Total Echocardiographic Score Research Articles

Factors Determining Outcomes of Aortic Valve Surgery in Patients with Aortic Regurgitation Due to Behçet's Disease: Impact of Preoperative Echocardiographic Features

Paravalvular leakage after open heart surgery is notoriously common in patients with aortic regurgitation (AR) due to Behçet's disease. The aim of this study was to test whether initial echocardiographic findings are useful to predict recurrent AR. Lesion severity on preoperative echocardiography was scored for redundant aortic valve cusp (0-2points), aortic pseudoaneurysm (0-2 points), and dissection of the adjacent interventricular septum (0-2 points) in 22 patients with severe AR due to Behçet's disease (13 men; mean age, 42.4 ± 11.5 years), which was confirmed by histologic examination after open heart surgery. Recurrent AR developed in 13 patients at a median of 12.6 months (range, 2.4-70.3 months) after the first operation, and 10, four, and one patient underwent second, third, and fourth surgery, respectively, to control recurrent AR; three patients died. Those patients with recurrent AR had a significantly higher incidence of repeat surgery or death (84.6% [11 of 13] vs 0%, P= .015). Multivariate analysis showed that perioperative immunotherapy (hazard ratio, 0.002; 95% confidence interval, 0.001-0.1761; P= .006) and total echocardiographic score (hazard ratio, 2.843; 95% confidence interval, 1.350-5.991; P= .006) were independent factors associated with recurrent AR. The 1-year, 3-year, and 5-year AR-free survival rates were 73 ± 10%, 46 ± 12%, and 39 ± 12%. The optimal cutoff value for total echocardiographic score was 3.0, and the 5-year AR-free survival rates were significantly lower in patients with scores ≥ 3 (20 ± 13% vs 50 ± 19%, P= .022). This retrospective study confirms that initial echocardiographic features can provide useful prognostic information in patients with AR due to Behçet's disease.

Follow-Up Assessment after Percutaneous Mitral Valvuloplasty (PMV) with Inoue Balloon

Background:Percutaneous Mitral Valvuloplasty (PMV) is the first-line treatment modality in selected patients with symptomatic mitral stenosis and more recently available Inoue single-balloon catheter technique produces good results with low incidence of complications. The purpose of this study was to evaluate the immediate and over 6 months follow-up results after successful PMV with an Inoue balloon and to identify the predictive factors for the results. Methods:From May 1995 to Feburary 1997, a PMV with an Inoue balloon was technically successful in 114 (95%) of the 119 patients treated at the Sejong General Hostpital. In this study, a series of echocardiographic follow-up were performed in 54 patients with rheumatic mitral stenosis, at least 6 months after their successful PMV. In PMV, the inflation was conducted in steps, starting with a recommended maximum size of balloon by the Inoue criteria. After each inflation, the mitral valve opening and competence were evaluated by Transesophageal echocardiography (TEE) and continuing increase balloon size. Results:Echocardiographic follow-up assessment was performed in 54 patients serially in a interval of 3 months or 6 months. Their mean age was 46±11 years (24 to 66 years) and the mean total echocardiographic score was 7.1±1.6. A optimal result was obtained in 95% of the cases (51/54). The post-PMV mitral valve area increased to 1.95±0.37 cm and 1.79± 0.28 cm by 2-D and Doppler method, the average transmitral mean diastolic pressure gradient decreased to 5.16±2.8 mmHg and LA pressure was decreased to 11.28±8.2 mmHg. The newly developed and aggravated mitral regurgitation was observed in 17 patients (31.5%). The restenosis was noted in 2 cases (3.7%) after 1 year follow-up. The pre-procedural echocardiographic score for leaflet mobility, thickening and calcification was more higher in patients with restenosis. There was significant tendency of decrement in the mitral valve area in patients with a echocardiographic score>8 compared with those≤8 over 6 months after the PMV. Conclusion: PMV with the Inoue balloon under TEE guide as a combined treatment modality of patient with symptomatic mitral stenosis is relatively safe and achieves good immediate and midterm follow-up results. The echocardiographic score is considered as useful predictor of midterm results and restenosis after PMV with Inoue balloon. (Korean Circulation J 1998;28(11):1841-1851)

