M-mode and cross-sectional (2D)echocardiograms in the diagnosis of mitral valve prolpase

Forty-nine patients were studied to assess the value of M-modeand cross-sectional echocardiography in the diagnosis of mitralvalve prolapse. There were 20 normal subjects and 29 patientswith clinical and phonocardiographic evidence which suggestedprolapse. Using an arbitrary line connecting the base of theanterior and posterior leaflets at their attachment to the atrioventricularjunction, 22 of the 29 patients had abnormal arching of themitral leaflets into the left atrium on cross-sectional echocardiograms(CSE); this was not seen in the normal subjects. There were15 patients with double leaflet prolapse, five with lone anteriorand two with lone posterior leaflet prolapse. M-mode recordingsfailed to show prolapse in six of the 22 patients with positiveCSE but showed prolapse in one patient with an inadequate cross-sectionalechocardiogram. The difficulty in demonstrating prolapse onM-mode was caused by multiple systolic echoes in four subjects,and poor separation of the posterior leaflet from the posteriorleft ventricular wall echoes in two subjects. The anterior leafletwas well seen on CSE with long axis parasternal views but theposterior leaflet could not be seen on the long axis view in13 of the 29 subjects in the abnormal group; short axis fourchamber views from the apex allowed definition of the posteriorleaflet in nine of these 13 patients. We conclude that CSE is better than M-mode echocardiographyand should be used in conjunction with it for the diagnosisof mitral valve prolapse. Superior arching of the mitral leafletsinto the left atrium is the characteristic feature, and longaxis parasternal views should be supplemented by short axisfour chamber apical views.     

Clinical Impact of Computational Heart Valve Models

This paper provides a review of engineering applications and computational methods used to analyze the dynamics of heart valve closures in healthy and diseased states. Computational methods are a cost-effective tool that can be used to evaluate the flow parameters of heart valves. Valve repair and replacement have long-term stability and biocompatibility issues, highlighting the need for a more robust method for resolving valvular disease. For example, while fluid–structure interaction analyses are still scarcely utilized to study aortic valves, computational fluid dynamics is used to assess the effect of different aortic valve morphologies on velocity profiles, flow patterns, helicity, wall shear stress, and oscillatory shear index in the thoracic aorta. It has been analyzed that computational flow dynamic analyses can be integrated with other methods to create a superior, more compatible method of understanding risk and compatibility.     

The Impact of Mitral Stenosis on Left Atrial Function Assessed by Two‐Dimensional Speckle Tracking Echocardiography

Aims: The aim of this study is to investigate the effect of mitral stenosis (MS) on left atrial (LA) function using two‐dimensional speckle tracking echocardiography (2DSTE). Methods and Results: The study subjects consisted of 52 patients with asymptomatic MS and 52 control subjects. LA function was assessed using prototype speckle tracking software and manual tracking method. Maximal LA volume (LAVmax) and minimal LA volume (LAVmin) and LA volume before atrial contraction (LAVpre‐a) were measured. Using these volumes, LA reservoir, conduit and booster pump fuction parameters were calculated. Indexed LAVmax, LAVmin, and LAVpre‐a measurements via speckle tracking were highly correlated with manual tracing methods in both groups. Expansion index (67.8 ± 36.4 vs. 148.3 ± 44.2), diastolic emptying index (37.7 ± 12.9 vs. 58.0 ± 8.5), passive emptying (37.3 ± 14.1 vs. 70.4 ± 10.4) and passive emptying index (13.3 ± 6.3 vs. 41.3 ± 10.6) were decreased significantly in MS patients (P < 0.001). In contrast active emptying index (62.6 ± 4.1 vs. 29.5 ± 10.1) increased in MS group (P < 0.001) while active emptying (28.1 ± 13.0 vs. 28.3 ± 6.9) remained same among both groups. Conclusions: This is the first study relating LA volumes and function assessed by 2DSTE to MS. 2D speckle tracking analysis of LA volume is relatively easy and provides more detailed information regarding the changes in LA volumes during the cardiac cycle.     

The valve patient and pregnancy

Pregnancy causes a significant and sustained increase in cardiac output that may be poorly tolerated in cases of underlying heart disease. Valvular stenosis is often poorly tolerated and may require intervention during pregnancy, percutaneous intervention being the favored option. Conversely, regurgitant valve diseases are generally well-tolerated. Pregnancy in patients who have previously undergone prosthetic valve replacement raises specific problems linked to anticoagulant therapy. The choice is difficult between oral anticoagulation, which carries a risk of embryopathy, and heparin therapy, which is safer for the fetus but is associated with a high thromboembolic risk for the mother. The diversity of cases highlights the need for appropriate evaluation of heart disease before pregnancy and close follow-up by specialized teams.     

Assessment of mitral valve commissural morphology by transoesophageal echocardiography predicts outcome after balloon mitral valvotomy

BackgroundBalloon mitral valvotomy (BMV) is a safe and an effective treatment in patients with symptomatic rheumatic mitral stenosis. This study was conducted to validate the importance of assessing the morphology of mitral valve commissures by transoesophageal echocardiography and thereby predicting the outcome after balloon mitral valvotomy [BMV].Materials and methodsStudy consisted of 100 patients with symptomatic mitral stenosis undergoing BMV. The Commissural Morphology and Wilkins score were assessed by transoesophageal echocardiography. Both the commissures (anterolateral and posteromedial) were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2) and calcification (score 0) and combined giving an overall commissural score of 0–4. Outcome of BMV was correlated with commissural score and Wilkins score.ResultsThe commissural score and outcome after BMV correlated significantly. 66 of 70 patients (94%) with a commissural score of 3–4 obtained a good outcome compared with only six (20%) patients of 30 with a commissural score of 0–2 (positive and negative predictive accuracy 94% and 80%, respectively, p < 0.001). Increase in 2DMVA post BMV was more in patients with higher commissural score (score of 3–4). Wilkins score <8 usually predicts a good outcome but even in patients with Wilkins score >8 a commissural score >2 predicts a 50% chance of a good result.ConclusionsA higher commissural score predicts a good outcome after BMV hence it can be concluded that along with Wilkins score, commissural morphology and score should be assessed with TOE in patients undergoing BMV.     

