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This study reports incidence of thromboembolic episodes in a series of 349 patients where the St. Jude Medical (SJM) valve was implanted in the mitral position (252 isolated mitral, 91 mitral and aortic, 4 triple valve and 2 mitral and tricuspid valve replacements). The mean follow up was 28 months (range 6 to 57 months) which represents 784 patient-years. Overall operative mortality was 15 patients (4.3%). There were no valve-related deaths. Late post-operative prosthetic thrombosis occurred in 3 poorly anticoagulated patients (0.4% patient-years). A further 4 patients had a thromboembolic episode (0.5% patient-years). The overall frequency of thromboembolic episodes was 0.9 events per 100 patient-years. Per- and post-operative anticoagulation methods are described. The frequency of thromboembolism was studied with respect to the performance of SJM valve analyzed by echocardiography regardless the positioning of the prosthesis in the mitral ring. Our experience indicates that the SJM valve offers an excellent alternative in the choice of mechanical valve.

Es wurden drei verschiedene Mitralklappenmodelle konstrulert, mit denen die Mechanismen fur die konkordante Bewegung der hinteren und vorderen Klappe bei Mitralstenosen untersucht wurden. Drei Bewegungsarten des Systems sind moglich: Bewegung des Mitralringes dorsoanterior, eigentliche Offnungs-und Schliesbewegung der Klappe sowie eine Torsion des gesamten Mitralklappenapparates. Die wahrscheinlichste Ursache fur die konkordante Bewegung der hinteren Klappe liegt aufgrund unserer In-vitro-Untersuchungen darin, das in der fruhdiastolischen Offnungsphase der Klappen der gesamte stenotische Klappenapparat nach oben, d. h. auf den Transducer hin, torquiert bzw. verdreht wird, wobei die Amplitude der Torsion groser ist als eine eventuell verbliebene Restoffnungsbewegung der hinteren Klappe.

The sensitivity and specificity of previously described 2-dimensional echocardiographic signs of mitral valve prolapse (MVP) were assessed in 70 patients with MVP and in 100 normal control subjects. Specificity of individual signs was uniformly high, ranging from 88% for excessive motion of the posterior mitral ring to 100% for several signs including systolic arching in the parasternal long-axis view, excessive posterior coaptation and diastolic doming of the anterior mitral leaflet. Sensitivity of individual signs was low to moderate, ranging from 1% for whip-like motion of both mitral leaflets to 70% for excessive posterior coaptation of the mitral leaflets in the apical 4-chamber view. The highest sensitivity value (87%) was associated with the presence of systolic arching of 1 or both mitral leaflets in the parasternal long-axis view or systolic bowing of 1 or both mitral leaflets in the apical 4-chamber view or excessive posterior coaptation of the mitral leaflets or a combination. This increase in sensitivity was achieved without sacrificing specificity (97%). Thus, the individual 2-dimensional echocardiographic signs tested possess uniformly high specificity, but only low to moderate sensitivity; however, sensitivity can be markedly enhanced without sacrificing specificity by using selected combinations of echocardiographic signs.

The necropsy observations on an unusual and rare cardiac aneurysm in a child are reported. The anatomic characteristics of the structure suggest that it was a congenital abnormality arising from the fibrous band of the mitral ring.

Five subjects with prosthetic Starr-Edwards valve replacement of the mitral valve were studied in order to delineate the transmission characteristics of the sounds produced by this valve. In sharp contrast to the first (so-called "mitral") component of the first sound, this sound, arising at the mitral ring, arrived earlier on the surface of the chest in the third and fourth left interspaces near the sternal edge as compared to the apex. This was well correlated to the location of the prosthetic valve as seen from roentgenogram of the chest. It is concluded that the transmission of sound from the prosthetic mitral valve is mainly in the form of transverse vibrations. Different transmission characteristics of this sound, as compared to the first component of the first heart sound, indicate a different source for the two sounds.

In this report, we present a case of supravalvular stenotic mitral ring in a child. The lesion created a picture of severe mitral stenosis and was successfully managed by resection of the ring. No other malformations of the mitral apparatus or left ventricular outflow tract were found. On analyzing the diagnostic criteria, we concluded that there appears to be only one useful criterion—the angiographic morphology. However, when there is an associated ventricular septal defect or findings of Shone's complex, we should suspect supravalvular ring rather than any other form of mitral stenosis.

