Presence Of Mitral Regurgitation Research Articles

Review of surgical ventricular restoration: A procedure to treat cardiac failure

Severe heart failure refractory to medical treatment necessitates the use of other modalities of treatment. Surgical ventricular restoration (SVR) surgery can provide relief until donour hearts are available or when transplantation is contraindicated. In this review we look at the physiological basis for improvement in cardiac function and cardiac and haemodynamic changes that occur after SVR. We also compile the reported factors affecting surgical outcome, criteria for patient selection and predictors of postoperative mortality. NYHA class, presence of diastolic failure, severe impairment of contractile function and presence of mitral regurgitation were the most important determinants. Various different procedures for achieving SVR are briefly discussed. Importance of mitral valve repair/replacement, coronary artery bypass grafting and intraoperative echocardiography in improving postoperative result is highlighted. Role of perioperative medication (anti-arrhythmics, ACE inhibitors and β-blockers) is briefly studied at the end of the review.

Mitral regurgitation is an independent predictor of 1-year mortality in ST-elevation myocardial infarction patients presenting in cardiogenic shock on admission.

Cardiogenic shock (CS) remains the most serious complication of acute ST-elevation myocardial infarction (STEMI). Mitral regurgitation (MR) is a frequent complication of STEMI and a well-known predictor of mortality in STEMI without CS. The purpose of this study was to determine the prognostic significance of MR in STEMI patients with CS on admission. Mitral regurgitation was assessed in 147 consecutive STEMI patients with CS on admission and treated by primary percutaneous coronary intervention (PCI). Color Doppler of MR was graded with a 0 to 3 scale (none, n = 26; 1 = mild, n = 62; 2 = moderate, n = 40; 3 = severe, n = 19). Overall one-year mortality in the study cohort was 27%. One-year mortality was 8%, 23%, 30% and 58% for patients with no, mild, moderate and severe MR respectively (P <0.001). For each grade of MR increase, the odds for mortality increased with 71% (OR: 1.71; 95% CI: 1.02-2.87; P = 0.043) when adjusted for age, gender, previous myocardial infarction, left ventricular ejection fraction (LVEF) <40%, multivessel disease and no-reflow. The presence of MR on early echocardiography is an important independent predictor of one-year mortality in STEMI patients with CS on admission treated by primary PCI.

Atrial fibrillation complicating acute myocardial infarction: how should it be interpreted and how should it be treated and prevented?

Atrial fibrillation (AF) has been reported to complicate the course of acute myocardial infarction (AMI) in ∼6–21% of hospitalized patients.1 Possible precipitating factors of AF in this setting include atrial ischaemia or infarction, right ventricular infarction, pericardial inflammation, acute hypoxia or hypokalaemia, and haemodynamic impairment secondary to left ventricular (LV) dysfunction.2–4 Endogenous or exogenous catecholamines may also precipitate AF. These factors can be found alone or in combination, and may superimpose on predisposing diseases affecting cardiac anatomy and physiology, such as previous cardiomyopathy, valvular impairment, or chronic lung disease. Finally, AF in the setting of AMI has been reported to be associated with ageing, severely impaired LV function, presence of mitral regurgitation, or frequent ventricular arrhythmias plus right bundle branch block, and presence of left bundle branch block. Although most of these factors are claimed to be causative of AF, the intimate relationship between their presence and AF occurrence is not known. Despite the variability of factors and conditions associated with AF in clinical practice, patients developing this arrhythmia during AMI are usually reported as a uniform category. AF can cause haemodynamic instability because of the rapid ventricular rate, irregular ventricular filling, and/or loss of atrial contribution to cardiac output,5 ultimately leading to an increase in oxygen demand. If deterioration of the haemodynamic balance secondary to AF may intuitively affect pre-discharge outcome of AMI victims, less intuitive is the association between AF in the early phase of AMI and long-term outcome. Schmitt et al. report on a clinical review evaluating the incidence, clinical features, and prognostic implication of AF in AMI.1 Through this investigation, the authors provide a summary on clinically relevant items such as identification of clinical variables associated with the development of AF and their prognostic implications, incidence of in-hospital and post-discharge … *Corresponding author. Tel: +39 02 5277 4337, Fax: +39 02 5560 3125, Email: rcappato{at}libero.it

