Cardiac Remodeling after Surgical Mitral Valvuloplasty for Barlow's Disease: Is it the Time to Look to the Load?

Abstract

We present the case of a 48-year-old man referred for a reduced exercise tolerance in whom a bileaflet mitral prolapse (Barlow's disease), associated with flail motion of posterior mitral leaflet and ruptured chordae tendineae and complicated by eccentric severe regurgitation, was incidentally diagnosed. Albeit paucisymptomatic, at echocardiography he showed the signs of LV dysfunction and, accordingly, was underwent surgical mitral valvuloplasty with implantation of the Memo 3D ReChord Ring without complications. We analyzed the changes of echocardiographic parameters of cardiac remodeling from baseline to post operative setting, highlighting the utility of modern imaging tools (strain and myocardial work) in grade to gauge with more sensitivity LV deformation and function in different conditions of pre and afterload and to overcome the limits of ancient ejection fraction. In conclusion, especially LV myocardial work may be a promising and accurate non load dipendent tool to quantify subclinical LV dysfunction, to guide therapeutic decisions and in post-surgical follow up.

Keywords: Barlow's disease; cardiac remodeling; mitral regurgitation; myocardial work.

Figure 1

At the top (Panel A), transesophageal echocardiographic views (three chamber view at 124°, four chamber view at 0°, three dimensional “en face” view of mitral valve) showing, in late systole, bileaflet mitral prolapse associated with flail motion of the central scallop of posterior mitral leaflet by chordal rupture and medially and anteriorly directed eccentric severe regurgitation. Mitral leaflets appear large, the chordae elongated and mitral annulus dilated with loss of the coaptation point. In Panel C intraoperative transesophageal echocardiographic views (bi-dimensional view, color view and three-dimensional “en face” view) reporting mitral valve annuloplasty with implantation of the Memo three-dimensional ReChord Ring and the good surgical result suggested by early improvement of mitral regurgitation (1+/4+). In Panel B and D, comparison between preoperative (Panel B) and postoperative (Panel D) speckle-tracking echocardiographic analysis in term of Global Longitudinal Strain, Global Myocardial Work Index and Global Myocardial Work Efficiency of the left ventricular (from left to right). Note the changes of global and segmental findings in bull's eye plots, suggesting a significant left ventricular remodeling after mitral annuloplasty