ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease)

Prosthetic mitral valve thrombosis: can fluoroscopy predict the efficacy of thrombolytic treatment?

BACKGROUND

Thrombolysis (T) is an effective therapy for prosthetic valve thrombosis (PVT). Debate still exists as to which clinical or noninvasive finding best predict the result of T. The aim of the study was to investigate the role of fluoroscopy (F) to predict efficacy of T in pts with mitral PVT.

METHODS

We evaluated 17 consecutive pts with bileaflet mitral PVT. F criteria for PVT were: abnormal disc motion and calculated opening angle >25 degrees. T was carried out with tissue-type plasminogen activator (tPA; 100 mg over 3 hours followed by heparin infusion for 24 hours) and was considered successful when normalization of leaflet motion and opening angle occurred. Results were evaluated according to symptom duration (<21 days, early PVT; >21 days, late PVT) and to F pattern of PVT (blocked leaflet versus hypomobile leaflet).

RESULTS

F showed disc motion alteration in 24 of 34 leaflets: 8 leaflets were blocked, whereas 16 were hypomobile. Early (12.7+/-6.1 days, range 3-21) and late (113+/-114 days, range 28-365) PVT was present in 8 and 7 pts, respectively. Thrombolysis was successful in 20 of 24 leaflets. Blocked leaflet fully recovered only in early PVT (n=4) pts, whereas they remained blocked in late PVT (n=4). On the contrary, in all of the cases with hypomobile leaflet, disc motion normalized regardless duration of symptoms and extent of disc motion reduction. Interestingly, 4 leaflets with late PVT was diagnosed as blocked by trans-thoracic (TTE). F showed a residual disc movement in all: they fully recovered after T. Two pts with late PVT had both leaflets affected (1 blocked +1 hypomobile); although blocked leaflet did not respond to T, the normalization of hypomobile significantly improved clinical condition.

CONCLUSIONS

F can predict result of T in mitral PVT. PVT with F evidence of hypomobile leaflet always recovers regardless of symptom duration and extent of disc motion reduction, suggesting that the small amount of thrombus needed to interfere with discs motion in bileaflet prostheses remains sensitive to T even after a long time. PVT with F evidence of blocked leaflet has a favorable response to T only in case of early PVT. Late PVT with blocked leaflet does not respond to T, suggesting a larger and stratified thrombus and the coexistence of pannus and, in our series, always required surgery. However, if a hypomobile leaflet coexists, T may be used to restore normal movement of hypomobile leaflet so that to improve patient clinical and hemodynamic condition before operation.

Distinct but parallel evolutionary patterns between alcohol and aldehyde dehydrogenases: addition of fish/human betaine aldehyde dehydrogenase divergence

Alcohol dehydrogenases (ADHs) of the MDR type (medium-chain dehydrogenases/reductases) have diverged into two evolutionary groups in eukaryotes: a set of 'constant' enzymes (class III) typical of basal enzymes, and a set of 'variable' enzymes (remaining classes) suggesting 'evolving' forms. The variable set has larger overall variability, different segment variability, and variability also in functional segments. Using a major aldehyde dehydrogenase (ALDH) from cod liver and fish ALDHs deduced from the draft genome sequence of Fugu rubripes (Japanese puffer fish), we found that ALDHs form more complex patterns than the ADHs. Nevertheless, ALDHs also group into 'constant' and 'variable' sets, have separate segment variabilities, and distinct functions. Betaine ALDH (class 9 ALDH) is 'constant,' has three segments of variability, all non-functional, and a limited fish/human divergence, reminiscent of the ADH class III pattern. Enzymatic properties of fish betaine ALDH were also determined. Although all ALDH patterns are still not known, overall patterns are related to those of ADH, and group separations may be distinguished. The results can be interpreted functionally, support ALDH isozyme distinctions, and assign properties to the multiplicities of the ADH and ALDH enzymes.

Infective endocarditis after oral body piercing

Body piercing has become an increasingly common practice in the United States and elsewhere. Although perceived as a relatively safe practice, it poses the risk of numerous infectious complications. Oral body piercing in particular has significant potential risk given the known relationship of oral flora to bacteremia. We describe a patient who developed infective endocarditis shortly after undergoing oral piercing.

Overview of transesophageal echocardiography for the chest physician

Transesophageal echocardiography (TEE) is a growing technology that is frequently utilized in the critical care setting by intensivists, surgeons, anesthesiologists as well as specialists in cardiovascular diseases. The clinical application of TEE continues to emerge, and the indications and diagnostic utility of this technology as currently available are summarized in this review.

