MP27. Is the Mechanics of the Posterior Mitral Leaflet the Trigger of Malignant Mitral Valve Prolapse?
Cardioteam Foundation
Torino, Piemonte
Italy - Contact Me
Freelancer cardiologist. Consultant cardiologist at The Cardioteam Foundation, Italy. Last hospital position (2022): Head Cardiology and Internal Medicine Grouping and Head of Echocardiography Lab. Cardiac Surgery Dept, San Gaudenzio Clinic, Novara, Policlinic of Monza Italy.
Education:
1980: Graduated the University of Medicine ‘Carol Davila’ Bucharest, Romania.
1984–1992: Cardiologist and echocardiographer at the University Hospital of Bucharest, and also University Assistant belonging to the Faculty of Medicine Carol Davila of Bucharest.
Specialist in Cardiology (1987) and Fellow in Cardiology (1993) - Carol Davila Medical University, Bucharest (winner of public competitions).
1992: International Scholarship in Cardiology at San Donato Hospital, Milan (winner of public competition)
1995: Graduated in Medicine (second MD degree), at the University of Milan.
2000: PhD title in Cardiology, Carol Davila University, Bucharest, Title of "Doctor of Medicine - Cum Laude" (winner of public competition).
PROFESSIONAL EXPERIENCE
Outstanding experience in clinical cardiology, with +30 years activity in management of pts candidate to open heart surgery in San Donato Institute and Novara. Vast experience in echocardiography with +40 years of experience, the last 30 years in cardiac surgery: Intraoperative Echo, ICU, various procedures in Hemodynamic Lab. Specific expertise in mitral valve diseases and generally in valves repair surgery. Lecturer & chairman in various international meetings. Since 1994 tutor and organizer of training programs in cardiology & cardiac surgery in Italy for the Italian, Romanian, Moldavian, Georgian and Polish doctors. Since 2010 promoter of the live streaming sessions in cardiac surgery & echocardiography either in Italy or Romania, as tool and novel modality of tele-learning programs in cardiology - more than 50 live sessions from the operating room to the congress halls abroad in Europe as Austria, Spain, Romania, Moldavia, Turkey, Georgia, Poland.
Description
Method: A 30 y.o. woman with negative T waves in D2, D3, recurrent prelipotymic crises and known trivial mitral regurgitation (tMR) is presented. In a fibroelastic deficiency MV, transthoracic echocardiography (TTE) reveals - Fig1: bileaflet prolapse (BiP), tMR, mitral annular disjunction (MAD of 9mm) and curling. Between the posterior mitral leaflet (PML) and inferior left ventricle wall (iLVW) a >90° angle was seen. TDI echo shows the pickelhaube helmet sign (PHS). ECG Holter shows complex ventricular arrhythmias (VA): a run of polymorphic ventricular tachycardia, premature ventricular complex (PVC) 25%, with bi and trigeminal beats. Exercise ECG test showed paired, bi, trigeminal PVC. Late Gadolinium Enhancement (LGE) was seen on the basal portion of the iLVW at CMR. In Heart Team the patient was judged to be MMVP at high risk of sudden death and surgery was proposed.
Results: In right minithoracotomy approach a thin MV was seen with BiP, more evident on P2. Surgery: P2 limited triangular resection + restoring of coaptation plan from left atrium inside of LV + PTFE chordae to stabilize P2 area + a complete prosthetic ring. TTE showed tMR, long coaptation (9mm), rebuilding of the coaptation triangle (CoT), loss of MAD, curling and of PHS.
CONCLUSIONS: MMVP can occur even in tMR uninfluenced by the degree of MR, if MyF is present and the key to analysis is the PML motion. Abnormal PML motion angle (>90°) releases kinetic energy to the MV hinge area creating cell damage, apoptosis and MyF. Since in a normal MV a sharp angle occurs between the PML and iLVW - creating a 3rd degree lever of forces, while in MMVP, due to the BiP, this angle increases >90° and so a lever of 1st degree rises. Loss of MAD, curling and PHS after surgery confirms that the PML jerk effect has been eliminated by rebuilding of a normal MV geometry. In fact, at 4y F-UP ECG is normal, the patient is asymptomatic with just 1,7% VA at Holter, prelipotyms disappeared and the ECG stress test showed only occasional bigeminal PVC. The only great difference from pre-Op and post-Op MV geometry at TTE was the restoring of CoT, initially absent, to a near normal one. Bringing back of the MV coaptation plane into the LV removes the mechanical triggers of PML in this arrhythmogenic prolapse. Further studies are needed for a better understanding of this life-threateni