Pre-discharge Transthoracic Echocardiography Research Articles

Transmitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

Intrinsic abnormalities of the mitral valve are common in patients with hypertrophic cardiomyopathy and may need to be addressed at operation. Consecutive patients undergoing transmitral septal myectomy were retrospectively reviewed. The ventricular septum was exposed through a left atriotomy, and the anterior leaflet of the mitral valve was detached from its annulus. An extended myectomy was performed to the base of the papillary muscles. After myectomy, the anterior leaflet was reattached and concomitant mitral valve repair or replacement was performed. In some cases, we performed a modified anterolateral commissural closure suture, which served to reposition the lateral aspect of the anterior leaflet out of the left ventricular outflow tract ("curtain stitch"). Twenty patients who underwent this procedure were identified (70% women; mean age 63 years). Mitral regurgitation was moderate in 55% and severe in 40%. Preoperative peak left ventricular outflow tract gradient was 92 ± 43 mm Hg. Mitral valve repair (n= 11) or replacement (n= 9) was performed. Predischarge transthoracic echocardiography demonstrated a left ventricular outflow tract gradient of 10 ± 5 mm Hg. There was no operative mortality. Follow-up was 100% complete and averaged 22 ± 25 months. No patient required reoperation, and there was no recurrence of left ventricular outflow tract obstruction or mitral regurgitation greater than mild. Potential advantages of transmitral myectomy include a panoramic view of the septum and mitral subvalvular apparatus and the ability to simultaneously address mitral valve pathology. Consideration should be given to using the transmitral approach to septal myectomy as the preferred approach for the surgical treatment of hypertrophic cardiomyopathy.

Timing on echocardiography and blood laboratory test is important for future outcome association in hospitalized heart failure patients

BackgroundWe investigated whether both echocardiography and blood examination parameters obtained before discharge are more closely associated with adverse events than those obtained upon admission in hospitalized heart failure (HF) patients. MethodsWe retrospectively selected 267 hospitalized HF patients who underwent comprehensive transthoracic echocardiography (TTE) within 2 days of admission (n=223) and/or within 7 days of discharge (n=157). Blood test results were also collected at the same time window. Patients were assigned into HF with reduced ejection fraction (HFrEF) and HF with preserved EF (HFpEF). ResultsDuring a median follow-up of 12.6 months, 60 of 223 patients with admission TTE and 39 of 157 patients with pre-discharge TTE had major adverse cardiac events (MACEs) after discharge. On admission, no echocardiography parameters, but uric acid, blood urea nitrogen (BUN), creatinine, and estimated glomerular filtration rate (eGFR) were associated with MACEs in HFpEF (n=45). In HFrEF (n=178), vena contracta, s′, BUN, eGFR, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with MACEs. Before discharge, BNP, NT-proBNP, and E/e′ were significantly associated with MACEs in HFpEF (n=41). In HFrEF (n=116), several echocardiography parameters and blood tests were significantly associated with MACEs. ConclusionsOptimal examination timing for prognostication is different between echocardiography but not for blood tests. TTE before discharge provides more information in both HF phenotypes, while blood tests play a role both upon admission and before discharge. Therefore, a pre-discharge TTE was recommended in patients admitted for HF.

Relation between calcium burden, echocardiographic stent frame eccentricity and paravalvular leakage after corevalve transcatheter aortic valve implantation.

