Clinical Outcome of Mitral Regurgitation Due to Flail Leaflet

doi:10.1056/NEJM199611073351902

Volume 335:1417-1423		November 7, 1996		Number 19

Clinical Outcome of Mitral Regurgitation Due to Flail Leaflet

Lieng H. Ling, M.B., B.S., Maurice Enriquez-Sarano, M.D., James B. Seward, M.D., A. Jamil Tajik, M.D., Hartzell V. Schaff, M.D., Kent R. Bailey, Ph.D., and Robert L. Frye, M.D.

Abstract

PDF

Letters

Add to Personal Archive

Add to Citation Manager

Notify a Friend

E-mail When Cited

PubMed Citation

ABSTRACT

Background Mitral regurgitation due to flail leaflet is difficultto manage, because it is frequently asymptomatic yet carriesa high risk of left ventricular dysfunction and because thenatural history of the condition is poorly defined.

Methods We obtained clinical follow-up data through 1994–1995in 229 patients with isolated mitral regurgitation due to flailleaflet; this condition was first diagnosed by echocardiographybetween 1980 and 1989.

Results The 86 patients who were treated medically had a mortalityrate significantly higher than expected (6.3 percent yearly,P = 0.016 for the comparison with the expected rate in the U.S.population according to the 1990 census). Independent determinantsof mortality were an older age, the presence of symptoms, anda lower ejection fraction. Patients who were even transientlyin New York Heart Association functional class III or IV hada high mortality rate (34 percent yearly), but the rate wasalso notable (4.1 percent yearly) among those in class I orII. At 10 years, the mean (±SE) rates of heart failure,atrial fibrillation, and death or surgery were 63±8,30±12, and 90±3 percent, respectively. In a multivariateanalysis, surgical correction of mitral regurgitation (performedin 143 patients) was associated with a reduced mortality rate(hazard ratio, 0.29; 95 percent confidence interval, 0.15 to0.56; P<0.001).

Conclusions When treated medically, mitral regurgitation dueto flail leaflet is associated with excess mortality and highmorbidity. Surgery is almost unavoidable within 10 years afterthe diagnosis and appears to be associated with an improvedprognosis; this finding suggests that surgery should be consideredearly in the course of the disease.

Mitral regurgitation is a common heart-valve disorder that isoften difficult to manage. Symptoms may be absent for years,¹despite severe regurgitation. Surgical correction of mitralregurgitation can relieve symptoms,² but when it is performedin symptomatic patients, it frequently leaves residual postoperativeleft ventricular dysfunction, which carries a poor prognosis.³^,⁴This serious complication, in conjunction with the feasibilityof valve repair,⁵ has led to the suggestion that surgical correctionbe performed early in the course of mitral regurgitation.³^,⁴^,⁵^,⁶The value of this approach is unclear, however, because of thelack of data on the course of medically treated mitral regurgitation.

Previous studies of the natural history of mitral regurgitation⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶have provided little information on morbidity and reported widelyvariable mortality rates. Reported survival rates at five yearshave ranged between 27 and 97 percent.⁹^,¹⁰ Such conflictingdata may be the result of poorly defined degrees of regurgitation,⁹^,¹¹^,¹⁶various selection biases,¹⁴^,¹⁵^,¹⁶ small study populations,⁷^,¹¹^,¹²^,¹³^,¹⁴and the presence of coexisting conditions that may be associatedwith mitral regurgitation.¹⁷ The discrepancies are difficultto reconcile, and they impede clinical decision making.

In patients with mitral regurgitation due to flail leaflet,the lesion results in uniformly high degrees of regurgitation¹⁸and is reliably diagnosed noninvasively by echocardiography.¹⁹^,²⁰In Western countries, flail mitral leaflet is the most frequentcause of mitral regurgitation requiring surgical correction.²¹^,²²Nevertheless, little is known about long-term clinical outcome,and the prognosis in patients treated medically has been characterizedvariously as poor²³ and good.²⁴

We conducted a follow-up study of patients with mitral regurgitationdue to flail leaflet, confirmed by echocardiography. The purposeof the study was to determine the long-term survival, the incidenceof cardiac complications, factors that predict the outcome,and the effect of surgical treatment on the prognosis.

Methods

Patients were included in the study if they had flail mitralleaflet that had first been diagnosed with the use of two-dimensionalechocardiography between January 1, 1980, and December 31, 1989,at the Mayo Clinic. Exclusion criteria were papillary-musclerupture, previous valve surgery, and associated aortic-valveor congenital heart disease. Patients who had coronary arterydisease or had undergone bypass grafting were not excluded.Base-line symptoms were defined as those occurring within onemonth before the diagnosis.

The 229 patients enrolled in the study were not followed onlyat our institution, and information on postdiagnostic eventswas obtained for all but 1 of the patients between March 1994and February 1995. Cardiac events and causes of death were ascertainedby contacting the patients' physicians and reviewing death certificates,coroners' reports, or autopsy records. The occurrence of arrhythmiashad to be confirmed by electrocardiography. Associated medicalconditions were assigned weights, and the results were summedas a modified comorbidity index.¹⁷

Echocardiographic Methods

Two-dimensional echocardiography was performed as describedpreviously,²⁵ and the diagnosis of flail leaflet was based onthe failure of leaflet coaptation, with rapid systolic movementof the involved leaflet tip in the left atrium.¹⁹^,²⁰ The degreeof mitral regurgitation was assessed semiquantitatively on ascale of 1+ to 4+.²⁶^,²⁷ Cardiac diameters were indexed to thebody-surface area. End-systolic wall stress was calculated²⁸with the use of noninvasive methods for estimating end-systolicpressure.²⁹ The left ventricular ejection fraction was measuredas described previously.³⁰^,³¹

Statistical Analysis

Continuous variables are expressed as means ±SD. Therates of mortality and other end points were estimated withthe use of the Kaplan–Meier method and linearized yearlyrates. To determine the outcome with medical treatment, datafor patients who underwent surgical treatment were censoredat the time of the surgery. To determine the effect of surgeryon the outcome, data during the entire follow-up period, includingthe immediate postsurgical phase, were used. Survival was comparedwith the expected survival of age- and sex-matched white membersof the U.S. population in 1990; differences in survival weredetermined with the one-sample log-rank test. Base-line predictorsof outcome were identified with a proportional-hazards analysis.To determine the effect on survival of events occurring afterthe diagnosis (surgery, congestive heart failure, and atrialfibrillation), a time-dependent proportional-hazards analysiswas performed within a multivariate model that included thebase-line predictors of survival with and without the comorbidityindex.

The effect of potential referral biases was tested by includingthe geographic origin of the patient and comorbidity in themultivariate analysis of survival and by repeating the analysiswith data from patients not referred for surgery within thefirst three months and not initially in New York Heart Association(NYHA) functional class I or II. A P value of less than 0.05was considered to indicate statistical significance.

Results

Base-Line Characteristics

The clinical characteristics of the 229 patients who met theinclusion criteria are shown in Table 1. A total of 188 patients(82 percent) had a history of an apical cardiac murmur or cardiacsymptoms for more than three months.

View this table:
[in this window]
[in a new window]
Table 1. Base-Line Characteristics of 229 Patients with Mitral Regurgitation Due to Flail Leaflet.

The presumed cause of the flail leaflet was an idiopathic conditionin 176 patients, infective endocarditis in 45, trauma in 5,and miscellaneous factors in 3. The posterior leaflet was involvedin 187 patients, the anterior leaflet in 37, and both leafletsin 5. Base-line echocardiographic data are shown in Table 1.The degree of mitral regurgitation was reported as grade 3+or 4+ in 168 of the 193 patients (87 percent) who were evaluatedby Doppler echocardiography and in 71 of the 75 patients (95percent) evaluated by left ventriculography.

Coronary angiography was performed in 92 patients, 28 of whomhad stenosis of 70 percent or more of the diameter of at leastone coronary artery.

