Recurrent stress incontinence

PREVIEW

Recognition and management of valvular heart disease have evolved considerably in the past two decades, thanks in large part to advances in echocardiography. In this article, Drs Harris and Robiolio summarize the initial patient assessment, diagnostic procedures, and treatment options for mitral regurgitation, aortic insufficiency, mitral stenosis, and aortic stenosis.     

Echocardiography. Basics for the primary care physician

Echocardiography is commonly performed to assess aortic stenosis, mitral valve prolapse, pericardial effusion and cardiac tamponade, myocardial infarction, endocarditis, and valvular regurgitation. We have found that the more defined and appropriate a request for an echocardiogram is, the better the technician and interpreter can relate observations to the requesting physician. Thus, thorough understanding of the indications and limitations of echocardiography by the primary care physician will result in improved patient care.     

Respective timing of maximal color Doppler jet areas and of peak velocity of jets in left-sided valvular lesions: clinical implications

Time intervals between the R wave of the electrocardiogram and maximal dimension of jet areas of color Doppler and the R wave of the electrocardiogram and peak velocity of valvular jets of continuous-wave Doppler were compared by use of paired and correlative studies for a group of 55 patients with a total of 71 left-sided lesions. Mean values of both time intervals, mean difference, and its standard error were equal to zero for stenoses. Time intervals of 71% for mitral stenosis and 52% for aortic stenosis did not differ by more than 0.01 second; correlation coefficients were 0.96 for mitral stenosis and 0.85 for aortic stenosis. For regurgitations, differences in mean values and a mean difference with a standard error were found but remained unsignificant. However, the percentage of differences in time intervals below or equal to 0.01 second decreased to 35 for aortic regurgitation and 13 for mitral regurgitation, which showed the widest 95% range of differences. Correlation coefficients were 0.84 for the aortic regurgitation and 0.33 for mitral regurgitation. Thus the close relationship of time intervals suggests that standardized timing of area measurements at peak velocity is feasible for stenoses and remains under consideration for aortic regurgitation. Timing of measurements should remain empiric for mitral regurgitation.     

Assessing Bedside Cardiologic Examination Skills Using "Harvey," a Cardiology Patient Simulator

Objective : To assess the cardiovascular physical examination skills of emergency medicine (EM) housestaff and attending physicians.
Methods : Prospective, cohort assessment of EM housestaff and faculty performance on 3 valvular abnormality simulations (mitral regurgitation, mitral stenosis, and aortic regurgitation) conducted on the cardiology patient simulator, "Harvey." Participants examined each of the 3 study disease simulations and proposed a diagnosis (session I). They were then given a cardiac examination form and repeated the programmed simulations (session II). The examination form was used to prompt physicians to interpret 23 separate cardiac findings for each simulation in a multiple-choice format.
Results : Forty-six EM housestaff (PGY1–3) and attending physicians were tested over a 2-month study period. Physician responses did not differ significantly among the different levels of postgraduate training. The overall correct response rates for participants were 59% for aortic regurgitation, 48% for mitral regurgitation, and 17% for mitral stenosis. For aortic regurgitation, recognition of a widened pulse pressure and recognition of diastolic decrescendo murmur were associated with a correct diagnosis (p < 0.01). For mitral regurgitation, correct assessment of the contour of the holosystolic murmur predicted a correct diagnosis (p < 0.001). For mitral stenosis, proper characterization of the mitral area diastolic murmur predicted a correct diagnosis (p < 0.001).
Conclusion : Housestaff and faculty had difficulty establishing a correct diagnosis for simulations of 3 common valvular heart diseases. However, accurate recognition of a few critical signs was associated with a correct diagnosis in each simulation. Training programs may need to focus attention on selected key components of the cardiovascular examination to facilitate teaching of physical diagnosis.     

The value of Doppler echocardiography in the management of patients with valvular heart disease: analysis of one year of clinical practice

