Echocardiographic versus Histologic Findings in Marfan Syndrome

This retrospective study attempted to establish the prevalence of multiple-valve involvement in Marfan syndrome and to compare echocardiographic with histopathologic findings in Marfan patients undergoing valvular or aortic surgery.We reviewed echocardiograms of 73 Marfan patients who underwent cardiovascular surgery from January 2004 through October 2009. Tissue histology was available for comparison in 29 patients.Among the 73 patients, 66 underwent aortic valve replacement or the Bentall procedure. Histologic findings were available in 29 patients, all of whom had myxomatous degeneration. Of 63 patients with moderate or severe aortic regurgitation as determined by echocardiography, 4 had thickened aortic valves. The echocardiographic findings in 18 patients with mitral involvement included mitral prolapse in 15. Of 11 patients with moderate or severe mitral regurgitation as determined by echocardiography, 4 underwent mitral valve repair and 7 mitral valve replacement. Histologic findings among mitral valve replacement patients showed thickened valve tissue and myxomatous degeneration. Tricuspid involvement was seen echocardiographically in 8 patients, all of whom had tricuspid prolapse. Two patients had severe tricuspid regurgitation, and both underwent repair. Both mitral and tricuspid involvement were seen echocardiographically in 7 patients.Among the 73 patients undergoing cardiac surgery for Marfan syndrome, 66 had moderate or severe aortic regurgitation, although their valves manifested few histologic changes. Eighteen patients had mitral involvement (moderate or severe mitral regurgitation, prolapse, or both), and 8 had tricuspid involvement. Mitral valves were most frequently found to have histologic changes, but the tricuspid valve was invariably involved.     

The importance of tricuspid valve structure and function in the surgical treatment of rheumatic mitral and aortic disease.

A significant proportion of individuals with rheumatic disease have tricuspid valve involvement which may be clinically important and alter the medical or surgical approach to treatment. Therefore 50 patients with rheumatic left-sided valvular lesions who were referred for operative treatment were studied. Thirty patients had angiographically significant tricuspid regurgitation (group I) and 20 had a competent tricuspid valve (group II). Pre-operative cardiac assessment included Doppler echocardiography and contrast ventriculography. Patients with tricuspid regurgitation more commonly had mitral valve disease or combined mitral and aortic valve lesions, (P less than 0.001) and were more likely to have atrial fibrillation than those without tricuspid regurgitation (P less than 0.001). Pulmonary arterial systolic and mean right atrial pressures were higher in group I (both P less than 0.01). A close relationship was found between the angiographic and Doppler assessment of the degree of tricuspid regurgitation (P less than 0.01). Doppler-derived measurement of the right ventricular-right atrial systolic pressure difference correlated well with the systolic trans-tricuspid pressure difference measured at cardiac catheterization (y = 0.7x + 22, r = 0.67, P less than 0.001) and the pulmonary arterial systolic pressure (y = 0.8x + 27, r = 0.71, P less than 0.001). Rheumatic involvement of the tricuspid valve identified by pre-operative echocardiography was confirmed in five patients at surgery. Of the 13 patients with functional tricuspid regurgitation at operation, only two had been diagnosed as having organic disease by echocardiography. Furthermore, in all 18 cases where Doppler suggested grade 3 or 4+ tricuspid regurgitation, surgical repair or replacement of the valve was performed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical evaluation versus Doppler echocardiography in the quantitative assessment of valvular heart disease

We tested the hypotheses that Doppler echocardiography has a higher accuracy than clinical evaluation in the detection of significant aortic and mitral valvular heart disease and that Doppler echocardiography is highly accurate as compared with cardiac catheterization for the assessment of valvular disease severity. Thus, cardiac catheterization for the assessment of valve lesion severity may be unnecessary in selected patients. We prospectively evaluated 75 consecutive patients, ages 20-74 years (mean, 52 years), with clinically suspected valvular heart disease. Specific clinical and Doppler echocardiographic criteria were used to categorize each valve lesion as absent, insignificant, or significant. Criteria for a significant lesion at cardiac catheterization was an aortic or mitral valve area less than 1.1 or 1.5 cm2, respectively, or equal to or greater than 3+ cm2 aortic or mitral regurgitation at angiography. In all valve lesions, Doppler echocardiography had a higher overall accuracy than clinical evaluation. Increases in accuracies of 28%, 19%, 15%, and 7% occurred for mitral stenosis, aortic stenosis, aortic regurgitation, and mitral regurgitation, respectively, resulting in overall accuracies of 97%, 100%, 95%, and 96%. Clinical evaluation alone made 28 errors (37% of patients and 19% of valve lesions assessed), and 17 of these errors (23% of patients and 12% of valve lesions) would have resulted in inappropriate management. In only four (24%) of these 17 patients, the attending cardiologist would not have proceeded to assess the valve at cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)     

