Early Surgery In Patients Research Articles

Bridging therapy for early surgery in patients on dual antiplatelet therapy after drug-eluting stent implantation

To evaluate stent-related adverse cardiac events and bleeding complications within 30days after surgical procedures in patients with recent drug-eluting stent (DES) implantation, in whom a bridging protocol was used. In our centre a bridging protocol is used in patients scheduled for cardiac or non-cardiac surgery within 6months after PCI with DES implantation. Clopidogrel and in some cases also acetylsalicylic acid is discontinued 5days prior to the planned intervention and patients are admitted 2 to 3days before the intervention for tirofiban infusion. This is discontinued 4h before intervention. Close postoperative monitoring is performed and double antiplatelet therapy is restarted as soon as possible. Thirty-six consecutive patients were included in the protocol, 15 receiving coronary artery bypass graft and 21 non-cardiac interventions. Thrombotic and bleeding complications were studied for up to 30days after the bridged procedure. No incidences of stent thrombosis or other adverse cardiac events (mortality, myocardial infarction) were seen in up to 30days of follow-up. However, 6 bleeding events were reported of which 5 required a blood transfusion. Our bridging protocol in patients requiring surgery after recent PCI with DES seems adequate to prevent stent thrombosis in this high-risk group. The bleeding risk is not insignificant but in our patient group controllable without major late sequelae. Larger studies should be performed to establish safety and efficacy in order to develop guidelines for these patients.

Evaluation of the Modified Albee Arthroplasty for Femoral Head Loss Secondary to Septic Arthritis in Young Children

Surgical treatment options for femoral head deficiency in infants secondary to septic arthritis of the hip are varied and associated with uncertain long-term outcomes. The modified Albee arthroplasty has been considered an acceptable procedure; however, the long-term outcomes of this procedure have not been reported, to our knowledge. We evaluated the long-term outcomes of the modified Albee arthroplasty in young patients with severe sequelae of septic arthritis of the hip. We retrospectively studied twenty-one children (twenty-one hips) in whom Choi type-IVB sequelae of septic arthritis of the hip had been treated with a modified Albee arthroplasty and six patients with the same sequelae who had been managed with simple observation. The Trendelenburg sign, pain, the range of motion, hip function, the Harris hip score, and limb-length discrepancy were assessed clinically. Remodeling of the femoral head, hip stability, and arthritic changes in the hip were evaluated radiographically. The twenty-one patients with the modified Albee arthroplasty were followed for an average of 121.2 ± 38.6 months and had better outcomes, in terms of the Trendelenburg sign, the Harris hip score, pain, the hip range of motion, and limb-length discrepancy, than the six patients who underwent simple observation. Patients who were two years of age or younger at the time of the arthroplasty exhibited a significantly less severe limb-length discrepancy and less loss of motion than those who were older than two at the time of the surgery. Furthermore, limb-length discrepancy was positively correlated and the range of motion of the hip and the Harris hip scores were negatively correlated with the patient's age at the time of the surgery, suggesting that early surgery in patients with severe sequelae of septic arthritis of the hip is associated with a better clinical outcome. The modified Albee arthroplasty is a feasible and clinically useful procedure for the treatment of severe sequelae of septic arthritis of the hip, particularly in children who are two years of age or younger.

Short-Term Antifibrinolytic Therapy Before Early Aneurysm Treatment in Subarachnoid Hemorrhage: Effects on Rehemorrhage, Cerebral Ischemia, and Hydrocephalus

