Presence Of Significant Mitral Regurgitation Research Articles

Abstract 11140: Mitral Valve Repair with the Mitraclip System in Patients with Cardiogenic Shock

Introduction: The presence of significant mitral regurgitation (MR) in patients with cardiogenic shock (CS) patients is associated with worse prognoses. Limited data exists on the effect of percutaneous mitral valve repair (PMVR) with MitraClip in this population. Hypothesis: We examined short term outcomes of MitraClip PMVR in patients with CS and MR at 30 days and six months. Methods: Single-center, retrospective study of patients with CS and MR undergoing PMVR between January 2015 and December 2020. All patients were followed up for 6 months. Baseline and procedural characteristics as well as 30-day and six-months outcomes of all-cause mortality, heart failure hospitalizations, stroke, new atrial fibrillation, new pacemaker placement, and improvement in MR severity ≥2 grades were assessed. Results: A total of 20 patient were included for analysis. The mean age was 72.8 ± 11.1 years; 9 patients (45%) were men. MR was due to primary pathology in 9 patients (45%), functional in 2 (10%) and mixed in 9 (45%). Characteristics of the population are shown in Table 1. At 30 days all-cause mortality was 20% (n=4), while 2 patients (10%) required HF hospitalization. MR severity improved by at least 2 grades in 10 patients (50%). At six months, all-cause mortality was 40% (n=8), while 4 patients (20%) required heart failure readmission. 10 patients (50%) maintained the improvement in MR severity. There was no incidence of stroke, new atrial fibrillation, or new pacemaker placement at 30 days or 6 months. Conclusions: PMVR with the MitraClip system is a feasible and a safe option for MR in patients with CS. Improved MR severity is maintained at 30 days and 6 months.

Prediction of atrial fibrillation in men with coronary artery disease by artificial neural network

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is quite common in patients with coronary artery disease (CАD). However, there is no data whether AF is associated with coronary lesion of specific localization. Purpose To select the most sensitive parameters for creating artificial neural networks (ANN) model to predict AF in men with CАD using ANN. Methods We selected the data of men of comparable age with angiographically proven CAD from the Register of coronary angiography: the main group - 180 men with AF, the comparison group - 713 men without AF. To assess the risk of AF the ANN mathematical model was applied - a multilayer perceptron with one hidden layer. The initial number of patients was divided into 3 samples: training, test and control. Results Patients with AF were significantly less frequently employed in budget organizations (55.0% vs 63.7%, p = 0.040), more often demonstrated higher (III-IV) heart failure NYHA classes (49.2% vs 21.1% , p < 0.001), had higher body mass index (BMI) (30.2 [27.4; 33.2] kg/m² vs 29.0 [26.1; 32.3] kg/m², p = 0.002), echocardiographic indices of increased left ventricular (LV) myocardial mass (163.7 [144.5; 192.4] g/m² vs 143.9 [126.1; 169.0] g/m², p < 0.001), LV (25.8 [24.1; 29.1] mm/m² vs 25.6 [23.9; 27.5] mm/m², p = 0.020) and right ventricular dimensions, enlarged left atrium (23.6 [21.7; 25.7] mm/m² vs 21.1 [19.7; 22.7] mm/m², p < 0.001). Rate of hemodynamically significant mitral regurgitation in AF patients was higher (48.2% vs 14.1%, p < 0.001), index of aortic root dimensions (7.7 [16.4; 19.0] mm/m² vs 18.3 [17.8; 20.0] mm/m², р=0.002) and LV ejection fraction (EF) in this group was lower (49 [42; 56]% vs 56 [47; 60]%, p < 0.001), coronary calcification (23.2% vs 15.7%, p = 0.024 ) and proximal lesions of the right coronary artery (RCA) (28.3% vs 22.7%, p = 0.025) were detected more often. Sensitivity of the final model which included 10 parameters was 85%, specificity 86%. Conclusion In CAD men AF can be predicted by ANN model that takes into account the presence of significant mitral regurgitation, non-budgetary employment, severity of heart failure, coronary calcification and proximal lesion of RCA, BMI, echocardiographic indices of the left heart and aortic root dimensions, LVEF.