Serial assessment of mitral regurgitation by pulsed Doppler echocardiography in patients undergoing balloon aortic valvuloplasty

Mitral regurgitation was serially assessed by pulsed Doppler echocardiography in 144 patients undergoing balloon aortic valvuloplasty for symptomatic aortic stenosis. Regurgitant scores of 0, 1, 2 and 3 were assigned to pulsed Doppler patterns corresponding to no, mild, moderate and severe mitral regurgitation, respectively. Before balloon aortic valvuloplasty, mitral regurgitant score correlated significantly (p less than 0.005) but weakly with aortic valve area (r = -0.24), left ventricular ejection fraction (r = -0.34) and left ventricular systolic pressure (r = 0.23). There was no significant correlation between mitral regurgitation and either mean catheterization or mean Doppler aortic valve gradient. Balloon aortic valvuloplasty produced significant decreases in both catheterization and Doppler mean transvalvular aortic valve gradients (56 +/- 19 to 31 +/- 12 and 60 +/- 19 to 48 +/- 16 mm Hg, respectively; both p less than 0.0001) and a significant increase (p less than 0.0001) in aortic valve area assessed by catheterization (0.6 +/- 0.2 to 0.9 +/- 0.3 cm2). Left ventricular ejection fraction did not change, but cardiac output increased (p less than 0.001) and pulmonary capillary wedge pressure decreased (p less than 0.0001). Pulsed Doppler findings of mitral regurgitation were present in 102 of the 144 patients. Eighty-eight patients had a score compatible with mild or more severe degrees of mitral regurgitation, and 49 had a score indicative of moderate or severe valvular insufficiency. In the entire group of 144 patients, mitral regurgitant score decreased significantly from 1.1 +/- 1.0 to 1.0 +/- 1.0 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Shu 508 A (Levovist)-enhanced Doppler echocardiography improves the assessment of valvular heart disease

OBJECTIVE: To investigate whether intravenous injection of SHU 508 A improves the diagnostic accuracy of Doppler echocardiography in the assessment of valvular pathologies. METHODS AND RESULTS: One hundred and twenty-five consecutive patients with valvular pathology (aortic stenosis, n = 48; aortic regurgitation, n = 20; mitral stenosis, n = 21; and mitral regurgitation, n = 36) and diagnostically insufficient Doppler signal were enrolled in this multicenter study. The severity of valvular pathology was graded on a four-point scale using unenhanced and contrast-enhanced Doppler echocardiography as well as cardiac catheterization. Agreement with cardiac catheterization findings increased from 63% using the unenhanced examination to 73% using the contrast-enhanced Doppler examination. Grading was possible in all patients using SHU 508 A, whereas the unenhanced Doppler examination remained inconclusive in six patients. The weighted kappa coefficient between contrast-enhanced Doppler and cardiac catheterization for all diagnoses was 0.76 as compared to 0.68 between unenhanced Doppler and cardiac catheterization. Agreement was especially improved in aortic stenosis (kappa 0.69 unenhanced vs 0.81 contrast-enhanced) and in aortic regurgitation (kappa 0.45 unenhanced vs 0.75 contrast-enhanced). Patients with mitral stenosis and mitral regurgitation experienced less improvement. CONCLUSIONS: In case of an inconclusive unenhanced Doppler echo study, the administration of a left heart contrast agent should be considered. SHU 508 A is especially useful in improving the severity grading of aortic stenosis and aortic regurgitation, while grading of mitral stenosis and mitral regurgitation is less improved.     

