Mitral Valve – ABC CARDIOL

IJCS

Case Report

Double-Orifice Mitral Valve with Severe Regurgitation Associated with Bicuspid Aortic Valve: A Case Report

Patricia Delgado Cedeño et al. Estefania Carolina Arteaga Herrera Cesar João Tumbaco Mite Elsie Valdivieso Valenzuela … Juan Javier Zuñiga Bohorquez Guillermo Navas Moreira

Introduction

Double-orifice mitral valve (DOMV) was first described in 1876 by the British pathologist William Smith Greenfield. It is a very rare congenital or acquired cardiac anomaly with limited epidemiologic data and no clear sex predilection.

Congenital DOMV rarely occurs in isolation and is commonly associated with other cardiac anomalies, such as aortic coarctation, patent ductus arteriosus, atrioventricular septal defects, and bicuspid aortic valve (BAV), among others. Functionally, it may behave normally and remain asymptomatic; however, symptoms may arise from mitral valve dysfunction, such as stenosis or regurgitation.

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ABCIC

Review Article

Mitral Valve Leaflet Hypoplasia in Adults: Role of Cardiovascular Imaging

Fábio Luis de Jesus Soares

Abstract

Mitral valve leaflet hypoplasia is a rare congenital anomaly, traditionally described in childhood but increasingly recognized in adults, often as an incidental finding or during the evaluation of mitral regurgitation. Clinical presentation is heterogeneous and depends on leaflet anatomy, the subvalvular apparatus, and the severity of regurgitation. In this narrative literature review, including case reports, case series, and review articles from nationally and internationally recognized journals, epidemiological and clinical aspects are discussed, with particular emphasis on echocardiographic findings. Posterior leaflet hypoplasia is the most common form and may be partial or complete. Three-dimensional echocardiography plays a central role in anatomical assessment, enabling direct measurements of leaflet area and length and helping differentiate true hypoplasia from mimicking entities such as mitral cleft, functional restriction, or subvalvular abnormalities. The estimated prevalence in asymptomatic adults is approximately 1:8,800. Therapeutic management is primarily determined by the severity of mitral regurgitation, with valve repair being feasible only in selected anatomical scenarios. Therefore, refined anatomical understanding, particularly through three-dimensional echocardiography, is essential for accurate diagnosis and appropriate therapeutic planning in this rare yet clinically relevant condition.

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ABCIC

Review Article

My Approach to Assessment of Mitral Paraprosthetic Leak

Abstract

Mitral paraprosthetic leak is a common, often asymptomatic condition. When presented with clinical manifestations such as heart failure and/or hemolysis, interventional treatment is indicated. The transcatheter approach has become increasingly popular, requiring careful planning using imaging methods, particularly echocardiography. Echocardiography is crucial for assessing the severity, location, size, shape, and number of leaks. Once these variables are determined, the treatment approach is planned, typically using the transseptal route. The optimal puncture site depends on various factors, with precise puncture location being paramount. Intraoperative echocardiographic evaluation is essential for procedure success, guiding device positioning and adjustments while also identifying any potential complications.

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ABCIC

Case Report

Dual Mechanism of Mitral Valve Injury: Additional Value of Three-Dimensional Transesophageal Echocardiography

Larissa Neto Espíndola et al. Angele Azevedo Alves Mattoso Geórgia dos Santos Couto Pompílio Sampaio Britto

Abstract

Infective endocarditis (IE) is a life-threatening condition and during its course several complications may occur, including embolic events, perivalvular extension and valvular destruction. Echocardiography is fundamental across all stages of the disease, from the diagnosis until the follow-up after completion of the definitive therapy. Three-dimensional transesophageal echocardiography (TEE) can demonstrate a better anatomical definition and it is especially useful in the assessment of perivalvular extension of the infection, prosthetic valve dehiscence and valve perforation. In this article we report a case of double damage in the same mitral valve: leaflet perforation and rupture of chords in a patient with IE.