Mitral Valve Repair in Patients With Advanced Heart Failure and Severe Functional Mitral Insufficiency Reverses Left Ventricular Remodeling and Improves Symptoms

Mitral regurgitation (MR) is commonly observed in patients with heart failure and associated with a poor prognosis.1–3 Mitral valve repair or replacement to restore valve competency is a well-established procedure when there are symptoms of heart failure and the primary disease is of the valve leaflets. However, recent interest has focused on functional or secondary mitral insufficiency in which the valve leaflets are anatomically normal but do not fully coapt because of annular dilatation and restricted leaflet motion secondary to increased ventricular size and sphericity. Such a remodeled ventricle is often associated with an ejection fraction of ≤40% and heart failure symptoms of New York Heart Association (NYHA) class III or IV. Surgery in this situation is controversial, as the MR is the consequence and not the cause of left ventricular (LV) dysfunction, and the prognosis, therefore, is more related to the underlying cardiomyopathic process. In addition, it has been thought in the past that elimination of a low pressure runoff might worsen the overload of the left ventricle and contribute to the high mortality seen with mitral valve surgery in heart failure patients. Progressive LV remodeling characterized by progressive LV dilatation and change to a more spherical shape can result in functional MR as a result of annular dilatation, papillary muscle displacement, and chordal tethering. The functional MR leads to an increased preload, increased wall tension, and increased LV workload, all of which contribute in a positive feedback loop to progressive heart failure. The presence of MR itself is the independent risk factor of poor outcome, both in nonischemic and ischemic etiologies.1–3 Even uncorrected mild MR, as well as moderate to severe MR associated with ischemic cardiomyopathy, is associated with reduced long-term survival.4 In addition, it is a progressive disorder in which MR-related LV volume overload …

Embolic Potential of Cardiac Tumors and Outcome After Resection

Embolic events have long been thought to occur in patients with cardiac tumors secondary to embolization of tumor fragments; however, there are no large studies examining the epidemiology and occurrence of embolism in this group of patients. From 1957 to 2006, 323 consecutive patients with primary cardiac tumors were treated surgically at our institution. Of these, patients who experienced an embolic event included 80 (cerebrovascular accident 31 [9.7%], transient ischemic attack 30 [9.3%], and other 19 [6%]). Those with no history of an embolic event (n=243 [75%]) were defined as control subjects. Age was similar between the case and control groups (mean 54.5 versus 53.9 years, P=0.8). A multivariate logistic regression model including tumor location, tumor burden, tumor histology, and cerebrovascular risk factors, indicated that left atrial tumors (OR, 1.95; P=0.04), aortic valve tumors (OR, 4.17; P=0.002), and smaller tumor burden (OR, 2.20; P=0.01) were the most significant factors in the occurrence of embolism (P<0.001). The presence of mitral regurgitation (OR, 0.12; P=0.006) and decreased functional status (New York Heart Association III/IV; OR, 0.31; P<0.001) were protective against the occurrence of embolism. Follow-up was obtained in 82% at a mean follow-up time of 6.17+/-6.9 years. There were no recurrent embolic events at follow-up. A Kaplan-Meier survival curve demonstrated no difference in survival between both groups (P=0.78). Aortic valve and left atrial tumors have the greatest anatomic risk for embolism. Furthermore, patients with smaller tumors, minimal symptomatology, and no evidence of mitral regurgitation have a high risk of embolism. Cardiac tumors can be resected with low early mortality, and late survival after operation in the context of an embolic event is similar to patients with cardiac tumors who undergo resection for other indications.

