Preoperative Cardiac Computed Tomography Characteristics Associated with Recurrent Aortic Regurgitation after Aortic Valve Re-Implantation

24 mm² (sensitivity, 76.5%; specificity 64.8%), and the area under the ROC curve (AUC) was 0.72. For ASR(area), the cut-off value was > 1.58 (sensitivity, 76.5%; specificity, 58.0%) and the AUC was 0.64. Multivariable Cox regression showed that ARO > 24 mm² (hazard ratio = 3.79, p = 0.020) was a potential independent parameter for recurrent 3 + AR. ROC for the linear regression model showed that the AUC for both ARO and ASR(area) was 0.73 (95% confidence interval, 0.64–0.81, p < 0.001).CONCLUSION: ARO and ASR(area) detected on preoperative cardiac CT would be potentially helpful for identifying AR patients who may benefit from the David operation.

Variable Hemodynamic Responses during Diastolic Stress Echocardiography in Patients Who Have Relaxation Abnormality with Possible Elevated Filling Pressure

BACKGROUND AND OBJECTIVES: The clinical characteristics of patients with diastolic dysfunction characterized by a relaxation abnormality with possible elevated filling pressure is remain to be determined. We sought to test whether diastolic stress echocardiography (DSE) is useful for characterization of these patients. METHODS: A total of 120 patients (58 men, mean age of 64±7 years) with E/A ratio 15, hLVFP) and 40 (30%) developed exercise-induced pulmonary hypertension (systolic pulomary arterial pressure > 50 mmHg, EiPH) without hLVFP. The remaining 33 patients did not show hLVFP or EiPH. The incidence of EiPH with hLVFP was 21% (25/120). By multivariate analysis, age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.00–1.13; p=0.039) and systolic pulmonary artery pressure at rest (OR, 1.14; 95% CI, 1.02–1.27; p=0.02) were associated with EiPH, whereas late diastolic transmitral velocity (OR, 1.04; 95% CI, 1.00–1.08; p=0.03) and diastolic blood pressure (OR, 0.94; 95% CI, 0.90–0.99; p=0.02) were associated with hLVFP during exercise. CONCLUSIONS: Patients with relaxation abnormality and possibly hLVFP showed markedly heterogeneous hemodynamic changes during low-level exercise and DSE was useful to characterize these patients.

Clinical Characteristics of Korean Patients with Bicuspid Aortic Valve Who Underwent Aortic Valve Surgery

BACKGROUND AND OBJECTIVES: Clinical data for Korean patients with bicuspid aortic valve (BAV) that underwent aortic valve (AV) surgery are currently limited. METHODS: Data for 1,160 consecutive adult BAV patients who underwent AV surgery from 2000 to 2014 in 4 tertiary referral centers were retrospectively analyzed. A standard case report form was used for clinical and echocardiographic parameters. RESULTS: Mean age at the time of AV surgery was 59±13 years. The most common cause of AV surgery was aortic stenosis (AS, 892 [77%]), followed by aortic regurgitation (AR, 199 [17%]), and infective endocarditis (69 [6%]). AS showed a skewed peak in the aged population and was the predominant cause of AV surgery (87%) in patients ≥50 years of age, whereas AR (46%) and active infective endocarditis (19%) were more common in younger patients (p < 0.001). Echocardiographic determination of the BAV phenotype revealed that fusion of the right coronary cusp (RCC) and left coronary cusp (LCC) was most common (622 [53%]), followed by fusion of RCC and non-coronary cusp (NCC) (313 [27%]), and fusion of LCC and NCC (42 [4%]); the BAV phenotype could not be determined in the remaining 183 patients (16%). Fusion of RCC and LCC was more commonly observed in patients with AR than in those with AS (74% vs. 49%; p < 0.001). CONCLUSION: BAV patients were characterized by distinct surgical indications according to their age. Possible associations between BAV phenotypes and surgical indications with potential impacts of ethnicity need to be tested in further studies.

Clinical Characteristics of Korean Patients with Bicuspid Aortic Valve Who Underwent Aortic Valve Surgery

