title: The crossed swords sign: insights into the dilemma of repair in bileaflet mitral valve prolapse.
abstract: BACKGROUND
  The need for bileaflet repair in bileaflet mitral valve prolapse (MVP) remains controversial. Will anterior leaflet prolapse resolve with posterior leaflet repair or should both leaflets be addressed? Single-leaflet MVP produces oppositely directed mitral regurgitant jets. Some patients show two crossed jets oppositely directed from the coaptation zone. We hypothesized that these indicate bileaflet lesions requiring complex repair.
  
  
  METHODS
  Echocardiograms and surgical reports of 52 consecutive patients with MVP undergoing surgery were reviewed.
  
  
  RESULTS
  First, all 14 patients with two oppositely directed jets had prolapse of more than one leaflet. Each jet was related to discrete leaflet distortions causing malcoaptation. Six underwent valve replacement. Seven had both leaflets repaired. One had posterior leaflet repair and annuloplasty, with persistent mitral regurgitation requiring valve replacement. Second, 36 of 38 patients with single jets had single-leaflet MVP. One underwent replacement; all others did well with single-leaflet repair. Two patients with bileaflet MVP but only one jet did well with single-leaflet repair or annuloplasty.
  
  
  CONCLUSIONS
  This crossed swords sign is an important clue to bileaflet mechanism of mitral regurgitation in MVP, associated with complex repair procedures. Thus, it provides a clue in the dilemma of bileaflet versus single-leaflet repair.
authors.affiliation: Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
authors.forename: Ronen
authors.initials: R
authors.lastname: Beeri
authors.forename: Scott C
authors.initials: SC
authors.lastname: Streckenbach
authors.forename: Eric M
authors.initials: EM
authors.lastname: Isselbacher
authors.forename: Cary W
authors.initials: CW
authors.lastname: Akins
authors.forename: Gus J
authors.initials: GJ
authors.lastname: Vlahakes
authors.forename: Mark S
authors.initials: MS
authors.lastname: Adams
authors.forename: Robert A
authors.initials: RA
authors.lastname: Levine
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008945:Mitral Valve Prolapse / Q000000981:diagnostic imaging* / Q000601:surgery*; D018579:Patient Selection; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014463:Ultrasonography