Hemodynamic measurements by Doppler echocardiography

This paper discusses the measurement of cardiac output and pulmonary artery pressures by Doppler echocardiography. Blood flow may be measured through the aortic valve, the left ventricle and the mitral and pulmonary valves. In each case certain conditions for the validity of calculations must be respected. These measurements contribute to the evaluation of valvular stenosis and regurgitation, intracardiac shunts and cardiac function. Pulmonary artery pressures may be estimated from Doppler signals of tricuspid and pulmonary regurgitation, from the morphology of systolic pulmonary blood flow and from the duration of the right ventricular isovolumic relaxation period. They provide important information for the evaluation of many cardiac and pulmonary diseases.     

Impact of intraoperative echocardiography on surgical management of congenital heart disease

Intraoperative echocardiography was performed by epicardial, 2-dimensional, low- and high-pulsed repetition frequency, continuous-wave Doppler and color flow mapping in 50 patients. Forty studies were performed before and 44 studies after cardiopulmonary bypass. Studies before cardiopulmonary bypass agreed with preoperative evaluation. After cardiopulmonary bypass, studies revealed that 11 of 25 patients who underwent repair of ventricular septal defects had residual ventricular septal defects, and 1 of 25 patients who underwent atrial septal repair had 1 residual atrial communication. One patient with a "Swiss cheese" ventricular septum underwent repeat cardiopulmonary bypass to close residual ventricular septal defects. The patient with a residual atrial communication required immediate reoperation because of a right to left shunt after a modified Fontan procedure. Eight of 10 remaining residual ventricular septal defects spontaneously closed 1 to 41 days after operation. Assessment of postcardiopulmonary bypass and postoperative valvular regurgitation in 21 valves revealed good correlation (p less than 0.01). However, 1 patient required reoperation for mitral valve replacement on the sixth postoperative day. The correlation was fair between postcardiopulmonary bypass and postoperative residual stenotic pressure gradients in 12 surgically repaired stenotic lesions. This study shows that little additional information is added to a comprehensive preoperative evaluation by precardiopulmonary bypass intraoperative echocardiography. Postcardiopulmonary bypass intraoperative echocardiography is useful in identifying residual shunts. Assessment of stenotic gradients and valvular regurgitation must be interpreted in light of a changing hemodynamic state.     

Intraoperative contrast echocardiography to evaluate mitral valve operations

Intraoperative two-dimensional contrast echocardiography was performed on 29 patients undergoing open heart surgery to determine the presence of mitral regurgitation before and immediately after the operative procedure: 14 patients had predominant mitral stenosis, 9 had severe mitral regurgitation and 6 had no mitral valve disease (control subjects). Two-dimensional echocardiography was performed by applying a 5 MHz transducer directly on the heart during injection of saline solution through an apical ventricular sump or transseptal needle, generating contrast microbubbles, with imaging in two planes. Baseline studies were performed after thoracotomy and pericardiotomy before cardiopulmonary bypass, and a second study was done after the operative procedure, with the patient off cardiopulmonary bypass with hemodynamic stabilization before chest closure. No control subject had contrast evidence of mitral regurgitation before or after cardiopulmonary bypass. Two of three patients with mitral valvuloplasty and two of five with commissurotomy required a second operative procedure before chest closure because of persistent mitral regurgitation detected by intraoperative two-dimensional contrast echocardiography. Thirteen of the 15 patients with valve replacement had no mitral regurgitation after cardiopulmonary bypass. Intraoperative two-dimensional echocardiographic findings correlated with data from postoperative clinical examinations and two-dimensional echocardiography-Doppler studies. It is concluded that two-dimensional echocardiography with contrast is an important intraoperative tool for assessing the presence and relative severity of mitral regurgitation after mitral commissurotomy, valvuloplasty or valve replacement. This technique may allow surgeons to be more aggressive in combining reparative operative procedures (that is, commissurotomy and valvuloplasty) in an attempt to retain native valves.     