Echocardiographic prediction of left ventricular dysfunction after mitral valve repair for mitral regurgitation as an indicator to decide the optimal timing of repair

OBJECTIVES

This study sought to determine whether echocardiography before mitral valve repair (MVR) for mitral regurgitation (MR) was predictive of postoperative left ventricular (LV) dysfunction and useful for deciding the optimal timing of repair.

BACKGROUND

Some reports have shown that the preoperative echocardiographic data of left ventricular ejection fraction (LVEF) and left ventricular end-systolic diameter (LVDs) were good predictors of postoperative LV dysfunction. However, few reports were based on long-term follow-up data of large numbers of patients who underwent MVR in the last decade.

METHODS

A total of 274 patients with moderate or severe MR underwent MVR between October 1, 1991, and September 30, 2000. Among them, 171 patients who had both an operation for isolated MR due to degenerative pathology and a postoperative echocardiogram were studied. Postoperative echocardiograms were performed 3.9 +/- 2.4 years after the operation. The LVEF decreased from 66 +/- 10% before surgery to 63 +/- 11% after surgery (p < 0.0001). On univariate analysis, preoperative LVEF and LVDs correlated with postoperative LVEF (r = 0.41 and r = -0.39, respectively). Overall, postoperative LV dysfunction (defined as LVEF <50%) was not frequent (12%). However, the incidence of postoperative LV dysfunction was high in patients with preoperative LVEF <55% (38%) or LVDs > or =40 mm (23%).

CONCLUSIONS

In patients with MR, the echocardiographic data of LVEF and LVDs were good predictors of postoperative LV dysfunction. When a decrease in LVEF or an increase in LVDs is detected, MVR should be considered to preserve postoperative LV function.

Early and late stroke after mitral valve replacement with a mechanical prosthesis: risk factor analysis of a 24-year experience

OBJECTIVE

We evaluated risk factors for mortality and stroke after mechanical mitral valve replacement between May 1977 and December 2001.

METHODS

Early and late mortality and stroke were assessed. Potential predictors of mortality and stroke were entered into a Cox proportional hazards model. Actuarial survival and freedom from stroke were determined by a log-rank test.

RESULTS

Mitral valve replacement was performed in 812 patients. Concomitant procedures included left atrial appendage closure in 493 (61%) patients, tricuspid annuloplasty-replacement in 348 (43%) patients, maze procedure in 185 (23%) patients, plication of the left atrium in 148 (18%) patients, and other procedures in 151 (19%) patients. Five-year actuarial survival was 91.1% +/- 2.3%. Freedom from stroke at 8 years was significantly better in patients with sinus rhythm versus atrial fibrillation (P <.001). Ninety-nine percent of patients with mitral valve replacement combined with a maze procedure were free from stroke, whereas only 89% of patients with mitral valve replacement alone were free from stroke at 8 years after surgical intervention. Seventy-two patients had late stroke; sixty-five patients (90%) were in atrial fibrillation, and 47 (65%) patients had the left atrial appendage closed. Multivariate analysis showed that late atrial fibrillation (odds ratio, 3.39; 95% confidence interval, 1.72-6.67; P =.0001) and omission of the maze procedure (odds ratio, 3.40; 95% confidence interval, 1.14-10.14; P =.003) were the significant risk factors for late stroke.

CONCLUSIONS

Persistent atrial fibrillation was the most significant risk factor for late stroke after mechanical mitral valve replacement. Restoration of sinus rhythm with a maze procedure nearly eliminated the risk of late stroke, whereas neither closure of the left atrial appendage nor therapeutic anticoagulation prevented this complication.

Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics

BACKGROUND

The prognostic value of dobutamine stress hemodynamic data in the setting of low-gradient aortic stenosis has been addressed in small, single-center studies. Larger studies are needed to define the criteria for selecting the patients who will benefit from valve replacement.

METHODS AND RESULTS

Six centers prospectively enrolled 136 patients with aortic stenosis (96 men; median age, 72 years [range, 65 to 77 years]; median aortic valve area, 0.7 cm2 [range, 0.6 to 0.8]; mean transaortic gradient, 29 mm Hg [range, 23 to 34 mm Hg]; cardiac index, 2.11 L x min(-1) x m(-2) [range, 1.75 to 2.55 L x min(-1) x m(-2)]). Left ventricular contractile reserve on the dobutamine stress Doppler study was present in 92 patients (group I) and absent in 44 patients (group II). Operative mortality was 5% (3 of 64 patients) in group I compared with 32% (10 of 31 patients) in group II (P=0.0002). Predictors for operative mortality were the lack of contractile reserve (odds ratio, 10.9; 95% confidence interval [CI], 2.6 to 43.4; P=0.001) and a mean transaortic gradient < or =20 mm Hg (odds ratio, 4.7; 95% CI, 1.1 to 21.0; P=0.04). Predictors for long-term survival were valve replacement (hazard ratio, 0.30; 95% CI, 0.17 to 0.53; P=0.001) and left ventricular contractile reserve (hazard ratio, 0.40; 95% CI, 0.23 to 0.69; P=0.001).

