Skip Navigation

European Journal of Echocardiography 2005 6(2):117-126; doi:10.1016/j.euje.2004.07.011
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Kaymaz, C.
Right arrow Articles by Özkan, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kaymaz, C.
Right arrow Articles by Özkan, M.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Copyright © 2005, The European Society of Cardiology

Differentiating clinical and echocardiographic characteristics of chordal rupture detected in patients with rheumatic mitral valve disease and floppy mitral valve: impact of the infective endocarditis on chordal rupture

Cihangir Kaymaz, Nihal Özdemir and Mehmet Özkan*

Department of Cardiology, Kosuyolu Heart and Research Hospital, Kadiköy, 81020 Istanbul, Turkey

Received 14 August 2002; received in revised form 26 May 2004; accepted after revision 29 July 2004.

* Corresponding author. Tel.: +90 216 3255457/+90 216 302 4885; fax: +90 216 3390441/+90 216 368 2527. memoozkan{at}superonline.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 
Aims We aimed to compare the clinical and echocardiographic correlates of chordal rupture in patients with rheumatic mitral valve disease and floppy mitral valve.

Methods and results The study group comprised of 224 patients who underwent transthoracic and transesophageal echocardiography because of the severe mitral regurgitation. Chordal rupture was detected in 58 (25.9%) out of the 224 patients, in 33 out of the 83 (39.7%) patients with floppy mitral valve, and in 25 out of the 141 (17.7%) patients with rheumatic mitral valve disease. Chordal rupture was more frequently associated with anterior leaflet (80%) in patients with rheumatic mitral valve disease, and posterior leaflet (72.7%) in patients with floppy mitral valve (p<0.05). Univariate correlates of chordal rupture were age, male sex, posterior mitral leaflet thickening and chordal elongation in patients with floppy mitral valve (p<0.05), and chordal shortening (p<0.0001) and infective endocarditis involving mitral anterior leaflet (p<0.05) in rheumatic group. Independent predictors of chordal rupture were age (>50 years), posterior mitral leaflet thickness (≥0.45cm), and male sex (p<0.05) in patients with floppy mitral valve while infective endocarditis involving mitral anterior leaflet (p<0.05) in patients with rheumatic mitral valve disease. Patients with chordal rupture due to floppy mitral valve had an older age (p<0.0001), a male dominance, longer mitral leaflets and chordae, and a larger mitral annulus circumference (p<0.05) as compared to those with rheumatic chordal rupture. Despite the comparable severity of mitral regurgitation and left atrial diameters between the two groups of chordal rupture (p>0.05), functional class and pulmonary artery systolic pressure were higher, and atrial fibrillation, acute deterioration, infective endocarditis, mitral leaflet rupture and need for mitral valve surgery in the 3 months were more frequent in rheumatic chordal rupture subgroup (p<0.05).

Conclusion Chordal rupture seems to be more frequently associated with anterior mitral leaflet in rheumatic mitral valve disease, whereas it was the posterior leaflet in floppy mitral valve. Chordal rupture was related to male sex, older age, posterior leaflet thickening, and chordal elongation in patients with floppy mitral valve. However, infective endocarditis, acute deterioration, and need for early mitral surgery were more frequent in patients with rheumatic chordal rupture.

Keywords: Chordal rupture; Rheumatic mitral valve; Floppy mitral valve


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusion
 References
 
In the last decades prevalence of rheumatic mitral valve disease has decreased in the western world, and primary mitral valve prolapse due to floppy mitral valve has become the most common cause of severe mitral regurgitation requiring mitral valve surgery.1–19 Floppy mitral leaflets, impaired mechanical properties of valvular and chordal apparatus due to myxomatous degeneration and collagen alterations, annular enlargement, and eventually chordal rupture have been documented to be the main mechanisms of progressive worsening of the mitral regurgitation in patients with mitral valve prolapse.1–19 However, rheumatic mitral valve disease still persists as an important cause of severe mitral regurgitation in the other part of the world.14,16,17,20–28 It is documented that severe pure rheumatic mitral regurgitation is as prevalent as pure rheumatic stenosis in developing countries, and has an entirely different time course, surgical anatomy, and disease activity which may be associated with a separate pathophysiologic mechanism.20–27 Severe rheumatic mitral regurgitation has been correlated to fibrosis, fusion and retraction in the chordal and valvular structures, and annular dilation.14,16,17,20–28 Documented frequency of severe pure mitral regurgitation in surgical series comprised of patients with rheumatic mitral valve disease varies between 24% and 72%.20–28