Effect of coronary bypass surgery and valve replacement on left ventricular function: assessment by intraoperative two-dimensional echocardiography

Intraoperative two-dimensional echocardiography (2DE) was performed in 15 patients during coronary artery bypass grafting (CABG) and in 14 patients during aortic (AVR) or mitral valve replacement (MVR) before and immediately after cardiopulmonary bypass by means of a 3.5 MHz transducer. Left ventricular ejection fraction (LVEF), end-diastolic (LVEDV) and end-systolic (LVESV) volumes were measured by a light pen system and biplane Simpson's rule from short-axis and apical two-chamber views. In seven patients with CABG and new abnormal Q waves or greater than 5% MB to total CPK ratio postoperatively, the mean LVEF decreased significantly (from 52 +/- 10 to 43 +/- 12%, p = 0.005). Patients undergoing MVR for mitral regurgitation showed, a significant decrease in LVEF (from 63 +/- 10 to 42 +/- 23%, p less than 0.025) and LVEDV (from 166 +/- 34 to 147 +/- 44 ml, p less than 0.05). Mean LVEF also decreased after AVR for aortic regurgitation (from 46 +/- 16 to 26 +/- 15%, p less than 0.05). Six patients with valve replacement and postoperative hypotension had the greatest decrease in intraoperative LVEF (from 50 +/- 12 to 24 +/- 10%, p less than 0.005). It is concluded that: Intraoperative 2DE can be used to assess immediate changes in left ventricular function after CABG or valve replacement. LVEF decreases significantly immediately after AVR for aortic regurgitation and MVR for mitral regurgitation. Intraoperative 2DE may identify those patients who can benefit from inotropic support in the immediate postoperative period after valve replacement.     

Characteristic cardiovascular manifestation in homozygous and heterozygous familial hypercholesterolemia

BACKGROUND: The aortic valve dysfunction of patients with homozygous familial hypercholesterolemia (FH) suggests that hypercholesterolemia affects not only coronary arteries but also the aortic valve. We studied the aortic root of patients with homozygous FH and those of patients with heterozygous FH to characterize the premature atherosclerotic lesions by using histopathologic specimens. METHODS AND RESULTS: The aortic roots of 10 patients with homozygous FH, age 9 to 58 years, were studied by cardiac catheterization with several angiographies. The aortic roots of 39 patients with heterozygous FH under age 60 years were also examined for aortic and mitral valvular functions by color Doppler echocardiography, and 30 normocholesterolemic patients with coronary artery disease were examined as control subjects. In addition, in 22 patients with FH and 20 control subjects, the internal diameter of the aortic annulus and the aortic ridge in cardiac cycles were measured. Of the 10 homozygotes with FH, 8 patients had aortic regurgitation demonstrated by aortography; 3 of them showed significant transvalvular pressure gradients. Stenotic changes of coronary ostia were observed in 8 of the 10 homozygotes with moderate coronary atherosclerosis. Of the 39 heterozygotes with FH, 10 patients had aortic regurgitation shown by Doppler echocardiography, as did only 1 of the 30 control subjects (P <.05). The average diameter and distensibility of the ascending aorta were significantly reduced in the heterozygotes compared with the control subjects. The surgically resected cusp specimens of aortic valves obtained from 1 homozygous and 1 heterozygous patient showed significant thickening of the cusp with foam cell infiltration. CONCLUSIONS: Premature atherosclerosis in FH had a characteristic distribution, affecting the aortic root dominantly. The involvement of the aortic valve indicating "hypercholesterolemic valvulopathy" was a peculiar feature of FH, especially its homozygous form, but was reminiscent of ubiquitous processes caused by hypercholesterolemia.     

Doppler hemodynamic evaluation of prosthetic (Starr-Edwards and Bj?rk-Shiley) and bioprosthetic (Hancock and Carpentier-Edwards) cardiac valves

