Myocardial asynchronism is a determinant of changes in functional mitral regurgitation severity during dynamic exercise in patients with chronic heart failure due to severe left ventricular systolic dysfunction.

AIMS: Functional mitral regurgitation (MR) and myocardial asynchronism occur commonly in patients with dilated cardiomyopathy and affect adversely their prognosis and symptoms. The aim of this study was to evaluate the mechanisms of changes in MR severity during dynamic exercise in patients with chronic heart failure (CHF). METHODS AND RESULTS: Seventy patients with CHF due to left ventricular (LV) systolic dysfunction [LV ejection fraction (EF) <40%] and functional MR were studied. All were in sinus rhythm. Medications were left unchanged for the study. Each patient performed a maximal symptom-limited exercise test with continuous 2D-Doppler echocardiography. Mitral regurgitant volume (RV) and effective regurgitant orifice (ERO) were determined at rest and during exercise. LV asynchrony using Doppler tissue imaging and interventricular asynchrony using conventional pulsed-Doppler were evaluated at rest. Resting LV EF averaged 25+/-8%. Mean resting LV and interventricular mechanical delays were 56+/-50 and 43+/-37 ms, respectively. The overall median values for mitral ERO and RV did not significantly change during dynamic exercise (11 [7-16] vs. 11 [6-21] mm2 and 14 [10-22] vs. 12 [9-23] mL, respectively). However, changes in mitral ERO and RV were individually variable and significantly correlated with the degree of LV asynchronism (r=0.66, P<0.0001 and r=0.66, P<0.0001, respectively). CONCLUSION: Changes in MR are variable during dynamic exercise. LV asynchronism at rest substantially contributes to worsening of functional MR during dynamic exercise in patients with CHF due to LV systolic dysfunction.     

The importance of secondary mitral valve involvement in primary aortic valve endocarditis; the mitral kissing vegetation.

AIMS: Secondary involvement of the mitral valve is well documented in primary aortic valve endocarditis. A poorly considered, but probably important causative mechanism, involving both left-sided valves, is 'mitral kissing vegetation'. This results from large aortic vegetations prolapsing into the left ventricular outflow tract and making contact with the ventricular aspect of the anterior mitral leaflet thus causing secondary infection. METHODS AND RESULTS: In 192 consecutive patients with aortic valve endocarditis, two to 18 (7.6+/-2.6) serial transoesophageal echocardiographic examinations were analysed per patient to demonstrate the development of mitral kissing vegetation on initially competent, morphologically normal mitral leaflets. In 19 patients (9.9%) with aortic valve endocarditis, mitral kissing vegetation was diagnosed within 11.6+/-9.0 (range 1-31) days following primary transoesophageal echocardiography. In all patients with mitral kissing vegetation, vegetations attached to aortic cusps were >6 mm. On hospital admission, patients with aortic valve endocarditis plus mitral kissing vegetation presented more often with a positive sepsis score, embolic events, renal failure and had larger aortic valve vegetations (9.9+/-3.3 vs 5.7+/-2.3 mm). Prognosis of aortic valve endocarditis plus mitral kissing vegetation was unfavourable (P<0.005) when compared to patients with aortic valve endocarditis alone. CONCLUSION: In aortic valve endocarditis early echocardiographic detection of mitral kissing vegetation and timely surgery may preserve the mitral valve apparatus, and favourably influence the long-term prognosis.     

Mitral annular calcification in the elderly – Quantitative assessment

PurposeTo determine the reliability of subjective and objective quantification of mitral annular calcification (MAC) in elderly patients with severe aortic stenosis, to define quantitative sex- and age-related reference values of MAC, and to correlate quantitative MAC with mitral valve disease.MethodsIn this retrospective, IRB-approved study, we included 559 patients (268 females, median age 81 years, inter-quartile range 77–85 years) with severe aortic stenosis undergoing CT. Four independent readers performed subjective MAC categorization as follows: no, mild, moderate, and severe MAC. Two independent readers performed quantitative evaluation of MAC using the Agatston score method (Agatston_MAC). Mitral valve disease was determined by echocardiography.ResultsSubjective MAC categorization showed high inter-reader agreement for no (k ?= ?0.88) and severe MAC (k ?= ?0.75), whereas agreement for moderate (k ?= ?0.59) and mild (k ?= ?0.45) MAC was moderate. Intra-reader agreement for subjective MAC categorization was substantial (k ?= ?0.69 and 0.62). Inter- and intra-reader agreement for Agatston_MAC were excellent (ICC ?= ?0.998 and 0.999, respectively), with minor inconsistencies in MAC involving the left ventricular outflow tract/aortic valve. There were significantly more women than men with MAC (n ?= ?227, 85% versus n ?= ?209, 72%; p ?< ?0.001), with a significantly higher Agatston_MAC (median 597, range 81–2055 versus median 244; range 0–1565; p ?< ?0.001), particularly in patients ≥85 years of age. Agatston_MAC showed an area-under-the-curve of 0.84 to diagnose mitral stenosis, whereas there was no association of Agatston_MAC with mitral regurgitation (p ?> ?0.05).ConclusionsOur study in elderly patients with severe aortic stenosis shows that quantitative MAC scoring is more reliable than subjective MAC assessment. Women show higher Agatston_MAC scores than men, particularly in the elderly population. Agatston_MAC shows high accuracy to diagnose mitral stenosis.     

Factors associated with moderate or severe left atrioventricular valve regurgitation within 30 days of repair of incomplete atrioventricular septal defect

Introduction

Left atrioventricular valve regurgitation is the most concerning residual lesion after surgical correction of atrioventricular septal defect.