Echocardiographic predictors of exercise capacity in algerian patients with heart failure and systolic dysfunction: role of mitral regurgitation

Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in Algerian patients with heart failure and systolic dysfunction. We included 290 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1 < 290 m and Group 2 > 290 m. Mitral regurgitation was detected in 215 patients (74%), which was significant in 87 (30%). Group 1 showed more significant mitral regurgitation (35 vs. 18%), increased left atrium area (27 ± 1 vs. 241 cm2), mitral E amplitude (88 ± 65 vs. 72 ± 3 cm/s) and systolic pulmonary pressure (37 ± 1 vs. 32 ± 1 mmHg, all P < 0.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P < 0.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r = 0.25, beta coefficient: _6.52 ± 2, P < 0.01). In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.

Artificial neural networks in prediction of atrial fibrillation in men with coronary artery disease

Aim. The aim of the study was to select, based on mathematical apparatus of artificial neural networks (ANN), the most sen- sitive parameters for creating an ANN model aimed at prediction of atrial fibrillation (AF) in men with coronary artery disease (CАD).Material and Methods. The study focused on data of men from the register of coronary angiography with angiographically proven coronary artery disease: the main group comprised 180 men with AF; the comparison group comprised 713 men of comparable age without AF. The ANN mathematical model, a multilayer perceptron with one hidden layer, was used to assess the risk of AF. The initial group of patients was divided into three samples: the training, test, and control samples.Results. Patients with AF were significantly less likely to be employed in budget organizations (55.0% vs 63.7%, p = 0.040) and more often showed higher (III–IV) heart failure NYHA classes (49.2% vs 21.1%, p &lt; 0.001), higher body mass index (BMI) (30.2 [27.4; 33.2] kg/m2 vs 29.0 [26.1; 32.3] kg/m2, p = 0.002), and higher echocardiographic indices of the left ventricular (LV) myocardial mass (163.7 [144.5; 192.4] g/m2 vs 143.9 [126.1; 169.0] g/m2, p &lt; 0.001), left (25.8 [24.1; 29.1] mm/m2 vs 25.6 [23.9; 27.5] mm/m2, p = 0.020) and right ventricular dimensions, and the left atrial diameter (23.6 [21.7; 25.7] mm/m2 vs 21.1 [19.7; 22.7] mm/m2, p &lt; 0.001). The group of AF patients had higher rate of hemodynamically significant mitral regurgitation (48.2% vs 14.1%, p &lt; 0.001). In this group of patients, the index of aortic root dimensions (7.7 [16.4; 19.0] mm/m2 vs 18.3 [17.8; 20.0] mm/m2, р = 0.002) and LV ejection fraction (EF) were lower (49 [42; 56]% vs 56 [47; 60]%, p &lt; 0.001); coronary calcification (23.2% vs 15.7%, p = 0.024 ) and proximal lesions of the right coronary artery (RCA) (28.3% vs 22.7%, p = 0.025) were detected more often. The final model, which included 10 parameters, had the diagnostic accuracy of 85%, sensitivity of 85%, and specificity of 86%.Conclusion. Atrial fibrillation in men with coronary artery disease can be predicted by ANN model that takes into account the presence of significant mitral regurgitation, extra-budgetary employment, severity of heart failure, coronary calcification, proximal lesion of RCA, BMI, echocardiographic indexes of left heart, aortic root dimensions, and LV EF.

Color Doppler Splay: A Clue to the Presence of Significant Mitral Regurgitation

The authors describe a previously unreported Doppler signal associated with mitral regurgitation (MR) as imaged using transthoracic echocardiography. Horizontal "splay" of the color Doppler signal along the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign. Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocardiography as less than moderate. The splay signal was present on at least one standard transthoracic view in each case. To better characterize the splay signal, two groups were created from existing clinically driven transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR. Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection fraction, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions compared with severe MR. Color scale did not differ between subjects with and those without splay, but color gain was higher when splay was present (P=.04). Machine settings were further explored in a single subject with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it. The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely generated as a side-lobe artifact due to a high-flux regurgitant jet.

Echocardiographic predictors of exercise capacity in Algerian patients with heart failure and systolic dysfunction: Role of mitral regurgitation

Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in Algerian patients with heart failure and systolic dysfunction. We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1 < 290 m and Group 2 > 290 m. Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs. 18%), increased left atrium area (27 ± 1 vs. 24+ ± 1 cm 2 ), mitral E amplitude (88 ± 65 vs. 72 ± 3 cm/s) and systolic pulmonary pressure (37 ± 1 vs. 32 ± 1 mmHg, all P < .05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02–11.66, P < .05). By multiple linear regression, the only independent predictor of walked distance was left atrium area ( r = 0.25, beta coefficient: _6.52 ± 2, P < .01). In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.