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ABCIC

Case Report

Takotsubo Syndrome After Mitral Valve Surgery: Multimedia Presentation of a Rare Diagnosis

Adnaldo da Silveira Maia et al. Germano de Sousa Leão Jhonathan Gouveia da Mota Dante Togeiro Bastos Filgueiras … Verônica Noronha Rodrigues Luiz Minuzzo Mario Issa

Introduction

The Takotsubo Syndrome, also known as “broken heart syndrome”, is characterized by a severe and transitory left ventricular dysfunction, with the presence of alterations in the contraction of the basal, medial, or apical segments of the left ventricular walls. The syndrome can be caused by an emotional or physical trigger, or by a combination of both; however, this is not a mandatory criterion for its diagnosis.

This study describes a case of Takotsubo Syndrome after mitral valve surgery to replace the valve with a mechanical prosthesis.

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ABCIC

Editorial

Mitral Valve Area Quantification Using Digital Image Processing: Is That Feasible?

Edgar Daminello et al. Paulo Pinto Alves Campos Vieira Cláudio Henrique Fischer Marcelo Luiz Campos Vieira

Echocardiography, since its initial descriptions in the 1950s, has evolved every decade with the incorporation of numerous new techniques, enabling structural cardiac analysis from multiple planes of spatial observation in real time. This occurred with the advent of nanotechnology, digital technology, application of modifiable algorithms based on the concept of machine learning and deep learning through the development of artificial intelligence (AI).^– The use of AI is an ever-increasing reality in medicine as a whole, mainly in operator-dependent imaging areas, such as ultrasonography imaging.

In the concept of analyzing the confluence of a very large number of pieces of information (e.g. radiomics, metabolomics, proteomics) for the formation of data clusters with the aim of integrated patient observation, the formation of precision medicine, AI is used in a rational and organized way. The use of AI allows faster, more balanced and homogeneous observation of inputs, in the sense of minimizing inter and intraobserver errors.^– In the specific echocardiographic evaluation, the use of AI presents a very wide range of applications, having been used for the acquisition of echocardiographic information for the quantification of left ventricular volumes and mass, analysis of biventricular systolic function, segmentation and qualification of the cusps, annulus and mitral valve apparatus, analysis of hypertrophic phenocopy (athletes, patients with hypertrophic cardiomyopathy), to predict the outcome of percutaneous hemodynamic procedures (e.g.: mitraclip). We are currently working on a project in association with the University of Chicago for AI analysis of patients affected by transthyretin cardiac amyloidosis.

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ABCIC

Original Article

Automatic Measurement of the Mitral Valve Based on Echocardiography Using Digital Image Processing

Genilton de França Barros Filho et al. Israel Solha Ewerton Freitas de Medeiros Alex dos Santos Felix … André Luiz Cerqueira de Almeida José Carlos de Lima Júnior Marcelo Dantas Tavares de Melo Marcelo Cavalcanti Rodrigues

Abstract

Background

The evaluation of mitral valve area through multiplanar reconstruction in 3-dimensional echocardiography is restricted to specific software and to the experience of echocardiographers. They need to manually select the video frame that contains the maximum mitral valve opening area, as this dimension is fundamental to identification of mitral stenosis.

Objective

To automate the process of determining the maximum mitral valve opening area, through the application of digital image processing (DIP) in echocardiography tests, developing an open algorithm with video reading in avi format.

Method

This cross-sectional observational pilot study was conducted with 25 different echocardiography exams, 15 with normal aperture and 10 with rheumatic mitral stenosis. With the authorization of the Research Ethics Committee, all exams were performed and made available by 2 specialists who used 2 models of echocardiographic devices: Vivid E95 (GE Healthcare) and Epiq 7 (Philips), with multiplanar transesophageal probes. All videos in avi format were submitted to DIP using the image segmentation technique.

Results

The measurements obtained manually by experienced echocardiographers and the values calculated by the developed system were compared using a Bland-Altman diagram. There was greater agreement between values in the range from 0.4 to 2.7 cm².

Conclusion

It was possible to automatically determine the maximum mitral valve opening area, for cases from both GE and Philips, using only 1 video as input data. The algorithm has been demonstrated to save time on measurements when compared to the usual method.