Long-term administration of the antifibrinolytic agent epsilon aminocaproic acid (EACA) reduces the rate of rehemorrhage in patients with aneurysmal subarachnoid hemorrhage (SAH), but is associated with cerebral ischemia. To evaluate short-term administration of EACA before early surgery in patients with SAH. Retrospective review of 356 patients admitted between June 2002 and December 2007 with a diagnosis of aneurysmal SAH. Medical records were reviewed to determine SAH risk factors, clinical grade at the time of admission, and incidence of rehemorrhage, permanent new-onset focal neurological deficits, computed tomography evidence of cerebral infarction, symptomatic vasospasm, and hydrocephalus. Patients underwent treatment of the ruptured aneurysm an average of 47.4 hours after admission and received an average total dose of 40.6 g of EACA. The mean length of time of administration of EACA was 35.6 hours. There was a total of 5 rehemorrhages, for an overall rebleeding rate of 1.4% and a rate of rehemorrhage per 24-hour period of 0.71%. Overall, the rates of symptomatic vasospasm and permanent neurological deficits attributable to ischemic stroke were 11.5% and 7.2%, respectively, and the incidence of shunt-dependent hydrocephalus was 42.3%. Patients who were treated with coiling had higher rates of symptomatic vasospasm and ischemic complications than patients who had surgery. Short-term administration of EACA is associated with rates of rehemorrhage, ischemic stroke, and symptomatic vasospasm that compare favorably with historical controls. The rate of hydrocephalus is relatively high and may be attributable to EACA treatment.

Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis

Guidelines exist for the surgical treatment of hip fracture, but the effect of early surgery on mortality and other outcomes that are important for patients remains unclear. We conducted a systematic review and meta-analysis to determine the effect of early surgery on the risk of death and common postoperative complications among elderly patients with hip fracture. We searched electronic databases (including MEDLINE and EMBASE), the archives of meetings of orthopedic associations and the bibliographies of relevant articles and questioned experts to identify prospective studies, published in any language, that evaluated the effects of early surgery in patients undergoing procedures for hip fracture. Two reviewers independently assessed methodologic quality and extracted relevant data. We pooled data by means of the DerSimonian and Laird random-effects model, which is based on the inverse variance method. We identified 1939 citations, of which 16 observational studies met our inclusion criteria. These studies had a total of 13 478 patients for whom mortality data were complete (1764 total deaths). Based on the five studies that reported adjusted risk of death (4208 patients, 721 deaths), irrespective of the cut-off for delay (24, 48 or 72 hours), earlier surgery (i.e., within the cut-off time) was associated with a significant reduction in mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68-0.96, p = 0.01). Unadjusted data indicated that earlier surgery also reduced in-hospital pneumonia (RR 0.59, 95% CI 0.37-0.93, p = 0.02) and pressure sores (RR 0.48, 95% CI 0.34-0.69, p < 0.001). Earlier surgery was associated with a lower risk of death and lower rates of postoperative pneumonia and pressure sores among elderly patients with hip fracture. These results suggest that reducing delays may reduce mortality and complications.

Evaluation of the Modified Albee Arthroplasty for Femoral Head Loss Secondary to Septic Arthritis in Young Children

Surgical treatment options for femoral head deficiency in infants secondary to septic arthritis of the hip are varied and associated with uncertain long-term outcomes. The modified Albee arthroplasty has been considered an acceptable procedure; however, the long-term outcomes of this procedure have not been reported, to our knowledge. We evaluated the long-term outcomes of the modified Albee arthroplasty in young patients with severe sequelae of septic arthritis of the hip. We retrospectively studied twenty-one children (twenty-one hips) in whom Choi type-IVB sequelae of septic arthritis of the hip had been treated with a modified Albee arthroplasty and six patients with the same sequelae who had been managed with simple observation. The Trendelenburg sign, pain, the range of motion, hip function, the Harris hip score, and limb-length discrepancy were assessed clinically. Remodeling of the femoral head, hip stability, and arthritic changes in the hip were evaluated radiographically. The twenty-one patients with the modified Albee arthroplasty were followed for an average of 121.2 +/- 38.6 months and had better outcomes, in terms of the Trendelenburg sign, the Harris hip score, pain, the hip range of motion, and limb-length discrepancy, than the six patients who underwent simple observation. Patients who were two years of age or younger at the time of the arthroplasty exhibited a significantly less severe limb-length discrepancy and less loss of motion than those who were older than two at the time of the surgery. Furthermore, limb-length discrepancy was positively correlated and the range of motion of the hip and the Harris hip scores were negatively correlated with the patient's age at the time of the surgery, suggesting that early surgery in patients with severe sequelae of septic arthritis of the hip is associated with a better clinical outcome. The modified Albee arthroplasty is a feasible and clinically useful procedure for the treatment of severe sequelae of septic arthritis of the hip, particularly in children who are two years of age or younger.

