Incidence Of Mitral Regurgitation Research Articles

Overview of the catheter-based methods for treatment of mitralregurgitation

Mitral regurgitation or mitral insuffi ciency is the second most common valve pathology requiring a surgical treatment worldwide. It is characterized by an abnormal return of blood from the left ventricle to the left atrium during the systole. The incidence of mitral regurgitation increases in line with the rise in the life expectancy and the overall aging of the world population. According to the pathoanatomy and the mechanism of development, there are two main types of mitral regurgitation: a primary (degenerative) regurgitation and secondary (functional) regurgitation. In the fi rst type, there is organic damage to the valve and/or the valve apparatus, and in the second type, there is a secondary dysfunction of the mitral valve due to damage to the structure and/or the function of the left ventricle. The treatment of choice for the management of the mitral regurgitation is a surgical intervention. In recent years new high-tech transcatheter methods of treatment have been introduced in clinical practice. The most popular and proven method of treatment in patients who could not undergo classic cardiac surgery is the MitraClip edge-to-edge transcatheter approximation system. Other endovascular methods of treatment are percutaneous plasty device Pascal (Edwards Lifesciences) and Cardioband using transseptal approach, and also NeoChord and Harpoon using transapical approach.

Long-term prognosis of non-st-segment elevation acute myocardial infarction with ischemic mitral regurgitation: Algerian cohort

Ischemic mitral regurgitation (MR) is a common complication of acute myocardial infarction and has a negative impact on prognosis. However, few studies have been carried out on MR after non-ST-segment elevation acute myocardial infarction (NSTEMI). Our objective was to investigate the incidence, clinical predictors, and long-term prognostic implications of MR in patients with NSTEMI. The prospective study included 237 consecutive patients who were discharged in functional class I or II after a first NSTEMI. Each underwent echocardiography during the first week of admission, and patients were followed up clinically for a median of 1011 days. The incidence of readmission for heart failure, unstable angina, reinfarction, death, or all combined (ie, the combined event or major adverse cardiac event [MACE]) was recorded. The patients’ mean age was 66 (13) years and 74% were male. The incidence of MR was 40% (grade I in 71 patients, grade II in 15, grade III in 6, and grade IV in 3). Age, diabetes mellitus, multivessel disease and MR (HR = 2.17; 95% confidence interval, 1.30–3.64; P = 0.003) were all independently associated with a poor long-term prognosis, in terms of MACEs. Even the milder grades of MR were associated with more events. In our milieu, MR frequently occurs after NSTEMI. Its presence together with other unfavorable factors implies a poor long-term prognosis. This is also true for milder grades of MR. Consequently, MR should be fully assessed and followed-up after NSTEMI in all patients.

Ischaemic mitral regurgitation: incidence, clinical and angiographic characteristics of 1000 patients with type 1 myocardial infarction undergoing percutaneous coronary intervention