Abstract 3184: Dynamics of Mitral Complex Geometry During Left Ventricular Pressure Overload: in Vivo Experimental Study by Real-time 3D Echocardiography

Background: Functional mitral regurgitation (MR) occurs as a consequence of regional or global left ventricular (LV) dysfunction despite a structurally normal mitral valve (MV). Degree of MV coaptation should be an important parameter in the assessment of functional MR. Purpose: We sought to investigate the change of MV coaptation and to clarify relationship between MV coaptation and development of MR in LV pressure overload. Methods: Using a canine model, LV pressure overload was induced by staged aortic banding (60 to 120mmHg). Echocardiographic examinations were performed before and during the banding. Degree of MR was evaluated by tracing the color jet MR area (MR area). By using a novel software system (RealView TM ) for 3D quantification, mitral annulus (MA) area, tenting volume, tenting length and 3D tenting surface area were analyzed. MA and surface of MV was manually traced both at the onset of MV closure [O] and at the maximum MV closure [M]. Coaptation index was calculated by the difference in 3D tenting surface area at O and at M devided by that at O. Results: MA area was gradually increased during banding ( p &lt; 0.01). Tenting length and tenting volume tended to increase during banding but they did not reach statistical significance (tenting length; p = 0.17, tenting volume; p = 0.12). MR area increased with decrease in coaptation index (Figure ). The best cutoff value of the coaptation index to predict presence of MR was calculated as 0.24, giving a sensitivity of 82 % and specificity of 86 %. Conclusions: During aortic banding, MA dilated and coaptation of the MV decreased with apparent leaflet tenting. Coptation index might be able to predict the appearance of functional MR.

Epidemiology of pure valvular regurgitation in the large middle-aged African American cohort of the Atherosclerosis Risk in Communities study

There are limited data on the prevalence and the clinical and echocardiographic correlates of pure valvular regurgitation in African Americans despite the higher rates of cardiovascular disease in this group. The Jackson, Mississippi, site of the Atherosclerosis Risk in Communities study provides a unique opportunity to study mitral regurgitation (MR), tricuspid regurgitation (TR), and aortic regurgitation (AR) in this population. There were 2285 participants who were available for analysis. The prevalence rates of MR, TR, and AR by severity were calculated for participants aged 50 to 59, 60 to 69, and > or = 70 years. Multivariable regression analyses were conducted to determine clinical and echo variables associated with the presence of MR, TR, and AR. Mild or greater MR and TR were present in 14.7% and 17.2% of participants, respectively. Aortic regurgitation was present in 15.6% of participants. In the multivariable regression model, MR was independently associated with age, sex, lower body mass index (BMI), systolic blood pressure, left atrial size, left ventricular (LV) diastolic diameter, and low LV ejection fraction. Tricuspid regurgitation was independently associated with age, sex, lower BMI, high-density lipid, left atrial size, and lower relative wall thickness. Aortic regurgitation was independently associated with age, sex, lower BMI, systolic blood pressure, LV diastolic diameter, LV hypertrophy, and low LV ejection fraction. In this middle-aged African Americans cohort, the prevalence of mild to greater MR and TR was similar to that seen in other cohorts; however, AR was more prevalent. Several cardiovascular risk factors and echo parameters were identified as independent correlates of valvular regurgitation.

Central haemodynamics and peripheral muscle function during exercise in patients with chronic heart failure

In this narrative review of the current literature, we examine the central and peripheral mechanisms responsible for the exercise intolerance of chronic heart failure and highlight briefly the benefits of exercise training in the treatment of this debilitating disorder. Specifically, we identify the common finding of reduced cardiac output reserve during exercise conditions leading to decreased exercise tolerance. We also reveal that the stroke volume response to exercise varies depending on the individual patient, the presence of mitral regurgitation, and the aetiology of heart failure. Chronic heart failure patients with left ventricular systolic dysfunction appear able to use the Frank-Starling mechanism to compensate (in part) for their decreased contractile reserve. Patients with left ventricular diastolic dysfunction have normal contractile function; however, they are unable to make use of the Frank-Starling mechanism during exercise conditions. We also reveal that pericardial constraint may limit diastolic filling and exercise capacity in patients with chronic heart failure. It appears that interventions that reduce pericardial constraint and mitral regurgitation enhance diastolic filling and increase exercise tolerance. A series of peripheral muscle changes also occur, including changes in muscle mass, cellular structure, energy metabolism, and blood flow. Each of these factors is associated with decreased exercise capacity and the symptoms of chronic heart failure. Exercise training has been shown to improve both central haemodynamics and peripheral muscle function leading to improvements in exercise capacity, functional status, and overall quality of life in patients with chronic heart failure.

Brain Natriuretic Peptide: Just a Guide to Heart Failure or Biomarker of LV Remodelling?