Evaluation of secondary tricuspid regurgitation by intraoperative epicardial pulsed Doppler echocardiography

Since 1985, we have evaluated secondary tricuspid regurgitation associated with acquired mitral valve disease in patients undergoing open mitral surgery by intraoperative epicardial two-dimensional and pulsed Doppler echocardiography. We found intraoperative pulsed Doppler echocardiography to be a sensitive, safe technique allowing surgeons to evaluate the severity of tricuspid regurgitation intraoperatively, even in critically ill patients who cannot afford preoperative cardiac catheterization. To assess the severity of tricuspid regurgitation intraoperatively, the transducer was placed directly on the right atrium. The ultrasound beam was transmitted into the right atrium at right angles to the tricuspid valve orifice to record intraoperative four-chamber two-dimensional echocardiograms, which were used to detect the sites of eight sample volumes, one in the right ventricle and seven in the right atrium, for pulsed Doppler echocardiography. The pulsed Doppler signals were recorded in each sample volume before and after cardiac procedures. The pansystolic abnormal signals lasting from tricuspid valve closure to the subsequent opening and consisting of components moving away from the tricuspid valve were interpreted as tricuspid regurgitant flows. Without operative correction of the tricuspid valve, secondary tricuspid regurgitation can resolve following mitral valve surgery alone. However, to our knowledge, there are no published reports of objective findings of intraoperative changes of secondary tricuspid regurgitation. Here we present the unique intraoperative pulsed Doppler echocardiographic features of tricuspid regurgitation before and after cardiac procedures. A 30-year-old woman with preoperative diagnosis of aortic regurgitation, mitral stenosis and severe tricuspid regurgitation underwent aortic and mitral valve replacement. The intraoperative pulsed Doppler echocardiograms recorded after pericardiotomy and before cannulation of the heart showed tricuspid regurgitant flow signal in all of the seven sample volumes in the right atrium, which was interpreted as severe tricuspid regurgitation. After surgical procedures, no regurgitant flow from the tricuspid orifice to the right atrium was detected in the eight sample volumes. This suggested that preoperative secondary tricuspid regurgitation improves without operative procedures for the tricuspid valve. All intraoperative echocardiographic procedures were performed within 5 min, and no arrhythmias or other complications related to this technique were noted. Epicardial pulsed Doppler echocardiography is helpful in assessing tricuspid valve function of patients undergoing mitral valve surgery bef     

Comparison of cardiac catheterization and Doppler echocardiography in the decision to operate in aortic and mitral valve disease

Clinical decisions utilizing either Doppler echocardiographic or cardiac catheterization data were compared in adult patients with isolated or combined aortic and mitral valve disease. A clinical decision to operate, not operate or remain uncertain was made by experienced cardiologists given either Doppler echocardiographic or cardiac catheterization data. A prospective evaluation was performed on 189 consecutive patients (mean age 67 years) with valvular heart disease who were being considered for surgical treatment on the basis of clinical information. All patients underwent cardiac catheterization and detailed Doppler echocardiographic examination. Three sets of two cardiologist decision makers who did not know patient identity were given clinical information in combination with either Doppler echocardiographic or cardiac catheterization data. The combination of Doppler echocardiographic and clinical data was considered inadequate for clinical decision making in 21% of patients with aortic and 5% of patients with mitral valve disease. The combination of cardiac catheterization and clinical data was considered inadequate in 2% of patients with aortic and 2% of patients with mitral valve disease. Among the remaining patients, the cardiologists using echocardiographic or angiographic data were in agreement on the decision to operate or not operate in 113 (76% overall). When the data were analyzed by specific valve lesion, decisions based on Doppler echocardiography or catheterization were in agreement in 92%, 90%, 83% and 69%, respectively, of patients with aortic regurgitation, mitral stenosis, aortic stenosis and mitral regurgitation. Differences in cardiac output determination, estimation of valvular regurgitation and information concerning coronary anatomy were the main reasons for different clinical management decisions. These results suggest that for most adult patients with aortic or mitral valve disease, alone or in combination, Doppler echocardiographic data enable the clinician to make the same decision reached with catheterization data.     

