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This study evaluates the efficacy of annuloplasty repair as a standalone procedure for treating bileaflet mitral valve prolapse with mitral regurgitation (MR). Various flexible ring bands for MR of different severities were compared to assess their biomechanical impact and treatment outcomes. Computational beating heart models, based on the Living Heart Human Model, were utilized to simulate annuloplasty repairs. Repairs using bands of varying lengths were modeled on moderate and severe MR cases, considering bileaflet mitral valve prolapse. Key parameters, including regurgitant orifice area (ROA), prolapse severity, coaptation length, leaflet position, and deformation, were computed to compare conditions before and after implantation. Annuloplasty repairs effectively reduced the ROA in both moderate and severe MR cases, achieving complete sealing in selective instances. Additionally, annuloplasty repair corrected bileaflet prolapse, with prolapse severity decreasing as the annular size increased. Successful coaptation was indicated by the expansion of each leaflet’s contact area distribution and percentage in contact with the opposing leaflet. The risk of systolic anterior motion, that may obstruct the left ventricular outflow tract, was minimized, as the anterior leaflet was directed towards the posterior position. In conclusion, annuloplasty repair alone can effectively treat MR when an appropriate band length is selected. It facilitates a significant reduction in ROA, correction of bileaflet prolapse, and improvement in leaflet coaptation. These findings have important clinical implications, potentially offering a less complex surgical treatment avenue and reducing complications in the management of MR.

Mitral annular disjunction (MAD) is a controversial entity. Recently, a distinction between pseudo-MAD, present in systole and secondary to juxtaposition of the billowing posterior leaflet on the left atrial wall, and true-MAD, where the insertion of the posterior leaflet is displaced on the atrial wall both in diastole or in systole, has been proposed. We investigated the prevalence of pseudo-MAD and true-MAD. This was a retrospective study, including consecutive patients referred to cardiovascular magnetic resonance (CMR). MAD was defined as a ≥1 mm displacement between the left atrial wall-mitral valve leaflet junction hinge and the top of the left ventricular wall, measured from cine-CMR images in the three long-axis views. Pseudo-MAD and true-MAD were defined as the presence of MAD only in systole or both in systole and diastole, respectively. Two hundred and ninety patients (59 [47–71] years; 181/290 men, 62%) were included. Mitral valve prolapse (MVP) and MAD were found in 24/290 (8%) and 145/290 (50%) patients, of which 100/290 (35%) with true-MAD and 45/290 (16%) with pseudo-MAD. In all measurements, systolic MAD extent (2.3 [1.7–3.0] mm) resulted equal to or greater than diastolic MAD extent (2.0 [1.5–2.9] mm). The most frequent MAD location was the inferior wall (117/290, 40%) and the inferolateral wall was the rarest (50/290, 17%). In patients with MVP, the prevalence of MAD was higher (21/24, 88%), mainly driven by a higher prevalence of pseudo-MAD, as the prevalence of true-MAD did not vary significantly in patients with vs without MVP (p = 0.22), except for the inferolateral wall (9/24, 38% vs 20/266, 8%; p < 0.001). The extent of pseudo-MAD was greater in patients with MVP (4.0 [3.0–5.6] mm) than in those without MVP (2.0 [1.5–3.0]; p < 0.001), whereas the extent of true-MAD did not differ significantly (2.5 [2.0–3.2] mm and 1.9 [1.5–2.9] mm; p = 0.06). At the inferolateral wall, the prevalence of pseudo-MAD was 7/24, 29% vs 14/266, 5% (p < 0.001) in patients with vs without MVP. True-MAD was a common imaging finding in patients undergoing CMR, irrespective of MVP. Patients with MVP showed higher prevalence and extent of pseudo-MAD in all locations and true-MAD in the inferolateral wall [Display omitted]

