be seen as early as 19 weeks of gestation. Patients with both valve ruptures generally have a poor prognosis, especially if they occur at close intervals.

CONCLUSION

Atrioventricular valve rupture in neonatal lupus is rare. A majority of patients with valve rupture had antenatally detected endocardial fibroelastosis in the valvar apparatus. Appropriate and expedited surgical repair of ruptured atrioventricular valves is feasible and has a low mortality risk. Rupture of both atrioventricular valves occurring at close intervals carries a high mortality risk.

Midterm Outcomes After Surgical Management for Mitral Valve Regurgitation in Infancy

Background

Mitral valve repair is preferred for pediatric mitral valve disease. However, it is technically difficult because of complex lesions, poor surgical exposure, and tissue fragility, especially in infants. We investigated the midterm outcomes of mitral valve surgery for mitral regurgitation in infancy.

Methods

We retrospectively reviewed 18 patients (aged <12 months old) undergoing mitral valve surgery for mitral regurgitation at our institution between October 2005 and March 2019. The patients had 10 acquired and 8 congenital valve lesions as follows: torn chordae ( n = 6), leaflet prolapse ( n = 4), posterior leaflet hypoplasia ( n = 3), anterior leaflet cleft ( n = 2), infective endocarditis ( n = 1), papillary muscle rupture ( n = 1), and hammock valve ( n = 1).

Results

All patients initially underwent mitral valve repair. There was no operative mortality, and 1 case of late death. The median follow-up period was 7 years and 9 months. Reoperation was performed in 3 patients, re-repair (twice) in 1 patient with a hammock valve, and mitral valve replacement in 2 patients. Fifteen patients had at most mild mitral regurgitation at the last follow-up. A transmitral mean pressure gradient of over 5 mm Hg was observed in 3 cases, including the patient with a hammock valve. Postoperative mitral annular diameter increased within the normal range in all patients. Survival and reoperation-free rates at 5 and 10 years were 94.4% and 83.0%, respectively.

Conclusions

Mitral valve repair for mitral regurgitation in infancy is safe and feasible with satisfactory midterm outcomes, even under serious preoperative conditions.

Cardiac Valvular Lesions due to Kawasaki Disease: A Japanese Nationwide Survey

OBJECTIVES

To clarify the characteristics of valvular lesions after Kawasaki disease with a Japanese nationwide survey.

STUDY DESIGN

Among 137 026 patients in the nationwide Japanese surveys between 2007 and 2016, 290 (0.2%) with valvular sequelae were investigated by questionnaires.

RESULTS

Among the 290 patients with valvular sequelae, mitral regurgitation (MR), tricuspid regurgitation, aortic regurgitation, and pulmonary regurgitation were present 1 month after the development of Kawasaki disease in 183 (63%), 112 (39%), 39 (13%), and 49 (17%) patients, respectively. The numbers of patients with MR during the acute phase and 1 year after developing Kawasaki disease were 208 (72%) and 95 (33%), respectively. MR improved significantly during the late period (P < .0001). Although aortic regurgitation and tricuspid regurgitation also improved significantly (P < .001), pulmonary regurgitation did not change. Ruptured mitral valves chordae tendineae occurred in 6 infants by 6 months of age, within 4 months after the onset of Kawasaki disease. Three patients needed mitral valve plasty, and 1 patient died of acute heart failure. Another 4-month-old girl died of an acute myocardial infarction with MR. In the acute phase, there was a significant difference in the MR severity between the intravenous immunoglobulin-responder group and the intravenous immunoglobulin-resistant group (P < .05).

CONCLUSIONS

The inflammation caused by acute Kawasaki disease affects the function of the mitral valves. Most cases of MR improve with the alleviation of inflammation. Severe MR may have decreased with the development of treatment for acute vasculitis. However, ruptured mitral valves chordae tendineae rarely occurs in infants younger than 6 months old, within 4 months after Kawasaki disease.

Cardiovascular Involvement in Kawasaki Disease Is Much More Than Mere Coronary Arteritis

Kawasaki disease (KD) is now a common cause of acquired heart disease in children. Coronary artery involvement is the most serious complication in children with KD. Several non-coronary complications have now been identified in this condition but these are often overlooked. Myocarditis is an integral component of KD and may be more common than coronary artery abnormalities. Pericardial involvement and valvular abnormalities have also been observed in patients with KD. KD shock syndrome is now being increasingly recognized and may be difficult to differentiate clinically from toxic shock syndrome. Endothelial dysfunction has been reported both during acute stage and also on follow-up. This may be a potentially modifiable cardiovascular risk factor.

Idiopathic Acute Mitral Regurgitation Due to Chordal Rupture in Infants: Surgical Management and Results

OBJECTIVE

Emergency surgical treatment is required for idiopathic acute mitral regurgitation due to chordae rupture in infants. Nevertheless, mitral valve repair for such a patient population still remains challenging. We report our experience with mitral valve repair for idiopathic acute mitral regurgitation due to chordae rupture in infants.

METHODS

From 2005 to 2017, six infants (four boys) were diagnosed with acute mitral regurgitation due to chordae rupture and underwent mitral valve repair. The median age, mean body weight, and median follow-up period were 5.5 months (range: 4-9 months), 6.8 kg (range: 5.5-8.0 kg), and 6.4 years (range: 6 months to 10 years), respectively.

