Systolic aortic regurgitation.

Aortic regurgitation is normally a diastolic phenomenon. Echocardiographic images of systolic aortic regurgitation in a patient with atrial fibrillation and heart failure are presented, and haemodynamic interpretation is provided.     

经导管主动脉瓣置入手术在主动脉瓣狭窄合并二尖瓣反流治疗中的疗效分析

目的:分析经导管主动脉瓣置入术在主动脉瓣狭窄合并二尖瓣反流(MR)的疗效。方法:选取我院就诊的主动脉瓣狭窄合并MR流患者31例,所有患者均行经导管主动脉瓣置入术,按照患者的MR流严重程度分为A组(轻度)和B组(中度、重度)。比较两组的并发症发生率、术后1个月的LVEF、LVEDD、MR和NYHA分级,比较两组在术后1个月、3个月时的死亡率和生活质量。结果:两组的各并发症发生率差异无统计学意义(P>0.05);A组在术后1个月时的LVEF和日常生活能力量表(ADL)评分均明显高于B组(P<0.05);A组在术后1个月时的死亡率、LVEDD、MR和NYHA分级明显低于B组(P<0.05);两组患者在术后3个月时的死亡率和ADL评分均差异无统计学意义(P>0.05)。结论:经导管主动脉瓣置入手术可用于主动脉瓣狭窄合并不同程度MR流患者的治疗中,反流的严重程度对患者远期死亡率和生活质量恢复的影响较小。     

肺静脉血流图鉴别二尖瓣血流图假性正常化的价值

目的 :探讨肺静脉血流图鉴别二尖瓣血流图假性正常化的价值。方法 :通过 69例高血压病 ( EH)患者根据其二尖瓣血流图形态及室壁厚度分组与 15例正常人作对照研究。结果 :二尖瓣血流图正常组 ,肺静脉血流图 S波、D波峰值的比值、S波流速积分与 S波、D波流速积分之和的比值( FVTIs)和 AR波持续时间与 A波持续时的比值 ( ARD/AD)已能显示异常。而二尖瓣血流图异常组 ,肺静脉血流图 FVTIs和 ARD/AD也能显示异常。结论 :肺静脉血流图对识别假性正常化的二尖瓣血流图有重要意义 ,也有助于反映 EH患者左室舒张功能受损的不同阶段 :1二尖瓣血流图正常、肺静脉血流图 FVTIs升高、ARD/AD下降 ;2二尖瓣血流图异常 ;3二尖瓣血流图正常、肺静脉血流图 FVTIs下降、ARD/AD升高 (二尖瓣血流图假性正常 )     

Evidence-based recommendations for PISA measurements in mitral regurgitation: systematic review,clinical and in-vitro study

Background

Guidelines for quantifying mitral regurgitation (MR) using “proximal isovelocity surface area” (PISA) instruct operators to measure the PISA radius from valve orifice to Doppler flow convergence “hemisphere”. Using clinical data and a physically-constructed MR model we (A) analyse the actually-observed colour Doppler PISA shape and (B) test whether instructions to measure a “hemisphere” are helpful.

Methods and results

In part A, the true shape of PISA shells was investigated using three separate approaches. First, a systematic review of published examples consistently showed non-hemispherical, “urchinoid” shapes. Second, our clinical data confirmed that the Doppler-visualized surface is non-hemispherical. Third, in-vitro experiments showed that round orifices never produce a colour Doppler hemisphere.In part B, six observers were instructed to measure hemisphere radius r_h and (on a second viewing) urchinoid distance (d_u) in 11 clinical PISA datasets; 6 established experts also measured PISA distance as the gold standard. r_h measurements, generated using the hemisphere instruction significantly underestimated expert values (− 28%, p < 0.0005), meaning r_h² was underestimated by approximately 2-fold. d_u measurements, generated using the non-hemisphere instruction were less biased (+ 7%, p = 0.03).Finally, frame-to-frame variability in PISA distance was found to have a coefficient of variation (CV) of 25% in patients and 9% in in-vitro data. Beat-to-beat variability had a CV of 15% in patients.

