Premature Closure Of Mitral Valve Research Articles

Clinical and echocardiographic predictors of decompensation in acute severe aortic regurgitation due to infective endocarditis.

Patients with acute severe aortic regurgitation (AR) due to infective endocarditis can progress rapidly from the hemodynamically stable patient to pulmonary edema and cardiogenic shock. We sought to identify patients at risk of decompensation where emergent surgery should be undertaken. We identified 90 patients with acute severe AR from the echocardiography laboratory database. Baseline clinical, hemodynamic (heart rate (HR) and blood pressure (BP)), and echocardiographic data including mitral filling, premature mitral valve closure (PMVC), and diastolic mitral regurgitation (DMR) were identified. The primary endpoint was subsequent development of pulmonary edema or severe hemodynamic instability. Patients who met the primary endpoint had a higher HR (98.5bpm vs 80.5bpm), lower diastolic BP (54mmHg vs 61.5mmHg), higher mitral E-wave velocity (113cm/s vs 83cm/s), higher E/e' ratio (12.4 vs 8), higher proportion of DMR (27.8% vs 7.4%), and PMVC (25% vs 9.3%) than patients who did not meet the endpoint. The proportion of patients with the primary endpoint increased as HR increased ((≤81bpm) 3/30 (10%), (81-94bpm) 11/31 (35.5%), (≥94bpm) 22/29 (75.9%), P<.0001) and as the diastolic BP reduced ((≤54mmHg) 19/31 (61.3%), (54-63mmHg) 12/31 (38.7%), (≥63mmHg) 5/28 (17.9%), P=.003). Independent predictors were a higher HR (OR 1.08 (95% CI 1.04-1.13) P=.0003) and DMR (OR 4.71 (95% CI 1.23-18.09), P=.02). Decompensation in acute severe AR is common. Independent predictors of decompensation are increasing HR(≥94bpm) and the presence of DMR. Those with these adverse markers should be considered for emergent surgery.

Acute Aortic Regurgitation

Aortic regurgitation (AR) is characterized by regurgitation of blood from the aorta to the left ventricle (LV) during diastole and is attributable to diverse congenital and acquired abnormalities of the aortic valve or the wall of the aortic root. AR can be either chronic or acute. The classic features of chronic AR have been known to clinicians for nearly 2 centuries. Corrigan described chronic AR in 1832 in his text “On Permanent Patency of the Mouth of the Aorta, or Inadequacy of the Aortic Valves.”1 Patients with chronic AR remain asymptomatic for many years as the LV becomes gradually enlarged; cardiac symptoms and clinical congestive heart failure then develop. On the other hand, acute severe AR, if untreated, leads to advanced heart failure and early death. Acute severe AR may be difficult to recognize clinically and is often erroneously diagnosed as another acute condition such as sepsis, pneumonia, or nonvalvular heart disease. Acute or subacute infective endocarditis, aortic dissection, and aortic valve damage caused by trauma are known causes of acute AR. We present 2 cases of acute AR (case 1, infective endocarditis; case 2, Stanford type A aortic dissection), and we propose management plans for each case (Figure 1A and 1B). Figure 1. Proposed management plan for acute aortic regurgitation (AR) due to infective endocarditis ( A ) and aortic dissection ( B ). CHF indicates congestive heart failure; TTE, transthoracic echocardiogram; TEE, transesophageal echocardiogram; IE, infective endocarditis; AR, aortic regurgitation; PMVC, premature mitral valve closure; DMR, diastolic mitral regurgitation; ESMR, early systolic mitral regurgitation; ICU, intensive care unit; EKG, electrocardiogram; LVOT, left ventricular outflow tract; and AV, aortic valve. A 23-year-old man admitted to an intensive care unit with Staphylococcus bacteremia presented with soft heart sounds and a to-and-fro murmur, which progressed to a silent precordium within 24 hours. Bedside transthoracic …

Relation between the presence of echocardiographic vegetations and the complication rate in infective endocarditis

