Secondary mitral regurgitation

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Clinical Significance of Exercise Pulmonary Hypertension in Secondary Mitral Regurgitation.

Clinical Significance of Exercise Pulmonary Hypertension in Secondary Mitral Regurgitation.

In patients with heart failure, exercise echocardiography can help in risk stratification and decision making. The prognostic significance of exercise pulmonary hypertension (PH) in patients with secondary mitral regurgitation (MR) remains unknown. The aim of the present study was to assess the prognostic value of exercise PH in patients with secondary MR and narrow QRS intervals. From 2005 to 2012, 159 consecutive patients with secondary MR, narrow QRS intervals, left ventricular dysfunction (mean ejection fraction 36 – 7%), and measurable systolic pulmonary arterial pressure (SPAP) during exercise echocardiog- raphy were included. Resting and exercise PH were defined as SPAP >50 and >60 mm Hg, respectively. Exercise PH was more frequent than resting PH (40% vs 13%, p <0.0001). On multivariate logistic regression, the independent determinants of exercise PH were resting SPAP (p <0.0001), exercise MR severity (p <0.0001), and e 0 -wave velocity (p [ 0.004). The incidence of cardiac events during follow-up was signi ficantly higher in patients with ex- ercise PH compared with those without exercise PH (4 years: 40 – 7% vs 20 – 5%, p <0.0001). Patients with exercise PH exhibited higher rates of cardiac events and death than those with resting PH. In a multivariate Cox proportional hazards model, exercise PH was independently associated with the occurrence of cardiac events (p <0.0001). In conclusion, in patients with secondary MR, exercise PH is determined mainly by resting SPAP, left ventricular diastolic burden, and exercise MR severity. Exercise PH is a powerful predictor of poor outcomes, with a 5.3-fold increased risk for cardiac-related death during follow-up. These results highlight the added value of exercise echocardiography in sec- ondary MR. Ó 2015 Elsevier Inc. All rights reserved. (Am J Cardiol 2015; - : - e - )
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Severe secondary mitral regurgitation in heart failure: A holistic approach

Severe secondary mitral regurgitation in heart failure: A holistic approach

CONCLUSION Secondary mitral regurgitation is associated with poor outcomes, but whether its correction reverses the under- lying left ventricular pathology or improves the prognosis remains controversial. The major determinants for a lack of survival benefit after surgical mitral repair include: (i) the risk of the procedure; (ii) the fact that the problem is the ventricle, not the valve; and (iii) the issue relat- ed to recurrent mitral regurgitation and the need for a late reintervention. Therefore, surgery for secondary mi- tral regurgitation is only reserved for patients with an acceptable operative risk. Moderate secondary mitral regurgitation should be left untreated at the time of cor- onary bypass grafting. For severe mitral regurgitation, repair is the optimal treatment when it is expected to be durable, otherwise valve replacement should be carried out. With advancements in technology, it is likely that, in the near future, surgery for secondary mitral regurgi- tation will be carried out only if percutaneous methods are contraindicated. To date, the interventional edge-to- edge repair technique, ie, MitraClip, has been established as a reliable method, which is associated with: (i) durable mitral regurgitation reduction; (ii) clinical improvements; and (iii) a signal for improved survival over optimized medical treatment. However, the efficacy of this thera- py might be limited in patients with severe biventricular heart failure due to a high 1-year mortality rate. 
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Progression of secondary mitral regurgitation: from heart failure to valvular heart failure.

Progression of secondary mitral regurgitation: from heart failure to valvular heart failure.

Correlation between total atrial conduction time estimated via tissue Doppler imaging (PA-TDI Interval), structural atrial remodeling and new-onset of atrial fibrillation after cardiac s[r]

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Transcatheter Mitral-Valve Repair in Patients with Heart Failure.

Transcatheter Mitral-Valve Repair in Patients with Heart Failure.