One hundred thirty-four patients with prosthetic or bioprosthetic heart valves were investigated with Doppler echocardiography to determine normal values for commonly used prosthetic valves and to test the specificity of abnormal Doppler findings. In 70 patients the aortic valves had been replaced and in 64 the mitral valves had been replaced. Gradients across prostheses in the aortic position were calculated from maximal velocity. Peak calculated aortic transvalvular gradients in normal subjects were 22 +/- 10 mm Hg in 33 Bj?rk-Shiley valves, 23 +/- 10 mm Hg in 27 porcine valves and 29 +/- 13 mm Hg in 6 Starr-Edwards valves. Mild aortic regurgitation was seen in 42% of Bj?rk-Shiley valves, 26% of porcine valves and 2 of 6 Starr-Edwards valves. Mitral valve orifice was calculated by the pressure half-time method. In clinically normal patients with mitral valve prostheses, the effective mitral valve orifice was 2.5 +/- 0.8 cm2 in 35 Bj?rk-Shiley valves, 2.1 +/- 0.7 cm2 in 17 porcine valves, and 2.0 +/- 0.3 cm2 in 10 Starr-Edwards valves. Mitral regurgitation was found in 11% of Bj?rk-Shiley valves, 19% of porcine valves and 30% of Starr-Edwards valves. Repeat studies at 2 weeks to 14 months revealed no difference in 8 aortic and 14 mitral prostheses. Seven aortic and 4 mitral valves functioned abnormally as determined by Doppler, and the abnormal function was confirmed in each at surgery or at cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler echocardiography assessment of prosthetic heart valves

Transthoracic Doppler echocardiography is an accurate noninvasive method for the evaluation of prosthetic valve function. The flow characteristics and pressure gradients of normally functioning mechanical and bioprosthetic valves have been, in general established. Normal functioning mitral valve prostheses have a valve area > 1.8 cm² with the St. Jude valve having the largest effective valve area and normally functioning aortic prosthetic valves have a peak instantaneous gradient of < 45 mmHg, with the Starr-Edwards valves (Starr-Edwards, Irvine CA) showing the highest gradients. The incidence of minimal or mild regurgitation is approximately 15% to 30% in the mitral position and 25% to 50% in the aortic position, with the higher incidence of regurgitation seen with mechanical compared to bioprosthetic valves. Transthoracic Doppler echocardiography can accurately detect patients with prosthetic valvular stenosis. The presence of prosthetic aortic regurgitation can also generally be accurately assessed, except in the presence of both prosthetic aortic and mitral valves. Assessment of prosthetic mitral regurgitation remains limited due to significant attenuation of the ultrasound beam by the prosthesis and the frequent underestimation of severity of regurgitation. Other limitations of transthoracic studies include assessment of leaflet morphology, detection of vegetations and valve abscesses, and differentiation between valvular and paravalvular regurgitation.     

Color flow and conventional echocardiography of the Marfan syndrome

Imaging and color flow Doppler echocardiography are an integral part of any evaluation of a patient with the Marfan syndrome. The major cardiovascular manifestations of this condition are aortic dilation, which may involve the proximal and distal aorta, aortic regurgitation, aortic dissection, mitral valve prolapse, and mitral regurgitation. Patients who have the Marfan syndrome should have serial echocardiograms to measure aortic root diameter carefully at the sinuses of Valsalva and subsequent levels (sinotubular junction, arch, descending and abdominal aorta). Additionally, color Doppler echocardiography assists in the diagnosis of aortic dissection and facilitates evaluation of the severity of aortic and mitral regurgitation that commonly complicate the Marfan syndrome. The risk of aortic dissection, which is the most serious manifestation of the Marfan syndrome, increases as the aorta enlarges. Therefore, elective composite graft surgery is recommended when the aortic root size reaches 60 mm, regardless of symptom status, or 55 mm in the presence of severe aortic regurgitation. Surgical replacement of the aortic root with a composite graft does not end the disease process. Color flow Doppler is useful in the diagnosis of dehiscence of the conduit sewing ring, coronary artery aneurysm, distal aortic dissections, and prosthetic valve dysfunction.     

Pulsed Doppler echocardiographic evaluation of valvular regurgitation in patients with mitral valve prolapse: comparison with normal subjects