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ABCIC

Case Report

Three-Dimensional Transesophageal Echocardiography in Native Valve Endocarditis: A Case Report and Similarities Between Echocardiography and Surgical Findings

Giulia Bevilacqua Schmitz et al. Amadeu Antonio Bertuol Filho Solano Vinicius Berger Rodrigo Petersen Saadi … Álvaro Albrecht Angela Barreto Santiago Santos

Abstract

Native valve bacterial endocarditis is an uncommon, complex, and highly morbid disease that requires prolonged clinical treatment and challenging surgical interventions. Transthoracic and transesophageal echocardiography are paramount assessment tools whose findings are included in the diagnostic criteria. Three-dimensional echocardiography shows further realistic imaging details. Here we present a case demonstrating the role of echocardiography in the diagnosis of endocarditis and the identification of its complications to show how advanced imaging techniques may have a remarkable resemblance with in vivo surgical findings.

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ABCIC

My Approach To

My Approach to the Echocardiographic Assessment of Mitral Annular Calcification: Challenges and Particularities

Antonio Carlos Leite de Barros Filho et al. Minna Moreira Dias Romano

Introduction

Mitral annular calcification (MAC) is a chronic degenerative process that affects the fibrous structure supporting the mitral valve. It is present in 8–15% of the general population; however, its prevalence can reach 40% in older people and 50% in patients with chronic kidney disease. Although it was previously classified as a degenerative pathophysiology associated with age or calcium metabolism, other etiological factors have been suggested, such as atherosclerotic disease and its risk factors (hypertension, obesity, dyslipidemia, diabetes mellitus, smoking), exposure to radiation therapy, and conditions that increase mitral valve stress, such as aortic valve stenosis, hypertrophic cardiomyopathy, and mitral valve prolapse.^–

MAC is related to an increased risk of a number of adverse cardiac events, such as acute myocardial infarction, stroke, arrhythmias (conduction disorders and atrial fibrillation), and mitral valve disease (mitral stenosis, mitral regurgitation, and infective endocarditis).^– It is also associated with a higher risk of complications and mortality in patients undergoing mitral valve surgery. Although most cases are not associated with mitral valve dysfunction, some may progress with an increased mitral transvalvular gradient.^,

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IJCS

Original Article

Women Undergoing Mitral Valve Replacement: A Retrospective Analysis

Júlia Lasserre Moreira et al. Pedro Henrique Andrade Araújo Salvatore Barletta José Augusto Baucia

Abstract

Background

Although cardiovascular disease is the leading cause of death in women, few data exist on risk factors and treatment of these diseases in women. This leads to a delay in the institution of appropriate therapies and worse outcomes in this population.

Objective

We aimed to identify predictors of morbidity and mortality in women undergoing isolated mitral valve replacement.

Methods

This was a retrospective cohort study with 104 women who underwent isolated mitral valve replacement at a referral hospital for treatment of cardiovascular diseases, performed from January 2011 to December 2016. Data were obtained from medical records. Statistical analysis was performed to calculate odds ratio, unpaired Student’s t-test, and binary logistic regression. P values <0.05 were considered statistically significant.

Results

Mean age of patients was 43.73 (±13.85) years. Most patients had a diagnosis of rheumatic disease prior to surgery (76%; N=79). Mortality rate was 4.9% (N = 5). There was a statistically higher risk of death among patients with reduced ejection fraction (EF) (<50%) (OR = 14.833, 95% CI 2.183 – 100.778, P=0.001) and older age (P = 0.009). There was an inverse association between a previous diagnosis of rheumatic disease and death (OR = 0.064, 95% CI 0.007 – 0.606, P=0.002). Logistic regression showed reduced EF at preoperative evaluation as a predictor of death and a diagnosis of rheumatic disease as a protective factor.

Conclusion

Older age and reduced EF were associated with postoperative mortality. Reduced EF was a predictor of death, and rheumatic disease was associated with better surgical outcomes.

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IJCS

Original Article

Bioprosthesis versus Mechanical Valve Heart Prosthesis: Assessment of Quality of Life

José Carlos Molero Junior et al. Rodrigo Daminello Raimundo, Joice Anaize Tonon do Amaral Luiz Carlos de Abreu João Roberto Breda

Abstract

Background:

The aim of this study was to evaluate the QoL of patients undergoing heart valve replacement using the SF-36 questionnaire, compare it between patients with mechanical prosthesis and patients with bioprosthesis, and correlate the results with sociodemographic variables.