Mitral annular disjunction (MAD) is routinely diagnosed by cardiac imaging, mostly by echocardiography, and shown to be a risk factor for ventricular arrhythmias. While MAD is associated with mitral valve (MV) prolapse (MVP), it is unknown which patients with MAD are at higher risk and which additional imaging features may help identify them. The value of cardiac computed tomography (CCT) for the diagnosis of MAD is unknown. Accordingly, we aimed to: (1) develop a standardized CCT approach to identify MAD in patients with MVP and severe mitral regurgitation (MR); (2) determine its prevalence and identify features that are associated with MAD in this population. We retrospectively studied 90 patients (age 63 ± 12 years) with MVP and severe MR, who had pre-operative CCT (256-slice scanner) of sufficient quality for analysis. The presence and degree of MAD was assessed by rotating the view plane around the MV center to visualize disjunction along the annulus. Additionally, detailed measurements of MV apparatus and left heart chambers were performed. Univariate logistic regression analysis was performed to determine which parameters were associated with MAD. MAD was identified in 18 patients (20%), and it was typically located adjacent to a prolapsed or flail mitral leaflet scallop. Of these patients, 75% had maximum MAD distance > 4.8 mm and 90% > 3.8 mm. Female gender was most strongly associated with MAD (p = 0.04). Additionally, smaller end-diastolic mitral annulus area (p = 0.045) and longer posterior leaflet (p = 0.03) were associated with greater MAD. No association was seen between MAD and left ventricular size and function, left atrial size, and papillary muscle geometry. CCT can be used to readily detect MAD, by taking advantage of the 3D nature of this modality. A significant portion of MVP patients referred for mitral valve repair have MAD. The presence of MAD is associated with female gender, smaller annulus size and greater posterior leaflet length.

The mitral annulus plays an important role in leaflet coaptation, in unloading mitral valve closing forces, and in promoting left atrial and left ventricular filling and emptying. Perturbations of annular mechanics figure prominently in a number of disorders including functional and ischemic mitral regurgitation, mitral valve prolapse, atrial fibrillation, mitral annular calcification, and annular submitral aneurysm. This review discusses the role of annular dysfunction in the pathogenesis of these disorders.

Background Two surgical techniques, leaflet resection and leaflet preservation, are widely used for mitral valve repair in severe mitral regurgitation due to posterior mitral leaflet prolapse. However, which technique is superior remains unclear. The leaflet resection technique may affect the postoperative mitral valve function differently from the leaflet preservation technique because it causes anatomical alterations in the corrected leaflet. We aimed to evaluate the effect of the leaflet resection technique on mitral valve mobility, compared with that of the leaflet preservation technique. Methods Forty-one patients underwent mitral valve repair for P2 prolapse. Among them, 27 underwent leaflet preservation and 14 underwent leaflet resection. We examined the effects of the leaflet resection technique on the mitral valve mobility. Results Postoperatively, the mobility of the corrected leaflet was significantly decreased in the leaflet resection group (leaflet preservation: 35.1 ± 13.8 vs. leaflet resection: 22.7 ± 13.7°, p = 0.009). Particularly, the maximum closed angle was significantly decreased (leaflet preservation: 29.1 ± 11.4° vs. leaflet resection: 40.7 ± 12.0°, p = 0.004). Therefore, the closing motion of the resected leaflet was more restricted than its opening motion. Mitral valve function, including mitral valve area, and peak and mean transmitral pressure gradients were comparable in both groups. Conclusions Although there were no differences in the mitral valve function, the leaflet preservation technique may be more effective than the leaflet resection technique at preserving the corrected leaflet mobility.