CONCLUSIONS

In the setting of low-gradient aortic stenosis, surgery seems beneficial for most of the patients with left ventricular contractile reserve. In contrast, the postoperative outcome of patients without reserve is compromised by a high operative mortality. Thus, dobutamine stress Doppler hemodynamics may be factored into the risk-benefit analysis for each patient.

An endovascular approach to cardioembolic stroke prevention in atrial fibrillation patients

This report is of a 62-year-old woman presenting with a 3-year history of chronic atrial fibrillation (AF) and unable to tolerate chronic warfarin therapy due to bleeding episodes and unstable INR values. Additional high risk factors for stroke are a history of congestive heart failure and previous embolic stroke. Percutaneous left atrial appendage transcatheter occlusion (PLAATO ) was performed to seal the LAA. A transesophageal echocardiography (TEE) at the 1- and 6-month follow-up showed no device migration and no new thrombus related to the implant. The patient has been doing well on postprocedure aspirin with no embolic events.

Plasma natriuretic peptide levels increase with symptoms and severity of mitral regurgitation

OBJECTIVES

This paper will describe associations between plasma natriuretic peptide levels and the severity and symptoms of mitral regurgitation (MR).

BACKGROUND

A biochemical test that assisted grading of the severity of MR and the interpretation of symptoms would be of clinical value.

METHODS

Forty-nine patients with isolated MR and left ventricular (LV) ejection fractions (EFs) of >55% underwent transthoracic echocardiography, assessment of symptoms, and measurement of atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and its amino-terminal portion, N-BNP.

RESULTS

The level of each natriuretic peptide rose with increasing severity of MR and with increases in left atrial (LA) dimensions (p < 0.001 for all comparisons), but no significant correlation existed between any natriuretic peptide and the LV dimensions or EF. Natriuretic peptide levels were higher in symptomatic MR (n = 16, BNP geometric mean 16.9 [95% confidence interval (CI) 13.3 to 21.4] pmol/l) compared with asymptomatic MR (n = 33, BNP 7.1 [95% CI 6.0 to 8.4] pmol/l, p < 0.001), and higher in asymptomatic MR than in normal controls (n = 100, BNP 5.3 [95% CI 4.8 to 5.8] pmol/l, p < 0.0001). These differences were similar for N-BNP and ANP and remained statistically significant (p < 0.05) after adjustment for echocardiographic measures of LV function and severity of MR. Both the sensitivity and the specificity for symptoms for the natriuretic peptides (area under receiver-operator characteristic curve for BNP = 0.90, N-BNP = 0.89, ANP = 0.89) were similar to the MR score (0.88) and greater than for LA dimension (0.81), vena contracta width (0.82), and LV end-systolic dimension (0.63).

CONCLUSIONS

Plasma natriuretic peptides levels increase with the severity of MR and are higher in symptomatic compared to asymptomatic patients, even when LV EF is normal.

A simple model to predict coronary disease in patients undergoing operation for mitral regurgitation

BACKGROUND

Coexistent coronary disease can be identified in a third of patients with mitral valve disease. This study aims to evaluate candidate selection strategy using risk factor identification and logistic regression and to develop an additive model for the prediction of coexistent coronary disease.

METHODS

The sample is a consecutive series of patients who had mitral repair from 1987 to 1999. Sensitivities and specificities were calculated for each risk factor. Variables for prediction of coronary disease were entered into a univariate analysis, and predictors were entered into a forward and backward stepwise multivariate logistic regression model to form a predictive score. An additive model was derived from transformation of the logistic model. Receiver operating characteristic curves were used to compare discrimination and precision quantified by the Hosmer-Lemeshow statistic.

RESULTS

The American Heart Association and American College of Cardiology risk factor identification selection criteria for the 359 patients who had screening coronary angiography yielded 100% sensitivity and 1% specificity. Risk prediction with our logistic model produced a receiver operating characteristic curve area of 0.91 and Hosmer-Lemeshow score of 3.4 (p = 0.9). Similar discriminating ability for our patients was achieved by the Cleveland Clinic logistic model (receiver operator characteristic curve area of 0.79; Hosmer-Lemeshow score of 12; p = 0.1). Our five-item additive model produced receiver operating characteristic curve area of 0.91 and Hosmer-Lemeshow score of 3.81 (p = 0.80).

