Correlation between mitral regurgitation and myocardial mechanical dyssynchrony and QRS duration in patients with cardiomyopathy

Several competing geometric and hemodynamic factors are suggested as contributing mechanisms for functional mitral regurgitation [MR] in heart failure patients. We aimed to study the relationships between the severity of MR and the QRS duration and dyssynchrony markers in patients with ischemic or dilated cardiomyopathy. We prospectively evaluated 251 heart failure patients with indications for echocardiographic evaluation of possible cardiac resynchronization therapy. All the patients were subjected to transthoracic echocardiography and tissue Doppler imaging to evaluate the left ventricular [LV] synchronicity. The patients were divided into two groups according to the severity of MR: /= moderate MR. The effects of different dyssynchrony indices were adjusted for global and regional left ventricular remodeling parameters. From the 251 patients [74.5% male, mean age = 53.38 +/- 16.68 years], 130 had /= moderate MR. There were no differences between the groups regarding the mean age, frequency of sex, and etiology of cardiomyopathy. The LV systolic and diastolic dimensions were greater in the patients with >/= moderate MR [all p values < 0.001]. Among the different echocardiographic factors, the QRS duration [150.75 +/- 34.66 vs. 126.77 +/- 29.044 ms; p value = 0.050] and interventricular mechanical delay [41.60 +/- 29.50 vs. 35.00 ms +/- 22.01; p value = 0.045] were significantly longer in the patients with

Doppler tissue imaging: a non-invasive technique for estimation of left ventricular end diastolic pressure in severe mitral regurgitation

Conventional Doppler measurements, including mitral inflow and pulmonary venous flow, are used to estimate left ventricular end diastolic pressure [LVEDP]. However, these parameters have limitations in predicting LVEDP among patients with mitral regurgitation. This study sought to establish whether the correlation between measurements derived from tissue Doppler echocardiography and LVEDP remains valid in the setting of severe mitral regurgitation. Thirty patients [mean age: 57.37 +/- 13.29 years] with severe mitral regurgitation and a mean left ventricular ejection fraction [EF] of 46.0 +/- 14.95 were enrolled; 16 [53.4%] patients were defined to have EF < 50% and 14 [46.6%] patients had EF >/= 50%. Doppler signals from the mitral inflow, pulmonary venous flow, and Doppler tissue imaging indices were obtained, and LVEDP was measured invasively through cardiac catheterization. The majority of the standard Doppler and Doppler tissue imaging indices were not significantly correlated with LVEDP in the univariate analysis. In the multiple linear regression, however, early [E] transmitral velocity to annular E' [E/E'] ratio [beta=1.09, p value < 0.01], E wave velocity to propagation velocity [E/Vp] ratio [beta=7.87, p value < 0.01], and isovolumic relaxation time [beta=0.21, p value=0.01] were shown as independent predictors of LVEDP [R[2]=91.7%]. The ratio of E/Vp and E/E' ratio and also the isovolumic relaxation time could be applied properly to estimate LVEDP in mitral regurgitation patients even in the setting of severe mitral regurgitation

Tricuspid regurgitation improvement in relation to the amount of pulmonary artery pressure reduction

Given the common concomitance of tricuspid regurgitation [TR] with significant mitral stenosis, we aimed at exploring the relation between TR severity and pulmonary artery hypertension [PAH] in patients who underwent mitral balloon valvotomy [MBV]. We analyzed the echocardiography data of 133 consecutive patients [82.0% female, mean age 44.68 +/- 12.56 years] with different degrees of TR severity that underwent MBV between April 2006 and March 2008. The pulmonary artery systolic pressure [PAPs] > 35 mmHg was considered as PAH. Before MBV, 36.20% of the patients had moderate to severe TR, 92.5% PAH, and 18.0% right ventricular [RV] dilation [RV dimension >/= 33 mm]. After MBV, TR severity improved in 41.4%, worsened in 8.3%, and did not change in 50.4%. Before and after MBV, PAPs was significantly correlated with TR severity, and the mean PAPs change in patients with improved TR was significantly more than that of patients without TR improvement [p value=0.042]. Tricuspid regurgitation severity and mean PAPs [from 52.83 +/- 18.82 to 35.89 +/- 9.39 mmHg] decreased significantly after MBV [both p values < 0.001]; this reduction was significantly correlated to the amount of PAPs decrease. A cut-off point of >/= 19 mmHg reduction in PAPs had a specificity of 71.79% and sensitivity of 52.73% to show TR severity improvement [by Receiver-Operative-Characteristics analysis]. The mean of RV dimension decreased from 28.94 +/- 5.43 to 27.95 +/- 4.67 mm [p value < 0.001]. In contrast to patients with RV dilation, TR reduced significantly in patients without RV dilation [p value < 0.001]. Improvement in TR severity was directly correlated with the amount of PAPs reduction after MBV. More studies are needed to better define a cut-off value for PAPs reduction related to TR severity improvement