Overall Outcome with Medical Treatment

The mortality and morbidity rates during medical treatment areshown in Table 2. Of the 229 patients, 45 (20 percent) diedduring medical treatment. The cause of death was cardiovascularin 31 patients (intractable heart failure in 13, cardiac arrestin 11, cerebral thromboembolism or hemorrhage in 3, and miscellaneousfactors in 4), noncardiac in 12, and unknown in 2. Long-termsurvival with medical treatment was shorter than the expectedsurvival (P = 0.016) (Figure 1). The rate of death from cardiaccauses was 21±4 percent at 5 years and 33±7 percentat 10 years.

View this table:
[in this window]
[in a new window]
Table 2. Outcome at 5 and 10 Years with Medical Treatment of Mitral Regurgitation Due to Flail Leaflet.

View larger version (2K):
[in this window]
[in a new window]
Figure 1. Long-Term Survival with Medical Treatment, as Compared with Expected Survival, in 229 Patients with Mitral Regurgitation Due to Flail Leaflet.

In the multivariate analysis (Table 3), the base-line variablesthat were independently predictive of survival were age, NYHAclass, and ejection fraction. Figure 2 and Figure 3 show theKaplan–Meier survival curves according to NYHA class andejection fraction, respectively.

View this table:
[in this window]
[in a new window]
Table 3. Multivariate Predictors of the Outcome of Mitral Regurgitation Due to Flail Leaflet.

View larger version (2K):
[in this window]
[in a new window]
Figure 2. Long-Term Survival with Medical Treatment, According to New York Heart Association Class.
The New York Heart Association class was not available for one patient.

View larger version (2K):
[in this window]
[in a new window]
Figure 3. Long-Term Survival with Medical Treatment, According to the Ejection Fraction (EF).

The incidence of congestive heart failure was 30±4 percentat 5 years and 63±8 percent at 10 years (Figure 4). Multivariatepredictors of the development of congestive heart failure wereage, ejection fraction, and left atrial diameter adjusted forbody-surface area (Table 3). Of the 55 patients with a firstepisode of heart failure after the diagnosis of mitral regurgitation,27 (49 percent) underwent surgery. Most of the remaining patientshad symptomatic improvement with medical treatment, but thesepatients nevertheless had a higher mortality rate than thosewithout an episode of heart failure (adjusted hazard ratio,16.53; 95 percent confidence interval, 8.72 to 31.36; P<0.001).

View larger version (2K):
[in this window]
[in a new window]
Figure 4. Incidence of Atrial Fibrillation (AF), Congestive Heart Failure (CHF), Mitral-Valve Surgery, and Surgery or Death.
A total of 175 patients were initially at risk for atrial fibrillation, and 229 were initially at risk for the other end points. The numbers in parentheses are numbers of events for each end point. Plus–minus values are mean (±SE) event rates at 10 years.

Of the 175 patients who were in sinus rhythm at presentation,13 had chronic atrial fibrillation (Table 2 and Figure 4), whichwas independently predicted only by age. Atrial fibrillationduring follow-up was not associated with excess mortality (P= 0.19).

The incidence of infective endocarditis, thromboembolic events,and major bleeding is shown in Table 2.

Mitral-Valve Surgery

Surgery was performed in 143 patients a mean of 23±32months after the diagnosis. The remaining 86 patients were treatedmedically. Indications for surgery were NYHA class III or IVdyspnea in 107 patients, the physician's preference in 24, infectiveendocarditis in 5, angina pectoris in 4, and thromboembolismin 1; the indications could not be determined in the cases of2 patients. The mitral valve was repaired in 95 patients andreplaced in 47; in 1 patient, operated on elsewhere, the natureof the procedure was not known. Concomitant coronary-arterybypass grafting was performed in 29 patients. The operativemortality was 4 percent (6 deaths among 143 patients) overalland 2 percent (3 among 121) for the patients operated on atour institution.

The cumulative likelihood of mitral-valve surgery and of thecombined end point of death or surgery is shown in Figure 4.

Effect of Symptoms on Outcome

The presence of symptoms was a major predictor of survival (Table 2and Figure 2), but there was no difference in survival betweenpatients in NYHA class III and those in class IV (P = 0.28)or between patients in class I and those in class II (P = 0.26).

Of the 66 patients in NYHA class III or IV at base line, 49(74 percent) eventually underwent surgery. The other 17 patientscontinued to be treated medically because of the high estimatedrisk associated with surgery (in 6 patients) or functional improvementwith treatment (in 11). Despite the frequent functional improvement,the outcome for these patients was poor (yearly mortality, 34percent) and worse than the outcome for the patients in classI or II (hazard ratio, 8.23; 95 percent confidence interval,4.22 to 16.05; P<0.001).

Nevertheless, the patients in NYHA class I or II had a notableannual mortality rate (4.1 percent). Of the 27 deaths that occurredduring medical treatment, 19 (70 percent) were from cardiaccauses, 7 of which were not preceded by class III or IV symptoms.No group was devoid of risk, with a 10-year survival of 69±10percent among the 92 patients in class I with an ejection fractionhigher than 60 percent and 78±6 percent among the 100patients in class I or II with a comorbidity index of 0. Morbiditywas high among both patients in class I and those in class II,but the likelihood of heart failure and surgery was higher amongthe patients in class II (Table 2).

Effect of Surgery on Survival

Among the patients who underwent surgery, survival at 5 and10 years was 79±3 and 66±4 percent, respectively(97 and 100 percent of the expected survival, respectively;P = 0.68). Thus, when the effect of surgery on survival wasconsidered, no excess mortality was observed.

In a multivariate proportional-hazards analysis that includedthe significant base-line predictors of survival, surgery performedat any time (time-dependent variable) independently and favorablyinfluenced survival (adjusted hazard ratio, 0.29; 95 percentconfidence interval, 0.15 to 0.56) (Table 3). This effect persistedeven when the comorbidity index was included in the model (Table 3).

Effect of Referral Patterns on Outcome

The geographic origin of the referral (<120 miles [193 Km]from Rochester, Minn., or >120 miles) had no effect on theoutcome in the multivariate analysis (P>0.20). The comorbidityrate at diagnosis (Table 1) was low, indicating that the choiceof medical over surgical treatment was influenced by the cardiacstatus of the patients and not by coexisting conditions. Theinclusion of comorbidity in the multivariate proportional-hazardsmodels did not modify the base-line predictors of outcome.

Among the 157 patients who were not immediately referred forsurgery (i.e., within 3 months after the diagnosis), the 10-yearcumulative incidence of surgery and surgery or death was 73±6and 85±4 percent, respectively; these rates are similarto the rates for the total study population. Among the 162 patientsinitially in NYHA class I or II, the 10-year incidence of heartfailure, atrial fibrillation, and surgery or death was 61±9,29±12, and 85±4 percent, respectively, valuesthat are similar to the rates for the total study population.

Discussion

In this study we investigated the long-term outcome of mitralregurgitation due to flail leaflet. Among the patients treatedmedically there was an excess mortality directly related tothe cardiac disease; a high incidence of cardiovascular complications;and an increased risk of late death among older patients, thosewith advanced symptoms, and those with a reduced ejection fractionat diagnosis. Death or the need for surgery is almost unavoidablewithin 10 years after the diagnosis. Surgical correction ofmitral regurgitation appeared to improve long-term survival.