We describe a patient with a long-standing dehiscence of a Carpentier ring and severe mitral insufficiency. The nature of the abnormality, which was suggested by transthoracic echocardiography, was definitively diagnosed by transesophageal echocardiography and was confirmed by surgery

Measurement of quantitative data from the time-motion echocardiogram of the mitral valve is often difficult. One-dimensional echo beams usually intercept the anterior mitral leaflet in a variety of places during the cardiac cycle and, most likely, do not accurately reflect the total motion of the entirety of the leaflet. Changes in the geometric configuration of the anterior mitral leaflet and its cyclic spatial relationships to the mitral ring were studied in twenty normal volunteers using a real time, two-dimensional, phased array imaging system. All patients were in normal sinus rhythm and were studied at rest. Breath was held at end expiration. Scans were obtained through both the long and short axes of the mitral valve.

A large surplus portion of the mitral leaflets appears to be involved in the systolic anterior motion (SAM) of the mitral valve in hypertrophic cardiomyopathy (HCM). To understand the exact features and the mechanism of the surplus leaflet, we studies the mitral valve and its ring quantitatively with two-dimensional echocardiography in 17 patients with HCM (5 with large SAM, 6 with small SAM and 6 without SAM) and 10 normal subjects. In the large SAM group, the surplus length of the anterior mitral leaflet (AML) increased but that of the posterior mitral leaflet (PML) did not increase when compared to the other 3 groups. In the large SAM group, the length of AML was greater than in the normal group and the length of PML was greater than in the other 3 groups. The mid-systolic anteroposterior diameter of the mitral ring did not differ among the 4 groups. The mid-systolic position of the coaptation was more anterior in the large SAM group than in the other 3 groups. In conclusion, the surplus size of AML is actually increased in the patients with HCM and large SAM, which is caused by the elongation of both AML and PML with anteriorly displaced coaptation and with no dilation of the mitral ring.

Echocardiograms were recorded in two patients with suspected aortic root dissection. In the first patient with a massive pulmonary embolus, a simultaneous recording of the mitral ring and posterior aortic wall created a pattern similar to true posterior aortic wall dissection; in the second patient with severe generalized atherosclerosis, thickened aortic walls recorded echocardiographically were found at autopsy to be atherosclerotic plaques. These cases emphasize the potential for the false positive ultrasonic diagnosis of aortic root dissection.

Left ventricular inflow obstruction (LVIO) in children can be caused by rare congenital abnormalities such as cor-triatriatum (CT), supra-valvar mitral ring (SVMR), and mitral valvar stenosis, either isolated (MS), or as part of a parachute mitral valve (PMV).

An identifiable ultrasound “echo” can be received, it is believed, from the mitral ring. Ring movement may thus be recorded in the intact subject. The recording shows a ventricular dimension type of curve, characteristically different from the well-known mitral valve echo pattern. Recorded from the apical area in 25 normal subjects, the movement amounted to 1·6 ± 0·4 cm, and the curve contour was remarkably constant. Deviations from normal were seen in heart disease.

Several empirical observations made during ultrasound examinations for pericardial effusion have led to the possibility that this diagnostic technique might be used to measure left ventricular stroke volume in man. The hypothesis that left ventricular stroke volume was proportional to the amplitude of an echo originating from a portion of the left ventricle near the mitral ring (MREa) times the distance between the echoes from the anterior and posterior ventricular walls (LVD) has been validated. Ultrasound examinations were performed simultaneously with cardiac output determinations using the direct Fick method on 16 patients proven to have competent mitral and aortic valves. Correlation between the two methods of measuring left ventricular stroke volume was excellent (r = 0.973; P < 0.001). When ultrasound measurements were used in the regression equation to predict stroke volume, the calculated values were within 11 ml or 15% of those determined by the Fick method. The fact that an ultrasound examination is simple, can be done as a bedside determination in a matter of minutes, and is totally harmless to the patient make it a promising diagnostic procedure. The measurement of left ventricular stroke volume represents another addition to the growing list of medical uses for this intriguing technique.

A new surgical procedure for correction of mitral insufficiency is presented. The clinical and hemodynamic results in 12 cases are discussed.

