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Ann Thorac Surg 2009;88:839-843. doi:10.1016/j.athoracsur.2009.06.004
© 2009 The Society of Thoracic Surgeons
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Original Articles: Pediatric Cardiac

Isolated Cleft of the Mitral Valve: Distinctive Features and Surgical Management

Sylvia Abadir, MDa, Virginie Fouilloux, MDb, Dominique Metras, MDb, Olivier Ghez, MDb, Bernard Kreitmann, MD, PhDb, Alain Fraisse, MD, PhDa,*

a Service of Pediatric Cardiology, Centre Hospitalo-Universitaire La Timone, Marseille, France
b Service of Thoracic and Cardiovascular Surgery, Centre Hospitalo-Universitaire La Timone, Marseille, France

Accepted for publication June 1, 2009.

* Address correspondence to Dr Fraisse, Cardiologie pédiatrique, Hôpital d'enfants de la Timone, 264 rue Saint Pierre, Marseille Cedex 5, 13385, France (Email: alain.fraisse{at}ap-hm.fr).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Controversy remains as to whether isolated cleft of the mitral valve and cleft of the atrioventricular septal defect are different entities. Our objectives were to provide a precise description of isolated cleft of the mitral valve and to clarify its surgical management and outcome.

Methods: Patients with surgical repair of isolated cleft of the mitral valve were included.

Results: Ten patients (9 female) underwent repair at a mean age of 12.1 ± 10.5 years and mean weight of 32.1 ± 17.8 kg. Preoperative echocardiography showed mild or less than mild mitral regurgitation in 6 cases and moderate to severe regurgitation in 4. Intraoperative examination confirmed in all cases a cleft dividing the anterior leaflet of an otherwise normal mitral valve. Attachment of the cleft to the ventricular septum by accessory chordae was found in 3 cases whereas preoperative echocardiography found such attachments in 5. Direct suture of the cleft was performed in 9 cases, associated with repair of tricuspid valve straddling (n = 1), subaortic stenosis (n = 1), and ventricular septal defect (n = 1). One patient with thickened cleft's edges required an Alfieri-type repair. After a mean follow-up of 4.9 years (range, 1.3 to 11.9), all patients are asymptomatic without significant mitral regurgitation.

Conclusions: Echocardiographic description of isolated cleft of the mitral valve is not always as accurate as intraoperative analysis. This is a distinct morphologic entity from the cleft of the left-sided valve of atrioventricular septal defect, and seems associated with a strong female predominance, with various cardiac and extracardiac features. Surgical repair is successful with excellent midterm results.


   Introduction
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 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Descriptions of isolated cleft of the mitral valve (ICMV) have previously been reported through echocardiographic and pathologic studies [1–10]. Echocardiographic criteria to distinguish ICMV from a cleft of the left-sided valve of atrioventricular (AV) septal defect have been established [3, 4, 6–8], and postmortem studies further provided a precise morphologic description of ICMV [5, 6, 10]. Nevertheless, in the current era, ICMV is still being considered as a "forme fruste" of AV canal (AVC) by some authors [10], whereas others believe it to be a distinct morphologic entity [4, 6, 8].

Also, previous studies failed to provide precise information about the indication and timing for surgery as well as its long-term results. In the largest published series of 22 ICMV patients with echocardiographic or intraoperative analysis, we confirmed the important morphologic differences between ICMV and AVC type cleft [3]. Furthermore, surgical repair seemed to be always possible with a good functional result. However, the morphologic description of the ICMV relied mainly on echocardiographic data, and fewer than half of the patients had surgical repair, with only short-term follow-up.

To further clarify the morphologic features of ICMV, its surgical management, and its midterm results, we retrospectively studied all the patients with ICMV undergoing surgical repair in our center.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patient Population
All patients with an ICMV who underwent surgical repair at our institution between January 1984 and June 2007 were included. We excluded patients operated on with AV septal defect features (an ostium primum septal defect or a deficiency of the inlet portion of the ventricular septum, or both) and patients with ICMV who had not been operated on. The study was approved by the Hospital Ethics Committee, which stated that no individual consent was necessary considering its retrospective nature.