Conclusions

Doppler-visualized PISA shells are not hemispherical: we should avoid advising observers to measure a hemispherical radius because it encourages underestimation of orifice area by approximately two-fold. If precision is needed (e.g. to detect changes reliably) multi-frame averaging is essential.     

PR间期与二尖瓣返流和左心室充盈的关系

目的 探讨异常PR间期对舒张期和收缩期二尖瓣返流的影响及对左心室充盈的影响。方法 选择心房心室分离患者为模型，采用数字化超声心动图技术观察PR间期与二尖瓣返流及左心室舒张期前向血流充盈时间的关系。结果 PR延长达一定程度将引起二尖瓣舒张期返流，本例患者PR间期临界宽度为0．27S；在一定范围内PR越长则二尖瓣舒张期返流持续时间越长；PR越长，舒张期前向血流充盈时间越短。结论 PR延长是形成二尖瓣舒张期返流的重要条件；同时，PR延长使左心室充盈时间显著缩短。     

Echocardiographic predictors of pulmonary hypertension in patients with severe aortic stenosis.

BACKGROUND: Pulmonary hypertension complicating severe aortic stenosis increases morbidity and mortality. Causes and mechanisms of this are unclear. METHODS: This is a retrospective observational study of 626 patients with severe aortic stenosis who had measurable pulmonary arterial pressure by Doppler echocardiography. Clinical, echocardiographic and pharmacological data were related to the presence of pulmonary hypertension. RESULTS: Of the 626 patients, 119 (19%) had severe pulmonary hypertension defined as pulmonary artery systolic pressure > or =60 mmHg. Patients with severe pulmonary hypertension had a smaller aortic valve area (P < 0.0001), a lower left ventricular ejection fraction (P < 0.0001), a higher mitral E/A velocity ratio (P < 0.0001) indicating a higher filling pressure and a higher prevalence of 3 or 4+ mitral regurgitation (P < 0.001). They were less likely to be on a beta blocker (P = 0.05) or a statin (P = 0.02). Smaller aortic valve area, left ventricular dysfunction, mitral regurgitation and lack of statin use were independent predictors of severe pulmonary hypertension. CONCLUSIONS: Severity of aortic stenosis, left ventricular dysfunction, and mitral regurgitation are risk factors for the genesis of pulmonary hypertension and statins may potentially be protective in patients with severe aortic stenosis.     

Successful repair of a large aortic abscess causing apical displacement of the anterior mitral valve

Anatomic continuity between the anterior mitral leaflet and the aortic root may predispose those patients with aortic root pathology to functional changes of the mitral valve without any involvement of this valve. A 34-year-old man presented with aortic valve endocarditis. Transthoracic echocardiograpy showed severe aortic regurgitation with a large aortic root abscess. The anterior leaflet of the mitral valve was displaced towards the apex of the heart causing moderate mitral regurgitation. The patient underwent aortic valve replacement with reconstruction of the aortic annulus and ventriculoaortic continuity. This procedure alone restored the mitral valve structure and function without any need for intervention on the mitral valve. Aortic abscess is a serious complication of aortic valve endocarditis and may alter the function of other structures of the heart, especially the mitral valve. Restoration of aortic wall integrity and left ventricular – aortic continuity usually restores the mitral valve structure and function if the valve is unaffected by the infection. A decision on the mitral valve should be made following correction of the aortic pathology.     

Assessment of subclinical left ventricular dysfunction in asymptomatic mitral regurgitation.

The management of asymptomatic severe mitral regurgitation is showing an increasing trend towards early surgery. However, in situations where either the valve or the patient is not optimal for surgery, watchful waiting remains a reasonable policy. In this situation, the longstanding challenge of assessing left ventricular function in the setting of severe mitral regurgitation has been simplified by a number of investigations, including stress echocardiography and myocardial imaging. This paper reviews the evidence base for each of these techniques.     