Background: The natriuretic peptide brain natriuretic peptide (BNP) is principally located within ventricular myocardium, and thought to be released to the circulation in response to elevated wall stress. In conjunction, it has been found that plasma BNP levels are elevated in heart failure (HF) leading to the development and widespread use of plasma BNP measurement as a diagnostic test for HF. However, it remains somewhat unclear as to whether plasma BNP is merely a correlate of overall HF severity or whether it is more specifically a biomarker for left ventricular remodelling. Methods: In this study we therefore examined the relationship between plasma BNP and indices of LV and LA remodelling including the presence of mitral regurgitation. Plasma BNP assays and echocardiography was conducted in 144 HF patients on a total of 203 occasions. Results: Plasma BNP was significantly correlated with LV end systolic diameter (r = 0.27, p < 0.001), LVEF (r = −0.38, p < 0.001), cardiac output (r = −0.30, p < 0.001), mitral regurgitation grade (r = 0.38, p < 0.001) and RV systolic pressure (r = 0.32, p < 0.001). Of note, plasma BNP did not correlate with LA dimension, RV diameter or LV mass. In a multiple regression analysis plasma BNP was most influenced by LVEF and RV systolic pressure (r = 0.47, p < 0.001). RV systolic pressure was strongly associated with the degree of MR (r = 0.35, p < 0.001). Conclusion: Plasma BNP is probably determined by a complex interplay between the extent of LV remodelling in conjunction with the extent of volume overload secondary to associated MR.

Relation between Sympathetic Overactivity and Left Atrial Spontaneous Echo Contrast in Patients with Mitral Stenosis and Sinus Rhythm

Spontaneous echo contrast (SEC) is common in patients with mitral stenosis (MS) and presence of SEC in left atrium (LA) is associated with a higher risk of thromboembolism. Recently, an increase in activation of platelets was demonstrated in patients with SEC raising the hypothesis that platelets are involved in the pathogenesis of SEC. In this study, we evaluated effects of autonomic nervous system activity on SEC formation in patients with rheumatic MS and sinus rhythm by heart rate variability analysis. Twenty-six patients with LASEC were compared with 28 patients without LASEC. Mean heart rate, low frequency (LF) and low frequency/high frequency (LF/HF) ratio were significantly higher, standard deviation of all NN (SDNN), root mean square of successive differences (RMSSD), number of NN intervals that differed by more than 50 ms from adjacent interval divided by the total number of all NN intervals (PNN50) and high frequency (HF) values were lower in the patients with LASEC. A standard deviation of all NN intervals <90ms separated the patients with LASEC from control subjects with a sensitivity of 77% and specificity of 90%; a low frequency >79.5 with a sensitivity of 92% and specificity of 90; a low frequency/high frequency ratio >3.7 with a sensitivity of 96% and specificity of 90%. A left atrial diameter >4.3 cm increased the LASEC formation by 3.0 folds, HR >78 beats/min by 6.4 folds, standard deviation of all NN intervals <90 ms by 9.2 folds, a low frequency/high frequency ratio >3.7 by 6.4 folds, sP-selectin>142 by 5.8 folds. Variables affecting sP-selectin levels were LA diameter, mitral valve area, transmitral mean gradient, left ventricular ejection fraction, the presence of mitral regurgitation, HR, standard deviation of all NN intervals, low frequency, high frequency and low frequency/high frequency ratio. Sympathetic overactivity and reduced heart rate variability are important determinants for LASEC formation and increased s-P selectin levels. Therefore, platelet activation via increased sympathetic activity may play an important role in pathogenesis of LASEC.

Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome

The development of mitral regurgitation (MR) after an acute myocardial infarction (AMI) is a recognized and frequent complication and its negative impact on survival has been observed. However, few data exist regarding MR after non-ST-segment elevation acute coronary syndrome (NSTSEACS). Our aim was to investigate the incidence, clinical predictors, and prognostic implications of MR in the setting of NSTSEACS. We studied 300 consecutive patients (71.7% men, mean age 66.9+/-13 years) admitted to our coronary care unit for an NSTSEACS. Every patient underwent an echocardiographic study during the first week after the index NSTSEACS and was clinically followed up. MR was detected in 42% (126 patients; 88 men, mean age 71.3+/-11 years). Mean follow-up was 425.6+/-194.8 days. Only age and left ventricular (LV) ejection fraction (EF) were found as independent markers of the development of MR; no variable was found as an independent predictor of in-hospital mortality and only MR was found as an independent predictor of long-term outcome. MR is frequent after an NSTSEACS. Age and a low LV EF are factors associated to its development. The presence and degree of MR confer a worse long-term prognosis to patients after a first NSTSEACS. Thus, the presence of MR should be specifically assessed in every patient after an NSTSEACS.