Abstract Background Previous studies of the incidence and severity of mitral regurgitation (MR) following acute myocardial infarction (MI) were limited by the study population (ST-elevation MI only), by diagnostic methods (lack of multiparametric quantification), or by the time-frame of study (late assessment post-MI). The true incidence of ischaemic MR (IMR) immediately following type 1 MI [non-ST-elevation (NSTEMI) and ST-elevation (STEMI)] patients in the modern era of universal early revascularisation remains unclear. Since even mild IMR confers a poor prognosis, factors which promote or protect against the development of MR require further evaluation. Purpose To determine the incidence, clinical and angiographic characteristics of patients with IMR following type 1 MI treated with PCI. Methods This was a single-centre study of 1000 consecutive, prospectively recruited patients admitted to the Queen Elizabeth Hospital Birmingham with type 1 MI who underwent PCI. Early inpatient transthoracic echocardiography (TTE) was performed by accredited echocardiographers using standard multiparametric quantification. Results MR was observed in 294/1000 patients (29.4%) post-MI, graded as mild (76%), moderate (21%) and severe (3%). Median time from symptom onset to PCI was 1 day (IQR 0–4) and to TTE 2 days (IQR 1–3). Compared to patients without MR (MR-), those with MR (MR+) were older (73±12 years vs 66±13 years; p<0.001), male (75% vs 64%; p<0.001) and more likely to have a history of hypertension (HTN) (63% vs 55%; p=0.0117), heart failure (HF) (3.4% vs 1.1%; p=0.0140) and previous MI (28% vs 20%; p<0.005). MR+ patients more frequently presented with HF (8.5% vs 4.2%; p=0.0075), lower LV ejection fraction (LVEF) (50±14% vs 55±11%; p<0.001) and higher peak high sensitivity troponin T (765ng/L, IQR 170–3032 vs 400ng/L, IQR 51–1966; p<0.0001). MR+ patients were more likely to have severe disease in the left circumflex (LCx) (50% vs 33%; p<0.0001) or right coronary artery (RCA) (51% vs 43%; p=0.0135). Incidence of severe disease in the left main stem and left anterior descending artery (LAD) did not significantly differ between the two groups. Incidence of MR was equal (29%) amongst STEMI (126/431) and NSTEMI (168/569) patients. While the time to revascularisation did not affect the prevalence of MR following STEMI (linear regression analysis of door-to-balloon time in MR+ and MR- patients p=0.843), NSTEMI patients were more likely to develop MR if revascularisation was delayed (linear regression analysis of symptom onset to PCI time MR+ vs MR- p=0.061). Conclusion Almost 1/3 of patients with type 1 MI undergoing revascularisation have MR evident on pre-discharge TTE. Factors promoting MR include older age, male sex, HTN, HF, larger non-LAD territory infarct, and depressed LVEF. The incidence of MR following STEMIs and NSTEMIs is equal. Earlier revascularisation is unlikely to reduce MR in STEMI patients but may improve MR prevalence following NSTEMI. Funding Acknowledgement Type of funding source: None

Signo “manchas de tigre” en síndrome coronario agudo

The incidence of mitral regurgitation in acute myocardial syndromes is variable. Echocardiographic evaluation is fundamental in making a proper diagnosis of mechanical complications and to offer timely treatment. We present a case of a 64-year-old male who was admitted to the ER in acute pulmonary edema. The electrocardiogram showed negative ST-segment deviation from V4-V6, positive ST-segment deviation in aVR. Multivessel disease with severe mitral regurgitation was seen in catheterization. A transthoracic echocardiogram revealed important mitral regurgitation showing the tiger stripes sign, seen in the presence of intracardial oscillating structures, in this case, suspected papillary muscle rupture. Echocardiographic evaluation is necessary in every case of myocardial infarction who present with new-onset mitral regurgitation. Treatment is complex and must be determined with an interdisciplinary group.

Percutaneous mitral commissurotomy versus surgical commissurotomy for rheumatic mitral stenosis: a systematic review and meta-analysis of randomised controlled trials

AimPatients with severe mitral stenosis (MS) and their clinicians typically choose percutaneous transvenous mitral commissurotomy (PTMC) over surgical commissurotomy (SC). However, the durability of PTMC relative to SC is uncertain....

Indirect Annuloplasty to Treat Functional Mitral Regurgitation: Current Results and Future Perspectives.

The incidence of mitral regurgitation (MR) is approximately 1.7% in the developed world, and this increases to more than 10% in patients aged over 75 years. Functional (or secondary) mitral regurgitation (FMR) is defined as poor leaflet coaptation and tethering secondary to either ischemic or non-ischemic left ventricular (LV) dysfunction and dilatation. FMR is more common than degenerative (or primary) MR and is associated with significantly worse outcomes in patients with heart failure, post myocardial infarction and following coronary artery bypass graft surgery. Patients with severe degenerative MR have excellent outcomes with surgical repair, however the benefits of surgery in FMR are less clear. Although annuloplasty is associated with a lower operative mortality compared to replacement, the recurrence rate of mitral regurgitation is high in patients with FMR and neither surgical repair or replacement have been shown to reduce hospitalisation or death in FMR. Furthermore, nearly half of patients are deemed too high risk for surgery and therefore most patients are managed conservatively and there remains an unmet clinical need. Transcatheter mitral valve interventions are an emerging alternative for those at high surgical risk. This mini review focuses on indirect mitral annuloplasty: anatomical considerations, patient selection, current devices, implantation techniques and the associated clinical outcome data.