We recorded clinical data (age, weight, and symptoms), as well as chest roentgenogram and electrocardiogram (ECG) interpretations. Preoperative two-dimensional transthoracic echocardiography (TTE) tape or compact disk were reviewed with the specific goal to describe the mitral clefts, chordal attachments, and papillary muscles, measuring mitral and tricuspid annuli, and evaluating left and right ventricular sizes and functions. Preoperative mitral regurgitation (MR) was evaluated semiquantitatively and graded as absent, trivial, mild, moderate, or severe according to the jet width at its origin and area as seen by color Doppler flow mapping. All echocardiographic descriptions were compared with surgical findings. Other congenital heart malformations were collected as well as extracardiac anomalies. Five patients included in the present study have previously been described: 4 in a previous large study that was based partly or totally on echocardiographic diagnosis only [3], and 1 as a case report [11].

Intraoperative Analysis
Surgery was performed at our institution through sternotomy or right posterolateral thoracotomy with standard procedures of extracorporeal circulation and aortic cross-clamping in all cases. After opening the left atrium, the mitral valve was exposed and carefully inspected by the surgeon to precisely describe the ICMV. Intraoperative pictures or videos were taken in the majority (n = 9) of the cases. Anatomic findings and procedural timings were recorded.

Follow-Up
Clinical and echocardiographic evaluations were performed postoperatively and every 6 to 12 months during follow-up. Transthoracic echocardiography looked for mitral stenosis or residual MR, which was graded as previously described.

Statistical Analysis
Results are expressed as mean value ± SD, or median value (range) when appropriate.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Patient Population
Ten patients (9 female) who underwent surgical repair of ICMV were included. A right posterolateral thoracotomy was used in 7 cases, and 3 patients were operated on through median sternotomy. Table 1 summarizes the clinical and morphologic features of the patients at presentation as well as the type of surgical repair. Mean age at presentation was 10.5 ± 10.7 years, and mean weight was 28.5 ± 17.8 kg. No patient was prenatally diagnosed. According to the New York Heart Association (NYHA) classification, 5 patients were in class I (asymptomatic), 4 in class II, and 1 in class III. Cardiac auscultation revealed a holosystolic murmur in all. Chest roentgenogram showed a normal cardiothoracic index in 8 patients and a cardiomegaly (0.6 and 0.66) in 2. On ECG, sinus rhythm was present in all, with normal PR interval (≤200 ms). Median QRS axis was 45 degrees (range, –35 to 90 degrees). The oldest patient of our series, with severe MR, experienced atrial fibrillation before surgical repair. Sinus rhythm was successfully restored with amiodarone.


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  		Table 1 Clinical and Morphologic Characteristics at Presentation and Surgical Management
 
Preoperative TTE showed in 10 patients a cleft of the anterior leaflet (Fig 1), this cleft being incomplete in 1. In 4 patients (1 patient included in 1984 and 3 after 2000), the orientation of the cleft and the presence of chordal attachments were not clearly specified. Further review of the echocardiographic material by the study investigators (S.A. and A.F.) failed to precisely describe such features. In the 5 other patients, chordal attachments were described. The size of both AV annuli was normal related to age and body weight, as well as the size of the left mural leaflet, the position of the posteromedial papillary muscle, and the left ventricular inlet/oulet ratio. Two normally positioned mitral papillary muscles were identified in all patients. Mitral regurgitation was present in 9 of the 10 patients, and was graded trivial in 1 patient, mild in 4, moderate in 2, and severe in 2 (Fig 2). One patient had no mitral regurgitation but had subaortic stenosis due to accessory chordae attachment. Left and right preoperative ventricular function was normal in all, with moderate left ventricular dilation in the 2 cases with severe MR and in 1 case with moderate MR. Associated cardiac malformations included a tricuspid valve straddling in 1, a subaortic stenosis due to chordal attachment in 1, and a perimembranous ventricular septal defect with moderate left ventricular overload in 1 patient. Extracardiac features were found in 2 patients: vesicoureteral reflux in 1 patient and Down syndrome in the other.


Figure 1
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  		Fig 1. Two-dimensional transthoracic echocardiography in a parasternal short-axis view in a patient with isolated anterior cleft of the mitral valve (*). Note the direction of the cleft, pointing toward the left ventricular outflow tract, and the thickness of the cleft edges. (LV = left ventricle; RV = right ventricle.)

 

Figure 2
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  		Fig 2. Transthoracic color Doppler flow echocardiography in a parasternal long-axis view, showing severe mitral regurgitation in a patient with isolated anterior cleft of the mitral valve. Note the direction of the mitral regurgitation flow toward the bottom of the left atrium, as seen in a prolapse of the mitral valve anterior leaflet.

