Balloon mitral valvotomy: comparison between antegrade Inoue and retrograde non-transseptal techniques

AIMS: The results of percutaneous mitral valvotomy performed by theantegrade transseptal method using the Inoue balloon (n=1000;group 1) and by the retrograde non-transseptal technique usinga polyethylene balloon (n=100; group 2) were compared in a retrospective,non-randomized study. METHODS AND RESULTS: Both the groups were similar with respect to baseline characteristics.The success rate was 95% in group 1 and 93% in group 2. Therewas a significant increase in mitral valve area estimated byGorlin's equation (Group 1: from 0·8 ± 0·5to 2·1 ± 0·8 cm²; Group 2: from 0·8± 0·3 to 1·9 ± 0·8 cm², bothP<0·001) and by Doppler echocardiography using thepressure half-time method (Group 1: from 0·9 ±0·4 to 2·2 ± 0·6 cm²; Group 2: from0·9 ± 0·3 to 2·0 ± 0·7cm², both P<0·001). However, the calculated immediatepost-valvotomy mitral valve area was larger with the Inoue technique(2·1 ± 0·8 vs 1·9 ± 0·8cm²; P<0·02). Results were considered optimal whenthe mitral valve area increased to 1·5 cm², the percentageincrease was 50, and mitral regurgitation was 2/4. Out of thetotal successful procedures, optimal results were obtained in95% patients in Group 1 and 94% in Group 2. Incidence of significantmitral regurgitation (grade 3/4) was similar in two groups (Group1: 4% vs Group 2: 5%, P=ns). A significant left to right atrialshunt (Qp/Qs 1·5:1) in 2·5% and tamponade in2% of cases occurred exclusively with the Inoue technique, whileconduction disturbances, such as transient (<24 h) left bundlebranch block (28%) and complete heart block (2%) were notedwith the retrograde technique (Group 2). Local complicationswere significantly higher in Group 2 (3% vs 0·5%, P<0·01).The procedure time with the Inoue technique was shorter thanwith the retrograde (Group 1: 15 ± 8, range 10 to 35min; Group 2: 22 ± 14, range 15 to 45 min, P=0·05).Echocardiographic follow-up at 1 year showed no significantdifference in mitral valve area between the two groups (Group1 (n=300): 1·8 ± 0·8 vs Group 2 (n=60):1·9 ± 0·9 cm²; P=0·3). CONCLUSION: Balloon mitral valvotomy using the Inoue balloon and the retrogradenon-transseptal technique results in significant immediate haemodynamicand symptomatic improvement. The Inoue technique achieved alarger immediate post-valvotomy mitral valve area, but the differencewas not apparent at 1 year follow-up. Incidence of significantmitral regurgitation was similar with both the techniques; however,local complications occurred more frequently with the retrogradetechnique. Both techniques may complement each other in technicallydifficult cases.     

Balloon aortic valvuloplasty in elderly patients at high risk for surgery, or inoperable: Immediate and mid-term results

Although aortic valve replacement is undoubtedly the treatmentof choice for aortic valve stenosis, balloon aortic valvuloplastymay represent the only possible treatment for some frail elderlypatients who may have additional medical problems. We evaluatedimmediate and 1-year results of balloon aortic valvuloplastyin 86 patients 80 years with severe aortic stenosis. Mean agewas 84±3 years. Forty-four % were 85 years or older.Mean gradient decreased from 68 to 26 mmHg and valve area increasedfrom 0•53 to 0•96 cm² (P<0•05). There weretwo per-procedural deaths. No local vascular complication wasobserved During the follow-up (13±9 months), 27 patientsdied, four had repeat balloon aortic valvuloplasty and eightunderwent aortic valve replacement. Persistent clinical improvementwas observed in 78% of the surviving patients. One-year actuarialsurvival rate was 73%. Balloon aortic valvuloplasty appearsto be a safe and valuable technique in cases where surgery cannotbe performed or carries a very high risk.     