The vast majority of the echocardiographic and surgical series concerning chordal rupture have been addressed to prediction, diagnosis, and management of chordal rupture occurring in patients with floppy mitral valve.1–19 However, data concerning the incidence and correlates of chordal rupture related to rheumatic mitral valve disease are still limited.14,16,17,27 The purposes of our study are to investigate the distinctive clinical and echocardiographic correlates of chordal rupture, and its clinical consequences in patients with severe mitral regurgitation due to floppy mitral valve and rheumatic mitral valve disease, and to assess the impact of infective endocarditis on chordal rupture.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusion
 References
 
Patients
Study group is comprised of 224 patients (male 118, female 106, age 46.3±15.3) with severe mitral regurgitation detected by transthoracic and transesophageal echocardiography. Rheumatic mitral valve disease was diagnosed in 141, and mitral valve prolapse due to floppy mitral valve in 83 out of the 224 patients with severe mitral regurgitation. Chordal rupture was diagnosed in 58 patients in overall study group, in 25 patients with rheumatic mitral valve disease (male 11, female 14, age 44±12.8), and in 33 patients with floppy mitral valve (male 26, female 7, age 55.4±11.6). The rhythm was atrial fibrillation in 130 (92%) patients with rheumatic mitral valve disease, and in 5 patients (6%) with floppy mitral valve.

Study design and echocardiographic evaluation
Transthoracic and transesophageal echocardiographic examinations were performed by a 3.25MHz transthoracic transducer and a 5MHz multiplane transesophageal probe connected to a VingMed CFM800 echocardiography system (Horten, Norway). Written informed consent was obtained from each patient before entry into the study, and the protocol was approved by the institutional review board. Transesophageal echocardiography was performed after >4h of fasting, under topical anesthesia with 10% lidocaine and conscious sedation with intravenous midazolam.

Patients with rheumatic mitral valve disease and floppy mitral valve were divided into subgroups of patients with and without chordal rupture, and were compared in reference to age, sex, rhythm, mitral leaflet(s) related to chordal rupture, mitral regurgitant jet area, left atrial diameter, mitral annulus circumference, left ventricular ejection fraction, chordal length of anterolateral and posteromedial papillary muscle groups, incidence of infective endocarditis, acute deterioration, functional class, pulmonary artery systolic pressure estimated by Doppler, and the need for mitral valve surgery in the following 3 months.

The diagnosis of rheumatic mitral valve disease was based on the clinical history of rheumatic fever, echocardiographic, hemodynamic, and surgical macroscopic and histopathological data in patients who underwent mitral valve surgery.17–28 Echocardiographic findings consistent with rheumatic valve involvement including: (1) leaflet thickening, deformation, and retraction; (2) fusion, shortening, and fibrosis of the subvalvular apparatus; and (3) accompanying aortic and/or tricuspid valve involvement.28 Mitral valve prolapse due to floppy mitral valve was defined as the presence of systolic displacement (≥3mm) of one or both thick and redundant leaflet(s) beyond the mitral annulus plane into the left atrium using the parasternal long axis approach.2 In reference to leaflet(s) prolapsing, mitral valve prolapse was defined as anterior, posterior or symmetrical prolapse.2,30–32 Mitral regurgitation was graded by color Doppler documentation of mitral regurgitant jet both on transthoracic and transesophageal echocardiography. The severity of mitral regurgitation was determined according to the generally accepted criteria.29 A mild, moderate and severe regurgitation was diagnosed when the regurgitant jet area was <4cm2, 4–8cm2 and >8cm2, respectively. In cases of eccentric jets precluding the planimetric measurement of the jet area, jet length was also used for grading the regurgitation severity, and the presence of systolic flow reversal in pulmonary veins also indicated severe mitral regurgitation. Flail mitral leaflet was defined as presence of one or both mitral leaflet(s) losing coaptation function, and fluttering coarsely in the left atrium during each systole.12,30–32 Chordal rupture was defined as the presence of the free and highly mobile, linear echoes associated with flail mitral leaflet(s).12,30–32 Chordal rupture was defined in reference to flail leaflet(s). Transesophageal echocardiography was considered as reference method in diagnosing chordal rupture and vegetation.30–32 Chordal length (cm) of the anterolateral and posteromedial papillary muscle groups was measured in transgastric (90°) position.32 Anteroposterior diameter of left atrium, length and thickness of mitral leaflets were measured in parasternal long axis, and mitral annulus circumference was measured in parasternal short axis planes on transthoracic echocardiography. The left ventricular ejection fraction was determined on transthoracic echocardiographic images by taking the average measurements by area length and Simpson's methods.33