Objective:

To assess the QoL of patients undergoing heart valve replacement and compare it between patients with bioprosthetic valves and patients with mechanical prosthetic valves.

Methods:

We included 36 consecutive patients (16 men) with a mean age of 51 years and six months, who underwent mitral or aortic valve replacement from September 2007 to December 2011. The study was conducted between March and May 2012 and involved the application of the SF-36 survey and a sociodemographic questionnaire. Statistical tests were performed, and data are expressed as absolute frequency and percentile, and median and interquartile range (P25 and P75) (Mann-Whitney test), considering a significance of 95%.

Results:

The average time of surgery was 32.5 months (8-61 months). Participants were asked about the practice of physical activity, and 41.7% were physically active. For the SF-36 domains, the highest scores were observed for the social domain whereas the lowest scores were found for mental health, with a mean of 89.25 and 54.44, respectively. In the statistical analysis, we found statistically higher values in emotional functional for patients with mechanical valve prosthesis (p = 0.0084).

Conclusion:

The QoL of the patients undergoing heart valve replacement improves considerably after the surgery, except for the mental health domain, probably due to the low practice of physical activity. The type of prosthesis seems not to influence the QoL or the patients in the late postoperative period.

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ABC

Original Article

Late Results of Cox Maze III Procedure in Patients with Atrial Fibrillation Associated with Structural Heart Disease

Gustavo Gir Gomes et al. Wagner Luis Gali Alvaro Valentim Lima Sarabanda Claudio Ribeiro da Cunha … Iruena Moraes Kessler Fernando Antibas Atik

Abstract

Background:

Cox-Maze III procedure is one of the surgical techniques used in the surgical treatment of atrial fibrillation (AF).

Objectives:

To determine late results of Cox-Maze III in terms of maintenance of sinus rhythm, and mortality and stroke rates.

Methods:

Between January 2006 and January 2013, 93 patients were submitted to the cut-and-sew Cox-Maze III procedure in combination with structural heart disease repair. Heart rhythm was determined by 24-hour Holter monitoring. Procedural success rates were determined by longitudinal methods and recurrence predictors by multivariate Cox regression models.

Results:

Thirteen patients that obtained hospital discharge alive were excluded due to lost follow-up. The remaining 80 patients were aged 49.9 ± 12 years and 47 (58.7%) of them were female. Involvement of mitral valve and rheumatic heart disease were found in 67 (83.7%) and 63 (78.7%) patients, respectively. Seventy patients (87.5%) had persistent or long-standing persistent AF. Mean follow-up with Holter monitoring was 27.5 months. There were no hospital deaths. Sinus rhythm maintenance rates were 88%, 85.1% and 80.6% at 6 months, 24 months and 36 months, respectively. Predictors of late recurrence of AF were female gender (HR 3.52; 95% CI 1.21-10.25; p = 0.02), coronary artery disease (HR 4.73 95% CI 1.37-16.36; p = 0.01) and greater left atrium diameter (HR 1.05; 95% CI 1.01-1.09; p = 0.02). Actuarial survival was 98.5% at 12, 24 and 48 months and actuarial freedom from stroke was 100%, 100% and 97.5% in the same time frames.

Conclusions:

The Cox-Maze III procedure, in our experience, is efficacious for sinus rhythm maintenance, with very low late mortality and stroke rates.

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IJCS

Case Report

Caseous Necrosis of the Mitral Valve: Imaging Methods Allow the Diagnosis and Prevent Surgery

Rodrigo de Moura Joaquim et al. Edileide de Barros Correia Suéllen Lacerda Bezerra Ibraim Masciarelli Francisco Pinto … Tiago Senra Garcia dos Santos Fabiano de Castro Albrecht

Introduction

Calcification of the mitral annulus (CMA) is defined as a chronic degeneration of the mitral annulus fibrous involving mainly the posterior annulus. It is a common condition in the elderly, especially in women, and is associated with hypertension. Caseous necrosis of the mitral valve (CNMV) is a rare and less known CMA variant with a prevalence of 0.64%, which can reach up to 2.7% in autopsy studies of patients with CMA.^–

On echocardiography, CNMV appears as a large rounded or semilunar echodense mass, with a liquid filling and central echolucency, similar to a periannular tumor.^, The mechanism of liquefaction and caseification are still not well understood, but it is believed to occur due to changes in calcium metabolism.