Determinants of pulmonary artery hypertension at rest and during exercise in patients with heart failure

Aims: Pulmonary hypertension, a marker of poor prognosis in heartfailure, may develop or increase during exercise. We soughtto examine the determinants of pulmonary hypertension at restand during exercise in heart failure patients. Methods and results: Forty-six patients with left ventricular (LV) dysfunction (ejectionfraction: 30 ± 6%) underwent a semi-recumbent, incrementalbicycle exercise Doppler echocardiography. LV systolic and diastolicfunction, pulmonary artery systolic pressure (PASP), functionalmitral regurgitation (MR), and left atrial volume were quantifiedat rest and during exercise. Wide changes in PASP at exercisewere unrelated to PASP at rest (r = 0.12). Independent predictorsof PASP at rest were left atrial volume (P = 0.006), E-wavevelocity (P = 0.02), mitral tenting area (P = 0.005), and mitraleffective regurgitant orifice (ERO) (P = 0.02). The incidenceof dyspnoea was similar in patients with and without moderatelysevere pulmonary hypertension at baseline. At peak exercise,LV ejection fraction (P = 0.03) and mitral ERO (P = 0.008) wereindependently associated with PASP. Patients with a larger exerciseincrease in PASP (>60 mmHg) interrupted frequently exercisefor dyspnoea (70 vs. 27%; P = 0.04). A larger rise in mitralregurgitant volume during exercise emerged as the single determinantof exercise-induced increases in PASP. Conclusion: In patients with HF, left atrial volume, mitral deformation,and mitral regurgitant orifice correlated with pulmonary pressureat rest, whereas dynamic MR and limited contractile reservecorrelated with pulmonary pressure at exercise. The magnitudeof pulmonary pressure during exercise in these patients mainlydepends on dynamic MR.     

Pulmonary arterial pulse pressure and mortality in pulmonary arterial hypertension

In the Framingham studies, systemic arterial pulse pressure correlated linearly with morbidity and mortality. Right ventricular (RV) systolic dysfunction and pulmonary circulation stiffening result in abnormalities of pulmonary arterial (PA) pulse pressure in PA hypertension (PAH). We investigated the prognostic potential of PA pulse pressure in 67 patients with PAH diagnosed between January 1996 and March 2004 (33 idiopathic PAH, 34 PAH-connective tissue disease). The population was arbitrarily divided into tertiles of PA pulse pressure (= systolic-diastolic PA pressure) and 5-year mortality was assessed using the Kaplan-Meier method. The extent of RV systolic dysfunction and pulmonary circulation stiffening within each tertile was assessed by comparing the mean cardiac index and alpha (a recently described measure of pulmonary circulation distensibility) in each. Independent predictors of mortality were identified by Cox regression. Five-year mortality rates in patients with low, intermediate and high pulse pressures were 40%, 91% and 54%, respectively. Pulse pressure did not independently predict mortality, but cardiac index, 6-min walk test distance and mixed venous oxygen saturation did. Pulse pressure correlated with circulation stiffening (alpha) but did not correlate with cardiac index which tended to be lower in patients with intermediate pulse pressure and high mortality. PA pulse pressure correlated with pulmonary circulation stiffening but did not predict mortality in this study. RV dysfunction provided better prognostic information and probably explains the higher mortality seen in patients with intermediate pulse pressure.     

Sensitivity and specificity of pulsed Doppler echocardiography in detection of aortic and mitral regurgitation

In order to assess the value of pulsed Doppler echocardiographyin detection of valvular regurgitation, 63 patients were evaluatedfor aortic and/or mitral regurgitation using pulsed Dopplerechocardiography and selective cineangiography. The Dopplerstudy was considered as positive when a turbulent flow was detectedbelow the aortic valve for aortic insufficiency and behind themitral valve for mitral insufficiency on a graphic display (timeinterval histogram) when technically adequate andor on an audiosignal.These results were compared with standard angiographic evaluationof the regurgitation: pulsed Doppler echocardiography had 94%sensitivity and the specificity rate was very high (87.5%) evenfor mild regurgitation. Thus, Doppler technique is highly specificand sensitive in detection of aortic and mitral regurgitationwhen both audiosignal and time interval histogram are simultaneouslyperformed.     

