Mitral valve endocarditis is most often due to infection by either Streptococcal or Staphylococcal bacteria. The principal organisms involved in native valve endocarditis are Streptococcus viridians or bovis and Staphylococcus aureus.
Mitral Valve Surgery, it is important to stress that the selection of the authors and their work(s) has been based on major medical bibliography references. We have read and analyzed their work using the primary sources in almost every instance. They were extracted from a large personal collection on the history of cardiovascular medicine.
This website (http://www.themitralvalve.org/) was designed to support you, the patient, or caregiver, through the entire heart-valve surgery process from diagnosis to recovery and provide various suggestions and tips to control heart related problems by medication and other performed tasks as per cardiologist prescriptions and suggestions.
The pathophysiological triad is composed of etiology (cause of the disease), valve lesions (resulting from the disease) and valve dysfunction (resulting from the lesions). These distinctions are relevant because long-term prognosis depends on etiology, whereas treatment strategy and surgical techniques depend on valve dysfunctions and lesions respectively.
Carpentier’s functional classification of mitral valve disease is used to describe the mechanism of valvular dysfunction.This classification is based on the opening and closing motions of the mitral leaflets. Valvular dysfunction may present four functional types in the setting of mitral regurgitation. Patients with type I dysfunction have normal leaflet motion with the free edges of the leaflets positioned 5 to 10 mm below the plane of the annulus. Mitral regurgitation in these patients is due to annular dilatation, or leaflet perforation or tear. There is an increased leaflet motion in patients with type II dysfunction with the free edge of one or more leaflets overriding the plane of the annulus during systole (leaflet prolapse). The most common lesions leading to type II dysfunction are chordae elongation or rupture, and papillary muscle(s) elongation or rupture. Patients with type IIIa dysfunction have a restricted leaflet motion during both diastole and systole. The most common lesions are leaflet thickening retraction,chordae thickening shortening or fusion, and commissural fusion encountered in rheumatic valve disease. Mitral regurgitation is usually associated with varying degrees of mitral stenosis. The mechanism of mitral regurgitation in Type IIIb dysfunction is restricted leaflet motion during systole. Left ventricular enlargement leading to apico-lateral papillary muscle displacement and chordae tethering causes this type of valve dysfunction. From Carpentier A, Adams DH, Filsoufi F. Carpentier’s Reconstructive Valve Surgery. Saunders (Elsevier), 2010.
The functional classification is further refined by segmental valve analysis which allows the precise localization of leaflet dysfunction which is of significant importance while performing reconstructive surgery.The mitral valve is ided into 8 segments. Antero-lateral and postero-medial commissures are two segments. Two indentations on the posterior leaflet ide this structure into 3 anatomically distinct scallops. The three scallops of the posterior leaflet are identified as
P1 (anterior scallop), P2 (middle scallop), and P3 (posterior scallop). The three corresponding segments of the anteriorleaflet are named A1 (anterior segment), A2 (middle segment), and A3 (posterior segment).
From Carpentier A, Adams DH, Filsoufi F. Carpentier’s Reconstructive Valve Surgery. Saunders (ElFrom Carpentier A, Adams DH, Filsoufi F. Carpentier’s Reconstructive Valve Surgery. Saunders (Elsevier), 2010. Preoperatively, the functional classification and segmental analysis allow the echocardiographer to determine the precise localization of valvular dysfunction in patients with mitral valve disease. Intraoperatively, it enables the surgeon to proceed to a full analysis of valvular lesions in the segments where a dysfunction has been deteFrom Carpentier A, Adams DH, Filsoufi F. Carpentier’s Reconstructive Valve Surgery. Saunders (Elsevier), 2010
From Carpentier A, Adams DH, Filsoufi F. Carpentier’s Reconstructive Valve Surgery. Saunders (Elsevier), 201Valvular dysfunctions and corresponding lesions and etiologies are summarized here. It is remarkable to notify the contrast between the complexity of valvular lesions and the simplicity of resulting valvular dysfunction(s).
Several varieties of prolapse require additional nosologic clarification:
Near prolapse: A condition in which the free edge of the leaflet approaches the plane of the annulus without overriding it during systole. Leaflet apposition is not perfect; there is, however, no valvular regurgitation. This condition can worsen overtime leading to
leaflet prolapse and significant mitral regurgitation.
A condition in which the free edge of the anterior leaflet is above the free edge of the posterior leaflet without overriding the plane of the annulus. Seen in type IIIb dysfunction, the jet of mitral regurgitation is posteriorly directed on echocardiography.
Defined by the systolic protrusion of the belly of the leaflet into the left atrium due to excess leaflet tissue while the free edge remains below the plane of the annulus. Seen in patients with Barlow’s disease, billowing leaflet(s) does not cause valvular regurgitation. It can, however, be complicated with leaflet prolapse secondary to chordae elongation rupture, leading to mitral regurgitation.
