Aortic Valvular Regurgitation Research Articles

Heart valve operation in acromegaly

Intractable congestive heart failure is known as a serious complication of acromegaly, but valvular heart disease rarely occurs in acromegalic patients. We experienced 5 surgical cases of valvular heart disease associated with acromegaly. We describe the features of those cases in this report. The patient characteristics and operative and pathologic findings were retrospectively studied. There were 4 men and 1 women. Age at operation was 59 +/- 5.5 years. Cardiac lesions consisted of 1 case of aortic regurgitation associated with mitral regurgitation, 1 of aortic regurgitation, and 3 of mitral regurgitation. Operative procedures consisted of 1 double valve replacement (aortic and mitral valve replacement), 1 aortic valve replacement, and 3 mitral valve replacements. The causes of aortic valvular regurgitation were aortic valvular degeneration and aortic annular dilatation. The causes of mitral regurgitation were chordal rupture and mitral valvular degeneration. Histopathologic examination of the excised valves showed mucopolysaccharide deposits and myxomatous degeneration of the leaflets. The myocardium showed fibrosis of interstitial spaces and endocardium, and disarrangement of muscle fibers. We report 5 successful surgical cases of valvular heart disease associated with acromegaly. Earlier operation is recommended for such cases because of acromegalic cardiomyopathy.

Quantitative Stress Echocardiography in Chronic Aortic and Mitral Regurgitation.

It was the purpose of the present study to prove the feasibility and reliability of quantitative stress-echocardiography as an alternative method to radionuclide angiography (RNA) in chronic regurgitant valvular lesions. Echocardiography and RNA are most commonly used to obtain various left ventricular (LV) morphometric and functional parameters that have been postulated to predict long-term prognosis in patients with aortic and mitral valvular regurgitation. Supine bicycle ergometry with a workload ranging from 25-250 Watts was used to evaluate stress dependent LV volumes and ejection fractions (EFs) in patients with pure aortic (n = 18) and mitral regurgitation (n = 14). Most patients (23/32) underwent simultaneous right heart catheterization. Echocardiographic EFs were validated by RNA with good correlations (r = 0.81, P < 0.01). Patients with aortic regurgitation and functional class I/II (9), had a significant increase in EF during exercise (60%-67%, P < 0.001) and a reduction in end-systolic volume (71-52 mL, P < 0.01). In comparison, patients with class III symptoms (9), had a drop in EF (53%-49%, P < 0.01), had larger baseline end-systolic volume (104 mL, P = NS), which did not decrease during stress (104 vs 107 mL, P = NS). In patients with chronic mitral regurgitation baseline and exercise EF did not differ between class I/II (6) and class III (8), however, mildly symptomatic patients increased from 57%-67%, (P < 0.01) versus patients in class III (65% vs 69%, P = NS). Stroke volume index was not different at baseline (44 vs 33 mL/m(2), P = NS); however, there were significant differences during exercise (70 vs 41 mL/m(2), P = 0.05). Quantitative stress-echocardiography is a noninvasive and safe alternative method to RNA, which allows reliable calculation of stress dependent LV volumes and EF. Determination of end-systolic volumes may be of additional prognostic value. The combination of a high baseline EF and low stroke volume index with the inability to improve during exercise might reflect early stages of impaired LV function in patients with severe mitral regurgitation.

Prognosis of patients with heart failure and unoperated severe aortic valvular regurgitation and relation to ejection fraction

Massell et al1 reported that 13 of 14 patients (93%) with unoperated severe chronic aortic regurgitation (AR) died within 2 years after the onset of congestive heart failure (CHF). We reported that left ventricular (LV) ejection fraction was the most important prognostic variable for mortality in elderly patients with CHF associated with coronary artery disease2 or unoperated severe valvular aortic stenosis.3 We report the results from a prospective study of elderly patients with CHF associated with unoperated severe valvular AR correlating normal and abnormal LV ejection fraction with cardiac mortality and total mortality.