Paravalvular aortic leakage (PVL) after transcatheter aortic valve implantation (TAVI) is a complication with potentially severe consequences. The relation between native aortic root calcium burden, stent frame eccentricity and PVL was not studied before. Two-hundred-and-twenty-three consecutive patients with severe aortic stenosis who underwent TAVI with a Medtronic CoreValve System© and who had available pre-discharge transthoracic echocardiography were studied. Echocardiographic stent inflow frame eccentricity was defined as major-minor diameter in a short-axis view >2 mm. PVL was scored according to the updated Valve Academic Research Consortium (VARC-2) recommendations. In a subgroup of 162 (73%) patients, the calcium Agatston score was available. Stent frame eccentricity was seen in 77 (35%) of patients. The correlation between the Agatston score and stent frame eccentricity was significant (ρ = 0.241, P = 0.003). Paravalvular leakage was absent in 91 cases (41%), mild in 67 (30%), moderate in 51 (23%), and severe in 14 (6%) cases. The correlation between stent frame eccentricity and PVL severity was significant (ρ = 0.525, P < 0.0001). There was a relation between particular eccentric stent frame shapes and the site of PVL. Calcification of the aortic annulus is associated with a subsequent eccentric shape of the CoreValve prosthesis. This eccentric shape results in more PVL, with the localization of PVL related to the shape of stent frame eccentricity.

Paravalvular leak after transcatheter aortic valve implantation: is it anatomically predictable or procedurally determined? MDCT study

To investigate the determinants of paravalvular leak (PVL) occurring after transcatheter aortic valve implantation (TAVI). One hundred and eight patients with severe symptomatic aortic stenosis (mean age 75.5±11.8 years, 72.2% male) underwent contrast-enhanced electrocardiogram (ECG)-gated multidetector computed tomography (MDCT) then successful TAVI. The following parameters were determined in the late systolic phase: annular and left ventricular outflow tract (LVOT) diameters, annular perimeter, ellipticity index, annular area, indexed annular area, LVOT perimeter, annulus/LVOT perimeter difference ratio, the LVOT to ascending aorta angle (< LVOT-AO). In the diastolic phase, the extent of calcification of the aortic valve (AVC) was assessed visually and graded semi-quantitatively as grade I, II, and III at the annulus, LVOT, and aortic cusps levels. Pre-discharge transthoracic echocardiography (TTE) was performed, and the PVL was graded as grade I, II, and III. The area-dependent device-annulus sizing ratio was calculated. Absence of PVL was observed in 44.44% of the patients, 30.56% had grade I PVL, 25% of the patients had grade II or above, and any PVL was observed in 55.56%. There was no statistically significant association between the degree of PVL and the extent or the distribution of AVC, aortic annulus diameters, ellipticity index, annulus/LVOT perimeter difference ratio or < LVOT-AO. The frequency of PVL was not significantly different with the use of balloon-expandable or self-expandable valves. A larger transcatheter heart valve (THV)/annulus sizing ratio was associated with a lower incidence and degree of PVL (p<0.001); there was no detectable PVL with a mean sizing ratio of 14.89±7.29, and grade I PVL occurred with a mean sizing ratio 12.43±0.84, while PVL of grade II or above occurred using the mean sizing ratio -0.42±5.57. The procedure-related THV/annulus sizing ratio was an important determinant of the degree of PVL after TAVI, whereas the MDCT-derived anatomical measurements of the aortic root and AVC were not predictors of PVL.

Management of small aortic annulus in the era of sutureless valves: A comparative study among different biological options

ObjectiveAortic valve replacement (AVR) in patients with a small aortic annulus is a challenging problem. The objective of this study was to compare 4 surgical approaches in terms of hemodynamics and perioperative outcomes. MethodsA retrospective single-center study included 351 consecutive patients with a small aortic annulus (≤21 mm) who underwent aortic valve surgery between January 2007 and December 2014. Surgical techniques included standard AVR in 259 (74%) patients, aortic root enlargement in 20 (6%), implantation of a stentless bioprosthesis in 23 (6%), and sutureless AVR in 49 (13%). ResultsThree hundred and eleven (89%) patients were female. The mean Logistic EuroSCORE II varied significantly among the groups and ranged from 6.5% ± 5.4% in the standard AVR group to 9.2% ± 4.7% in the stentless group. Early mortality occurred in 26 (7%) patients. Patients in the stentless group had the lowest aortic valve mean gradients on predischarge transthoracic echocardiography (10.9 ± 6.2 mm Hg; P < .001). In the stented group, the Trifecta prosthesis displayed the lowest postoperative mean transaortic gradient (10.3 ± 3.6; P < .001) with no severe prosthesis-patient mismatch. Postoperative gradients of the sutureless group were comparable with stented prostheses. ConclusionsIn our study, stentless AVR and Trifecta bioprostheses had the best hemodynamic outcomes. The Perceval sutureless prosthesis provides reasonable hemodynamic performance and is a safe alternative.