T h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 380;20 nejm.org May 16, 2019 1980 Why is there an absence of benefit in the MITRA-FR trial and a dramatic improvement in clinical out- comes in the COAPT trial? The left ventricular dimension was, on average, greater among pa- tients in the MITRA-FR trial, which reflects more advanced disease. Perhaps more important, in the COAPT trial, nearly 60% of screened patients (911 of 1576) did not undergo randomization. The success of the MitraClip device is critically dependent on whether strict echocardiographic criteria are met. Enrollment was supervised by the sponsor (Abbott) in the COAPT trial and was physician-led and independent of industry in the MITRA-FR trial. The results of the COAPT trial suggest that transcatheter mitral-valve repair may be beneficial in highly selected patients with heart failure who have secondary mitral regurgitation. However, we are concerned that the real-world effect of this therapy may prove to be more like the results presented in the MITRA-FR trial.
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Quantitative Three-Dimensional Color Flow Echocardiography of Chronic Mitral Regurgitation: New Methods, New Perspectives, New Challenges

Quantitative Three-Dimensional Color Flow Echocardiography of Chronic Mitral Regurgitation: New Methods, New Perspectives, New Challenges

Perhaps qualitative or eyeball methods (our face) and quantitative 2D CFD techniques (our neck—the truth standard) have aged grace- fully. In any event, integrated 2D and 3D echocardiography should be the new standard to quantify MR, which will also spur technological developments to match the clinical needs and to incentivize the wider adoption of 3D echocardiographic techniques. Ultimately, the predic- tive value of this integrated approach will have to be tested in prospec- tive multicenter studies with clinical events as end points, such as the Progression and Outcome of Secondary Mitral Regurgitation study (POMAR). 15 This study will test the accuracy of automated 3D PISA and stroke volume methods and will examine the incremental value of 3D quantitation in predicting clinical outcomes compared with CMR. An additional question to be answered is when and how CMR incrementally complements the integrated assessment of MR severity using these newer 3D echocardiographic approaches.
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Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease.

Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease.

Comparisons of surgery and percutaneous intervention in secondary mitral regurgitation Direct comparisons between percutaneous EE repair and surgery in secondary MR are difficult since patients treated with either strategy are significantly different. One small non-randomized series re- ported higher efficacy of surgery compared with percutaneous intervention (freedom from MR ≥3+ at 1 year 94 vs. 79%, P ¼ 0.01). 46 In contrast, post hoc analysis of the EVEREST II trial demon- strated equivalence of the two strategies in this setting. 22 , 29 How- ever, in the absence of a medical therapy control group, it is not possible to establish whether either treatment has positive impact on survival—ongoing randomized studies will address this question. Surgery following failed percutaneous EE repair can be challen- ging as a consequence of clip-induced scarring and fibrosis (Figure 4 ). 50 , 51 Whilst this may be acceptable in high-risk patients with secondary MR, this is not the case in low-risk primary MR patients—percutaneous techniques are not appropriate in this population.
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Three-dimensional echocardiographic assessments of exercise-induced changes in left ventricular shape and dyssynchrony in patients with dynamic functional mitral regurgitation.

Three-dimensional echocardiographic assessments of exercise-induced changes in left ventricular shape and dyssynchrony in patients with dynamic functional mitral regurgitation.

Exercise-induced changes in left ventricular shape and synchronicity The effects of exercise on LV function and shape are summar- ized in Table 2. During exercise, changes in EDVI, ESVI, and EF were similar in both the EMR and the NEMR groups. Conver- sely, changes in mitral valvular deformation parameters (sys- tolic tenting area, coaptation distance, and annular diameter) were more pronounced in the EMR patients. More severe the deformation, more significant the MR. By 3DE, the LV sphericity index (P , 0.0007) and the extent of LV dys- synchrony increased significantly in the EMR patients, whereas these parameters remained fairly unchanged in the NEMR group. To note, the 3D sphericity index was greater at rest in the EMR group (P , 0.0001). Under resting conditions, the 3D sphericity index was the sole significant parameter
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Secondary tricuspid regurgitation in patients with left ventricular systolic dysfunction: cause for concern or innocent bystander?