Influence of aortic regurgitation on the assessment of the pressure half-time and derived mitral-valve area in patients with mitral stenosis

The influence of aortic regurgitation on the Doppler assessmentof pressure half-time (T) and on the derived calculation ofthe mitral-valve area has not yet been adequately evaluatedin patients with mitral stenosis and associated aortic regurgitation.Therefore this study was undertaken to verify the accuracy ofthe T method for the noninvasive estimation of mitral-valvearea in patients with mitral stenosis and associated aorticregurgitation. Data were obtained from 31 selected patientswho underwent cardiac catheterization within 24 h of the noninvasiveexamination. From the Doppler velocity curve, T was calculatedas the interval between the peak transmitral velocity and velocity/. Mitral-valve area was measured fromthe T with a computerized system using the equation: 220/T,in cm². Calculation of the mitral-valve area at catheterizationwas derived applying the modified Gorlin formula. Mean mitral-valvearea, as determined at catheterization, ranged from 0.5 to 2.8cm² (1.3±0.6). Mean mitral-valve area, as calculatedby continuous-wave Doppler, ranged from 0.7 to 2.7 cm² (1.5± 0.6). Linear-regression analysis of data revealed agood correlation between Gorlin and Doppler measurements ofthe mitral-valve area (r = 0.90, SEE = 0.28 cm², P<0.001,y = 1.0x + 0.2). Doppler showed a systematic overestimate ofthe mitral-valve area (26%) in patients with mitral stenosisand aortic regurgitation as compared to the Gorlin formula.The overestimate of continuous-wave Doppler was even greater(39%) in a subgroup of patients with 2 + or 3 + angiographicaortic regurgitation. Thus the Doppler T method still providesaccurate noninvasive estimates of mitral-valve area in patientswith mitral stenosis and associated aortic regurgitation. However,when the degree of aortic regurgitation is significant, Dopplercan lead to important overestimation of the mitral orifice size.     

Lack of correlation between haemodynamic and cardiopulmonary exercise capacity improvement after catheter-balloon mitral valvuloplasty

The long-term effects of percutaneous transvenous mitral commissurotomyon exercise capacity and ventilation were investigated to determinewhether a dissociation between haemodynamic improvement andexercise capacity increase occurs in patients with mitral stenosis.Eighteen patients aged 45 ± 12.3 years (mean ±SD) with symptomatic mitral stenosis performed a symptom-limitedbicycle exercise test while respiratory gases were measuredbefore and 6 months after percutaneous transvenous mitral commissurotomy.The mitral valve area increased from 1.07 ±0.22 to 1.98±0.67 cm². P<0.0001 and the mean mitral gradient decreasedfrom 12.9 ±4.5 to 5.3±4.8mmHg, P<0.001, withouta significant increase in cardiac output index (from 2.64 ±0.55 to 2.77 ± 0.56 l. min_{– 1}. m_{– 2}, P= ns).This haemodynamic improvement was still present at the 6-monthfollow-up catheterization. Mean exercise workload and peak oxygenuptake increased 6 months after percutaneous transvenous mitralcommissurotomy from 88.3 ± 28.1 to 97.8 ± 25.1watts, P= 0.01, and from 18.1 ± 5.3 to 19.9 ±4.8 ml. kg_{– 1}.min_{– 1}, P<0.05. Total ventilation,ventilatory equivalents and oxygen pulse at the end of the exercisetest remained unchanged Correlations between peak oxygen orexercise capacity improvement and mitral valve area increasewere poor (r= 0.27, P= ns, r= 0.24, P=ns). This clear dissociationbetween haemodynamic improvement and improvements in minor exercisecapacity after percutaneous transvenous mitral commissurotomysuggests that peripheral alterations persist. Future studiesin which patients are trained after valvuloplasty may be helpful.     

Critical assessment of two-dimensional echocardiographic estimation of the mitral valve area in rheumatic mitral valve disease: calcific deposits in the valve as a major determinant of the accuracy of the method

The accuracy of two-dimensional echocardiographic estimationof the mitral valve area (MVA) and the effects which the morphologicalfeatures of the valve (degree of stenosis, coexistent regurgitation,extent of calcific deposits) exert on the approximation of sucha measurement have been evaluated. In 29 patients, who underwent surgical replacement of a rheumaticmitral valve, correlation was assessed between the echocardiographicvalues of MVA and the anatomical ones measured on excised valvesby means of a sizer set to detect area differences up to 0.1cm² Though the correlation obtained was statistically significant(P <0.001) the percentage deviation (%) between the two seriesof measurements was appreciable (29.38 ± 20.14%, mean± 1 s.d.). The degree of stenosis and the presence or absence of regurgitationdid not affect %. Only the amount of calcific deposits, evaluatedfrom the radiographs of the excised valves, influenced the discrepancybetween the two methods, % being significantly higher (P <0.05) in the calcified valves than in the not or minimally calcifiedones. Though the two-dimensional echocardiographic estimates ofM VAin rheumatic mitral valve disease are correlated with the anatomicalarea, their predictive value in the estimation of the true orificesize is poor in the individual patient, in view of the largediscrepancy between the echocardiographic and anatomical measurementsfound in our study.     