CONCLUSIONS

Simple risk factor identification has excellent sensitivity but is limited by specificity. Logistic regression modeling is an accurate risk prediction method but is difficult to apply at the bedside. Simplicity and accuracy may be achieved by the logistic regression-derived simple additive model.

Pathophysiology of valvular aortic stenosis in the elderly

Aortic stenosis in the elderly is related to calcification of either a bicuspid valve or a morphologically normal tricuspid valve. There is increasing evidence that factors relating to atherosclerosis are involved in valvular calcification and that it is an actively regulated process rather than a degenerative one. With severe aortic stenosis left ventricular hypertrophy occurs, decreasing wall stress and supporting the left ventricular ejection fraction. However, with pathologic hypertrophy there is a dropout of myocardial cells, subendocardial ischemia, and fibrosis. Eventually, symptoms of angina, non-Q wave myocardial infarction, exertional syncope, and heart failure occur. Once symptoms begin, the prognosis is poor, with sudden death occurring in about one third of patients who die. In the elderly, symptoms can be recognized very late in the course of the disease since they can be attributed to other problems and since the elderly patient may have reduced physical activity to a minimum. The more comorbidities that exist, the greater the risk of valve replacement. Symptomatic patients with severe aortic stenosis even over age 80 can be operated upon with a relatively low mortality and morbidity. In patients over age 80, prolongation of life for any meaningful length of time is not as important as relief of symptoms and improvement in the quality of life. Thus, it is unlikely that any truly asymptomatic patient over age 80, even with severe aortic stenosis, should be sent to surgery.

Nitroprusside in critically ill patients with left ventricular dysfunction and aortic stenosis

BACKGROUND

Vasodilators are considered to be contraindicated in patients with severe aortic stenosis because of concern that they may precipitate life-threatening hypotension. However, vasodilators such as nitroprusside may improve myocardial performance if peripheral vasoconstriction is contributing to afterload.

METHODS

We determined the response to intravenous nitroprusside in 25 patients with severe aortic stenosis and left ventricular systolic dysfunction. Patients were included in the study if they had been admitted to the intensive care unit for invasive hemodynamic monitoring of heart failure and if they had a depressed ejection fraction (<or=0.35), severe aortic stenosis (aortic-valve area, <or=1 cm2), and a depressed cardiac index (<or=2.2 liters per minute per square meter). Patients were excluded if they had hypotension, defined as either the need for intravenous inotropic or pressor agents or a low mean systemic arterial pressure (<60 mm Hg). Patients were enrolled irrespective of other, coexisting valve disease or coronary artery disease.

RESULTS

At base line, the mean (+/-SD) ejection fraction was 0.21+/-0.08; the aortic-valve area was 0.6+/-0.2 cm2, with peak and mean gradients of 65+/-37 and 39+/-23 mm Hg, respectively; and the cardiac index was 1.60+/-0.35 liters per minute per square meter. After six hours of therapy with nitroprusside (at which time the dose had been increased to a mean of 103+/-67 microg per minute), the cardiac index had increased to 2.22+/-0.44 liters per minute per square meter (P<0.001 for the comparison with base line). After 24 hours of nitroprusside infusion (dose, 128+/-96 microg per minute), the cardiac index had increased further, to 2.52+/-0.55 liters per minute per square meter (P<0.001 for the comparison with base line). Nitroprusside was well tolerated and had minimal side effects.

CONCLUSIONS

Nitroprusside rapidly and markedly improves cardiac function in patients with decompensated heart failure due to severe left ventricular systolic dysfunction and severe aortic stenosis. It provides a safe and effective bridge to aortic-valve replacement or oral vasodilator therapy in these critically ill patients.

Prophylactic aortic valve replacement in older patients for mild aortic stenosis during coronary bypass surgery

Coronary bypass surgery (CBS) is performed in many older patients who frequently also have mild calcific aortic stenosis. It is important that a correct assessment of the severity of aortic stenosis is done by calculating the aortic valve area. Mild aortic stenosis is aortic valve area >1.5 cm(2), >0.9 cm(2)/m(2); severe aortic stenosis is aortic valve area < or =1.0 cm(2), < or =0.6 cm(2)/m(2). Patients who have severe aortic stenosis should have aortic valve replacement (AVR) at the time of CBS. Patients with mild aortic stenosis should not have AVR simultaneously with CBS because: 1) patients having AVR+CBS have a higher operative and 10-year mortality; 2) prosthetic heart valves are associated with a complication rate of 2%-6% per year; and 3) only about 12% of patients with mild aortic stenosis will have developed severe aortic stenosis in 10 years. Performing AVR for mild aortic stenosis at the time of CBS will probably result in 91 unnecessary AVRs and 29 excess deaths in 10 years.