Long-term prognosis of non-ST-segment elevation acute myocardial infarction with ischemic mitral regurgitation: Algerian cohort

Ischemic mitral regurgitation (MR) is a common complication of acute myocardial infarction and has a negative impact on prognosis. However, few studies have been carried out on MR after non-ST-segment elevation acute myocardial infarction (NSTEMI). Our objective was to investigate the incidence, clinical predictors, and long-term prognostic implications of MR in patients with NSTEMI. The prospective study included 237 consecutive patients who were discharged in functional class I or II after a first NSTEMI. Each underwent echocardiography during the first week of admission, and patients were followed up clinically for a median of 1011 days. The incidence of readmission for heart failure, unstable angina, reinfarction, death, or all combined (i.e., the combined event or major adverse cardiac event [MACE]) was recorded. The patients’ mean age was 66 (13) years and 74% were male. The incidence of MR was 40% (grade I in 71 patients, grade II in 15, grade III in 6, and grade IV in 3). Age, diabetes mellitus, multivessel disease and MR (HR = 2.17; 95% confidence interval, 1.30–3.64; P = 0.003) were all independently associated with a poor long-term prognosis, in terms of MACEs. Even the milder grades of MR were associated with more events. In our milieu, MR frequently occurs after NSTEMI. Its presence together with other unfavorable factors implies a poor long-term prognosis. This is also true for milder grades of MR. Consequently, MR should be fully assessed and followed-up after NSTEMI in all patients.

Evidence for time‐dependent and adaptive mechanisms in the mitral valve following prolonged Angiotensin II infusion

Activation of angiotensin II (AngII) signaling has been implicated in the pathogenesis of human myxomatous mitral valve prolapse (MVP). To determine whether chronic AngII infusion can elicit molecular and phenotypic manifestations of MVP, we implanted C57BL/6J mice with osmotic minipumps delivering AngII (1000ng/kg/min) or saline for 2 or 4 weeks. We probed changes in mRNA (qRT-PCR) and protein (immunohistochemistry) levels in mitral valves, and assessed valve function by echocardiography. In line with previous findings from human MVP, 2-week AngII infusion was associated with increased pro-fibrotic (e.g. TGFβ2 and CTGF) and “classical” pro-calcific (Wnt/β-catenin) gene expression in mouse mitral valves. Increased immunofluorescence of phospho-SMAD2 and nuclear β-catenin suggested canonical activation of these pathways. Increased gene expression of the transcription factor Runx2 (1.8 fold-change [FC]) and the proliferation marker KI67 (3.9 FC) were also recaptured by AngII. Surprisingly, we found that increases in Runx2 and KI67 mRNA were attenuated (both ~1.3FC) following 4 weeks of AngII, and transcriptional changes in TGFβ and Wnt/β-catenin pathway target genes were no longer evident. The incidence of mitral regurgitation after 2 weeks of AngII (38%) did not increase when mice were treated for 4 weeks (40%). Collectively, these data suggest that there may be adaptive molecular changes occurring following prolonged AngII treatment, which oppose fibrogenic and proliferative signaling pathways. Future studies aimed at identifying key protective and deleterious molecular changes following prolonged AngII infusion will be critical to understanding mechanisms contributing to evolution of MVP.