M-mode and two-dimensional echocardiograms of 77 patients with infective endocarditis were examined to determine if presence and/or size of vegetations on echocardigram were predictive of morbidity and mortality. Patients with (n = 43) or without (n = 34) vegetations on echocardiogram did not differ significantly in the proportions developing congestive heart failure (23 of 43 or 53% vs 12 of 34 or 35%) or emboli (11 of 43 or 24% vs 6 of 34 or 18%), whereas a slightly lower proportion of those with vegetations required surgery (5 of 43 or 12% vs 7 of 34 or 21%) or died (3 of 43 or 7% vs 4 of 34 or 12%). No significant relationship was found between vegetation size and the frequency of complications, the need for surgery, or death. In contrast, patients whose echocardiograms demonstrated premature mitral valve closure or chordal or cusp rupture had a significantly higher incidence of heart failure (10 of 13 or 77% vs 22 of 60 or 37%, p < 0.003) and surgery (3 of 13 or 23% vs 7 of 60 or 12%, p < 0.05). We conclude that: (1) the presence of vegetation on the initial echocardiogram is not predictive of the clinical course in infective endocarditis; (2) vegetation size does not predict complications, need for surgery, or death; but (3) valve cusp or chordal rupture and/or premature mitral valve closure are associated with congestive heart failure and the need for surgery.

Left Ventricular Function in Aortic Valve Endocarditis

The value of M-mode echocardiography in assessment of left ventricular (LV) function in patients with aortic regurgitation due to aortic valve endocarditis (AVE) was studied in 12 consecutive patients and compared with the findings in 30 patients with chronic aortic regurgitation (CAR). Patients with AVE had markedly increased LV end-diastolic and end-systolic diameters, whereas fractional shortening was normal. A linear correlation was found between the LV ejection fractions calculated by echocardiography and angiography, but echocardiography markedly overestimated the ejection fractions. There was a close linear correlation between the prematurity of mitral valve closure (MVC) and LV end-diastolic pressure. Patients with CAR had lower end-diastolic pressure, similarly increased LV internal diameters and none had premature MVC. Thus, M-mode echocardiography can identify patients with premature MVC and high LV filling pressure. However, echocardiographic LV function indices based on measurement of internal dimensions overestimate the LV function and these data should be interpreted with caution.

Recognition and Treatment of Acute Aortic Regurgitation

Acute aortic regurgitation usually results from infective endocarditis, but is also caused by aortic dissection and trauma to the heart. Most of the left ventricular stroke volume is regurgitated back into the left ventricle; thus, the forward stroke volume to the body and the cardiac output may be severely compromised. An acute increase in left ventricular end-diastolic volume results in a marked increase in left ventricular end-diastolic pressure, and the mitral valve usually closes prematurely. Compensatory tachycardia is the rule and helps to shorten diastole; thus, the time available for aortic regurgitation to occur is reduced, and the cardiac output is often maintained. On physical examination, there is tachycardia; the peripheral arterial pulse shows a rapid rise, but the systolic pressure is normal; the diastolic pressure is normal or even reduced; and the pulse pressure is often normal. The electrocardiogram (ECG) may be normal except for sinus tachycardia and often for nonspecific ST-T changes. The chest roentgenogram usually shows signs of pulmonary venous hypertension or even pulmonary edema. Echocardiography may show vegetations on the aortic valve, prolapse of an aortic leaflet into the left ventricle, and premature mitral valve closure. Doppler echocardiography is useful in detecting the presence of aortic regurgitation. In cases of infective endocarditis, the appropriate antibiotic therapy must be given. Aortic regurgitation due to dissection of the aorta is usually an indication for surgery. In patients with severe aortic regurgitation, available medical therapy includes digitalis, diuretics, and vasodilators. When patients respond dramatically to the use of digitalis, diuretics, and arterial dilators, surgical therapy can be delayed until heart failure and infection are controlled and the patient is more stable. If the patient does not respond immediately and dramatically to therapy, then valve replacement should not be delayed, even if the infection is uncontrolled or the patient has had little antibiotic therapy.

Effects of timing of atrial systole on LV filling and mitral valve closure: computer and dog studies

Atrioventricular (AV) delay that results in maximum ventricular filling and physiological mechanisms that govern dependence of filling on timing of atrial systole were studied by combining computer experiments with experiments in the anesthetized dog instrumented to measure phasic mitral flow. Ventricular filling volume is maximized at AV delay of 100 ms in the computer study and 80 ms in the dog study. At any time in diastole atrial contraction accelerates mitral flow, opening the mitral valve widely; atrial relaxation then decelerates mitral flow, moving the valve leaflets toward closure. The time the valve remains closed following atrial systole varies inversely with AV delay. When AV delay is optimal, the mitral valve is moving rapidly toward closure but is not yet closed at onset of ventricular systole. The decline in filling volume as AV delay decreases below its optimum value is primarily the result of premature termination of atrial ejection by ventricular systole. As AV delay increases above its optimal value, filling volume progressively decreases because of premature mitral valve closure that limits effective diastolic filling period. There is no significant retrograde mitral flow at any point in diastole for any AV delay.