Biplane transoesophageal echocardiography, transthoracic Doppler, and magnetic resonance imaging in the assesment of coarctation of the aorta

This study compared flow-sensitive magnetic resonance imagingwith biplane transoesophageal echocardiography in combinationwith continuous wave Doppler from the suprasternal notch inpatients with native coarctation or after surgical repair. Twenty patients (mean age 33 years, range 17–60) wereinvestigated, of whom 15 had undergone surgery at mean age 13years, range 5.43. Peak and mean flow in the ascending and descendingaorta as well as coarctation peak velocity were determined withthe magnetic resonance imaging phase contrast technique. Coarctationpeak velocity was also measured by Doppler from the jugulum.Magnetic resonance imaging axial sections as well as biplanetransoesophageal echocardiography were used to measure the smallestdiameter of the constricted segment. Sixteen healthy volunteers,mean age 36 years, range 22.63, provided reference values formagnetic resonance imaging determined volume of flow in theaorta. Peak flow in the descending aorta was 9.2 ±3.71.min ^{– 1} (reference 130 ± 2.5, P<0.01) and meanflow 3.1 ±0.9 I. min^{– 1} (reference 3.4 ±0.8,P>0.05). The ratio of descending-to-ascending peak flow was0.54 ±0.17 (reference 0.69 ± 0.10, P<0.01)and mean flow 0.68 ± 0.15 (reference 0.69 ± 0.08,P>0.05). The coarctation velocity was slightly higher withDoppler than with magnetic resonance imaging (+ 0.24 ±0.44 m. s^{– 1}, 95% confidence interval +0.45 to + 0.02m.s^{– 1}, P= 0.05). The coarctation diameter was slightlylarger with magnetic resonance imaging than with transoesophagealechocardiography (1.4 ±3.5 mm, 95% confidence interval+ 3.1 to – 0.3 mm, P= 0.11). Both methods are suitable for the assessment and follow-up ofcoarctation of the aorta Flow assessment with magnetic resonanceimaging provides a hitherto unavailable measure with which toassess the severity of obstruction.     

Effects of percutaneous balloon mitral valvuloplasty and exercise training on the kinetics of recovery oxygen consumption after exercise in patients with mitral stenosis

Aims Kinetics of recovery oxygen consumption after exercise playsan important role in determining exer-cise capacity. This studywas performed to assess the kinetics of recovery oxygen consumptionin mitral stenosis and evaluate the effects of percutaneousballoon mitral valvuloplasty and exercise training on the kinetics. Methods and Results Thirty patients with mitral stenosis (valve area 1·0cm²)and same sized age- and size-matched healthy volunteers wereincluded for this study. All subjects performed maximal uprightgraded bicycle exercise. Thirty consecutive patients who underwentsuccessful percutaneous balloon mitral valvuloplasty (valvearea 1·5cm²and mitral regurgitation grade 2), were randomizedto an exercise training group or non-training group. The exercisegroup performed daily exercise training for 3 months. Half-recoverytime of peak oxygen consumption was significantly delayed inmitral stenosis as compared to normal subjects (120±42svs 59±5,P<0·01). Peak oxygen consumption (ml.min^–1.kg^–1)was significantly increased in both the training (16·8±4·9to 25·3±6·9) and non-training groups (16·3±5·1to 19·6±6·0) 3 months after percutaneousballoon mitral valvuloplasty. Half-recovery time of peak oxygenconsumption was significantly shortened in the training group(124±39 to 76±13,P<0·01), but not inthe non-training group (114±46 to 109±44s,P=0·12)at 3 months follow-up. The degrees of symptomatic improvementafter percutaneous balloon mitral valvuloplasty were more closelycorrelated with the changes of the half-recovery time of peakoxygen consumption than those of peak oxygen consumption. Conclusion Kinetics of recovery oxygen consumption was markedly delayedin mitral stenosis, which was improved after exercise trainingbut not after percutaneous balloon mitral valvuloplasty alone.These results suggest that adjunctive exercise training maybe useful for improvement of recovery kinetics and subjectivesymptoms after percutaneous balloon mitral valvuloplasty.     