Management recommendations based on Doppler echocardiographic examination and cardiac catheterization were compared in a prospective study in 100 consecutive patients who were admitted for evaluation and treatment of suspected valvular heart disease during 1988. Management recommendations were provided independently after both Doppler echocardiography and cardiac catheterization by different and blinded investigators. Criteria for severe (clinically significant) and moderate to mild (insignificant) valvular lesions and management recommendations were agreed on in advance. There was disagreement on the severity of aortic stenosis based on the aortic valve area and maximum instantaneous pressure gradient in 1 of 54 patients, which resulted in differing management recommendations. Mitral stenosis was severe (valve area less than or equal to 1 cm2) at Doppler echocardiography but not at cardiac catheterization in 5 of 14 patients. Because pulmonary artery pressure increase during exercise at cardiac catheterization also suggested severe obstruction, management recommendations were similar. There was a potentially significant disagreement on the severity of aortic regurgitation in 9 of 76 patients and of mitral regurgitation in 14 of 90 patients; however, this did not produce differing management recommendations because with most patients coexistent valvular lesions or an impaired ventricular function mainly determined the ultimate management decision. Although of good quality, Doppler echocardiographic examination was nonconclusive for clinical decision-making in 15% of the study population because of uncertainty about the severity of mitral regurgitation or aortic regurgitation or because of problems in assessing the degree of left ventricular dysfunction in patients with severe regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Advances in percutaneous valvular intervention

We are entering a new era in the percutaneous treatment of valvular heart disease. Novel techniques and devices have given rise to the possible treatment of a range of valvular heart diseases that previously necessitated surgical therapies, including aortic stenosis, pulmonary regurgitation and mitral regurgitation. Despite the enormous potential of these percutaneous therapies, enthusiasm needs to be balanced by an understanding of the challenges that need to be overcome before such therapies can be widely embraced. This review provides a critical assessment of the status of the major developments in percutaneous valvular intervention to date, and provides the authors' perspective on the current role and future potential of these techniques.     

彩色多普勒超声在老年退行性心脏瓣膜病诊断中的应用价值

目的:探讨彩色多普勒超声在老年退行性心脏瓣膜病诊断中的应用价值。方法:本研究选取2017年11月-2019年11月我院收治的876例心脏病患者,均接受心脏彩色多普勒超声检查,对其临床资料进行回顾性分析。结果:本组876例心脏病患者共检出老年退行性心脏瓣膜病281例,总检出率为32.08%;男性检出率显著高于女性(P<0.05)。80岁以上年龄段疾病检出率最高,显著高于70~79岁及60~69岁人群(P<0.05)。281例患者中单纯主动脉瓣受累占比61.57%,单纯二尖瓣受累占比18.86%,主动脉瓣、二尖瓣同时受累19.57%。主动脉瓣狭窄49例,二尖瓣狭窄7例;瓣膜功能障碍87例,主动脉瓣反流占70.11%,二尖瓣反流18.39%。结论:心脏超声检查在老年退行性心脏瓣膜病诊断中具有重要应用价值,可作为疾病诊断检查的重要手段。     

Radionuclide quantification of mitral and aortic regurgitation

Abstract. Gated equilibrium bloodpool scintigraphy was used to obtain the ratio of left and right ventricular stroke counts (end-diastolic minus end-systolic counts within ventricular areas of interest), the radionuclide equivalent of stroke volumes. This ratio or stroke count index (SCI) should be unity in normal subjects and increased in patients with aortic or mitral regurgitation, when left ventricular stroke output rises to compensate for regurgitant flow. Results of this non-invasive method were compared with semiquantitative angiographic grading of mitral (1 to 4+) or aortic (1 to 3+) regurgitation in ninety-seven patients. We found a SCI of 1.15 ± 0.18 (SD) in thirty-six control subjects without evidence of mitral or aortic regurgitation at cardiac catheterization. Subsequently, a ratio of 1.50 was chosen as the upper limit of normal for the analysis of thirty-seven patients with mitral regurgitation and twenty-four patients with aortic regurgitation. Clearly, elevated SCI values were obtained in the presence of grade 3 and 4 mitral regurgitation (eighteen out of twenty patients) and of grade 2 and 3 aortic regurgitation (seventeen out of eighteen patients). Only two out of seventeen subjects with grade 1 or 2 mitral incompetence had an elevated SCI, while none of six subjects with grade I aortic regurgitation had an abnormal SCI. If these lesser degrees of valvular incompetence are considered of minor significance, overall sensitivity of the radionuclide method in our patient population was 92%, specificity 95%. Occasional discrepancies between SCI and angiographic severity of left-sided valvular regurgitation are probably a result of methodological limitations. We could not demonstrate any relation with global left ventricular function as measured from the radionuclide ejection fraction. We conclude that the SCI may be used as a non-invasive tool for diagnosis and management of patients with valvular heart disease, both before and after interventions.     