Extended aortic valvuloplasty for recurrent valvular stenosis and regurgitation in children

Recurrent significant aortic valvular stenosis or regurgitation, or both, after balloon or open valvotomy in pediatric patients often necessitates aortic valve replacement. In an attempt to preserve the aortic valve, we performed extended aortic valvuloplasty in 21 children with recurrent aortic valve stenosis or regurgitation from January 1989 to March 1993. Previous related procedures were one open aortic valvotomy or more (n = 15), balloon valvotomy (n = 4), balloon valvotomy after surgical valvotomy (n = 1), and repair of iatrogenic valve tear (n = 1). Mean age at the time of the extended aortic valvuloplasty was 6 +/- 3.4 years. Mean pressure gradient across the aortic valve was 56 +/- 12 torr. Regurgitation was moderate (grade 2 to 3) in nine and severe (grade 4) in 12 patients. Extended aortic valvuloplasty techniques consisted of thinning of valve leaflets (n = 15), augmentation of scarred and retracted leaflets with autologous pericardium (n = 11), resuspension of the augmented leaflet (n = 14), release of the rudimentary commissure from the aortic wall (n = 5), extension of the valvotomy incision into the aortic wall on both sides of the commissure (n = 20), patch repair of the sinus of Valsalva perforation (n = 1), reapproximation of tears (n = 5), and narrowing of the ventriculoaortic junction (n = 2). No operative deaths occurred. The postoperative mean pressure gradient, assessed by most recent Doppler echocardiography or cardiac catheterization at a follow-up of 18 +/- 6 months, was 19 +/- 6 torr (p < 0.01 versus the preoperative gradient). Aortic regurgitation was absent in 13, mild in 6, and moderate-to-severe, necessitating subsequent aortic valve replacement, in 2. This short-term experience indicates that extended aortic valvuloplasty is a safe and effective surgical approach that minimizes the need for aortic valve replacement in children with significant recurrent aortic valve stenosis or regurgitation.

Communicating versus Noncommunicating Acute Thoracic Aortic Dissection: Two Case Reports and Diagnostic Value of Transesophageal Echocardiography and Alternative Imaging Modalities

Two patients, with communicating and noncommunicating Stanford type A acute aortic dissection each, are reported with anatomic and hemodynamic features diagnosed by single-plane transesophageal echocardiography (TEE) with color flow imaging. TEE demonstrated a communicating dissection, more in detail than aortography and computed tomography, with an intimai flap, the extent of dissection, the dissecting intimai flap prolapse through the aortic valve during diastole, flow patterns in the true and false lumina, presence and absence of aortic valvular regurgitation, and absence of pericardial effusion. TEE showed the presence of a noncommunicating (variant) dissection, which was nondiagnostic by magnetic resonance imaging and aortography before surgery, with intramural thrombus (hematoma) formation and its extent and location, accurate measurement of aortic wall thickness, and the presence of an intimai flap or intramural blood flow. In addition, TEE also permitted evaluation of global and regional systolic performance. Therefore, TEE can be recommended as the first-line modality of choice for an early diagnosis of an acute thoracic aortic dissection.

Noninvasive detection of acute rejection in a new experimental model of heart transplantation

We have shown that positron emission scintigraphy detects changes in the uptake of 18-F 2-deoxyglucose and 13-N ammonia by the acutely rejecting myocardium in a nonworking model of heterotopic heart transplantation in the rat. We developed a new working model of heterotopic heart transplantation to determine the possible relevance of these changes to clinical transplantation. Moderate aortic valvular regurgitation was produced allowing the heterotopic left ventricle to fill and eject. Rejecting allografts and nonrejecting isografts (controls) were studied 4 days after transplantation. Histologically, isografts were normal and all allografts showed mild acute rejection. Decay-corrected uptakes of 18-F 2-deoxyglucose and 13-N ammonia reflect glucose metabolism and blood flow, respectively. Values are presented as percent of injected dose per gram of tissue. Uptake of 18-F 2-deoxyglucose was higher in rejecting allografts compared with nonrejecting isografts (3.0 ± 1.8 versus 1.1 ± 0.4; P = 0.024). Ammonia uptake was elevated in allografts compared with isografts (2.2 ± 0.5 versus 1.3 ± 0.5; P = 0.023). Uptakes of 18-F 2-deoxyglucose and 13-N ammonia are higher in mildly rejecting allografts, implying increased glucose utilization and blood flow during acute rejection. These data support our earlier findings of changes in myocardial metabolism in the absence of diminishing blood flow in acutely rejecting hearts. This model may lead to a better understanding of the physiology and metabolism of acute rejection.