Clinical Utility of Left Atrial Strain in Children in the Acute Phase of Kawasaki Disease

We aimed to evaluate the diagnostic utility of peak left atrial longitudinal strain (PALS) during left ventricular (LV) systole to differentiate children in the acute phase of Kawasaki disease (aKD) from controls. We also aimed to compare the diagnostic utility of PALS with those of conventional echocardiographic indices of diastolic function. Retrospectively measured PALS, LV longitudinal peak systolic strain, and strain rate obtained via velocity vector imaging were compared in a derivation cohort comprising 95 aKD and 67 controls. The utility of PALS in differentiating aKD from controls was compared with those of E/E', E/A, and maximum left atrial volume index (LAVImax). Derived cutoffs from receiver operating characteristic curves were validated in a separate validation cohort comprising 37 aKD and 19 controls. In the derivation cohort, PALS was significantly decreased in aKD as compared with in controls. For differentiating aKD from controls, PALS outperformed E/E', E/A, and LAVImax. However, cutoffs of PALS (≤40% and ≤39%, before and after adjusting for the presence of significant mitral regurgitation and LV systolic dysfunction, respectively), like those of E/E', E/A, and LAVImax, showed low sensitivity and poor discriminative ability for differentiating aKD from controls. In the validation cohort, for differentiating aKD from controls, both cutoffs of PALS showed low sensitivity, like those of E/E', E/A, and LAVImax. In aKD, impaired left atrial reservoir function could be detected as decreased PALS. For differentiating aKD from controls, PALS outperforms E/E', E/A, and LAVImax. However, like E/E', E/A, and LAVImax, PALS as a single parameter is limited in its clinical utility to differentiate aKD from controls because of its low sensitivity and poor discriminative ability.

Prognostic Significance of Non-Dilated Left Ventricular Size and Mitral Regurgitation in Patients With Dilated Phase of Hypertrophic Cardiomyopathy.

Although a subtype of hypertrophic cardiomyopathy (HCM), dilated phase of HCM (D-HCM) characterized by left ventricular (LV) systolic dysfunction, has been reported to have a poor prognosis, some patients with D-HCM survive for a relatively long period. The degree of LV dilatation and functional mitral regurgitation (MR) are generally thought to be important predictors of poor prognosis in patients with LV systolic dysfunction. However, there is little information available on the relations among LV size, presence of significant MR, and prognosis in D-HCM patients.We retrospectively studied 31 patients with D-HCM to determine whether echocardiographic assessment of LV size and MR provides incremental prognostic information.During a follow-up period of 5.6 ± 4.2 years, there were 13 cardiovascular deaths. When the patients were divided into two groups by LV size at diagnosis of D-HCM, a non-dilated LV group (LV end-diastolic diameter (LVEDD) < 50 mm, n = 9) and a dilated LV group (LVEDD ≥ 50 mm, n = 22), the clinical course in the non-dilated LV group was significantly worse. As for the clinical impact of MR, no patient in the non-dilated LV group showed significant MR and 7 of the patients with dilated LV size showed significant MR during follow-up. Once significant MR was reached, cardiovascular deaths were significantly more frequent in patients with MR.Patients with D-HCM, particularly those with less LV dilatation at diagnosis of dilated phase and with significant MR during follow-up, have a poor prognosis.

0157: Echocardiographic predictors of exercise capacity in Algerian patients with heart failure and systolic dysfunction: role of mitral regurgitation

Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in Algerian patients with heart failure and systolic dysfunction. We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290m): Group 1 <290m and Group 2 >290m. Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%).Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1cm 2 ), mitral E amplitude (88±65 vs 72±3 cm/s) and systolic pulmonary pressure (37±1 vs 32±1 mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: _6.52±2, P<.01). In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.