Changing demographics of valvular heart disease and impact on surgical and transcatheter valve therapies

Valvular heart disease remains frequent in industrialised countries since the decrease in frequency of rheumatic heart diseases has been accompanied by an increase in degenerative valve diseases. The prevalence of valvular disease increases sharply with age, as a consequence of the predominance of degenerative valvular diseases. Aortic stenosis and mitral regurgitation are the two most frequent diseases among patients referred because of valvular disease in Europe. The burden of heart valve disease in the elderly has an important impact on patient management, given the frequency of comorbidity and the increase in the risk of interventions. The changes in demographics explain why new procedures, such as transcatheter aortic valve implantation and percutaneous mitral valve repair, are potentially attractive in patients with high risk or even contraindications for surgery.     

多平面经食管超声心动图观察主动脉瓣病变

本文对３１例主动脉瓣病变患者进行了多平面经食道超声心动图（ＭＴＥＥ）的研究，其中主动脉瓣狭窄１２例（主动脉瓣二瓣化７例，风湿性３例，退行性病变２例），主动脉瓣关闭不全１９例（风湿性１０例，升主动脉夹层动脉瘤４例，赘生物３例，单纯脱垂２例）。主要从食管中上段的一系列切面观察主动脉瓣的形态结构。ＭＴＥＥ在确定主动脉瓣病变的病因方面明显优于ＴＴＥ。在判断主动脉瓣狭窄和主动脉瓣返流的程度方面ＭＴＥＥ具有重     

经皮二尖瓣球囊成形术8例分析

应用Inone法经皮二尖瓣球囊成形术治疗风湿性心脏病单纯二尖瓣狭窄3例，二尖瓣狭窄伴轻度二尖瓣返流3例，二失瓣狭窄伴主动脉瓣关闭不全2例，均获成功。手术后二尖瓣面积、肺动脉压，左房平均压均较手术前明显改善，部分心功能改善。术前病例选择，术中房问隔穿刺及球襄直径的选择，对增加成功率，预防并发症极为重要。     

经食管超声心动图在风心病二尖瓣狭窄手术方式选择中的应用

目的：评价经食管超声心动图(TEE)在风心病二尖瓣狭窄手术方式选择中的应用价值。方法：67例风心病二尖瓣狭窄患者术前作经胸超声(TTE)和TEE检查，重点探查左房血栓、左心耳血栓、左房雾影、瓣膜返流和瓣膜病变等情况。结果：TTE检查拟行二尖瓣置换术21例，球囊成形术46例。46例球囊成形术者又经TEE检查后，新发现左心耳血栓12例，改二尖瓣置换术；10例二尖瓣轻度返流，TEE证实为中度返流，改二尖瓣置换术。结论：TEE在风心病二尖瓣狭窄手术方式选择中有决定性的作用，对左房血栓、左心耳血栓、左房雾影检出及二尖瓣返流的定量判断较准确、可靠。     

Effects of valve dysfunction on Doppler Tei index.

BACKGROUND: Recently proposed Doppler Tei index, defined as the sum of isovolumic contraction time or mitral valve closure to aortic valve opening time and isovolumic relaxation time or aortic valve closure to mitral valve opening time divided by ejection time, is a simple measure which enables noninvasive estimation of combined systolic and diastolic function and prediction of patients' prognosis. However, effects of valve dysfunction on Tei index have not been investigated. This study was designed to compare Tei index before and after surgical valve replacement or repair to evaluate effects of valve dysfunction on Tei index. METHODS: Participants consisted of 76 consecutive patients with aortic or mitral valve surgery (26 patients with aortic stenosis [AS], 16 with aortic regurgitation, 17 with mitral stenosis, and 17 with mitral regurgitation). Doppler Tei index was evaluated before and after the surgery by obtaining (a-b)/b, where a is the interval between the cessation and onset of Doppler mitral filling flow and b is the aortic flow ejection time. RESULTS: Tei index significantly increased after surgery in patients with AS (0.38 +/- 0.07 to 0.49 +/- 0.06, P <.001), aortic regurgitation (0.60 +/- 0.20 to 0.70 +/- 0.18, P <.01), mitral stenosis (0.34 +/- 0.03 to 0.39 +/- 0.04, P <.01), and decreased with no significance in mitral regurgitation (0.50 +/- 0.03 to 0.46 +/- 0.03). Percent change in Tei index after valve surgery was maximal in patients with AS (27 +/- 6 vs 17 +/- 2 vs 16 +/- 6 vs -9% +/- 6%, AS vs aortic regurgitation vs mitral stenosis vs mitral regurgitation, P <.001). CONCLUSION: Tei index significantly changes after valve surgery especially in patients with AS. Considerations for the effects of valve dysfunction on Tei index are required for its application to evaluate ventricular function in patients with valve disease.     