Single-plane transesophageal echocardiography for assessing function of mechanical or bioprosthetic valves in the aortic valve position

To assess the value and limitations of single-plane transesophageal echocardiography in the evaluation of prosthetic aortic valve function, 89 patients (69 mechanical and 20 bioprosthetic aortic valves) were studied by combined transthoracic and transesophageal 2-dimensional and color flow Doppler echocardiography. In the assessment of aortic regurgitation, the transthoracic and transe sophageal echocardiographic findings were concordant in 71 of 89 patients (80%). In 8 patients, the degree of aortic regurgitation was underestimated by the transthoracic approach; in each case the quality of the transthoracic echocardiogram was poor. In 10 patients, transesophageal echocardiography failed to detect trivial aortic regurgitation due to acoustic shadowing of the left ventricular outflow tract from a mechanical valve in the mitral valve position. Transesophageal echocardiography was superior to transthoracic echocardiography in diagnosing perivalvular abscess, subaortic perforation, valvular dehiscence, torn or thickened bioprosthetic aortic valve cusps, and in clearly distinguishing perivalvular from valvular aortic regurgitation. Transesophageal echocardiography correctly diagnosed bioprosthetic valve obstruction in 1 patient, but failed to diagnose mechanical valve obstruction in another. In conclusion, transesophageal echocardiography offers no advantage over the transthoracic approach in the detection and quantification of prosthetic aortic regurgitation unless the transthoracic image quality is poor. Transesophageal echocardiography is limited in detecting mechanical valve obstruction and in detecting aortic regurgitation in the presence of a mechanical prosthesis in the mitral valve position. However, it is superior to transthoracic echocardiography in identifying perivalvular pathology, differentiating perivalvular from valvular regurgitation and in defining the anatomic abnormality responsible for the prosthetic valve dysfunction. Combined transthoracic and transesophageal examination provides complete anatomic and hemodynamic assessment of prosthetic aortic valve function.

Unruptured Noncoronary Sinus of Valsalva Aneurysm: Preoperative Characterization by Transesophageal Echocardiography

We describe a patient with a large unruptured sinus of Valsalva aneurysm that was discovered incidentally. Transesophageal echocardiography was used to characterize the aneurysm preoperatively, and was helpful intraoperatively in assessment of the degree of native aortic valvular regurgitation after repair. The use of transthoracic echocardiography, contrast echocardiography, Doppler echocardiography, and transesophageal echocardiography are discussed in this condition.

Doppler echocardiographic findings of mitral and aortic valvular regurgitation in children manifesting only rheumatic arthritis

Several recent reports 1,2 have indicated that Doppler echocardiography, by providing an ultrasensitive modality for studying alterations of blood flow patterns within the heart and great vessels, is capable of unmasking mitral and aortic insufficiency in the absence of murmurs in both the acute and quiescent phases of rheumatic fever. To further investigate this possibility, we evaluated a series of children admitted consecutively for acute rheumatic fever and concentrated our investigation on those presenting only with arthritis.

Abnormalities of dynamic ventricular shape change in patients with aortic and mitral valvular regurgitation: assessment by Fourier shape analysis and global geometric indexes.

The normal cardiac cycle is associated with dynamic changes in left ventricular shape, which can be disturbed in disease states. To assess the influences of diastolic volume, percent ejected volume, and abnormalities of acute or chronic systolic loading on general and detailed chamber geometry, we studied dynamic shape change recorded by x-ray contrast ventriculography in both normal patients and those with aortic (AR) or mitral (MR) valve regurgitation. While both lesions increased diastolic volume, the character of load throughout ejection differed markedly. Detailed cavity geometry was assessed by a Fourier analysis technique and general shape by eccentricity and circularity indexes. Normal hearts, showed increased systolic elongation by all indexes. AR patients displayed a similar rise in eccentricity during ejection; however, the extent of shape change when measured by Fourier and circular indexes was reduced. In contrast, MR patients displayed enhanced systolic shape change, particularly in chamber elongation. Neither simple eccentricity of circular indexes adequately differentiated these shape abnormalities, whereas detailed Fourier geometric analysis precisely characterized the abnormalities of shape change in these two diseases. Relations between the extent of shape change and ejected volume for each patient group revealed significantly more systolic deformation with a different shape versus volume relation for the MR hearts as compared with AR and controls. Thus, while dynamic left ventricular shape is certainly influenced by the extent of volume change, it also varies independently from volume related to the specific nature of loading during ejection.