Infective endocarditis was diagnosed as the presence of vegetation and/or abscess formation detected by transesophageal echocardiography, and supported by clinical findings, positive blood cultures or pathological criteria of infective endocarditis.34 Vegetations were defined as soft or partially calcified, non-homogenous, and mobile echodensities related to leaflet(s) and/or chordae. Pulmonary artery systolic pressure was measured from spectral profile of the tricuspid regurgitation by continuous wave Doppler. Functional class was graded from I to IV by using the New York Heart Association (NYHA) criteria. Acute deterioration was defined as the presence of acute onset symptoms and signs consistent with functional class III or IV suggesting low cardiac output and/or pulmonary venous congestion, or at least one class increase in the functional class than prior status in patients with class II.

Preoperative cardiac catheterization was performed in all patients who underwent mitral valve surgery, and coronary angiography was added to the catheterization in patients aged over 40 years and/or having risk factors for coronary artery disease. Patients with floppy mitral valve suffered from atypical chest pain or typical angina pectoris in whom indications of optimally timed mitral valve surgery were lacking were assessed by single photon emission computed tomographic myocardial perfusion scintigraphy using the Thallium-201 and Technetium-99m-sestamibi.35

Indications for mitral valve surgery
According to AHA/ACC Guidelines for Management of Valvular Heart Disease, patients with acute and symptomatic severe mitral regurgitation, patients with NYHA functional class II, III and IV symptoms with normal left ventricular function, and patients with symptomatic or asymptomatic severe mitral regurgitation with mild or moderate left ventricular dysfunction were considered to have class I indications for mitral valve surgery.36 In patients who underwent mitral valve surgery, presence of chordal rupture, leaflet(s) related to rupture and vegetations were investigated by intraoperative morphological assessment and histopathological analysis of the excised valve tissue.

Statistical analysis
The continuous variables are presented as mean±SD. Continuous variables were compared using the unpaired Student's t-test, and categorical variables were compared using the chi-square test. Independent correlates of chordal rupture were investigated by stepwise logistic regression analysis. A p value <0.05 was accepted as statistically significant.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusion
 References
 
Mitral leaflets associated with chordal rupture
In patients with rheumatic mitral valve disease, rupture was found to be associated with chordae to the mitral anterior leaflet in 20 (80%), those to the posterior leaflet in 4 (16%), and those to the both leaflets in 1 (4%) (Fig. 1). In patients with floppy mitral valve, chordal rupture was associated with chordae to the posterior leaflet in 24 (72.7%), those to the anterior leaflet in 6 (18.2%), and those to the both leaflets in 3 (9%) patients (Fig. 1). Mitral leaflet rupture concomitant with chordal rupture was detected in 9 (36%) patients with rheumatic mitral valve disease, and in 1 patient (3%) with floppy mitral valve.


Figure 1
View larger version (21K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 Mitral leaflets related to ruptured chordae in patients with rheumatic mitral valve disease and mitral valve prolapse. Abbreviations: RMVD, rheumatic mitral valve disease; MVP, mitral valve prolapse.

 
Patients with floppy mitral valve
Clinical and echocardiographic variables in patients with floppy mitral valve with and without chordal rupture are shown in Table 1. Male gender was dominant (p<0.05), mean age (p<0.0001), mitral regurgitant jet area (p<0.05), thickness of posterior mitral leaflet (p<0.001), length of the anterolateral (p<0.05) and posteromedial chordae (p<0.05) were higher in subgroup of patients with chordal rupture than in patients without. However, the prevalence of atrial fibrillation, thickness of the anterior mitral leaflets, length of the mitral leaflets, mitral annulus circumference, left ventricular ejection fraction, pulmonary artery systolic pressure, and mean functional class were comparable between patients with and without chordal rupture (p>0.05) (Table 1).


View this table:
[in this window]
[in a new window]

  		Table 1 Characteristics of patients in mitral valve prolapse with and without chordal rupture

 
Patients with rheumatic mitral valve disease
Table 2 summarizes the clinical and echocardiographic variables in patients with rheumatic mitral valve disease with and without chordal rupture. Mean age, male to female sex ratio, prevalence of atrial fibrillation, left atrial diameter, length and thickness of the both mitral leaflets, mitral annulus circumference and left ventricular ejection fraction were comparable between patients of rheumatic mitral regurgitation with and without chordal rupture (p>0.05). However, mean functional class, mitral regurgitant jet area, and pulmonary artery systolic pressure were higher (p<0.05), infective endocarditis were more frequent (p<0.0001), and length of the anterolateral and posteromedial chordae (p<0.0001) were lower in patients with rheumatic mitral valve disease complicated by chordal rupture than in patients without chordal rupture. Anterior mitral leaflet involvement and rupture of the related chordae were noted in all the patients with infective endocarditis.


