Mild Valvular Regurgitation Research Articles

Comparison of Cardiac Output of Both 2 and 3 Dimensional Transoesophageal Echocardiography With Transpulmonary Thermodilution During Cardiac Surgery

Purpose: Transpulmonary thermodilution (TD) is the gold standard for cardiac output (CO) monitoring during cardiac surgery but is feasible with TOE, but 2D TOE underestimates CO due to assumption of a circular LVOT, when 3D TOE demonstrates it is ovoid. The aim of this study is to determine if 3D TOE correlates better with TD than 2-D TOE. Methodology: After ethics approval, 50 adult patients without more than mild valvular regurgitation or A who were scheduled for bypass cardiac surgery were recruited prospectively at two institutions. CO was measured simultaneously by TD and TOE (2D/3D) before and after CPB. CO was calculated using the continuity method (product of VTI, area and heart rate) using the modal and outer-edge trace of the LVOT VTI. The aortic valve area was estimated with planimetry by both 2D and 3D TOE. Agreement analysis was performed using the Deming model II regression analysis and Bland-Altman technique (TD as the reference method). Results: Proportional but not fixed bias was present for the VTI modal method but not for any other method. Correlation for LVOT modal was poor (0.40) and CO was underestimated (mean bias = -1.59 L.min-1), but the limits of agreement were similar to other methods. Tracing the edge of the LVOT VTI rather than the modal line reduced the bias (-0.59 L.min-1), and improved correlation (0.92). 3D planimetry of the AV and continuous wave Doppler had the best agreement with TD. The mean bias approached zero for the 3D methods but with similar limits of agreement. Conclusion: For 2D measurements, tracing around the LVOT VTI rather than through the modal line improved precision. The other 2D and 3D measurements of CO showed absence of bias, and reasonable agreement with TD.

Comparison of cardiac output of both 2 and 3 dimensional transoesophageal echocardiography with transpulmonary thermodilution during cardiac surgery

Transpulmonary thermodilution (TD) is the most used method for cardiac output (CO) monitoring during cardiac surgery. Although 2D transoesophageal (TOE) measurement of CO using spectral Doppler correlates with TD, 3D TOE more accurately measures left ventricular outflow tract (LVOT) and aortic valve (AV) area, which are used to calculate CO. The aim of this study is to compare the precision of CO measurement between 2D and 3D TOE against TD. After ethics approval, 50 patients aged over 18 years scheduled for on-bypass cardiac surgery were recruited prospectively at two institutions. Exclusion criteria included more than mild valvular regurgitation, and atrial fibrillation. CO was measured simultaneously by TD and TOE before sternotomy and after cardiopulmonary bypass. CO was calculated using TOE by the product of either the LVOT or AV area, the velocity-time integral (VTI) of flow at the same site and heart rate. The LVOT area was assumed circular and calculated using the LVOT diameter for 2D but with planimetry using 3D TOE. The AV area was estimated with planimetry by both 2D and 3D TOE, and VTI with continuous wave Doppler. Both modal and outer edge traces of LVOT VTI were performed with the cursor 0.5 cm from the annulus. Measurements were averaged from 3 consecutive beats by 2 observers. Deming model II regression was used to assess fixed and proportional bias of agreement with TD. Bland-Altman technique was used to assess closeness of fit. CO was measured at 94 time-points (50 before sternotomy, 44 after chest closure) in 50 patients. The 3D methods had better agreement than 2D with TD, with the best agreement with 3D planimetry of the AV (bias -0.04 Lmin-1, SD of difference between the mean 1.37 Lmin-1), followed by 3D LVOT area planimetry (0.14, 1.41), 2D AV area planimetry (0.28, 1.3) and 2D LVOT VTI outer edge trace (-0.59, 1.29). 3D LVOT area planimetry had the best correlation (slope 1.39, 95%CI 0.97-1.82), followed by 2D AV planimetry (1.15, 0.81-1.48), 3D AV planimetry (1.07, 0.76-1.39), and 2D LVOT VTI outer edge trace (0.92, 0.33-1.52), all of which had no proportional or fixed bias. The VTI modal trace model had the worst agreement (-1.59, 1.37) and correlation (0.40, 0.08-0.69) and had proportional but not fixed bias. However the limits of agreement were similar amongst all methods. Tracing the edge of the LVOT VTI rather than the modal line reduced the bias (-0.59, 1.29), and improved correlation (0.92, 0.33-1.52). For 2D measurements, tracing around the LVOT VTI rather than through the modal line improved precision. The other 2D and 3D measurements of CO showed absence of fixed or proportional bias, and reasonable agreement with thermodilution as the reference method.

