Severity Of Valvular Regurgitation Research Articles

Outcome following acute and recurrent rheumatic fever

ABSTRACT Background Rheumatic carditis is the leading cause of permanent disability caused by damage of the cardiac valve. This study aimed to determine the outcome and predictors of valve surgery in patients with acute rheumatic fever (ARF) and recurrent rheumatic fever (RRF). Methods This was a retrospective study of patients diagnosed with ARF and RRF between 2006 and 2021. The predictors of valve surgery were analysed using multivariable Cox proportional regression. Results The median age of patients with ARF and RRF (n=92) was 11 years (range 5–18). Seventeen patients (18%) were diagnosed with RRF. The most common presenting symptoms included clinical carditis (87%), heart failure (HF) (63%), fever (49%) and polyarthralgia (24%). Patients with moderate-to-severe rheumatic carditis (88%) were given prednisolone. After treatment, the severity of valvular regurgitation was reduced in 52 patients (59%). Twenty-three patients (25%) underwent valve surgery. The incidence of HF, RRF, severe mitral regurgitation on presentation, left ventricular enlargement and pulmonary hypertension was greater in the surgical group than in the non-surgical group. Recurrent rheumatic fever (hazard ratio 7.9, 95% CI 1.9–33.1), tricuspid regurgitation (TR) gradient ≥ 42 mmHg (HR 6.3, 95%CI 1.1–38.7) and left ventricular end-diastolic dimension (LVEDD) ≥6 cm (HR 8.7, 95% CI 2.1–35.9) were predictors of valve surgery (multivariable Cox proportional regression analysis). Conclusion Clinical carditis was the most common presenting symptom in patients with ARF and RRF. The majority of patients responded positively to prednisolone. These findings highlight the predictors of valve surgery following ARF, including RRF, TR gradient ≥ 42 mmHg and LVEDD ≥ 6 cm. Abbreviations: ARF: acute rheumatic fever; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; GAS: group A beta-haemolytic Streptococcus; HF: heart failure; HR: hazard ratio; LVEDD: left ventricular end-diastolic dimension; MR: mitral regurgitation; RHD: rheumatic heart disease; RRF: recurrent rheumatic fever; TR: tricuspid regurgitation.

Management of Chronic Congestive Heart Failure Caused by Myxomatous Mitral Valve Disease in Dogs: A Narrative Review from 1970 to 2020.

Simple SummaryMyxomatous mitral valve disease (MMVD) is the most common acquired cardiovascular disease in dogs. The progression of the disease and the increasing severity of valvular regurgitation cause a volume overload of the left heart, leading to left atrial and ventricular remodeling and congestive heart failure (CHF). The treatment of chronic CHF secondary to MMVD in dogs has not always been the same over time. In the last fifty years, the drugs utilized have considerably changed, as well as the therapeutic protocols. Some drugs have also changed their intended use. An analysis of the literature concerning the therapy of chronic heart failure in dogs affected by this widespread degenerative disease is not available; a synthesis of the published literature on this topic and a description of its current state of art are needed. To the authors’ knowledge, a review of this topic has never been published in veterinary medicine; therefore, the aim of this study is to overview the treatments of chronic CHF secondary to MMVD in dogs from 1970 to 2020 using the general framework of narrative reviews.The treatment of chronic congestive heart failure (CHF), secondary to myxomatous mitral valve disease (MMVD) in dogs, has considerably changed in the last fifty years. An analysis of the literature concerning the therapy of chronic CHF in dogs affected by MMVD is not available, and it is needed. Narrative reviews (NRs) are aimed at identifying and summarizing what has been previously published, avoiding duplications, and seeking new study areas that have not yet been addressed. The most accessible open-access databases, PubMed, Embase, and Google Scholar, were chosen, and the searching time frame was set in five decades, from 1970 to 2020. The 384 selected studies were classified into categories depending on the aim of the study, the population target, the pathogenesis of MMVD (natural/induced), and the resulting CHF. Over the years, the types of studies have increased considerably in veterinary medicine. In particular, there have been 43 (24.29%) clinical trials, 41 (23.16%) randomized controlled trials, 10 (5.65%) cross-over trials, 40 (22.60%) reviews, 5 (2.82%) comparative studies, 17 (9.60%) case-control studies, 2 (1.13%) cohort studies, 2 (1.13%) experimental studies, 2 (1.13%) questionnaires, 6 (3.40%) case-reports, 7 (3.95%) retrospective studies, and 2 (1.13%) guidelines. The experimental studies on dogs with an induced form of the disease were less numerous (49–27.68%) than the studies on dogs affected by spontaneous MMVD (128–72.32%). The therapy of chronic CHF in dogs has considerably changed in the last fifty years: in the last century, some of the currently prescribed drugs did not exist yet, while others had different indications.