Left atrial myxoma—influence of tumour size on electrocardiographic findings

ObjectiveThe data of 51 patients (33 females) who underwent excision of left atrial (LA) myxoma were retrospectively reviewed for correlation of tumour size and electrocardiographic (ECG) findings. Methods and resultsMean age was 39.1 ± 15 years (range 9–53 years). The LA enlargement (LAE) on ECG was defined by standard criteria. The LAE in ECG in these patients did not correlate with echocardiographic LA dimensions or with the degree of left ventricular (LV) inflow obstruction. But it was found that the presence of LAE in ECG predicted maximum tumour dimension of >5 cm and correlated with the degree of mitral regurgitation (MR). The LAE in ECG disappeared following surgery in 87.5% of patients. ConclusionThe LA enlargement on ECG in a patient with LA myxoma signifies larger tumour size or the presence of significant MR but is not necessarily associated with an increased LA size or LV inflow obstruction.

Predictores ecocardiográficos de capacidad de ejercicio en pacientes con insuficiencia cardiaca sistólica. Valor de la insuficiencia mitral

Introduction and objectives Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction. Methods We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2 , ≥290 m. Results Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1 cm 2), mitral E amplitude (88±5 vs 72±3 cm/s) and systolic pulmonary pressure (37±1 vs 32±1 mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: −6.52 ± 2, P<.01). Conclusions In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation. Full English text available from: www.revespcardiol.org

Echocardiographic Predictors of Exercise Capacity in Patients With Heart Failure and Systolic Dysfunction: Role of Mitral Regurgitation

Introduction and objectives Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction. Methods We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2, ≥290 m. Results Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1 cm 2), mitral E amplitude (88±5 vs 72±3 cm/s) and systolic pulmonary pressure (37±1 vs 32±1 mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: −6.52±2, P<.01). Conclusions In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.

Assessment of left ventricular function using mitral annular velocities in patients with congestive heart failure with or without the presence of significant mitral regurgitation

Myocardial velocities in patients with congestive heart failure (CHF) were studied using pulsed wave Doppler tissue imaging. Velocities were recorded at the mitral and tricuspid annulus. Four sites at the mitral annuli were selected corresponding to the septal, lateral, inferior, and anterior walls of the left ventricle from apical 4- and 2-chamber views. A mean value from the above 4 sites was selected to describe the mitral annular velocities. Only one site of the tricuspid annulus was selected, corresponding to the right ventricular free wall. Three different annular velocities were recorded: the peak systolic, and the peak early and late diastolic velocities. A total of 96 patients were compared with 12 age-matched healthy participants. Patients with CHF had significantly decreased mitral and tricuspid systolic velocities compared with healthy participants (4.9 vs 9.3 cm/s, P <.001, for the mitral annulus and 10.4 vs 14.6 cm/s, P <.001, for the tricuspid annulus). The early diastolic velocity was also reduced in patients compared with healthy participants (5.9 vs 10.9 cm/s, P <.001, for the mitral annulus and 8.6 vs 12.9 cm/s, P <.001, for the tricuspid annulus). Patients with CHF had a severely depressed left ventricular ejection fraction (EF) (27%). The correlation the between systolic mitral annular velocity and EF was relatively good (r = 0.59 and P <.001). The patients with CHF were divided into 2 subgroups depending on the presence or absence of significant mitral regurgitation. There was a correlation between EF and the systolic mitral annular velocity both in patients with (r = 0.61, P <.001) and without (r = 0.59, P <.001) significant mitral regurgitation. In conclusion, compared with healthy participants, the mitral and tricuspid annular velocities are significantly decreased in patients with CHF. The correlation between EF and the systolic mitral annular velocity is relatively good irrespective of the presence or absence of significant mitral regurgitation. Measurements of annular velocities constitute a simple and useful method for evaluating patients with CHF. (J Am Soc Echocardiogr 2003;16:240-5.)

Mild mitral regurgitation was associated with increased prevalence of thromboembolic events in patients with nonrheumatic atrial fibrillation

Although several studies demonstrated that the presence of significant mitral regurgitation was associated with reduced occurrence of thromboembolism, little data is available concerning the effect of mild mitral regurgitation on the occurrence of thromboembolic events. To evaluate the association between mild mitral regurgitation and thromboembolic events, we reviewed 232 patients’ records between January 1996 and September 1997 who had nonrheumatic atrial fibrillation. There were 59 patients (25%) with mitral regurgitation ≧grade 2, 69 patients (30%) with grade 1 mitral regurgitation, and 104 patients (45%) with no mitral regurgitation. Patients with grade 1 mitral regurgitation had significantly higher prevalence of thromboembolic events (28%) than those with mitral regurgitation ≧grade 2 (8%, P=0.006) or those with no mitral regurgitation (11%, P=0.007). A history of previous thromboembolic events were compared between 173 patients with grade 1 mitral regurgitation and those with no mitral regurgitation using the logistic regression analysis adjusted for age, sex, administration of warfarin, and presence of hypertension, diabetes mellitus, structural heart disease, enlarged left atrium (≧40 mm), chronic atrial fibrillation, and grade 1 mitral regurgitation. Grade 1 mitral regurgitation (odds ratio=2.689, 95% confidence interval=1.039–7.189, P=0.0434) and no warfarin administration (odds ratio=0.045, 95% confidence interval=0.002–0.242, P=0.0036) were significantly associated with the history of thromboembolic events. The presence of mild mitral regurgitation in nonrheumatic atrial fibrillation was associated with higher prevalence of thromboembolic events.