0132: Ischemic mitral regurgitation and non-ST-segment elevation acute myocardial infarction: long-term prognosis in Algerian cohorte

Ischemic mitral regurgitation (MR) is a common complication of acute myocardial infarction and has a negative impact on prognosis. However, few studies have been carried out on MR after non-ST-segment elevation acute myocardial infarction (NSTEMI). Our objective was to investigate the incidence, clinical predictors, and long-term prognostic implications of MR in patients with NSTEMI. The prospective study included 165 consecutive patients who were discharged in functional class I or II after a first NSTEMI. Each underwent echocardiography during the first week of admission, and patients were followed up clinically for a median of 2.3 years. The incidence of readmission for heart failure, unstable angina, reinfarction, death, or all combined (ie, the combined event or major adverse cardiac event [MACE]) was recorded. The patients’ mean age was 68 years and 69% were male. The incidence of MR was 40% (grade I in 45 patients, grade II in 11, grade III in 7, and grade IV in 3). Age, diabetes mellitus, multivessel disease and MR (HR=2.17; 95% confidence interval, 1.30–3.64; P=.003) were all independently associated with a poor long-term prognosis, in terms of MACEs. Even the milder grades of MR were associated with more events. In our milieu, MR frequently occurs after NSTEMI. Its presence together with other unfavorable factors implies a poor long-term prognosis. This is also true for milder grades of MR. Consequently, MR should be fully assessed and followed-up after NSTEMI in all patients.

Development of mitral and tricuspid regurgitation in right ventricular apex versus right ventricular outflow tract pacing

This study aimed at comparing the development of tricuspid and mitral regurgitation between the right ventricular outflow tract (RVOT) and right ventricular apex (RVA) pacing. We prospectively enrolled 164 patients for permanent pacemaker implantation due to sick sinus syndrome or atrioventricular block and randomly divided them into two equal groups to receive either RVOT or RVA pacing. Patients with heart failure or valvular disease were excluded. The post-procedural echocardiographic evaluations were performed 1year after the pre-procedural echocardiography, and the results were compared with respect to the development of mitral and tricuspid regurgitation and probable changes in the ejection fraction (EF). Age, gender, pacing mode, and baseline cardiac rhythm did not significantly differ between the RVOT and RVA pacing groups. The incidence of mitral regurgitation was significantly higher in the RVA group (p = 0.03), but the incidence of tricuspid regurgitation was similar in both groups. There was a trend toward less tricuspid regurgitation in the RVOT group; however, it was not statistically significant. The mean EF was not significantly different between the study groups. It seems that the incidence of mitral regurgitation in RVA pacing is significantly higher than that in RVOT pacing. The formation of tricuspid regurgitation needs to be discussed in the future. IRCT201103146061N1.

Immediate and ten years long term results of a new balloon mitral valvuloplasty technique

Background Percutaneous balloon mitral valvuloplasty (PBMV) is the standard non-surgical treatment of rheumatic mitral stenosis (MS). The success of PBMV depends on achieving higher mitral valve area (MVA) with commissural splitting. The direction of major force is an important determinant of PBMV outcome. Single balloon direct the major force toward the leaflet while double balloon technique direct the force toward the commissures. Objectives To test the hypothesis that stepwise dilation of mitral valve using single followed by double balloons (Bonhoeffer multi-track system) inflations would gradually apply bidirectional forces and hence yield better outcome. Methods Six hundred and twenty-four patients with symptomatic MS were prospectively randomized to either standard multi-track PBMV (group I: 381 pts had simultaneous inflation of two equal size balloons), or new modified technique (group II: 243 pts had stepwise dilation using single 20 mm balloon inflation followed by double balloon inflation, i.e., 20 + 16, 18, or 20 mm to body surface area). Results Both groups had comparable basic data: mean age (19.03 ± 6.44 vs. 18.62 ± 6.24 years), male/female ratio (70/311 vs. 32/211), echo score (6.18 ± 1.29 vs. 6.32 ± 1.38), MVA (0.82 ± 0.18 vs. 0.84 ± 0.12 cm 2 ), and trans-mitral gradient (26.94 ± 6.19 vs. 27.41 ± 7.13 mmHg). They had similar success rates (96.8% vs. 95.9%). Modified technique achieved significantly higher MVA (2.19 ± 0.34 vs. 1.87 ± 0.96 cm 2 , p = 0.0001) with more opened commissures (65% vs. 49.1%, p = 0.0001), and less mitral regurgitation (30/243 vs. 77/381, p = 0.011). In long term follow up, modified technique had significant lower restenosis rate (9.46% vs. 23.88%, p = 0.0001), redo surgery (2.88% vs. 7.34%, p = 0.029), and mitral valve area gain loss (0.09 ± 0.04 vs. 0.27 ± 0.06 cm 2 , p = 0.0001). Kaplan–Meier curve revealed no differences (hazard ratio = 1.04, 95% CI = 0.53 ± 2.01, p = 0.901) of total events (death, perforation, thrombo-embolism, atria-fibrillation, and large ASD). Conclusions This study demonstrates the benefits of applying bidirectional stepwise forces using modified multi-track technique which resulted into higher post dilation valve areas, less incidence of mitral regurgitation and lower long term restenosis rate.