Pulsed Doppler echocardiography was used to determine prospectively the prevalence of mitral, aortic, tricuspid and pulmonary regurgitation in 80 consecutive patients with mitral valve prolapse and 85 normal subjects with similar age and sex distribution. Mitral valve prolapse was defined by posterior systolic displacement of the mitral valve on M-mode echocardiography of 3 mm or more (40 patients), the presence of one or more mid- or late systolic clicks (61 patients), or both. Mitral regurgitation, detected by pulsed Doppler techniques in 53 patients with prolapse, was holosystolic in 24, early to mid-systolic in 6, late systolic in 15 and both holosystolic and late systolic behind different portions of the valve in 8. Definitive M-mode findings were present in only 27 of the 53 patients, and only 21 had mitral regurgitation audible on physical examination. Tricuspid regurgitation was evident by pulsed Doppler echocardiography in 15 patients (holosystolic in 9, early to mid-systolic in 1, late systolic in 4 and both holosystolic and late systolic in 1); 12 of these 15 patients, including all with an isolated late systolic pattern, had an echocardiographic pattern of tricuspid prolapse, but none had audible tricuspid regurgitation. A Doppler pattern compatible with aortic regurgitation was recorded in seven patients, all without echocardiographic aortic valve prolapse and only two with audible aortic insufficiency. A Doppler shift in the right ventricular outflow tract in diastole, suggestive of pulmonary regurgitation, was recorded in 16 of the 78 patients with an adequate Doppler examination: only 1 of the 16 had audible pulmonary insufficiency. Of the 85 normal subjects without audible regurgitation, pulsed Doppler examination detected mitral regurgitation in 3 subjects (holosystolic in 1 and early to mid-systolic in 2), aortic regurgitation in none, tricuspid regurgitation in 9 (holosystolic alone in 8 and both holosystolic and late systolic in 1) and right ventricular outflow tract turbulence compatible with pulmonary insufficiency in 15. The prevalence of valvular regurgitation, detected by pulsed Doppler echocardiography, is high in patients with mitral valve prolapse. Regurgitation may involve any of the four cardiac valves and is clinically silent in the majority of patients. The prevalence rates of mitral and aortic regurgitation are significantly higher in patients with mitral prolapse than in normal subjects, suggesting that alterations in underlying valve structure in the prolapse syndrome may indeed be responsible for this regurgitation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Intraoperative echocardiography for surgical repair of the aortic valve and left ventricular outflow tract

Valve conservation surgery represents an exciting advance in the evolution of valve surgery. Recent studies have shown the significant advantages of mitral valve repair over valve replacement. While there are significant advantages for valve repair, the surgeon requires a greater understanding of the mechanism of valvular dysfunction prior to repair and requires an accurate means to assess the adequacy of the repair in the operating room immediately following the repair. Intraoperative echocardiography with color flow Doppler mapping provides immediate and accurate assessment of cardiac anatomy, hemodynamics, and valve integrity. These data are vital for optimal intraoperative surgical decision making. Intraoperative echocardiography has an important role in the evaluation in patients undergoing surgery to the aortic valve and left ventricular outflow tract by the delineation of presence and mechanism of left ventricular outflow tract obstruction, the quantification of severity of the left ventricular outflow tract gradient, the severity and mechanism of aortic regurgitation, the distribution and severity of left ventricular hypertrophy, and identification of associated lesions such as mitral regurgitation. Aortic valve conservation surgery is more complex than mitral valve surgery. The surgical techniques for aortic valve repair have been slower to evolve than mitral repair with a much smaller percentage of patients currently suitable for valve repair. However, with the aid of intraoperative echocardiography, the future shows similar promise that has already been fulfilled with mitral valve repair. Even in its infancy, intraoperative echocardiography has become indispensable to the innovative cardiac surgeon. However, without consideration of adequate echocardiographic training, incorrect echocardiography diagnoses can lead to inappropriate surgical decisions.     

Doppler and echocardiographic features of normal and dysfunctioning bioprosthetic valves