Early Surgery Versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis

The optimal timing of surgical intervention remains controversial in asymptomatic patients with very severe aortic stenosis. We therefore compared the long-term results of early surgery and a conventional treatment strategy. From 1996 to 2006, we prospectively included a total of 197 consecutive asymptomatic patients (99 men; age, 63+/-12 years) with very severe aortic stenosis. Patients were excluded if they had angina, syncope, exertional dyspnea, ejection fraction <0.50, significant mitral valve disease, or age >85 years. Very severe aortic stenosis was defined as a critical stenosis in the aortic valve area < or =0.75 cm(2) accompanied by a peak aortic jet velocity > or =4.5 m/s or a mean transaortic pressure gradient > or =50 mm Hg on Doppler echocardiography. The primary end point was defined as the composite of operative mortality and cardiac death during follow-up. Early surgery was performed on 102 patients, and a conventional treatment strategy was used for 95 patients. There were no significant differences between the 2 groups in terms of age, gender, European System for Cardiac Operative Risk Evaluation score, or ejection fraction. During a median follow-up of 1501 days, the operated group had no operative mortalities, no cardiac deaths, and 3 noncardiac deaths; the conventional treatment group had 18 cardiac and 10 noncardiac deaths. The estimated actuarial 6-year cardiac and all-cause mortality rates were 0% and 2+/-1% in the operated group and 24+/-5% and 32+/-6% in the conventional treatment group, respectively (P<0.001), and for 57 propensity score-matched pairs, the risk of all-cause mortality was significantly lower in the operated group than in the conventional treatment group (hazard ratio, 0.135; 95% confidence interval, 0.030 to 0.597; P=0.008). Compared with the conventional treatment strategy, early surgery in patients with very severe aortic stenosis is associated with an improved long-term survival by decreasing cardiac mortality. Early surgery is therefore a therapeutic option to further improve clinical outcomes in asymptomatic patients with very severe aortic stenosis and low operative risk.

Early Surgery Is Recommended for Mitral Regurgitation

Mitral regurgitation (MR), the systolic flow reversal from the left ventricle to the left atrium, is currently the most frequent valvular heart disease.1 Because MR affects predominantly patients ≥65 years of age,1 with age at surgery most often in the sixth decade,2 the observed prevalence will increase with the aging of the population. Thus, the number of US citizens affected by moderate or severe MR will almost double between 2000 and 2030, reaching almost 5 million by then.1 MR mechanism is classified as organic (intrinsic valve lesions) or functional (structurally normal mitral valve with MR caused by ventricular dysfunction).3 Indications of mitral surgery, the only current approved treatment of MR, are disputed because large clinical trials in MR have not been reported and outcome studies provide the best evidence available but require careful interpretation. The benefit of surgery is uncertain in functional MR and is not addressed here.4 However, we illustrate here that overwhelmingly coherent cumulative evidence obtained worldwide shows that early surgery should be the preferred management approach for organic MR. This approach differs from standard guidelines, and it is essential that its principles, rationales, and conduct be fully considered. Response by Gillam and Schwartz see p 804 Guidelines for the management of valve diseases mention class I versus class II indications as having agreed-on versus conflicting evidence/opinions.5 This classification is problematic for MR treatment because class I indications, based mostly on symptoms and overt left ventricular (LV) dysfunction, lead to the performance of rescue surgery (surgery for patients at considerable risk if unoperated) but do not result in optimal long-term outcomes for patients with organic MR.6,7 The concept of uniform surgical recommendations that supposedly apply equally to all centers is also problematic; recent studies have shown that the quality of …

Endoscopic placement of double-J ureteric stents in children as a treatment for primary obstructive megaureter