Outcomes of left ventricular reconstruction when established parameters are followed, and subsequent questions

The 2010 Task Force guidelines from the European Society of Cardiology/European Association of Cardiothoracic Surgery (ESC/EACTS) recommend ‘consideration of surgical ventricular restoration (SVR) to treat ischemic dilated cardiomyopathy, following measurement of ventricular volume and assessment of myocardial scar in centers with high experience’ [1]. This issue contains a report by Cho et al. [2] concerning ‘Long-term results and mid-term features of left ventricular reconstruction procedures on left ventricular volume, geometry, function and mitral regurgitation’ that amplifies the importance of surgical ventricular restoration (SVR) to architecturally remedy the failing hearts of patients with ischaemic dilated cardiomyopathy. Their superb results confirm how this procedure carries a very low perioperative mortality (1.6%), dramatically diminishes rehospitalization for cardiac causes over a 7-year interval and allows 79% long-term survival. These beneficial results are in concert with the broad number of world-wide SVR reports [3] and thus provide yet another contradiction to the flawed Surgical Treatment for Ischemic Heart Failure (STICH) study [4], whose misguided results have caused global curtailment of properly treating ischaemic dilated cardiomyopathy. Cho et al. precisely followed the benchmark SVR entry criteria of >60 ml/m left ventricular end-systolic volume index (LVESVI), >35% scarring of the left ventricle (LV) perimeter and achieved the requisite 40% reduction of ventricular volume to reduce the LVESVI of <60 ml/m. These SVR-induced changes show why LVESVI <60 ml/m is an independent predictor of prognosis [5], as the very low 7-year mortality ‘resulted from the natural events of neoplasm and infection’ rather than from pump failure or sudden death. These splendid results were similarly achieved by the Dor, linear closure and septal anterior ventricular exclusion (SAVE) procedures, yet each outcome was accompanied by creating a more spherical ventricle instead of the intended elliptical form. Confirmation of improved systolic performance was garnered from the increased systolic eccentricity index that indicated the smaller remote muscle contracted more efficiently as it became more helical during ejection. Moreover, late findings in patients with larger pre-SVR ventricular volumes showed the development of a 22% incidence of mitral regurgitation (MR), which parallels Di Donato’s report of 38% later mitral insufficiency in patients with even larger preoperative ventricular volumes [6]. These shape and MR change direct attention towards how the procedure execution influenced these findings, since Pocar recently pointed out the disadvantage of a more spherical chamber and functional MR [7].

Investigational devices for mitral regurgitation: state of the art

The incidence of mitral regurgitation (MR) is rising as a result of an aging population worldwide. Surgical repair or replacement of the mitral valve remains the standard of care for patients with severe MR as the only approach to achieve sustained relief of symptoms or heart failure. However, the majority of patients with severe MR do not undergo surgery because of high perceived perioperative risk. Recently, there has been great enthusiasm in the pursuit of a less invasive percutaneous approach to the treatment of MR to avoid thoracotomy or cardiopulmonary bypass, even if less efficacious. This article reviews the latest developments of various percutaneous options in the treatment of MR.