Features of chronic heart failure in COVID-19 pandemic

RelevanceCurrent and past coronavirus infection can provoke and aggravate the course of previous chronic heart failure by initiating the processes of thrombus formation, inflammation and fibrinogen synthesis, affecting the pleuropericardial space, increasing the load on the right heart due to pulmonary hypertension.Purpose of the studyTo identify the features of chronic heart failure after COVID-19 infection with lung damage.MaterialAn open cohort prospective study of 50 patients was carried out. Inclusion criteria: the presence of a positive brain natriuretic peptide and echocardiographic changes corresponding to systolic or diastolic dysfunction before the onset of the pandemic, signed informed consent. The diagnosis of COVID - 19 was confirmed by a positive PCR test and the presence of M and G antibodies, lung damage - by the results of computed tomography of the lungs.MethodsStandard clinical examination, quality of life questionnaire, echocardiography with measurement of cavity volume, indicators of left ventricular systolic and diastolic function, size and function of the right ventricle. The second examination was carried out one month after hospitalization.ResultsThe features of the clinical picture were an increase in shortness of breath (38 people, 86%), a decrease in exercise tolerance (40 people, 90%), an increase in chest pain (25 people, 60%), palpitations (40 people, 90%). On echocardiography, the most frequent dynamics compared to the 2019 echocardiography indicators were an increase in pressure in the pulmonary artery (44 people, 100%), the size of the right (38 people, 86%) and left ventricles (30 people, 68%), left atrium (38 people, 86%), an increase in the severity of valvular regurgitation (44 people, 100%) and a decrease in the ejection fraction within the “gray zone” (38 people, 86%). The newly emerging decrease in EF below 45% was recorded much less frequently, in 13 people (30%). In 40 (80%) patients, certain signs of deterioration of left ventricular diastolic function were revealed: dilatation of the left atrium, decrease in the mean e, increase in E/e' according to tissue Doppler ultrasonography. The TAPSE index, which characterizes the global function of the right ventricle, practically did not decrease. Frequent findings during echocardiography one month after the disease were a small amount of fluid in the pericardial cavity (30 people, 68%) and pleuropericardial adhesions.ConclusionThe clinical condition of patients with CHF in the first month after a previous infection with COVID-19 with lung involvement corresponded to a worsening of CHF with rhythm disturbances and instability of blood pressure, which on echocardiographic examination was manifested by dilatation of the heart cavities, valvular regurgitation, diastolic dysfunction of the left ventricle and increased pressure in the arteries.Funding AcknowledgementType of funding sources: None. Dynamics of echocardiography in patients

Longitudinal Variation in Presence and Severity of Cardiac Valve Regurgitation in Healthy Children

The goal of this study was to document the frequency and longitudinal variation in the presence and severity of echocardiographically documented valvular regurgitation (VR) in healthy children free of evidence of heart disease. We hypothesized that significant variation is common, and our specific aim was to determine change in prevalence and severity of VR in children free of heart disease. The presence of VR was documented on each of the four valves, and the severity of regurgitation was assessed as the body surface area (BSA)-adjusted width of the vena contracta on each of two sequential echocardiograms in healthy children free of clinical and echocardiographic evidence of heart disease. We included 200 children ages 10.0±4.5years, BSA=1.2±0.43m2, at the first exam and 12.8±4.9years, BSA=1.42±0.44m2, at the second exam. Frequency of VR was similar on the two exams (tricuspid=61.5% vs 57.0%, pulmonary=55.5 vs 57.5%, mitral=14.5% vs 16.0%, aortic=3.0 vs 3.5%). The frequency of new appearance was similar to the frequency of resolution of VR for all four valves. For instances where the severity of VR was classified as trace versus mild, the frequency of change from mild to trace between the two exams was similar to the frequency of change from trace to mild. In healthy children with no evidence of heart disease, there is substantial temporal variation in the presence and severity of tricuspid and pulmonary VR. The prevalence of mitral and aortic VR is lower in healthy children, but temporal variation is also noted for these valves. The finding of new-onset echocardiographic trace or mild VR cannot be assumed to represent incident valve pathology.

P1275 In-hospital outcome of patients with infective endocarditis: is echocardiography enough?

