The influence of sleep on emotion dysregulation in borderline personality disorder, generalized anxiety disorder, and healthy controls.

Emotion dysregulation is central to borderline personality disorder (BPD) and exacerbated by sleep disruptions. This study investigated whether homeostatic (i.e., sleep efficiency), circadian (i.e., chronotype), and subjective (i.e., sleep quality) sleep elements predict emotion dysregulation in BPD, healthy controls (HCs), and a generalized anxiety disorder (GAD) group. Participants (N = 120) with BPD, GAD, and HCs completed daily sleep measures for seven days prior to an experiment wherein baseline emotion, emotional reactions to stressors (i.e., reactivity), and the extent to which they can decrease their emotion using mindfulness and distraction (i.e., emotion regulation) were measured across self-reported, sympathetic, and parasympathetic emotion. Across groups, earlier chronotypes and higher sleep quality predicted less self-reported baseline negative emotion, and higher sleep quality predicted better parasympathetic emotion regulation. For HCs, higher sleep efficiency and lower sleep quality predicted higher parasympathetic baseline emotion, and higher sleep efficiency predicted more self-reported baseline negative emotion. Also in HCs, earlier chronotype predicted better sympathetic emotion regulation, and there was a quadratic relationship between sleep efficiency and self-reported emotion regulation. Optimizing sleep quality and improving alignment between chronotype and daily living may improve baseline emotion and emotion regulation. Healthy individuals may be particularly vulnerable to high or low sleep efficiency.

Intermediate-term results of a nonresectional dynamic repair technique in 662 patients with mitral valve prolapse and mitral regurgitation.

OBJECTIVE: A nonresectional technique has been developed for repair of mitral leaflet prolapse causing mitral regurgitation. Polytetrafluoroethylene chordae are used for correction of edge misalignment of the prolapsed mitral leaflet. New chordal length is adjusted during progressive left ventricular inflation to systolic pressure. Annular sizing is determined dynamically after leaflet edge alignment is accomplished to produce an optimal zone of predefined leaflet apposition. The aim of this study was to document the 8- to 10-year durability of this nonresectional approach. METHODS: From 1983 through 2008, 1121 consecutive patients had mitral valve repair on one service. Of these, 662 had repair of mitral leaflet prolapse. From 1983 until 1998, standard quadratic leaflet resection/plication was used in 72 (11.1%) patients, similar but smaller resection in 93 (14.1%) patients, and then smaller resection and polytetrafluoroethylene chordae in 24 (3.7%) patients. All received Puig-Massana fully flexible rings (Shiley, Inc, Irvine, Calif). After 1998, no leaflet resections or valve replacements have been performed regardless of leaflet size in 566 consecutive patients. Of the 662 patients, the mean age was 62.6±14.1 years, and 424 (64.1%) patients were male. Coronary artery disease was present in 147 (22.2%) patients and 33 (5.0%) had prior coronary artery bypass. Leaflets corrected were as follows: anterior, 152 (23.0%) patients; posterior, 427 (64.5%); and both, 83 (12.5%) Common pathologic characteristics of prolapsing valves were as follows: myxomatous, 332 (50.2%) patients, degenerative, 83 (12.5%), ischemic, 31 (4.7%), and rheumatic, 29 (4.4%). RESULTS: Perioperative mortality was 2.9% (19/662) overall and 0.49% (2/414) for isolated repair. Freedom from reoperation at 10 years (Kaplan-Meier) was 90.1% and freedom from significant mitral regurgitation (echocardiography) was 93.9%. CONCLUSIONS: This study confirms that mitral regurgitation from mitral leaflet prolapse can be repaired in all cases by a nonresectional technique provided that accurate dynamic evaluation of chordal length and annular sizing is achieved. The intermediate-term results are durable.

Nonresectional repair of the barlow mitral valve: importance of dynamic annular evaluation.

BACKGROUND: The most extensive form of myxomatous degeneration of the mitral valve causing severe mitral regurgitation is "Barlow disease." Surgical repair of this condition has been considered difficult because of the extent and magnitude of annular, leaflet, and chordal abnormalities and has usually involved partial resection of one or both mitral leaflets. METHODS: A surgical approach has been developed which does not involve leaflet resection. Instead, by means of precise dynamic annular sizing, a predetermined zone of leaflet apposition is achieved. The leaflets are positioned so that their large area is contained within the left ventricle. Normal annular, leaflet, and papillary muscle dynamic function is restored. RESULTS: This procedure was performed in 61 patients. The repair rate was 100%. The mean age was 57.6 +/- 12.7 years. They were 67.2% male. The preoperative anteroposterior annular dimension was 52.1 +/- 4.3 mm. The full, flexible complete ring size was 33.4 +/- 1.9 mm. There was no perioperative mortality. There was no systolic anterior leaflet motion. All patients were discharged with no or mild mitral regurgitation. At a follow-up interval of 1.2 +/- 2.1 years one patient had developed recurrent mitral regurgitation, secondary to marked remodeling to normal left ventricular function. CONCLUSIONS: Initial experience with a nonresectional approach for Barlow disease has produced good early results.

Feasibility and intermediate term outcome of repair of prolapsing anterior mitral leaflets with artificial chordal replacement in 152 patients.

BACKGROUND: Mitral valve repair of the anterior leaflet has been more difficult than at other sites. METHODS: Between February 1983 and June 2004, 607 mitral valve repairs were performed on one service. Of these, 410 patients had leaflet repair procedures: 152 were anterior leaflet repairs; isolated in 94, and combined with posterior repair in 58 patients. The results in these patients were compared with the results of posterior leaflet repair in 258 patients. All patients received flexible ring annuloplasty. RESULTS: Age and sex of the anterior leaflet and posterior leaflet patients were similar: mean age 62.5 +/- 14.3, 62.9 +/- 14.9 years; males, 50.6%, p = not significant (NS). Preoperative ejection fraction was for anterior repairs 52.6 +/- 12.8%; posterior repair, 58.2 +/- 11.8%, p = NS. Coronary artery bypass was more frequently performed with anterior leaflet repair in 18 patients (19.1%) versus 45 (6.6%) for posterior leaflet repair (p = NS). The median number of chordae was similar in the anterior leaflet and posterior leaflet patients 4 (2-8), 4 (2-6), p = NS. Perioperative mortality was similar: anterior leaflet patients, 3.3% (2/94); posterior leaflet patients, 1.1% (2/258), p = NS. Hospital stay was for anterior leaflet patients and posterior leaflet patients: 12.86 +/- 13.3 vs 11.0 +/- 12.3, p = NS. Kaplan-Meier estimates of freedom from reoperation at 3 years were: for anterior leaflet patients, 91.9%: for posterior leaflet patients, 90.7%, p = 0.77. No structural polytetrafluoroethylene (PTFE) chordal failures were observed. Late echocardiographic data were obtained in 136 patients on 222 occasions at a mean of 3.2 +/- 3.34 years. Severe mitral regurgitation was present in 10 patients (7.3%). CONCLUSIONS: Repair of the anterior leaflet is facilitated by the use of PTFE replacement. Anterior leaflet repair can be performed reproducibly with the same results as posterior leaflet repair.