The Prediction of Successful Outcome after Percutaneous Mitral Valvuloplasty

Background:Several predictors of successful outcome after percutaneous mitral valvuloplsty (PMV) have been identified but the results were controversial. We analyzes the clinical and echocardiographic predictors of successful outcome after PMV. Methods:We studied 214 patients(167 women and 47 men) undergoing PMV from October 1991 to December 1995. Echocardiographic evaluation was performed before and after PMV. Results:The study population had mean age of 41±11 years, and the total echocardiographic score was 7.5±1.5. PMV using Inoue balloon and double balloon technique were performed in 113 cases and 101 cases respectively. The successful outcome from PMV(defined as mitral valve area ≥ 1.5cm and increase in valve area ≥25% and less than grade 3 mitral regurgitation(MR)) was achieved in 178 cases(83.2%). The mean mitral valve area was increased from 0.90±0.21cm 2 to 1.82±0.34cm(p 8(0.83±0.22cm, p<0.01). Significant MR(≥grade 3 MR) after PMV was developed in 10 cases(4.7%). In patients with significant MR after PMV, echocardiographic calcification score were high(2.3±0.8 vs. 1.7±0.7, p<0.01) and mitral valve area before PMV were smaller(0.82±0.10cm vs. 0.90±0.22cm , p<0.05) than in those without significant MR. Conclusions:The predictors of successful outcome after PMV are large mitral valve area and good echocardiograpic score. The predictors of significant MR is severe calcified mitral valve and small mitral valve area before PMV.

Inoue balloon mitral valvotomy in patients with severe valvular and subvalvular deformity

This study evaluated the immediate and long-term results of percutaneous Inoue balloon mitral valvotomy in patients with severe valvular and subvalvular deformity. We reviewed the prevalvotomy transthoracic echocardiograms of patients from the North American multicenter Inoue registry with total Massachusetts General Hospital (MGH) echocardiographic scores > or = 10. The echocardiograms were rescored by two investigators to assess valvular and subvalvular morphology to eliminate interinstitutional variability. Ninety patients were originally assigned scores > or = 10. After rescoring, 18 patients (20%) were eliminated, leaving 72 study patients. Balloon mitral valvotomy was technically successful in 69 (96%) of the 72 patients. Mean (+/- SD) mitral valve area increased from 0.9 +/- 0.3 to 1.5 +/- 0.5 cm2. An immediate optimal result, defined as > or = 50% increase in mitral valve area or a final area > or = 1.5 cm2 with no major complications, was achieved in 46 patients (64%). End points for clinical follow-up (events) included mitral valve replacement, repeat valvotomy or death. At a mean follow-up of 22.9 +/- 11.0 months, 22 patients (31%) required mitral valve replacement or a second valvotomy, 9 patients (13%) died, and 32 patients (45%) were in New York Heart Association functional class I or II. Univariate predictors of an immediate optimal result included sinus rhythm, male gender and a lower University of Southern California commissural calcium score. Only sinus rhythm predicted an optimal result by multivariate analysis. Actuarial 3-year event-free survival was 42%. Univariate predictors of event-free survival were a lower grade of mitral regurgitation, lower MGH total echocardiographic score, lower MGH leaflet thickness subscore and lower prevalvotomy left ventricular systolic pressure. Only grade of mitral regurgitation after valvotomy predicted event-free survival by multivariate analysis. Inoue mitral valvotomy in patients with severe valvular and subvalvular deformity has a high technical success rate and good immediate hemodynamic result but a high cardiovascular event rate in follow-up. Mitral valve replacement should be considered in surgical candidates with an MGH total echocardiographic score > or = 10 because it may be able to provide better long-term event-free survival. Balloon valvotomy remains a reasonable palliative therapeutic option for some patients with severe valvular deformity and high surgical risk.

Early and late results of percutaneous mitral valvuloplasty for mitral stenosis associated with mild mitral regurgitation

To assess the influence of mild mitral regurgitation (MR) on the initial and long-term results of percutaneous mitral valvuloplasty (PMV), the baseline characteristics, early results and followup of 102 consecutive patients with mild MR before PMV (group I) were prospectively analyzed and compared with those of 186 consecutive patients without MR (group II). Age, gender and symptomatic status were similar in both groups, but more patients in group I were in atrial fibrillation (70 vs 54%, p < 0.05) and had had a previous episode of pulmonary edema (25 vs 14%, p < 0.05). On echocardiography, patients in group I had larger left atria (58 ± 12 vs 53 ± 10 mm, p < 0.05) and more calcified mitral valves (score 1.9 ± 0.8 vs 1.5 ± 0.7, p < 0.05), but the total echocardiographic score (8.0 ± 2 vs 7.3 ± 2) was similar in both groups. Baseline hemodynamic data were also similar in both groups. On multivariate analysis, group I patients were only independently associated with more calcified mitral valves and larger left atria. PMV success (area gain ≥50% without complications) was similar (88 vs 86%) in both groups, but mitral valve area gain was smaller (0.8 ± 0.3 vs 1.0 ± 0.3 cm 2, p < 0.05) in group I. After PMV an increase in the severity of MR ≥2 grades (17 vs 6%, p < 0.05) occurred more frequently in group II patients. Although the incidence of severe MR after PMV (6 vs 7%) was similar in both groups, the number of patients with moderate MR after PMV was eventually higher in group I (31 vs 11%, p < 0.05). Follow-up studies were obtained in 198 patients (92% eligible). At last follow-up (18 ± 13 months), 22 patients (11%) developed restenosis, 3 required mitral valve replacement and 3 patients died. On actuarial analysis the event-free survival at 2 years was higher in group II (88 vs 71%, p < 0.05). Thus, patients with mild MR undergoing PMV have more calcified mitral valves, larger left atria, and obtain a similar success rate than other patients, although with smaller increments in mitral valve area. These patients should be closely followed since they are less frequently event-free at follow-up.