The natural history of mitral regurgitation is poorly defined,with widely disparate estimates of long-term survival. Reportedsurvival rates of 95 percent at 20 years,⁹ 70 percent at 10years,¹⁶ 46 and 50 percent at 5 years,¹¹^,¹⁵ and even as lowas 27 percent at 5 years¹⁰ are difficult to reconcile. Thesedisparities are probably due to small study populations⁷^,¹⁰^,¹¹^,¹²^,¹⁴and multiple selection biases⁸^,¹⁰^,¹¹^,¹⁴^,¹⁵^,¹⁶ associated withill-defined degrees of regurgitation,⁷^,⁹^,¹¹^,¹⁵^,¹⁶^,³²^,³³ whichtogether may have resulted in underestimation or overestimationof the hazards of medically treated mitral regurgitation. Theearlier predominance of rheumatic disease as the cause of mitralregurgitation⁹^,¹¹^,¹⁶^,³²^,³³ also makes these data less applicableto contemporary practice, since other causes are now more common.²¹^,²²

Mitral regurgitation due to flail leaflet is uniformly associatedwith a large volume overload,¹⁸^,³⁴^,³⁵ whether the presentationof regurgitation is acute³⁵ or (as it more frequently is) chronic,¹⁸^,³⁶^,³⁷and the condition is diagnosed reliably with echocardiography.¹⁹^,²⁰Nevertheless, different observations have been made about theclinical outcome, which has been noted to be poor²³^,³⁵^,³⁸^,³⁹or good,³⁷^,⁴⁰^,⁴¹ and different recommendations have been madeabout the need for immediate surgery²³^,³⁹ or conservative treatmenteven for patients with hemodynamic decompensation.¹³^,²⁴ Theseinconsistent findings are based on data from small series andare not helpful in making clinical decisions, which are criticallyimportant because of the high incidence of postoperative leftventricular dysfunction in patients who undergo mitral-valvesurgery at a symptomatic stage.³^,⁴ The suggestion that earliersurgery may be appropriate,⁴^,⁶ especially given the currentfeasibility⁴² and safety⁵ of valve repair, is debatable withoutfirm information about the natural history of mitral regurgitationdue to flail leaflet.

The present study shows that patients treated medically haveexcess mortality, as compared with the general population. Thisexcess mortality is due to cardiac causes and appears to bedirectly related to the valvular heart disease, underscoringthe severity of the disease. The 6.3 percent yearly mortalityrate in our study is similar to the rate among patients withtriple-vessel coronary disease.⁴³ The incidence of related cardiacmorbidity, which has not been consistently recognized,⁹^,¹² wasalso high in our study, with a 63 percent incidence of congestiveheart failure and a 30 percent incidence of chronic atrial fibrillationat 10 years, although most of the patients were initially inNYHA class I or II. Ten years after the diagnosis, either deathor surgery is almost unavoidable, even taking into account thepotential bias associated with direct referrals for surgery.The observation of excess mortality and high morbidity, duringan era when both medical and surgical²^,³^,⁵^,⁶^,⁴² treatments havebeen available, should raise awareness of the serious prognosticimplications of the diagnosis of mitral regurgitation due toflail leaflet and should lead to a consideration of surgerybased on the patient's condition at the time of the diagnosis.

Base-line predictors of death in our study were older age, higherNYHA class, and reduced ejection fraction. The high predictivepower of the functional class was related in part to the pooroutcome among patients in class III or IV who were not treatedsurgically. In the cases of these patients and those not operatedon after an episode of heart failure, the attending physicianwas falsely reassured by rapid improvement with medical treatment.The clinical implication of this finding is that class III symptoms,even if transient, should trigger the consideration of immediatesurgery, even in patients at notable operative risk.

The importance of the ejection fraction in predicting the outcomeunderscores the clinical significance of left ventricular dysfunctionas a complication of mitral regurgitation.³^,⁴ Despite profoundchanges in loading conditions,⁴⁴ the ejection fraction is apowerful predictor of the outcome of mitral regurgitation.²^,³^,⁷^,⁸Even a mildly decreased ejection fraction (<60 percent) carriesan increased risk of late mortality and heart failure and shouldlead to the consideration of immediate surgery.

The left atrial size, which is related to the degree of regurgitation,⁴⁵^,⁴⁶significantly predicted the occurrence of congestive heart failurebut not of subsequent atrial fibrillation.⁴⁷ If the atrial diameteris larger than 30 mm per square meter of body-surface area,surgery should be considered.

Surgical treatment of mitral regurgitation unequivocally improvessymptoms and has been considered indicated primarily for patientswith NYHA class III or IV symptoms.²^,³ Evidence that surgeryimproves the prognosis for patients with a decreased ejectionfraction is limited.⁷ Although there are no definitive datafrom randomized trials, the present, nonrandomized study providesevidence that surgery, whenever it is performed, is associatedwith improved survival independently of base-line characteristicsand comorbid conditions.

Our study does not document the true natural history of mitralregurgitation due to flail leaflet — that is, the naturalhistory of the disorder when both medical and surgical treatmentsare withheld. The only clinically relevant consideration isthe risk incurred when surgical treatment is delayed. In ourpatients, the overriding reason for deferring surgical treatmentwas the absence of severe symptoms during medical therapy, whereasin previous series, many patients received medical treatmentbecause of an unacceptably high operative risk.¹⁰^,¹¹^,¹⁵

In asymptomatic patients it is impossible to date the onsetof the flail leaflet exactly.⁴⁸ Echocardiography is the onlyreliable method of diagnosing partial flail leaflet, however,¹⁹^,²⁰and it provides a meaningful starting point. In our study, all143 patients examined at surgery had flail leaflets (141 withruptured chordae and 2 with elongated chordae).

We used echocardiographic measurements of the ejection fractionbecause they were available for all patients. The value of thesemeasurements³⁰^,³¹ in mitral regurgitation has been verified³^,⁴^,⁵and is confirmed by the prognostic importance of the ejectionfraction in our study. Use of the echocardiographic diagnosisof flail leaflet also allowed the inclusion of a large numberof asymptomatic or minimally symptomatic patients — thosemost commonly seen in routine clinical practice.

Since our study could not be population-based, a referral biascannot be ruled out. However, adjustment for the geographicorigin of the referrals, the presence of coexisting conditions,and the possibility of direct referrals for surgery did notaffect the results, suggesting a low probability of referralbias.

Conclusions

In this study, mitral regurgitation due to flail leaflet wasassociated with excess mortality and high morbidity. Most patientseither died or required mitral-valve surgery within 10 yearsafter the diagnosis, underscoring the severity of the disease.A lower ejection fraction and the presence of symptoms at baseline were predictors of mortality, and a larger left atrialsize was a predictor of heart failure. However, even asymptomaticpatients had a substantial mortality rate. Multivariate analysessuggest that surgical correction of mitral regurgitation improvessurvival and that surgery should therefore be considered earlyin the disease in patients with repairable valves and a lowsurgical risk.

We are indebted to Christine M. Boos for expert assistance withthe data analysis.

Source Information

From the Division of Cardiovascular Diseases and Internal Medicine (L.H.L., M.E.-S., J.B.S., A.J.T., R.L.F.), the Section of Cardiovascular Surgery (H.V.S.), and the Section of Biostatistics (K.R.B.), Mayo Clinic and Mayo Foundation, Rochester, Minn.

Address reprint requests to Dr. Enriquez-Sarano at the Mayo Clinic, 200 First St. SW, Rochester, MN 55905.

