Mitral valve early systolic billowing induces following annular expansion and leaflet augmentation in Barlow's disease: sequential analysis using 3D echocardiography.

AIMS: Although systolic expansion of the annulus has been recognized in Barlow's disease, the mechanisms of the unique pathological movement of the annulus and its relation to the leaflet augmentation have not yet been clarified. We aimed to investigate the detailed mechanisms of the characteristic mitral apparatus dynamics in Barlow's disease by frame-by-frame sequential geometric analysis using real-time 3D transoesophageal echocardiography. METHODS AND RESULTS: Fifty-three patients with Barlow's disease and severe mitral regurgitation without torn chordae, as well as 10 controls, were included. We evaluated geometric changes in the mitral complex using 3D transoesophageal echocardiography at five points during systole. To identify early systolic billowing of leaflets, the annulo-leaflet angle was measured. We also performed a more detailed analysis in four consecutive frames just before and after leaflet free-edge prolapse above the annulus plane. The median annulo-leaflet angle of both leaflets in early systole was >0° (above annulus plane) in patients with Barlow's disease, and billowing of the leaflet body was observed from early systole. The prolapse volume of both leaflets increased markedly from early to mid-systole [1.60 (0.85-2.80) to 4.00 (2.10-6.45) mL; analysis of variance (ANOVA), P < 0.001; post hoc, P < 0.05]. With frame-by-frame analysis, dynamic augmentation of the annulus and leaflets developed between frames just before and just after leaflet free-edge prolapse (ANOVA, P < 0.01; post hoc, P < 0.05). CONCLUSION: In Barlow's disease, early systolic billowing of the mitral leaflet induces systolic annulus expansion followed by leaflet augmentation and leaflet free-edge prolapse.

Mitral valve repair for extreme billowing and prolapsing valve.

Objectives: We describe our method and results of mitral valve repair up to 20 years in a defined group of patients with mitral regurgitation caused by an extreme billowing and prolapsing valve. Methods: An extreme billowing and prolapsing valve was defined by the presence of excess tissue on both leaflets and prolapse of 2 or more of the 3 segments of each leaflet. Among 1344 consecutive patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2012 at the Sakakibara Heart Institute, 73 patients met our definition of an extreme billowing and prolapsing valve. From these 73 patients, 67 patients who underwent mitral valve repair based on the surgical strategy we developed in July 1996 were enrolled in this study. Our strategy of mitral valve repair for extreme billowing and prolapsing valves consists of (1) volume reduction of the leaflets, (2) physiologic remodeling annuloplasty for long anterior leaflet, and (3) wide usage of artificial chordae. Results: Mean age of the patients was 46.6 ± 12.9 years. There were no hospital deaths and 6 late deaths in this series. Kaplan-Meier survival at 10 years was 96.8 ± 2.2%. There were 2 reoperations. Cumulative incidence rate of mitral valve reoperation and moderate or severe mitral regurgitation at 10 years was 1.8 ± 1.8% and 11.2 ± 4.0%. Number of artificial chordal replacement was associated with decreased risk of recurrent moderate mitral regurgitation (hazard ratio, 0.60; P = .03). Conclusions: Long-term echo follow-up demonstrates good results of mitral valve repair for extreme billowing and prolapsing valves using our strategy.

Billowing Of Endologix Powerlink Stent Mimicking Endoleaks.

INTRODUCTION: Endoleaks remains one of the primary concerns of endovascular aortic aneurysm repair (EVAR) and is routinely followed with CT angiography (CTA). However, certain imaging findings can mimic endoleaks. CASE PRESENTATION: A 65-year-old woman who had endovascular aortic repair (EVAR) of an abdominal aortic aneurysm with Endologix Powerlink system developed marked new circumferential cauliflower-like bulging of contrast-filled sacs at mid-stent-graft with enlargement of the excluded aneurysm at 3-year follow-up. CONCLUSIONS: Considering the unique construct of the Powerlink stents, this is thought to represent aneurysmal degeneration of the outer fabric material from the metal struts and may potentially pressurize the excluded sac with risk for rupture.

Research on intraoperative iris behavior in rabbits treated with tamsulosin and finasteride.

AIM: The purpose of this study was to investigate intraoperative iris behavior during some phacoemulsification maneuvers in rabbits treated with tamsulosin or finasteride. MATERIAL AND METHOD: An experimental study was conducted on 26 Metis male rabbits aged 1.5 - 2 years, body weight between 3.4 and 5.6 kg, divided into three groups: Group 1 - Control, 6 rabbits; Group 2 - tamsulosin, 10 rabbits; Group 3 - finasteride, 10 rabbits. Dose calculation was performed according to body surface area ratio man/rabbit, taking into account the median lethal dose LD50. Surgery study in rabbits was done over two days by the same specialist using an adapted protocol. He was not informed before or during surgeries which group the animal belonged to, the order being random with a quasi-uniform distribution. Valid results for a modified iris behavior were obtained from two steps of the procedure (cannula irrigation maneuver and irrigation-aspiration). The iris billowing was graded from 0 to 3, according to severity. RESULTS: The risk of intraoperative iris billowing was higher in rabbits included in tamsulosin group [OR=8.33 (CI 95% 0.63-110.09)], but insignificant statistically compare with control group (p= 0.13). In rabbits treated with finasteride the risk of intraoperative iris billowing is increased compared with those without treatment [OR=11.6 (CI 95% 0.92-147.6)], but insignificant statistically (p= 0.11). CONCLUSION: In our research, we showed an increased risk of intraoperative iris billowing in rabbits treated with finasteride, almost similar with those obtained in rabbits treated with tamsulosin. Further experimental or clinical studies to confirm the role of finasteride in the etiology of intraoperative floppy iris syndrome in humans are needed. Hippokratia 2015, 19 (1): 20-24.

A new definition for an old entity: improved definition of mitral valve prolapse using three-dimensional echocardiography and color-coded parametric models.

BACKGROUND: Differentiating between mitral valve (MV) prolapse (MVP) and MV billowing (MVB) on two-dimensional echocardiography is challenging. The aim of this study was to test the hypothesis that color-coded models of maximal leaflet displacement from the annular plane into the atrium derived from three-dimensional transesophageal echocardiography would allow discrimination between these lesions. METHODS: Three-dimensional transesophageal echocardiographic imaging of the MV was performed in 50 patients with (n = 38) and without (n = 12) degenerative MV disease. Definitive diagnosis of MVP versus MVB was made using inspection of dynamic three-dimensional renderings and multiple two-dimensional cut planes extracted from three-dimensional data sets. This was used as a reference standard to test an alternative approach, wherein the color-coded parametric models were inspected for integrity of the coaptation line and location of the maximally displaced portion of the leaflet. Diagnostic interpretations of these models by two independent readers were compared with the reference standard. RESULTS: In all cases of MVP, the color-coded models depicted loss of integrity of the coaptation line and maximal leaflet displacement extending to the coaptation line. MVB was depicted by preserved leaflet apposition with maximal displacement away from the coaptation line. Interpretation of the 50 color-coded models by novice readers took 5 to 10 min and resulted in good agreement with the reference technique (κ = 0.81 and κ = 0.73 for the two readers). CONCLUSIONS: Three-dimensional color-coded models provide a static display of MV leaflet displacement, allowing differentiation between MVP and MVB, without the need to inspect multiple planes and while taking into account the saddle shape of the mitral annulus.