Predictors of outcome after radiofrequency catheter ablation of the atrioventricular node for atrial fibrillation and congestive heart failure

Background Although radiofrequency catheter ablation of the atrioventricular (AV) node is an established treatment for atrial fibrillation (AF) with uncontrolled ventricular response, factors that predict clinical outcome in patients with associated congestive heart failure (CHF) are unknown. Methods and Results AV node ablation and permanent pacemaker implantation was performed in 44 consecutive patients (mean age 71 ± 10 years) with CHF and AF associated with uncontrolled ventricular response. Immediately before ablation, mean left ventricular ejection fraction (EF) measured by 2-dimensional echocardiogram was 34.6% ± 9.8%, mean exercise tolerance time was 2.6 ± 1.8 minutes, and mean quality of life score was 62.3 ± 19.7. Complete AV block was achieved in all 44 patients but was complicated by death in 1 patient from cardiogenic shock soon after ablation. By 1 month after ablation, EF increased to 43.8% ± 13.7% ( P < .01), exercise tolerance time was 4.0 ± 2.5 minutes ( P < .01), and mean quality of life score decreased to 35.6 ± 18.1 ( P < .01). Improved cardiac performance (increase in EF ≥9% over baseline EF) was detected in 20 (45%) of the patients. During a mean follow-up of 17 ± 9 months, 5 patients died suddenly of presumed ventricular tachyarrhythmia and 4 others died of progressive CHF. Multivariate Cox survival analysis identified baseline EF ≤30%, presence of significant mitral regurgitation (>2+) before ablation, and failure to exhibit improved cardiac performance by 1 month after ablation as the only independent predictors of death. Conclusions Baseline variables and failure of EF to improve soon after AV node ablation identifies patients with CHF and AF who have a high mortality rate. Adjunctive therapy to reduce sudden death and progressive heart failure should be evaluated in this subgroup. (Am Heart J 1998;136:647-57.)

Doppler-derived left ventricular rate of pressure rise and inotropic requirements during mitral valve surgery

Background: The estimation of left ventricular (LV) contractility is difficult in the presence of significant mitral regurgitation (MR). Prediction of LV performance after MR repair is even more problematic. The intraoperative Doppler-derived LV rate of pressure rise (LV ΔP/ Δt) analyzed before cardiopulmonary bypass (CPB) was presumed to be a useful predictive parameter for LV performance. Therefore, its relation to perioperative inotropic requirements (PIR) necessary for separation from CPB after surgical MR repair was investigated. Methods: Twenty-eight patients scheduled for surgical MR repair fulfilled the selection criteria. Pre-CPB LV ΔP/ Δt, pre-CPB echocardiographic LV fractional area change (LV FAC), and pre-CPB thermodilution-derived cardiac index (CI) were recorded. After MR repair, separation from CPB was performed with regard to standardized guidelines. PIR during the first 60 minutes following separation were recorded. Results: Pre-CPB LV ΔP/ Δt could be assessed in 22 patients. Pre-CPB LV ΔP/ Δt was 882 ± 450 mmHg/sec, pre-CPB LV FAC was 49% ± 9%, and pre-CPB CI was 2.0 ± 0.2 L/kg/min. Pre-CPB LV ΔP/ Δt was significantly correlated with pre-CPB LV FAC ( r = 0.56), and with pre-CPB CI ( r = 0.72). Inotropic support was necessary in 16 patients (73%), and was best predicted by the pre-CPB LV ΔP/ Δt, by means of logistic regression ( p = 0.026). Conclusions: Doppler-derived LV ΔP/ Δt was assessable in most patients with severe chronic MR, and was the best intraoperative predictive parameter of post-CPB inotropic requirements after surgical MR repair.