Factors influencing immediate results, complications, and short-term follow-up status after inoue balloon mitral valvotomy: A North American multicenter study

Clinical trials with the Inoue mitral valvotomy balloon have recently begun in the United States. We assessed the effects of 17 demographic, echocardiographic, procedural, and hemodynamic variables on the immediate results, complications, and short-term follow-up of 200 patients in 15 centers undergoing valvotomy with this device. The study population had a mean age ± SD of 53 ± 15 years, and the total echocardiographic score was 7.2 ± 2.4. Valvotomy was technically successful in 96.5% of procedures and increased the mean mitral valve area from 1.0 ± 0.3 to 1.8 ± 0.7 cm 2 ( p < 0.001); 72% had an increase in valve area ≥50%, and 67% had a final area ≥1.5 cm 2. Major procedural complications included cardiac tamponade during transseptal puncture (1.0%), systemic embolism (1.5%), and severe mitral regurgitation (2.4%); there were no procedural deaths and one hospital death. Multivariate analysis identified the absence of prior surgical commissurotomy and younger age as significant predictors of the gain in mitral valve area, but the correlation coefficients were low. Although the absence of subvalvular disease on echocardiograms was a predictor of a final valve area ≥1.5 cm 2, the total echocardiographic score did not correlate well with the immediate outcome ( r = 0.01, p = NS). No variable was identified as predictive of restenosis, which occurred according to echocardiographic criteria in 14 of 66 (21%) patients evaluated 6 months after valvotomy. Good hemodynamic results with valvotomy were achieved in the majority of patients with low complication rates by many investigators with the use of the Inoue balloon device. In contrast to findings in previous studies that used other techniques, the immediate results with the Inoue procedure may be less influenced by age and echocardiographic valve morphology.

Two-dimensional and Doppler echocardiographic determinants of the natural history of mitral valve narrowing in patients with rheumatic mitral stenosis: Implications for follow-up

Fifty patients with rheumatic mitral stenosis were studied with serial two-dimensional and Doppler echocardiography to determine the natural history of changes in mitral valve area and its relation to transmitral gradients and mitral valve morphology. Over the 39-month observation period (range 7 to 74 months) the decline in valve area was 0.09 ± 0.21 cm2/year. In addition, there were significant increases in total echocardiographic score (p = 0.0001), severity of mitral anulus calcification (p = 0.05) and severity of mitral regurgitation (p = 0.0007). Patients with an echocardiographic score ≥8 had a more progressive course.In addition, patients with a more progressive course (decline in valve area ≥0.1 cm2/year) had a significantly greater initial mean gradient (p = 0.01), peak gradient (p = 0.007) and total echocardiographic score (p = 0.0008). Initial valve area did not correlate with the rate of stenosis progression. Of 22 patients with an echocardiographic score <8 and a peak mitral gradient <10 mm Hg, only 1 patient (5%) had a more progressive course, compared with 80% of those with a total echocardiographic score ≥8 and a gradient ≥10 mm Hg.The rate of mitral valve narrowing in individual patients with rheumatic mitral stenosis is variable. Patients whose valve disease progresses rapidly are those with a greater mitral valve echocardiographic score and higher peak and mean transmitral gradients. These findings emphasize the importance of noninvasive evaluation of valvular morphology and hemodynamics and have implications for the frequency of follow-up and prognosis in patients with mitral stenosis.

Mitral regurgitation following mitral balloon valvotomy. Differing mechanisms for severe versus mild-to-moderate lesions.