Secondary tricuspid regurgitation in patients with left ventricular systolic dysfunction: cause for concern or innocent bystander?

in the current issue of the European Heart Journal, where the authors studied the specific risk attached to TR in the presence of left ven- tricular (LV) systolic dysfunction. 8 In order to separate the wheat from the chaff, the authors selected only patients with secondary TR and reduced LV ejection fraction (EF <50%). Importantly, the study patients had no other significant valvular heart disease, defined as or- ganic valve lesions of moderate or higher severity, neither did they have organic or primary TR, congenital causes of TR, or any previous valve surgery. The stringent selection criteria positioned the authors’ work well at isolating the impact of secondary TR on long-term outcome.
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Remplacement valvulaire mitral par homogreffe

Remplacement valvulaire mitral par homogreffe

Les premiers travaux expérimentaux sur l’uti- lisation d’homogreffes mitrales furent publiés par Cachera et coll. en 1964 (3). Ces auteurs étu- dièrent l’utilisation de tissu mitral pour réparer une perte de substance au niveau d’un feuillet valvulaire. Ils étudièrent le remplacement partiel de la valvule mitrale en substituant le feuillet antérieur par celui d’une homogreffe, avec réim- plantation des cordages et des muscles papil- laires dont il dépend et, enfin, réalisèrent les premiers remplacements complets de la valvule mitrale par homogreffe. Un peu plus tard, diffé- rents travaux expérimentaux confirmaient la fai- sabilité du remplacement valvulaire par homogreffe chez le chien (4, 5), tandis que les premières applications cliniques se soldèrent invariablement par un échec à court terme (6, 7). La meilleure connaissance de la valvule mitrale, au plan anatomique et physiologique, et surtout l’expertise chirurgicale acquise par la pratique régulière de la chirurgie réparatrice et l’application des principes édictés par Carpen- tier, ont permis de revisiter le sujet. Christophe Acar et coll. (8) ont été les premiers à avoir constitué et étudié une série clinique consistante, tandis que Pomar et coll. appliquaient avec suc- cès l’utilisation des homogreffes mitrales à la chirurgie de l’endocardite infectieuse tricuspide (9). Dans une contribution fondamentale publiée en 1996 (8), Acar et coll. démontraient la faisa- bilité et la reproductibilité de cette intervention. Deux principes chirurgicaux nouveaux ont permis l’obtention de résultats immédiats tout à fait corrects : il s’agit, d’une part, de la réim- plantation côte à côte des muscles papillaires, qui, dans le passé, avait souvent constitué un écueil technique; d’autre part, de l’établissement d’une méthode de mesure échographique per- mettant de déterminer la taille de l’homogreffe.
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Assessment of left ventricular volumes and primary mitral regurgitation severity by 2D echocardiography and cardiovascular magnetic resonance.

Assessment of left ventricular volumes and primary mitral regurgitation severity by 2D echocardiography and cardiovascular magnetic resonance.

Methods Study population The present study concerned 41 prospectively included patients in 2 Belgian centres (CHU Sart Tilman Liège and University of Antwerp Hospital) with at least mod- erate primary MR (effective regurgitant orifice [ERO] ≥ 20 mm 2 and/or a RVol ≥ 30 ml) and without overt signs of LV dysfunction or dilatation (LV ejection fraction (EF) ≥60% and LV end-systolic diameter ≤45 mm) after in- formed consent. Patients with poor echogenicity, history of coronary artery disease, persistent arrhythmias or other significant concomitant valvular heart disease (> mild mi- tral/aortic stenosis or regurgitation) were excluded. More- over, we did not enrol patients with CMR-incompatible devices or claustrophobia. The ethical committee of the 2 centres approved the study protocol (Ethisch comité Uni- versitair Ziekenhuis Antwerpen and Comité d'éthique Hospitalo-Facultaire Universitaire de Liège).
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The value of adding sub-valvular procedures for chronic ischemic mitral regurgitation surgery: a meta-analysis.