The clinical spectrum of tricuspid regurgitation detected by pulsed Doppler echocardiography

The clinical diagnosis of tricuspid regurgitation (TR) is often difficult. Two-dimensional pulsed Doppler echocardiography offers a sensitive and specific method for detecting and semi-quantitating tricuspid regurgitation. The clinical, radiographic, radionuclide, echocardiographic, and when available, the right cardiac catheterization findings were evaluated in 36 patients with a diagnosis of tricuspid regurgitation by pulsed Doppler. Ten healthy subjects served as controls. The underlying cardiac cause was rheumatic heart disease in 7 (20%), ischemic heart disease in 12 (33%), dilated cardiomyopathy in 5 (14%), hypertensive heart disease in 2 (5%), aortic valve stenosis and/or regurgitation in 3 (8%), mitral valve prolapse with mitral regurgitation in 1 (3%), and congenital heart disease in 6 (17%). Seven patients (19%) had a temporary or permanent transvenous right ventricular pacing wire. A systolic murmur was heard in 29 patients (81%) with 16 (46%) having an elevated jugular venous pressure. Tricuspid regurgitation was clinically suspected in only 2 patients (6%). Isolated tricuspid regurgitation was uncommon, seen in 6 patients (17%), and usually secondary to congenital heart disease, ischemic heart disease, with the use of a transvenous pacing wire and following mitral valve replacement. Right cardiac catheterization was performed in 10 patients, of which 7 demonstrated elevated right atrial and pulmonary artery pressure. Pulsed Doppler echocardiography offers a practical and accurate method of detecting and evaluating the severity of tricuspid regurgitation. Tricuspid regurgitation is generally a functional disorder, and frequently occurs in association with left sided valvular heart disease, cardiomyopathy or congenital heart disease.     

Impact of valvular calcification on the diagnostic accuracy of transesophageal echocardiography for the detection of congenital aortic valve malformation

BACKGROUND: Degeneration of congenital bicuspid or unicuspid aortic valves can progress more rapidly than that of tricuspid valves, and an early diagnosis significantly impacts decision making and outcome. We hypothesized that the extent of valvular calcification would negatively influence the diagnostic accuracy of multiplane transesophageal echocardiography (TEE) for the diagnosis of congenital aortic valve disease. METHODS: TEE was performed in 57 patients undergoing aortic valve replacement surgery for aortic stenosis (n = 46), pure regurgitation (n = 9), or significant regurgitation with less than severe aortic stenosis (n = 2). The degree of aortic valve calcification and the number of valve cusps were determined at surgery. RESULTS: Surgical inspection confirmed 14 bicuspid and 43 tricuspid aortic valves. Sensitivity and specificity of TEE for the diagnosis of congenital aortic valve malformation was 93% (13/14) and 91% (39/43) (P = 0.0001), respectively. In patients with no or mild aortic valve calcification (n = 13), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 100% (5/5) and 100% (8/8) (P = 0.001), respectively. In patients with moderate or marked aortic valve calcification (n = 44), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 89% (8/9) and 89% (31/35) (P<0.0001), respectively. In this subgroup of 44 patients, there were four false-positive and one false-negative diagnoses due to valvular calcification. CONCLUSIONS: Although TEE is highly sensitive and specific for the detection of congenital aortic valve malformations, presence of moderate or marked calcification of the aortic valve may result in false positive and false negative diagnoses.     

The progression of fenfluramine-associated valvular heart disease assessed by echocardiography

BACKGROUND: An association between the dietary suppressants fenfluramine and dexfenfluramine and valvular heart disease was first described in patients from North Dakota and Minnesota in 1997. Limited data are available on the natural history of this valvulopathy after discontinuation of drug therapy. OBJECTIVE: To follow the progression of fenfluramine-associated valvular heart disease after discontinuation of therapy by using serial echocardiography. DESIGN: Retrospective cohort study. SETTING: Regional medical center in Fargo, North Dakota. PATIENTS: 50 patients with previous exposure to fenfluramines who had at least mild mitral regurgitation or aortic regurgitation after exposure to fenfluramines on serial echocardiography between December 1994 and February 1999 (96% were female, mean body mass index was 36.6 kg/m(2), and mean duration of drug exposure was 447 days). MEASUREMENTS: Serial echocardiograms were reviewed by two echocardiographers who were blinded to the order of image acquisition. The severity of valvular regurgitation and presence or absence of valve leaflet restriction were assessed. RESULTS: As described in the initial report, significant valvular disease on initial postexposure echocardiography was common in this cohort; 38 patients (76%) had at least mild mitral regurgitation and 43 patients (86%) had at least mild aortic regurgitation. On serial echocardiograms obtained an average of 356 days apart, mitral regurgitation improved by at least one grade in 17 patients (P = 0.001) and aortic regurgitation improved by at least one grade in 19 patients (P = 0.004). Nineteen and 22 patients, respectively, experienced no change in severity of mitral and aortic regurgitation. Two patients in each group experienced worsening of regurgitation by at least one grade. Results were similar for tricuspid (P = 0.002) and pulmonic (P = 0.012) regurgitation. CONCLUSION: On serial echocardiography, fenfluramine-associated valvular regurgitation improved or remained stable in most patients after therapy ended. Worsening of valvular regurgitation was uncommon. The potential for stabilization or regression of valvular regurgitation should be taken into account when counseling patients and considering the need for and timing of valve surgery.     