Abstract Background Despite improvements in medical and surgical therapy, infective endocarditis (IE) remains a deadly disease. Echocardiography is the first-line diagnostic tool. However, data regarding its role in the prognostic assessment of in-hospital clinical outcome of IE are scarce. Purpose We sought to assess the role of echocardiography to predict the in-hospital outcome in a large cohort of patients diagnosed with definite IE and its association with clinical presentation and microorganisms. Methods We retrospectively included patients from two centers between 2006 and 2018. Transthoracic and transesophageal echocardiography were performed in all patients. The clinical endpoints were in-hospital death, embolic events (cerebrovascular and non-cerebrovascular), shock (septic shock and cardiogenic shock) and cardiac surgery. Results 183 patients with definite IE (age 68.9 ± 14.2 years old, 68.9% male) were evaluated. Ninety three (50.8%) patients had aortic valve IE and 81 (44.3%) patients presented with mitral valve IE. Twenty three patients had multivalvular IE. The in-hospital mortality rate was 22.4%. Sixty patients (32.8%) had embolic events and 42 (23%) patients developed shock during hospitalization. Surgery was performed in 103 (56.3%) patients. Mitral valve IE on echocardiography was an independent predictor of in-hospital mortality (p = 0.038, OR 0.38, 95% CI 0.15 – 0.94) and aortic valve IE on echocardiography was an independent predictor of embolic events (p = 0.018, OR 0.36, 95% 0.16-0.84). The presence of a new cardiac murmur upon admission was predictive for the need of cardiac surgery (p = 0.042, OR 0.51, 95% CI 0.22- 1.09) and correlated with the severity of valvular regurgitation identified by echocardiography (p = 0.024). Methicillin resistant Staphylococcus aureus (MRSA) as the causative microorganism was an independent predictor for in - hospital mortality and for the development of shock during hospitalization (p = 0.010, OR 0.13 95% CI 0.30 - 0.62 and p = 0.027, OR 6.11, 95% CI 1.22 – 30.37, respectively). No correlation was found between MRSA and echocardiographic parameters. Conclusion Mitral valve IE was an independent predictor of in - hospital mortality. Furthermore, aortic valve IE was an independent predictor of embolic events. The presence of a new cardiac murmur was predictive for the need of cardiac surgery and correlated with the severity of valvular regurgitation by echocardiography. Our findings suggest that a thorough physical examination upon admission is required in combination with a comprehensive echocardiographic exam for early identification of patients with IE at high - risk for in-hospital death and complications.

P1350 New 3D Doppler flow method for quantitation of aortic regurgitation

Abstract Funding Acknowledgements Centre for Innovative Ultrasound Solutions, NTNU OnBehalf Centre for Innovative Ultrasound Solutions Introduction The echocardiographic assessment of valvular regurgitation severity may be challenging. This is reflected in the current EACVI and ASE recommendations, which are quite extensive and include numerous parameters. To date, there are no widely reliable quantitative methods. Moreover, the inter-observer variability in the overall severity assessment is substantial. Purpose Development of a new, automated 3D Doppler method for reliable and accurate quantitation of regurgitant volume. Methods A 3D high frame rate plane wave imaging sequence is employed to insonate the vena contracta region of the jet using a modified GEVU Vivid E95 system with a 4V probe. In this way we obtain spectral information from all voxels within the sample volume of approximately 2cm x 2cm x 2cm. Vena contracta is localised from the plane containing the maximum velocities and its cross sectional area determined by a power threshold. Velocity-time-integral is then estimated for all voxels within the designated cross sectional area. For clinical validation, we include patients with aortic regurgitation ranging from mild to severe with a stable sinus rhythm. 3D flow data is recorded immediately after a comprehensive standard echocardiographic exam. The standard exam undergoes expert evaluation in accordance with EACVI recommendations. 3D flow data are currently processed and analysed offline by an independent investigator, blinded to the results from the standard exam. Results The results from the first twelve patients are presented in Figure 1. Compared to expert echocardiographic evaluation, the 3D flow method seems to overestimate the regurgitant volume in some patients with mild aortic regurgitation. This may be caused by limitations in lateral resolution. Due to failure of aligning the vena contracta within the sample volume, there is a significant underestimation of regurgitant volume in one patient (Figure 1: red dot). As 3D flow analysis is currently performed offline, this was not obvious at the time of recording. The 3D flow method clearly discriminates the other two patients with severe aortic regurgitation from the patients with mild or moderate regurgitation. Conclusion We find these preliminary results encouraging, motivating further work on method refinement and validation. Abstract P1350 Figure 1

The neutrophil-to-lymphocyte ratio and mean platelet volume can be associated with severity of valvular involvement in patients with acute rheumatic carditis.