The value of adding sub-valvular procedures for chronic ischemic mitral regurgitation surgery: a meta-analysis.

presence of predictors of repair failure as part of the sensitivity analysis. 8,10,11 Borger 12 included patients with severe MR as well; however, data could not be sep- arated from patients with moderate MR, hence, was not included in the sensitivity analysis. Calafiore 9 excluded patients with CD >10 mm who directly underwent replacement with no attempt to repair. A classical restricted annuloplasty, as originally described by Bolling, 1 was not used in the SVP groups, where a mod- erate downsizing or natural size technique was pre- ferred. This possibly may be a favorable surgical philosophy in line with recent findings that show that RA might be associated with a higher trans-mitral gra- dient at rest and maximal exercise. However, correla- tion with functional capacity has yet to be determined. 16 The adjunction of SVP led to statistically significantly prolonged CPB time and XCT. However, that did not increase the mortality rate (Table 3). In the surgical community, one of the most common reasons for crossover to CABG alone is the concern about the risk associated with valve repair. 14 In a prospective rand- omized trial, Smith et al. observed that RA was associ- ated with prolonged CPB and XCT time and a higher rate of stroke than CABG alone. 14 In this meta-analysis, only Langer 11 and Borger 12 reported the incidence of major neurological events that was not statistically dif- ferent between groups.
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Assisted auscultation : creation and visualization of high dimensional feature spaces for the detection of mitral regurgitation

Assisted auscultation : creation and visualization of high dimensional feature spaces for the detection of mitral regurgitation

5-11 SOMs showing the distribution of patients in the physiological feature space based on their prototypical systoles using two sets of prototypical beats created wit[r]

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The Conundrum of Tricuspid Regurgitation Grading.

The Conundrum of Tricuspid Regurgitation Grading.

Traditionally, TR is graded into mild, moderate, and severe, following the severity grading conventions that also apply to mitral, aortic, and pulmonary valves. Severe TR is defined quantitatively as an effective regurgitant orifice area (EROA) of ≥40 mm 2 and a regurgitant volume of ≥45 ml according to both the European Association of Cardiovascular Imaging (EACVI) and American Society of Echocardiography (ASE) recommendations ( 9 , 10 ). In particular, the EACVI recommendations made provision for massive TR. Massive TR is referred to as TR that is beyond severe and it is associated with a low TR jet velocity of <2 m/s as there is near equalization of right ventricular and right atrial pressures ( 9 ). However, in the EACVI recommendations, massive TR was defined qualitatively. There were no quantitative or semi-quantitative parameters that distinguish massive from severe TR and therein lies a 2-fold problem. For starter, the distinction between severe and massive is not always clear. Qualitative parameters such as the size of the TR jet on color Doppler can change substantially according to the Nyquist limits and loading conditions. Similarly, in the case of massive TR with very large regurgitant orifice area, a distinct color jet may not be apparent due to the presence of laminar, low velocity flow ( 10 ). Also, the use of descriptive terminology without proper standardization and quantification lacks the scientific rigor necessary for quality research. Terms such as very severe, free, massive, or torrential are descriptive and thus subjected to interpretation. Loose application or interchangeable usage of these terms are not uncommon both the published literature and clinical practice, making meaningful, quantitative comparisons impossible.
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Changes in mitral regurgitation and left ventricular geometry during exercise affect exercise capacity in patients with systolic heart failure.

Changes in mitral regurgitation and left ventricular geometry during exercise affect exercise capacity in patients with systolic heart failure.