Renal failure after percutaneous coronary intervention is associated with high mortality

Renal failure is a marker of poor outcome in the general population. Renal failure after percutaneous coronary artery intervention (PCI) is associated with an increased hazard of in-hospital mortality. We hypothesized that post-PCI renal insufficiency would be a predictor of long-term mortality in patients undergoing PCI who survive for over 30 days after the procedure. A retrospective analysis was conducted from a registry of 9,067 patients undergoing PCI at our center from 1997 to 2001. A rise in creatinine by 1 mg/dl from baseline was defined as post-PCI renal insufficiency. Vital status was assessed using Social Security Death Index. There were a total of 996 deaths over a mean follow-up period of 3.2 years. In a multivariate analysis, history of recent acute myocardial infarction, older age, insulin-dependent diabetes, baseline creatinine greater than 1.5 mg/dl, and presence of mitral regurgitation were associated with post-PCI renal insufficiency. Developing post-PCI renal insufficiency was associated with a 4.31-fold hazard of mortality in univariate analysis and a 1.77-fold hazard after adjustment for known predictors of mortality after PCI. The 1-year survival in patients with renal failure was 70.3% +/- 3.91%, compared to a survival of 93.6% +/- 0.27% in those without any post-PCI renal insufficiency (P < 0.0001). Acute renal insufficiency after PCI is a strong and independent predictor of long-term mortality in patients who survived for 30 days after the procedure.

Importance of mitral regurgitation in ischaemic heart disease—more than just a bystander

This editorial refers to ‘Prognostic influence of mitral regurgitation prior to a first myocardial infarction’† by J. Zamorano et al. , on page 343 Coronary artery disease (CAD) prognosis has been known for many years to depend on many factors, including the degree of left ventricular (LV) dysfunction as well as the presence of inducible ischaemia, viable dysfunctioning myocardium, and degree of coronary artery lesions. Mitral regurgitation (MR) is often a bystander and is a frequent finding after acute myocardial infarction (AMI) (in 15–64% of patients). It is an independent predictor of cardiovascular mortality,1–4 and results from many factors, such as papillary muscle dysfunction and/or mitral annulus dilatation, and LV remodelling with papillary muscle migration causing malcoaptation of the leaflets and excess valvular tenting with loss of systolic annular contraction.2 Myocardial viability in the infarct area reduces infarct expansion and ventricular remodelling, and prevents the development of MR. In the study by Golia et al. 1 of 191 patients after uncomplicated AMI, MR was present in 58.6% of the patients and it was significant (>grade 1) in 26 patients (13.6%). It was associated with increased age, lower regional wall motion score index during dobutamine stress echocardiography, more severe CAD, and more frequent anterior/inferior infarctions. At multivariate analysis the extent of LV dysfunction and the presence of MR were significantly related to mortality. Auscultation may not detect a murmur due to decreased turbulence, and echocardiography should be performed routinely on all patients for diagnosis. A regurgitant volume ≥30 mL, or an effective regurgitant orifice ≥2 mm2 defines a high-risk group.4,5 Many papers have focused on the importance of correcting MR during coronary artery bypass grafting (CABG) for a better long-term prognosis, even when there is no definite major organic cause (such … *Tel: +351 21 8465469; fax: +351 21 8465469. E-mail address: branco.online{at}mail.telepac.pt

Correlates of left atrial size in hypertensive patients with left ventricular hypertrophy: the Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) Study.