View this table:
[in this window]
[in a new window]

  		Table 2 Characteristics of patients in rheumatic mitral regurgitation with and without chordal rupture

 
Mitral valve surgery for severe mitral regurgitation
Mitral valve surgery was performed in 114 out of the 224 (50.9%) patients in the 3 months following the echocardiographic diagnosis of severe mitral regurgitation. Among the patients with floppy mitral valve, 16 out of the 33 (48.4%) patients with chordal rupture, and 21 out of the 50 (42%) patients without chordal rupture underwent mitral valve surgery (>0.05) (Table 1). Among the patients with severe mitral regurgitation due to rheumatic mitral valve disease, all of the 25 patients with chordal rupture, and 52 out of the 116 patients without chordal rupture underwent mitral valve surgery (100% vs 44%, p<0.05) (Table 2).

Comparison between the patients with chordal rupture related to floppy mitral valve and rheumatic mitral valve disease
In the analysis of the chordal rupture in reference to underlying etiology, incidence of male sex (p<0.05), mean age (p<0.0001), length of the both anterior and posterior leaflets (p<0.05), length of anterolateral (p<0.00001) and posteromedial chordae (p<0.00001), and mitral annulus circumference (p<0.05) were significantly higher in patients with chordal rupture due to floppy mitral valve than in patients with rheumatic chordal rupture. Thickness of the both leaflets, left atrial diameter and mitral regurgitant jet area were not different between patients with chordal rupture due to floppy mitral valve and rheumatic mitral valve disease (p>0.05). Chordae to the anterior mitral leaflet in patients with rheumatic mitral valve disease (80% vs 18.2%, p<0.05), and those to the posterior leaflet in patients with floppy mitral valve (72.7% vs 16%, p<0.05) were more frequently ruptured. Infective endocarditis (64% vs 11.5%, p<0.001) and mitral leaflet rupture (36% vs 3%, p<0.05) were more frequent in patients with rheumatic chordal rupture than in patients with chordal rupture due to floppy mitral valve. Moreover, mean NYHA functional class (p<0.05), pulmonary artery systolic pressure (p<0.05), prevalence of atrial fibrillation (p<0.001) and acute deterioration (p<0.05) were higher in patients with rheumatic mitral valve disease complicated by chordal rupture than in patients of floppy mitral valve with chordal rupture. Need for early mitral surgery was also more frequent in patients with rheumatic mitral valve disease complicated by chordal rupture than in patients with chordal rupture due to floppy mitral valve (100% vs 48.4%, p<0.05). However, in the absence of chordal rupture, incidence of early mitral valve surgery was similar between patients with floppy mitral valve and rheumatic mitral valve disease (42% vs 44%, p>0.05) (Table 3).


View this table:
[in this window]
[in a new window]

  		Table 3 Characteristics of patients with chordal rupture related to mitral valve prolapse and rheumatic mitral valve disease

 
Independent predictors of chordal rupture
Variables related to chordal rupture in univariate analysis were entered into stepwise multiple logistic regression analysis. Independent predictors of chordal rupture were age over 50 years (p<0.05), posterior leaflet thickness (≥0.45cm) (p<0.05), and male sex (p<0.05) in patients with floppy mitral valve while infective endocarditis involving mitral anterior leaflet (p<0.05) in patients with rheumatic mitral valve disease (Table 4).


View this table:
[in this window]
[in a new window]

  		Table 4 Independent predictors of chordal rupture

 
Assessment of myocardial ischemia
Coronary angiography and left ventriculography performed in 41 patients prior to mitral valve surgery showed neither significant coronary artery stenosis, nor segmentary left ventricular contraction abnormality irrespective of the primary etiology. Moreover, single photon emission computed tomographic myocardial perfusion scintigraphy performed in 72 patients with floppy mitral valve showed no perfusion defect consistent with myocardial ischemia.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusion
 References
 