The numeric age, which started a few decades ago, provides new tools of communication to all domains, including medicine. An enormous amount of data can be collected and thousands of figures can be stored so as to be used whenever necessary. Doctor Farzan Filsoufi, from Mount Sinai Medical Center in New York, took advantage of these revolutionary tools to develop an original program of teaching anatomy, pathology and surgical management of heart valves. His keen interest and deep culture in history as well as his large experience in valve surgery allowed him to offer us a master website where the reader can navigate from one valve to another and from the past to the present, picking up several thousands of genuine information and several hundreds of figures, some of them so rare that they cannot be found in commonly available treatise. The largest place has been given to the mitral valve because of its complexity, its functional importance and the possibility to effectively repair it for the rest of the patient’s life. The other valves will receive similar development in the near future.I have been watching with admiration and respect the considerable amount of work displayed by the author to collect the necessary documentation drawn from the most reliable sources. The information is analyzed and presented in an organized manner so as to be easily available to all specialists, from historians to practitioners, anatomists to physiologists and physicians to surgeons.
This website also shed some light to the future by its interactive section on “case studies and news” from all over the world, involving the most prominent specialists. No doubt that it will be a reference in the field. A true masterpiece!
Alain Carpentier, MD, PhD
Mitral valve prolapse is the most common heart valve abnormality, affecting five to ten percent of the world population. Mitral valve prolapse also known as click murmur syndrome and Barlow’s syndrome.
In patients with degenerative mitral valve disease, the very low operative mortality (less than 0.5%) and excellent long-term results of mitral valve reconstruction have considerably modified the indications of surgery during the last decade. Several factors such as clinical symptoms, atrial fibrillation, severity of mitral regurgitation, left ventricular ejection fraction, left ventricular end-systolic diameter, pulmonary hypertension, and the overall surgical risk profile (age, co-morbid factors) should be taken into consideration for the decision-making with regard to the indication of surgery.
All symptomatic patients with moderate or severe mitral regurgitation should be referred for surgical intervention. It is preferable to operate on patients early in their symptomatic course, as long-term survival following mitral valve reconstruction is less favorable in patients with New York Heart Association Class III or IV symptoms or left ventricular ejection fraction <60%. It is important to stress that in patients with degenerative mitral valve disease with New York Heart Association Class I or II and ejection fraction >60%, the life-expectancy following mitral valve reconstruction is similar to that of an age and gender matched general population. As Carpentier stated “following valvular reconstruction most patients with degenerative valve disease are cured for the rest of their lives”.
Heart Disease: During the second half of the 20th century the improvement in the socio-economic situation and the widespread use of antibiotics led to the eradication of rheumatic fever in developed countries. In contrast, the incidence of this disease has remained extremely high in non-industrialized countries. Today, rheumatic fever still remains the principle cause of valvular heart disease and particularly mitral valve disease worldwide. As discussed extensively in the historic review section, a history of untreated group A Beta hemolytic streptococcal pharyngitis is the event that may lead to rheumatic fever. In this scenario, the rate of development of rheumatic fever is about 3%. The two major factors that should be considered regarding the risk of rheumatic fever are: 1) the intensity of the immune response during the episode of streptococcal pharyngitis and 2) the persistence of the organism during the recovery. The strain of Group A streptococcus also plays a role as M-types are associated with strong immune response. These so-called rheumatogenic strains have a cell wall which contains M proteins that are highly antigenic. The immunologic response to M proteins produces antibodies that may cross react with cardiac myosin. They also cross react with perivascular connective tissue leading to the formation of Aschoff bodies. It has also been suggested that cell-mediated immunity plays a definite role in the constitution of acute rheumatic valvular lesions. Jones Criteria, first described in 1944 and updated in 1992, remain relevant and are used for the diagnosis of initial attacks of rheumatic fever. They are divided into two categories of major and minor criteria. JOHNES CRITERIA: Major criteria: Carditis Polyarthrits Chorea Erythema marginatum Subcutaneous modules Minor criteria: Clinical findings:fever,arthralgia Laboratory finding:Elevated erythrocyte sedimentation rate or C-reative protein EKG changes:prolonged PR interval During the acute phase, carditis is noted in about 50% of patients. As mentioned first by Bouillaud, cardiac involvement is a pancarditis and acute valvulitis involving the left-sided valves is a characteristic feature of this disease. Mitral valve regurgitation due to type I dysfunction with annular dilatation is a hallmark of acute rheumatic carditis. With the resolution of the acute phase, the long-term prognosis is dominated by the extent and the progression of valvular heart disease. During the chronic phase, in patients with valvular manifestations but with no known history of rheumatic fever or untreated streptococcal pharyngitis, it may be difficult to establish the rheumatic origin of their valve disease. Echocardiography and intraoperative valve analysis may demonstrate characteristic lesions which would confirm this etiology.