Ischemic Mitral Regurgitation and Non-ST-Segment Elevation Acute Myocardial Infarction: Long-Term Prognosis

Ischemic mitral regurgitation (MR) is a common complication of acute myocardial infarction and has a negative impact on prognosis. However, few studies have been carried out on MR after non-ST-segment elevation acute myocardial infarction (NSTEMI). Our objective was to investigate the incidence, clinical predictors and long-term prognostic implications of MR in patients with NSTEMI. The prospective study included 237 consecutive patients who were discharged in functional class I or II after a first NSTEMI. Each underwent echocardiography during the first week of admission, and patients were followed up clinically for a median of 1011 days. The incidence of readmission for heart failure, unstable angina, reinfarction, death or all combined (i.e. the combined event or major adverse cardiac event [MACE]) was recorded. The patients' mean age was 66+/-13 years and 74% were male. The incidence of MR was 40% (grade I in 71 patients, grade II in 15, grade III in 6, and grade IV in 3). Age, diabetes mellitus, multivessel disease and MR (HR=2.17; 95% confidence interval 1.30-3.64; P=.003) were all independently associated with a poor long-term prognosis, in terms of MACEs. Even the milder grades of MR were associated with more events. In our milieu, MR frequently occurs after NSTEMI. Its presence together with other unfavorable factors implies a poor long-term prognosis. This is also true for milder grades of MR. Consequently, MR should be fully assessed and followed-up after NSTEMI in all patients.

Cardiac toxicity of high-dose cyclophosphamide and melphalan in patients with multiple myeloma treated with tandem autologous hematopoietic stem cell transplantation

Tandem autologous hematopoetic stem cell transplantation (HSCT) is an effective treatment in patients with multiple myeloma (MM). Patients receive high-dose cyclophosphamide (CY) followed by two myeloablative dosages of melphalan (MEL). Cardiotoxicity treatment related data are scanty. In 30 patients with MM chemotherapy was followed by high-dose CY (cycle CY), and two autologous tandem HSCT treatments with MEL (cycles MEL I and MEL II). During each 15-day treatment troponin I (TnI), brain natriuretic peptide (BNP) and endothelin-1 (ET-1) were controlled at six time points. All patients underwent conventional and tissue Doppler echocardiography prior to CY therapy (Eho 0), before cycle MEL I (Eho 1), before cycle MEL II (Eho 2), and 3 months after the completion of therapy (Eho 3). None of the patients developed clinical signs of heart failure. The peak TnI concentrations were noted at days 8, 11, and 15 during all three chemotherapy cycles. During all three cycles there was a significant increase in baseline BNP concentrations and BNP levels measured at day 1 after treatment with CY and MEL (CY: P = 0.0001, MEL I: P = 0.001, MEL II: P = 0.001). The highest BNP concentration occurred during CY treatment (0.517 +/- 0.391 microg/L). During cycles MEL I and MEL II we noted the peak BNP concentrations at day 4 following chemotherapy (MEL I 0.376 +/- 0.418 microg/L; MEL II 0.363 +/- 0.379 microg/L). During all three cycles the highest ET-1 levels occurred at day 1 after chemotherapy (CY 1.146 +/- 1.313 ng/L; MEL I 1.054 +/- 2.242 ng/L; MEL II 0.618 +/- 0.539 ng/L). A significant increase in ET-1 concentrations relative to the basal values occurred only in cycle MEL II (P = 0.003). The duration of wave a in the Doppler pulmonary vein flow increased significantly (Eho 0/Eho 1: P = 0.008, Eho 0/Eho 3: P = 0.026). There was a significant decrease in the A/a ratio in flow velocities during chemotherapy (Eho 0/Eho 1: P = 0.002, Eho 0/Eho 3: P < 0.0001). Early diastolic tissue Doppler velocities (Em) decreased significantly during individual cycles of chemotherapy (P = 0.006). A significant post-treatment increase in the incidence of mitral regurgitation was observed (Eho 0/Eho 3: P = 0.003). Treatment of MM patients with tandem autologous HSCT is cardiotoxic. Our patients did not develop clinically overt heart failure or myocardial necrosis. Increased plasma levels of BNP and ET-1 were compatible with transient neurohormonal activation of heart failure. Doppler echocardiography studies revealed worsening of left ventricular diastolic function and occurrence of functional mitral regurgitation.