References

Selzer A, Katayama F. Mitral regurgitation: clinical patterns, pathophysiology and natural history. Medicine (Baltimore) 1972;51:337-366. [Medline]
Phillips HR, Levine FH, Carter JE, et al. Mitral valve replacement for isolated mitral regurgitation: analysis of clinical course and late postoperative left ventricular ejection fraction. Am J Cardiol 1981;48:647-654. [CrossRef][Medline]
Enriquez-Sarano M, Tajik AJ, Schaff HV, Orszulak TA, Bailey KR, Frye RL. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation 1994;90:830-837. [Free Full Text]
Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications. J Am Coll Cardiol 1994;24:1536-1543. [Abstract]
Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR, Frye RL. Valve repair improves the outcome of surgery for mitral regurgitation: a multivariate analysis. Circulation 1995;91:1022-1028. [Free Full Text]
Acar J, Michel PL, Luxereau P, Vahanian A, Cormier B. Indications for surgery in mitral regurgitation. Eur Heart J 1991;12:Suppl B:52-54.
Hochreiter C, Niles N, Devereux RB, Kligfield P, Borer JS. Mitral regurgitation: relationship of noninvasive descriptors of right and left ventricular performance to clinical and hemodynamic findings and to prognosis in medically and surgically treated patients. Circulation 1986;73:900-912. [Free Full Text]
Ramanathan KB, Knowles J, Connor MJ, et al. Natural history of chronic mitral insufficiency: relation of peak systolic pressure/end-systolic volume ratio to morbidity and mortality. J Am Coll Cardiol 1984;3:1412-1416. [Abstract]
Wilson MG, Lim WN. The natural history of rheumatic heart disease in the third, fourth, and fifth decades of life. I. Prognosis with special reference to survivorship. Circulation 1957;16:700-712. [Medline]
Horstkotte D, Loogen F, Kleikamp G, Schulte HD, Trampisch HJ, Bircks W. Der Einflu ${beta}$ des prothetischen Herzklappenersatzes auf den natürlichen Verlauf von isolierten Mitral- und Aortenklappenfehlern sowie Mehrklappenerkrankungen: Klinische Ergebmisse bei 783 Patienten bis zu 8 Jahren nach Implantation von Björk-Shiley-Kippscheibenprothensen. Z Kardiol 1983;72:494-503. [Medline]
Munoz S, Gallardo J, Diaz-Gorrin JR, Medina O. Influence of surgery on the natural history of rheumatic mitral and aortic valve disease. Am J Cardiol 1975;35:234-242. [CrossRef][Medline]
Rosen SE, Borer JS, Hochreiter C, et al. Natural history of the asymptomatic/minimally symptomatic patient with severe mitral regurgitation secondary to mitral valve prolapse and normal right and left ventricular performance. Am J Cardiol 1994;74:374-380. [CrossRef][Medline]
DePace NL, Mintz GS, Ren JF, et al. Natural history of the flail mitral leaflet syndrome: a serial 2-dimensional echocardiographic study. Am J Cardiol 1983;52:789-795. [CrossRef][Medline]
Hammermeister KE, Fisher L, Kennedy W, Samuels S, Dodge HT. Prediction of late survival in patients with mitral valve disease from clinical, hemodynamic, and quantitative angiographic variables. Circulation 1978;57:341-349. [Free Full Text]
Delahaye JP, Gare JP, Viguier E, Delahaye F, De Gevigney G, Milon H. Natural history of severe mitral regurgitation. Eur Heart J 1991;12:Suppl B:5-9.
Rapaport E. Natural history of aortic and mitral valve disease. Am J Cardiol 1975;35:221-227. [CrossRef][Medline]
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-383. [CrossRef][Medline]
Pearson AC, St Vrain J, Mrosek D, Labovitz AJ. Color Doppler echocardiographic evaluation of patients with a flail mitral leaflet. J Am Coll Cardiol 1990;16:232-239. [Abstract]
Mintz GS, Kotler MN, Segal BL, Parry WR. Two-dimensional echocardiographic recognition of ruptured chordae tendineae. Circulation 1978;57:244-250. [Free Full Text]
Mintz GS, Kotler MN, Parry WR, Segal BL. Statistical comparison of M mode and two dimensional echocardiographic diagnosis of flail mitral leaflets. Am J Cardiol 1980;45:253-259. [CrossRef][Medline]
Olson LJ, Subramanian R, Ackermann DM, Orszulak TA, Edwards WD. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin Proc 1987;62:22-34. [Medline]
Luxereau P, Dorent R, De Gevigney G, Bruneval P, Chomette G, Delahaye G. Aetiology of surgically treated mitral regurgitation. Eur Heart J 1991;12:Suppl B:2-4.
Sanders CA, Austen WG, Harthorne JW, Dinsmore RE, Scannell JG. Diagnosis and surgical treatment of mitral regurgitation secondary to ruptured chordae tendineae. N Engl J Med 1967;276:943-949.
Mitral regurgitation. In: Barlow JB. Perspectives on the mitral valve. Philadelphia: F.A. Davis, 1987:113-50.
Tajik AJ, Seward JB, Hagler DJ, Mair DD, Lie JT. Two-dimensional real-time ultrasonic imaging of the heart and great vessels: technique, image orientation, structure identification, and validation. Mayo Clin Proc 1978;53:271-303. [Medline]
Abbasi AS, Allen MW, DeCristofaro D, Ungar I. Detection and estimation of the degree of mitral regurgitation by range-gated pulsed Doppler echocardiography. Circulation 1980;61:143-147. [Free Full Text]
Helmcke F, Nanda NC, Hsiung MC, et al. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation 1987;75:175-183. [Free Full Text]
Reichek N, Wilson J, St John Sutton M, Plappert TA, Goldberg S, Hirshfeld JW. Noninvasive determination of left ventricular end-systolic stress: validation of the method and initial application. Circulation 1982;65:99-108. [Free Full Text]
Rozich JD, Carabello BA, Usher BW, Kratz JM, Bell AE, Zile MR. Mitral valve replacement with and without chordal preservation in patients with chronic mitral regurgitation: mechanisms for differences in postoperative ejection performance. Circulation 1992;86:1718-1726. [Free Full Text]
Rich S, Sheikh A, Gallastegui J, Kondos GT, Mason T, Lam W. Determination of left ventricular ejection fraction by visual estimation during real-time two-dimensional echocardiography. Am Heart J 1982;104:603-606. [CrossRef][Medline]
Quinones MA, Waggoner AD, Reduto LA, et al. A new, simplified and accurate method for determining ejection fraction with two-dimensional echocardiography. Circulation 1981;64:744-753. [Free Full Text]
Ellis LB, Ramirez A. The clinical course of patients with severe "rheumatic" mitral insufficiency. Am Heart J 1969;78:406-418. [Medline]
Jhaveri S, Czoniczer G, Reider RB, Massell BF. Relatively benign "pure" mitral regurgitation of rheumatic origin: a study of seventy-four adult patients. Circulation 1960;22:39-48. [Free Full Text]
Enriquez-Sarano M, Seward JB, Bailey KR, Tajik AJ. Effective regurgitant orifice area: a noninvasive Doppler development of an old hemodynamic concept. J Am Coll Cardiol 1994;23:443-451. [Abstract]
Baxley WA, Kennedy JW, Feild B, Dodge HT. Hemodynamics in ruptured chordae tendineae and chronic rheumatic mitral regurgitation. Circulation 1973;48:1288-1294. [Free Full Text]
Oliveira DB, Dawkins KD, Kay PH, Paneth M. Chordal rupture. I. Aetiology and natural history. Br Heart J 1983;50:312-317. [Free Full Text]
Bergeron GA. Minimally symptomatic patients with ruptured chordae tendineae due to myxomatous degeneration of the mitral valve. Am J Med 1986;81:333-335. [CrossRef][Medline]
Roberts WC, Braunwald E, Morrow AG. Acute severe mitral regurgitation secondary to ruptured chordae tendineae: clinical, hemodynamic, and pathologic considerations. Circulation 1966;33:58-70. [Free Full Text]
Sanders CA, Scannell JG, Harthorne JW, Austen WG. Severe mitral regurgitation secondary to ruptured chordae tendineae. Circulation 1965;31:506-516. [Free Full Text]
Grenadier E, Keidar S, Sahn DJ, et al. Ruptured mitral chordae tendineae may be a frequent and insignificant complication in the mitral valve prolapse syndrome. Eur Heart J 1985;6:1006-1015. [Free Full Text]
Ren JF, Panidis IP, Kotler MN, Mintz GS, Goel I, Ross J. Flail mitral valve syndrome: comparison with chronic mitral regurgitation of other etiologies. Am Heart J 1985;109:435-442. [Medline]
Galloway AC, Colvin SB, Baumann FG, et al. Long-term results of mitral valve reconstruction with Carpentier techniques in 148 patients with mitral insufficiency. Circulation 1988;78:I-97.
Emond M, Mock MB, Davis KB, et al. Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry. Circulation 1994;90:2645-2657. [Free Full Text]
Carabello BA. Mitral regurgitation. 1. Basic pathophysiologic principles. Mod Concepts Cardiovasc Dis 1988;57:53-64.
Gehl LG, Mintz GS, Kotler MN, Segal BL. Left atrial volume overload in mitral regurgitation: a two dimensional echocardiographic study. Am J Cardiol 1982;49:33-38. [CrossRef][Medline]
Burwash IG, Blackmore GL, Koilpillai CJ. Usefulness of left atrial and left ventricular chamber sizes as predictors of the severity of mitral regurgitation. Am J Cardiol 1992;70:774-779. [CrossRef][Medline]
Vaziri SM, Larson MG, Benjamin EJ, Levy D. Echocardiographic predictors of nonrheumatic atrial fibrillation: the Framingham Heart Study. Circulation 1994;89:724-730. [Free Full Text]
Kolibash AJ Jr, Kilman JW, Bush CA, Ryan JM, Fontana ME, Wooley CF. Evidence for progression from mild to severe mitral regurgitation in mitral valve prolapse. Am J Cardiol 1986;58:762-767. [CrossRef][Medline]