Surgical experience with diseases of the tricuspid valve. Cross-sectional and Doppler echocardiographic evaluation following DeVega's repair

Seventy-eight patients undergoing mitral valve surgery with or without replacement of the aortic valve also underwent procedures on the tricuspid valve over a period of 10 years. All patients were in functional class III or IV preoperatively. The procedures were performed in all patients with organic disease of the tricuspid valve (N = 44) and in those with moderate or severe functional tricuspid valvar regurgitation (N = 34). Seventy-one patients underwent DeVega's annuloplasty with or without commissurotomy. The overall mortality was 11.5%. 65 long-term survivors were followed up for a period of 6 months to 10 years (mean 5.3 years). Sixty-three patients were in functional class I or II at the last follow-up. Six patients had clinical evidence of mild to moderate tricuspid regurgitation. Regression of cardiomegaly (as judged by the chest radiograph and right ventricular hypertrophy seen in the electrocardiogram) was evident in most cases. Fifty-one of 54 patients evaluated by cross-sectional echocardiography were reported to have a functionally normal tricuspid valve. Doppler echocardiography in 28 patients showed no significant tricuspid regurgitation or stenosis in 26 patients. Eleven consecutive patients undergoing DeVega's annuloplasty were studied prospectively with pre- and postoperative Doppler echocardiography. Good correlation existed between right ventricular systolic pressures predicted by Doppler with those obtained preoperatively at cardiac catheterization. Postoperative Doppler echocardiography in these 11 patients showed complete restoration of competence of the tricuspid valve as well as normalisation of the right ventricular systolic pressure in 10 patients.     

The effect of cardiac catheterization upon management of advanced aortic and mitral valve disease

We assessed the incremental effect of cardiac catheterization upon the management of 93 adult patients with aortic and/or mitral valve disease, referred for surgical consideration. There were 52 patients with aortic valve disease, 29 with mitral valve disease and 12 with aortic and mitral valve disease. Prior to cardiac catheterization, a detailed unblinded ultrasound assessment of each valve was made utilizing 2D and Doppler ultrasound. Based upon the ultrasound result and the clinical assessment, the patient's cardiologist recorded a grading of valve severity and a management decision for each valve. Following catheterization and coronary angiography, the cardiologist repeated the gradings of valve severity and recorded a final management decision. After catheterization, management changed in nine patients and was unchanged in 84. Reasons for management change included differences between echocardiographic and catheterization assessment of valvular regurgitation (three patients), information on coronary anatomy (two patients), minor differences in assessed aortic valve area (one patient) and left ventricular function (one patient), and confirmation of ultrasound findings where clinical and ultrasound findings had been conflicting before catheterization (two patients). Both mitral and aortic valve disease were present in the three patients in whom management changed as a result of significant differences between echocardiography and catheterization assessment of valvular regurgitation. Management was unchanged in the 16 patients with isolated mitral stenosis. In this study, a combination of clinical and noninvasive assessment including Doppler echocardiography, resulted in a reliable evaluation of valvular disease in a large majority of patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of ejection fraction and valvular regurgitation on the accuracy of aortic valve area determination