二尖瓣位生物瓣置换术后瓣膜毁损的临床特征及超声表现

目的探究二尖瓣位生物瓣膜置换术再次手术患者临床表现及超声心动图特征,为二尖瓣生物瓣膜毁损病因学诊断提供依据。方法回顾性分析24例经手术证实二尖瓣生物瓣膜置换术后,需再次手术患者的一般临床资料和超声心动图改变,总结患者心脏生物瓣膜毁损一般临床特征及超声表现。结果 24例患者中,中位年龄为66岁,男8例,女16例。24例中初次二尖瓣生物瓣置换术后出现生物瓣毁损再次手术原因:12例单纯性瓣膜关闭不全,4例瓣膜狭窄并关闭不全,3例瓣膜关闭不全合并瓣周漏,2例单纯性瓣膜狭窄,1例瓣膜关闭不全伴感染性心内膜炎,1例瓣膜狭窄伴附壁血栓,1例瓣膜关闭不全伴赘生物形成。结论二尖瓣位生物瓣置换术后行再次换瓣术间隔时间长短不一,本研究大部分病例生物瓣置换术后第8~9年之间出现瓣膜毁损需再次手术,时间短者大部与感染有关,时间长者大多与瓣膜老化有关。     

Potential of noninvasive determination of the left atrioventricular aperture in mitral stenosis (according to data of ultrasound studies)

The results of the measurement of the mitral opening in mitral stenosis patients by planimetry and by the computation method via the half-cycle of the atrioventricular pressure were found to be in satisfactory agreement except those in a group of patients with concomitant failure of the semilunar aortic valve. Moderate or appreciable mitral regurgitation and stenosis of the aortic ostium associated with mitral stenosis exerted no substantial effect on the accuracy of the design parameter of the mitral opening.     

Morphometric Study of Human Myocardium in Acquired Valvular Diseases

To study the effect of various valvular heart diseases on the quantitative histology of myocardium, 38 human hearts with valvular lesions were examined (11 aortic stenoses, nine mitral stenoses, nine mitral incompetences and nine combined aortic and mitral valve lesions). The control group consisted of ten hearts without any valvular lesions. With morphometrical methods the volume fractions of myocardial components (myocardial fibres, interstitial space and diffuse connective tissue), the numerical density of arterioles and the mean fibre diameter were estimated.

Myocardial fibrosis was more severe in hearts with valvular lesions than in the controls (5.4% vs 3.3%, P<0.01), but did not correlate with the anatomical severity of the valvular lesions. The most severe myocardial fibrosis was found in hearts with mitral imcompetence (6.7%). Fibre hypertrophy was most severe in hearts with aortic stenosis and in hearts with mitral incompetence (22 urn and 23 urn, respectively). In hearts with severe valvular lesions the mean fibre diameter was 23 u.m and in hearts with mild to moderate lesions 19 urn (P<0.01). Good correlation was observed between the mean fibre diameter and the weight of the left ventricle (A = 0.81, P<0.01). The volume fractions of connective tissue and interstitial space were significantly higher and the volume fraction of myocardial fibres was correspondingly lower in the subendocardium than in the subepicardium in hearts with either pressure overload (aortic stenosis) or volume overload (mitral incompetence). In conclusion, myocardial fibrosis occurs in patients with various valvular lesions, but the severity of the fibrosis does not correlate with the anatomical severity of valvular lesions. Marked transmural differences were observed in the volume fractions of myocardial components between the subendocardium and the subepicardium in patients with aortic stenosis and in patients with mitral incompetence. These transmural differences should be taken into account when endomyocardial biopsies are used in clinical practice.     

Etiology of valvular heart disease

The etiology of valvular heart diseases (VHD) has changed in the last 50 years in the industrialized countries. A significant reduction in the incidence of rheumatic fever and its sequelae, increase in life expectancy, recognition of new causes of VHD and advancement in technology are responsible for the metamorphosis of the etiology of VHD. Heritable disorders of connective tissue (marfan syndrome, Ehlers–Danlos syndrome, adult polycystic kidney disease, floppy mitral valve/mitral valve prolapse); congenital heart disease (bicuspid aortic valve); inflammatory/immunologic disorders (rheumatic fever, AIDS, Kawasaki disease, syphilis, seronegative spondyloarthropathies, systemic lupus erythematosus, antiphospholipid syndrome); endocardial disorders (nonbacteremic thrombotic endocarditis, infective endocarditis, endomyocardial fibroelastosis); myocardial dysfunction (ischemic heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy); diseases and disorders of other organs (chronic renal failure, carcinoid heart disease); aging (calcific aortic stenosis, mitral annular calcification); postinterventional valvular disease; drugs and physical agents are all clinical entities associated with VHD. It should be emphasized that VHDs still constitute a major health problem which will increase with the aging population.     