BACKGROUND AND OBJECTIVES@#Clinical data for Korean patients with bicuspid aortic valve (BAV) that underwent aortic valve (AV) surgery are currently limited.@*METHODS@#Data for 1,160 consecutive adult BAV patients who underwent AV surgery from 2000 to 2014 in 4 tertiary referral centers were retrospectively analyzed. A standard case report form was used for clinical and echocardiographic parameters.@*RESULTS@#Mean age at the time of AV surgery was 59±13 years. The most common cause of AV surgery was aortic stenosis (AS, 892 [77%]), followed by aortic regurgitation (AR, 199 [17%]), and infective endocarditis (69 [6%]). AS showed a skewed peak in the aged population and was the predominant cause of AV surgery (87%) in patients ≥50 years of age, whereas AR (46%) and active infective endocarditis (19%) were more common in younger patients (p < 0.001). Echocardiographic determination of the BAV phenotype revealed that fusion of the right coronary cusp (RCC) and left coronary cusp (LCC) was most common (622 [53%]), followed by fusion of RCC and non-coronary cusp (NCC) (313 [27%]), and fusion of LCC and NCC (42 [4%]); the BAV phenotype could not be determined in the remaining 183 patients (16%). Fusion of RCC and LCC was more commonly observed in patients with AR than in those with AS (74% vs. 49%; p < 0.001).@*CONCLUSION@#BAV patients were characterized by distinct surgical indications according to their age. Possible associations between BAV phenotypes and surgical indications with potential impacts of ethnicity need to be tested in further studies.

Variable Hemodynamic Responses during Diastolic Stress Echocardiography in Patients Who Have Relaxation Abnormality with Possible Elevated Filling Pressure

BACKGROUND AND OBJECTIVES@#The clinical characteristics of patients with diastolic dysfunction characterized by a relaxation abnormality with possible elevated filling pressure is remain to be determined. We sought to test whether diastolic stress echocardiography (DSE) is useful for characterization of these patients.@*METHODS@#A total of 120 patients (58 men, mean age of 64±7 years) with E/A ratio 15, hLVFP) and 40 (30%) developed exercise-induced pulmonary hypertension (systolic pulomary arterial pressure > 50 mmHg, EiPH) without hLVFP. The remaining 33 patients did not show hLVFP or EiPH. The incidence of EiPH with hLVFP was 21% (25/120). By multivariate analysis, age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.00–1.13; p=0.039) and systolic pulmonary artery pressure at rest (OR, 1.14; 95% CI, 1.02–1.27; p=0.02) were associated with EiPH, whereas late diastolic transmitral velocity (OR, 1.04; 95% CI, 1.00–1.08; p=0.03) and diastolic blood pressure (OR, 0.94; 95% CI, 0.90–0.99; p=0.02) were associated with hLVFP during exercise.@*CONCLUSIONS@#Patients with relaxation abnormality and possibly hLVFP showed markedly heterogeneous hemodynamic changes during low-level exercise and DSE was useful to characterize these patients.

Impact of a Geometric Correction for Proximal Flow Constraint on the Assessment of Mitral Regurgitation Severity Using the Proximal Flow Convergence Method

BACKGROUND: Overestimation of the severity of mitral regurgitation (MR) by the proximal isovelocity surface area (PISA) method has been reported. We sought to test whether angle correction (AC) of the constrained flow field is helpful to eliminate overestimation in patients with eccentric MR. METHODS: In a total of 33 patients with MR due to prolapse or flail mitral valve, both echocardiography and cardiac magnetic resonance image (CMR) were performed to calculate regurgitant volume (RV). In addition to RV by conventional PISA (RV(PISA)), convergence angle (α) was measured from 2-dimensional Doppler color flow maps and RV was corrected by multiplying by α/180 (RV(AC)). RV measured by CMR (RV(CMR)) was used as a gold standard, which was calculated by the difference between total stroke volume measured by planimetry of the short axis slices and aortic stroke volume by phase-contrast image. RESULTS: The correlation between RV(CMR) and RV by echocardiography was modest [RV(CMR) vs. RV(PISA) (r = 0.712, p < 0.001) and RV(CMR) vs. RV(AC) (r = 0.766, p < 0.001)]. However, RV(PISA) showed significant overestimation (RV(PISA) - RV(CMR) = 50.6 ± 40.6 mL vs. RV(AC) - RV(CMR) = 7.7 ± 23.4 mL, p < 0.001). The overall accuracy of RV(PISA) for diagnosis of severe MR, defined as RV ≥ 60 mL, was 57.6% (19/33), whereas it increased to 84.8% (28/33) by using RV(AC) (p = 0.028). CONCLUSION: Conventional PISA method tends to provide falsely large RV in patients with eccentric MR and a simple geometric AC of the proximal constraint flow largely eliminates overestimation.