This study demonstrates differential clinical and echocardiographic characteristics of chordal rupture detected in patients with mitral valve prolapse due to floppy mitral valve and in patients with rheumatic mitral valve disease. Rupture was more likely to be associated with chordae to the posterior leaflet in patients with mitral valve prolapse due to floppy mitral valve, and those to the anterior leaflet in patients with rheumatic mitral valve disease. Independent predictors of chordal rupture were age over 50 years, posterior leaflet thickness (≥0.45cm), and male sex in patients with floppy mitral valve, and infective endocarditis involving mitral anterior leaflet in patients with rheumatic mitral valve disease. None of the patients with chordal rupture assessed by either coronary angiography or myocardial perfusion scintigraphy was found to have coronary artery disease. Patients with chordal rupture due to floppy mitral valve had high incidences of posterior leaflet thickening, chordal elongation and annular enlargement, and a more tolerable clinical course as compared to patients with rheumatic mitral valve disease complicated by chordal rupture. However, infective endocarditis, mitral leaflet rupture, clinical deterioration, and need for early mitral surgery were more frequent in patients with rheumatic mitral valve disease complicated by chordal rupture than in patients with chordal rupture related to floppy mitral valve.

In patients with floppy mitral valve, increased incidence of chordal rupture related to chordae to the posterior leaflet, and its middle scallop as compared to those to the anterior leaflet has been correlated to differences in anatomic position of each leaflets, and stress loading them during systole.9,11–19,31,32,37,38 In normal mitral valve closure, anterior leaflet has a larger area, and remains in tangential position in reference to systolic flow and pressure direction, and meets less systolic stress per cm2 than posterior leaflet remaining perpendicular to systolic stress with its smaller surface area.18,19,37,38 Anterior leaflet is also attached to the central fibrous body, and often has two large thick "strut" chordae whereas posterior leaflet has short and thin chordae.13–19,36 In patients with floppy mitral valve, unbalanced systolic tension for long duration on the mitral closure apparatus having impaired mechanical properties due to collagen alterations and acid mucopolysaccharide accumulation in mitral leaflets and chordae tendineae may lead to spontaneous chordal rupture.13–19,37–39 Several studies demonstrated that older age, male sex, thickening, elongation and redundancy of the mitral leaflets and chordae, and severe mitral regurgitation were correlates of the chordal rupture in patients with floppy mitral valve.2–19 Results of the present study are concordant with other series in reference to association between chordal rupture and older age, male sex, posterior leaflet thickening, and chordal elongation in patients with floppy mitral valve.

In contrast to cumulated data regarding chordal rupture occurring in patients with floppy mitral valve, the incidence and characteristics of chordal rupture in patients with rheumatic mitral valve disease remain to be determined.14,16,17,19,27 In the series of chordal rupture reported by Oliveria et al., the incidence of chronic rheumatic mitral valve disease and infective endocarditis superimposed on rheumatic mitral valve disease were 8.9% and 4.7%, respectively.19 In that series, incidence of chordal rupture associated with posterior leaflet was 62% in patients diagnosed as primary spontaneous chordal rupture whereas incidence of chordal rupture related to chordae to the anterior and posterior mitral leaflets were similar (42%) in patients with chronic rheumatic mitral valve disease.19 Oliveria et al. also reported that incidence of rupture of chordae to the anterior leaflet increased to 80% in patients with rheumatic mitral valve disease complicated by infective endocarditis, and rupture of the anterior mitral leaflet concomitant with chordal rupture was frequent in that subgroup.19 Retrospective analysis of other series also suggest that rupture of chordae to the anterior mitral leaflet is frequent in patients with chordal rupture superimposed on rheumatic mitral valve disease.14,16,17,27 Mechanisms of severe mitral regurgitation and chordal rupture in rheumatic mitral valve disease appear to be different from those in floppy mitral valve. In patients with rheumatic mitral valve disease, thickening and retraction of posterior leaflet, and chordal thickening and fusion may protect posterior leaflet from rupture.14,16,17,27 Altered systolic coaptation dynamics may divert systolic stress towards the anterior leaflet, and may lead to systolic prolapse of this leaflet in concordance with its pliability.14,16,17,19,27 However, chronic rheumatic degeneration solely may not result in chordal rupture in the absence of infective endocarditis.16,17,19 In our study, patients with rheumatic mitral valve disease having chordal rupture had higher incidences of infective endocarditis, rupture in chordae to the anterior leaflet with or without anterior leaflet rupture as compared to patients with floppy mitral valve complicated by chordal rupture. The relatively high incidence of chordal rupture (17%) in patients with severe rheumatic mitral regurgitation seems to be associated with infective endocarditis in this subset. Multivariate analysis also showed that infective endocarditis involving mitral anterior leaflet was the independent predictor of chordal rupture in the subgroup of rheumatic mitral regurgitation. However, mitral valve morphology defined by previous and final echocardiographic examinations, surgical and histopathologic assessment excluded the possibility of infective endocarditis related previously normal native valves. Although left atrial diameter and mitral regurgitant jet area were comparable between the two subgroups of chordal rupture due to different etiology, hemodynamic deterioration and the worst clinical outcome following the chordal rupture seem to be more frequent in patients with rheumatic mitral valve disease than in patients with floppy mitral valve. These differences may be associated with concomitant infective endocarditis, acute increase in the severity of mitral regurgitation in the presence of atrial fibrillation and non-compliant left atrium limiting the hemodynamic adaptation to acute pressure and volume load in chronic rheumatic mitral valve disease.40–43 In our rheumatic subgroup, despite the comparable mitral regurgitation severity between patients with and without chordal rupture, the first group of patients had shorter chordae than patients without chordal rupture. This may be associated with an abrupt increase in mitral regurgitation severity following the chordal and/or mitral leaflet rupture in patients with rheumatic mitral valve with lower grade of regurgitation related to fibrotic chordae without significant elongation prior to rupture. However, chordal length in patients with chronic severe mitral regurgitation due to rheumatic etiology and floppy mitral valves seems to reflect the impact of the severe regurgitation on subvalvular apparatus along the natural course of mitral regurgitation. However, patients with floppy mitral valve having severe mitral regurgitation are usually unaware of the onset of chordal rupture, and clinical signs of new-onset pulmonary venous congestion are frequently absent in cases of sinus rhythm and compliant left atrium.2–15 In these patients, chordal rupture has been frequently diagnosed during routine echocardiographic assessment of mitral regurgitation.2–13,15,30 Relatively asymptomatic course after chordal rupture in patients with floppy mitral valve as compared to patients with rheumatic mitral valve disease may be associated with more compliant left atrium loaded by severe mitral regurgitation for long duration prior to chordal rupture.