Cardiopatías estructurales y funcionales en pacientes adultos con inmunodeficiencia comun variable

Antecedentes: la inmunodeficiencia común variable es la inmunodeficiencia primaria con mayor cantidad de comorbilidades en la vida adulta. Se ha asociado con bronquiectasias en 17 a 76%, y éstas, con complicaciones cardiovasculares, como hipertensión arterial pulmonar e insuficiencia cardiaca. Los nuevos métodos diagnósticos de imagen permiten evaluar la conformación estructural y funcional cardiovascular de los pacientes adultos con bronquiectasias y, de esta manera, establecer diagnósticos más eficientes y oportunos.Objetivo: determinar las cardiopatías estructurales y funcionales en pacientes con inmunodeficiencia común variable mediante ecocardiografía transtorácica.Material y método: estudio transversal, descriptivo, efectuado en una cohorte de 26 pacientes adultos con diagnóstico de inmunodeficiencia común variable y tratamiento sustitutivo con inmunoglobulina intravenosa (IgIV), pertenecientes a la Clínica de Inmunodeficiencias. A todos los pacientes se les realizó ecocardiografía transtorácica con ecocardiograma doppler y tisular; los resultados fueron evaluados por un médico cardiólogo ecocardiografista.Resultados: evaluamos a 26 pacientes; de ellos, 10 fueron del género masculino, con media de edad de 35.7 ± 13.7 años. Los resultados de la ecocargiografia torácica en las cavidades cardiacas izquierdas reportaron las siguientes alteraciones funcionales: 17 de 26 pacientes tuvieron insuficiencia mitral y sólo 2 tuvieron insuficiencia aórtica; ninguno de ellos con síntomas. Respecto de las alteraciones estructurales de las cavidades derechas: 8 pacientes adultos con inmunodeficiencia común variable tuvieron crecimiento de las cavidades derechas y en 5 pacientes se encontró tabique interauricular delgado e hipermóvil; respecto de las alteraciones funcionales, 24 pacientes tuvieron insuficiencia tricuspídea, en 21 de ellos fue leve y sólo en 3 fue moderada. Además, 12 pacientes tuvieron insuficiencia de la válvula pulmonar y 6 pacientes tuvieron hipertensión arterial pulmonar; de ellos, en 2 sujetos fue leve y en 2, moderada y 4 pacientes tuvieron presión sistólica de la arteria pulmonar con valores límites altos.Conclusiones: los pacientes con inmunodeficiencia común variable, a pesar de tener alta incidencia de bronquiectasias, tienen baja incidencia de hipertensión arterial pulmonar; pero un número importante de pacientes tiene presión sistólica de la arteria pulmonar con valor límite alto, por lo que estos pacientes deben tener un seguimiento anual, debido a que probablemente evolucionarán a hipertensión arterial pulmonar. Además, tienen alta incidencia de insuficiencias valvulares leves debido a cambios degenerativos con esclerosis valvular, por lo que también requieren vigilancia periódica.