With a prevalence of 2–3% in the general population, mitral valve prolapse (MVP) is the most common valvular heart disease. The clinical course is benign in the majority of patients, although severe mitral regurgitation, heart failure, and sudden cardiac death affect a non-negligible subset of patients. Imaging of MVP was confined to echocardiography until a few years ago when it became apparent that cardiovascular magnetic resonance (CMR) could offer comparative advantages for detecting and quantifying mitral valve abnormalities alongside tissue myocardial characterization. The present review highlights the growing body of evidence supporting the role of CMR in patients with MVP. Based on the recent literature, CMR appears not as a simple alternative to echocardiography in patients with poor acoustic windows, but as a complementary imaging modality instrumental for better quantifying mitral valve abnormalities, mitral regurgitation severity, ventricular remodeling, and myocardial tissue changes. In this respect, pivotal CMR studies highlight that mitral annular disjunction and myocardial fibrosis by late gadolinium enhancement are associated with a heightened risk of life-threatening ventricular arrhythmias (arrhythmic MVP). We also delineate how these and other markers (e.g., the severity of mitral regurgitation) could enable a personalized risk assessment in patients with MVP and implement clinical decision-making. Here, we provide a comprehensive review of the current literature, with an emphasis on the arrhythmic MVP phenotype. The review also provides some practical suggestions on how to carry out a dedicated CMR protocol in MVP and composes a thorough report to inform clinicians on key aspects of this valvular heart disease. [Display omitted]

Background Percutaneous balloon mitral valvuloplasty (PBMV) is the ACC/AHA class I recommendation for treating symptomatic rheumatic mitral stenosis with suitable valve morphology, less than moderate MR and absence of left atrium clot. The mitral valve restenosis and significant mitral regurgitation (MR) are known adverse outcomes of PBMV. This study aimed to evaluate the outcomes of PBMV in patients with severe mitral stenosis and the effect of Commissural Calcification (CC) on the outcomes. Methods In this single-center retrospective cohort study, 876 patients who underwent PBMV were categorized into three groups based on their Wilkins score (Group I: score ≤ 8, Group II: score 9–10, and Group III: score 11–12). Patients were evaluated before, early after PBMV and at 6- and 24-month follow-ups. Main clinical outcomes were defined as significant restenosis and or symptomatic significant MR (moderate to severe and severe MR) or candidate for mitral valve replacement (MVR). The outcomes were compared between patients with and without CC. Results A total of 876 patients with mean age 46.4 ± 12.3 years (81.0% females) were categorized based on Wilkins score. 333 (38.0%) were in Group I, 501 (57.2%) were in Group II, and 42 (4.8%) were in Group III. CC was present in 175 (20.0%) of the patients, among whom 95 (54.3%) had calcification of the anterolateral commissure, 64 (36.6%) had calcification of the posteromedial commissure, and in 16 (9.1%) patients both commissures were calcified. There was a significant difference in Wilkins score between patients with and without CC ( P  < 0.001). CC was associated with higher odds of significant symptomatic MR at early and mid-term follow up (OR: 1.69, 95%CI 1.19–2.41, P  = 0.003; and OR: 3.90, 95%CI 2.61–5.83, P  < 0.001, respectively), but not with restenosis ( P  = 0.128). Wilkins Groups II and III did not show higher odds of significant symptomatic MR compared to Group I at early (II: P  = 0.784; III: P  = 0.098) and mid-term follow up (II: P  = 0.216; III: P  = 0.227). Patients in Wilkins Group II had higher odds of restenosis compared to Group I (OR: 2.96,95%CI: 1.35–6.27, P  = 0.007). Conclusion Commissural calcification (CC) is an independent predictor of the significant symptomatic MR (an important determinant of adverse outcome) following PBMV in the early and mid-term follow-up. Mitral valve restenosis occurs more in patients with higher Wilkins score compared to group I with score ≤ 8. Combined Wilkins score and CC should be considered for patient suitability for PBMV.