Interpretative reproducibility of two-dimensional echocardiographic images. Analysis of intraobserver, interobserver and beat to beat reproducibility of the mitral value orifice

The intraobserver, interobserver and beat to beat interpretativereproducibility of two-dimensional echocardiographic imagesof the mitral valve area has been studied retrospectively ina group of 37 patients affected by rheumatic mitral valve disease.Reproducibility has been expressed either in terms of mean absoluteor percent error of duplicate measurements. A group of 11 normalsubjects was used for comparison. In our normal group the intraobserver, interobserver and beatto beat reproducibility averaged 1.8±2.1%, 3.1±1.4%,2.7±2.0% or 0.12± 0.14 cm², 0.21±0.10cm²,0.17±0.13 cm², respectively. In our patient populationthe intraobserver, interobserver and beat to beat reproducibilityaveraged 2.7±2.7%, 4.1±4.9%, 4.6± 3.6%or 0.05±0.05 cm², 0.08± 0.10cm², 0.08±0.06cm².In both groups there was no statistical difference among intraobserver,interobserver and beat to beat reproducibility either in termsof percent or absolute value. The mean percent error did not significantly differ betweennormal or stenotic valves or, in this latter group, among valvesof different sizes (1.4cm²; 1.5–2.4 cm²; 2.5 cm²). Themean absolute error, on the contrary, statistically differedbetween the two groups or among valves of different sizes, beinglarger in normals or in valves 1.5 cm². Thus, the interpretativereproducibility for two-dimensional echocardiographic imagesof the mitral valve area is small and acceptable for most clinicalpurposes. The use of mean percent error of duplicate measurementsmakes the quantification of reproducibility easily comprehensiblein clinical practice and insensitive to the actual cross sectionalarea of the structure examined thus allowing the data to beextended to cardiac structures of different sizes.     

Left ventricular systolic and diastolic function in aortic stenosis: Prognostic value after valve replacement and underlying mechanisms

AIMS: The aims of the study were to examine the prognostic value ofpre-operative left ventricular systolic and diastolic functionon early, and late mortality after valve replacement for aorticstenosis, and to identify possible underlying mechanisms. METHODS AND RESULTS: Ninety-one prospectively recruited consecutive patients witha mean age of 61 years underwent valve replacement for aorticstenosis with concomitant coronary artery bypass grafting in32 and a minimum postoperative observation period of 5·4years. There were six early (30 days postoperatively) and 19late deaths, and 18 deaths from specific causes (cardiac andprosthetic valve related). Early mortality occurred exclusivelyamong patients with a combined subnormal left ventricular systolicfunction (subnormal ejection fraction or peak ejection rate,or supranormal time-to-peak ejection — duration of systoleratio) and a subnormal fast filling fraction. In Cox regressionmodels on crude mortality and specific deaths, a subnormal ejectionfraction and a fast filling fraction of 45% were the only independentrisk factors. Patients with none of these risk factors had normalsex- and age-specific survival, those with any one factor hadan early, and those with both factors a massive early and alate excess mortality, with 5-year crude survival of 92%, 77%,and 50%, respectively (P<0·0001). Systolic wall stresswas without prognostic value. Further analyses indicated thatimpairment of left ventricular function occurred with increasingmuscle mass over two phases: (1) diastolic dysfunction characterizedby a pattern of severe relative concentric hypertrophy; (2)the addition of systolic dysfunction characterized by a moredilated, less concentric chamber geometry. Coronary artery diseaseseemed to provoke the latter development sooner. CONCLUSIONS: Impaired systolic and diastolic left ventricular function, irrespectiveof afterload, were decisive independent pre-operative risk factorsfor early as well as late mortality after aortic valve replacementfor aortic stenosis. The adverse influence of concentric hypertrophywas the main underlying mechanism. Operative intervention, beforeimpairment of diastolic and systolic function, should be advocated.     

Balloon occlusion during coronary angioplasty as a model of myocardial ischaemia: reproducibility of sequential inflations