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ABC

Artigo Original

Mitral valve and atrial septal defect surgery: minimally invasive or sternotomy approach

Josué V. Castro Neto et al. Emanuel Melo Juliana Fernandes Regina Gomes … Caroline Freitas João Machado Francisco Martins Aloísio Barbosa Bernardo Oliveira Cesar Gondim

BACKGROUND: To decrease the surgical trauma in heart procedures, minimally invasive (MI) techniques were alternatively introduced. OBJECTIVE: To compare MI surgical access with median sternotomy (MS) for the treatment of mitral valve (MV) disease and atrial septal defect (ASD). METHODS: Forty patients underwent surgery for correction of MV disease or ASD. Patients were divided into group A (GA) (n=20), access by right minithoracotomy and video-assistance; and group B (GB) (n=20), access by full MS. Aortic cross-clamp and cardiopulmonary bypass time, intensive care unit (ICU) time, hospital stay and morbidity were compared in this prospective study . RESULTS: Fifteen patients were submitted to MV procedures and five to ASD corrections in each group. There were 9 mitral replacements (7 bioprostetic and 2 mechanical) and 6 repairs in GA, and 10 (all bioprostetic) and five in GB. The mean aortic cross-clamp and cardiopulmonary bypass time, in minutes, were 65.1 ± 29.3 in GA and 50.2 ± 21.4 in GB (p=0.074); and 91.8±35 in GA and 63.7±27.3 in GB ( p=0.008). The mean ICU time, in hours, were 51.7 ± 16.3 in GA and 55.8±17.5 in GB (p=0.45). The in hospital stay, in days, were 5.2 ± 1 in GA and 6.4±1.5 in GB (p=0.009). CONCLUSION: MI access for correction of the MV disease and ASD implicated in a longer cardiopulmonary bypass time for finalization of the main procedure, nevertheless it didn´t affect patient’s recuperation. MI treated patients were discharged earlier than sternotomy treated patients.

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Artigo Original

Autonomic regulation of mechanical properties in porcine mitral valve cusps

Xiang Hu et al. Qiang Zhao Xiaofeng Ye

BACKGROUND: The presence of nerves in heart valves was first depicted decades ago and identified into subpopulations: sympathetic, parasympathetic. So valves are expected to be greatly affected by the autonomic nerves. However, few studies have focused on the regulation of heart valves by the autonomic nervous system. OBJECTIVE: We sought to identify the role of the autonomic nervous system in the regulation of the mechanical properties of porcine mitral valve tissues. METHODS: Mechanical properties of porcine mitral valve leaflets were evaluated in response to norepinephrine (NE) and acetylcholine (ACH), the main neurotransmitters. At the same time, phentolamine (Phent), metoprolol (Metop), atropine (Atrop) and endothelial denudation were added to the reactive system. RESULTS: Under physiological conditions, the stiffness was not affected by endothelial denudation (p > 0.05). NE elevated the valve stiffness significantly per 10-fold increase in concentration (10-6 vs 10-7, p < 0.05; 10-5 vs 10-6, p < 0.05). This response was mitigated by Phent, Metop or endothelial denudation (p < 0.05), however, it was still increased significantly when compared to Controls (p < 0.05). ACH caused a decrease in stiffness accompanied by an increase in its concentration (significant change in stiffness per 10-fold increase in ACH concentration, 10-6 vs Control, p < 0.05; 10-5 vs 10-6, p 0.05 vs Control). CONCLUSION: These findings highlight the role of the autonomic nervous system in the regulation of the mechanical properties of porcine mitral valve cusps, which underline the importance of autonomic nervous status for optimal valve function.

