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Double Orifice Mitral Valve Treatment & Management

  • Author: Georgios A Hartas, MD; Chief Editor: Stuart Berger, MD  more...
 
Updated: Mar 19, 2014
 

Medical Care

General principles

Patients with double orifice mitral valve (DOMV) are evaluated as outpatients. Patients should be admitted to the hospital for the treatment of severe heart failure, for pulmonary edema, for cardiac catheterization and for surgery.

Management depends on the type and severity of mitral valve dysfunction. Isolated double orifice mitral valve causing neither obstruction nor regurgitation needs no active intervention. This principle is important because the hemodynamics of a double orifice mitral valve at rest and during exercise do not differ from those of a normal mitral valve with a similar valvular area.

However, long-term follow-up and care are necessary to detect the onset of hemodynamic problems or complications.

All patients with clinically significant mitral stenosis or regurgitation require medical therapy and possibly transcatheter balloon or surgical treatment.

Roles of medical therapy

The roles of medical treatment include the following:

  • To initially stabilize the patient and to relieve pulmonary edema
  • To control congestive heart failure while detailed assessment and surgical repair is awaited
  • To serve as an adjunct to surgical repair in the postoperative period
  • To treat small infants, in whom medical therapy may be the only option (Control of congestive heart failure may defer surgery until the child grows to an appropriate age and size.)

Adjunctive therapy

Physical activity restriction of symptomatic patients. Treat patients with severe pulmonary venous congestion in a sitting or propped-up position. Administer parenteral morphine in patients with pulmonary edema to help relieve anxiety and reduce pulmonary congestion.

Administer oxygen by a nasal catheter or mask to improve oxygenation in patients with acute pulmonary edema. Vigorously treat concurrent infections or other aggravating factors. Correcting anemia, if present, is important. Increasing the oxygen-carrying capacity by a packed-cell transfusion in patients with severe symptoms or heart failure may provide considerable relief.

According to the updated guidelines of the American Heart Association, patients with double orifice mitral valve do not need antibiotic prophylaxis against infective endocarditis.[24]

Percutaneous transcatheter balloon dilatation

Selected cases of double orifice mitral valve with mitral stenosis are amenable to percutaneous transcatheter balloon dilatation. This option offers a nonsurgical method of relieving obstruction.[25] Successful dilatation has been reported in patients with the bridge type of double orifice mitral valve, especially if the bridge is incomplete.[26] Stepwise dilatations by using an Inoue balloon are applied to the posteromedial orifice of the double orifice mitral valve. The results are best if the double orifice mitral valve is an isolated defect and if no major deformity of the subvalvular tensor apparatus is present.

Surgical standby is recommended to manage incomplete relief of obstruction or clinically significant disruption of the valve apparatus that causes mitral regurgitation.

Consultations

Obtain consultations with a cardiologist and a cardiothoracic surgeon.

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Surgical Care

No surgery is necessary if the mitral valve is competent without mitral stenosis or mitral regurgitation.

This mitral anomaly can be difficult for even the most experienced surgeon to assess. The valve function should be tested to determine the cause of the regurgitation. If the regurgitation is due to a cleft in one orifice, then minor repair of the cleft may result in satisfactory function. Radical repair of the mitral valve has very poor outcome. The aim of surgical treatment of double orifice mitral valve is to correct abnormal mitral valve function and to repair all associated defects. A functionally normal double orifice mitral valve may be left intact even when the accompanying lesions are repaired.[19]

Surgical repair should be performed in all symptomatic patients with regurgitant double orifice mitral valve. It should also be performed in patients with stenotic double orifice mitral valve, if balloon dilation is not feasible or fails to relieve obstruction. Emergency surgical intervention is occasionally needed to manage severe mitral regurgitation resulting from balloon valvuloplasty for mitral stenosis.