RESULTS

In all cases, surgical intervention was performed within 24 hours of admission. Artificial chordae reconstruction and paracommissural edge-to-edge repair were utilized in three and four cases, respectively, while Kay's annuloplasty was performed in all cases. Mean cardiopulmonary bypass time and aortic cross-clamp time were 117 minutes (range: 70-143 minutes) and 73 minutes (range: 35-108 minutes), respectively. No early or late deaths and reoperations had occurred during the follow-up period. Moreover, postoperative mitral regurgitation was significantly reduced, while no chronologic progression of mitral regurgitation was observed.

CONCLUSIONS

The combination of various techniques, such as artificial chordae reconstruction, paracomissural edge-to-edge repair, and Kay's annuloplasty, can be a promising surgical option for idiopathic acute mitral regurgitation due to chordae rupture in infants.

Streptococcus pyogenes Endocarditis Associated With Varicella-Case Report and Review of the Literature

Infection with varicella zoster virus (VZV) is usually a benign and self-limiting disease. Serious complications by bacterial pathogens do occur, such as necrotising fasciitis (NF). One of the most important is Streptococcus pyogenes (or Group A Streptococcus, GAS), which colonizes epithelial surfaces, primarily of the throat and skin. In rare instances, varicella may also be associated with S. pyogenes endocarditis. Review of the literature reveals only 18 children with infective endocarditis (IE) caused by GAS since 1942. VZV as antecedent illness was found in five (28%). Fourteen (78%) had no pre-existing cardiac abnormalities. Death occurred in three (17%) children. Infective endocarditis with acute deterioration secondary to rupture of mitral valve chordae tendineae necessitating cardiac surgery has not been reported in the literature yet. We present this rare and instructive pediatric case and the results of a literature search on S. pyogenes endocarditis in children.

Ruptured mitral valves chordae tendineae around a convalescent infant with acute Kawasaki disease

Severe valvulitis owing to acute Kawasaki disease leading to severe mitral regurgitation is a rare event in infants. Further, there is less information about underlying ruptured mitral chordae tendineae causing severe mitral regurgitation. We encountered ruptured mitral chordae tendineae in three female patients after Kawasaki disease. The age at the onset of Kawasaki disease ranged from 3 to 8 months, and detection of ruptured mitral chordae tendineae was from 24 to 90 days. Two patients had acute heart failure, and one was asymptomatic. One patient underwent mitral annuloplasty, and the others responded to medication. These ruptured mitral chordae tendineae occurred after the remission of the initial acute Kawasaki disease, in the early course and the convalescent of acute Kawasaki disease. Further, the recurrent fever was also detected in them. The ruptured mitral chordae tendineae in an infant within 6 months can be detected by systolic heart murmur around the convalescent stage of acute Kawasaki disease, although the prevalence is very low.

Macrophages and cytotoxic T cells infiltrate the destructed mitral tissue in Kawasaki disease

Kawasaki disease (KD) is an acute febrile systemic vasculitic syndrome especially affecting medium-sized arteries, including the coronary artery. Inflammation may involve all organs, and valvulitis is one of the cardiovascular complications that occurs in the acute phase of KD. However, details regarding the mechanism are unclear. An infant developed KD and severe mitral regurgitation with deformity and prolapse of the mitral tissue and underwent mitral valvotomy 1 year later. Histopathological study was conducted, and infiltrating cells consisted of mainly macrophages and cytotoxic T cells were found in resected mitral valve tissue. In addition, inflammation remained a long time after KD had developed.

Echocardiographic and hemodynamic assessment for predicting early clinical events in severe acute mitral regurgitation

The diagnostic role of echocardiographic and hemodynamic assessment in acute mitral regurgitation (AMR) remains unclear. The central question of this study was to determine if echocardiographic and hemodynamic parameters can predict early clinical events in AMR. AMR was induced by percutaneously severing the mitral valve chordae tendineae in 39 Yorkshire pigs. Immediately after AMR induction, echocardiographic and hemodynamic exams were performed, and compared between those who died and those who survived within 30-days of the procedure. Echocardiographic indices of MR severity as well as the left atrial pressure showed significant differences between survivors and non-survivors in univariate analysis. Multi-variate logistic regression analysis revealed that echocardiography-derived regurgitant fraction and vena contracta as well as mean left atrial pressure could be used to segment the cohort into survivors and non-survivors. Our study demonstrated, for the first time, that echocardiographic and hemodynamic assessment of AMR provides predictive information on early clinical events in a clinically relevant animal model of AMR.

Idiopathic mitral valve chordae rupture in an infant: importance of rapid diagnosis and surgery

Mitral valve chordae rupture in infancy is a rare, but life-threatening disease. The progression of acute cardiac failure has been reported, with emergency surgery being required in most cases. Mitral valve chordae rupture typically occurs at the age of 4-6 months. Echocardiography is needed to diagnose this disease, and accurate diagnosis is difficult for general pediatricians. We herein describe the case of an acutely ill 4-month-old infant, who was saved and discharged without neurological sequelae due to the early diagnosis of mitral valve chordae rupture, life support, and surgery. We confirm the importance of acute pre-surgery treatment and immediate surgery for the survival and good outcome of infants.