Transthoracic Echocardiography Is Still Useful in the Initial Evaluation of Patients With Suspected Infective Endocarditis: Evaluation of a Large Cohort at a Tertiary Referral Center

ObjectivesTo examine the sensitivity of contemporary transthoracic echocardiography (TTE) for the detection of vegetation, abscess cavity, or prosthetic valve dehiscence (Vg) in patients with suspected infective endocarditis (IE) and to identify whether a relatively normal initial TTE finding can be effectively used as a rule out test, obviating the need for transesophageal echocardiography (TEE). Patients and MethodsWe evaluated clinical, microbiological, and echocardiographic data for all patients with suspected IE referred for both TTE and TEE between January 1, 2005, and December 31, 2010. Patients were stratified into 3 groups by baseline TTE findings: negative TTE (native valves with less than or equal to mild regurgitation and no Vg), equivocal TTE (no Vg but prosthetic valve or greater than mild native valvular regurgitation), and positive TTE (Vg detected). ResultsWe studied 622 consecutive patients (68% male; mean ± SD age, 62±17 years), including 256 with Staphylococcus aureus bacteremia (SAB). The presence of Vg was confirmed by TEE in 141 patients (23%). The TTE had low sensitivity for the detection of Vg (58%). A total of 271 patients (44%) had an initial negative TTE. Of these, TEE demonstrated Vg in only 8 patients (negative predictive value [NPV] of negative TTE, 97%). The negative TTE group included 132 patients with SAB, only 6 of whom had Vg (NPV, 95%). Of 265 patients with equivocal TTE, Vg was demonstrated in 51 (19%). ConclusionIn a hospital population with clinically suspected IE, TTE had low sensitivity for the detection of Vg; however, a negative initial TTE was a common finding, with a high NPV, even in the setting of SAB. A TEE may be avoided in many patients with suspected IE.

44 Are We Using BNP Wisely? Audit of the Utility of Natriuretic Peptide Testing (NT-Probnp) in Banes, Wiltshire and Somerset for Patients with Suspected Heart Failure

IntroductionThe NICE guidelines on Chronic Heart Failure 2010 recommend the use of natriuretic peptide (NP) testing in patients with suspected heart failure without previous myocardial infarction (MI). NP testing is...

Benfluorex and Mortality: A Fresh Perspective

Benfluorex, a drug related to fenfluramine, has been sold under the trade name “Mediator” by Servier Laboratories and was introduced to the French market in 1976, licenced for the treatment of type 2 diabetes and dyslipidemia. Although the evidence that benfluorex increases the risk of mild valvular regurgitant abnormalities is convincing, it is also apparent that no data exist from which to calculate the risk of death attributable to benfluorex use. Despite this, two studies have attempted to make such estimates, the results of which have been the focus of much media attention. In this review, we attempt to provide a further assessment of the evidence base, explore the limitations of the estimates of death that have been made, and calculate the population risk of mild valvular regurgitation and hospitalisation attributable to benfluorex use. We conclude that the previously published estimates of deaths attributed to the use of this agent are unsafe, based on unfounded assumptions, and are highly likely to be inaccurate.

Predictors of improvement in diastolic function after transcatheter aortic valve implantation.

Aortic stenosis is associated with concentric left ventricle (LV) hypertrophy or remodeling resulting in impaired diastolic function and elevated left-sided filling pressure. We investigated the changes in LV geometry and LV filling hemodynamics, giving emphasis to parameters associated with changes in diastolic function after transcatheter aortic valve implantation (TAVI). Comprehensive diastolic assessment was performed before and six months after TAVI in 70 patients with severe aortic stenosis. Patients with any degree of mitral stenosis or >mild left-sided valvular regurgitation were excluded. In the entire cohort six months after TAVI, LV end-diastolic diameter increased (44.1±6 versus 45±6mm, P=0.02), whereas LV mass and relative wall thickness (RWT) decreased (270.1±76 versus 245.1±75g and 0.53±0.15 versus 0.46±0.1, respectively; P<0.0001 for both). Lateral e' increased (5.8±2 versus 6.6±3cm/s, P=0.03) and left atrium (LA) volume, E/e' ratio, and systolic pulmonary pressure decreased (88.1±30 versus 80±28cc, 18±7.8 versus 16.3±5.5, and 42.7±14.9 versus 38.7±12mmHg, respectively; P<0.05 for all), suggesting reduction in LA pressure. The improvement in LA volume and E/e' was almost exclusively seen in patients with LV hypertrophy before TAVI (P<0.05 both), as opposed to patients with concentric remodeling. In our preliminary study, TAVI resulted in LV and LA reverse remodeling, and improved LV relaxation and LA filling pressure in patients with severe aortic stenosis and concentric hypertrophy. Patients with concentric remodeling at baseline seem to have limited improvement in LV diastolic function and filling pressure following TAVI, but larger clinical trials would be required to conclude if they have no improvement at all.