 
Surgical Findings
Surgical repair of the mitral cleft was performed at a mean age of 12.1 ± 10.5 years, and a mean weight of 32.1 ± 17.8 kg. Only 1 patient had a previous surgery (patent ductus arteriosus ligation). Mitral valve inspection confirmed in all patients a cleft dividing the anterior (aortic) leaflet of the mitral valve into two and directed toward the aortic root (Fig 3). In 1 patient, the cleft was incomplete and did not reach the mitral annulus. The mural leaflet had a normal size in all cases. Attachment of both sides of the cleft to the ventricular septum by accessory chordae was found in 3 cases, all previously described on preoperative TTE. The 2 additional cases of septal attachment that were reported on preoperative echocardiography were not confirmed by intraoperative inspection. Intraoperative transesophageal echocardiography that was performed on a systematic basis in 8 of the 10 patients (including the 2 cases with chordal attachment misdiagnosis) did not provide additional information about the morphology of ICMV. In all the cases, the edges of the mitral valve were thickened and more or less rolled up (Fig 3). The morphology of the mitral annulus and papillary muscles was normal.


Figure 3
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  		Fig 3. Intraoperative view of an isolated cleft of the anterior leaflet of the mitral valve, pointing toward the aorta. Note the thickness of the cleft edges with retraction of both parts of the anterior leaflet.

 
Direct suture of the cleft was performed in 9 patients. In 1 patient with severe and long-standing MR, the edges of the cleft were retracted and thickened by fibrous tissue. Given this lack of valvar tissue, she required an Alfieri-type repair, with partial direct closure of the cleft (close to the annulus) and apposition of a well developed mid-portion of posterior leaflet (P2) with the still partially "clefted" anterior leaflet. Suture of the cleft was associated with a partial posterior annuloplasty in 1 patient, resection of a subaortic obstruction by transaortic approach in another, and a ventricular septal defect closure in a third. No mitral valve replacement was performed. The mean ± SD cardiopulmonary bypass and aortic cross-clamp times were 70.1 ± 17.6 minutes and 51.1± 16.3 minutes, respectively.

Follow-Up
Postoperative course was uneventful in all cases. All patients were extubated within 24 hours, and there were no postoperative complications. Postoperative TTE showed no MR in 6 patients and trivial regurgitation in 4 patients. No patient had mitral stenosis. After a mean follow up of 4.9 years (range, 1.25 to 11.9), all patients are asymptomatic with a normal physical examination. Echocardiography demonstrates an excellent midterm surgical result, with no residual MR in 6 children and trivial MR in 4. No late complications occurred.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
This study provides a precise and comparative description of ICMV based on echocardiographic and intraoperative analysis in all the cases. Our study confirmed that ICMV is a morphologically different entity from the AVC cleft. Echocardiography failed to specify important morphologic features like cleft orientation and chordal attachment in some cases. Surgical suture of the cleft proved to be a safe and effective surgical procedure without midterm morbidity and mortality.

Morphologic Considerations
From a morphologic standpoint, ICMV is a different entity from AVC. Whereas previous postmortem or echocardiographic analysis assimilated ICMV to partial AVC [10], no features of AVC were found in our series. Our combined echocardiographic and intraoperative analysis showed that the size of the left mural leaflet, the position of the posteromedial papillary muscle, and the left ventricular inlet/outlet ratio were normal, as previously stated by others [4, 6]. Our description of ICMV also agrees with Anderson's writing more than 2 decades ago: the cleft appears very much like an "artificial cleft produced in a normal valve with a scalpel" [12]. To further enhance this morphologic distinction between AVC and ICMV, the median QRS axis on the ECG of our patients clearly differed from the classic left QRS axis deviation in AVC defects.

A recent postmortem study analyzing cases with cleft of the MV and normally related great arteries reported AVC features in all cases [10]. Clearly, AVC without ostium primum exists independently of ICMV and is even possibly more frequently encountered. However, natural history and postoperative outcome of ICMV and AVC are different as well. Isolated cleft of the mitral valve is a simple cardiac congenital defect: apart from the cleft, cardiac anatomy is either normal or associated with simple malformation. The likelihood to survive even without surgery is very high. Similarly, surgical repair of ICMV carry a very low risk. Conversely, AVC comprises a wide spectrum of defects, some of which are potentially lethal or with a greater operative risk (eg, umbalanced ventricles, multiple outflow tract obstructions). We suggest that postmortem specimen of ICMV is not frequently encountered simply because patients with ICMV are seldom at risk for death. The exception is when complex congenital heart diseases are associated, especially in the case of ventriculoarterial discordance [10, 13].