In order to evaluate the potential of balloon occlusion duringcoronary angioplasty as a model of myocardial ischaemia in manwe have measured coronary sinus blood flow (CSBF), myocardialoxygen consumption (MVO₂), lactate extraction (LER) and electrocardiographicchanges in 11 patients undergoing left anterior descending artery(LAD) angioplasty. Baseline measurements were made before ballooncrossing and between inflations. Four consecutive inflationseach of 60 s duration were made; 5 min return to baseline wasallowed between inflations. There was a significant reduction in CSBF and MVO₂ (ml min^–1)during inflations 2, 3 and 4 (CSBF: 121±6694±53,113±4999±42, 124±66102±41, P<0.02;MVO₂:11.3±6.6–9.1±3.9, 10.4±3.7–8.7±2.4,12.2±4.49.4±2.8, P<0.05). However during thefirst period of balloon occlusion there were inconsistent changesin coronary flow with an overall rise in mean flow (97±35128±80ml min^–1, P = NS) and an overall rise in mean myocardialoxygen consumption (9.6 ± 3.812.5 ± 7.5 ml min^–1,P = NS). There was lactate production during all four inflationsbut the changes during the first one did not achieve statisticalsignificance. These inconsistent changes during the first inflation were thoughtto be due to partial obstruction of the stenosis by the deflatedballoon before primary dilatation. The changes due to crossingand during the first two inflations were further investigatedin another group of 12 patients undergoing LAD angioplasty.Great cardiac vein flow (GCVF), CSBF, MVO₂ and LER were recordedat baseline, during crossing and during the first two inflations.With the deflated balloon across the stenosis there were nochanges in CSBF or MVO₂ but there was a fall in GCVF (103±2877±50,P = NS) and a significant fall in LER (77±5716±37,P<0.01). Although there was a fall during the first inflationin CSBF, GCVF, MVO₂ and lactate extraction none of these changeswere significant. During the second inflation these changeswere of greater magnitude and achieved statistical significance. While balloon occlusion during coronary angioplasty has thepotential of providing a model of ischaemia in man we have foundthe first inflation period unreliable, due to the variable degreeof occlusion by the deflated balloon. We suggest that only subsequentinflations after the primary dilatation are used for observations.These findings are of significance when evaluating the effectsof therapeutic interventions during PTCA. Various refinementsin measurements of the effects of ischaemia will improve thespecificity of the model.     

Role of BNP in patients with severe asymptomatic aortic stenosis.

This editorial refers to "Predictors of outcome in patientswith severe aortic stenosis and normal left ventricular function:role of B-type natriuretic peptide" by P. Lim et al. on page2048 Senile degenerative valvular aortic stenosis affects approximately2% of the population over the age of 65. Aortic stenosis impedesleft ventricular emptying and increases left ventricular wallstress, which leads to elevation of brain natriuretic peptide(BNP) levels. Aortic stenosis progresses slowly, allowing theleft ventricle to develop concentric hypertrophy, which normalizeswall stress. These compensatory mechanisms maintain cardiacoutput for several years, during which time the patient remainsasymptomatic. Development of haemodynamically significant aorticstenosis (aortic valve area <1.0 cm²) is associated withsymptoms of exercise-induced angina, syncope and dyspnoea. Limet al.,¹ in this issue of the      

Haemodynamic findings in experimental right ventricular ischaemia after right coronary arterial ligation

Acute ischaemia limited to the free wall of the right ventriclewas produced by right coronary arterial ligation (RCAL) in 20dogs. Contrast M-mode and cross-sectional echocardiography wasperformed in 7 cases to investigate the presence of tricuspidinsufficiency. The haemodynamic findings obtained with an openpericardium at 15 to 30 min showed increases in right (l.20.5to 2.70.7 mmHg, P0.01) andleft (5.0 0.8 to 6.60.9 mmHg, P005)ventricular end-diastolic pressures, and decreases in heartrate (1394.9 to 1195.1 bpm, P0.01), cardiac index (1066.6 to817.3 ml min^–1 kg^–1, P001), stroke index (79 6 to72 8 ml x 100 beat^–1 kg^–1, P0.02), right (23.8l.5to 19.41.5 mmHg, P0.01) and left (1097.2 to 958.2 mmHg, P005)ventricular systolic pressures and right ventricular strokework index (18.32.4 to 11.41.8 g m kg^–1, P0.01). In 6of 15 cases the 'y' descent became deeper than the 'x' descentin right atrial pressure (RAP). Tricuspid insufficiency gradeI–II/IV was present in 3 of 7 cases, 2 of them with a'y'>'x' in RAP. Right ventricular mechanical alternans, probablysecondary to a decrease in contractility, appeared in 10 of20 cases after RCAL. Closure of the pericardium exaggeratedthe haemodynamic alterations and a dip-plateau appeared in 2cases on the right ventricular pressure curve. We conclude thatsignificant aemodynamic alterations in right ventricular functionare produced by RCAL in dogs, and they are exaggerated afterclosing the pericardium.     