Is there any indication for aortic valvuloplasty in the elderly?

Elderly patients with severe symptomatic calcific aortic stenosis do poorly with medical management. The optimal treatment for this group of patients is surgical valve replacement. Balloon valvuloplasty may be useful as a bridge to aortic valve replacement in hemodynamically unstable patients, in patients undergoing emergent noncardiac surgery, and in patients with severe comorbidities who are too ill to undergo cardiac surgery. Balloon valvuloplasty often results in symptomatic improvement; however, the postvalvuloplasty valve area is usually <1.0 cm2, the major periprocedural complication rate is roughly 5%, and the 6-month restenosis rate is quite high. There is no evidence that balloon valvuloplasty alters the natural history of aortic stenosis, although no randomized study has been performed.

Diagnostic methods. Current best practices and guidelines for isolation of bacteria and fungi in infective endocarditis

As the etiological character of IE changes, the microbiological tools used to confirm the diagnosis have also evolved. Here the authors have reviewed the current methods for optimal laboratory diagnosis of bacterial and fungal endocarditis using traditional growth-based technologies and offered good practice guidelines and recommendations. Newer techniques will be required to improve sensitivity of detection for known organisms and to identify emerging or as-yet unknown pathogens (see article by Lepidi et al in this issue).

Increased plasma natriuretic peptide levels reflect symptom onset in aortic stenosis

BACKGROUND

The onset of symptoms is a critical point in the natural history of aortic stenosis and the cardinal indication for valve replacement. This study assessed the associations between natriuretic peptide levels, disease severity, and cardiac symptoms in aortic stenosis.

METHODS AND RESULTS

Seventy-four patients with isolated aortic stenosis underwent independent assessment of symptoms, transthoracic echocardiography, and measurement of plasma levels of atrial natriuretic peptide, brain natriuretic peptide (BNP), and N-BNP. Natriuretic peptide levels were also measured in 100 clinically normal control subjects. The aortic valve area was smaller in symptomatic patients (n=45) than in asymptomatic patients (n=29; mean, 0.71+/-0.23 cm2 and 0.99+/-0.31 cm2, respectively; P<0.0001). Plasma natriuretic peptide levels were higher in symptomatic patients than in asymptomatic patients (for N-BNP: median, 112 versus 33 pmol/L; interquartile range, 70 to 193 versus 16 to 58 pmol/L, respectively; P=0.0002). After adjustment for age, sex, serum creatinine, aortic valve area, and left ventricular ejection fraction, N-BNP levels were 1.74 times higher (95% confidence interval, 1.12 to 2.69) for symptomatic than asymptomatic patients with aortic stenosis (P=0.014). Natriuretic peptide levels increased with the New York Heart Association class (for N-BNP median values were 13, 34, 105, and 202 pmol/L for normal control subjects, class I, class II, and class III/IV patients, respectively; interquartile ranges for the same patients were 8 to 21, 16 to 58, 57 to 159, and 87 to 394 pmol/L; P<0.0001). Similar associations were observed for BNP and atrial natriuretic peptide.

CONCLUSIONS

Plasma natriuretic peptide levels are elevated in symptomatic patients with aortic stenosis. Measurement of natriuretic peptides may complement clinical and echocardiographic evaluation of patients with aortic stenosis.

The safety and efficacy of repeated courses of tissue-type plasminogen activator in patients with stuck mitral valves who did not fully respond to the initial thrombolytic course

In carefully selected patients with stuck mitral valves, thrombolytic therapy is becoming an established therapeutic modality. However, the management of patient with a suboptimal response to an initial thrombolytic course is unclear. The objective was to evaluate the efficacy and safety of re-administration of tissue-type plasminogen activator (rt-PA) in patients with stuck mitral valves in whom the first thrombolytic course has failed to restore normal prosthetic valve function. The study group included patients who received rt-PA and did achieve a full restoration of valve function after the initial course. Data were gathered on the safety and success rates of additional thrombolytic courses in the same hospitalization period, and their predictors. Twelve patients with stuck mitral valves experienced a total of 13 episodes in which a full resolution of leaflet abnormality was not achieved after the initial thrombolytic course. A repeated thrombolytic course was attempted in 10 patients (11 episodes). Six patients (60%) showed full success rate with repeated thrombolysis, one (10%) showed partial success, and three patients (30%) had no improvement following the second course. These last three were those with initial failure. Age, gender, valve model, worst functional class, time since valve implantation and International Normalized Ratio (INR) levels were similar in both groups. No major adverse events were noted. In this small group of patients with stuck mitral valves, re-administration of rt-PA after a partial response to an initial thrombolytic course was effective and safe. However, total failure of the first thrombolytic course predicted inefficiency of further courses.