Morphometric study of human myocardium in acquired valvular diseases

To study the effect of various valvular heart diseases on the quantitative histology of myocardium, 38 human hearts with valvular lesions were examined (11 aortic stenoses, nine mitral stenoses, nine mitral incompetence and nine combined aortic and mitral valve lesions). The control group consisted of ten hearts without any valvular lesions. With morphometrical methods the volume fractions of myocardial components (myocardial fibres, interstitial space and diffuse connective tissue), the numerical density of arterioles and the mean fibre diameter were estimated. Myocardial fibrosis was more severe in hearts with valvular lesions than in the controls (5.4% vs 3.3%, P less than 0.01), but did not correlate with the anatomical severity of the valvular lesions. The most severe myocardial fibrosis was found in hearts with mitral incompetence (6.7%). Fibre hypertrophy was most severe in hearts with aortic stenosis and in hearts with mitral incompetence (22 microns and 23 microns, respectively). In hearts with severe valvular lesions the mean fibre diameter was 23 microns and in hearts with mild to moderate lesions 19 microns (P less than 0.01). Good correlation was observed between the mean fibre diameter and the weight of the left ventricle (r = 0.81, P less than 0.01). The volume fractions of connective tissue and interstitial space were significantly higher and the volume fraction of myocardial fibres was correspondingly lower in the subendocardium than in the subepicardium in hearts with either pressure overload (aortic stenosis) or volume overload (mitral incompetence). In conclusion, myocardial fibrosis occurs in patients with various valvular lesions, but the severity of the fibrosis does not correlate with the anatomical severity of valvular lesions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Etiology of valvular heart disease

The etiology of valvular heart diseases (VHD) has changed in the last 50 years in the industrialized countries. A significant reduction in the incidence of rheumatic fever and its sequelae, increase in life expectancy, recognition of new causes of VHD and advancement in technology are responsible for the metamorphosis of the etiology of VHD. Heritable disorders of connective tissue (marfan syndrome, Ehlers-Danlos syndrome, adult polycystic kidney disease, floppy mitral valve/mitral valve prolapse); congenital heart disease (bicuspid aortic valve); inflammatory/immunologic disorders (rheumatic fever, AIDS, Kawasaki disease, syphilis, seronegative spondyloarthropathies, systemic lupus erythematosus, antiphospholipid syndrome); endocardial disorders (nonbacteremic thrombotic endocarditis, infective endocarditis, endomyocardial fibroelastosis); myocardial dysfunction (ischemic heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy); diseases and disorders of other organs (chronic renal failure, carcinoid heart disease); aging (calcific aortic stenosis, mitral annular calcification); postinterventional valvular disease; drugs and physical agents are all clinical entities associated with VHD. It should be emphasized that VHDs still constitute a major health problem which will increase with the aging population.     

Myocardial mechanics in aortic and mitral valvular regurgitation: the concept of instantaneous impedance as a determinant of the performance of the intact heart

The effects on myocardial mechanics of acute, artificial aortic and mitral regurgitation were studied in the dog to determine the manner in which the changes in load induced by valvular regurgitation alter ventricular performance. With mitral and aortic regurgitant volumes of approximately the same magnitude as the forward stroke volume, immediate increases occurred in total stroke volume, left ventricular enddiastolic pressure, and peak ejection velocity, whereas contractility remained unchanged. Although calculated myocardial fiber tension rose, the rate of decline of tension during ejection was accelerated with regurgitation due to the more rapid decrease in ventricular size. Average tension therefore decreased relative to average pressure. As a consequence of the increased fiber length and this unloading, contractile element velocity, work, and power were increased. Despite unchanged contractility of the myocardium, the ejection fraction rose with both aortic and mitral regurgitation.When regurgitant beats were compared with control beats at a constant end-diastolic volume, ventricular stroke volume, work, power, and ejection fraction, as well as contractile element velocity, work, and power consistently increased. Thus, reduction of instantaneous impedance to ejection allowed the ventricle to empty further, reducing ventricular wall tension with a resultant increase in the velocity of shortening. External energy output was increased despite unchanged contractility and diastolic fiber length. It is concluded that the impedance to ejection and myocardial fiber tension during ejection govern the velocity and extent of contractile element shortening, and hence affect stroke volume, peak aortic flow rate, and ejection fraction. The alterations of ventricular function accompanying valvular regurgitation can be explained by an evaluation of the effects of these lesions on the instantaneous impedance to left ventricular ejection.