Outcome of cases of Mitral Stenosis after Percutenuous Transvenous Mitral Commissurotomy (PTMC)

This prospective study was carried out in the National Institute of Cardiovascular Diseases and Hospital (NIC VD), Dhaka, Bangladesh during the period January 2002 to December 2002. The result of percutenuous ballon mitral valvotomy were evaluated in 153 cases of mitral stenosis patients (mean age 36±15 years) with symptomatic rheumatic mitral stenosis with single Inoue ballon technique PTMC results significant increase mitral valve area. 79.18 to 1.86 ±.37. Transmitral mean pressure gradient 19.6 ± 8.9 to 3.7±38, Decrease mean left atrial size 41.33±9.3 to 30.56±8.16 and Pulmonary artery systolic pressure 56±24 to 39 ±17, Peak pressure gradient (PPG) 19.6±8.9 to 8.7 ±3.8, But lower incidence of mitral regurgitation, only two cases developed MR grade Ill which were treated medically, one patient develop moderate haemopericardium which was treated conservatively. One patient was failed due to severe tight MS of valve area 0.5. No surgical intervention was needed.

A prospective randomized trial of complete atrioventricular transplantation versus ventricular transplantation with atrioplasty

Background: The standard technique of ventricular transplantation with atrioplasty (SOHT) distorts atrial anatomy. This may compromise diastolic ventricular function, impair atrioventricular valve competence and elevate resting ANP secretion. In contrast, complete atrioventricular anastomosis (CAVT) preserves atrial geometry. Methods We evaluated long term outcome in a prospective randomized trial of CAVT vs. SOHT. The primary outcome measures were peak oxygen uptake, atrioventricular valve regurgitation and ANP secretion. Results 58 recipients (median age 49 years; range 21–64) were consecutively randomized (29 CAVT; 29 SOHT). There were no differences in total ischaemic time, cardiopulmonary bypass time, postoperative bleeding or immunosuppression. Cardiopulmonary exercise tolerance testing was performed by 29 recipients at 742 to 1825 days. Pulmonary function was equivalent. Peak oxygen consumption expressed as a percentage of predicted maximum was 53.5% with CAVT and 63.8% with SOHT ( p = 0.14). Echocardiography was performed on 41 recipients at 944 to 1665 days. There was less tricuspid regurgitation with CAVT (3/22 [13.6%] CAVT vs 10/19 [52.6%] SOHT; p = 0.019). The incidence of mitral regurgitation was similar (5/22 [22.7%] CAVT vs 4/19 [21.1%] SOHT; p = 0.803). Resting ANP secretion was assessed in 17 recipients at 1013 to 1812 days. All were hemodynamically stable and none had concurrent rejection. Resting ANP secretion was less with CAVT (CAVT: 283 pg/ml; SOHT: 521.4; p = 0.041). Conclusions Peak oxygen consumption was not influenced by implantation technique. However, CAVT reduced the incidence of tricuspid regurgitation and attenuated the elevation in resting ANP secretion.

Percutaneous balloon mitral valvuloplasty using the Inoue balloon: analysis of echocardiographic and other variables related to immediate outcome