M-mode and two-dimensional echocardiographic findings in pulmonic valve endocarditis

1. Botvinick EH, Schiller NB, Wickramasekaran R, Klausner SC, Gertz E: Echocardiographic demonstration of early mitral valve closure in severe aortic insufficiency. Its clinical implications. Circulation 519336, 1975. 2. Wigle ED, Labrosse CJ: Sudden, severe aortic insufficiency. Circulation 32:708, 1965. 3. Meadows WR, Van Praagh S, Indreika M, Sharp JT: Premature mitral valve closure. A hemodynamic explanation for absence of the first sound in aortic insufficiency. Circulation 28:251, 1963. 4. Rees JR, Epstein EJ, Criley MJ, Ross RS: Hemodynamic effects of severe aortic regurgitation. Br Heart J 26:412, Case 1. A 24-year-old male heroine addict was hospitalized with chills, fatigue, left pleuritic chest pain, and temperature of 101.4O F. A low-frequency, early diastolic murmur was heard along the upper left sternal border. A chest x-ray film showed bilateral nodular densities consistent with septic pulmonary emboli. Blood cultures were positive for Staphylococcus aureus. An M-mode echocardiogram revealed coarse, shaggy echoes on the pulmonic valve during systole consistent with a vegetation (Fig. 1, left). The other cardiac valves appeared normal. A 2DE revealed a globular mobile vegetation on the posterior leaflet of the pulmonic valve (Fig. 1, right). Oxacillin and gentamicin were administered for 6 weeks with an excellent clinical response. A repeat 2DE at this time again showed the vegetation, although it appeared to have decreased in size. On reevaluation 17 months later the vegetation was no longer seen. 5.

M-mode echocardiographic features of severe aortic valve endocarditis.

We describe and discuss the M-mode echocardiographic features in 10 patients with infective endocarditis of the aortic valve requiring surgery. Operative findings and aortic valve histology were obtained in each case. Vegetations were visualized in six out of seven patients (86%) with proven vegetations while pre-existing aortic valve disease masked their echocardiographic recognition in one patient. Diastolic echoes indistinguishable from vegetations were recorded from the ragged edge of a perforated aortic cusp in one patient who at operation had no demonstrable vegetations. Left ventricular outflow tract (LVOT) echoes were seen in five patients. Non-vibrating LVOT echoes were identified as vegetations while rapidly vibrating LVOT echoes were recorded from a flail aortic cusp. Premature mitral valve closure (PMVC) was seen in five out of seven patients (70%) with a short (less than or equal to four month) history of severe aortic regurgitation. Subannular aneurysms were detected in three out of five patients (60%) with this complication. Increased septal and left ventricular posterior wall motion suggestive of severe aortic regurgitation was seen in each case. The detection of a flail aortic valve leaflet, PMVC and subannular aneurysms indicates the need for surgery. The demonstration of vegetations defines a further subgroup of patients who should be managed in a centre with facilities for cardiac surgery. Echocardiography obviated the need for pre-operative cardiac catheterization in nine out of 10 patients (90%).

ACUTE AORTIC REGURGITATION WITH CONGESTIVE HEART FAILURE DUE TO BACTERIAL ENDOCARDITIS: DIAGNOSED BY ECHOCARDIOGRAM AND TREATED SUCCESSFULLY BY SURGERY A CASE REPORT

A 23-year-old Japanese male with no evidence of previous heart disease was presented with bicuspid aortic valve and a life threatening acute aortic regurgitation due to subacute bacterial endocarditis. By echocardiographic techniques, a precise diagnosis was made based on the following findings: 1) premature mitral valve closure, 2) snowfall-like echoes between the systolic aortic cusps, 3) eccentricity of a diastolic aortic valvular echo. The echocardiographic diagnosis was confirmed on surgery, in which aortic valve replacement was performed with satisfactory postoperative results.

Echocardiographic Diagnosis of Acute Aortic Valve Endocarditis and Its Complications

Staphylococcus aureus aortic valve endocarditis and its complications in a patient were readily recognized by echocardiography. "Shaggy" echoes recorded from the aortic leaflets in diastole as well as irregular diastolic densities in the left ventricular outflow tract suggested flail aortic leaflets secondary to bacterial endocarditis. The presence of a double echo of the anterior aortic wall was an unusual finding. Initially thought to represent a localized dissection, abscess formation and pocket of edematous fluid accumulation was found between the anterior aortic wall and pulmonary artery. Premature closure of the mitral valve was evident shortly before the patient died. The specific echocardiographic features of flail aortic leaflets and premature mitral valve closure should alert the physician to consider immediate aortic valve replacement.