Limitations of the study
Symptoms and signs consistent with chordal rupture were assessed by retrospective analysis of the clinical history. Prospective follow-up period is relatively short to evaluate and compare the clinical and hemodynamic course after chordal rupture. Because our study focused on differential characteristics of chordal rupture and short-term outcome after diagnosis of chordal rupture in patients with floppy mitral valve and rheumatic mitral valve disease, initial success and durability of mitral valve repair, and clinical course with respect to etiologic differences of chordal rupture were not investigated. Moreover, detailed echocardiographic definition of mitral scallops related to prolapse and/or ruptured chordae, and its impact on the clinical course and surgical strategies were not included in this study.


   Conclusion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
References
 
Results of this study demonstrate that rupture of chordae to the anterior mitral leaflet in patients with rheumatic mitral valve disease, and those to the posterior leaflet in patients with floppy mitral valve are more frequent. Chordal rupture relates to male sex, older age, posterior leaflet thickening, and chordal elongation in patients with floppy mitral valve, and infective endocarditis in patients with rheumatic mitral valve disease. Clinical deterioration and the need for early surgical intervention after chordal rupture were more frequent in patients with rheumatic mitral valve disease as compared to patients with floppy mitral valve.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusion
 References
 

  1. Barlow J.B., Pocock W.A. Mitral valve prolapse, the specific billowing mitral leaflet syndrome, or an insignificant non-ejection systolic click. Am Heart J (1979) 97:277–285.[CrossRef][Web of Science][Medline]
  2. Marks A., Choong C., Chir M.B.B., Sanfilippo A., Ferre M., Weyman A. Identification of high-risk and low-risk subgroups of patients with mitral valve prolapse. N Eng J Med (1989) 320:1031–1036.[Abstract]
  3. Fukuda N., Oki T., Iuchi A., Tabata T.T., Manabe K., Kageji Y. Predisposing factors for severe mitral regurgitation in idiopathic mitral valve prolapse. Am J Cardiol (1995) 76:503–507.[CrossRef][Web of Science][Medline]
  4. Wilcken D., Hickey A. Lifetime risk for patients with mitral valve prolapse of developing severe valve regurgitation requiring surgery. Circulation (1988) 78:10–14.[Abstract/Free Full Text]
  5. Zuppirolli A., Rinaldi M., Kramer-Fox, Favilli S. Natural history of mitral valve prolapse. Am Heart J (1995) 75:1028–1032.
  6. Nishimura R.A., Mc Goon M.D. Perspectives on mitral valve prolapse. N Engl J Med (1999) 341:48–50.[Free Full Text]
  7. Devereux R.B., Hawkins I., Kramer-Fox R., et al. Complications of mitral valve prolapse: disproportionate occurrence in men and older patients. Am J Med (1986) 81:751–758.[CrossRef][Web of Science][Medline]
  8. Boudoulas H., Wooley C.F. Floopy mitral valve, mitral valve prolapse, and mitral valvular regurgitation. Curr Treat Options Cardiovasc Med (2001) 1:15–24.
  9. Singh R.G., Cappucci R., Kramer-Fox R., et al. Severe mitral regurgitation due to mitral valve prolapse; risk factors for development, progression, and need for mitral valve surgery. Am J Cardiol (2000) 2:193–198.
  10. Kim S., Kuroda T., Nishinaga M., et al. Relationship between severity of mitral regurgitation and prognosis of mitral valve prolapse: echocardiographic follow-up study. Am Heart J (1996) 2:348–355.