The aim of the study was to investigate the association between the severity of acute rheumatic carditis (ARC) and the neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV). Paediatric patients diagnosed with ARC between 2010 and 2016 and age- and gender-matched controls were retrospectively analysed. At the time of diagnosis, we reviewed the demographic features obtained: echocardiographic data, complete blood count reports, acute-phase reactants, including C-reactive protein, and erythrocyte sedimentation rate values. The patient group was further divided into two subgroups according to the degree of valvular regurgitation, which included those with severe and those with mild-to-moderate valvular regurgitation. The number of cases with ARC and age- and gender-matched controls were 120 and 50, respectively. The mean age of the patients was 12.25 ± 2.89 (range: 7-18) years. NLR, MPV, anti-streptolysin-O, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), haemoglobin level, and white blood cell (WBC) and neutrophil count were significantly higher in patients with acute carditis compared with the controls (p < 0.001). NLR was found to have a significantly positive correlation with CRP (r = 0.177, p = 0.001), ESR (r = 0.81, p = 0.03) and WBC count ( r = 0.47, p = 0.001). Moreover, we found a positive correlation between NLR and severity of valvular regurgitation (r = 0.34, p < 0.001), and a negative correlation between MPV and severity of valvular regurgitation ( r = -0.38, p < 0.05) in our patients. In multiple linear regression analysis, severe valvular regurgitation was associated with NLR (0.51; 95% CI: 0.32-0.68; p = 0.006) and MPV ( -0.78; 95% CI: -0.72 to -0.98; p = 0.008). NLR and MPV are novel inflammatory markers and simple, rapid and easily accessible prognostic parameters that can be associated with severity of valvular involvement in patients with ARC.

Evaluation of Neutrophil Gelatinase-Associated Lipocalin in Children with Sydenham's Chorea Accompanying Valvular Regurgitation

Background Acute rheumatic fever (ARF) is a nonsuppurative complications of Group A β-hemolytic streptococcal (GABHS) infection due to a delayed immune response. Sydenham's chorea (SC) is an important neurological manifestation of ARF, and heart involvement is seen in a large proportion of patients with SC. The immune system has a crucial role in initiating and spreading inflammation, which causes tissue damage in ARF. Aim The purpose of this study was to investigate urine neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for kidney injury in children with rheumatic chorea accompanying valvular involvement. Materials and Methods Twenty-eight consecutive children with SC accompanying evidence of valvular involvement, and 30 nonrheumatic, age- and sex-matched healthy children were included in the study. Cardiac evaluations were performed, and urinary NGAL, micro-total protein and creatinine levels were measured in all participants. Results Age, gender, weight, and height were similar in the patients and controls. Twenty-three patients had isolated mitral regurgitation, and five patients had mitral and aortic regurgitation. While there was no statistically significant difference between the urine creatinine and micro-total protein levels in patients and controls, the patient group demonstrated a significantly higher mean urine NGAL level (18.01 ± 7.9 vs. 3.22 ± 1.4, p = 0.002) and mean urine NGAL/creatinine ratio (2.80 ± 1.9 vs. 0.33 ± 0.1, p = 0.008). However, there were no correlations between severity of chorea and urinary NGAL or urinary NGAL/creatinine ratio, there were significant positive correlations between severity of valvular regurgitation and urinary NGAL (r = 0.751, p &lt; 0.001) and urinary NGAL/creatinine ratio (r = 0.694, p &lt; 0.001). Conclusion The present study revealed that urinary NGAL level and urinary NGAL/creatinine ratio were higher in patients with SC accompanying valvular involvement. The results obtained from this study suggest that ARF may cause subclinical renal injury in patients with intense and prolonged cellular immune response leading to chorea and carditis.

Segmentation of jet area to quantity the severity of mitral regurgitation by color Doppler echocardiography

Mitral regurgitation (MR) is a disorder of mitral valve and it is one of the most common causes of cardiovascular morbidity and mortality. Mitral valve allows blood to flow from left atrium, to the left ventricle and Mitral Valve regurgitation results in poor apposition of the valvular leaflets, so that the heart's mitral valve doesn't close tightly, allowing blood to flow backward into the left atrium. Transthoracic Echocardiography (TTE) with Doppler is the widely used non-invasive technology for the detection and evaluation of severity of valvular regurgitation. Proximal isovelocity surface area (PISA) method has been widely accepted by clinicians as a means for grading MR severity. In this paper an alternate method to PISA to automatically quantify mitral valve regurgitation severity is proposed. This work attempts to automatically segment the jet region in color Doppler images using K-Means clustering. Further to quantify mitral regurgitation, jet area parameters and shape features are extracted from the segmented jet region which are then modeled using classifiers such as Support Vector machine (SVM) and Back Propagation Neural Network (BPNN). Quantifying MR with PISA calls for considerable expertise as a number of components must be taken into account to fully assess the severity of mitral regurgitation, however the results of the proposed method indicate that it could be used as an alternate method to automatically assess the severity of mitral regurgitation.