OBJECTIVE: To examine the influence of left ventricular dysfunction, aortic regurgitation, and mitral regurgitation on commonly used methods for aortic valve area (AVA) determination. BACKGROUND: Each method for AVA determination has its inherent limitations. METHODS: AVA determinations by transesophageal echocardiography (TEE) using planimetry, transthoracic echocardiography (TTE) with application of the continuity equation, and cardiac catheterization applying the Gorlin formula were performed in 74 patients with aortic stenosis. The severity of the aortic stenosis was defined by consensus of at least two methods. Over- or underestimation of AVA associated with ejection fraction, aortic regurgitation, mitral regurgitation, or severity of the aortic stenosis for each method in relation to the other two methods was assessed. RESULTS: Mean AVAs were 1.05 +/- 0.51 by TEE, 1.06 +/- 0.51 by TTE, and 1.08 +/- 0.53 by cardiac catheterization. An overestimation of the severity of the aortic stenosis by the Gorlin formula in patients with moderate-to-severe aortic regurgitation as compared to TEE-derived data was found (P = 0.014). A similar trend of overestimation by catheterization in comparison with the TTE data was found. In the context of moderate-to-severe mitral regurgitation, AVA determination by TTE overestimated the degree of aortic stenosis as compared to TEE (P = 0.011) and cardiac catheterization (P = 0.023). CONCLUSIONS: Overall mean AVA did not differ between methods, suggesting that these three methods are equally accurate in a nonselected clinical patient group. However, in the presence of significant aortic regurgitation, the two echocardiographic methods appear more accurate. Our observation of an overestimation of the severity of aortic stenosis by TTE in the presence of moderate-to-severe mitral regurgitation indicates that this possibility should be accounted for in clinical decisions based on TTE determinations of AVA.     

Preoperative invasive testing in mitral stenosis: Indications based on assessment of diagnostic yield

The role of preoperative invasive testing in mitral stenosis was assessed in 82 patients undergoing cardiac catheterization for isolated mitral stenosis. The patients were diagnosed by physical examination and echocardiography and were considered for surgical treatment primarily to relieve dyspnea. They had no precordial murmur attributable to an aortic valvular lesion and had no history of chest pain. The presence of mitral stenosis was confirmed at catheterization in all patients. All 38 patients in New York Heart Association functional class III and 8 of 9 patients in class IV had hemodynamic confirmation of mitral disease warranting operation. Although a mitral gradient was present in all 35 patients in class II, operation was not recommended in 9 (26%) of 35 with normal or mildly elevated pulmonary arterial wedge pressure. Invasive testing did not increase preoperative knowledge of aortic, tricuspid, or pulmonary valvular lesions which required surgical treatment. Coronary arteriography was performed in 44 patients (54%) and identified 4 patients with luminal narrowing (> 70% diameter reduction) affecting 1 or 2 arteries. These results suggest that preoperative invasive testing in patients with mitral stenosis is unnecessary when symptoms are moderate to severe and clinical evidence of aortic valvular or coronary artery disease is absent. However, preoperative cardiac catheterization is indicated in patients with mild symptoms to avoid unnecessary or premature mitral valve operations.     

Clinical uses of two dimensional echocardiography

The added advantages of two dimensional over M mode echocardiography in the diagnosis of cardiac disorders occurring in adults are reviewed. In patients with coronary artery disease, left ventricular aneurysm, wall motion abnormalities and ventricular dysfunction can be reliably evaluated with two dimensional echocardiography. Preliminary studies have demonstrated that two dimensional echocardiography is useful for assessing regional cardiac dilatation and prognosis after acute myocardial infarction, detecting left main coronary stenosis and predicting operability in patients with ventricular aneurysm. Determination of mitral valve area by two dimensional echocardiography in patients with mitral stenosis has shown good correlation with measurements of mitral valve area and size performed at the time of operation or calculated from cardiac catheterization data. The cause of mitral regurgitation can be more reliably elucidated by the differentiation of valvular and myocardial pathologic conditions. In addition, precise anatomic cardiac detail can be obtained in the localization of left and right ventricular and aortic outflow obstruction. Tricuspid valve disorders are particularly apparent because all three leaflets of the tricuspid valve can be visualized in real time studies and the detection of tricuspid regurgitation can be readily accomplished. Two dimensional echocardiography appears to be more reliable than M mode echocardiography in the detection of complications occurring as a result of bacterial endocarditis. Bioprosthetic valve function and localization and site of pericardial effusions as well as aortic aneurysms can be determined with two dimensional echocardiography. Two dimensional echocardiography can provide an accurate appreciation of the size, shape, mobility and origin of an intracardiac mass. With the use of contrast echocardiography, right to left shunting or the negative contrast effect can be demonstrated in patients with an atrial septal defect. Thus, the precision, accuracy and sensitivity of two dimensional echocardiography affords the clinician a valuable noninvasive instrument in the detection of cardiac disease.     

Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography

STUDY OBJECTIVE: To determine the relation between heart valve regurgitation detected by Doppler echocardiography and audible regurgitant murmurs. DESIGN: Consecutive sample. SETTING: Adult echocardiography laboratory in a tertiary care university hospital. PATIENTS: Sequential sample of 408 patients presenting for clinical echocardiographic studies who had technically satisfactory studies and were available for auscultation. MEASUREMENT AND MAIN RESULTS: Valvular regurgitation occurred in 43% of patients at the mitral valve, 39% of patients at the tricuspid valve, 33% of patients at the aortic valve, and 15% of patients at the pulmonic valve. Corresponding regurgitant murmurs were frequently absent. A murmur corresponding to Doppler-detected regurgitation was detected in 56% of patients with mitral regurgitation, 61% of patients with aortic regurgitation, 28% of patients with tricuspid regurgitation, and 15% of patients with pulmonic regurgitation. There was a highly significant positive correlation of audibility with severity of valve regurgitation for the aortic, tricuspid, and mitral valves. Audibility ranged from 10% to 40% for mild regurgitation to 86% to 100% for severe regurgitation. Murmur audibility was not related to the type of valvular disease present. CONCLUSIONS: Doppler echocardiography is a sensitive method for detecting valve regurgitation. Corresponding regurgitant murmurs are frequently not present. The audibility of regurgitant murmur is highly dependent on the severity of valve regurgitant and has little relation to the type of valve disease present.     

Assessment of rheumatic mitral valve disease. Value of echocardiography in patients clinically suspected of predominant stenosis.

The value of echocardiography as compared with cardiac catheterisation was evaluated prospectively in 33 consecutive patients clinically suspected of predominant mitral stenosis. Patients with clinical signs of accompanying mitral regurgitation, no matter how severe, and patients with clinical findings indicating insignificant aortic valve disease were included. Critical mitral stenosis was defined by a valve area of less than or equal to 1 cm2. Severe mitral regurgitation was diagnosed by echocardiography on the basis of left ventricular dilatation (more than 3.2 cm/m2 at end-diastole) if not explained otherwise. Significant aortic valve disease was suspected in cases with aortic valve deformity and left ventricular dilatation or hypertrophy as defined by echocardiography. Mitral valve area by echocardiography correlated well with mitral valve area calculated from catheterisation data and a good interobserver correlation was found for echocardiographic measurement. Mitral stenosis, critical or non-critical, may mask significant coexistent valve lesions; echocardiography failed to discover severe mitral regurgitation requiring valve replacement in two patients with non-critical stenosis, and significant aortic regurgitation needing valve replacement was underestimated in one patient with critical mitral stenosis. A correct echocardiographic classification with respect to surgery, however, was obtained in: (1) all patients with clinically pure mitral stenosis (nine patients), and (2) all patients with combined mitral stenosis and regurgitation when either critical stenosis or severe regurgitation was found at echocardiography (12 patients). It thus appears that two out of three patients with mitral valve disease in whom the clinical findings indicate predominant stenosis can be correctly evaluated with the echocardiogram.     

INCIDENCE OF VERRUCOUS VEGETATIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS. THE ASSOCIATION WITH ANTIPHOSPHOLIPID ANTIBODIES

Background: Valvular heart disease is prevalent in systemic lupus erythematosus (SLE) and is a common cause of morbidity and mortality. Valvular thickening and verrucous valvular vegetations (Libman–Sacks) are the most common lesions. The purpose of this prospective study was to analyze the incidence of Libman–Sacks vegetations in patients with SLE. Methods: Two hundred and seventeen consecutive patients (196 females, 21 males, aged 53 ± 11 years) with SLE were evaluated with M‐mode, 2D, and Doppler echocardiography. Libman–Sacks vegetations were defined as distinct localized masses of varying size and shape on the surface of the valve leaflets and exhibiting no independent motion. In 76 (35%) patients with SLE there were antiphospholipid antibodies (APL) present. Results: Thirty‐two (14.7%) patients with SLE had Libman–Sacks vegetations and in 21 (65.6%) of them there was a presence of antiphospholipid antibodies. In 22 patients the location of the masses was in the mitral, in 9 in the aortic, and in 1 in the tricuspid valve, whereas in 4 cases in BOTH valves. Valvular regurgitation was the predominant lesion in 18 mitral, 9 aortic, and 1 tricuspid, but only 2 cases had severe mitral regurgitation. Valvular stenosis was detected in 5 cases. Three patients had severe mitral stenosis and one of them died, while in the other two patients mitral stenosis was reversed with treatment of the underlying disease. The remaining two cases had severe aortic stenosis but one of them, also having severe mitral regurgitation, died suddenly. Conclusion: Our results show that Libman–Sacks vegetations are quite frequent in patients with SLE and are related to the presence of antiphospholipid antibodies. The most common lesion is valvular regurgitation and rarely valvular stenosis.     