	Abstract
	PDF


	Letters


	Add to Personal Archive
	Add to Citation Manager
	Notify a Friend
	E-mail When Cited


	PubMed Citation

Related Letters:

Mitral Regurgitation Due to Flail Leaflet
Barlow J. B., Kinsley R. H., Fetscher S. R., Enriquez-Sarano M., Ross J.
Extract | Full Text
N Engl J Med 1997; 336:1322-1324, May 1, 1997. Correspondence

This article has been cited by other articles:

Avierinos, J.-F., Inamo, J., Grigioni, F., Gersh, B., Shub, C., Enriquez-Sarano, M. (2008). Sex Differences in Morphology and Outcomes of Mitral Valve Prolapse. ANN INTERN MED 149: 787-794 [Abstract] [Full Text]
2006 WRITING COMMITTEE MEMBERS, , Bonow, R. O., Carabello, B. A., Chatterjee, K., de Leon, A. C. Jr, Faxon, D. P., Freed, M. D., Gaasch, W. H., Lytle, B. W., Nishimura, R. A., O'Gara, P. T., O'Rourke, R. A., Otto, C. M., Shah, P. M., Shanewise, J. S. (2008). 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 118: e523-e661 [Full Text]
Bonow, R. O., Carabello, B. A., Chatterjee, K., de Leon, A. C. Jr, Faxon, D. P., Freed, M. D., Gaasch, W. H., Lytle, B. W., Nishimura, R. A., O'Gara, P. T., O'Rourke, R. A., Otto, C. M., Shah, P. M., Shanewise, J. S., Nishimura, R. A., Carabello, B. A., Faxon, D. P., Freed, M. D., Lytle, B. W., O'Gara, P. T., O'Rourke, R. A., Shah, P. M. (2008). 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 52: e1-e142 [Full Text]
Buck, T., Plicht, B., Kahlert, P., Schenk, I. M., Hunold, P., Erbel, R. (2008). Effect of Dynamic Flow Rate and Orifice Area on Mitral Regurgitant Stroke Volume Quantification Using the Proximal Isovelocity Surface Area Method. J Am Coll Cardiol 52: 767-778 [Abstract] [Full Text]
Carabello, B. A. (2008). The Current Therapy for Mitral Regurgitation. J Am Coll Cardiol 52: 319-326 [Abstract] [Full Text]
Sekuri, C., Utuk, O., Bayturan, O., Bilge, A., Kurhan, Z., Tavli, T. (2008). Effect of losartan on exercise tolerance and echocardiographic parameters in patients with mitral regurgitation. Journal of Renin-Angiotensin-Aldosterone System 9: 107-111 [Abstract]
Levine, R. A., Durst, R. (2008). Mitral Valve Prolapse: A Deeper Look. J Am Coll Cardiol Img 1: 304-306 [Full Text]
Neilan, T. G., Ton-Nu, T.-T., Kawase, Y., Yoneyama, R., Hoshino, K., del Monte, F., Hajjar, R. J., Picard, M. H., Levine, R. A., Hung, J. (2008). Progressive nature of chronic mitral regurgitation and the role of tissue Doppler-derived indexes. Am. J. Physiol. Heart Circ. Physiol. 294: H2106-H2111 [Abstract] [Full Text]
Grigioni, F., Tribouilloy, C., Avierinos, J. F., Barbieri, A., Ferlito, M., Trojette, F., Tafanelli, L., Branzi, A., Szymanski, C., Habib, G., Modena, M. G., Enriquez-Sarano, M., on behalf of the MIDA Investigators, (2008). Outcomes in Mitral Regurgitation Due to Flail Leaflets: A Multicenter European Study. J Am Coll Cardiol Img 1: 133-141 [Abstract] [Full Text]
Grayburn, P. A. (2008). Should We Operate on Asymptomatic Patients With Severe Mitral Regurgitation?. J Am Coll Cardiol Img 1: 142-144 [Full Text]
Mittnacht, A. J., Fanshawe, M., Konstadt, S. (2008). Anesthetic Considerations in the Patient With Valvular Heart Disease Undergoing Noncardiac Surgery. SEMIN CARDIOTHORAC VASC ANESTH 12: 33-59 [Abstract]
Fedak, P. W.M., McCarthy, P. M., Bonow, R. O. (2008). Evolving Concepts and Technologies in Mitral Valve Repair. Circulation 117: 963-974 [Full Text]
Kerr, A. J., Raffel, O. C., Whalley, G. A., Zeng, I., Stewart, R. A. (2008). Elevated B-type natriuretic peptide despite normal left ventricular function on rest and exercise stress echocardiography in mitral regurgitation. Eur Heart J 29: 363-370 [Abstract] [Full Text]
Beeri, R., Yosefy, C., Guerrero, J. L., Nesta, F., Abedat, S., Chaput, M., del Monte, F., Handschumacher, M. D., Stroud, R., Sullivan, S., Pugatsch, T., Gilon, D., Vlahakes, G. J., Spinale, F. G., Hajjar, R. J., Levine, R. A. (2008). Mitral regurgitation augments post-myocardial infarction remodeling failure of hypertrophic compensation.. J Am Coll Cardiol 51: 476-486 [Abstract] [Full Text]
Enriquez-Sarano, M., Nkomo, V. T., Michelena, H. (2008). Principles and Practice of Echocardiography in Cardiac Surgery. Card Surg Adult 3: 315-348 [Full Text]
Fann, J. I., Ingels, N. B. Jr., Miller, D. C. (2008). Pathophysiology of Mitral Valve Disease. Card Surg Adult 3: 973-1012 [Full Text]
Chen, F. Y., Cohn, L. H. (2008). Mitral Valve Repair. Card Surg Adult 3: 1013-1030 [Full Text]
Gudbjartsson, T., Absi, T., Aranki, S. (2008). Mitral Valve Replacement. Card Surg Adult 3: 1031-1068 [Full Text]
Marciniak, A., Claus, P., Sutherland, G. R., Marciniak, M., Karu, T., Baltabaeva, A., Merli, E., Bijnens, B., Jahangiri, M. (2007). Changes in systolic left ventricular function in isolated mitral regurgitation. A strain rate imaging study. Eur Heart J 28: 2627-2636 [Abstract] [Full Text]
Beeri, R., Yosefy, C., Guerrero, J. L., Abedat, S., Handschumacher, M. D., Stroud, R. E., Sullivan, S., Chaput, M., Gilon, D., Vlahakes, G. J., Spinale, F. G., Hajjar, R. J., Levine, R. A. (2007). Early Repair of Moderate Ischemic Mitral Regurgitation Reverses Left Ventricular Remodeling: A Functional and Molecular Study. Circulation 116: I-288-I-293 [Abstract] [Full Text]
Messika-Zeitoun, D., Bellamy, M., Avierinos, J.-F., Breen, J., Eusemann, C., Rossi, A., Behrenbeck, T., Scott, C., Tajik, J. A., Enriquez-Sarano, M. (2007). Left atrial remodelling in mitral regurgitation--methodologic approach, physiological determinants, and outcome implications: a prospective quantitative Doppler-echocardiographic and electron beam-computed tomographic study. Eur Heart J 28: 1773-1781 [Abstract] [Full Text]
Mirabel, M., Iung, B., Baron, G., Messika-Zeitoun, D., Detaint, D., Vanoverschelde, J.-L., Butchart, E. G., Ravaud, P., Vahanian, A. (2007). What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery?. Eur Heart J 28: 1358-1365 [Abstract] [Full Text]