Does the myocardial performance index affect pulmonary artery pressure in patients with mitral stenosis? A tissue Doppler imaging study

BACKGROUND

The relation between systolic pulmonary artery pressure (PAP) and mitral stenosis (MS) has been poorly understood. Although the mitral valve area (MVA) is an important factor affecting the PAP, there is a wide spectrum of the PAP in patients with MS despite a similar MVA. So, we analyzed whether the left and right ventricular myocardial performance index (MPI) correlated with the PAP.

METHODS

Two-dimensional Doppler echocardiography was performed in 46 patients with MS. The left atrial diameter, mean mitral gradient, and MVA were measured. The PAP was derived from the tricuspid regurgitant jet velocity. The ejection time (ET), isovolumetric relaxation time (IRT), and contraction time (ICT) were measured on annulus of interventricular septum, lateral, inferior and anterior wall of left ventricle, and right ventricle free wall from apical two- and four-chamber views in patients with MS and 40 age-matched healthy patients by tissue Doppler imaging (TDI). Then the MPI was calculated as (IRT + ICT)/ET for both left and right ventricle. The correlation of PAP with MVA, mean mitral gradient, left atrial diameter, and left and right ventricular MPI was evaluated.

RESULTS

MVA and PAP were measured as 1.57 +/- 0.39 cm2 (0.8-2.5 cm2)and 42 +/- 16 mmHg, respectively. It was determined that the MPI increased in patients with MS(0.59 +/- 0.1 vs 0.48 +/- 0.07, P < 0.001). It was also demonstrated that the MVA, left atrial diameter, mean diastolic gradient, and left ventricular MPI were correlated with PAP(r =-0.39 [P = 0.007], r = 0.43 [P = 0.003], r = 0.58 [P < 0.001], and r = 0.65 [P < 0.001], respectively). In multivariate analysis, although the PAP correlated with mean diastolic gradient and MPI (r = 0.39 [P = 0.013], and r = 0.48 [P < 0.001]), it did not correlate with left atrial diameter and MVA. The PAP also correlated with right ventricular MPI(r = 0.63 [P < 0.001]).

CONCLUSION

This study demonstrates that the left ventricular MPI obtained by TDI is an important marker of PAP, and right ventricular MPI correlates with the PAP in patients with MS.

Choice of prosthetic heart valve for adult patients

This review summarizes the major long-term (> or =10 to 15 years) patient outcomes after insertion of many Food and Drug Administration approved prosthetic heart valves (PHV). Mechanical PHV was associated with a better survival (p < 0.02) at 15 years after aortic valve replacement (AVR) than with a bioprosthesis in the Department of Veterans Affairs (DVA) trial. In both the DVA and the Edinburgh Heart Valve trials, bioprosthesis were associated with structural valve deterioration (SVD) (mitral valve replacement [MVR] > AVR) and, therefore, for replacement of the PHV. Thromboembolism and bleeding rate were higher with mechanical PHV. Mortality after AVR and MVR is high at 10 to 15 years because of the associated comorbid conditions and older age of patients. Outcomes with "new" good valves are similar to that with "older" good valves. Complication rates of thromboembolism, bleeding, endocarditis, and leak vary widely; the rates of these complications are not different among different mechanical PHV and among different bioprosthetic PHV. Structural valve deterioration is rare with mechanical PHV. Structural valve deterioration of bioprosthesis after MVR is higher than after AVR; after AVR, homografts and bioprosthesis have similar rates of SVD. The exact rate of SVD of the pulmonary autograft is uncertain. Valve prosthesis-patient mismatch is clinically important when it is severe and in selected patients when it is moderate. Bioprosthesis have a low rate of SVD in the older patient and, thus, are the PHV of choice for AVR in patients > or =60 to 65 years of age and for MVR in patients > or =65 to 70 years of age; in younger patients mechanical valves are the PHV of choice. In individual patients there may be exceptions to these general rules.

Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure

The goal of this study was to examine the frequency of mitral regurgitation (MR) in patients with left ventricular (LV) systolic dysfunction and to relate its presence and severity to long-term survival. Remodeling of the left ventricle after myocyte injury leads to a progressive change in LV size and shape, and it may lead to the development of MR. The frequency of MR and its relation to survival in patients with LV systolic dysfunction has not been completely characterized. We analyzed the histories, coronary anatomy, and degree of MR in patients with symptomatic heart failure and LV ejection fraction <40% who underwent cardiac catheterization between 1986 and 2000. Cox's proportional hazards modeling was used to assess the independent effect of MR on survival. Two thousand fifty-seven patients met study criteria; MR was common in this cohort (56.2%). Of patients with MR, 811 (70.1%) had mild (grades 1+ or 2+) and 345 (29.8%) had moderate or severe (grades 3+ or 4+) regurgitation. Survival rates at 1, 3, and 5 years were significantly lower in patients with moderate to severe MR versus those with mild or no MR (p <0.001). MR was found to be an independent predictor of mortality after multivariable analysis (hazards ratio 1.23, 95% confidence interval 1.13 to 1.34, p = 0.0001). This relation of MR and survival was present in those with ischemic and nonischemic cardiomyopathies. MR is common in patients with LV systolic dysfunction and heart failure. After adjusting for other clinical variables, the presence of MR independently predicted worsened survival.

Embolic risk in subacute bacterial endocarditis: determinants and role of transesophageal echocardiography

Embolic events are a frequent and life-threatening complication of subacute bacterial endocarditis (SBE), and are associated with a high mortality and morbidity. The prediction of the embolic risk in an individual patient remains a challenge. Echocardiography plays a key role in the management of infective endocarditis both for the diagnostic and prognostic assessment of these patients, but its value in predicting embolic events is still debated. This review focuses on the characteristics of embolic events in SBE, and on the role of echocardiography, especially transesophageal echocardiography (TEE), in the prediction of embolic events. The review confirms that, among other factors, TEE may be helpful in both the prediction of the embolic risk, and the decision to perform early surgery.

Left ventricular remodeling, mechanics, and tissue characterization in congenital aortic stenosis

BACKGROUND

As the response of the myocardium to pressure overload is age-dependent, this study was designed to examine left ventricular (LV) remodeling, mechanics, and tissue characterization in children with moderate congenital aortic stenosis.

METHODS

We studied by echocardiography Doppler 22 patients (mean age 12.4 +/- 5.6 years) with peak and mean transvalvular gradient of 63 +/- 6 and 32 +/- 4 mm Hg, respectively. In addition, 30 age- and body surface area-matched participants with structurally normal hearts were used as a control group. Sex- and age-specific cut-off levels for LV mass/height(2.7) and relative wall thickness were defined to assess LV geometry. As a load-independent index of myocardial contractility, the relation between the rate-corrected velocity of circumferential fiber shortening both at endocardium and midwall, and meridional end-systolic stress was assessed. In addition, LV diastolic function was also evaluated by the mitral flow indexes. Finally, ultrasonic tissue characterization of the LV myocardium was performed by calculating the magnitude of cyclic variation, which reflects the intramural contractile function, and the averaged myocardial intensity of integrated backscatter, which is directly related to the myocardium collagen content.

RESULTS

The endocardial velocity of circumferential fiber shortening endocardium and meridional end-systolic stress relationship was within the normal range (mean +/- 2SD) in 18 of 22 patients (81.8%), and midwall velocity of circumferential fiber shortening at endocardium and meridional end-systolic stress was normal in all 22 patients. No mitral flow index of LV diastolic function was significantly different between aortic stenosis group and normal participants. In our study population, 16 of 22 patients (72.7%) showed normal LV geometry, 3 (13.6%) had a pattern of concentric remodeling, and 3 (13.6%) concentric hypertrophy. LV hypertrophy was not marked (left ventricular mass index [LVMI] < 51 g/m(2.7)) in any patient. Finally, compared with control participants our study population showed, both at interventricular septum and posterior wall, comparable values of cyclic variation integrated backscatter, but significantly higher values of averaged myocardial integrated backscatter intensity (P <.01).

CONCLUSIONS

In children with moderate congenital aortic stenosis, the total amount of myocardial collagen was increased despite normal LV myocardial contractility and diastolic function. Furthermore, LV remodeling was abnormal in only about a quarter of our patients and none had more than mild hypertrophy. Although the majority of these patients do not have markers now recognized to predict higher risk of cardiovascular events, the long-term significance of myocardial fibrosis and its response to treatment remain to be investigated.