Aim:To determine the efficacy and potential complications of double-J ureteric stents in the treatment of persistent or progressive primary obstructive megaureter in pediatric patients within our institution.Materials and Methods:A retrospective case-note review of all patients with double-J ureteric stents, between 1997 and 2004, was performed. In all, 38 stents were inserted in 31 patients aged between 2 months and 15 years of age. Complications and results of follow-up investigations and the need for follow-up investigations were recorded. Patients were followed up clinically and radiologically for a minimum of 2 years following stent insertion.Results:Endoscopic placement of double-J ureteric stents in childhood is straightforward and complications are uncommon (8/38 insertions). In non-resolving or progressive primary non-refluxing megaureter, double-J ureteric stenting alone is effective with resolution of primary non-refluxing megaureter in 66% of cases (25/38 insertions).Conclusions:Ureteric stenting provides an alternative to early surgery in patients with primary non-refluxing megaureter. The youngest patient in our series was 2 months old at the time of endoscopic ureteric double-J stent insertion. Endoscopic placement of ureteric double-J stents should be considered as a first-line treatment in the management of persistent or progressive non-refluxing megaureter leading to progressive hydronephrosis or pyonephrosis.

Asymptomatic Severe Mitral Valve Regurgitation

Management of patients with mitral valve regurgitation (MR) has changed dramatically over the past 20 years; this change is largely attributable to 3 factors. First, there have been significant improvements in operative techniques that have led to predictable and durable results after valve repair. In current practice at our clinic, >95% of patients with pure MR caused by degenerative diseases have valve repair rather than prosthetic replacement, and with modern, simplified methods of leaflet repair and annuloplasty, the risk of reoperation after correction of MR is no greater than that after mitral valve replacement.1 Article p 797 The second major shift in mitral valve disease is the change in pathology and pathophysiology of MR. In current practice, almost 80% of patients having mitral valve operations have pure regurgitation rather than valve stenosis or mixed regurgitation and stenosis, and the cause is most often degenerative or myxomatous disease; there is a declining frequency of postinflammatory disease in North America and many other areas of the world. The third important change in the management of patients with mitral valve disease is the better understanding of the natural history of MR, which has been made possible by both detailed natural history studies and improved techniques of 2-dimensional and Doppler echocardiography.2–4 The article by Kang et al5 in this issue of Circulation provides important new and confirmatory information on the outcome of asymptomatic patients with severe MR. Before the 1990s, most clinicians viewed MR as a relatively benign condition, and surgery was reserved for patients who were severely symptomatic or failed medical management.6,7 Reluctance to proceed with operation was related to the likelihood of prosthetic valve replacement and to the notion that asymptomatic patients with severe MR were a …

The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures

BackgroundWhether reducing time-to-surgery for elderly patients suffering from hip fracture results in better outcomes remains subject to controversial debates.MethodsAs part of a prospective observational study conducted between January 2002 and September 2003 on hip-fracture patients from 268 acute-care hospitals all over Germany, we investigated the relationship of time-to-surgery with frequency of post-operative complications and one-year mortality in elderly patients (age ≥65) with isolated proximal femoral fracture (femoral neck fracture or pertrochanteric femoral fracture). Patients with short (≤12 h), medium (> 12 h to ≤36 h) and long (> 36 h) times-to-surgery, counting from the time of the fracture event, were compared for patient characteristics, operative procedures, post-operative complications and one-year mortality.ResultsHospital data were available for 2916 hip-fracture patients (mean age (SD) in years: 82.1 (7.4), median age: 82; 79.7% women). Comparison of groups with short (n = 802), medium (n = 1191) and long (n = 923) time-to-surgery revealed statistically significant differences in a few patient characteristics (age, American Society of Anesthesiologists ratings classification and type of admission) and in operative procedures (total hip endoprosthesis, hemi-endoprosthetic implants, other osteosynthetic procedures). However, comparison of these same groups for frequency of postoperative complications revealed only some non-significant associations with certain complications such as post-operative bleeding requiring treatment (early surgery patients) and urinary tract infections (delayed surgery patients). Both unadjusted rates of one-year all-cause mortality (between 18.1% and 20.5%), and the multivariate-adjusted hazard ratios (HR for time-to-surgery: 1.04; p = 0.55) showed no association between mortality and time-to-surgery.ConclusionAlthough this study found a trend toward more frequent post-operative complications in the longest time-to-surgery group, there was no effect of time-to-surgery on mortality. Shorter time-to-surgery may be associated with somewhat lower rates of post-operative complications such as decubitus ulcers, urinary tract infections, thromboses, pneumonia and cardiovascular events, and with somewhat higher rates of others such as post-operative bleeding or implant complications.