Measurement of atrial septal defect size: a comparative study between transesophageal echocardiography and balloon occlusive diameter method

Transcatheter closure of atrial septal defect secundum [ASD-II] has become an alternative method for surgery. We sought to compare the two-dimensional transesophageal echocardiography [TEE] method for measuring atrial septal defect with balloon occlusive diameter [BOD] in transcatheter ASD-II closure. A total of 39 patients [71.1% female, mean age: 35.31 +/- 15.37 years] who underwent successful transcatheter closure of ASD-II between November 2005 and July 2008 were enrolled in this study. Transthoracic echocardiography [TTE] and TEE were performed to select suitable cases for device closure and measure the defect size before the procedure, and BOD measurement was performed during catheterization via TEE. The final size of the selected device was usually either equal to or 1-2 mm larger than the BOD of the defect. The mean defect size obtained by TEE and BOD was 18.50 +/- 5.08 mm and 22.86 +/- 4.76 mm, respectively. The mean difference between the values of ASD size obtained by TEE and BOD was 4.36 +/- 2.93 mm. In comparison with BOD, TEE underestimated the defect size in 94.9%, but TEE value being equal to BOD was observed in 5.1%. There was a good linear correlation between the two measurements: BOD=0.773 ASD size by TEE+8.562; r2=67.9.1%. A negative correlation was found between TEE sizing and the difference between BOD and TEE values [r=-0.394, p value=0.013]. In this study, BOD was larger than ASD size obtained by two-dimensional TEE. However, TEE maximal defect sizing correlates with BOD and may provide credible information in device size selection for transcatheter ASD closure

Impact of isolated coronary artery bypass grafting on non-organic tricuspid regurgitation severity

Moderate non-organic tricuspid regurgitation [TR] concomitant with coronary artery disease is not uncommon, Whether or not TR improves after pure coronary artery bypass grafting [CABG], however, is unclear. The aim of this study was to evaluate the effect of isolated CABG on moderate non-organic TR. This study recruited 50 patients [40% female, mean age: 65.38 +/- 8.01 years, mean left ventricular ejection fraction [LVEF]: 45.74 +/- 13.05%] with moderate non-organic TR who underwent isolated CABG. TR severity before and after CABG was compared. Pulmonary arterial systolic pressure [PAPs] > 30mmHg and LVEF < 50% were considered elevated PAPs [EPAPs] and LV systolic dysfunction, respectively. Presence of Q-wave in leads II, III, and aVF was considered inferior myocardial infarction [inf. MI]. Pre-operatively, 81.5% of the patients had EPAPs, 16% right ventricle [RV] dilation, and 50% left ventricle [LV] and 16% RV systolic dysfunction. TR severity improved in 64% after CABG, whereas it remained unchanged or even worsened in others [P value < 0.001]. Patients with inf. MI showed no improvement in TR, while patients without inf. MI had significant TR regression after CABG [P value= 0.050]. Improvement of TR severity after CABG was not related to pre-operative RV size and function, LV systolic function, or PAPs reduction. Although TR severity decreased remarkably after isolated CABG, a considerable number of the patients had no TR regression. In addition, only absence of inf. MI was significantly correlated to TR improvement after CABG. Further prospective studies with long-term follow-up needed to determine the other factors predicting TR regression after isolated CABG

Transesophageal echocardiographic characteristics of secundum-type atrial-septal defect in adult patients

Given the dearth of data in the existing literature on the size and morphologic variability of secundum-type atrial-septal defect [ASD-II] in adult patients, we aimed to address this issue in a series of consecutive adult patients evaluated by transesophagesal echocardiography [TEE]. A total of 50 patients [68.0% female] with isolated ASD-II underwent TEE for the evaluation of the defect. The morphological characteristics of eh defect were evaluated, and the largest defect size was measured. The ASD rim was divided into 6 sectors: the superior-anterior, superior-posterior; superior, inferior-anterior, inferior-posterior, and inferior. The minimal length of the defect rims was determined. Mean age at the time of evaluation was 33.62 +/- 14.48 years. Mean defect diameter in the all the study patients was 20.80 +/- 8.17 mm. Thirteenmorphological variations were detected. Deficiency of one rim was detected in 14 [28%] patients, two in 16 [32%], three in 2 [4%], and four in 2 [4%]. Deficiency of the superior anterior rim was found din 24% of the patients [gamma= 0.558, P value < 0.001]. Forty-eight [96%] patients emerged for defect closure: 22 [46.2%] suitable for percutaneous closure and 26 [53.8%] for surgical closure. Two patients with small defects were recommended for medical treatment and follow-up. ASD-II is larger and more morphologically variable in adults than in children. Based on the findings of the present and previous studies and given the advantages of percutaneous treatment, it is advisable to make a decision on ASD-II closure as soon as possible before it outgrows the transcatheter closure suitability criteria