Detection of diastolic atrioventricular valvular regurgitation by pulsed Doppler echocardiography and its association with complete heart block

The cineangiographic and hemodynamic presence of diastolic mitral regurgitation has been described in patients with complete heart block, aortic valvular regurgitation, hypertrophic cardiomyopathy, and in patients with long diastolic filling periods in atrial fibrillation. 1–3 However, because of its relatively low velocity, diastolic mitral regurgitation may be difficult to diagnose noninvasively. Pulsed Doppler echocardiography provides noninvasive evaluation of blood flow through cardiac valves and has been shown to be sensitive in the detection of valvular regurgitation. 4,5 We studied 8 consecutive, nonselected patients with complete heart block over a 6-month period, and all had Doppler evidence of diastolic mitral or tricuspid regurgitation.

Femoral pseudoaneurysm following nonpenetrating trauma in a patient with aortic insufficiency

Although not uncommon after penetrating vascular trauma, arterial pseudoaneurysms rarely develop following blunt trauma. A patient is described in whom indirect trauma led to pseudoaneurysm of the profunda femoris artery, and persistent bleeding required surgical intervention. In this case, the coexistence of significant aortic valvular regurgitation suggests that wide pulse pressure may predispose to this arterial complication.

Idiopathic degeneration of the aortic valve: A common cause of isolated aortic regurgitation

To establish the etiology of isolated aortic valvular regurgitation, histologic examination was carried out on 27 consecutive surgically removed aortic valves from patients with aortic regurgitation. In 12 patients, the regurgitation was due to rheumatic or syphilitic valvular disease or a congenital bicuspid aortic valve. In the remaining 15, no etiology was apparent. In the latter group, seven aortic valves were identified by the surgeon as redundant and eight as thickened and retracted. Despite these gross differences, the histologic features of the 15 valves were similar and consisted of increased and disorganized elastic and collagen fibers, with variable quantities of acid mucopolysaccharide and calcium. Although small foci of myxomatous stroma were present, they did not differ substantially from those observed in age-matched competent aortic valves removed at necropsy, nor were they as extensive as described in reports of floppy aortic valves. Idiopathic degeneration was the most common cause of aortic regurgitation, occurring in more than half of the surgically treated patients. An underlying defect in the synthesis of collagen or elastic fibers, similar to that described in mitral valve prolapse, may be an important feature in aortic valve degeneration.

The development of real-time two-dimensional Doppler echocardiography and its clinical significance in acquired valvular diseases. With special reference to the evaluation of valvular regurgitation.

A noninvasive method for real time blood-flow imaging using ultrasound has long been required in the fields of cardiology and cardiovascular surgery. Recently, we developed a method of two-dimensional Doppler echocardiography (hereafter abbreviated as "2-D Doppler") for clinical use which allows us to obtain noninvasively, intracardiac blood-flow images in real time. The main purpose of this paper is to describe the newly developed blood-flow imaging system "2-D Doppler" and to demonstrate its clinical usefulness in acquired valvular diseases, particularly in the evaluation of valvular regurgitation. The device, in principle, combines a conventional pulsed-Doppler system and a newly developed auto-correlator, in which blood-flow images within a given cross section of a beating heart are noninvasively displayed in real time, simultaneously with conventional two-dimensional echocardiograms. The system can provide three kinds of information, direction, velocity and turbulence of blood flow. The 2-D Doppler examinations were carried out on 72 patients with acquired valvular diseases whose diagnoses were confirmed by angiography and/or surgery. Studies were performed comparing the findings of the 2-D Doppler and those of angiography (for aortic and mitral lesions) or with operative findings (for tricuspid lesions) in the quantitative evaluation of valvular regurgitation. Aortic, mitral and tricuspid valvular regurgitation have been quantitatively demonstrated with 2-D Doppler, and, for each value, the severity of the regurgitation showed a high correlation between the findings of 2-D Doppler and of angiography or surgery. In conclusion, we have found that (1) 2-D Doppler is very useful in detecting and estimating the severity of valvular regurgitation, and that (2) 2-D Doppler may replace conventional angiography in some situations.