  11. Roberts W., McIntosh C., Wallace R.B. Mechanisms of severe mitral regurgitation in mitral valve prolapse determined from analysis of operatively excised valves. Am Heart J (1987) 113:1316–1323.[CrossRef][Web of Science][Medline]
  12. Benhalima B., Cohen A., Chauvel C., Abergel E. Morphological study by transesophageal echocardiography and clinical aspects of ruptured chordae tendineae in the elderly. Arch Mal Coeur Vaiss (1995) 88(3):345–352.[Web of Science][Medline]
  13. Hickey A.J., Wilcken D.E., Wright J.S., Warren B.A. Primary (spontaneous) chordal rupture: relation to myxomatous valve disease and mitral valve prolapse. J Am Coll Cardiol (1985) 6:1341–1346.
  14. van der Bel-Khan J., Becker A.E. The surgical pathology of rheumatic and floopy mitral valves. Distinctive morphologic features upon gross examination. Am J Surg Pathol (1986) 4:282–292.
  15. Grenadier E., Keidar S., Sahn D.J., et al. Ruptured mitral chordae tendineae may be a frequent and insignificant complication in the mitral valve prolapse syndrome. Eur Heart J (1985) 12:1006–1015.
  16. Fornes P., Heudes D., Fuzellier J.F., Tixier, Bruneval P., Carpentier A. Correlation between clinical and histologic patterns of degenerative mitral valve insufficiency: a histomorphometric study of 130 excised segments. Cardiovasc Pathol (1999) 2:81–92.
  17. Olson L.J., Subramanian R., Ackermann D.M., Orszulak T.A., Edwards W.D. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin Proc (1987) 1:22–34.[Medline]
  18. Jeresaty R., Edwards J., Chawla S.K. Mitral valve prolapse and chordae tendineae. Am J Cardiol (1985) 55:138–142.[CrossRef][Web of Science][Medline]
  19. Oliveria D.B., Dawkins K.D., Kay P.H. Paneth: chordal rupture. I. Aetiology and natural history. Br Heart J (1983) 50:312–317.[Abstract/Free Full Text]
  20. Kumar A.S., Rao P.N., Saxena A. Results of mitral valve reconstruction in children with rheumatic heart disease. Ann Thorac Surg (1995) 60(4):1044–1047.[Abstract/Free Full Text]
  21. Skoularigis J., Sinovitch V., Joubert G., Sareli P. Evaluation of the long-term results of mitral valve repair in 254 young patients with rheumatic mitral regurgitation. Circulation (1994) 90(5 Pt 2):II167–II174.[Medline]
  22. Marcus R.H., Sareli P., Pocock W.A., Barlow J.B. The spectrum of severe rheumatic mitral valve disease in a developing country. Correlations among clinical presentation, surgical pathologic findings, and hemodynamic sequelae. Ann Intern Med (1994) 120(3):177–183.[Abstract/Free Full Text]
  23. Wisenbaugh T., Skudicky D., Sareli P. Prediction of outcome after valve replacement for rheumatic mitral regurgitation in the era of chordal preservation. Circulation (1994) 89(1):191–197.[Abstract/Free Full Text]
  24. Kalil R.A., Lucchese F.A., Prates P.R., Sant'Anna J.R., Faes F.C., Pereira E., et al. Late outcome of supported annuloplasty for rheumatic mitral regurgitation. J Am Coll Cardiol (1993) 22(7):1915–1920.[Abstract]
  25. Duran C.M., Gometza B., Balasundaram S., al Halees Z. A feasibility study of valve repair in rheumatic mitral regurgitation. Eur Heart J (1991) 12(Suppl. B):34–38.[Abstract/Free Full Text]
  26. Turri M, Thiene G, Bortolotti U, Mazzucco A, Gallucci V. Surgical pathology of disease of the mitral valve, with special reference to lesions promoting valvar incompetence. Int J Cardiol; 22(2):213–9.
  27. Kalangos A., Beghetti M., Vala D., et al. Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency. Ann Thorac Surg (2000) 3:755–756.