Left ventricular hypertrophy has been suggested to mediate the relation between hypertension and left atrial enlargement, with associated risks of atrial fibrillation and stroke. However, less is known about correlates of left atrial size in hypertensive patients with left ventricular hypertrophy. We assessed left atrial size by echocardiography in 941 hypertensive patients, age 55 to 80 (mean, 66) years, with electrocardiographic left ventricular hypertrophy at baseline in the Losartan Intervention For Endpoint reduction in hypertension study. Enlarged left atrial diameter (women, >3.8 cm; men, >4.2 cm) was present in 56% of women and 38% of men (P<0.01). Compared with the 512 patients with normal left atrial size, the 429 patients with enlarged left atrium more often had mitral regurgitation, atrial fibrillation, and echocardiographic left ventricular hypertrophy. They also had higher age, systolic blood pressure, pulse pressure, weight, body mass index, left ventricular internal chamber dimension, stroke volume, and mass and lower relative wall thickness and ejection fraction (all, P<0.05). In logistic regression analysis, left atrial enlargement was related to left ventricular hypertrophy and eccentric geometry; greater body mass index, systolic blood pressure, and age; female gender; mitral regurgitation; and atrial fibrillation (all, P<0.05). Thus, left atrial size in hypertensive patients with electrocardiographic left ventricular hypertrophy is influenced by gender, age, obesity, systolic blood pressure, and left ventricular geometry independently of left ventricular mass and presence of mitral regurgitation or atrial fibrillation.

Relationship between mitral regurgitation and myocardial viability after acute myocardial infarction: their impact on prognosis

Mitral regurgitation (MR) after acute myocardial infarction (AMI) is an important prognostic factor. Although its mechanisms are still debated, ventricular remodeling probably plays an important role. Because myocardial viability (MV) in the infarct zone reduces infarct expansion and ventricular remodeling, it is also possible that its presence counteracts the development of mitral regurgitation in infarcted patients. To evaluate this issue 191 patients with uncomplicated AMI, wall motion abnormalities (akinesis) and semiquantitative evaluation of MR were retrospectively selected from those consecutively examined at our echo-laboratory to evaluate MV using low-dose dobutamine echocardiography (DbE). Follow-up evaluation was performed at 30±13 months. Seventy-nine patients had no MR; 86 patients had grade 1 MR, 11 patients had grade 2 MR, nine patients had grade 3 MR, and six patients had grade 4 MR. Patients with significant MR (>grade 1) were older (63±7 vs. 59±10 years, P=0.03), had lower reduction of RWMSI (ΔRWMSI) during DbE (0.08±0.11 vs. 0.22±0.28, P=0.01), more stenotic vessels at coronary angiography (2.35±0.93 vs. 1.67±1.12, P=0.01), and more frequently had anterior–inferior AMI ( P<0.0001); they also had a non-significant tendency to higher RWMSI (2.04±0.38 vs. 1.92±0.28, P=0.06). In a multivariate regression analysis, ΔRWMSI proved to be significantly related to the grade of MR ( P=0.02). Eighteen patients died during follow-up. Death was more frequent in patients with MR (10/165 vs. 8/26, P=0.0003). At multivariate stepwise Cox regression analysis both the extent of ventricular dysfunction and the presence of MR were significantly related to mortality ( P<0.0001 and P=0.01, respectively); ΔRWMSI showed a non-significant tendency to influence mortality ( P=0.09). When MR was excluded from the multivariate analysis, ΔRWMSI remained significantly related to mortality ( P=0.05). In conclusion our study suggests that the presence of MV in infarcted patients influences the development of MR. This reduction of MR may be one of the mechanisms by which MV affects mortality after AMI and should be considered in all studies that evaluate MV after myocardial infarction.

Echocardiographic Prediction of Severe Mitral Regurgitation after Percutaneous Mitral Valvuloplasty with the Inoue Balloon