A granular approach to improve reproducibility of the echocardiographic assessment of paravalvular regurgitation after TAVI.

Paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) is challenging to quantitate. Transthoracic echocardiography (TTE) is the main tool used for the assessment of PVL but is modestly reproducible. We sought to develop a reproducible echocardiographic approach to assess PVL in the post-TAVI setting. Four observers independently analyzed eleven parameters of PVL severity in 50 pre-discharge TTE studies performed after TAVI. The parameters included color-Doppler parameters [jet circumferential extent (CE) and planimetered vena contracta area in the short-axis view and jet breadth and qualitative features in the long-axis views], continuous-wave Doppler parameters [jet velocity time integral (VTI) and pressure half time (PHT)], quantitative Doppler parameters (regurgitation volume and fraction and effective regurgitant orifice area), aortic diastolic flow reversal and valve stent eccentricity. Intraclass correlation coefficient (ICC) and coefficient of variation (CV) for numerical parameters and kappa coefficient (κ) for categorical parameters were calculated for inter- and intra-observer comparisons. Inter-observer ICC was highest and CV lowest for CE (0.88 and 0.36), jet origin breadth (0.82 and 0.39), jet qualitative features in long-axis views (0.87 and 0.26), jet VTI (0.87 and 0.04) and PHT (0.73 and 0.10). Similar results were found in intra-observer comparisons. A 2-step granular approach combining the most reproducible parameters was used to grade PVL by the four observers. Inter-observer agreement was achieved in 86 % of cases (κ = 0.79). Combining color Doppler and continuous wave Doppler parameters in a granular algorithm yields excellent reproducibility of PVL assessment by TTE.Electronic supplementary materialThe online version of this article (doi:10.1007/s10554-016-0947-4) contains supplementary material, which is available to authorized users.

Right ventricular systolic function as a marker of prognosis after ST-elevation inferior myocardial infarction 5-year follow-up

BackgroundThere is scarce data about clinical value of right ventricular (RV) systolic function assessed in pre-discharge transthoracic echocardiography for predicting long-term prognosis in patients with inferior ST-elevation myocardial infarction (MI). MethodsThe aim of this study was to assess correlations of RV function parameters in patients after inferior ST-elevation MI with preserved or mildly impaired left ventricular ejection fraction with prognosis during 5-year follow-up. Primary endpoint was death from any cause or unscheduled hospitalization for cardiac causes (unstable angina/MI, percutaneous coronary intervention/coronary artery bypass grafting due to progression of coronary artery disease, heart failure exacerbation or pacemaker implantation), secondary endpoints were all listed above components analyzed separately. RV systolic function was measured with pulsed tissue Doppler as systolic myocardial velocity at the basal segment of RV free wall in the acute phase and pre-discharge echocardiography. ResultsFollow-up was conducted in 86 consecutive patients (mean age 61±10years, 74% males). Multivariate regression analysis revealed that only RV systolic function in pre-discharge echocardiography correlated independently with the primary endpoint (OR 0.56, 95% CI 0.34–0.92, p=0.02). A positive predictive value of 44% and a negative predictive value of 83% (sensitivity 80%, specificity 49%, AUC 0.7) for predicting the primary endpoint was established for RV systolic myocardial velocity<13cm/s in pre-discharge echocardiography. ConclusionsIn patients after inferior wall ST-elevation MI with preserved or slightly impaired LV systolic function, pre-discharge RV systolic dysfunction correlated independently with worse long-term prognosis.

Transcatheter Procedure for ResidualMitral Regurgitation After MitraClip Implantation Using AmplatzerDuct Occluder II.