De Castro, S., Caselli, S., Maron, M., Pelliccia, A., Cavarretta, E., Maddukuri, P., Cartoni, D., Di Angelantonio, E., Kuvin, J. T, Patel, A. R, Pandian, N. G (2007). Left ventricular remodelling index (LVRI) in various pathophysiological conditions: a real-time three-dimensional echocardiographic study. Heart 93: 205-209 [Abstract] [Full Text]
Authors/Task Force Members, , Vahanian, A., Baumgartner, H., Bax, J., Butchart, E., Dion, R., Filippatos, G., Flachskampf, F., Hall, R., Iung, B., Kasprzak, J., Nataf, P., Tornos, P., Torracca, L., Wenink, A., ESC Committee for Practice Guidelines (CPG), , Priori, S. G., Blanc, J.-J., Budaj, A., Camm, J., Dean, V., Deckers, J., Dickstein, K., Lekakis, J., McGregor, K., Metra, M., Morais, J., Osterspey, A., Tamargo, J., Zamorano, J. L., Document Reviewers, , Zamorano, J. L., Angelini, A., Antunes, M., Fernandez, M. A. G., Gohlke-Baerwolf, C., Habib, G., McMurray, J., Otto, C., Pierard, L., Pomar, J. L., Prendergast, B., Rosenhek, R., Uva, M. S., Tamargo, J. (2007). Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 0: ehl428v1-39 [Full Text]
Ray, S., Chambers, J., Gohlke-Baerwolf, C., Bridgewater, B. (2006). Mitral valve repair for severe mitral regurgitation: the way forward?. Eur Heart J 27: 2925-2928 [Abstract] [Full Text]
Sacks, M. S., Enomoto, Y., Graybill, J. R., Merryman, W. D., Zeeshan, A., Yoganathan, A. P., Levy, R. J., Gorman, R. C., Gorman, J. H. III (2006). In-vivo dynamic deformation of the mitral valve anterior leaflet.. Ann. Thorac. Surg. 82: 1369-1377 [Abstract] [Full Text]
Bonow, R. O., Carabello, B. A., Chatterjee, K., de Leon, A. C. Jr, Faxon, D. P., Freed, M. D., Gaasch, W. H., Lytle, B. W., Nishimura, R. A., O'Gara, P. T., O'Rourke, R. A., Otto, C. M., Shah, P. M., Shanewise, J. S., Smith, S. C. Jr, Jacobs, A. K., Adams, C. D., Anderson, J. L., Antman, E. M., Faxon, D. P., Fuster, V., Halperin, J. L., Hiratzka, L. F., Hunt, S. A., Lytle, B. W., Nishimura, R., Page, R. L., Riegel, B. (2006). ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 48: e1-e148 [Full Text]
Bonow, R. O., Carabello, B. A., Chatterjee, K., de Leon, A. C. Jr, Faxon, D. P., Freed, M. D., Gaasch, W. H., Lytle, B. W., Nishimura, R. A., O'Gara, P. T., O'Rourke, R. A., Otto, C. M., Shah, P. M., Shanewise, J. S., Smith, S. C. Jr, Jacobs, A. K., Adams, C. D., Anderson, J. L., Antman, E. M., Faxon, D. P., Fuster, V., Halperin, J. L., Hiratzka, L. F., Hunt, S. A., Lytle, B. W., Nishimura, R., Page, R. L., Riegel, B. (2006). ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 48: 598-675 [Full Text]
Detaint, D., Sundt, T. M., Nkomo, V. T., Scott, C. G., Tajik, A. J., Schaff, H. V., Enriquez-Sarano, M. (2006). Surgical Correction of Mitral Regurgitation in the Elderly: Outcomes and Recent Improvements. Circulation 114: 265-272 [Abstract] [Full Text]
Bridgewater, B, Hooper, T, Munsch, C, Hunter, S, von Oppell, U, Livesey, S, Keogh, B, Wells, F, Patrick, M, Kneeshaw, J, Chambers, J, Masani, N, Ray, S (2006). Mitral repair best practice: proposed standards. Heart 92: 939-944 [Abstract] [Full Text]
Messika-Zeitoun, D., Johnson, B. D., Nkomo, V., Avierinos, J.-F., Allison, T. G., Scott, C., Tajik, A. J., Enriquez-Sarano, M. (2006). Cardiopulmonary Exercise Testing Determination of Functional Capacity in Mitral Regurgitation: Physiologic and Outcome Implications. J Am Coll Cardiol 47: 2521-2527 [Abstract] [Full Text]
Rosenhek, R., Rader, F., Klaar, U., Gabriel, H., Krejc, M., Kalbeck, D., Schemper, M., Maurer, G., Baumgartner, H. (2006). Outcome of Watchful Waiting in Asymptomatic Severe Mitral Regurgitation. Circulation 113: 2238-2244 [Abstract] [Full Text]
Mohty-Echahidi, D., Malouf, J. F., Girard, S. E., Schaff, H. V., Grill, D. E., Enriquez-Sarano, M. E., Miller, F. A. Jr (2006). Impact of Prosthesis-Patient Mismatch on Long-Term Survival in Patients With Small St Jude Medical Mechanical Prostheses in the Aortic Position. Circulation 113: 420-426 [Abstract] [Full Text]
Lee, R, Haluska, B, Leung, D Y, Case, C, Mundy, J, Marwick, T H (2005). Functional and prognostic implications of left ventricular contractile reserve in patients with asymptomatic severe mitral regurgitation. Heart 91: 1407-1412 [Abstract] [Full Text]
Eguchi, K., Ohtaki, E., Matsumura, T., Tanaka, K., Tohbaru, T., Iguchi, N., Misu, K., Asano, R., Nagayama, M., Sumiyoshi, T., Kasegawa, H., Hosoda, S. (2005). Pre-operative atrial fibrillation as the key determinant of outcome of mitral valve repair for degenerative mitral regurgitation. Eur Heart J 26: 1866-1872 [Abstract] [Full Text]
Lembcke, A., Borges, A. C., Dushe, S., Dohmen, P. M., Wiese, T. H., Rogalla, P., Hermann, K.-G. A., Hamm, B., Enzweiler, C. N. H. (2005). Assessment of Mitral Valve Regurgitation at Electron-Beam CT: Comparison with Doppler Echocardiography. Radiology 236: 47-55 [Abstract] [Full Text]
Zheng, H., Zhan, H., Enriquez-Sarano, M., Schaff, H. V., Tajik, A. J. (2005). Surgery for Asymptomatic Mitral Regurgitation. NEJM 352: 2245-2246 [Full Text]
Detaint, D., Messika-Zeitoun, D., Avierinos, J.-F., Scott, C., Chen, H., Burnett, J. C. Jr, Enriquez-Sarano, M. (2005). B-Type Natriuretic Peptide in Organic Mitral Regurgitation: Determinants and Impact on Outcome. Circulation 111: 2391-2397 [Abstract] [Full Text]
Bando, K., Kasegawa, H., Okada, Y., Kobayashi, J., Kada, A., Shimokawa, T., Nasu, M., Nakatani, S., Niwaya, K., Tagusari, O., Nakajima, H., Hirata, M., Yagihara, T., Kitamura, S. (2005). Impact of preoperative and postoperative atrial fibrillation on outcome after mitral valvuloplasty for nonischemic mitral regurgitation. J. Thorac. Cardiovasc. Surg. 129: 1032-1040 [Abstract] [Full Text]
Accola, K. D., Scott, M. L., Thompson, P. A., Palmer, G. J. III, Sand, M. E., Ebra, G. (2005). Midterm Outcomes Using the Physio Ring in Mitral Valve Reconstruction: Experience in 492 Patients. Ann. Thorac. Surg. 79: 1276-1283 [Abstract] [Full Text]