Long-Term Results of Early Surgery versus Conventional Treatment for Infective Endocarditis Trial

BACKGROUND AND OBJECTIVES: Compared with conventional treatment, early surgery significantly reduced the composite end point of all-cause death and embolic events during hospitalization, but long-term data in this area are lacking. This study sought to compare long-term outcomes of early surgery with a conventional treatment strategy in patients with infective endocarditis (IE) and large vegetations. SUBJECTS AND METHODS: The Early Surgery versus Conventional Treatment in Infective Endocarditis (EASE) trial randomly assigned patients with left-sided IE, severe valve disease and large vegetation to early surgery (37 patients) or conventional treatment groups (39 patients). The pre-specified end points were all-cause death, embolic events, recurrence of IE and repeat hospitalizations due to the development of congestive heart failure occurring during follow-up. RESULTS: There were no significant differences between the early surgery and the conventional treatment group in all-cause mortality at 4 years (8.1% and 7.7%, respectively; hazard ratio [HR] 1.04; 95% CI, 0.21 to 5.15; p=0.96). The rate of the composite end point of death from any cause, embolic events or recurrence of IE at 4 years was 8.1% in the early surgery group and 30.8% in the conventional treatment group (HR, 0.22; 95% CI, 0.06-0.78; p=0.02). The estimated actuarial rate of end points at 7 years was significantly lower in the early surgery group than in the conventional treatment group (log-rank p=0.007). CONCLUSION: There was a substantial benefit in having early surgery for patients with IE and large vegetations whose health was sustained up to 7 years, and late clinical outcome after surgery was excellent in survivors of IE. (EASE clinicaltrials.gov identifier: NCT00750373)

Subclinical Coronary Artery Disease as Detected by Coronary Computed Tomography Angiography in an Asymptomatic Population

BACKGROUND AND OBJECTIVES: Primary prevention of coronary artery disease (CAD) has become a public health issue, according to increasing awareness of the substantial risks posed by asymptomatic atherosclerosis. The aims of this study were to determine the prevalence and characteristics of subclinical CAD using coronary computed tomography angiography (CCTA), and to evaluate the role of this advanced technology in identifying subclinical CAD in asymptomatic Korean individuals, compared with conventional risk stratification. SUBJECTS AND METHODS: We enrolled 4,320 consecutive asymptomatic individuals (61% males, aged 50+/-9 years), who underwent 64-slice CCTA during a routine health check. RESULTS: Coronary artery plaques were present in 1,053 (24%) individuals. Significant stenosis (diameter stenosis > or =50%) was identified in 139 (3%) subjects, and most of the significant lesions (87%) were located in the left anterior descending artery. CCTA revealed noncalcified plaques in 5% of subjects with a coronary calcium score of zero (n=801). Although 25% (n=10) of those with noncalcified plaque had significant stenosis, most of them (90%) were classified into low- or moderate-risk groups according to National Cholesterol Education Program risk stratification guidelines. In a young population (age < or =55 years for males, < or =65 years for females), 30% of subjects with significant stenosis were classified into a low-risk group and 60% had low (0 to 100) calcium scores. CONCLUSION: Subclinical CAD in asymptomatic individuals cannot be ignored for its considerable prevalence, CCTA may be helpful in identifying at-risk subclinical CAD in a noninvasive manner, especially in the young and traditionally low-risk population.

Clinical Significance and Outcomes of Initial No Growth Peritonitis from Peritoneal Dialysis Patients: Role of Mycobacterial or Fungal Peritonitis / 대한신장학회지

PURPOSE: Peritoneal dialysis associated peritonitis (PD peritonitis) is an important complication in maintaining. There have been only a few reports on the clinical outcome of initial no-growth peritonitis (INGP). METHODS: We reviewed 332 episodes of PD peritonitis between January 2002 and August 2009. INGP was defined as PD peritonitis with no growth of etiologic microorganism within 3 days of peritonitis. INGP was compared with initial positive growth peritonitis (IPGP) in view of clinical manifestations and outcomes. RESULTS: We divided PD peritonitis episodes into two groups: INGP (n=90) and IPGP (n=242). Peritonitis-related mortality was 5.6% in INGP, while 0.8% in IPGP (p=0.017). Further relapse was noted in INGP (10.0%) than in IPGP (vs. 4.1%; p=0.041). Salvage antibiotics were used more frequently in INGP (21.1%) than in IPGP (vs. 11.6%; p=0.027). Odds ratio of INGP to IPGP for peritonitis-related mortality was 7.14 (95% CI 1.36-37.51; p=0.017). Growth of mycobacteria or fungi increased the risk of peritonitis-related mortality with an odds ratio of 18.11 (95% CI 2.99-109.89; p=0.013). In multivariate analysis, growth of mycobacteria or fungi was the only independent risk factor for peritonitis-related mortality with an odds ratio of 10.63 (95% CI 1.27-88.75; p=0.029). CONCLUSION: INGP revealed poorer outcome than IPGP. Higher growth rate of mycobacteria or fungi in INGP than in IPGP accounted for the poor outcome. Thus one should make vigorous efforts to detect surreptitious organism when there is no growth by 3 days, especially for the possibility of either mycobacteria or fungi.