Resultados perinatológicos del servicio de Cardiopatía y Embarazo del Hospital Ginecobstétrico "Ramón González Coro" en el bienio 2000-2001, Habana

OBJETIVOS: establecer las bases para el tratamiento y atención de la mujer portadora de cardiopatía en edad fértil, caracterizando al grupo de gestantes atendidas en servicio. MÉTODOS: realizó un estudio descriptivo y las mujeres fueran clasificadas según cardiopatía y grado de afectación funcional en relación con los resultados, se decribiendo las complicaciones durante el embarazo, parto y puerperio y los resultados perinatales. Variables analizadas: tipo de cardiopatía y clasificación funcional de las mismas, complicaciones obstétricas y/o cardiovasculares, edad gestacional al parto, modo de nacimiento, peso y puntaje de Apgar en el recién nacido y mortalidad materna y del recién nacido. RESULTADOS: encontramos 129 valvulopatías adquiridas, 79 congénitas, 18 casos de trastornos del ritmo. Lesiones más frecuentes valvulopatías mitrales (92) y comunicaciones interauriculares (31). 21 pacientes presentaron empeoramiento funcional durante el embarazo. Aparecieron complicaciones cardiovasculares en 19 pacientes y obstétricas en 142. 14 requirieron ingreso en Servicios de Terapia Intensiva y tres fallecieron. CONCLUSIONES: Se confirmó la asociación entre clasificación funcional y complicaciones cardiovasculares durante el embarazo, parto y puerperio. Las complicaciones obstétricas se comportan igual que en las gestaciones de pacientes sanas y más de la mitad de los partos fueron eutócicos.

Calcific aortic stenosis: new pathophysiologic insights and possible new medical therapy

Aortic stenosis is a progressive disease of aging with serious complications. A common disease of the elderly, it may inexorably progress to stenosis. Recent retrospective studies have correlated risk factors commonly associated with coronary and vascular atherosclerosis with an accelerated rate of aortic valve stenosis. Although hydroxymethyl glutaryl co-enzyme A reductase inhibitor (statin) treatment therapy has been shown to delay the rate of progression of valvular aortic stenosis, the salutary mechanism of the statin may be cholesterol-lowering and/or anti-inflammatory. Further prospective studies are warranted to investigate the mechanism and medical therapy of aortic sclerosis and stenosis.

Discrepancies between catheter and Doppler estimates of valve effective orifice area can be predicted from the pressure recovery phenomenon: practical implications with regard to quantification of aortic stenosis severity

OBJECTIVES

We sought to obtain more coherent evaluations of aortic stenosis severity.

BACKGROUND

The valve effective orifice area (EOA) is routinely used to assess aortic stenosis severity. However, there are often discrepancies between measurements of EOA by Doppler echocardiography (EOA(Dop)) and those by a catheter (EOA(cath)). We hypothesized that these discrepancies might be due to the influence of pressure recovery.

METHODS

The relationship between EOA(cath) and EOA(Dop) was studied as follows: 1) in an in vitro model measuring the effects of different flow rates and aortic diameters on two fixed stenoses and seven bioprostheses; 2) in an animal model of supravalvular aortic stenosis (14 pigs); and 3) based on catheterization data from 37 patients studied by Schöbel et al.

RESULTS

Pooling of in vitro, animal, and patient data showed a good correlation (r = 0.97) between EOA(cath) (range 0.3 to 2.3 cm(2)) and EOA(Dop) (range 0.2 to 1.7 cm(2)), but EOA(cath) systematically overestimated EOA(Dop) (24 +/- 17% [mean +/- SD]). However, when the energy loss coefficient (ELCo) was calculated from EOA(Dop) and aortic cross-sectional area (A(A)) to account for pressure recovery, a similar correlation (r = 0.97) with EOA(cath) was observed, but the previously noted overestimation was no longer present.

CONCLUSIONS

Discrepancies between EOA(cath) and EOA(Dop) are largely due to the pressure recovery phenomenon and can be reconciled by calculating ELCo from the echocardiogram. Thus, ELCo and EOA(cath) are equivalent indexes representing the net energy loss due to stenosis and probably are the most appropriate for quantifying aortic stenosis severity.

Evaluación de la severidad y decisiones quirúrgicas en las valvulopatías

A better knowledge of the natural history of valvular disease and the advances in surgical techniques are allowing to improve the prognosis of patients with valvular heart disease. At present, imaging techniques, particularly Doppler-echocardiography, is the main tool to determine the diagnosis and prognosis of patients with valvular heart disease. Consequently, decision making in valvular heart disease is now days based on a combination of symptomatic status and echocardiographic findings. The main applications of Doppler-echocardiography with this purpose are summarized in this article. Therapeutic algorithms for patients with valvular heart disease are proposed, as well as the potential application of new imaging modalities appeared in the last years. The state of the art of clinical practice guidelines are also reviewed.