Enriquez-Sarano, M., Avierinos, J.-F., Messika-Zeitoun, D., Detaint, D., Capps, M., Nkomo, V., Scott, C., Schaff, H. V., Tajik, A. J. (2005). Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation. NEJM 352: 875-883 [Abstract] [Full Text]
Kaymaz, C., Ozdemir, N., Ozkan, M. (2005). 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. Eur J Echocardiogr 6: 117-126 [Abstract] [Full Text]
Grigioni, F., Detaint, D., Avierinos, J.-F., Scott, C., Tajik, J., Enriquez-Sarano, M. (2005). Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction. J Am Coll Cardiol 45: 260-267 [Abstract] [Full Text]
Delabays, A., Jeanrenaud, X., Chassot, P.-G., Von Segesser, L.K., Kappenberger, L. (2004). Localization and quantification of mitral valve prolapse using three-dimensional echocardiography. Eur J Echocardiogr 5: 422-429 [Abstract] [Full Text]
Hellgren, L., Kvidal, P., Horte, L.-G., Krusemo, U.-B., Stahle, E. (2004). Survival After Mitral Valve Replacement: Rationale for Surgery Before Occurrence of Severe Symptoms. Ann. Thorac. Surg. 78: 1241-1247 [Abstract] [Full Text]
DiGregorio, V., Zehr, K. J., Orszulak, T. A., Mullany, C. J., Daly, R. C., Dearani, J. A., Schaff, H. V. (2004). Results of mitral surgery in octogenarians with isolated nonrheumatic mitral regurgitation. Ann. Thorac. Surg. 78: 807-813 [Abstract] [Full Text]
Messika-Zeitoun, D., Thomson, H., Bellamy, M., Scott, C., Tribouilloy, C., Dearani, J., Tajik, A. J., Schaff, H., Enriquez-Sarano, M. (2004). Medical and surgical outcome of tricuspid regurgitation caused by flail leaflets. J. Thorac. Cardiovasc. Surg. 128: 296-302 [Abstract] [Full Text]
Carabello, B. A. (2004). Is it ever too late to operate on the patient with valvular heart disease?. J Am Coll Cardiol 44: 376-383 [Abstract] [Full Text]
Macnab, A, Jenkins, N P, Ewington, I, Bridgewater, B J M, Hooper, T L, Greenhalgh, D L, Patrick, M R, Ray, S G (2004). A method for the morphological analysis of the regurgitant mitral valve using three dimensional echocardiography. Heart 90: 771-776 [Abstract] [Full Text]
Kuhl, H. P., Schreckenberg, M., Rulands, D., Katoh, M., Schafer, W., Schummers, G., Bucker, A., Hanrath, P., Franke, A. (2004). High-resolution transthoracic real-time three-dimensional echocardiography: Quantitation of cardiac volumes and function using semi-automatic border detection and comparison with cardiac magnetic resonance imaging. J Am Coll Cardiol 43: 2083-2090 [Abstract] [Full Text]
Calafiore, A. M., Di Mauro, M., Gallina, S., Di Giammarco, G., Iaco, A. L., Teodori, G., Tavarozzi, I. (2004). Mitral valve surgery for chronic ischemic mitral regurgitation. Ann. Thorac. Surg. 77: 1989-1997 [Abstract] [Full Text]
Macnab, A., Jenkins, N. P, Bridgewater, B. J.M, Hooper, T. L, Greenhalgh, D. L, Patrick, M. R, Ray, S. G (2004). Three-dimensional echocardiography is superior to multiplane transoesophageal echo in the assessment of regurgitant mitral valve morphology. Eur J Echocardiogr 5: 212-222 [Abstract] [Full Text]
Agricola, E, Galderisi, M, Oppizzi, M, Schinkel, A F L, Maisano, F, De Bonis, M, Margonato, A, Maseri, A, Alfieri, O (2004). Pulsed tissue Doppler imaging detects early myocardial dysfunction in asymptomatic patients with severe mitral regurgitation. Heart 90: 406-410 [Abstract] [Full Text]
Yacoub, M. H., Cohn, L. H. (2004). Novel Approaches to Cardiac Valve Repair: From Structure to Function: Part II. Circulation 109: 1064-1072 [Full Text]
Borer, J. S., Bonow, R. O. (2003). Contemporary Approach to Aortic and Mitral Regurgitation. Circulation 108: 2432-2438 [Full Text]
Bech-Hanssen, O., Ryden, T., Schersten, H., Oden, A., Nilsson, F., Jeppsson, A. (2003). Mortality after mitral regurgitation surgery: importance of clinical and echocardiographic variables. Eur. J. Cardiothorac. Surg. 24: 723-730 [Abstract] [Full Text]
Dahlberg, P. S., Orszulak, T. A., Mullany, C. J., Daly, R. C., Enriquez-Sarano, M., Schaff, H. V. (2003). Late outcome of mitral valve surgery for patients with coronary artery disease. Ann. Thorac. Surg. 76: 1539-1548 [Abstract] [Full Text]
Matsumura, T., Ohtaki, E., Tanaka, K., Misu, K., Tobaru, T., Asano, R., Nagayama, M., Kitahara, K., Umemura, J., Sumiyoshi, T., Kasegawa, H., Hosoda, S. (2003). Echocardiographic prediction ofleft ventricular dysfunction aftermitral valve repair for mitral regurgitation as anindicator to decide the optimal timing of repair. J Am Coll Cardiol 42: 458-463 [Abstract] [Full Text]
Otto, C. M (2003). Timing of surgery in mitral regurgitation. Heart 89: 100-105 [Full Text]
Fann, J. I., Ingels, N. B. Jr., Miller, D. C. (2003). Pathophysiology of Mitral Valve Disease. Card Surg Adult 2: 901-931 [Full Text]
Gillinov, A. M., Cosgrove, D. M. III (2003). Mitral Valve Repair. Card Surg Adult 2: 933-950 [Full Text]
Gudbjartsson, T., Aranki, S., Cohn, L. H. (2003). Mechanical/Bioprosthetic Mitral Valve Replacement. Card Surg Adult 2: 951-986 [Full Text]
Enriquez-Sarano, M, Tribouilloy, C (2002). Quantitation of mitral regurgitation: rationale, approach, and interpretation in clinical practice. Heart 88: iv1-3 [Full Text]
Avierinos, J.-F., Gersh, B. J., Melton, L. J. III, Bailey, K. R., Shub, C., Nishimura, R. A., Tajik, A. J., Enriquez-Sarano, M. (2002). Natural History of Asymptomatic Mitral Valve Prolapse in the Community. Circulation 106: 1355-1361 [Abstract] [Full Text]
Iung, B., Gohlke-Barwolf, C., Tornos, P., Tribouilloy, C., Hall, R., Butchart, E., Vahanian, A. (2002). Recommendations on the management of the asymptomatic patient with valvular heart disease. Eur Heart J 23: 1253-1266
Grigioni, F., Avierinos, J.-F., Ling, L. H., Scott, C. G., Bailey, K. R., Tajik, A. J., Frye, R. L., Enriquez-Sarano, M. (2002). Atrial fibrillation complicating the course of degenerative mitral regurgitation: Determinants and long-term outcome. J Am Coll Cardiol 40: 84-92 [Abstract] [Full Text]