Background and Objectives:This study was designed to predict the development of severe mitral regurgitation (MR) following percutaneous mitral valvuloplasty (PMV) in patients with a favorable morphology of the mitral valve (MV). Subjects and Methods:We prospectively examined 253 patients with severe mitral stenosis from 1997 to 2000. Echocardiographic evaluation of MV morphology was performed prior to PMV. We proposed commissural calcification, severe relative prolapse, and uneven thickening of MV as predictors of MR following PMV and defined the MR risk group as patients with any of these 3 features. The balloon size was expressed as the value of the effective balloon dilating area divided by the body surface area. The larger balloon group was defined as patients in whom balloon size>3.8 cm/m was selected for PMV. The development of severe MR was defined as the presence of MR≥3+ on echocardiography following PMV. Results:Severe MR developed in 14 (5.5%) patients. On multiple logistic regression analysis, the MR risk group (p 8 and MR risk group was 43%, 88% and 71%, 86% respectively. In the MR risk group, severe MR developed in 8 (53.3%) of 15 patients of the larger balloon group as compared with 2 (6.9%) of 29 patients of the smaller balloon group (p=0.001). Conclusion: Echocardiography can identify patients with a high risk of developing MR after PMV and the use of a smaller Inoue balloon may prevent severe MR in selected patients. (Korean Circulation J 2001;31(12):1311-1317)

Comparative Study Between Various Methods of Percutaneous Transvenous Mitral Commissurotomy Metallic Valvotome, Inoue Balloon, and Double-Balloon Techniques (VID) Study

The aim of this study was to compare the immediate results of percutaneous mitral commissurotomy using metallic valvotome, Inoue balloon, or double-balloon techniques. We conducted a randomized trial comparing the immediate results of the three procedures in 150 patients (50 patients in each group) who were rheumatic mitral stenosis candidates for valvuloplasty. The procedures used per group were metallic valvotome (group I), Inoue balloon (group II), and double balloon (group III). The three groups were similar in age, sex, MVA, transmitral PG, LV function, predicted PAP, and presence of mitral re gurgitation. Patients in group I had a higher MV score (>9) than group II and III. The MVA was increased by a similar degree in groups I and III (2.1 ± 0.5 cm2, 2.0 ± 1.2 cm2) but greater than group II (1.87 ± 0.4 cm2) (P = 0.01). Mean transmitral PG was lower in group III (4.3 ± 1.9 mmHg) than in groups I and II (6.3 ± 3.7 mmHg, 6.3 ± 5.3 mmHg), respectively (P = 0.01). Echocardiographic data showed a higher depth score of posterior commissural splitting in groups I and III (0.7 ± 0.3 cm, 0.8 ± 0.3 cm, respectively) than in group II (0.6 ± 0.3) (P = 0.006), while the depth score of anterior commissure splitting was comparable in all groups (0.6 ± 0.3, 0.6 ± 0.3, and 0.7 ± 0.3, respectively) (P = 0.4). Stepwise multivariate regression analysis revealed that the following variables significantly affect the success of valvuloplasty as evidenced by a MVA ≥ 1.5 cm2. (1) techniques, the larger MVA was achieved by valvotome and double balloon (P = 0.0001); (2) MVA before valvuloplasty, the larger the MVA before, the larger the MVA after (P = 0.0008); (3) valve thickness, the more the thickness, the smaller the achieved MVA (P = 0.01); und (4) valve mobility, the more limited mobility, the smaller the MVA (P = 0.007). Small and restrictive ASD was present in 14 (28%) patients in group I, 2 (4%) patients in group II, and 3 (6%) patients in group III. Changes in grade of mitral regurgitation was comparable in all groups as the grade increased by I grade (40% in group I, 36% in group II, and 36% in group III). In contrast to the Inoue balloon technique, the metallic valvotome, and double-balloon technique produced an excellent and comparable early improvement of MVA associated with minimal complications. However, the good results achieved with patients who had a higher MV score (≥9) by metallic valvotome and lower cost indicate that metallic valvotome should be the treatment of choice for tight mitral stenosis.

Duration of Preoperative Electrocardiographic QRS Complex and the Incidence of Heart Arrest after Aorto Coronary Bypass Surgery

Sudden heart arrest (HA) in the early phase after aorto coronary bypass surgery represents a serious event necessitating resuscitation, and for those who survive usually also an extra stay in the coronary care unit. Since such episodes of heart standstill may be related to conduction defects, a study was conducted to determine whether the duration of the QRS complex on the preoperative ECG is a marker for this morbid event. A cohort of 1011 consecutive patients operated on between 1982 and 1986 and followed to January 1st, 1993 were included in the study. Incidence of lethal or non-lethal HA during the first 4 weeks after surgery was considered as the primary endpoint and total mortality as the secondary endpoint. The incidence of HA was 40/1011 = 4%, with the majority of events (60%) being lethal. Independent risk factors of HA using the multivariate logistic model were previous coronary artery bypass surgery, presence of mitral regurgitation, left ventricular ejection fraction and the intraoperative cross-clamp time of aorta. Adjusting for the effect of confounder variables showed that the gradient effect of QRS complex duration on the endpoint HA was still present (p