Angioscopic evaluation of prolonged vs standard balloon inflations during coronary angioplasty: A randomized study

To study the immediate effects of prolonged total balloon inflationduring PTCA, 41 patients (44 lesions) with chronic-stable anginawere randomized for prolonged sequential inflations (three tofive inflations of 3 to 5 min each, for a total duration of 12 min, group 1, n=20 lesions) or ‘standard’ sequentialinflations (three to five inflations of 1 min each, for a totalduration of 3 min, group 2, n-24 lesions). The mean durationof total balloon inflation time was 958 ± 129 s in group1 vs 205 ±46 s in group 2. Results of angioplasty wereassessed on both angiography and percutaneous transluminal coronaryangioscopy performed immediately after the procedure. High qualityimaging of the coronary lumen and lesion morphology was possibleon angioscopy in all patients without any complications. Post-PTCAangiographic percent diameter stenosis was significantly lessin group 1 compared to group 2: 26 ± 10% vs 36 ±8% (P<0.05). On angioscopy, flaps were seen in 16 patientsin group 2, but in only six in group 1 (P<0.02). There wasno difference in the incidence of thrombi on angioscopy betweenthe two groups (group 1: nine cases, group 2: 10 cases). Sensitivityof angiographic detection of flaps and thrombi was poor: 10%and 12% respectively. One patient in each group developed alongitudinal dissection, detected on both angiography and angioscopy. Conclusions: (1) prolonged sequential balloon inflations leadto less residual luminal stenosis after PTCA, with a decreasedincidence of intimal flaps in comparison with standard inflations.(2) Post-PTCA transluminal coronary angioscopy is safe and offersbetter assessment of luminal effects of PTCA than angiography.     

Minimal heart rates and longest pauses in healthy adult subjects on two occasions eight years apart

A 24-h Holter monitoring (HM) record was obtained on two occasions8 years apart in 183 healthy subjects (120 male and 63 female),aged 40–85 years. The purpose of the study was to determinethe minimal mean heart rate (-min) and longest pauses in heart rhythm, and to examine possiblechanges in these parameters over a longer period of time. (-min was calculated from a I-min sampleperiod.) -min was influenced by physical activity level and smoking habit, but was independentof age. Females had higher than males. In the male group mean was 54 beats min^–1 and 53 beats min^–1 on the tworecordings (P>0·05) (range 36–75 beats min^–1and 38–69 beats min^–1). <40 beats min^–1 was seen in 2·5% of the males.In the female group, the lowest recorded HR was 42 beats min^–1and mean on the two recordings was 58 beats min^–1 and 56 beats min^–1 (P<0001).The paired observations were highly correlated. In all subjects, pauses > 1·75s were registered in 6% and6·5% on the two recordings.The occurrence of pauses was related to low . Above the age of 60 years sinus arrest was thetype of pause most often seen. It is concluded that (1) <40 beats min^–1 and pauses> 2·0 s are rare events in non-athletes, and shouldbe considered abnormal; (2) for a given individual, , seems to be a stable parameter overlong periods of time, but is influenced by sex, smoking andphysical activity; (3) limits for in an adult population can be determined from one 24-h HM.     

Velocity distributions in the left ventricular outflow tract in patients with valvular aortic stenosis: Effect on the measurement of aortic valve area by using the continuity equation

The cross-sectional velocity distribution in the left ventricularoutflow tract was studied in 40 patients with valvular aorticstenosis. Doppler colour flow mapping and a time-interpolationmethod were used to construct the cross-sectional velocity andtime-velocity integral (TVI) profiles at different levels. Byusing pulsed Doppler, the subaorticflow velocity was sampledfrom the anterior, middle and posterior regions along the diameterof the left ventricular outflow tract (at 0.5 to 1.0 cm proximalto the aortic anulus) in the apical long axis view. Thus, foreach patient, three aortic valve areas were calculated by usingthe continuity equation. Each patient was assigned to one oft/treesubgroups according to the left ventricular ejection fraction(EF): subgroup I with EF25% (n=10), subgroup II with 25%<EF50%(n=17) and subgroup III with EF>50% (n = 13). Velocity distributionsin the three subgroups were compared to each other. Results:(1) The velocity distribution in the left ventricular outflowtract was skewed with the highest velocities and TVIs alongthe anterior wall and septum. The skewness of the velocity distributionwas more pronounced in the apical long axis view than in thefour chamber view (P<0.05). The extent of skewness of theTVI profile was positively correlated to the left ventricularEF both in the long axis view (r=0.63; P<0.001) and in thefour chamber view (r=0–57; P<0.001). (2) Pulsed Dopplersampling from different regions along the diameter produceddifferent TVIs, and therefore yielded significantly differentcalculated aortic valve areas, especially in subgroup III. Due to the skewness of the velocity distribution in the leftventricular outflow tract, location of the pulsed Doppler samplevolume significantly affects the accuracy of aortic valve areacalculation by using the continuity equation, especially inpatients with relatively high left ventricular EF. In patientswith low EF, selection of pulsed Doppler sampling site is lessimportant.     