Mid-Systolic Sound Associated with Aortic Insufficiency and Bisferiens Pulse

Systolic ejection clicks, often associated with cardiac disease, can be distinguished from mid-systolic clicks of mitral and tricuspid origin, which are frequently benign. A different mid-systolic sound has been recognized, with timing similar to the mid-systolic clicks, which is associated with aortic insufficiency. This report describes a case in which such a sound was identified prior to aortic valve replacement, and disappeared with surgery, thus adding evidence to previous concepts of the origin of this sound, and its relationship to the hemodynamic abnormality associated with aortic valvular regurgitation.

Noninvasive quantitation of valvular regurgitation by gated equilibrium radionuclide angiography.

R-wave synchronous equilbrium radionuclide angiography (RNA) is a noninvasive method that provides time-activity curve count information proportional to ventricular volumes and is used for relative volume comparisons within the left or right ventricle to derive the ejection fraction. Comparison of the ventricular count output between both ventricles may permit quantitation of the relative amount of valvular regurgitation, i.e., the regurgitant fraction. We performed resting gated RNA in 30 consecutive patients undergoing cardiac catheterization and quantitative contrast ventriculography for aortic or mitral valvular regurgitation. RNA regurgitant fraction correlated well with cardiac catheterization regurgitant fraction (r = 0.85). In 11 patients imaged before and 1-4 months after successful valve replacement, the regurgitant fraction declined from 0.68 +/- 0.11 to -0.09 +/- 0.13 (p < 0.001). In 20 control patients without valvular regurgitation, the calculated regurgitant fraction did not exceed 0.20. We conclude that valvular regurgitation may be accurately detected, quantitative and followed serially after therapeutic intervention using gated RNA.

Quantification of aortic valvular regurgitation in dogs by nuclear imaging.

Radionuclide gated cardiac blood pool (GBP) imaging was used to quantitatively assess the severity of acute aortic valvular regurgitation produced experimentally in 10 anesthetized dogs. Right ventricular (RV) and left ventricular (LV) stroke counts (end-diastolic minus end-systolic counts in RV and LV regions of interest) were used as indices of the stroke volumes of the two ventricles. Regurgitant fraction (RFGBP) was derived by assuming that an excess of LV stroke counts compared to RV stroke counts was due to regurgitant flow: RFGBP = LV stroke counts - RV stroke counts/LV stroke counts X 100. Regurgitant fraction (RFEMF) was also estimated directly from an electromagnetic flowmeter (EMF) on the ascending aorta. Mean RFEMF was 55.8 +/- 17.9% (+/-SD). Close agreement was found between regurgitant fractions measured by GBP and EMF (RFGBP = 1.09, RFEMF - 4.7%, r = 0.88, p less than 0.001, SEE = 9.98%). The severity of regurgitation from blood pool images also correlated closely with aortic pulse pressure (r = 0.89) and the length of the tear in the aortic valve (r = 0.84). These results suggest that blood pool imaging may be sueful for noninvasive quantification of regurgitant flow in patients with valvular insufficiency.

Takayasu's Arteritis With Surgically Corrected Severe Aortic Valvular Regurgitation

Takayasu's Arteritis With Surgically Corrected Severe Aortic Valvular Regurgitation

Intermittent Severe Mitral Regurgitation

The findings in two patients with hemodynamic evidence of intermittent severe mitral regurgitation with cyclic variation in right and left ventricular pressures are presented. Both patients had aortic and mitral valvular regurgitation of unknown etiology without definite evidence of papillary muscle dysfunction. The basis for the variation in the degree of mitral regurgitation is unclear.

Radiographic evaluation of dynamic geometry of the left ventricle.