Perventricular Closure of Perimembranous Ventricular Septal Defects Using the Concentric Occluder Device

This report summarizes the authors' clinical experience with perventricular closure of the perimembranous ventricular septal defect (PmVSD) using the concentric occluder as a minimally invasive technique without cardiopulmonary bypass and following transesophageal echocardiography (TEE) guidance. Between July 2011 and March 2013, 61 patients with PmVSD underwent perventricular concentric device closure using a minimally invasive inferior sternotomy approach. The basal diameter of the PmVSD ranged from 2.5 to 7 mm. The diameter of the occlusion device waist ranged from 4 to 8 mm. A ventricular septal aneurysm or an adhesive tricuspid valve was present in 49 patients. Multiple orifices in the aneurysm were treated in ten patients, including dispersed orifices in four patients and comparatively concentrated orifices in the remaining six patients. The occlusion devices were deployed via the right ventricle with TEE guidance and no cardiopulmonary bypass. Complete shunt occlusion was achieved for all the patients in the operating room. The orifices of the ventricular septal aneurysm were closed in 46 patients, with the left disc of the concentric devices placed in the aneurysms, whereas the PmVSDs in the remaining 15 patients were closed from the ventricular septal defect (VSD) basal part following the rule that the upper rim of the PmVSD be more than 2 mm from the aortic valve. Ventricular premature beats occurred in one patient. The follow-up period ranged from 1 to 21 months (median 13.5 ± 8.2 months), and the patients had stable heart function postoperatively. None of the patients had more than mild valvular regurgitation, and no worsening regurgitation was observed in those who had tricuspid or aortic regurgitation before surgery. No complete atrioventricular block, position shift of the occlusion devices, thrombosis, or residual VSD occurred during the follow-up period. The perventricular concentric device closure of PmVSD with an inferior sternotomy in selected patients is a safe, feasible, and simple treatment. The concentric device is easier to anchor than the eccentric device and has proved to be a reasonable choice for PmVSD occlusion, especially in patients with a perimembranous aneurysm formation or PmVSD extending to the inflow tract.

Appropriateness of Outpatient Echo Requests Within Capital Health

BACKGROUND: Increasing use of transthoracic echocardiogram (TTE) studies and repeat echocardiography studies within Canada continues as a rising concern in the face of long wait times. To aid with such a concern, the American Society of Echocardiography (ASE) created the Appropriate Use Criteria to define appropriate and inappropriately ordered echocardiography studies. The objective of this study was to use the ASE criteria to determine the appropriateness of outpatient echocardiography requests within the Halifax Regional Municipality (HRM) in the setting of long wait times and in order to evaluate efficiency. METHODS AND RESULTS: All consecutive adult outpatient transthoracic echo requisitions of studies performed within HRM for the month of November, 2011 were collected. Following collection, the requisitions were divided amongst four clinicians. Each study was evaluated for a number of criteria including a classification of appropriate, uncertain or inappropriate indication as per the 2011 ASE Appropriate Use Criteria. This data was then collected and analyzed using mainly descriptive statistics. During the study period, 98% of the 688 outpatient echocardiograms were collected and 95% of these were matched to an ASE indication. Analysis discovered that 80% were appropriately indicated, 10% uncertainly indicated, and 10% inappropriately indicated. The referrals deemed 'inappropriate' most commonly included: (1) routine surveillance <3 years after valve implantation of prosthetic valve if no suspected valve dysfunction (does not include post-op); (2) routine surveillance <1 year of known cardiomyopathy; (3) routine surveillance<1 year of moderate or severe valve stenosis without a change in status; (4) routine surveillance <3 years of mild valvular regurgitation without change in status; (5) routine surveillance<3 years of mild valvular stenosis without a change in status. CONCLUSION: As medicine continues to advance in its diagnostic capability it is essential to review our systems for proper use in order to maximize system efficiency and minimize health care expenditure. This review was effective in identifying the most common inappropriate referrals for echocardiography within the HRM and creating a baseline for future studies. The results of this study have already been used to change clinical referring practice.