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Artigo Original

Warfarin or Aspirin in embolism prevention in patients with mitral valvulopathy and atrial fibrillation

Paulo de Lara Lavitola et al. Roney Orismar Sampaio Walter Amorim de Oliveira Berta Napchan Bôer … Flavio Tarasoutchi Guilherme Sobreira Spina Max Grinberg

BACKGROUND: Atrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control. OBJECTIVE: To compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD. METHODS: A total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin – 200 mg/day (Group Aspirin – GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin – GW). RESULTS: There were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups. CONCLUSION: In patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.

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Case Report

Late spontaneous regression of obstructive tumor in the mitral valve

Cardiac rhabdomyoma is uncommonly found in the mitral valve. However, in the case reported, although the tumor was large (15×14 mm) and even caused obstruction at this level in the first months of life, its complete and spontaneous regression was observed as from 68 months of age, with progressive reduction until the patient was 14 years old.

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Artigo Original

Frequency of left ventricular diastolic dysfunction by mitral doppler in healthy elderly individuals

Luiz Sérgio Alves-Silva et al. Edmundo José Nassri Câmara Carlos Alfredo Marcílio de Souza

BACKGROUND: Healthy elderly individuals present alterations in mitral Doppler velocities, which are characteristic of left ventricular (LV) diastolic dysfunction with impaired relaxation. OBJECTIVE: To determine the frequency of LV diastolic dysfunction by mitral Doppler in healthy elderly individuals and identify clinical and echocardiographic characteristics associated to this finding. METHODS: Seventy-three apparently healthy individuals (64% women, aged 60 to 80) were carefully selected and submitted to clinical, laboratory and Doppler-echocardiographic assessment, with particular regard to the characteristics of the mitral flow. RESULTS: A total of 33 patients (45%) presented an impaired LV relaxation pattern (group I), characterized by the association between the maximum velocities of the mitral wave flow (E/A ratio) 240 ms, and 40 (55%) with a normal pattern (group II). Group I presented a larger aortic root diameter (32.1±4.2 vs 30.3±3.3 mm; p=0.044) and a longer PR interval (156±22 vs 139±23 ms; p=0.002). CONCLUSION: A large proportion of individuals aged 60 to 80 years present normal diastolic function at the Doppler-echocardiographic assessment of the mitral flow. Healthy elderly individuals with impaired LV relaxation filling have a larger aortic root diameter and longer PR interval.

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Artigo Original

Isolated mitral and aortic valve replacement with the St. Jude Medical valve: a midterm follow-up

Alfredo José Rodrigues et al. Paulo Roberto Barbosa Évora Solange Bassetto Lafaiete Alves Jr. … Adilson Scorzoni Filho Walter Villela A. Vicente

BACKGROUND: In our country, the biological valvular prostheses predominate, considering the difficulties related to anticoagulation, even in young patients, in spite of the need for repeated operations due to the degeneration of the bioprostheses. OBJECTIVES: To report our consecutive series of recipients of isolated St Jude Medical mechanical valve prosthesis in the mitral (MVR) or aortic (AVR) position. METHODS: Data from patients operated between January 1995 and December 2003 were revised in order to determine patient survival and prosthesis-related events up to December 2006. RESULTS: One hundred sixty eight patients had MVR and 117 had AVR. In the MVR cohort, the mean age was 45 years, 75% were 55 years old or younger, and 65% were females. In the ARV cohort, the mean age was 45 years, 66% were 55 years old or younger and 69% were males. Operative mortality for AVR and MVR was 7% and 7.5%, respectively. Freedom from late mortality was 81.8% at 10 years for MVR and 83% for AVR (p=0.752). Freedom from valve-related death at 10 years for the MVR cohort and AVR was 85.6% and 88.7%, respectively (p=0.698). In the MVR cohort, the freedom from reoperation was 97% and 99% in the AVR cohort (p=0.335). Freedom from thromboembolic events was 82% in the MVR cohort and 98% in the AVR cohort (p=0.049). Freedom from bleeding was 71% in the MVR cohort and 86% n the AVR cohort (0.579). Freedom from endocarditis was 98% in the MVR cohort and 99% in the AVR cohort (p=0.534). CONCLUSIONS: This series of predominantly young adult patients undergoing isolated MVR and AVR with the St Jude Medical mechanical prosthesis confirms the good performance of this valve prosthesis in agreement with previous reports.