经皮二尖瓣球囊成形术治疗二尖瓣狭窄伴主动脉瓣关闭不全的疗效评价

目的　探讨风湿性心脏病 (RHD)二尖瓣狭窄 (MS)合并轻、中度主动脉瓣关闭不全 (AR)患者行经皮二尖瓣球囊成形术 (PBMV)的效果。方法　将 2 6例MS合并轻、中度AR患者 (A组 )和 34例单纯MS患者 (B组 )的PBMV术后即刻及随访结果作对比研究。结果　A组左心房平均压力(MLAP)从术前 2 3 5± 4 6mmHg降至 11 2± 2 9mmHg(P <0 0 1) ,二尖瓣跨瓣压差 (MVG)从 17 2±7 7mmHg降至 2 3± 2 6mmHg(P <0 0 1) ,二尖瓣口面积 (MVA)从 1 1± 0 2cm2 增至 2 1± 0 2cm2(P <0 0 1) ,左心房内径 (LAD)从 43 3± 5 0mm降至 36 4± 3 7mm(P <0 0 1)。二尖瓣区舒张期杂音消失率为 73%。心功能分级 (NYHA)从术前 2 7± 0 5级改善至 1 1± 0 7级 (P <0 0 1)。随访与术后比较 ,除MVA外各项指标均无显著性差异 (P >0 0 5 )。以上各项参数与B组比较 ,差异均无显著性(P >0 0 5 )。且A组随访左心室内径 (LVD)仍在正常范围 ,亦无主动脉瓣返流增加。结论　对于MS合并轻、中度AR ,PBMV是一种有效和安全的治疗措施 ,应列入PBMV的手术适应症。     

Images in cardiovascular medicine: prosthetic aortic valve and conduit dehiscence with large periconduit cavity, ascending aortic aneurysm and severe mitral regurgitation

Prosthetic aortic valve and conduit dehiscence with periconduitcavity and ascending aortic aneurysm is an uncommon complicationof aortic root surgery. It is usually recognizable at echocardiographydue to an abnormal position of the prosthetic valve and conduitin relation to the native aortic annulus in conjunction withan abnormal echolucent periconduit space that fills with colorflow. Mitral regurgitation is an unusual complication of thiscondition. We present a patient with severe mitral regurgitation secondaryto prosthetic aortic valve and conduit dehiscence with a largepericonduit cavity and aneurysm of the intervalvular fibrosa.The mechanism of mitral regurgitation is secondary to functionalinvolvement of the anterior mitral valve leaflet and intervalvularfibrosa with anterior mitral leaflet restriction in conjunctionwith mild left ventricular remodeling. Significant mitral regurgitationpersisted post resection of the periconduit cavity and aorticvalve replacement, requiring mitral valve replacement. This case study reports a new mechanism of mitral regurgitationin the setting of prosthetic aortic valve and conduit dehiscence.     

Effects of surgery on ischaemic mitral regurgitation: a prospective multicentre registry (SIMRAM registry).

AIMS: Functional ischaemic mitral regurgitation (IMR) is common in patients with ischaemic left ventricular dysfunction undergoing coronary artery bypass surgery. Although the presence of IMR negatively affects prognosis, the additional benefit of valve repair is debated, particularly with mild IMR at rest. Exercise echocardiography may help identify a subset of patients at higher risk of cardiovascular events by revealing the dynamic component of IMR. METHODS: A large prospective, multicentre, non-randomized registry is designed to evaluate the effects of surgery on IMR at rest and on its dynamic component at exercise (z). SIMRAM will enrol approximately 550 patients with IMR in up to 17 centres with clinical and exercise follow-up for 1 year. Three sets of outcomes will be prospectively assessed and several hypotheses will be tested including determinants of adverse outcome and progressive left ventricular remodeling, efficacy of treatment and role of ischaemia on the dynamic consequences of IMR. Enrolment began in November 2006 and is expected to end by early 2008.     

Impact of pulmonary hypertension on mortality after operation for isolated aortic valve stenosis

Background

Pulmonary hypertension (PH) is a well-known independent risk factor for mortality and morbidity after cardiac surgery. However, no weight is given to PH in the current guidelines for the management of patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of our study was to evaluate the impact of preoperative PH on early and five-year survival in patients with severe AS undergoing isolated AVR.