Methods Subjects This prospective study included 36 clinically stable CHF patients with LV systolic dysfunction (ejection fraction ,45%). Of these, one patient with primary mitral valve disease and five patients with poor quality images were excluded from the study. Of the remaining 30 patients, 10 patients were in New York Heart Association functional class I, 19 in class II, and 1 in class III. All patients were clinically stable; they had no changes in the prescribed medications within the last 3 months before enrolment. Ischaemic disease was determined when a patient had either previous myocardial infarction (.6 months) or significant coronary artery disease (.75% stenosis in one of the major epicardial coronary arteries); 12 patients had ischae- mic heart disease and 18 had idiopathic dilated cardiomyopathy. Nine- teen patients had a narrow QRS complex (,120 ms) and 11 had a wide QRS complex (.120 ms). This study also included 15 age- matched healthy controls with no specific medical history or organic cardiovascular disease. This study was performed in accordance with the ethical principles set forth in the Declaration of Helsinki. The study protocol was approved by the St Marianna University School of Medicine Institutional Committee on Human Research (No. 1288). Written informed consent was obtained from all participants before enrolment.
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Assessment of severity of pulmonary regurgitation: Reply

Assessment of severity of pulmonary regurgitation: Reply

Concerning the definition of severe PR, we would like to underline that in patients with normal pulmonary artery pressures, PR frac- tion is limited by fast equilibration of pulmon- ary artery and diastolic right ventricular pressures. Therefore, regurgitation fractions above 40% are relatively rare, even with free regurgitation without any valvular function. 2 Cardiac magnetic resonance imaging (CMR) is nowadays the gold standard to measure regurgitation fraction of the pulmonary valve. A regurgitation fraction of .20% assessed with CMR is associated with the same magnitude of right ventricular enlarge- ment as a regurgitation fraction of .40%. Therefore, a regurgitation fraction of .20% can be regarded as severe regurgitation. 2
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Évaluation multimodale exhaustive du prolapsus valvulaire mitral myxoïde au C.H.U

Évaluation multimodale exhaustive du prolapsus valvulaire mitral myxoïde au C.H.U

II. Physiopathologie du PVM : 1- Présentation et historique Le PVM est la pathologie valvulaire la plus fréquente dans les pays occidentaux avec une prévalence dans la population générale estimée entre 2 et 3 %.(1) Il se divise en deux sous- types principaux. Le plus fréquent, qui représente 75% des PVM est une forme de dégénérescence fibro-élastique de l’appareil valvulaire mitral (FED) (14). Elle est caractérisée par un tissu valvulaire fin, translucide, sans modification histologique (15) responsable d’un allongement des cordages pouvant évoluant vers leur rupture. Elle touche plus volontiers les patients âgés. Une seconde forme de PVM, dite myxoïde, a été décrite pour la première fois par Barlow en 1968 (16). Elle est caractérisée par une hypertrophie du tissu valvulaire mitral par infiltration de protéoglycanes (17) qui devient redondant, avec pour conséquence un épaississement des feuillets valvulaires et un allongement des cordages. A partir de 1973, le PVM a été associé à la survenue de cas de MS, relation initialement décrite au travers de séries de cas autopsiques. (18). Ultérieurement, Pocock et Barlow ont spécifiquement ciblé le phénotype myxoide de PVM dans la survenue d’arythmies ventriculaires (19).
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Echocardiographic characteristics and outcome of straddling mitral valve