Diagnosis of ICMV and Pathogenic Considerations
The female predominance (90%) is a surprising finding in the present study that was not noted in previous reports, including those from our institution [3, 4, 9, 10, 13]. This bias may represent a male lethal effect during pregnancy, in which only females can compensate for the deleterious effects of a missing or mutated copy of a causative gene. We speculate that this effect is likely to be gene-dosage dependant, with affected males exhibiting defects so severe as to cause early fetal demise. Similar effects have been well described in other studies [14]. Yet no syndromes with exclusive heart disease are know to exhibit male embryonic lethality. Moreover, this female predominance was not shown in most of the previous studies on ICMV that were based partly or totally on echocardiographic diagnosis only [3, 4, 9, 10, 13], and that raises the concern of the diagnosis accuracy and a possible mismatch between patients with ICMV and "forme fruste" of AVC septal defect when the diagnosis is only based on echocardiographic features. In agreement with the potential inaccuracy of echocardiography for ICMV diagnosis and description is the postmortem study by Van Praagh and colleagues [10]. In that report, the cleft was only diagnosed by echocardiography in 62% of cases (8 of 13) [10].

Our study is the first to really confront echocardiographic and intraoperative findings in all patients. We suggest that the sensitivity of echocardiography is high, at least when it is associated with mild or more than mild MR. During the entire inclusion period, ICMV was never diagnosed intraoperatively without being diagnosed preoperatively by echocardiography. However, ultrasound screening is not always accurate for the precise description of ICMV. We experienced numerous errors with the echocardiographic description of chordal attachments (2 of 5) and in the morphology of the MV. Interestingly, we found, as did other authors [9], that transesophageal echocardiography did not provide more precise information about ICMV morphologic assessment and chordal attachments. Conversely, other authors claimed that echocardiography can accurately describe ICMV. In a study only based on echocardiographic findings, Khol and associates [4] reported that "Accessory chordae arising from the cleft leaflet commissure and attaching to the ventricular septum were a constant finding in our patients. Without such attachment, the divided anterior leaflet would be flail" [4]. Based on our findings that the majority of the ICMV do not have septal attachments, such a statement seems incorrect. Consequently, the spectrum of extracardiac features that was reported in previous studies that only rely on echocardiography may not be accurate.

Of interest, 1 patient in the present study had Down syndrome, as this is frequently encountered in AVC patients [15]. However, Down syndrome has already been reported in other series of ICMV [3, 9], as well as in postmortem series of cleft mitral valve without ostium primum defect [6, 10]. That raises the hypothesis of a common genetic link between ICMV and AVC. Although the two entities represent different phenotypes, they are likely to have common genetic underpinnings, as was suggested in our previous study [3]. If further advances in genetic analysis confirm this hypothesis in the future, it may have important implications for prenatal diagnosis and counseling.

Surgical Considerations
Our series confirmed that surgical treatment of ICMV associated with MR can be carried out without mitral valve replacement [9, 16], even in the presence of moderate to severe MR, as was the case in 4 of our patients. As a matter of fact, repair with a direct suture of the cleft seems to be feasible in the majority of the cases. Of concern is the lack of valvular tissue due to retraction of the cleft's edges that potentially increases with time. For patients with severe MR due to wideness of the cleft, Perier and coworkers [16] reported the need of an additional pericardial patch to accomplish a successful cleft suture. In our series, only 1 patient with severe MR and important retraction of the cleft's edges could not be repaired though direct suture and needed Alfieri-type repair. Interestingly, patients were operated on at a younger age in our study than in the Perier study, with possibly less retraction of the cleft edges by a long-standing MR. Finally, ICMV repair is a straightforward operation in the majority of the cases and can be done with short cardiopulmonary bypass and aortic cross-clamp times. The approach can be very esthetic and minimally invasive with a short posterior right thoracotomy before breast development, or alternatively with an anterolateral submammary incision. The risk for reoperation or other morbidity seems low, as opposed to AV septal defect repair [17]. Although we cannot comment on the long-term fate of repaired ICMV, our study provides midterm follow-up showing that initial good results endure, with no increase of postoperative MR at midterm TTE evaluations. Patients operated on later in life may have more retracted cleft edges and may consequently experience a more complicated surgical repair with interposition of patches on the mitral valve [16], which can presumably impair the long-term results. All this suggests that surgical repair should be indicated for cases of mild or more than mild MR, even for asymptomatic patients. For patients with trivial or no significant MR, elective MV repair cannot be recommended, but careful follow-up is warranted.