Echocardiographic and Doppler studies were performed on 183 clinically normal and 58 severely dysfunctioning bioprosthetic mitral, aortic and tricuspid valves. The valve dysfunction resulted from spontaneous cusp degeneration in 49 instances and from paravalvular regurgitation in 9. The pulsed Doppler study demonstrated regurgitant flow in 36 (92%) of 39 regurgitant valves and 8 (90%) of 9 paravalvular regurgitant valves. Diagnostic echocardiographic features were present in only 51 and 10% of the patients, respectively. Although the Doppler regurgitant jet was peripheral in seven of the nine patients with paravalvular regurgitation, it was not possible to differentiate these patients from those who had valve degeneration and cusp tear at the periphery of the valve ring. Eight patients presented with a musical holosystolic murmur of mitral insufficiency. In all eight there was a characteristic honking intonation on the audio signal and a striated shuddering appearance on the video Doppler signal. Ten stenotic mitral bioprosthetic valves (less than or equal to 1.1 cm2 valve orifice) were identified by Doppler study. Diagnostic echocardiographic features were present in only two of these patients. The Doppler-derived valve orifice dimension correlated well (r = 0.83) with cardiac catheterization values. Fourteen asymptomatic or minimally symptomatic patients had echocardiographically thickened mitral cusps (greater than or equal to 3 mm). These patients had a significantly (p less than 0.0001) smaller valve area as compared with normal control valves, and during 4 to 24 months of follow-up, five of these patients developed severe valve regurgitation or stenosis. Doppler ultrasound is more sensitive than echocardiography in diagnosing bioprosthetic valve stenosis and regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler echocardiographic evaluation of Hancock and Bj?rk-Shiley prosthetic values

Doppler echocardiographic characteristics of normally functioning Hancock and Bj?rk-Shiley prostheses in the mitral and aortic positions were studied in 50 patients whose valvular function was considered normal by clinical evaluation. Doppler studies were also performed in 46 patients with suspected malfunction of Hancock and Bj?rk-Shiley valves and who subsequently underwent cardiac catheterization. Mean gradients were estimated for both mitral and aortic valve prostheses and valve area was calculated for the mitral prostheses. Doppler prosthetic mitral valve gradient and valve area showed good correlation with values obtained with cardiac catheterization (r = 0.93 and 0.97, respectively) for both types of prosthetic valves. The correlation coefficient (r = 0.93) for mean prosthetic aortic valve gradient was also good, although Doppler echocardiography overestimated the mean gradient at lower degrees of obstruction. Regurgitation of Hancock and Bj?rk-Shiley prostheses in the mitral and aortic positions was correctly diagnosed. These results suggest that Doppler echocardiography is a reliable method for the characterization of normal and abnormal prosthetic valve function.     

Prevalence and clinical significance of aortic valve prolapse

The prevalence and clinical significance of aortic valve prolapse were determined prospectively in 2000 consecutive patients undergoing routine clinical cross sectional echocardiography. Two hundred and twelve patients were excluded because the aortic cusps were not adequately visualised. Aortic valve prolapse was defined as downward displacement of cuspal material below a line joining the points of attachment of the aortic valve leaflets. Twenty four cases of aortic valve prolapse (1.2%) were identified. The patients were aged 12-64 years and nine were women. All had underlying valvar heart disease and the commonest lesion (in 11 cases) was prolapse of the larger cusp in bicuspid valves. Aortic valve prolapse was seen in four patients with mitral valve prolapse (two with severe regurgitation), one of whom had marfanoid aortic root dilatation. The remaining examples of aortic prolapse were seen in patients with various disorders including one with pulmonary atresia, two with aortic root disease (one with dissection and one with idiopathic dilatation), and one case of severe mitral regurgitation. Valves destroyed by infective endocarditis were seen in two cases. Aortic valve prolapse may be detected in various cardiac disorders and does not imply the presence of aortic regurgitation, but when bicuspid aortic valves are present it may well be important in producing such regurgitation. Although aortic valve prolapse may be associated with severe forms of mitral valve prolapse, these patients rarely have aortic regurgitation.     

Prevalence and clinical significance of aortic valve prolapse.

The prevalence and clinical significance of aortic valve prolapse were determined prospectively in 2000 consecutive patients undergoing routine clinical cross sectional echocardiography. Two hundred and twelve patients were excluded because the aortic cusps were not adequately visualised. Aortic valve prolapse was defined as downward displacement of cuspal material below a line joining the points of attachment of the aortic valve leaflets. Twenty four cases of aortic valve prolapse (1.2%) were identified. The patients were aged 12-64 years and nine were women. All had underlying valvar heart disease and the commonest lesion (in 11 cases) was prolapse of the larger cusp in bicuspid valves. Aortic valve prolapse was seen in four patients with mitral valve prolapse (two with severe regurgitation), one of whom had marfanoid aortic root dilatation. The remaining examples of aortic prolapse were seen in patients with various disorders including one with pulmonary atresia, two with aortic root disease (one with dissection and one with idiopathic dilatation), and one case of severe mitral regurgitation. Valves destroyed by infective endocarditis were seen in two cases. Aortic valve prolapse may be detected in various cardiac disorders and does not imply the presence of aortic regurgitation, but when bicuspid aortic valves are present it may well be important in producing such regurgitation. Although aortic valve prolapse may be associated with severe forms of mitral valve prolapse, these patients rarely have aortic regurgitation.     