Objectives Mitral valve repair for Barlow’s disease offers good outcomes but excessive and myxomatous valvular tissue is associated with systolic anterior motion. Although valvular disease might progress after repair and cause long-term systolic anterior motion, few reports focus on this aspect. Herein, we will review our 16-year experience with mitral valve repair for Barlow’s disease and systolic anterior motion incidence. Methods We retrospectively reviewed surgical outcomes of 92 cases of mitral valve repair using a balanced leaflet/large ring strategy plus median sternotomy for Barlow’s disease (median age 45.1 ± 12.7 years old [19–72], 37 females) from 2004 to 2019. Concomitant surgeries, except for tricuspid valve or anti-arrhythmic surgeries, were excluded. Results The follow-up period was 5.8 ± 4.4 years with no deaths. Patients had mitral regurgitation of grade 3/4 (15 cases) or 4/4 (77 cases) due to anterior leaflet (3 cases), posterior leaflet (75 cases), or bileaflet (14 cases) prolapse, with chord elongation (39 cases), chord rupture (22 cases), or a combination of both (14 cases). All cases required ring annuloplasty (median size of 33.0 ± 5.4 mm) combined with leaflet resection (91 cases), chord intervention (12 cases), or indentation closure (2 cases). No case had short- or long-term SAM. The freedom-from-mitral-regurgitation (of greater than grade 2/4) rate was 94.1% over 5 years and 76.0% over 10 years without reoperation. Conclusions Our two-pronged strategy for mitral valve repair in Barlow’s disease avoids systolic anterior motion over the long-term, with good outcomes.

Abstract Objectives Repairing severe mitral regurgitation (MR) in patients with degenerative bileaflet prolapse and reduced left ventricular ejection fraction (LVrEF) is challenging. The Free Margin Running Suture (FMRS) technique offers a non-resectional approach, but mid-term data are limited. Methods We analysed 28 patients with bileaflet degenerative MR and LVrEF (≤40%) undergoing FMRS. Primary outcomes were mid-term survival and MR recurrence; secondary outcomes included LVEF, in-hospital complications, transmitral gradient, coaptation length, and mitral valve orifice area. Results Mean age was 59.3 ± 12.8 years; 69.4% were male. No perioperative deaths; 1 patient required ECMO. Mean aortic cross-clamp time was 47 ± 18.6 min. Over 4.7 years, survival was 100%, with 1 case of moderate MR recurrence. At follow-up, LVEF improved to 43.04 ± 2.26 (P < 0.001), and all patients were NYHA I-II. Conclusions FMRS is a minimally invasive, reproducible technique providing durable repair, symptomatic improvement, and excellent mid-term survival. Mitral valve (MV) repair is the surgical intervention of first choice in degenerative primary mitral regurgitation (MR). Graphical Abstract

ObjectivesCleft-like indentations (CLI) are deep separations between scallops of the mitral posterior leaflet observed in myxomatous mitral valve disease (MMVD), but their diagnosis, mechanisms and implications are unknown. Using 3D transoesophageal echocardiography (3DTOC), we aimed at assessing diagnostic accuracy and defining mechanisms of CLI in patients undergoing surgery for MMVD.Methods3DTOC of mitral valve was acquired in 49 patients with MMVD and severe regurgitation prior to valve repair. Qualitative review compared 3DTOC diagnosis of CLI with surgical inspection. Mitral, annular and leaflet dimensions were quantified with dedicated software and compared between those with and without CLI.ResultsDiagnosis of CLI was made by 3DTOC in 17 (35%) while none was identified by 2D and was confirmed in 15 (88%) by surgical inspection. Mechanistically, LV diameters and mitral regurgitant volume (RVol) were similar with and without CLI (p>0.49). Conversely, mitral annulus was smaller with CLI (anteroposterior diameter 42.2±7.1 vs 47.0±7.5 mm, p=0.04; circumference 133±16 vs 148±19 mm, p=0.009; area 1289±326 vs 1619±427 mm2, p=0.008). Prolapse volume tended to be smaller with CLI (1.9±1.2 vs 4.0±4.3 mL, p=0.06) involving single posterior scallop at surgery (82% vs 44%, p=0.007) with smaller 3DTOC leaflet area (1574±409 vs 2019±652 mm2, p=0.01). During valve repair, surgical closure of all surgically diagnosed CLI was required.ConclusionsPosterior leaflet CLI are frequent in MMVD, are identified by 3DTOC with high accuracy and require closure during valve repair. CLI are mechanistically not related to excess annular enlargement or excess prolapse. Conversely, CLI occur in the context of single scallop prolapse with tissue paucity causing excess separation of scallops. These 3DTOC data enhance diagnostic and mechanistic comprehension of the diversity of MMVD phenotypical presentation.