Cardiopulmonary dysfunction in the Osteogenesis imperfecta mouse model Aga2 and human patients are caused by bone-independent mechanisms

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder with skeletal dysplasia of varying severity, predominantly caused by mutations in the collagen I genes (COL1A1/COL1A2). Extraskeletal findings such as cardiac and pulmonary complications are generally considered to be significant secondary features. Aga2, a murine model for human OI, was systemically analyzed in the German Mouse Clinic by means of in vivo and in vitro examinations of the cardiopulmonary system, to identify novel mechanisms accounting for perinatal lethality. Pulmonary and, especially, cardiac fibroblast of perinatal lethal Aga2/+ animals display a strong down-regulation of Col1a1 transcripts in vivo and in vitro, resulting in a loss of extracellular matrix integrity. In addition, dysregulated gene expression of Nppa, different types of collagen and Agt in heart and lung tissue support a bone-independent vicious cycle of heart dysfunction, including hypertrophy, loss of myocardial matrix integrity, pulmonary hypertension, pneumonia and hypoxia leading to death in Aga2. These murine findings are corroborated by a pediatric OI cohort study, displaying significant progressive decline in pulmonary function and restrictive pulmonary disease independent of scoliosis. Most participants show mild cardiac valvular regurgitation, independent of pulmonary and skeletal findings. Data obtained from human OI patients and the mouse model Aga2 provide novel evidence for primary effects of type I collagen mutations on the heart and lung. The findings will have potential benefits of anticipatory clinical exams and early intervention in OI patients.

Case of the mysterious signal

A 76-year-old man underwent direct aortic CoreValve® (Medtronic Inc., Minneapolis, MN, USA). After successful implantation of the CoreValve, a transoesophageal echocardiogram showed mean and peak gradients of 5 and 14 mmHg, respectively, along with mild valvular and paravalvular aortic regurgitation. Prior to discharge from the hospital, a transthoracic echocardiogram …

What is the Current Incremental Diagnostic Benefit from TOE for the Diagnosis of Infective Endocarditis? An Evaluation of a Large Cohort from a Tertiary Referral Centre

Background: The diagnosis of infective endocarditis (IE) incorporates clinical and echocardiographic information. Guidelines recommend transoesophageal echo (TOE) for definitive assessment of vegetations or tissue invasion (VG), particularly if the organism is Staphylococcus aureus, largely based on data from fundamental trans-thoracic echo (TTE) imaging. We examined whether TOE provides significant incremental value in the assessment of endocarditis using current imaging technologies. Methods: We retrospectively evaluated clinical, microbiological and echocardiographic data in all patients with a clinical suspicion of endocarditis referred for both TTE and TOE at our institution between January 2005 and September 2010. Patients were stratified into three groups by baseline TTE results: “Normal TTE” = native valves with ≤mild regurgitation and no VG; “Abnormal TTE/VG-” = no VG but prosthetic valve or >mild native valvular regurgitation; “Abnormal TTE VG+” = vegetation detected. Results: Of 707 consecutive patients (69% male, average 59 years) undergoing TTE and TOE for investigation of IE, VG was confirmed by TOE in 145 patients (21%). Of 310 patients with normal TTE, TOE demonstrated VG in only 11 cases (NPV of Normal TTE = 96%). The normal TTE group included 147 patients with S. aureus bacteraemia, only six of whom had VG demonstrated by TOE (NPV 96%). Of 308 patients with Abnormal TTE/VG-, TOE demonstrated VG in 45 (15%) patients. Of the remaining 89 patients with Abnormal TTE VG+, TOE confirmed VG in all. Conclusion: In a hospital based population with clinical suspicion of endocarditis, a normal TTE, even in the setting of S. aureus bacteraemia, has a high negative predictive value, with minimal incremental value of performing TOE. However, in patients with an abnormal TTE but without visible VG, TOE still provides significant incremental diagnostic value.