Comparative value of Doppler echocardiography and cardiac catheterization for management decision-making in patients with left-sided valvular regurgitation

OBJECTIVE: The purpose of this study was to examine the value of non-invasiveclinical and Doppler echocardio-graphic findings, compared tocardiac catherization, in management decision-making for patientswith left-sided valvular regurgitation. METHODS: One hundred and thirty-five consecutive patients with left-sidedvalvular regurgitation who underwent cardiac catherization anddetailed Doppler echocardiography were prospectively studied.Two independent groups of experienced cardiologists, given clinicalinformation combined with either Doppler echocardiographic orcardiac catherization data, decided to operate, not to operate,or remained uncertain. RESULTS: In 63 (81%) of 78 patients with mitral regurgitation, therewas agreement on the decision for valve surgery or medical treatmentbetween Doppler echocardiography and cardiac catherization.Valve repair was performed in 22 patients, which agreed withthe echocardiographic decision. In the remaining 15 patients,although the severity and type of mitral valve lesions and leftventricular functional status were confirmed by Doppler echocardiography,the clinical decision was uncertain; additional informationconcerning coronary anatomy (13 patients) and pulmonary arterypressure (one patient) or both (one patient) was required. In47 of 57 patients (82%) with aortic regurgitation, there wasagreement on their management as a result of Doppler echocardiographyand cardiac catheterization findings. In 10 patients, the clinicaldecision reached with the help of Doppler echocardiography alonewas uncertain and coronary (seven patients), left ventricular(two patients) angiography or aortography (one patient) wererequested. Overall, there were no conflicting clinical decisionsmade by the two methods in patients with either mitral or aorticregurgitation. CONCLUSIONS: In every patient in whom it was considered that a decision couldbe reached by echocardiography alone (more than 80% of patients)there was l00% agreement from the cardiac catherization assessmentgroup on the management decision. Therefore, in patients withsignificant mitral or aortic regurgitation where echocardiographicdata is adequate, cardiac catherization can be safely omittedfrom the investigative process for surgery. Where echocardiographicindices are conflicting, or significant coronary artery diseaseis suspected, cardiac catherization is required.     

Quantitative assessment of regional left ventricular motion using endocardial landmarks

Doppler echocardiography was performed in 136 patients with a normally functioning prosthetic valve in the aortic (n = 59), mitral (n = 74) and tricuspid (n = 3) positions. These included patients with St. Jude (n = 82), Bj?rk-Shiley (n = 18), Beall (n = 13), Starr-Edwards (n = 7) or tissue (n = 16) valves. Peak and mean pressure gradients across the prostheses were measured using the simplified Bernoulli equation. The prosthetic valve orifice (PVO, in square centimeters), only in the mitral position, was calculated by the equation: PVO = 220/pressure half-time. In the aortic position, the St. Jude valve had a lower peak velocity (2.3 +/- 0.6 m/s, range 1.0 to 3.9), peak gradient (22 +/- 12 mm Hg, range 4 to 61) and mean gradient (12 +/- 7 mm Hg, range 2 to 32) than the other valves (p less than 0.05) when compared with Starr-Edwards). In the mitral position, the St. Jude valve had the largest orifice (3.0 +/- 0.6 cm2, range 1.8 to 5.0) (p less than 0.0001 compared with all other valves). Insignificant regurgitation was commonly found by pulsed mode Doppler technique in patients with a St. Jude or Bj?rk-Shiley valve in the aortic or mitral position and in patients with a Starr-Edwards or tissue valve in the aortic position. In 17 other patients with a malfunctioning prosthesis (four St. Jude, two Bj?rk-Shiley, four Beall and seven tissue valves) proven by cardiac catheterization, surgery or autopsy, Doppler echocardiography correctly identified the complication (significant regurgitation or obstruction) in all but 2 patients who had a Beall valve. It is concluded that 1) the St. Jude valve appears to have the most optimal hemodynamics; mild regurgitation can be detected by the Doppler technique in normally functioning St. Jude and Bj?rk-Shiley valves in the aortic or mitral position and in Starr-Edwards and tissue valves in the aortic position, and 2) Doppler echocardiography is a useful method for the detection of prosthetic valve malfunction, especially when the St. Jude, Bj?rk-Shiley and tissue valves are assessed.     