This study reports a novel transcatheter procedure for residual mitral regurgitation (MR) after MitraClip implantation using the Amplatzer Duct Occluder II (ADO II). Although the MitraClip procedure is a transcatheter treatment option for patients at high surgicalrisk with severe MR, management of significant residual MR after MitraClip implantation is still challenging. We describe a case series of 9 consecutive patients who underwent transcatheter deployment of the ADO II plug for significant residual MR after MitraClip implantation from April to October2015. The mean age was 79.3 ± 11.4 years. The deployment of the ADO II plug was performed at the initial MitraClip procedure in 7 patients and at the second procedure for recurrent symptoms in 2 patients. There were 2 types of residual MR seen after MitraClip implantation: residual commissural MR (n = 3) and residual intraclip MR (n = 6). The ADO II was successfully deployed with significant reduction of MR flow and left atrial pressure in all patients. The ADO II plug was retrieved in 1 patient because of device embolization to the ostial right coronary artery. However, all patients were discharged 1.8 ± 1.2 days after the procedure, with no significant MR on pre-discharge transthoracic echocardiography. In 8 patients who underwent 1-month symptomatic assessment, clinical symptoms were diminished to New York Heart Association functional class I or II. Transcatheter deployment of the ADO II plug was effective for the reduction of residual commissuralMR and intraclip MR after MitraClip implantation. The potential role of this technique should be established for challenging cases.

136-55: Pericardial effusion during transvenous lead extraction: not always the same story

Purpose: Pericardial effusion (PE) may be a life-threatening complication of lead extraction procedure (TLE). We evaluated causative mechanism of PE formation during TLE and subsequent patient management. Method: From January 2009 to June 2015, TLE of 264 leads in 184 patients(pts)(mean age 69 ± 14 years, 131 male, mean BMI 27 ± 11m2/kg, LVEF 43± 27%) was performed. Indications for TLE included lead dysfunction (60.4%), upgrade (18.9%), infection (13.2%), or other (6.3%). TLE was first attempted using mechanical approach, and eventually combined with laser technique. Extraction procedures were performed under general anesthesia with continuous invasive arterial blood pressure and transesophageal echocardiography (TEE) monitoring. Severity of PE was defined as mild (<10 mm), moderate (11–20 mm), or severe (≥20 mm). Summary of Results: TLE was complete for 256 of 264 leads (97.0%). PE developed in 11 pts (6.0%): mild in 6 pts (3.3%) and severe in 5 pts (2.7%). All patients with severe PE experienced hemodynamic instability; 3 pts required urgent cardiac surgery and 2 patients were treated medically. Key differences between these patients was the site of lesion, namely RV in all patients treated in a conservative manner (fluid infusion and repeated echocardiographic examinations). Laceration of the superior vena cava (2 pts) and right atrial free wall (1 pt) resulted in rescue surgery. Pre-discharge transthoracic echocardiography excluded PE evolution in all cases and no recurrences occurred during follow-up. Conclusion: Sudden onset of severe PE during TLE is a life-threatening condition. Evolution and subsequent pt management depends on the site of lesion, with RV site lesions being self-limiting.

A creative transcatheter approach to correct complex recurring mitral regurgitation after previous surgical repair

Leaflet perforations are usually not treated by interventional therapy. In our case we describe a clinical scenario after previous surgical repair of mitral regurgitation combining several treatment strategies for correction. Under general anaesthesia, and using echocardiographic as well as fluoroscopic guidance, a transseptal approach was carried out and two MitraClips were implanted at the level of A2/P2. At completion echocardiography, a new large regurgitation jet was observed in the centre of the anterior mitral leaflet. We decided to proceed with the implantation of an 8 mm AMPLATZER ASD septal occluder device (AMPLATZER Septal Occluder; St. Jude Medical, St. Paul, MN, USA) to seal the defect. This was accomplished and final echo showed remaining trivial regurgitation from the coaptation area, while the perforation was completely sealed. The patient was discharged in a clinically improved condition. Pre-discharge transthoracic echocardiography showed the two MitraClips as well as the Amplatzer device in a stable correct position with trivial residual mitral regurgitation. The harmonisation of two diametral techniques for the treatment of recurring mitral regurgitation was effective in correcting the underlying problem. This approach may serve as an addition to the armamentarium of physicians treating patients with structural heart valve defects.