Enriquez-Sarano, M. (2002). Timing of mitral valve surgery. Heart 87: 79-85 [Full Text]
Alfieri, O., Maisano, F., De Bonis, M., Stefano, P. L., Torracca, L., Oppizzi, M., La Canna, G. (2001). The double-orifice technique in mitral valve repair: A simple solution for complex problems. J. Thorac. Cardiovasc. Surg. 122: 674-681 [Abstract] [Full Text]
Smolens, I. A., Pagani, F. D., Deeb, G. M., Prager, R. L., Sonnad, S. S., Bolling, S. F. (2001). Prophylactic mitral reconstruction for mitral regurgitation. Ann. Thorac. Surg. 72: 1210-1216 [Abstract] [Full Text]
Mohty, D., Orszulak, T. A., Schaff, H. V., Avierinos, J.-F., Tajik, J. A., Enriquez-Sarano, M. (2001). Very Long-Term Survival and Durability of Mitral Valve Repair for Mitral Valve Prolapse. Circulation 104: I-1-7 [Abstract] [Full Text]
Braunberger, E., Deloche, A., Berrebi, A., Abdallah, F., Celestin, J.A, Meimoun, P., Chatellier, G., Chauvaud, S., Fabiani, J.N., Carpentier, A. (2001). Very Long-Term Results (More Than 20 Years) of Valve Repair With Carpentier's Techniques in Nonrheumatic Mitral Valve Insufficiency. Circulation 104: I-8-11 [Abstract] [Full Text]
Otto, C. M. (2001). Evaluation and Management of Chronic Mitral Regurgitation. NEJM 345: 740-746 [Full Text]
Grigioni, F., Enriquez-Sarano, M., Zehr, K. J., Bailey, K. R., Tajik, A. J. (2001). Ischemic Mitral Regurgitation : Long-Term Outcome and Prognostic Implications With Quantitative Doppler Assessment. Circulation 103: 1759-1764 [Abstract] [Full Text]
Le Tourneau, T., de Groote, P., Millaire, A., Foucher, C., Savoye, C., Pigny, P., Prat, A., Warembourg, H., Lablanche, J. M. (2000). Effect of mitral valve surgery on exercise capacity, ventricular ejection fraction and neurohormonal activation in patients with severe mitral regurgitation. J Am Coll Cardiol 36: 2263-2269 [Abstract] [Full Text]
Phillips, M. R., Daly, R. C., Schaff, H. V., Dearani, J. A., Mullany, C. J., Orszulak, T. A. (2000). Repair of anterior leaflet mitral valve prolapse: chordal replacement versus chordal shortening. Ann. Thorac. Surg. 69: 25-29 [Abstract] [Full Text]
Grigioni, F., Enriquez-Sarano, M., Ling, L. H., Bailey, K. R., Seward, J. B., Tajik, A. J., Frye, R. L. (1999). Sudden death in mitral regurgitation due to flail leaflet. J Am Coll Cardiol 34: 2078-2085 [Abstract] [Full Text]
Enriquez-Sarano, M., Freeman, W. K., Tribouilloy, C. M., Orszulak, T. A., Khandheria, B. K., Seward, J. B., Bailey, K. R., Tajik, A. J. (1999). Functional anatomy of mitral regurgitation: Accuracy and outcome implications of transesophageal echocardiography. J Am Coll Cardiol 34: 1129-1136 [Abstract] [Full Text]
Enriquez-Sarano, M., Basmadjian, A.-J., Rossi, A., Bailey, K. R., Seward, J. B., Tajik, A. J. (1999). Progression of mitral regurgitation: A prospective Doppler echocardiographic study. J Am Coll Cardiol 34: 1137-1144 [Abstract] [Full Text]
Schlant, R. C. (1999). Timing of Surgery for Patients With Nonischemic Severe Mitral Regurgitation. Circulation 99: 338-339 [Full Text]
Tribouilloy, C. M., Enriquez-Sarano, M., Schaff, H. V., Orszulak, T. A., Bailey, K. R., Tajik, A. J., Frye, R. L. (1999). Impact of Preoperative Symptoms on Survival After Surgical Correction of Organic Mitral Regurgitation : Rationale for Optimizing Surgical Indications. Circulation 99: 400-405 [Abstract] [Full Text]
Rossi, A., Golia, G., Gasparini, G., Prioli, M. A., Anselmi, M., Zardini, P. (1999). Left atrial filling volume can be used to reliably estimate the regurgitant volume in mitral regurgitation. J Am Coll Cardiol 33: 212-217 [Abstract] [Full Text]
Dalrymple-Hay, M. J.R., Bryant, M., Jones, R. A., Langley, S. M., Livesey, S. A., Monro, J. L. (1998). Degenerative mitral regurgitation: When should we operate?. Ann. Thorac. Surg. 66: 1579-1584 [Abstract] [Full Text]
Sun, J. P., Yang, X. S., Qin, J. X., Greenberg, N. L., Zhou, J., Vazquez, C. J., Griffin, B. P., Stewart, W. J., Thomas, J. D. (1998). Quantification of mitral regurgitation by automated cardiac output measurement: experimental and clinical validation. J Am Coll Cardiol 32: 1074-1082 [Abstract] [Full Text]
van den Brink, R. B.A., Dekker, E., Verheul, H. A., Tijssen, J. G.P., Enriquez-Sarano, M., Bailey, K. R. (1998). Effect of Age Adjustment in Predicting Outcome � Response. Circulation 98 : 1350-1353 [Full Text]
David, T. E., Omran, A., Armstrong, S., Sun, Z., Ivanov, J. (1998). Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures. J. Thorac. Cardiovasc. Surg. 115: 1279-1283 [Abstract] [Full Text]
Maisano, F., Torracca, L., Oppizzi, M., Stefano, P.L., D'Addario, G., La Canna, G., Zogno, M., Alfieri, O. (1998). The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur. J. Cardiothorac. Surg. 13: 240-246 [Abstract] [Full Text]
Dujardin, K. S., Enriquez-Sarano, M., Bailey, K. R., Nishimura, R. A., Seward, J. B., Tajik, A. J. (1997). Grading of Mitral Regurgitation by Quantitative Doppler Echocardiography : Calibration by Left Ventricular Angiography in Routine Clinical Practice. Circulation 96: 3409-3415 [Abstract] [Full Text]
Ling, L. H., Enriquez-Sarano, M., Seward, J. B., Orszulak, T. A., Schaff, H. V., Bailey, K. R., Tajik, A. J., Frye, R. L. (1997). Early Surgery in Patients With Mitral Regurgitation Due to Flail Leaflets : A Long-term Outcome Study. Circulation 96: 1819-1825 [Abstract] [Full Text]
Barlow, J. B., Kinsley, R. H., Fetscher, S. R., Enriquez-Sarano, M., Ross, J. (1997). Mitral Regurgitation Due to Flail Leaflet. NEJM 336: 1322-1324 [Full Text]
Thomas, J. D. (1997). How Leaky Is That Mitral Valve?: Simplified Doppler Methods to Measure Regurgitant Orifice Area. Circulation 95: 548-550 [Full Text]
(1996). Surgery for MR Due to Flail Leaflet. Journal Watch Cardiology 1996: 5-5 [Full Text]
Ross, J. (1996). The Timing of Surgery for Severe Mitral Regurgitation. NEJM 335: 1456-1458 [Full Text]

Comments and questions? Please contact us.