Computational analysis of the effect of mitral and aortic regurgitation on the function of ventricular assist devices using 3D cardiac electromechanical model

Valvular insufficiency affects cardiac responses and the pumping efficacy of left ventricular assist devices (LVADs) when patients undergo LVAD therapy. Knowledge of the effect of valvular regurgitation on the function of LVADs is important when treating heart failure patients. The goal of this study was to examine the effect of valvular regurgitation on the ventricular mechanics of a heart under LVAD treatment and the pumping efficacy of an LVAD using a computational model of the cardiovascular system. For this purpose, a 3D electromechanical model of failing ventricles in a human heart was coupled with a lumped-parameter model of valvular regurgitation and an LVAD-implanted vascular system. We used the computational model to predict cardiac responses with respect to the severity of valvular regurgitation in the presence of LVAD treatment. An LVAD could reduce left ventricle (LV) pressure (up to 34%) and end-diastolic ventricular volume (up to 80%) and maintain cardiac output at the estimated flow rate from the LVAD under the condition of mitral regurgitation (MR); however, the opposite would occur under the condition of aortic regurgitation (AR). Considering these physiological responses, we conclude that AR, and not MR, diminishes the pumping function of LVADs.

Prominently Increased of Mannose Binding Lectin (MBL) and Myeloperoxidase (MPO) Levels in Severe Valve Regurgitation and Heart Failure of Rheumatic Heart Disease

Rheumatic heart disease (RHD) is mediated by an abnormal immunological response following a Streptococcus pyogenes infection that induces a disturbance of oxidants and antioxidants balances. Mannose-binding lectin (MBL) binds to N-acetylglucosamine, a molecule present on the Streptococcus cell wall and human heart valves. There is a disturbance of oxidant and antioxidant balance in rheumatic disease. Myeloperoxidase (MPO) is a marker of oxidative stress and inflammation. This study was aimed to determine the correlation of MBL and MPO levels and severity of valvular regurgitation and heart failure (HF) in RHD patients. A case-control study was conduct using human peripheral blood samples from 32 children aged 6 to 14 years old. The subjects were divided into two groups: 16 RHD patients included in the case group and 16 healthy children as a control group. The level of MBL and MPO was investigated using ELISA method. There were significant differences on MBL and MPO level between patient and control group. The level of MBL and MPO were significantly increased in RHD group, especially on severe valvular regurgitation. There was a strong correlation between MBL and MPO levels and the severity of valvular regurgitation (r = 0.94 and r = 0.88). The least significant diff-erence (LSD) analysis showed that significant difference occurs in the severe heart failure group. Our research revealed that the MBL and MPO levels in pediatric RHD patients were significantly higher than in healthy children. The MBL and MPO levels were significantly correlated with the severity of valvular regurgitation and heart failure.

Texture based classification of the severity of mitral regurgitation

Clinically, the severity of valvular regurgitation is assessed by manual tracing of the regurgitant jet in the respective chambers. This work presents a computer-aided diagnostic (CAD) system for the assessment of the severity of mitral regurgitation (MR) based on image processing that does not require the intervention of the radiologist or clinician. Eight different texture feature sets from the regurgitant area (selected through an arbitrary criterion) have been used in the present approach. First order statistics have been used initially, however, observing their limitations, the other texture features such as spatial gray level difference matrix, gray level difference statistics, neighborhood gray tone difference matrix, statistical feature matrix, Laws’ textures energy measure, fractal dimension texture analysis and Fourier power spectrum have additionally been used. For the classification task a supervised classifier i.e., support vector machine has been used in the present approach. The classification accuracy has been improved significantly by using these texture features in combination, in comparison to when fed individually as input to the classifier. The classification accuracy of 95.65±1.09, 95.65±1.09 and 95.36±1.13 has been obtained in apical two chamber, apical four chamber and parasternal long axis views, respectively. Therefore, the results of this paper indicate that the proposed CAD system may effectively assist the radiologists in establishing (confirming) the MR stages, namely, mild, moderate and severe.

Atrial Natriuretic Peptide as an Indicator of the Severity of Valvular Regurgitation and Heart Failure in Horses