Calcific degeneration and rupture of the aortic valve and ascending aorta: from cardiac auscultation to multimodality imaging.

Calcific degeneration and rupture of the aortic valve and ascending aorta: from cardiac auscultation to multimodality imaging.

Prediction of paravalvular leakage after transcatheter aortic valve implantation.

Significant paravalvular leakage (PVL) after transcatheter aortic valve implantation (TAVI) is related to patient mortality. Predicting the development of PVL has focused on computed tomography (CT) derived variables but literature targeting CoreValve devices is limited, controversial, and did not make use of standardized echocardiographic methods. The study included 164 consecutive patients with severe aortic stenosis that underwent TAVI with a Medtronic CoreValve system©, with available pre-TAVI CT and pre-discharge transthoracic echocardiography. The predictive value for significant PVL of the CT-derived Agatston score, aortic annulus size and eccentricity, and “cover index” was assessed, according to both echocardiographic Valve Academic Research Consortium (VARC) criteria and angiographic Sellers criteria. Univariate predictors for more than mild PVL were the maximal diameter of the aortic annulus size (for both angiographic and echocardiographic assessment of PVL), cover index (for echocardiographic assessment of PVL only), and Agatston score (for both angiographic and echocardiographic assessment of PVL). The aortic annulus eccentricity index was not predicting PVL. At multivariate analysis, Agatston score was the only independent predictor for both angiographic and echocardiographic assessment of PVL. Agatston score is the only independent predictor of PVL regardless of the used imaging technique for the definition of PVL.

Predischarge Transthoracic Echocardiography after Surgery for Congenital Heart Disease: A Routine withaReason?

Predischarge (pre-d/c) transthoracic echocardiography (TTE) is routine after surgery for congenital heart disease, but how it affects clinical care is unknown. The aim of this study was to test the hypothesis that pre-d/c TTE frequently reveals findings associated with short-term clinical course through a systematic review of findings on pre-d/c TTE and clinical events that followed. Clinical outcomes of mortality, hospitalization, catheterization, and surgery at 1year were examined for pediatric patients undergoing pre-d/c TTE between June 2010 and June 2012. Using logistic regression, a multivariate model was generated associating clinical, pre-d/c transthoracic echocardiographic, and demographic variables with unplanned postdischarge cardiac events (UCEs) within 1 year. Of 462 patients who underwent pre-d/c TTE, there were 265 male patients (57%) and 197 female patients (43%); the median age was 0.8years (range, 0-33years). Two hundred thirty-seven patients (51%) had findings (valve regurgitation, hemodynamic obstruction, ventricular dysfunction, unintended shunt, or pericardial effusion) on pre-d/c TTE, 57 of which were of more than mild severity. Agreement between pre-d/c TTE and postoperative transesophageal echocardiographic findings was only fair to moderate (κ= 0.27-0.43). Sixty-four patients (14%) had UCEs. Univariate analysis revealed that UCE were more frequent in patients with diagnoses and surgical procedures of high complexity. After accounting for these confounding nonechocardiographic variables, pre-d/c transthoracic echocardiographic findings, specifically valve regurgitation of more than mild severity, and ventricular dysfunction and obstructions of any severity were independently associated with UCEs (odds ratios, 1.90, 1.99, and 1.85, respectively). Findings on pre-d/c TTE are frequent, commonly discordant with postoperative transesophageal echocardiographic results, and associated with adverse clinical events after surgery for congenital heart disease. These data would strongly support the practice of pre-d/c TTE after surgery for congenital heart disease.