Defining left ventricular segmental and global function by echocardiographic intraventricular contrast flow patterns

Contrast echocardiography improves left ventricular (LV) endocardial border delineation by enhancement of the blood-tissue interface. In particular, the contrast appearing within the LV chamber exhibits characteristic flow patterns over the cardiac cycle, which may be related to the surrounding myocardial wall motion. To determine the relation between the LV intracavitary contrast flow pattern and surrounding wall motion, we reviewed the contrast-enhanced images of 348 consecutive patients studied at rest. We defined 2 different patterns of intracavitary contrast flow as visualized from apical views: a swift, vertical, and homogenous flow towards the apex (pattern A), and a distinctly protracted, swirling, and heterogeneous flow (pattern B). Images recorded on videotapes were reviewed and the type of pattern (A or B) was determined within the initial 30 to 45 seconds of contrast appearance in the left ventricle. Contrast flow patterns interpreted by independent reviewer were then compared with the interpretation of the LV segmental and global function in each patient. Results demonstrate that 224 of 245 (91%) patients exhibiting pattern A had normal LV segmental function. Furthermore, all but 1 patient (102 of 103) with pattern B had ≥1 wall motion abnormality (p <0.0001). Contrast flow pattern B was observed irrespective of the location of LV wall motion abnormality. Global LV function was normal in 93% of patients exhibiting pattern A, whereas varying degrees of LV dysfunction were noted in 83% of patients with pattern B (p <0.0001). The presence of mitral regurgitation (p = 0.46), aortic insufficiency (p = 0.066), or mitral inflow Doppler abnormality (p = 0.102) was not significantly associated with either pattern. Thus, during contrast echocardiography, the LV intracavitary contrast flow pattern complements the assessment of global and segmental LV function.

Mitral regurgitation after atrioventricular node catheter ablation for atrial fibrillation and heart failure: Acute hemodynamic features

Background Radiofrequency catheter ablation of the atrioventricular node and pacemaker insertion have been associated with occasional development of mitral regurgitation (MR). Ventricular pacing might result in MR if (1) left ventricular (LV) compliance is decreased and/or (2) mitral valve leaflet apposition is disturbed. We studied acute hemodynamic changes resulting from initiation of ventricular pacing in patients undergoing ablation. Methods and Results Thirteen patients (10 men and 3 women) with a mean age of 73.4 ± 8.6 years, with chronic atrial fibrillation and congestive heart failure, had permanent ventricular pacemaker insertion with lead placement at the right ventricular (RV) apex. The following hemodynamic recordings were obtained before ablation (during atrial fibrillation) and then immediately after ablation (during RV pacing): heart rate, mean arterial pressure, LV end-diastolic pressure (LVEDP), mean pulmonary capillary wedge pressure, V-wave amplitude, and cardiac index. Presence of MR was assessed by V-wave amplitude and the results of LV angiography. In patients who had MR, recordings were also obtained during temporary ventricular pacing from the RV outflow tract (RVOT). As a group there were no significant changes in any hemodynamic measurement. Before ablation, mild MR by LV angiogram was present in 5 patients, but none had large V-wave amplitude. After ablation, mild MR was present by LV angiogram in 6 patients, and in 3 of these patients large V-wave amplitude developed (mean amplitude 42.7 ± 2.2 mm Hg; assigned to group 1). This was associated with a rise in LVEDP in 1 patient (consistent with reduced LV compliance), but LVEDP was unchanged in the other 2 patients (suggesting abnormal mitral valve leaflet apposition). All patients in group 1 exhibited a fall in V-wave amplitude when the pacing site was moved to the RVOT. Conclusions Both reduced LV compliance and disturbed mitral valve leaflet apposition contribute to MR after ablation. MR is reduced by pacing from the RVOT. (Am Heart J 1999;138:1166-75.)