Early surgery was better than conservative care for short-term disability and pain in sciatica

ED FROM Peul WC, van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results...

Journal Scan: Journal of Pediatric Orthopaedics

Here is my view of the top-10 most potentially influential papers from the Journal of Pediatric Orthopaedics from 2007. Included are the papers that were thought to provide the most useful examinations of treatments and outcomes.

Management of intracerebral hemorrhage

Following quickly behind improvements in acute ischemic stroke care have been important advances in the understanding and management of intracerebral hemorrhage (ICH). Among these are accurate diagnosis of cerebral amyloid angiopathy (CAA) during life, recognition of the association between CAA and warfarin-related ICH, use of newer hemostatic treatments, and the combination of minimally invasive surgery with hematoma thrombolysis. Currently recommended management includes prompt evaluation of the patient at a facility with stroke and neurosurgical expertise, consideration of early surgery for patients with clinical deterioration or cerebellar hemorrhages larger than 3 cm, and early treatment of coagulopathies and other neurologic and medical complications. Over the past 2 years, two major randomized studies in ICH (comparing early surgery with best medical management and testing the utility of hemostatic treatment within 4 hours using recombinant factor VIIa) have yielded neutral results. This review focuses on comprehensive management of ICH in light of recent evidence.

Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial

Objectives To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up.Design Randomised controlled trial.Setting Nine Dutch hospitals.Participants...

Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial

Objective To determine whether the faster recovery after early surgery for sciatica compared with prolonged conservative care is attained at reasonable costs.Design Cost utility analysis alongside a randomised controlled trial.Setting...

Glaucoma following congenital cataract surgery – the role of early surgery and posterior capsulotomy

BackgroundTo determine the rate of glaucoma following congenital cataract surgery at Moorfields Eye Hospital (MEH), and to investigate potential risk factors for glaucoma in our case series.MethodsA retrospective case notes review was undertaken of all congenital cataract lensectomies performed at MEH between 1994 and 2000. The following parameters were ascertained: age at surgery, unilateral or bilateral cataract, whether a posterior capsulotomy (PC) was performed at the time of surgery, whether an intraocular lens (IOL) was inserted, duration of follow-up, and if aphakic glaucoma (AG) developed. All lensectomies were performed through a limbal incision by a single consultant surgeon.ResultsA total of 47 subjects were identified – 40 patients with bilateral cataracts and 7 with unilateral. Of the 40 bilateral cataract patients, 76 eyes had lensectomies; with 37 of these patients (71 lensectomies) having at least 5 year follow-up. Based on patient count, the 5 year risk of AG in at least one eye following surgery was 21.6%. Based on eye count, the 5 year risk of AG after lensectomy was 15.5%. The average age at surgery of patients who did not develop AG, and had at least 5 years follow-up, was 28.7 months (range 2 weeks to 6 years), with 20% having surgery within the first month of life. In comparison, the average age at surgery of patients with at least 5 years follow-up, who developed AG was 1.6 months (range 2 weeks to 7 months), with 60% having surgery within the first month of life. In subjects with at least 5 years follow-up, a PC rate of 100% was identified in the eyes that developed AG, compared to 61% in eyes that did not develop AG. An IOL was inserted in O% of eyes with AG, compared to 57% in eyes that did not develop AG. Onset of AG ranged from one month post surgery to 7 years, with an average yearly incidence of 5.3%.ConclusionEarly surgery in patients with bilateral cataracts is associated with a marked increase in risk of AG. Our data suggest that an intact posterior capsule may be associated with a lower rate of AG.

Echocardiographic risk stratification for early surgery with endocarditis: a cost-effectiveness analysis

Background: Despite widespread acceptance of echocardiography for diagnosis of infective endocarditis, few investigators have evaluated its utility as a risk-stratification tool to aid therapeutic decision-making. Methods: A decision tree and...