A NOVEL APPROACH FOR THE SURGICAL MANAGEMENT OF UNICUSPID AORTIC VALVES: TECHNICAL FEASIBILITY AND EARLY ECHOCARDIOGRAPHIC Results

Despite their overall low incidence, unicuspid valves (one commissure [dashed arrow], two raphes [full arrows], pre-op TEE) are frequent in very young patients with significant aortic valve disease (< 35 years) and present a surgical challenge. Valve repair, which consists of transforming it into a symmetrical bicuspid valve using autologous pericardium, offers the opportunity of delaying replacement. We herein examine our initial experience using this technique to evaluate the technical feasibility and early clinical and echocardiographic results. From June 2012 to December 2013, 7 patients (age: 5 to 25 years) underwent bicuspidization of a dysfunctional unicuspid valve (mean follow-up 1±0.6 years). Aortic regurgitation was the main indication for surgery for all patients (grade 3-4/4). Two patients had concomitant aortic stenosis. Three patients (43%) underwent previous percutaneous valvuloplasty. Four patients (57%) had concomitant ascending aortic replacement (aorta >45mm). All patients had a transthoracic echocardiography before discharge. In all cases, >50% of the valve surface was preserved and the diseased portion replaced with autologous pericardium, to create 2 diametrically opposed commissures and 2 symmetrical cusps (dashed arrows, post-op TEE). The procedure was technically successful in all patients. There were no perioperative mortalities. One patient had a parietal stroke with full recovery. There were no other complications. On pre-discharge transthoracic echocardiography, no patients had ≥1/4 aortic regurgitation. Median mean gradient of 19 mmHg (range 12-35 mmHg) and median peak gradient was 30.3 mmHg (range 22-46mmHg). Median aortic valve area was 1.95 cm2 (range 1.1-2.4 cm2). At last follow-up, all patients were in NYHA class 1. Bicuspidization of the unicuspid aortic valve is a safe and reproducible operation in young patients with encouraging short-term clinical and echocardiographic results. Continued technical improvements and longer term follow-up will determine the potential benefit of this approach in delaying replacement and the need for anticoagulation in this young patient population.

All anterior and bileaflet mitral valve prolapses are repairable in the modern era of reconstructive surgery

Although mitral valve repair is the preferred treatment for degenerative mitral valve disease, valve replacement still remains prevalent, particularly in the setting of anterior leaflet prolapse. We sought to determine the feasibility and mid-term durability of a lesion-based surgical strategy applied systematically in a consecutive and nonexclusionary (all comers) series of patients with degenerative mitral valve disease and either isolated anterior leaflet or bileaflet prolapse. From January 2002 to December 2010, 188 consecutive patients [mean age 56 ± 14 years (range 12-86), 31% female, mean left ventricular ejection fraction 55 ± 9%] underwent surgery for degenerative anterior mitral leaflet prolapse [isolated (n = 42, 22%) or bileaflet prolapse (n = 146, 78%)]. Degenerative aetiology was Barlow's disease in 110 (58%) patients and fibroelastic deficiency in 78 (42%). Patients with anterior leaflet prolapse were significantly more symptomatic (New York Heart Association functional Class III-IV) than those with bileaflet prolapse (28.6 vs 9.6%; P = 0.003) at the time of surgery. All patients underwent mitral valve repair and ring annuloplasty. There was 1 immediate valve replacement due to atrioventricular groove bleeding and consequent haematoma in an elderly female patient (99.5% repair rate). Predominant repair techniques were polytetrafluoroethylene neochordoplasty (or loop technique) in 93 (49%) patients, chordal transfer in 86 (46%) and posterior leaflet flip technique in 21 (11%). Median length of stay was 6 (interquartile 5-8) days. In-hospital mortality was 1% (n = 2). Predischarge transthoracic echocardiography showed none to trace mitral regurgitation in 91% of the patients and mild mitral regurgitation in 9%. The Kaplan-Meier estimates for cumulative survival at 1 and 7 years were 98.4 ± 0.9 and 88.7 ± 2.2%, respectively. Freedom from ≥ moderate mitral regurgitation was 100% at 1 year, 93.7 ± 2.2% at 4 years and 90.3 ± 3.7% at 7 years. When the interval-censored estimator was used, freedom from ≥ moderate mitral regurgitation at 1, 4 and 7 years was 100, 96 and 92%, respectively. A lesion-based surgical approach with an intention to repair all degenerative valves with anterior leaflet prolapse was applied to a consecutive series of patients with degenerative mitral valve disease. We were able to achieve a near-100% repair rate. Repair of all degenerative valves may be feasible with good mid-term durability, regardless of valve morphology, patient age or comorbidities.