Limitations of the Study
This study has the inherent limitations of its retrospective nature. Our series of 10 patients is a homogeneous but small one. We cannot fully assess the accuracy of echocardiography since only the patients in whom ICMV was diagnosed by surgery were included. Hence, although none of the surgeons of the team remembers such a case, we cannot comment on potential false positive diagnosis of ICMV by echocardiography for which intraoperative analysis demonstrated AVC variant.

In conclusion, through echocardiographic and intraoperative description, we show that the echocardiographic description of ICMV is not always as accurate as intraoperative analysis. We also confirm that ICMV is a distinct morphologic entity from the cleft of the left-sided valve of AV septal defect. It seems characterized by a strong female predominance, and various cardiac and extracardiac features may be associated. Surgical repair of ICMV is safe and effective, especially when this is accomplished before valve deterioration, with excellent midterm results.


   References
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 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Di Segni E, Bass JL, Lucas RV, Einzig S. Isolated cleft mitral valve: a variety of congenital mitral regurgitation identified by 2-dimensional echocardiography Am J Cardiol 1983;51:927-931.[Medline]
  2. Di Segni E, Edwards JE. Cleft anterior leaflet of the mitral valve with intact septa. A study of 20 cases. Am J Cardiol 1983;51:919-926.[Medline]
  3. Fraisse A, Massih TA, Kreitmann B, et al. Characteristics and management of cleft mitral valve J Am Coll Cardiol 2003;42:1988-1993.[Abstract/Free Full Text]
  4. Kohl T, Silverman NH. Comparison of cleft and papillary muscle position in cleft mitral valve and atrioventricular septal defect Am J Cardiol 1996;77:164-169.[Medline]
  5. Penkoske PA, Neches WH, Anderson RH, Zuberbuhler JR. Further observations on the morphology of atrioventricular septal defects J Thorac Cardiovasc Surg 1985;90:611-622.[Abstract]
  6. Sigfusson G, Ettedgui JA, Silverman NH, Anderson RH. Is a cleft in the anterior leaflet of an otherwise normal mitral valve an atrioventricular canal malformation? J Am Coll Cardiol 1995;26:508-515.[Abstract]
  7. Smallhorn JF, de Leval M, Stark J, et al. Isolated anterior mitral cleft. Two dimensional echocardiographic assessment and differentiation from "clefts" associated with atrioventricular septal defect. Br Heart J 1982;48:109-116.[Abstract/Free Full Text]
  8. Sulafa AK, Tamimi O, Najm HK, Godman MJ. Echocardiographic differentiation of atrioventricular septal defects from inlet ventricular septal defects and mitral valve clefts Am J Cardiol 2005;95:607-610.[Medline]
  9. Tamura M, Menahem S, Brizard C. Clinical features and management of isolated cleft mitral valve in childhood J Am Coll Cardiol 2000;35:764-770.[Abstract/Free Full Text]
  10. Van Praagh S, Porras D, Oppido G, Geva T, Van Praagh R. Cleft mitral valve without ostium primum defect: anatomic data and surgical considerations based on 41 cases Ann Thorac Surg 2003;75:1752-1762.[Abstract/Free Full Text]
  11. Eberhardt L, Chetaille P, Kreitmann B. A very unusual combination of straddling and overriding of the tricuspid valve associated with clefting of the mitral valve Cardiol Young 2005;15:422-424.[Medline]
  12. Anderson RH, Zuberbuhler JR, Penkoske PA, Neches WH. Of clefts, commissures, and things J Thorac Cardiovasc Surg 1985;90:605-610.[Abstract]
  13. Fraisse A, Massih TA, Vouhé P, et al. Management and outcome of patients with abnormal ventriculo-arterial connections and mitral valve cleft Ann Thorac Surg 2002;74:786-791.[Abstract/Free Full Text]
  14. Levin JH, Kaler SG. Non-random maternal X-chromosome inactivation associated with PHACES Clin Genet 2007;72:345-350.[Medline]
  15. Al-Hay AA, MacNeill SJ, Yacoub M, Shore DF, Shinebourne EA. Complete atrioventricular septal defect, Down syndrome, and surgical outcome: risk factors Ann Thorac Surg 2003;75:412-421.[Abstract/Free Full Text]
  16. Perier P, Clausnizer B. Isolated cleft mitral valve: valve reconstruction techniques Ann Thorac Surg 1995;59:56-59.[Abstract/Free Full Text]
  17. Moran AM, Daebritz S, Keane JF, Mayer JE. Surgical management of mitral regurgitation after repair of endocardial cushion defects: early and midterm results Circulation 2000;102(Suppl 3):160-165.



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