Extreme care must be taken in the production of experimental mitral stenosis in dogs by the method of controlled progressive constriction of the mitral ring in order to prevent the inadvertent constriction of the thoracic inferior vena cava and resultant elevation of the inferior caval pressure. After a report from Hamilton, Ellison, Hague and Brown (Georgia Laboratories) that ascites formation was a common occurrence in dogs with experimental mitral stenosis produced by this technique, an attempt was made by Davis and Howell (Bethesda workers) to repeat these observations. From experiments performed in Bethesda, it was found that a stricture of the thoracic inferior vena cava was produced when the Georgia technique for production of mitral stenosis was used; this constriction provided an explanation for the ascites formation. These results were communicated to the Georgia workers who explored the two surviving dogs of their first series and found evidence which suggested that the inferior vena cava was patent even though the dogs were producing ascites profusely. Later, the Georgia group produced mitral stenosis in two additional dogs by the original technique and these animals gave unequivocal evidence that the stricture was present. Great care was then taken by the Georgia workers in placing the constricting ligature to avoid stricture of the orifice of the inferior vena cava. Of the 13 dogs so treated only 1 produced ascites and it had a small obstruction in the inferior vena cava. These last experiments by the Georgia workers as well as those of the Bethesda group suggest that ascites does not occur secondary to experimental mitral stenosis in dogs.

Thirty cases were evaluated in order to study the etiology of prosthetic valvular dehiscence in view of its continued occurrence in a small percentage of cases. The clinical course, management, initial valvular pathology, as well as findings at reoperation and necropsy were the main basis of this study. Factors in the genesis of prosthetic valvular dehiscence in the early and late groups seemed to be distinctly different. Of the 24 patients in the early group, defined as those with evident regurgitation within six months of the operation, in 12 the stitches, which were well tied in, had come loose from the tissue bed. The left ventricular contraction was believed to be the disrupting force in at least six patients with grossly dilated mitral ring.

The movements of two ultrasound echo signals, believed to arise from the anterior mitral leaflet and from the mitral ring, were studied in 30 normal subjects and in 100 heart-catheterization patients. Fifty patients had proven mitral stenosis. The echo from the anterior mitral leaflet is shown to have a complex pattern of movement. This pattern is analyzed into the opening and closing movements of the leaflet, and the underlying movement transmitted from the mitral ring. In the normal condition, the characteristic feature of leaflet motion is a sharp closing movement that follows the initial opening in diastole. This sharp closing movement is not seen in the presence of mitral stenosis. It is believed that the demonstration of a sustained wide-open poisition of the leaflet in diastole has the same diagnostic significance as the finding of a persistent positive-pressure gradient across the valve. The value of this method in diagnosing the severity of the stenosis is discussed.

The most important observations in regard to the "P" wave of the human electrocardiogram have been those concerning its changes in mitral stenosis. Various workers, including Einthoven, 1 Krauss and Nicolai, 2 and Samjoloff, 3 have called attention to an increase in height and often also a broadening of the P wave in this disease. To quote the last: Wir fanden ebenfalls bei Mitralstenose Verstarkung und meist auch Verlangerung der P-Erhebung. (We found likewise in mitral stenosis an augmentation, and generally also a prolongation of the P wave.) Since the increase in the height of the P wave has been thought due to the auricular hypertrophy resulting from the narrowing of the mitral ring, it would be reasonable to believe that auricular hypertrophy, the result of any other pathological change, would have the same effect. Hence it has been the custom at this station to consider high

RationaleRemodeling concept annuloplasty is one of the golden rule of long term efficacy of mitral valve reconstruction using Carpentier's techniques. Sizing is a key issue to avoid undersizing (risk of SAM) or oversizing (residual MR) in degenerative mitral regurgitation (MR). There are no studies who try to predict the accurate ring annuloplasty size based upon echocardiographic measurement of the height of anterior leaflet height (A2)AimTo establish a correlation between height of the anterior leaflet height (A2) measured by intra-operative (IOE) transesophageal echocardiography (TEE) and annuloplasty ring size measured by surgeons in type II degenerative MR.MethodProspective monocentric study. Measurement of the height of anterior leaflet (A2) in long axis view using multiplane IOE TEE (pre pump) and mitral annuloplasty ring size (Carpentier-Edwards Physio) measured systematically by surgeons with sizers. Intra Class Correlation test and Bland-Altman plot were done.ResultsFifty patients were included. The mitral ring diameter was 41.4mm +/− 3.7. The anterior leaflet height was 32.7mm +/− 2.9. Size of annuloplasty ring was 32.8mm +/− 2.9. The anterior leaflet height was significantly correlated with the prosthetic ring used, r=0.869 [0.780, 0.923], p