Prevalence and causes of failure of receiving thrombolytic therapy in patients with acute ST-segment elevation myocardial infarction

Abstract Background Missing thrombolytic therapy in patients with acute ST-elevation myocardial infarction (STEMI) can have dire consequences. We studied the prevalence and causes of failure of receiving thrombolytic therapy in patients with STEMI and its impact on the clinical outcome during hospitalization. Patients and methods This was an observational, analytic, cross sectional study carried out in the CCU and emergency departments of three public hospitals in Port Said, Egypt. We interrogated all patients admitted within 72 h of possible acute coronary syndrome and only patients proved to have STEMI as defined by the updated ACC criteria were analyzed for receiving thrombolytic therapy or not. All STEMI patients were subjected to: medical history taking, thorough clinical examination, 12-leads surface electrocardiography, cardiac biomarkers (troponin I), and predischarge trans-thoracic echocardiography. Results Of 6522 patients screened, only 288 patients had STEMI. The prevalence of missed thrombolysis in these patients was 45%. Delayed presentation after the onset of symptoms represented the most common cause for failure to receive thrombolysis (54% of the cases), while misdiagnosis at the emergency department represented 35% of the cases. Female gender, diabetes mellitus and inferior location of myocardial infarction were independent predictors of missed thrombolytic therapy. Cardiac death, clinical heart failure and significant cardiac dysrhythmias were higher in patients who missed thrombolysis than in those who received it. Conclusion In this study, up to 45% of patients with STEMI missed the opportunity to receive thrombolysis, most likely due to delayed presentation or misdiagnosis at the emergency department. Patients with missed thrombolysis were at higher risk of cardiac death, clinical heart failure, and hemodynamically significant cardiac dysrhythmias.

Discrepancy Between Intraoperative Transesophageal Echocardiography and Postoperative Transthoracic Echocardiography in Assessing Congenital Valve Surgery

The purpose of this study was to investigate the discrepancy between intraoperative transesophageal and postoperative transthoracic echocardiography in assessing residual regurgitation in children undergoing valve repair. Forty-two consecutive children (median age, 5.1 years) who underwent valve repair for valvar regurgitation from 2001 to 2004 were retrospectively analyzed. The patients were divided into two groups: atrioventricular valve group (n = 33) and aortic valve group (n = 9). Regurgitation grade, fractional shortening, and atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography were compared with those obtained by transthoracic echocardiography at discharge (median, 11 days) and at follow-up (median, 8 months). Intraoperative transesophageal echocardiography revealed specific residual lesions in 4 patients, leading to successful re-repair. Fractional shortening obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the atrioventricular valve group, the regurgitation grade obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (0.7 +/- 0.8 versus 1.4 +/- 0.9; p < 0.01), and agreement between the two examinations was found in 12 patients (38%). Peak atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the aortic valve group, there was no significant difference between the regurgitation grades in the two examinations (0.8 +/- 0.8 versus 1.1 +/- 0.9), and complete agreement in regurgitation grade was found in 5 (56%) of 9 patients. There were considerable discrepancies between the examinations in evaluation of residual atrioventricular valve regurgitation and potential atrioventricular valve stenosis: most of the residual regurgitations were underestimated by intraoperative transesophageal echocardiography. In contrast, reasonable agreement was found between the two examinations in evaluation of aortic valve regurgitation.