ArticleRadiographic evaluation of dynamic geometry of the left ventricle.A A BoveA A BovePublished Online:01 Aug 1971https://doi.org/10.1152/jappl.1971.31.2.227MoreSectionsPDF (2 MB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations ShareShare onFacebookTwitterLinkedInWeChat Previous Back to Top Next Download PDF FiguresReferencesRelatedInformation Cited ByMeasurements of changes in left ventricular volume, strain, and twist during isovolumic relaxation using MRIJune Cheng-Baron, Kelvin Chow, Nee Scze Khoo, Ben T. Esch, Jessica M. Scott, Mark J. Haykowsky, John V. Tyberg, and Richard B. Thompson1 June 2010 | American Journal of Physiology-Heart and Circulatory Physiology, Vol. 298, No. 6Intracardiac measurement of pre-ejection myocardial velocities estimates the transmural extent of viable myocardium early after reperfusion in acute myocardial infarctionJournal of the American College of Cardiology, Vol. 38, No. 6Pre-ejectional left ventricular wall motions studied on conscious dogs using Doppler myocardial imaging: relationships with indices of left ventricular functionUltrasound in Medicine & Biology, Vol. 24, No. 9Epicardial surface dynamics in the closed-chest normal canineJournal of Biomechanics, Vol. 28, No. 11Left ventricular volume determined echocardiographically by assuming a constant left ventricular epicardial long-axis/ short-axis dimension ratio throughout the cardiac cycleJournal of the American College of Cardiology, Vol. 20, No. 4Mechanical Heart-Lung Interaction in the Adult Respiratory Distress SyndromeClinics in Chest Medicine, Vol. 11, No. 4Cardiovascular FunctionEffects of Mechanical Ventilation on Right and Left Ventricular FunctionClinics in Chest Medicine, Vol. 9, No. 1Abnormalities of dynamic ventricular shape change in patients with aortic and mitral valvular regurgitation: assessment by Fourier shape analysis and global geometric indexes.Circulation Research, Vol. 62, No. 1Quantitative regional curvature analysis: An application of shape determination for the assessment of segmental left ventricular function in manAmerican Heart Journal, Vol. 113, No. 2The changes in regional myocardial surface area during coronary occlusion and reperfusionBasic Research in Cardiology, Vol. 82, No. 1Quantitation of regional myocardial function by cine computed tomography: Pharmacologic changes in wall thicknessJournal of the American College of Cardiology, Vol. 8, No. 3Computer recognition of radiopaque myocardial markersComputers and Biomedical Research, Vol. 17, No. 6Use of left ventricular filling and ejection patterns in assessing severity of chronic mitral and aortic regurgitationThe American Journal of Cardiology, Vol. 53, No. 8Left ventricular wall motion: Its dynamic transmural characteristicsJournal of Surgical Research, Vol. 36, No. 1Use of ventriculography in assessing performance and oxygen consumption of the left ventricle: Response to altered afterloadCatheterization and Cardiovascular Diagnosis, Vol. 8, No. 6Left ventricular geometry during partial and complete coronary occlusion in the conscious dogInternational Journal of Cardiology, Vol. 1, No. 5-6The deformational characteristics of the left ventricle in the conscious dog.Circulation Research, Vol. 49, No. 4Ventricular performance, pump function and compensatory mechanisms in patients with aortic stenosis.Circulation, Vol. 62, No. 3Computer analysis of left ventricular dynamic geometry in manThe American Journal of Cardiology, Vol. 41, No. 7The three-dimensional dynamic geometry of the left ventricle in the conscious dog.Circulation Research, Vol. 39, No. 3Echographic determination of left ventricular volumes in pediatric patients.Circulation, Vol. 51, No. 2Changes in left ventricular wall dimensions during regional myocardial ischemiaThe American Journal of Cardiology, Vol. 34, No. 1Late Systolic Bulging of Left Ventricle in Patients with Angina PectorisChest, Vol. 65, No. 2Brief Reviews : Determination of Left Ventricular Size and ShapeCirculation Research, Vol. 34, No. 1A Comparative Study of Various Single-Plane Cineangiocardiographic Methods to Measure Left-Ventricular VolumeIEEE Transactions on Biomedical Engineering, Vol. BME-20, No. 6Left Ventricular Wall Motion During the Isovolumic Relaxation PeriodCirculation, Vol. 48, No. 3Changes in myocardial wall thickness (MWT) in open chest dogsPflügers Archiv, Vol. 340, No. 1 More from this issue > Volume 31Issue 2August 1971Pages 227-34 https://doi.org/10.1152/jappl.1971.31.2.227PubMed5558245History Published online 1 August 1971 Published in print 1 August 1971 Metrics