Evaluation and prognostic significance of left ventricular diastolic function assessed by Doppler echocardiography in the early phase of a first acute myocardial infarction

AIM: To study the prognostic significance of left ventricular diastolicfunction evaluated by transmitral and pulmonary venous flowvelocities obtained in the early phase of a first acute myocardialinfarction in relation to later development of congestive heartfailure. METHODS: Pulsed Doppler echocardiography of transmitral and pulmonaryvenous flow was assessed in 65 consecutive patients with a firstmyocardial infarction within 1 h of arrival in the coronarycare unit. RESULTS: A univariate regression analysis identified age, left ventricularejection fraction 45%, mitral E deceleration time 130 ms, E/Aratio >1·5, peak pulmonary venous atrial flow velocity30 cm . s^–1 and a difference between mitral and pulmonaryvenous atrial flow duration >0 ms as variables significantlyrelated to the development of congestive heart failure. However,in a multivariate analysis only mitral E deceleration time 130ms and age were significant independent variables related tothe development of congestive heart failure during the firstweek following a first acute myocardial infarction. CONCLUSION: Assessment of left ventricular diastolic function complementsmeasurements of systolic function in the evaluation of cardiacfunction, and mitral deceleration 130 ms best identifies patientsat risk of development of congestive heart failure followingacute myocardial infarction.     

Determination of the mean pressure gradient in aortic stenosis by Doppler echocardiography

Measurement of the mean pressure gradient across the stenoticaortic valve provides important information about the severityof aortic stenosis. However, determination of the mean pressuregradient by Doppler echocardiography has been difficult dueto the squared relation between instantaneous velocities andpressure gradients. In this study, the velocity curves in aorticstenosis were analysed mathematically to develop a new and simplemethod for calculating the mean pressure gradient ( Pm>)from Doppler velocity tracings. The new formula is: Pm = 8V2m[Vp/(Vp+Vm)] where Vp is the peak systolic velocity and Vmthe mean systolic velocity. Doppler echocardiography and cardiaccatheterisation were performed in 41 patients with aortic stenosisto evaluate the accuracy of this mathematical method. Therewas a high correlation between the peak pressure gradients determinedby Doppler technique using a modified Bernoulli equation andby catheterisation (r = 0.95, SEE=8.58 mmHg), and the differencebetween the two measurements was not significant. The comparisonbetween the mean pressure gradients determined by Doppler echocardiographyusing the new formula and by catheterisation yielded a highcorrelation (r = 0.95, SEE=5.60 mmHg), and there was no significantdifference between the two means. These results demonstratethe reliability of Doppler echocardiography for determiningthe mean pressure gradient in aortic stenosis using our mathematicalmethod. Measurement of the mean pressure gradient will furtherenhance the usefulness of Doppler echocardiography in the non-invasiveevaluation of patients with aortic stenosis.     

Subjective symptoms and well-being differ in women and men after myocardial infarction

The frequency of subjective cardiac and psychological complaintsamong men and women a year after a confirmed diagnosis of myocardialinfarction (MI) were compared. Among 660 survivors, 595 patientscompleted mailed questionnaires at home one year after the MI.There were 421 men, mean age 67.1±10.7 years, and 174women, mean age 72.1±10.6 years. Controlling for the significantly higher mean age among thewomen, the latter more often had a previous history of anginapectoris, 54.6% (P0.05) versus 42.9%, and heart failure, 24.7%versus 13.5% (P0.01). Despite these facts, the women were significantlyless often referred to CCU, 82.2% versus 91.7% (P0.05). Oneyear after the MI, controlling for differences in age and co-morbidity,women reported significantly higher frequencies of psychologicaland psychosomatic complaints, including sleep disturbances.These differences may have clinical implications for diagnosisand treatment of women with coronary heart disease.     

Antihypertensive treatment with felodipine but not with a diuretic reduces episodes of myocardial ischaemia in elderly patients with hypertension