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Artigo Original

Surgical mitral valve repair in children with rheumatic fever

Andréa Rocha e Silva et al. Gesmar Volga Haddad Herdy Alan Araujo Vieira Luiz Carlos Simões

BACKGROUND: Mitral repair is well accepted in children with rheumatic fever. OBJECTIVE: To analyze the outcomes of surgical mitral repair in children with rheumatic lesions after four years of follow-up. METHODS: Retrospective study of 40 patients younger than 18 years, who underwent surgery in the National Institute of Cardiology (Rio de Janeiro) between January 1998 and January 2003. The echocardiographic degree of mitral regurgitation; surgical technique used; pre and postoperative functional class; patient outcome; need for valve replacement; and deaths were analyzed. RESULTS: Twenty one patients (52.5%) were females. Severe mitral regurgitation was observed in 32 patients (80%) and moderate in eight (20%). Three immediate deaths occurred (7.5%). Three months after surgery, echocardiography showed no valve regurgitation or mild regurgitation in 35 of 37 cases (94.6%) patients, and severe regurgitation in two (5.2%). Thirty three cases (82.5%) were in functional class III or IV in the preoperative period, and three months after surgery all the 37 cases (100%) were in functional class I or II. The differences between the degree of mitral regurgitation and functional class in pre and postoperative periods were statistically significant (p<0.01). Seven (19%) patients underwent heart valve replacement before four years of follow-up. CONCLUSION: Mitral valve repair showed favorable results in most of the cases as regards the degree of mitral regurgitation and the pre and postoperative functional class. Only 19% of the patients required surgical valve replacement before four years of follow-up.

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Artigo Original

Unsupported valvuloplasty for degenerative mitral regurgitation: long-term results

Alexsandra L. Balbinot et al. Renato A. K. Kalil Paulo R. Prates João Ricardo M. Sant'Anna … Orlando C. Wender Guaracy Fernandes Teixeira Filho Rogério S. Abrahão Ivo A. Nesralla

BACKGROUND: The advantages of valve repair for treatment of degenerative mitral regurgitation are well established. The procedure is associated with low mortality and morbidity rates, and low indices of reoperation, thromboembolic events and endocarditis have been reported. In most series, annuloplasty rings are implanted, but some institutions give preference to unsupported valvuloplasty. OBJECTIVE: To assess the clinical outcome of patients submitted to unsupported valvuloplasty for degenerative mitral regurgitation. METHODS: Between January 1980 and January 2003, 116 patients were submitted to the procedure. A total of 62 (53.4%) were men, and mean age was 47.2 ± 16.5 years. The procedures included: Wooler annuloplasty (65.5%), unilateral annuloplasty (15.5%), quadrangular resection of the posterior leaflet (35.3%), anterior chordal shortening (20.7%), posterior chordal shortening (6.9%), and calcium debridement (0.9%). Mean follow-up was 6.5 ± 5.1 years, and the longest follow-up was 24 years. RESULTS: Mortality was 0.86% (1 pt) early and 6.03% (7 pt) late. Actuarial survival was 85.3% in 20 years. Most patients (55.2%) presented preoperative NYHA functional class III, whereas class I was more frequent in the postoperative period (66.4%). Thromboembolic complications were observed in 4 patients (3.4%), and no correlation was seen with atrial fibrillation. Freedom from thromboembolic events was 94.8%, and similar results were observed for bacterial endocarditis. Survival free from reoperation was 79%, and 53% at 5 and 10 years, respectively. CONCLUSION: Unsupported valvuloplasty is effective and safe for treatment of degenerative mitral regurgitation, representing an adequate therapeutic alternative for selected cases.