Natriuretic peptides are cardiac biomarkers, routinely used for diagnosis, prognosis, and guidance for treatment in human and small animal cardiology. However, their diagnostic and prognostic value in horses has received little study. The aim of this study was to investigate the plasma atrial natriuretic concentration (ANPPl) in a large group of horses with various degrees of valvular regurgitation (VR) and congestive heart failure (CHF). Clinical examination and two-dimensional time-motion mode and Doppler echocardiography were performed on 91 horses admitted to the Equine Teaching Hospital of Liege University, with either no, mild, moderate, or severe VR and presenting various stages of CHF. Plasma atrial natriuretic concentration was measured using a commercially available human radioimmunoassay test. Mean values of body weight, age, ANPPl, and echocardiographic parameters were compared among horses with no, mild, moderate, and severe VR and among horses in different CHF stages. Correlation and linear regression of ANPPl with each echocardiographic parameter and with the percentage of dilation of each of cardiac chambers were assessed. Horses with severe or moderate VR had significantly higher ANPPl than those with mild or no VR. Plasma atrial natriuretic concentration was significantly higher in horses presenting CHF than those without CHF. Plasma atrial natriuretic concentration was significantly correlated with the left atrial diameter and its percentage of dilation. These results suggest a diagnostic value of ANPPl in horses with VR, especially with tricuspid or mitral insufficiency with dilation of the atria.

THE SIGNIFICANCE OF FUNCTIONAL AND ETIOLOGICAL DIAGNOSTIC FOR TREATMENT STRATEGY DECISION IN PATIENTS WITH DILATED CARDIOMYOPATHY

Aim. To evaluate the role and importance of the functional and etiological diagnosis in determining the surgical treatment of patients with dilated cardiomyopathy (DCM). Material and methods. We examined 156 patients (40 women and 116 men) with dilated cardiomyopathy (DCM) aged 18-75 (average age — 48.8+/- 11.4) for the period from 2008 to 2013. The history of the disease averaging 54.8 +/-5.7 months; 15 (10%) of patients were in functional class II, 49 (31%) — in class III, 92 (59%) — in class IV. Results. The mean end-diastolic LV diameter was 7.45+/-1.2 cm, ejection fraction — 26.7+/- 2.1%. We performed blood PCR analysis in all the patients: Genome of herpes simplex virus type 1 was reported in 14 (9%), type 2 — in 7 (4%), type 6 — in 12 (8%) patients; of cytomegalovirus — in 20 (13%), of Epstein-Barr virus — in 24 (15%), of parvovirus B19 — in 29 (19%); we performed morphological study of the myocardium to detect cardiotropic viruses genome in 66 patients: genome of herpes simplex virus type 6 was found in 13 (23%), of cytomegalovirus — in 7 (12%), of Epstein-Barr virus — in 9 (15%), of parvovirus B19 — in 24 (42%). Depending on etiological factors, initial functional state of the patient as well as the severity of valvular regurgitation and the degree of interventricular dyssynchrony, 24 patients were implanted with cardioverter defibrillator (ICD) and 38 patients — with cardiac resynchronization therapy with cardioverter defibrillator function (CRT-D): in total, 62 patients with DCM; 24 patients underwent organ conserving reverse cardiac remodeling; orthotopic heart transplantation was performed in 13 patients; conservative treatment group consisted of 57 patients with DCM for whom surgical treatment was not recommended or impossible at the moment of the examination. Conclusion. These data indicate that application of complex etiological and functional diagnostics allows us not only to make nosological diagnosis of patients with DCM but also to determine the type of treatment and prognosis.

Usefulness of the multiplanar reformatting mode of three-dimensional echocardiography in evaluating valvular and structural heart disease: An experience from Saudi Arabia

ObjectiveThe aim of this study is to compare the feasibility and capacity of multiplanar reformatting (MPR) mode of three-dimensional echocardiography (3DE-MPR technique) with two-dimensional echocardiography (2DE) for visualizing morphological details during evaluation of congenital heart disease (CHD). The study also seeks to validate the accuracy of 3DE MPR in determining cardiac valvular lesions and the application of the 3DE-MPR technique in daily clinical practice. MethodsA cross-sectional study was carried out at Madinah Cardiac Centre, Saudi Arabia from May to December 2012. Various forms of CHD were diagnosed in 43 patients by conventional 2DE, and the patients were then examined with the 3DE-MPR technique using dedicated software and a standard protocol. ResultsOf the 43 patients, 23 (53.5%) were males and 20 (46.5%) females. Their age varied from 30days to 146months (mean age, 70.2months and SD=42.5months) and their weight from 4 to 42kg (mean weight, 20.2kg and SD=9.7kg). The 2DE showed left heart lesions in nine patients (20.9%), right heart lesions in 23 (53.5%), atrial septal defects in five (11.6%) and complex CHD in six patients (14%). The 3DE MPR technique application and analysis was possible in all patients. The study demonstrated the fields where 3DE MPR was of additive value to conventional 2DE for the vena contracta area in valvular regurgitation severity and the planimetry for the valvular stenosis precise estimation, enface views of atrial septal defects with direct visualisation of shape and size of the defect, and segmental analysis of complex CHD using one window. The clinician and surgeon were then able to determine the mechanism and severity of the lesions and thus decide on appropriate treatment and management. ConclusionThe study demonstrated the usefulness of 3DE-MPR as a complement to conventional 2DE. The technique is a significant technological breakthrough that allows instant visualization of morphological details and precise determination of cardiac valvular lesions, which were less clearly delineated by 2DE alone.