Episodes of transient myocardial ischaemia can frequently beobserved in hypertensive patients. To assess the effects ofantihypertensive treatment with the calcium antagonist felodipineor the diuretic combination hydrochlorothiazidel triamtereneon episodes of ischaemic-type ST-segment depression (ST-D),simultaneous ambulatory electrocardio-graphic and blood pressure(BP) monitoring was performed in 42 elderly hypertensives withoutmanifest coronary artery disease. All patients (mean age 79± 6 years, office BP 160/95 mmHg) were evaluated offany antihypertensive or anti-ischaemic therapy and after 3 monthstreatment with either felodipine or the diuretic (randomized,double-blind study) for episodes of significant ST-D (0.1 mV,duration 1 min, interval 1 min). The reduction in office BPand daytime ambulatory BP was similar for both agents, as wasa significant reduction in the heart rate x systolic BP product(DP) over 24 h (felodipine: 12 441 ±2076 vs 11 643 ±1953 mmHg. min^–1; P=0.048; diuretic: 12 366 ± 2782vs 11 062 ± 2012 mmHg. min^–1; P=0.003). While felodipinesignificantly decreased the total number of ST-D (from 40 tosix episodes; P=0.03), the total number of ST-D remained unchangedwith the diuretic (non-significant increase from 31 to 45 episodes;P=0.24). The same trend was observed for the number of patientswith ST-D. The ischaemic threshold, defined as DP at the onsetof the episodes of ST-D, increased with felodipine (12 171 ±340vs 13 770 ± 138 mmHg. min^–1) and decreased withthe diuretic (16 210 ±312 vs 14 092 ± 319 mmHg.min^–1). In conclusion, antihypertensive treatment withfelodipine reduces blood pressure and episodes of transientmyocardial ischaemia in elderly hypertensive patients, whilehydrochlorothiazidel triamterene increases these episodes despitea similar BP reduction. Felodipine may influence structuraland functional factors at the coronary micro circulation level.These mechanisms improve coronary blood flow and increase theischaemic threshold.     

Differences in restenosis propensity of devices for transluminal coronary intervention: A quantitative angiographic comparison of balloon angioplasty, directional atherectomy, stent implantation and excimer laser angioplasty

With the increasing clinical application of new devices forpercutaneous coronary revascularization, maximization of theacute angiographic result has become widely recognized as akey factor in maintained clinical and angiographic success.What is unclear, however, is whether the specific mode of actionof different devices might exert an additional independent effecton late luminal renarrowing. The purpose of this study was toinvestigate such a difference in the degree of provocation ofluminal renarrowing (or ‘restenosis propensity’)by different devices, among 3660 patients, who had 4342 lesionssuccessfully treated by balloon angioplasty (n=3797), directionalcoronary atherectomy (n= 200), Palmaz-Schatz stent implantation(n= 229) or excimer laser coronary angioplasty (n= 116) andwho also underwent quantitative angiographic analysis pre- andpost-intervention and at 6-month follow-up. To allow valid comparisonsbetween the groups, because of significant differences in coronaryvessel size (balloon angioplasty=2.62±0.55 mm, directionalcoronary atherectomy= 3.28±0.62 mm, excimer laser coronaryangioplasty= 2.51±0.47 mm, Palmaz-Schatz=3.01±0.44mm;P<0.0001), the comparative measurements of interest selectedwere the ‘relative loss’ in luminal diameter (RLoss=losslvessel size) to denote the restenosis process, and the‘relative lumen at follow-up’ (RLfup=minimal luminaldiameter at follow uplvessel size) to represent the angiographicoutcome. For consistency, lesion severity pre-intervention was representedby the ‘relative lumen pre’ (RLpre=minimal luminaldiameter prelvessel size) and the luminal increase at interventionwas measured as ‘relative gain’ (relative gain=gainl vessel size). Differences in restenosis propensity betweendevices was evaluated by univariate and multivariate analysis.Multivariate models were constructed to determine relative lossand relative lumen at follow-up, taking account of relativelumen pre-intervention, lesion location, relative gain, vesselsize and the device used. In addition, model-estimated relativeloss and relative lumen at follow-up at given relative lumenpre-intervention relative gain and vessel size, were comparedamong the four groups. Significant differences were detectedamong the groups both with respect to these estimates, as wellas in the degree of influence of progressively increasing relativegain, on the extent of renarrowing (relative loss) and angiographicoutcome (relative lumen at follow-up), particularly at higherlevels of luminal increase (relative gain). Specifically, lesionstreated by balloon angioplasty or Palmaz-Schatz stent implantation(the predominantly ‘dilating’ interventions) wereassociated with more favourable angiographic profiles than directionalatherectomy or excimer laser (the mainly ‘debulking’interventions). Significant effects of lesion severity and location,as well as the well known influence of luminal increase on bothluminal renarrowing and late angiographic outcome were alsonoted. These findings indicate that propensity to restenosis afterapparently successful intervention is influenced not only bythe degree of luminal enlargement achieved at intervention,but by the device used to achieve it. In view of the clinicalimplications of such findings, further evaluation in largerrandomized patient populations is warranted.