Objective

To determine factors associated with moderate or greater left atrioventricular valve regurgitation within 30 days of surgical repair of incomplete atrioventricular septal defect.

Methods

We assessed the results of 51 consecutive patients 14 years-old and younger presenting with incomplete atrioventricular septal defect that were operated on at our practice between 2002 and 2010. The following variables were considered: age, weight, absence of Down syndrome, grade of preoperative left atrioventricular valve regurgitation, abnormalities on the left atrioventricular valve and the use of annuloplasty. The median age was 4.1 years; the median weight was 13.4 Kg; 37.2% had Down syndrome. At the time of preoperative evaluation, there were 23 cases with moderate or greater left atrioventricular valve regurgitation (45.1%). Abnormalities on the left atrioventricular valve were found in 17.6%; annuloplasty was performed in 21.6%.

Results

At the time of postoperative evaluation, there were 12 cases with moderate or greater left atrioventricular valve regurgitation (23.5%). The variation between pre- and postoperative grades of left atrioventricular valve regurgitation of patients with atrioventricular valve malformation did not reach significance (P=0.26), unlike patients without such abnormalities (P=0.016). During univariate analysis, only absence of Down syndrome was statistically significant (P=0.02). However, after a multivariate analysis, none of the factors reached significance.

Conclusion

None of the factors studied was determinant of a moderate or greater left atrioventricular valve regurgitation within the first 30 days of repair of incomplete atrioventricular septal defect in the sample. Patients without abnormalities on the left atrioventricular valve benefit more of the operation.     

Pituitary Apoplexy Following Mitral Valvuloplasty

Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome caused by the sudden enlargement of a pituitary adenoma secondary to hemorrhage or infarction. Pituitary apoplexy after cardiac surgery is a very rare perioperative complication. Factors associated with open heart surgery that may lead to pituitary apoplexy include hemodynamic instability during cardiopulmonary bypass and systemic heparinization. We report a case of pituitary apoplexy after mitral valvuloplasty with cardiopulmonary bypass. After early pituitary tumor resection and hormonal replacement therapy, the patient made a full recovery.     

二尖瓣替换术后房颤转复为窦性心律的临床分析

在风湿性心脏病二尖瓣病变中，慢性心房纤颤（简称房颤）是一种常见的并发症。房颤会给病人带来许多问题，如左房血栓形成、体循环栓塞、心房扩大和心输出量减少等并发症，从而增加了死亡率，影响了生活质量的提高。因此，人们一直采用各种方法使之转复为窦性心律。风湿性心脏病二尖瓣替换术同时给予电除颤，可使部分病人恢复窦性心律。本组对89例患风湿性心脏病二尖瓣替换术后房颤转复情况进行了回顾性研究，根据手术后病人出院时的心律情况将病人分为两组，A组为出院时仍为房颤者，B组为出院时为窦性心律者。分析结果表明，风湿性心脏病二尖瓣替换术后，解除了机械梗阻，部分术前伴有房颤的病人术后可以转复为窦性心律，但能维持至1个月以上者较少，仅占手术病人的15．7％。病人手术时的年龄、房颤病史长短及左房径对房颤转复情况有显著影响，且可以预见其短期效果，根据本组病例分析的结果表明，年龄小于40岁、房颤病史不超过一年、左房径小于55mm的病人，窦性心律可维持在1个月以上。     

经皮二尖瓣球囊扩张术治疗二尖瓣狭窄伴中度返流

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

Semi-automated Segmentation and Quantification of Mitral Annulus and Leaflets from Transesophageal 3-D Echocardiographic Images

Quantification of three-dimensional (3-D) morphology of the mitral valve (MV) using real-time 3-D transesophageal echocardiography (RT3-D TEE) has proved to be a valuable tool for the assessment of MV pathologies, but of limited use in clinical practice because it relies on user-intensive approaches. This study presents a new algorithm for the segmentation and morphologic quantification of the mitral annulus (MA) and mitral leaflets (ML) in closed valve configuration from RT3-D TEE volumes. Following initialization, the MA and the ML and the coaptation line (CL) are automatically obtained in 3-D. Validation with manual tracings was performed on 33 patients, resulting in segmentation errors in the order of 0.7 mm and 0.6 mm for the MA and ML segmentation, in addition to good intra- and inter-observer reproducibility (coefficients of variation below 12% and 15%, respectively). The ability of the algorithm to assess different MV pathologies as well as repaired valves with implanted annular rings was also explored. The reported performance of the proposed fast, semi-automated MA and ML quantification makes it promising for future applications in clinical settings such as the operating room, where obtaining results in short time is important.     

双脉冲多普勒成像评价二尖瓣环组织运动与瓣口血流的耦联关系

目的探讨双脉冲多普勒(DPW)技术同步评价二尖瓣环组织运动和主动脉瓣、二尖瓣血流的耦联关系。方法选取健康成年志愿者110名,采用DPW技术同步获取二尖瓣环组织运动与瓣口血流频谱图,测量峰值起始时间(Ts)和达峰时间(Tp),并进行统计学分析。结果二尖瓣瓣环收缩期Ts及Tp均早于主动脉瓣口血流速度的Ts和Tp[Ts:(42.65±9.36)ms vs(61.38±12.19)ms;Tp:(96.63±14.77)ms vs(145.88±21.50)ms,P均<0.05];在整个心动周期中,二尖瓣瓣环Ts与瓣口血流Ts均有相关性(r=0.323、0.703、0.275,P均<0.05);二尖瓣瓣环Tp与瓣口血流Tp仅在舒张早期有相关性(r=0.760,P<0.001)。结论正常成年人心肌收缩与瓣口血流形成存在机械收缩-血流形成延迟,且心肌运动与瓣口血流形成有相关性。