To determine whether the mitral valve morphology influences the results of percutaneous balloon mitral valvuloplasty for mitral stenosis, two-dimensional echocardiography was performed before valvuloplasty in 126 patients (mean age 25.5±9.4 years) and in 30 normal controls. The 2D echocardiographic features of mitral valve leaflets: thickness, length and motion; diastolic mitral valvular excursion; chordal length; mitral annular diameter; subvalvular distance ratio; distance between mid mitral annulus to left ventricular apex, base and tip of papillary muscle and effective balloon dilating area, effective balloon dilating area/body surface area and effective balloon dilating diameter/mitral annular diameter were then correlated to the immediate post-valvuloplasty mitral valve area. For the total patients population, post-valvuloplasty valve area increased from 0.67±0.17 to 2.1±0.86 cm 2 ( P<0.0001), mean transmitral diastolic gradient decreased from 24.5±9.0 to 6.0±3.0 mmHg ( P<0.0001), mean left atrial pressure decreased from 29.7±6.2 to 12.7±4.8 mmHg ( P<0.0001), mean pulmonary artery pressure decreased from 44.8±14.2 to 25.4±9.5 mmHg ( P<0.0001) and cardiac index increased from 2.7±0.38 to 3.1±0.55 l/min/m 2 ( P<0.0001). The patients were divided into three groups on the basis of post-valvuloplasty mitral valve area. Group I had valve area <1.5 cm 2, group II had valve area from 1.5 to 1.9 cm 2 and group III had valve area ≥2.0 cm 2. On comparison, no statistically significant difference was found in any of the echocardiographic variables in the three groups. On univariate, multivariate, multiple regression and discriminate function analysis, none of the variables were found to have significant influence on immediate result of valvuloplasty. There was no significant difference in the incidence of mitral regurgitation in any of the three groups. We conclude that the extent of mitral valvular and subvalvular deformity do not have a significant effect on the immediate outcome of mitral valvuloplasty using the Inoue balloon and it can be successfully performed in patients with severe subvalvular fibrosis. Unique balloon geometry and stepwise balloon sizing may explain these acceptable immediate results in severely deformed valves.

Valvular Regurgitation in Patients with Graves' Disease

The high cardiac output state and an increased incidence of atrial fibrillation are well-known cardiovascular complications of Graves’ disease, whereas the valvular complications are less well recognized. With 2D color Doppler echocardiography, the cardiac and valvular function of 39 patients with Graves’ disease were evaluated and our data were compared with previous Kage’s study. The incidences of mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with Graves’ disease were 54% and 51%, respectively. There was no correlation between the incidence of MR and ventricular dilatation. In patients with congestive heart failure (CHF), the incidences of severe TR and atrial fibrillation were significantly higher than in patients without CHF. The incidences of TR and MR in patients with Graves’ disease were not different by thyroid function status (hyperthyroid vs. euthyroid). We suggest that the examination for TR and MR in patients with Graves’ disease is important not only their high prevalence but also their clinical significance as a risk factor for CHF. (Korean Circulation J 1999;29(5):487-491)

Pressure zone used and the occurrence of mitral regurgitation in Inoue balloon mitral commissurotomy.

Mitral regurgitation (MR) is a known complication of Inoue balloon mitral commissurotomy (BMC) and has been variously ascribed to the presence of severe subvalvular pathology (SVP), preexisting MR, calcification, or oversizing. The pressure zone used--with the low pressure zone (LPZ) the lower half of the spectrum of sizes available out of a single balloon, and the high pressure zone (HPZ) the upper two levels, i.e., within 2 mm of its maximum size--could have a bearing on the occurrence of MR, but has not been studied before. We analysed 251 consecutive patients (mean age 28.6 + 9.7 years), undergoing BMC from October 1993 onwards, with pliable, non-calcific, splittable (bilateral dark zones present) valves with not more than trivial MR (1 + in grades of 1-4). Balloon sizing was done with standard formula using height with stepwise dilatation starting 2 mm below the reference size. Thirty-two patients additionally had severe SVP. Patients were divided into two groups, HPZ-BMC and LPZ-BMC, depending upon the final balloon size needed for a successful result. Incidence of MR (2+ or more) was significantly lower in the LPZ BMC (18%) vs. HPZ BMC (32.2%) (P < 0.05). Moderate to severe MR (3+/4+) was also less in LPZ BMC (2.8%) vs. HPZ BMC (8.2%) (P < 0.05). Amongst patients with severe SVP, 3/15 (20%) developed MR in the LPZ-BMC group (all mild only) as against 8/17 (42%) (P < 0.05) in the HPZ-BMC group with half of them having moderate to severe MR. In 54 patients where the reference size had to be exceeded, no patient (0/8) developed MR as long as the higher size was in the LPZ of the particular balloon used as compared to 17/46 (36.9%) who developed MR when the size used fell in the HPZ. We conclude that the pressure zone used has a strong bearing on the occurrence of MR in Inoue BMC and that a low-pressure strategy could avoid MR.