Stress Echocardiography in Regurgitant Valve Disease

Because of its wide availability, low cost, versatility, and clinical use, stress echocardiography has become increasingly recognized as a valuable tool in the assessment of patients with regurgitant valvular heart disease. Exercise testing is favored compared with pharmacological stress testing for risk stratification in asymptomatic patients and can identify what might otherwise be considered as a moderate valve disease. It has been shown to provide insights into exertional symptoms disproportionate to resting hemodynamics in these patients and to facilitate individual risk stratification. Aggravation of valvular regurgitation severity, exercise-induced pulmonary hypertension (PHT), impaired left ventricular (LV) contractile reserve, inducible ischemia, dynamic LV dyssynchrony, and altered exercise capacity, together with the development of symptoms during exercise echocardiography, provide the clinician with straightforward prognostic information, therefore enabling a more accurate definition of the optimal timing of intervention in patients with valvular regurgitation.1,2 In contrast, dobutamine stress echocardiography has little value in cases of valvular regurgitation. Dobutamine infusion is almost systematically associated with a decrease in the severity of regurgitation; however, it might be of interest in the detection of LV contractile reserve and inducible ischemia. The most common form of exercise used in conjunction with echocardiography is immediate postexercise imaging on a treadmill or upright bicycle ergometer. However, semisupine exercise testing on an appropriate tilted table allows continuous echocardiographic monitoring, which represents an advantageous tool for quantifying changes in valvular regurgitation severity, LV function, and pulmonary pressure (Table). This exercise stress echocardiography modality (ie, per-exercise echocardiography) is the most used in Europe, and we strongly suggest this approach in the setting of valvular heart disease to detect evanescent changes. A symptom-limited graded exercise test is recommended, and ≥80% of the age-predicted upper heart rate should be reached in the absence of symptoms. The test is adapted to the clinical conditions …

Induction and aggravation of atrioventricular valve regurgitation in the course of chronic right ventricular apical pacing

Valvular regurgitation, especially on the right side of the heart, is a common finding even in patients without endocardial pacing leads. The severity of valvular regurgitation can change after permanent pacemaker (PPM) implantation. Ventricular pacing has been shown to cause ventricular dysfunction. The purpose of this study was to evaluate the mid-term effects of right ventricular (RV) apical pacing on atrioventricular (AV) valvular regurgitation in patients with a normal left ventricular function before PPM implantation. Patients who required dual-chamber pacemakers due to a high-degree AV block were enrolled in the study. Initial echocardiography was performed before PPM implantation and re-evaluation by echocardiography was performed every 24 months thereafter. A total of 125 patients (61 male; mean age: 66.57 ± 6.45 years) were included in the study, and 115 pacemaker-dependent patients were followed up (mean ± SD; 4.08 ± 0.8 years). Echocardiography demonstrated mild tricuspid regurgitation (TR) and mitral regurgitation (MR) in 70 (60.1%) and 34 (29.6%) patients before PPM implantation, respectively. Moderate TR and MR were detected in 10 (8.7%) and 1 (0.9%) patients, respectively. Thirty-six (31.6%) patients showed moderate-to-severe TR at long-term follow-up, compared with the 10 (8.7%) patients, who had the same degree of TR before RV apical pacing (P < 0.001). Mild and moderate MR were detected in 54 (47%) and 8 (7%) patients after PPM implantation on the last echocardiography(P < 0.001). Baseline systolic pulmonary artery pressure (PAP) was 29.24 ± 8.45 mmHg, which increased to 36 ± 11 mmHg on the last echocardiography (P < 0.001). Considering the haemodynamic effects at mid-term follow-up, left ventricular dysfunction is rare in patients with RV apical pacing and normal baseline left ventricular function. Right ventricular apical pacing is associated with a significant increase in the prevalence and severity of TR and MR.

Is it safe to perform coronary angiography during acute endocarditis?