Clinical significance of the echocardiographic degree of mitral valve prolapse

To assess the clinical significance of the echocardiographic degree of mitral valve prolapse, we prospectively evaluated with Doppler echocardiography 246 consecutive patients referred with signs or symptoms consistent with a diagnosis of mitral valve prolapse. The echocardiographic degree of mitral valve prolapse was measured by a scoring system that incorporates an assessment of mitral systolic displacement from the M-mode aa well as the two-dimensional long-axis and apical four-chamber views (range 0 to 9, 0 = no mitral valve prolapse). A structured questionnaire was used to record the frequency and severity of symptoms. Pulsed and continuous-wave Doppler echocardiography were performed to document mitral regurgitation and determine the ratio of peak early to atrial diastolic filling velocities. Patients were grouped according to the degree of mitral valve prolapse; 45 patients had no echocardiographic evidence of mitral valve prolapse. There was no statistically significant relationship between the mitral valve prolapse score and symptoms or left ventricular systolic or diastolic function. There was, however, a strong relationship between the echocardiographic degree of mitral valve prolapse and the presence of significant mitral regurgitation. Patients without echocardiographic evidence of mitral valve prolapse had a 4% incidence of mitral regurgitation, which was not significantly different than that of persons with mild degrees of prolapse (6%). However, the groups with the most marked degree of prolapse (scores of 6, 7, 8, and 9) had a significantly higher incidence of mitral regurgitation (20% and 60% respectively, p < 0.01). Thus the phenomenon of mitral valve prolapse as assessed by echocardiography is a continuous spectrum wherein patients with the most severe degree of prolapse have a proportionately higher prevalence of mitral regurgitation. However, there does not appear to be a relationship between the echocardiographic degree of mitral valve prolapse and either symptoms or left ventricular function.

Chronic Chagas' heart disease in children and adolescents: a clinicopathologic study

A retrospective study of the medical records filed at the University Hospital from 1965 to 1983 and of 18456 autopsies carried out in the Department of Pathology of this Institution from 1953 to 1983, referring to patients aged less than 18 years was performed in an attempt to fully characterize chronic Chagas' heart disease in children and adolescents. Only 19 of these patients fulfilled the criteria for inclusion in the present study (12 cases with only clinical information and 7 cases with clinical and pathological information). We noted that the clinical manifestations of chronic Chagas' heart disease are congestive heart failure, thromboembolism and sudden death. Radiologic, electrocardiographic and anatomo-pathological findings demonstrated serious myocardial involvement. This set of alterations is also detected in adults with chronic Chagas' heart disease. Among adolescents, however, the disease exhibits relevant peculiarities such as rapid evolution to death within a short period of time (128 days), diagnostic difficulty related to the presence of significant mitral regurgitation (61% erroneous initial diagnosis), and low frequency of right bundle branch block (11% of cases). These findings suggest that among children and adolescents, chronic Chagas' heart disease may be of a peculiar type and therefore may be useful to clarify the pathogenetic mechanism of the disease.

Cross-sectional echocardiographic detection of rheumatic mitral regurgitation

Short-axis, cross-sectional echocardiograms of the mitral valve were performed in 20 consecutive patients with rheumatic mitral valve disease to determine if mitral regurgitation could be detected. In four patients, cross-sectional echocardiograms were technically inadequate. Of the 16 remaining patients, 8 had no significant mitral regurgitation on cineangiography, and 8 had significant regurgitation. Two independent observers reviewed videotapes of the cross-sectional echocardiograms without knowledge of the cineangtograms or clinical findings. In each case, the presence of significant mitral regurgitation was correctly predicted by viewing the cross-sectional echocardiograms. The thickened leaflets of the mitral orifice could easily be identified during both diastole and systole. Closure of the two leaflets was best observed early in systole before caudal movement of the anulus caused the orifice to move out of range of the ultrasonic beam. Complete closure of the leaflets was seen in patients without mitral regurgitation. Failure of closure of small areas of either the medial or lateral aspect of the valve was associated with insignificant mitral regurgitation. Failure of both sides to close or failure to close in the center of the valve indicated significant mitral regurgitation. Thus, it appears that significant mitral regurgitation in patients with rheumatic mitral valve disease can be detected by qualitative analysis of short-axis, cross-sectional echocardiograms.