  28. Ozkan M., Kaymaz C., Kirma C., et al. Predictors of left atrial thrombus and spontaneous echo contrast in rheumatic valve disease before and after mitral valve replacement. Am J Cardiol (1998) 82:1066–1070.[CrossRef][Web of Science][Medline]
  29. Helmcke F., Nanda N., Hsiung M., Soto B., Adey C.K., Goyal R.G., et al. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation (1987) 75:175–183.[Abstract/Free Full Text]
  30. Mintz G., Kotler M., Segal B., Parry W. Two-dimensional echocardiographic recognition of ruptured chordae tendineae. Circulation (1978) 57(2):244–250.[Abstract/Free Full Text]
  31. Malkowski M.J., Guo R., Orsinelli D.A., Wooley C.F., Tice F.D., Pearson A.C., et al. The morphologic characteristics of flail mitral leaflets by transesophageal echocardiography. J Heart Valve Dis (1997) 6(1):54–59.[Web of Science][Medline]
  32. Kaymaz C., Kirma C., Özdemir N., et al. Diagnostic value of transthoracic and transesophageal echocardiography in the assessment of primary mitral valve prolapse associated with severe mitral regurgitation. Arch Turk Soc Cardiol (1998) 26:502–509.
  33. Schiller M.B., Shah P.M., Crawford M., De Maria A., Devereux R., Feigenbaum H., et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr (1989) 2:358–363.[Medline]
  34. Durack D.T., Lukes A.S., Bright D.K. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med (1994) 96(3):200–209.[CrossRef][Web of Science][Medline]
  35. Özkan M., Kaymaz C., Dinçkal H., et al. Single-photon emission computed tomographic myocardial perfusion imaging in patients with mitral valve prolapse. Am J Cardiol (2000) 85:516–518.[CrossRef][Web of Science][Medline]
  36. Bonow R.O., Carabello B., de Leon A.C. Jr., et al. ACC/AHA guidelines for the management of patients with valvular heart disease: executive summary. In: Circulation (1998) 98:1949–1984. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease).[Free Full Text]
  37. Nazari S., Carli F., Salvi S., et al. Patterns of systolic stress distribution on mitral valve anterior leaflet chordal apparatus. A structural mechanical theoretical analysis. J Cardiovasc Surg (2000) 2:193–202.
  38. Barber J.E., Radliff N.B., Cosgrove D.M., Griffin B.P., Vesely I. Myxomatous mitral valve chordae mechanical characteristics. J Heart Valve Dis (2001) 3:320–324.
  39. Baker P.B., Bansal G., Boudoulas H., Kolibash A.J., Kilman J., Wooley C.F. Floppy mitral valve chordae tendineae: histopathologic alterations. Hum Pathol (1988) 19(5):507–512.[CrossRef][Web of Science][Medline]
  40. Roberts W.C., Braunwald E., Morrow A.G. Acute severe mitral regurgitation secondary to ruptured chordae tendineae. Clinical, hemodynamic and pathologic considerations. Circulation (1966) 33(1):58–70.[Free Full Text]
  41. Rippe J.M., Howe J.P. III. Acute mitral regurgitation. In: Valvular heart disease—Dalen J.E., Alpert J.S., eds. (1987) 2nd ed. Boston: Little, Brown and Co. 151–176.
  42. Enriquez-Sarano M., Dujardin K.S., Tribouilloy C.M., et al. Determinants of pulmonary venous flow reversal in mitral regurgitation and its usefulness in determining the severity of regurgitation. Am J Cardiol (1999) 83(4):535–541.[CrossRef][Web of Science][Medline]
  43. Ling L.H., Enriquez-Sarano M., Seward J.B. Clinical outcome of mitral regurgitation due to flail leaflet. N Engl J Med (1996) 335(19):1417–1423.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Kaymaz, C.
Right arrow Articles by Özkan, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kaymaz, C.
Right arrow Articles by Özkan, M.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?