Doppler echocardiographic analysis of the short-term results of surgical repair of mitral valve prolapse in myxomatous degeneration

Ten consecutive patients with pure mitral regurgitation due to floppy valve underwent valve repair operations. Postoperative mitral continence or regurgitation and diastolic flow across the valve were evaluated by Doppler echocardiography. Mean follow-up was 6.4 months. Four patients showed minimal and 3 mild regurgitation; no regurgitation was detected in 3. A significant peak diastolic atrioventricular gradient (10 mmHg) was observed in only one patient. All patients showed symptomatic improvement and a decrease in ventricular diameters. Repair of floppy mitral valves is feasible and gives good results. Doppler echocardiography is a useful technique for monitoring postoperative valve function.     

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.     

Clinical and necropsy observations early after simultaneous replacement of the mitral and aortic valves

Clinical and necropsy findings are described in 54 patients, aged 25 to 83 years (mean 53), who died within 60 days of simultaneous replacements of both mitral and aortic valves. The patients were separated into 4 groups on the basis of the presence of stenosis (with or without associated regurgitation) or pure regurgitation of each valve: 30 patients (56%) had combined mitral and aortic valve stenosis; 12 patients (22%) had mitral stenosis and pure aortic regurgitation; 8 patients (15%) had pure regurgitation of both valves; and 4 patients (7%) had pure aortic regurgitation and mitral stenosis. Necropsy examination in the 54 patients disclosed a high frequency (48%) of anatomic evidence of interference to poppet or disc movement in either the mitral or aortic valve position or both. Anatomic evidence of interference to movement of a poppet or disc in the aortic valve position was twice as common as anatomic evidence of interference to poppet or disc movement in the mitral position. Interference to poppet movement is attributable to the prosthesis's being too large for the ascending aorta or left ventricular cavity in which it resided. The ascending aorta is infrequently enlarged in patients with combined mitral and aortic valve dysfunction irrespective of whether the aortic valve is stenotic or purely regurgitant. Likewise, the left ventricular cavity is usually not dilated in patients with combined mitral and aortic valve stenosis, the most common indication for replacement of both left-sided cardiac valves. Of the 54 patients, 12 (22%) had 1 mechanical and 1 bioprosthesis inserted. It is recommended that both substitute valves should be mechanical prostheses or both should be bioprostheses.     

Intraoperative Doppler color flow mapping for assessment of valve repair for mitral regurgitation

The ability of color Doppler flow mapping to provide intraoperative information about mitral regurgitation (MR) severity and to evaluate adequacy of mitral valve repair was assessed by performing color Doppler echocardiography immediately before and after cardiopulmonary bypass, with the transducer placed directly on the epicardium. In 56 patients, the degree of MR by intraoperative color Doppler correlated well with left ventricular angiography (kappa = 0.80) and with closed-chest preoperative color Doppler (kappa = 0.84) and had good interobserver reproducibility (kappa = 0.88). Good correlation was also seen between closed-chest color Doppler and angiography (kappa = 0.75). After mitral valve repair in 18 patients (15 ischemic MR, 3 cleft valves), color Doppler was used to assess severity of residual MR intraoperatively and postoperatively. Intraoperative color Doppler identified satisfactory repair (MR less than or equal to 2+) in 15 patients and failure (MR greater than or equal to 3+) in 3, whereas conventional surgical assessment of MR by fluid filling of the arrested ventricle failed to provide reliable differentiation. MR severity on subsequent closed-chest color Doppler follow-up did not change significantly compared with intraoperative evaluation after repair. Intraoperative color Doppler provides accurate grading of MR severity, offers instantaneous evaluation of the adequacy of mitral valve repair before chest closure, and appears to predict the degree of postoperative MR seen on subsequent closed-chest follow-up studies.