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Artigo Original

Hypoplastic left heart syndrome: the influence of surgical strategy on outcomes

José Pedro da Silva et al. Luciana da Fonseca José Francisco Baumgratz Rodrigo Moreira Castro … Sonia Meiken Franchi Cristina de Sylos Liliane M. G. Pozzi Grassi César Augusto M. Cattani Lílian Maria Lopes José Henrique Andrade Vila

OBJECTIVES: To report a surgical strategy for the Norwood procedure in the hypoplastic left heart syndrome (HLHS) that enables short hypothermic circulatory arrest time and aortic arch reconstruction with autologous pericardium patch, and to compare the results of the modified Blalock-Taussig (mBT) shunt with the right ventricle-to-pulmonary artery (RV-PA) conduit procedures as the source of pulmonary blood flow. METHODS: Retrospective study of 71 newborns with HLHS consecutively operated between March, 1999 and February, 2006. One technique for reconstruction of the neoaorta and two different techniques for reestablishment of the pulmonary blood flow were used: the mBT shunt in the first 37 newborns and RV-PA conduit in the last 34. Cannulation of the ductus arteriosus for arterial perfusion was the main part of the surgical strategy to reduce the hypothermic circulatory arrest time. RESULTS: In-hospital survival for the entire cohort was 74.64%, or 67.57% and 82.35% for the mBT shunt and RV-PA conduit groups, respectively (p=0.1808). Mortality rates between the first and second palliation stages were 40% and 4.4% for the mBT shunt and RV-PA conduit groups, respectively (p=0.0054). Hypothermic circulatory arrest times were 45.79±1.99 min and 36.62±1.62min (p=0.0012), respectively. Late coarctation of the aorta occurred in five patients (7.2%). CONCLUSION: This surgical strategy resulted in short circulatory arrest time, low mortality and favorable morphology of the neoaorta, with low incidence of late coarctation of the aorta. The higher rate of survival to first palliation stage with the RV-PA conduit was not significant, but interstage mortality was statistically lower when compared with the modified Blalock-Taussig shunt procedure.

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Case Report

Patient with von Willebrand disease undergoing mitral valve repair: a strategy for the control of the coagulopathy

Ally Nader Roquetti Saroute et al. Carlos Manuel de Almeida Brandão Marco Antônio Vieira Guedes Cyrillo Cavalheiro Filho Pablo Maria Alberto Pomerantzeff

We report a case of a 60 year-old woman with von Willebrand disease type I that was submitted to a mitral valve repair. The patient needed special care due coagulopathy and needed VIII factor (VIIIf) and von Willebrand factor (vWf), before, during and after surgery. There was no complication during or after surgery. Patient is asymptomatic nine months postoperatively. The correction of VIIIf and vWf allowed the realization of a safety surgery.

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Original Article

Surgical treatment of partial atrioventricular septal defect: functional analysis of the mitral valve in the postoperative period

Josué Viana Castro Neto et al. Paulo Chaccur Cláudio Leo Gelape Eliseu de Sousa Santos … Hélio Carlos Falcão Mário Issa Antoninho Sanfins Arnoni Flávio Sanches Almeida Camilo Abdulmassih Neto Jarbas Jackson Dinkhuysen Luís Carlos Bento Souza Paulo Paredes Paulista

OBJECTIVE: To study mitral valve function in the postoperative period after correction of the partial form of atrioventricular septal defect. METHODS: Fifty patients underwent surgical correction of the partial form of atrioventricular septal defect. Their mean age was 11.8 years and 62% of the patients were males. Preoperative echocardiography showed moderate and severe mitral insufficiency in 44% of the patients. The mitral valve cleft was sutured in 45 (90%) patients (group II – GII). Echocardiographies were performed in the early postoperative period, and 6 and 12 months after hospital discharge. RESULTS: The patients who had some type of arrhythmia in the postoperative period had ostium primum atrial septal defect of a larger size (2.74 x 2.08 cm). All 5 patients in group I (GI), who did not undergo closure of the cleft, had a competent mitral valve or mild mitral insufficiency in the preoperative period. One of these patients began to have moderate mitral insufficiency in the postoperative period. On the other hand, in GII, 88.8% and 82.2% of the patients had competent mitral valve or mild mitral insufficiency in the early and late postoperative periods, respectively. CONCLUSION: The mitral valve cleft was repaired in 90% of cases. Echocardiography revealed competent mitral valve or mild mitral insufficiency in 88.8% and 82.2% of GII patients in the early and late postoperative periods, respectively.

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