Echocardiographic diagnosis of acute aortic valve endocarditis and its complications

<i>Staphylococcus aureus</i>aortic valve endocarditis and its complications in a patient were readily recognized by echocardiography. "Shaggy" echoes recorded from the aortic leaflets in diastole as well as irregular diastolic densities in the left ventricular outflow tract suggested flail aortic leaflets secondary to bacterial endocarditis. The presence of a double echo of the anterior aortic wall was an unusual finding. Initially thought to represent a localized dissection, abscess formation and pocket of edematous fluid accumulation was found between the anterior aortic wall and pulmonary artery. Premature closure of the mitral valve was evident shortly before the patient died. The specific echocardiographic features of flail aortic leaflets and premature mitral valve closure should alert the physician to consider immediate aortic valve replacement. (<i>Arch Intern Med</i>137:85-89, 1977)

Spectrum of echocardiographic findings in bacterial endocarditis.

Forty-seven echocardiograms were obtained in 32 patients with bacterial endocarditis. Preexistent abnormalities were found in 14 patients. In five of them thought to have bacterial endocarditis on normal valves, echocardiography showed mitral stenosis (one), bicuspid aortic valve (two), and prolapse of mitral valve (two). Definite vegetations were seen in 22 patients--on the aortic valve in seven, the mitral valve in 12, and both valves in three. Ten patients had milder changes suggestive but not diagnostic of vegetations. In 12 patients, surgery confirmed the echocardiographic findings. Fourteen had systemic embolic episodes and all had echocardiographic evidence of vegetations. Abnormalities secondary to bacterial endocarditis, other than vegetations, were common. Twenty-one patients had left ventricular volume overload. Ten had a flail posterior leaflet of the mitral valve, three of which were confirmed surgically. Eight had abnormal coarsely fluttering echoes in the left ventricular outflow tract consistent with a prolapsing aortic valve or underlying aortic vegetations; four were confirmed by surgery. Five had signs of severe aortic regurgitation of recent onset (premature mitral valve closure) and all had confirmation by surgery. Echocardiographic abnormalities persisted after successful medical treatment. We conclude that echocardiography is helpful in patients with bacterial endocarditis. It permits recognition of unsuspected preexistent lesions and the characteristic vegetations, as well as the extent and nature of valvular damage secondary to bacterial endocarditis. However, echocardiography does not differentiate between active and healed lesions.

Reversal of premature mitral valve closure by nitroprusside infusion in severe aortic insufficiency: Beat to beat pressure-flow and echocardiographic relationships

Reversal of premature mitral valve closure by nitroprusside infusion in severe aortic insufficiency: Beat to beat pressure-flow and echocardiographic relationships

Diastolic murmurs in the presence of Starr-Edwards mitral prosthesis.

Diastolic murmurs associated with the Starr-Edwards mitral prosthesis have not been described previously. In this report, five patients with mitral prostheses are described in whom apical mid-diastolic and presystolic murmurs resulted from two different causes. Three patients had clots obstructing the prosthetic orifice. The other two had normally functioning protheses and moderately severe aortic insufficiency. The occurrence of mid-diastolic and presystolic murmurs in the presence of a normally functioning prosthetic mitral valve demonstrates that 1) the mid-diastolic Austin Flint murmur can occur in the absence of incomplete mitral valve opening, premature mitral valve closure, vibrating mitral leaflets, or relative mitral stenosis and 2) the presystolic Austin Flint murmur can occur in the absence of incomplete valve opening or presystolic mitral regurgitation. However, the presystolic murmur was associated with early closure movement of the presthetic poppet.

Premature Mitral Valve Closure

The phenomenon of premature mitral valve closure is described in three patients with severe aortic insufficiency and related to absence of the first heart sound. The occurrence of premature mitral closure is favored by severe aortic regurgitation probably with increased impedance to left ventricular filling. Available evidence suggests that this phenomenon usually occurs in the more rapidly developing forms of aortic incompetence (bacterial endocarditis, post surgical, and traumatic rupture of the valve), that it is uncommon, and that it often implies a grave prognosis. It should be suspected when the apical first heart sound is absent in aortic incompetence.