Prevalence of exercise‐associated arrhythmias in normal performing dressage horses

Exercise-associated arrhythmias are important differentials when evaluating poor performance sport horses. However, most studies of arrhythmias have been conducted in racehorses and therefore there is a paucity of knowledge concerning the prevalence and significance of exercise-associated arrhythmias in riding horses. The objective of this study was to examine the prevalence of arrhythmias, particularly supraventricular premature complex (SVPCs) and ventricular premature complex (VPCs), associated with exercise in normal performing dressage horses. In total, 21 normal performing dressage horses, aged 5-16 years (mean 9 years), were examined clinically and echocardiographically to detect the prevalence of valvular regurgitation. Electrocardiographic (ECG) examinations were performed during rest and during a standardised dressage exercise programme, as well as during recovery period 1 h after exercise. All ECG recordings were analysed for presence and frequency of arrhythmias and arrhythmias were correlated with HR. Mean HR for walk, trot, canter and for specific dressage movements, as well as maximum HR was calculated. Fisher's exact test was used to test for associations between arrhythmias, valvular regurgitation, age and gender. SVPCs occurred rarely during rest, but occurred during exercise in 6 (28.6%), and in 13 (61.9%) horses during recovery period. Most horses had ≤ 3 SVPCs. Ventricular premature complex were seen in one horse, which developed twice during exercise. Mild valvular regurgitation was seen in 11 (52%) of the horses. No significant associations between arrhythmia and age, gender or valvular regurgitation were observed. Reference values for normal performing dressage horses are presented for the first time, demonstrating that arrhythmias occur infrequently during exercise and recovery. Maximum HR in dressage horses is low compared to both showjumping and racehorses. Studies of dressage horses with moderate to severe valvular regurgitation at rest or poor performance are needed to further elucidate the significance of cardiac arrhythmias.

Features of Carcinoid Heart Disease Identified by 2- and 3-Dimensional Echocardiography and Cardiac MRI

Background— Carcinoid heart disease is a rare form of valvular heart disease. We sought describe the spectrum of carcinoid heart disease identified by echocardiography and cardiac MRI. Method and Results— Two hundred fifty-two patients with carcinoid syndrome underwent a range of investigations including 2D transthoracic echocardiography, 3D transthoracic echocardiography and transesophageal echocardiography, and cardiac MRI. Fifty-two patients had evidence of carcinoid heart disease. Involvement of the tricuspid, pulmonary, mitral, and aortic valves were found in 47 (90%), 36 (69%), 15 (29%), and 14 (27%), respectively. Myocardial metastases were found in 2 (3.8%) patients. Several patterns of disease were identified depending on the extent and severity to which each leaflet and its associated subvavlular apparatus was affected. Thirteen of 15 (87%) patients with left-sided carcinoid involvement had a patent foramen ovale. Three patients with severe degree of shunting had severe valvular regurgitation. Patients with mild/moderate degree of shunting had mild or moderate valvular regurgitation. Three-dimensional transthoracic echocardiography/transesophageal echocardiography provided detailed anatomic information particularly for the tricuspid and pulmonary valves. Cardiac MRI allowed complementary assessment of valvular heart disease and delineation of myocardial metastases. Gallium-68 octreotide positron emission tomography identified neuroendocrine metastases. Conclusions— Carcinoid heart disease is a heterogeneous disease with a wide spectrum of echocardiographic findings. A multimodality approach is needed in patients with this complex pathology.

Gender effects on cardiac valvular function in hyperprolactinaemic patients receiving cabergoline: a retrospective study