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

Measurement of the mean pressure gradient provides an importantestimation of the severity of mitral stenosis. However, determinationof the mean pressure gradient from Doppler recordings has beenunsatisfactory using previously described methods. In this study,a new method for calculating the mean pressure gradient, theintegral method is described. It was developed from mathematicalanalysis of Doppler velocity curves. Doppler echocardiographyand cardiac catheterisation were performed in 23 patients withmitral stenosis to evaluate the accuracy of three current mathematicalmethods of determining the mean pressure gradient. The meanpressure gradients calculated by the three methods correlatedhighly with that measured by catheterisation (r=0.93). However,the mean pressure gradients calculated by the previously describedmean velocity square method and the arithmetical average methodunderestimated significantly that measured by cardiac catheterisation.In contrast, there was no significant difference between themean pressure gradients calculated by the integral method andmeasured by cardiac catheterisation. These results confirm theusefulness of Doppler echocardiography for determining the meanpressure gradient in mitral stenosis and demonstrate that amongcurrent methods, the integral method provides the most accuratecalculations of the mean pressure gradient.     

Ruptured mitral chordae tendineae may be a frequent and insignificant complication in the mitral valve prolapse syndrome

In this study, we performed 512 echocardiographic studies on264 consecutive, unselected patients with the idiopathic mitralvalve prolapse syndrome. Twenty-eight patients (10.6%) had evidenceof ruptured chordae tendineae of the mitral valve on M-modeexamination and in 24 the diagnosis was confirmed by two-dimensionalechocardiography. Mild to severe mitral insufficiency was provenin all of them by left ventriculography during cardiac catheterization.Eight patients underwent surgery to relieve symptomatic severemitral regurgitation. At operation all had myxomatous degenerationof the mitral valve, two patients were found to have ruptureof anterior mitral chordae, and six had rupture of posteriormitral chordae. Twenty (71%) patients with chordal rupture hadeither mild symptoms or were completely asymptomatic. It isconcluded that chordal rupture in patients with the mitral valveprolapse syndrome may be present in asymptomatic patients andgo undetected clinically in a substantial number of patientsunless a high index of suspicion is maintained. Serial M-modeand two-dimensional echocardiographic studies are of importancein identifying the progression of prolapse findings and mayreveal the natural history of this pathologic condition in asymptomaticpatients.     

超声心动图在二尖瓣球囊成形中的应用价值

目的：应用超声心动图检查方法估价二尖瓣球囊成形术的疗效。材料和方法：选择１９９１０１～１９９５０４，２５例风湿性二尖瓣狭窄拟行二尖瓣球囊扩张患者于术前４８小时，术后立即及５～７天，部分患者于术后３个月，６个月及１年进行超声心动图随访观察。结果：二尖瓣球囊扩张后检查二尖瓣口面积由术前０８５±０２０ｃｍ扩大至１６９±０３０ｃｍ；瓣下最大血流速度（Ｖｍａｘ）由（２３５±０３９）ｍ／ｓ降至（１６０±０３３）ｍ／ｓ；ＰＧｍａｘ及ＰＧｍｅａｎ分别由术前（２９±１０）ｋＰａ及（１８±０８）ｋＰａ降至（１４±０５）ｋＰａ及（０６±０３）ｋＰａ。本组术后房间隔穿刺部位缺口以４～６ｍｍ多见，２３例（９２％）出现房水平左向右分流，２例１年检查仍存在分流。术后再狭窄最早出现时间为３个月３例（３／１７），６个月１例（１／１１）。结论：本组２５例二尖瓣球囊成形患者均获得成功，其效果满意。超声心动图可用于评价二尖瓣球囊成形术的效果并可及时检出其并发症。     

Balloon-occluded retrograde transvenous obliteration performed in a pediatric patient with isolated gastric fundal varices

Background

For giant gastric varices in association with portal hypertension, endoscopic treatment often is difficult. Although balloon-occluded retrograde transvenous obliteration (B-RTO) has been performed successfully in adult cirrhotic patients, there has been no report in pediatric patients.

Methods

A 10-year-old girl with biliary atresia (BA) who had been free of jaundice after hepatic portoenterostomy was detected to have isolated gastric fundal varices by routine endoscopy. They gradually enlarged up to 4 cm in diameter, showing a tense appearance, so prophylactic treatment was conducted. Magnetic resonance angiography showed the blood flow of the varices mainly drained by a large gastrorenal shunt. A balloon catheter was introduced into the gastrorenal shunt via the femoral vein and was inflated to occlude the outflow of the varices. Five percent ethanolamine oleate was injected into the varices, and the outflow occlusion was kept for more than 30 minutes. Extensive thrombosis was achieved by an additional embolotherapy after 17 months. Throughout the course, the patient has been doing well without bleeding or worsening of the liver function tests.

Conclusions

B-RTO for isolated gastric fundal varices has been performed safely in a pediatric patient and seems effective in reducing the variceal size and tension.