Methods

From January 2005 to July 2010, 422 consecutive patients with severe AS underwent isolated AVR. According to systolic pulmonary artery pressure (sPAP), PH was classified as none (sPAPS < 35 mmHg, N = 224), mild–moderate (35 ≤ sPAP < 50 mmHg, N = 159) and severe (sPAP ≥ 50 mmHg, N = 39).

Results

Overall in-hospital mortality was 2.8%. Unadjusted mortality was 0.9%, 3.8% and 10.2% for patients with normal, mild–moderate and severe PH (p = 0.003). In multivariable analysis, severe PH (OR 4.1, 95 CI 1.1–15.3, p = 0.04) and New York Heart Association class III–IV (OR 14.9, 95% CI 1.8–117.8, p = 0.01) were independent risk factors of in-hospital mortality. Multivariable predictors of five-year survival were extracardiac arteriopathy (HR 2.8, 95%CI 1.6–4.9, p < 0.0001), severe PH (HR 2.4, 95%CI 1.2–4.6 p = 0.01), NHYA III–IV class (HR 2.3, 95% CI 1.3–4, p = 0.003), preoperative serum creatinine (HR 2.2, 95%CI, 1.6–3.1,p < 0.0001) and age (HR 1.08, 95%CI 1.03 - 1.13, p = 0.01). Five-year survival was 86% ± 3% with normal sPAP, 81% ± 4% with mild–moderate PH and 63 ± 10% with severe PH (p < 0.001).

Conclusions

In patients undergoing isolated AVR with severe AS, severe PH is an independent predictor of in-hospital mortality and five-year survival     

Noncompaction cardiomyopathy: A new mechanism for mitral regurgitation with distinct clinical,echocardiographic features and pathological correlations

Noncompaction cardiomyopathy (NCCM) is a primary, genetic cardiomyopathy with variable clinical manifestations that include mitral regurgitation (MR).

Methods

This study comprised patients diagnosed with NCCM and MR in two cardiac centers (King Abdul-Aziz Cardiac Center, Riyadh, Kingdom of Saudi Arabia and Sudan Heart Institute, Khartoum, Sudan), and seen in the period between 2002 and 2013. The study describes follow up, clinical, echocardiographic, and histopathological findings.

Results

Nineteen cases (85% females) were identified. Ten percent of the cases had relapses and remissions of heart failure. Echocardiographic features included leaflet retraction in all patients, characteristic malcoaptation, and a zigzag deformity of anterior leaflet in 57% of patients. Ruptured chordae were found in 15% of the patients. One patient had pathological examination of the mitral valve which showed myxomatous degeneration, and sclerotic and calcific changes.

Conclusion

We describe and discuss a new mechanism for MR caused by NCCM with identifiable clinical and echocardiographic features, and pathological correlations.     

经皮二尖瓣球囊扩张术治疗二尖瓣狭窄伴中度返流

目的　探讨经皮二尖瓣球囊扩张术 (PBMV)治疗二尖瓣狭窄 (MS)伴中度二尖瓣返流(MR)的近、远期疗效。方法　采用自制二尖瓣球囊导管治疗MS伴中度MR患者 6 2例 ,其中二尖瓣膜明显增厚、钙化者 7例 ,对左室最大前后径、二尖瓣口面积、左房平均压、二尖瓣跨瓣压差及心功能(NYHA分级 )等主要指标随访观察 12～ 36个月。结果　术后二尖瓣口面积明显增大 [(0 83± 0 18)cm2 比 (1 86± 0 2 4 )cm2 ,P <0 0 1],左房平均压 [(32± 8)mmHg比 (13± 8)mmHg ,P <0 0 1,1mmHg=0 133kPa]及二尖瓣跨瓣压差 [(18± 9)mmHg比 (5± 3)mmHg ,P <0 0 1]明显降低 ,心功能明显改善 [(2 81± 0 2 4 )级比 (1 4 6± 0 37)级 ,P <0 0 1],左室最大前后径无显著改变 [(4 5± 4 )mm比 (4 6± 4 )mm ,P >0 0 5 ]。对左室最大前后径、二尖瓣口面积及心功能等指标随访观察 12～ 36个月均无明显改变。结论　选择合适病例 ,严格把握球囊扩张终点 ,风湿性二尖瓣狭窄并中度返流患者PBMV的近、远期疗效显著。