Ergot-derived dopamine agonists are associated with increased risk of valvular dysfunction in Parkinson's disease. The risk of valvular disease associated with lower doses of cabergoline used to treat prolactinomas remains controversial. To determine whether there is an association of cabergoline and valvular function in patients with hyperprolactinaemia according to gender. Case-record retrospective study. Outpatient neuroendocrine clinical centre at a tertiary care hospital. One hundred patients (48 men and 52 women) with hyperprolactinaemia who had an echocardiogram while receiving cabergoline for at least 6 months. One hundred controls (48 men and 52 women) selected from Massachusetts general hospital (MGH) database of echocardiograms without clinically significant findings, matched to patients for age, gender, body mass index (BMI) and hypertension. Echocardiogram. There were no significant differences in valvular function in patients compared with controls. However, women patients had a higher prevalence of mild tricuspid regurgitation (TR) than female controls (15.4%vs. 1.9%, P = 0.03). Among men only, patients had more trace TR than controls (68.8%vs. 45.8%, P = 0.02). The mild valvular regurgitation in patients was not clinically significant and did not correlate with dose, duration or cumulative dose. Overall cabergoline was not associated with valvulopathy. However, subdivided by gender, hyperprolactinaemic men and women had higher prevalence of trace or mild TR, respectively, compared with gender matched controls. There may be gender differences in valvular dysfunction associated with cabergoline. Longer term, larger studies are necessary to evaluate definitively an effect of cabergoline on valvular function in hyperprolactinaemic patients.

Quantification of valvular regurgitation area and geometry using HPRF 3-D doppler

It is important to determine the severity of valvular regurgitation accurately because surgery is indicated only in severe regurgitations. The evaluation of, for example, mitral regurgitation is complex, and the current methods have limitations. We have developed a 3-D Doppler method to estimate the cross-sectional area and the geometry of a regurgitant jet at the vena contracta just downstream from the actual orifice. The back-scattered Doppler signal from multiple beams distributed over the area of interest was measured. The received power from these beams was then calibrated using both a priori knowledge of the lateral extent of the beams and a reference beam that was completely enclosed by the vena contracta. To isolate the Doppler signal received from the core of a regurgitant jet, a high pulse repetition frequency and a steep clutter filter are required. The method has been implemented and verified by computer simulations and by in vitro experiments using a pulsatile flow phantom and prosthetic valves with a range of holes. We were able to distinguish between mild, moderate, and severe valvular regurgitation. We were also able to quantify the regurgitational area as well as show the geometry of the regurgitation.

Valvular heart disease and the use of cabergoline for the treatment of prolactinoma

The use of high doses of the ergot-derived dopamine agonist cabergoline (> 3 mg/day), especially with cumulative doses > 4000 mg, has been associated with an increase in cardiac valvular thickening and significant (moderate to severe) regurgitation. Whether lower doses commonly used in the treatment of prolactinomas (0.25-3 mg/week) are also associated with significant valvulopathy is controversial. The mitral valve tenting area, a subclinical index of leaflet stiffening, has also been correlated with the cumulative dose of cabergoline and severity of valvular regurgitation. We performed transthoracic echocardiography (TTE) on 50 prolactinoma patients (48% macroprolactinomas, 52% microprolactinomas, 30 male, 20 female, age 51.2 +/- 2.2 years, mean +/- SEM) who had been taking cabergoline for 6.6 +/- 0.5 years (range 1-13 years) with cumulative doses of 443 +/- 53 mg, to determine the prevalence of significant valvular thickening (> 0.5 cm) and regurgitation, and measured the mitral valve tenting area and height. The results were compared to those from age- and sex-matched controls with normal left ventricular function. No significant valvular thickening or regurgitation of any valve was detected in the prolactinoma group and the prevalence of mild valvular regurgitation was not higher than in the case-control group. The mitral valve tenting area and height were not significantly greater than in the control group. There was no correlation between tenting area or height and cumulative cabergoline dose. We found no evidence of increased mitral valve tenting area/height, valvular thickening or significant regurgitation with the long-term administration of the commonly used doses of cabergoline to treat prolactinoma.