Early surgical treatment of middle cerebral artery aneurysms associated with intracerebral haematoma

Objective Patients with haematoma secondary to middle cerebral artery aneurysm often require urgent surgical treatment consisting of evacuation of the haematoma and aneurysmal clipping. Methods . We present our experience over 5 years with 12 patients who underwent surgery before the first 8 h of bleeding. Surgery included craniotomy, evacuation of the haematoma, and aneurysmal clipping. Preoperative angiography was performed in all cases. Results All patients had a score of 4 or 5 on the scale of the World Federation of Neurological Surgeons. Five of the patients were evolving well after 1 year. Clinical status upon admission, temporal lobe versus sylvian location of the haematoma, right-hemisphere involvement, and a midline deviation of less than 2 cm, were all most frequently associated with a good prognosis. Conclusions In our experience, and in the literature available to us, early surgery in patients with haematoma secondary to middle cerebral artery aneurysm offers acceptable results in patients with World Federation of Neurological Surgeons scores of 4 or 5.

Early Surgery in Patients with Infective Endocarditis: A Propensity Score Analysis

An accurate assessment of the predictors of long-term mortality in patients with infective endocarditis is not possible using retrospective data because of inherent treatment biases and predictable imbalances in the distribution of prognostic factors. Largely because of these limitations, the role of surgery in long-term survival has not been adequately studied. Data were collected prospectively from 426 patients with infective endocarditis. Variables associated with surgery in patients who did not have intracardiac devices who had left-side-associated valvular infections were determined using multivariable analysis. Propensity scores were then assigned to each patient based on the likelihood of undergoing surgery. Using individual propensity scores, 51 patients who received medical and surgical treatment were matched with 51 patients who received medical treatment only. The following factors were statistically associated with surgical therapy: age, transfer from an outside hospital, evidence of infective endocarditis on physical examination, the presence of infection with staphylococci, congestive heart failure, intracardiac abscess, and undergoing hemodialysis without a chronic catheter. After adjusting for surgical selection bias by propensity score matching, regression analysis of the matched cohorts revealed that surgery was associated with decreased mortality (hazard ratio, 0.27; 95% confidence interval, 0.13-0.55). A history of diabetes mellitus (hazard ratio, 4.81; 95% confidence interval, 2.41-9.62), the presence of chronic intravenous catheters at the beginning of the episode (hazard ratio, 2.65; 95% confidence interval, 1.31-5.33), and paravalvular complications (hazard ratio, 2.16; 95% confidence interval, 1.06-4.44) were independently associated with increased mortality. Differences between clinical characteristics of patients with infective endocarditis who receive medical therapy versus patients who receive surgical and medical therapy are paramount. After controlling for inherent treatment selection bias and imbalances in prognostic factors using propensity score methodology, risk factors associated with increased long-term mortality included diabetes mellitus, the presence of a chronic catheter at the onset of infection, and paravalvular complications. In contrast, surgical therapy was associated with a significant long-term survival benefit.

977 Quantitative assessment of myocardial contractile reserve during exercise in patients with mitral valve prolapse

Background: Although the actual trends is toward early surgery in patients with asymptomatic severe organic mitral regurgitation (MR), some of them might already have latent left ventricular (LV) dysfunction. This study sought to examine whether tissue Doppler imaging measurement of longitudinal function could be used to identify contractile reserve (CR) during exercise in NYHA I-II patients with MR due to mitral valve prolapse. Methods: Forty-seven patients underwent quantitative off-line assessment of longitudinal function by averaging peak mitral annular velocities (PSv) obtained at rest and during semi-supine exercise test. Results: During test, CR defined by 34% improvement in ejection fraction was present in 25 patients. As compared to patients with CR, the degree of MR at rest (effective regurgitant orifice (ERO): 43±18 vs 24±14 mm2, p=0.0048) and at peak exercise (ERO 46±22 vs 23±19 mm2, p=0.0049) was greater in the absence of CR whereas ejection fraction was similar (69±6 vs 66±6%, p=ns). The increase in PSv (11±1.9 vs 8±2.5 cm/s, p=0.00029) and changes in LV end-systolic volume (-14±7 vs 4.4±12 ml p=0.0029) during exercise were higher in the CR group. In multivariate analysis, exercise-induced changes in LV end-systolic volume and in PSv independently predicted the presence of CR. An increase in PSv by 32 cm/s yielded a sensitivity of 88% and a specificity of 82% to identify positive CR. Conclusions: Latent LV dysfunction in patients with mitral valve prolapse could be reliably identified using tissue Doppler imaging.