A best evidence topic was written according to a structured protocol. The question addressed was 'Is it safe to perform coronary angiography (CA) in acute endocarditis?' Three hundred and ninety-seven papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, key results and limitations of these papers are tabulated. One of the papers is a case report, which reported a fatal vegetation embolism from an infected aortic valve into the left main coronary artery 14 h after angiography. The remaining five papers are cohort studies. Four of these studies were performed between 1970 and 1980 before the era of echocardiography and were aimed at quantifying the severity of valvular regurgitation. No embolic complications or dislodgement of vegetations occurred in any of the five studies (186 patients). Guidelines published by the European Society of Cardiology (ESC) in 2009 recommended CA in the context of infective endocarditis (IE) for men >40 years old, postmenopausal women, and patients with at least one cardiovascular risk factor or a history of coronary artery disease. Exceptions include patients with large aortic vegetations which may be dislodged during catheterisation, and when emergency surgery is necessary - 1) native aortic or mitral IE with severe acute regurgitation or valve obstruction, or prosthetic valve IE with severe prosthetic dysfunction (dehiscence or obstruction) causing refractory pulmonary oedema or cardiogenic shock; 2) native aortic, mitral, or prosthetic valve IE with fistula into a cardiac chamber or pericardium causing refractory pulmonary oedema or shock. This is reiterated by the guidelines on the management of valvular heart disease published by the ESC in 2007. From the findings of the six papers, it can be concluded that coronary angiography can be performed safely in IE and should be performed if deemed necessary, unless the patients are haemodynamically unstable requiring emergency surgery, or have large vegetations of the aortic valve. This is consistent with the ESC guidelines.

Mismatch of Right- and Left-Sided Filling Pressures in Chronic Heart Failure

Background In patients with advanced heart failure (HF), elevated jugular venous pressure (JVP) is the most reliable sign of elevated left-sided filling pressures. However, discordance between right- and left-sided filling pressure s (R-L mismatch) could lead to inadequate or excessive therapy guided by JVP. We determined the prevalence of R-L mismatch in the current era and investigated whether mismatch might be identified from clinical information. Methods and Results Right-sided heart catheterization was performed in 537 consecutive patients hospitalized with advanced HF during complete transplantation evaluation. Patients with high filling pressures were categorized as matched (right atrial pressure (RAP) ≥10 mm Hg and pulmonary wedge pressure (PCWP) ≥22 mm Hg), high-R mismatch (RAP ≥10 but PCWP <22 mm Hg) or high-L mismatch (PCWP ≥22 but RAP <10 mm Hg). Among all of the patients, 195 (36%) were matched low and 194 (36%) were matched high, and 148 (28%) had R-L mismatch. Among patients with high filling pressures, 194 (57%) were matched high and 82 (24%) had high-L and 66 (19%) high-R mismatch. Mismatches were not associated with differences in demographic or clinical data, including pulmonary and hepatic function, or severity of valvular regurgitation and right ventricular function by echo. However, among all patients with RAP ≥10 mm Hg, pulmonary artery systolic pressure (PASP) was higher in those patients with matched high left- and right-sided pressures (59 ± 12 mm Hg) versus high-R mismatch (41 ± 13 mm Hg; P < .0001). Similarly among all patients with low RAP, PASP was lower in patients with matched low right- and left-side pressures (33 ± 11 mm Hg) versus high-L mismatch (53 ± 13 mm Hg; P < .0001). Conclusions R-L mismatch was present in >1 in 4 total patients, and >1 in 3 with elevated filling pressures. Regardless of clinical history, when empiric therapy to optimize volume status to JVP is not effective, additional measurement should be considered to establish the R-L relationship.

Color Doppler Echocardiographic Assessment of Valvular Regurgitation in Normal Infants

Despite valvular regurgitation being a common finding in children, its prevalence in infants is unclear. The aim of this study was to determine the presence and severity of valvular regurgitation in normal infants using echocardiographic screening. Two-dimensional (2D) color Doppler echocardiography was performed on 420 consecutive infants (aged 1-12 months) with structurally normal hearts. Pulsed, continuous-wave, and color Doppler imaging techniques were used to detect and evaluate regurgitant blood flow at each valve. Valvular regurgitation was present in 258 infants (61.4%). Among these, 41 (15.9%) were found to have a heart murmur. Tricuspid regurgitation was found in 237 (56.4%) infants, pulmonary regurgitation in 71 (16.9%), mitral regurgitation in 51 (12.1%), and aortic regurgitation in nine (2.1%). Regurgitation of one valve occurred in 161 (38.3%) infants, of two valves in 84 (20%), and of three valves in 13 (3.1%). Right-sided regurgitation was significantly more common than left-sided regurgitation (p < 0.05). The degree of regurgitation was trivial or mild in 97.3% of infants and the peak velocities of the regurgitant jets were < or = 2.5 m/sec in all the valves, by Doppler echocardiography. The prevalence of inaudible valvular regurgitation is high in infants with structurally normal hearts. Multiple-valve involvement with regurgitation is not uncommon. Mild severity and low velocity on color Doppler, and the structural information provided by 2D imaging strongly suggest that these regurgitant flows are physiologically normal in infancy.