Mitral valvuloplasty[27] and valve replacement both have a place in the management of the double orifice mitral valve.[28]

Closure of one orifice might produce acute diminution of the mitral valve area leading to a stenotic condition. It may also cause deformity at the fibrous bridging tissue, leading to incompetence of another intact orifice.[29]

The type of operation should depend on the anatomic abnormality in the mitral valve apparatus. In many patients, the valve may be amenable to repair and reconstruction procedures, including resection of tissue, repair of defects and clefts, shortening of chordae, placement of artificial chordae, and annuloplasty. However, the delicate relationships among the various components of the valve and the subvalvar apparatus should be preserved.[30]

Replacement of the mitral valve is indicated, if the valvular mechanism is markedly abnormal.

For high-risk surgical patients, such as the elderly, percutaneous mitral valve therapies, including the MitraClip, are being developed for the treatment of severe mitral regurgitation.[31, 32]

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Diet

Asymptomatic patients with double orifice mitral valve require no special diet. Counsel patients with heart failure to avoid excess intake of salt or to reduce their salt intake. Prescribe salt restriction cautiously in infants.

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Activity

Patients with pulmonary venous congestion or congestive heart failure should avoid strenuous exertion.

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Contributor Information and Disclosures
Author

Georgios A Hartas, MD Pediatric Interventional Cardiologist, The Children's Heart Institute

Georgios A Hartas, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Texas Medical Association, Texas Pediatric Society, Harris County Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

P Syamasundar Rao, MD Professor of Pediatrics and Medicine, Division of Cardiology, Emeritus Chief of Pediatric Cardiology, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital

P Syamasundar Rao, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society for Pediatric Research

Disclosure: Nothing to disclose.

Duraisamy Balaguru, MBBS MRCP, FACC, FAAP, FSCAI, Associate Professor of Pediatrics, Division of Pediatric Cardiology, University of Texas Medical School at Houston; Attending Physician, Division of Pediatric Cardiology, Children’s Memorial Hermann Hospital

Duraisamy Balaguru, MBBS is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, American Stroke Association, Pediatric Cardiac Intensive Care Society, International Society of Invasive Cardiology in Congenital Heart Disease, World Society for Pediatric and Congenital Heart Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Julian M Stewart, MD, PhD Associate Chairman of Pediatrics, Director, Center for Hypotension, Westchester Medical Center; Professor of Pediatrics and Physiology, New York Medical College

Julian M Stewart, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Autonomic Society, American Physiological Society

Disclosure: Received grant/research funds from Lundbeck Pharmaceuticals for none.

Chief Editor

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Additional Contributors

Juan Carlos Alejos, MD Clinical Professor, Department of Pediatrics, Division of Cardiology, University of California, Los Angeles, David Geffen School of Medicine

Juan Carlos Alejos, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Medical Association, International Society for Heart and Lung Transplantation

Disclosure: Received honoraria from Actelion for speaking and teaching.

References
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Two-dimensional echocardiogram (apical view) in a patient with duplicate mitral valve. Two mitral valves can be seen opening into the left ventricle. Each valve has a separate annulus, and a separate set of mitral valve leaflets and subvalvar apparatus.
Two-dimensional echocardiogram (parasternal short-axis view) shows double-orifice mitral valve, the orifice being divided by a bridge of tissue.
Two-dimensional echocardiogram of a double-orifice mitral valve (apical view) with color flow mapping, which shows diastolic flow through 2 separate orifices.
Two-dimensional echocardiogram (parasternal short-axis view) in a patient with duplicate mitral valve. This diastolic frame shows two typical mitral valve orifices opening into the left ventricle. The two orifices are placed apart unlike the more common type of double-orifice mitral valve (see image above) where the orifice is divided by a bridge of tissue.
Real-time two-dimensional echocardiogram (apical view) in a patient with duplicate mitral valve. Two mitral valves can be seen opening into the left ventricle. Each valve has a separate annulus, and a separate set of mitral valve leaflets and subvalvar apparatus.
Real-time two-dimensional echocardiogram (subcostal short-axis view) in a patient with duplicate mitral valve showing two typical mitral valves opening into the left ventricle. The two orifices are placed apart unlike the more common type of double-orifice mitral valve (see image above) where the orifice is divided by a bridge of tissue.
 
 
 
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