Coronary atherosclerosis in patients with acquired valvular disease

BACKGROUND: Coronary atherosclerosis often coexists with acquired valvular disorders. There is growing evidence in literature that these two conditions may have common aetiology. AIM: To assess the incidence of coronary atherosclerosis in patients with acquired valvular disorders and to compare clinical parameters as well as the prevalence of risk factors between patients with aortic and mitral valve diseases. METHODS: The study group consisted of 155 patients (101 males, 54 females, mean age 58.2+/-9.7 years) with acquired valvular disorder who between 2000 and 2002 underwent invasive cardiac evaluation in our department prior to planned cardiac surgery. Aortic stenosis was detected in 74 patients, aortic insufficiency -- in 26, mitral stenosis -- in 33, and mitral regurgitation -- in 14 subjects. All patients underwent clinical evaluation, echocardiography, coronary angiography and laboratory tests. RESULTS: Patients with aortic stenosis had similar prevalence of coronary atherosclerosis to patients with aortic insufficiency, and patients with mitral stenosis -- to patients with mitral regurgitation. When the two groups -- patients with aortic valve disease and patients with mitral valve disease were compared, significant coronary lesions were more often detected in patients with aortic valve disease (36% vs 12.8%, p<0.05). Also, patients with aortic valve disorder were older, predominantly of male gender, had more often angina but less often heart failure, and had higher total cholesterol level than patients with mitral valve disease. CONCLUSIONS: Significant coronary lesions are more frequently encountered in patients with aortic valve disorder than in those with mitral valve disease. A high prevalence of atherosclerotic risk factors in patients with aortic valve disease may suggest that this condition has similar aetiology to that of coronary artery disease.     

Value of echocardiographic findings in predicting cardiovascular complications in infective endocarditis.

Echocardiography allows the detection of vegetations and estimation of valvular dysfunction in patients with infective endocarditis. The value of echocardiographic findings in predicting cardiac and other vascular complications in infective endocarditis is not well understood. Identification of high-risk patients and early surgery may improve their prognosis. The authors reviewed echocardiographic findings and related them to the development of congestive heart failure, systemic embolism, and the need for surgery or the risk of death without surgery in patients with infective endocarditis. There were 125 episodes of endocarditis in 114 patients (84 episodes [67%] in men) with a mean age +/- standard deviation of 37 +/- 7 years. Vegetations were detected by echocardiography on at least 1 valve in 87 episodes (70%); on the mitral valve in 36 episodes (29%); on the aortic valve in 21 episodes (17%); and on the tricuspid valve in 45 episodes (36%). Severe aortic regurgitation was present in 9 episodes (7%) and severe mitral regurgitation in 4 instances (3%). In 12 of 21 episodes (57%) of vegetations on the aortic valve compared with 15 of 104 patients (14%) without vegetations on the aortic valve (p < 0.001), and in 8 of 9 instances (89%) of severe aortic regurgitation compared with 19 of 116 episodes (16%) without severe aortic regurgitation (p<0.00001), the patients developed congestive heart failure. In 18 of 55 episodes (33%) of vegetations on the aortic/mitral valve compared with 17 of 70 episodes (25%) without vegetations on the aortic valve/mitral valve (p = NS), the patients developed systemic embolism. In 13 of 21 episodes (62%) of vegetations on the aortic valve compared with 19 of 104 episodes (19%) without vegetations on the aortic valve (p < 0.001), and in 8 of 9 episodes (89%) of severe aortic regurgitation compared with 24 of 116 episodes (21%) without severe aortic regurgitation (p < 0.00001), the patients either had surgery or died without surgery. Echocardiographic findings do not reliably predict the risk of systemic embolism in patients with infective endocarditis. Vegetations on the aortic valve and severe aortic regurgitation detected by echocardiography predict a high risk of developing congestive heart failure, and for the combined outcome of requiring surgery, or dying without surgery in infective endocarditis. Early surgery may improve the outlook for survival of these patients.