Echocardiographic characteristics and outcome of straddling mitral valve

Clinical and echocardiographic data. The clinical records, echocardiograms, surgical reports and, when applicable, autopsy reports were reviewed. The following data were recorded for each patient, based on clinical records: demo- graphic information, age at diagnosis, age at first surgery, age at last surgery and type of surgical procedures. The following anatomical details were documented based on review of the echocardiograms: segmental anatomy (17), atrioventricular (AV) relationship, ventricular size and func- tion, mitral valve morphology and attachments (including number and location of the papillary muscles), tricuspid valve (TV) morphology and function, type of conus, semi- lunar valve morphology and function, outflow tract obstruc- tion (defined as peak Doppler gradient ⱖ20 mm Hg) and the morphology of the great arteries. All associated malfor- mations were recorded. Ventricular size was graded as normal or hypoplastic (defined as ventricular sinus apex reaching ⱕ2/3 of the cardiac apex). Ventricular function was qualitatively graded as normal or mildly, moderately or severely depressed. The type of VSD and its relationship to the semilunar valves were classified as subaortic, subpulmo- nary, doubly committed or uncommitted according to pub- lished criteria (18). Straddling mitral valve was defined as attachments of MV chordae tendineae on both sides of the ventricular septum (1– 4). Patients with chordal attachments on the left ventricular septal surface were not considered to have SMV and were not included in this study. Major degree of SMV was defined as more than half of the MV related to the infundibulum on the basis of qualitative assessment from a short-axis view (either subxiphoid or parasternal) and from the apical four-chamber view during diastole. The anatomical definitions of right ventricle (RV) sinus, infundibulum and the nomenclature of segmental anatomy were previously published (17–20).
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A Simplified Rotational Spring Model for Mitral Valve Dynamics

A Simplified Rotational Spring Model for Mitral Valve Dynamics

The mitral valve separates the left atrium and ventricle. When functioning correctly, it allows blood to flow from the atrium to the ventricle during diastole, and prevents it flowing back during systole. For a normal mitral valve, about 70-80% of the blood flow occurs during the early filling phase of the left ventricle. After this phase, the left atrial contraction contributes approximately 20% more to the volume in the left ventricle prior to mitral valve closure and ventricular systole. Similar behaviour is seen in the right ventricle with the tricuspid valve. Abnormal dynamics in this filling phase in either ventricle may suggest valve dysfunction, but could also suggest a wider problem with the circulation, for example pulmonary embolism (Ristow et al., 2007). Pulmonary embolism is often characterised by tricuspid regurgitation and causes the secondary effect of increased volume in the atrium and/or ventricle, (Ristow et al., 2007). Thus, significant research concentrates on the understanding of detailed flow dynamics and pressure around the valves and atria.
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Secondary cancers in childhood

Secondary cancers in childhood

RÉSUMÉ : Devant l’amélioration de la survie des patients pédiatriques atteints de cancer, nous devrons faire face de plus en plus souvent à des séquelles tardives dont notamment l’ap- pa[r]

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Mitral valve disease−morphology and mechanisms

Mitral valve disease−morphology and mechanisms

Mitral valve development begins soon after looping of the early embryonic heart tube. In response to growth factors including several proteins of the TGFβ super family (TGFβ1–3, BMP2–4), a subset of the endocardial cells of the early embryonic heart become activated and transform into a mesenchymal phenotype, known as endothelial‐to‐mesenchymal transition (EMT; Figure 5). 71,75 The endothelial cells that do not undergo EMT express NFATc1, which suppresses important transcriptional factors needed for the phenotypic transition of the cells to proliferate and elongate to form the maturing leaflets. 76 NFATc1 limits EMT by suppression of its positive regulators Snail and Slug. 69 The molecular and cellular events that occur after this initial EMT are complex and poorly understood. Post‐ EMT leaflet maturation involves migration and proliferation of mesenchymal cells to distend the forming cushions into the lumen, under the control of growth factors, 72,75,77 followed by their gradual thinning and elongation. One hypothesis for this leaflet maturation is that cell proliferation results in polarized, aligned cell arrays that collectively migrate and extrude leaflet tissue into the lumen, referred to as a convergent extension process. 69 Indeed, microscopic analysis of developing valves shows alignment of cells during post‐EMT and neonatal development. 69 Concomitant with the early remodelling phase is differentiation of the cushion mesenchyme into interstitial cells. 74 Based on this fundamental change in cell phenotype, the matrix surrounding these fibroblasts matures into a highly organized lamellar and fibrous tissue, making the valve more rigid and thereby able to handle the increasing haemodynamic load of the beating heart. 74 Slight defects in any of these fundamental processes might lead to structural and functional valve disease that presents in postnatal life and can progress into degenerative changes in adult life.
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