This study was designed to evaluate the incidence and mechanisms of mitral regurgitation following mitral balloon valvotomy (MBV) in 40 consecutive patients with symptomatic tight pliable mitral stenosis. Transthoracic echocardiography with color flow mapping was performed before and 24 hours after the procedure. Patients who developed significant mitral regurgitation following MBV also underwent transesophageal echocardiography. The relation between increased mitral regurgitation and both valvular morphology and procedure-related factors was examined. Gorlin mitral valve area increased from 0.81 +/- 0.3 to 1.95 +/- 0.7 cm2 (p less than 0.001). No patient had more than 2+ mitral regurgitation by angiography and color Doppler prior to MBV. There was a moderate correlation between Doppler and angiographic increase in mitral regurgitation (r = 0.73, p less than 0.0001). By Doppler criteria 33 patients had no (n = 6) or mild (n = 27) increase in mitral regurgitation (group 1), and seven developed significant new mitral regurgitation (group 2). Baseline clinical, echocardiographic, and procedure-related data for the two groups were similar. Multiple regression analysis did not select any individual valve characteristic (valvular thickening, mobility, calcification, and subvalvular disease), total echocardiographic score, balloon diameter, or ratio of balloon to mitral annular diameter as disruption with a torn anterior or posterior mitral leaflet in six and a ruptured papillary muscle in one. Two of these patients have required mitral valve replacement (6 and 9 months following the procedure), whereas the remainder are significantly symptomatic. By contrast, mitral regurgitation in group 1 either occurred at the site of commissural split (n = 20) or was associated with prolapse of the anterior mitral leaflet (n = 6). Thus, severe new mitral regurgitation following MBV is due to noncommissural tearing of the mitral leaflet and confers an adverse long-term prognosis. A mild increase in mitral regurgitation following MBV is frequent and occurs at the site of commissural split or is associated with prolapse of the anterior leaflet. Furthermore, in this study, an increase in mitral regurgitation could not be predicted from any valvular or procedure-related factor.

Prediction of successful outcome in 130 patients undergoing percutaneous balloon mitral valvotomy.

We studied 130 patients undergoing percutaneous balloon mitral valvotomy. The relation between valvular morphology according to a previously described echocardiographic scoring system and hemodynamic outcome expressed as qualitative ("good" and suboptimal) and as absolute change in valve area was analyzed. The relative importance of the individual components of this echocardiographic score (valvular thickening, mobility, calcification, and subvalvular disease) to the change in valve area after valvotomy was also examined. Mean transmitral pressure gradient decreased from 16 +/- 6 to 6 +/- 3 mm Hg (p less than 0.0001), and mitral valve area increased from 0.9 +/- 0.3 to 1.8 +/- 0.7 cm2 (p less than 0.0001). Results in individual patients were variable. Eighty-four percent (61 of 73) of patients with an echocardiographic score of 8 or less had a "good" outcome (final valve area greater than or equal to 1.5 cm2 and an increase in valve area of greater than or equal to 25%), whereas 58% (33 of 57) of patients with an echocardiographic score of 8 or more had a suboptimal result (p less than 0.001). The sensitivity of an echocardiographic score of 8 or less for predicting a "good" outcome was 72%, and the specificity was 73%. The echocardiographic score correlated negatively (r = -0.40, p less than 0.0001) with the absolute increase in mitral valve area after valvotomy, but there was substantial scatter in the data. Of the four components of the total echocardiographic score, valvular thickening correlated best with the absolute change in value area (r = -0.47, p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation.

Twenty two patients (four men, 18 women, mean age 56 years, range 21 to 88 years) with a history of rheumatic mitral stenosis were studied by cross sectional echocardiography before and after balloon dilatation of the mitral valve. The appearance of the mitral valve on the pre-dilatation echocardiogram was scored for leaflet mobility, leaflet thickening, subvalvar thickening, and calcification. Mitral valve area, left atrial volume, transmitral pressure difference, pulmonary artery pressure, cardiac output, cardiac rhythm, New York Heart Association functional class, age, and sex were also studied. Because there was some increase in valve area in almost all patients the results were classified as optimal or suboptimal (final valve area less than 1.0 cm2, final left atrial pressure greater than 10 mm Hg, or final valve area less than 25% greater than the initial area). The best multiple logistic regression fit was found with the total echocardiographic score alone. A high score (advanced leaflet deformity) was associated with a suboptimal outcome while a low score (a mobile valve with limited thickening) was associated with an optimal outcome. No other haemodynamic or clinical variables emerged as predictors of outcome in this analysis. Examination of pre-dilatation and post-dilatation echocardiograms showed that balloon dilatation reliably resulted in cleavage of the commissural plane and thus an increase in valve area.