Large Annuloplasty Rings Facilitate Mitral Valve Repair in Barlow’s Disease

Excess leaflet tissue in Barlow's disease predisposes patients to left ventricular outflow tract obstruction and residual mitral regurgitation after mitral valve repair as a result of systolic anterior motion of the anterior mitral leaflet. In addition to conventional repair techniques such as sliding plasty and leaflet shortening, our approach in Barlow's disease has included the use of large remodeling annuloplasty rings (up to size 40 mm). We report our experience with the use of large rings in Barlow's disease. From January 2002 to December 2005, 67 patients with Barlow's disease (46 men and 21 women; median age, 55 years; range, 22 to 85 years), mean ejection fraction 0.55 +/- 0.08, and grade 3+ or greater mitral regurgitation underwent mitral valve repair. All had Carpentier type II leaflet dysfunction, with anterior (n = 2), posterior (n = 41), or bileaflet (n = 24) prolapse. Predominant reconstructive techniques were posterior leaflet sliding plasty/plication (n = 65), anterior leaflet triangular resection (n = 16), and chordal transfer (n = 25). Concomitant procedures included coronary artery bypass grafting surgery (n = 8), tricuspid valve repair (n = 20), aortic valve replacement (n = 3), and CryoMaze (n = 22). Mitral valve repair was successfully completed in all patients. Annuloplasty ring size was 36 mm (n = 17), 38 mm (n = 22), and 40 mm (n = 28). Predischarge transthoracic echocardiography showed absence of systolic anterior motion (n = 67), no or trace mitral regurgitation (n = 62), and mild mitral regurgitation (n = 5). There was no operative mortality. Mitral valve repair can be predictably performed in Barlow's disease with excellent early outcomes. Large annuloplasty rings help minimize the risk of systolic anterior motion and are an important adjunct to established repair techniques in this patient cohort with large annular size and excess leaflet tissue.

An unusual complication after chordal sparing mitral valve replacement

J Thorac Cardiovasc Surg 2004;127:599-600 Miomir Dj. Jovic and Miroslav M. Jakovljevic Dusko G. Nezic, Milan M. Vukovic, Milan V. Cirkovic, Aleksandar M. Knezevic,An unusual complication after chordal sparing mitral valve replacement http://jtcs.ctsnetjournals.org/cgi/content/full/127/2/599 located on the World Wide Web at: The online version of this article, along with updated information and services, is

The “clover technique” as a novel approach for correction of post-traumatic tricuspid regurgitation

Objective To describe a novel technique, named “clover,” to correct complex post-traumatic tricuspid valve lesions. Methods Five patients with severe post-traumatic tricuspid insufficiency underwent valve reconstruction with the clover technique, a new surgical approach that consists of stitching together the middle point of the free edges of the tricuspid leaflets, producing a clover-shaped valve. The mechanism of tricuspid regurgitation was complex in all patients, and right ventricular function was always moderately to severely depressed. An echocardiographic study was performed after cardiopulmonary bypass, at discharge, and at follow-up. Results Cardiopulmonary bypass time was 32 ± 6.3 minutes and crossclamp time was 23 ± 7.4. There was no hospital mortality or morbidity. Intraoperative transesophageal and predischarge transthoracic echocardiography showed perfect results in all patients. No late deaths occurred. At the latest follow-up, extending to 14.2 months (mean 11.3; median 12.4), all patients were asymptomatic (New York Heart Association class I) with trivial (2 patients) or no residual regurgitation (3 patients) on 2-dimensional echocardiogram. No transvalvular gradient was revealed in any patient. A significant reduction of the right ventricular end-diastolic dimensions was noted as well (from 54 ± 7.1 mm to 40 ± 7.5 mm, P < .001). Conclusions In this preliminary experience, the clover technique increased the feasibility of tricuspid valve repair in case of severe traumatic tricuspid valve insufficiency, leading to very satisfactory mid-term results even in the presence of complex lesions or dilatation and deterioration of the right ventricle.