Low dose cabergoline for hyperprolactinaemia is not associated with clinically significant valvular heart disease

Recent trials suggest that using ergot-derived dopamine agonists such as cabergoline in the treatment of Parkinson's disease is associated with an increased risk of valvular heart disease. However, the dose of cabergoline used to treat hyperprolactinaemia is considerably less than that used in Parkinson's disease. A cross-sectional comparative assessment. Forty-four patients treated with cabergoline for hyperprolactinaemia underwent transthoracic echocardiography and were compared with 566 sequential subjects complaining of palpitations, taken from a contemporary echocardiography database. The mean cumulative dose of cabergoline in the cases was 311 mg. There was no significant, severe or moderate, right- or left-sided valvular regurgitation in either group. Left heart: in the mitral and aortic valves, the rate of mild and trivial valvular regurgitation was not different between the two groups. Right heart: mild tricuspid and pulmonary regurgitation on colour Doppler alone was increased significantly in the cabergoline group, odds ratios of 3.1 and 7.8 respectively (95% confidence interval 1.0-9.6 and 0.8-78.4, P=0.04 and P<0.0001 respectively). Cabergoline at doses sufficient to suppress hyperprolactinaemia for a period of 3-4 years is not associated with an increased risk of clinically significant valvular regurgitation.

AJR Teaching File: High-Output Cardiac Failure in a Patient with a History of Hereditary Hemorrhagic Telangiectasia

Case History A 62-year-old woman with a history of hereditary hemorrhagic telangiectasia (HHT) presents with high-output cardiac failure. Radiologic Description An anteroposterior chest radiograph (Fig. 1A) reveals cardio-megaly and enlargement of the central pulmonary vasculature, cephalization of pulmonary blood flow, and left pleural effusion. A single axial contrast-enhanced CT image of the chest obtained 2 years previously (Fig. 1B) shows an opacity in the right upper lobe that measures 10×9×15 mm. Pulmonary vessels are seen entering and exiting the opacity, which is suggestive of a pulmonary arteriovenous malformation. Transthoracic echocardiography, not shown, reveals a mildly to moderately dilated right ventricle, mild tricuspid valvular regurgitation, and a moderately to severely dilated right atrium. The left ventricle ejection fraction is estimated to be 65-75%. Axial images from the early arterial phase (Fig. 1C) and late arterial phase (Fig. ID) of contrast-enhanced CT of the abdomen show hepatomegaly, an enlarged inferior vena cava, and early opacification of the hepatic veins. Subcentimeter nodules that are too numerous to count fill the liver and show rapid enhancement, which is consistent with telangiectasia. No findings of cirrhosis or portal hypertension are evident. Differential Diagnosis The differential diagnosis for high-output cardiac failure is hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), arteriovenous fistula, chronic anemia, Paget's disease, hyperthyroidism, thiamine deficiency (beriberi), and poly-cythemia vera. Diagnosis The diagnosis is hereditary hemorrhagic telangiectasia. Commentary The differential diagnosis for high-output cardiac failure is broad. In addition to radiographic findings and clinical history, one can use laboratory data to help narrow the diagnosis. The patient's normal laboratory values, including hemoglobin and hematocrit, iron studies, thiamine, and thyroid function tests, help eliminate chronic anemia, hyperthyroidism, thiamine deficiency, and polycythemia vera from the differential diagnosis. Without a history of solid organ biopsy, penetrating trauma, or catheterization, an arteriovenous fistula would be much less likely. Paget's disease would manifest with diffuse osseous findings of blastic, lyric, or mixed lesions. A review of images showed that chest, abdomen, and pelvic CT images obtained at bone window settings were negative for such findings [1].

Late Outcome After Repair of Aortico-Left Ventricular Tunnel 10-Year Follow-up

Despite successful surgical repair, patients with congenital aortico-left ventricular tunnel (ALVT) are at risk of developing aortic incompetence in the late postoperative period. Two cases of ALVT were followed for 10 years with special reference to aortic incompetence and geometry of the aortic root. The patients underwent repair of ALVT, one at 4 years of age and the other at 4 months of age. The first patient had a slit-like tunnel (type I) and the aortic orifice was closed with a pericardial patch. The second patient had a large tunnel with an extracardiac aneurysm (type II) and was closed with a pericardial patch at the aortic orifice and a Dacron patch at the left ventricular orifice, thereby completely obliterating the tunnel. The last echocardiographic evaluation showed no residual flow in the tunnel and no aortic incompetence in case 1, but there was mild aortic valvular regurgitation with deformity of the right sinus in case 2. Careful long-term follow-up is necessary because patients with ALVT have some inherent structural abnormalities from the left ventricular outflow tract to the aortic root.