Função atrial esquerda pelo método de speckle tracking: além da avaliação volumétrica / Left atrial function using speckle tracking: beyond volumetric evaluation

Atualmente, a avaliação da função atrial esquerda é um método emergente que pode ter relação com o prognóstico dos pacientes. Classicamente, as medidas estáticas de diâmetro, área e volume são as mais usadas com esta finalidade. A técnica conhecida como speckle tracking é capaz de fornecer informações dinâmicas do átrio esquerdo ao longo do ciclo cardíaco, assim como detectar alterações na função atrial esquerda em fases subclínicas, antes de ocorrerem aumentos volumétricos ou disfunções diastólicas. Valores de normalidade para o speckle tracking estão sendo propostos, mas as diferenças metodológicas e de técnicas empregadas dificultam sua padronização. Esta revisão da literatura se propõe a discutir os avanços na análise da função atrial esquerda, em especial via speckle tracking

Atrial Strain and Strain Rate: A Novel Method for the Evaluation of Atrial Stunning / Strain Atrial e Strain Rate: Novo Método para Avaliar Atordoamento Atrial

Abstract Background: Atrial fibrillation (AF) is the most common arrhythmia seen in adults. Atrial stunning is defined as the temporary mechanical dysfunction of the atrial appendage developing after AF has returned to sinus rhythm (SR). Objectives: We aimed to evaluate atrial contractile functions by strain and strain rate in patients with AF, following pharmacological and electrical cardioversion and to compare it with conventional methods. Methods: This study included 41 patients with persistent AF and 35 age-matched control cases with SR. All the AF patients included in the study had transthoracic and transesophageal echocardiography performed before and after. Septum (SEPsSR), left atrium (LAsSR) and right atrium peak systolic strain rate (RAsSR) were defined as the maximum negative value during atrial contraction and septum (SEPε), left atrium (LAε) and right atrium peak systolic strain (RAε) was defined as the percentage of change. Parameters of two groups were compared. Results: In the AF group, 1st hour and 24th hour LAε, RAε, SEPε, LAsSR, RAsSR, SEPsSR found to be significantly lower than in the control group (LAε: 2.61%±0.13, 3.06%±0.19 vs 6.45%±0.27, p<0.0001; RAε: 4.03%±0.38, 4.50%±0.47 vs 10.12%±0.64, p<0.0001; SEPε: 3.0%±0.22, 3.19%±0.15 vs 6.23%±0.49, p<0.0001; LAsSR: 0.61±0.04s-1, 0.75±0.04s- 1 vs 1.35±0.04s-1, p<0.0001; RAsSR: 1.13±0.06s-1, 1.23±0.07s-1 vs 2.10±0.08s- 1, p<0.0001; SEPsSR: 0.76±0.04s- 1, 0.78±0.04s- 1 vs 1.42±0.06 s- 1, p<0.0001). Conclusion: Atrial strain and strain rate parameters are superior to conventional echocardiographic parameters for the evaluation of atrial stunning in AF cases where SR has been achieved.

Resumo Fundamento: A fibrilação atrial (FA) é a arritmia mais comum em adultos. Define-se atordoamento atrial como a disfunção mecânica temporária do apêndice atrial que se desenvolve depois de reversão da FA ao ritmo sinusal (RS). Objetivos: Avaliar as funções atriais contráteis através de strain atrial e strain rate em pacientes com FA, após cardioversão farmacológica e elétrica, assim como compará-los com os métodos convencionais. Métodos: Este estudo incluiu 41 pacientes com FA persistente e 35 controles com RS e pareados por idade. Todos os pacientes com FA incluídos neste estudo foram submetidos a ecocardiografia transtorácica e transesofágica antes e após. Strain rates de pico sistólico do septo (SEPsSR), do átrio esquerdo (LAsSR) e do átrio direito (RAsSR) foram definidas como o máximo valor negativo durante contração atrial. Strains de pico sistólico do septo (SEPε), do átrio esquerdo (LAε) e do átrio direito (RAε) foram definidas como porcentagem de mudança. Resultados: No grupo com FA, os parâmetros LAε, RAε, SEPε, LAsSR, RAsSR e SEPsSR da 1a hora e da 24a hora foram significativamente mais baixos que no grupo controle (LAε: 2,61%±0,13; 3,06%±0,19 vs 6,45%±0,27; p<0,0001; RAε: 4,03%±0,38; 4,50%±0,47 vs 10,12%±0,64; p<0,0001; SEPε: 3,0%±0,22; 3,19%±0,15 vs 6,23%±0,49; p<0,0001; LAsSR: 0,61±0,04s-1; 0,75±0,04s-1 vs 1,35±0,04s-1; p<0,0001; RAsSR: 1,13±0,06s-1; 1,23±0,07s-1 vs 2,10±0,08s-1; p<0,0001; SEPsSR: 0,76±0,04s-1; 0,78±0,04s-1 vs 1,42±0,06 s-1; p<0,0001). Conclusão: Os parâmetros strain atrial e strain rate são superiores aos parâmetros ecocardiográficos convencionais para avaliar atordoamento atrial em pacientes com FA que reverteram ao RS.

Biological significance of miR-126 expression in atrial fibrillation and heart failure

We investigated the biological significance of microRNA-126 (miR-126) expression in patients with atrial fibrillation (AF) and/or heart failure (HF) to examine the possible mechanism of miR-126-dependent AF and development of HF. A total of 103 patients were divided into three groups: AF group (18 men and 17 women, mean age: 65.62±12.72 years), HF group (17 men and 15 women, mean age: 63.95±19.71 years), and HF-AF group (20 men and 16 women, mean age: 66.56±14.37 years). Quantitative real-time PCR was used to measure relative miR-126 expression as calculated by the 2−ΔΔCt method. miR-126 was frequently downregulated in the 3 patient groups compared with controls. This reduction was significantly lower in permanent and persistent AF patients than in those with paroxysmal AF (P<0.05, t-test). Moreover, miR-126 expression was markedly lower in the HF-AF group compared with the AF and HF groups. The 3 patient groups had higher N-terminal prohormone brain natriuretic peptide (NT-proBNP) levels, lower left ventricular ejection fraction (LVEF), larger left atrial diameter, and higher cardiothoracic ratio compared with controls. There were significant differences in NT-proBNP levels and LVEF among the AF, HF, and HF-AF groups. Pearson correlation analysis showed that relative miR-126 expression was positively associated with LVEF, logarithm of NT-proBNP, left atrial diameter, cardiothoracic ratio, and age in HF-AF patients. Multiple linear regression analysis showed that miR-126 expression was positively correlated with LVEF, but negatively correlated with the logarithm of NT-pro BNP and the cardiothoracic ratio (all P<0.05). Serum miR-126 levels could serve as a potential candidate biomarker for evaluating the severity of AF and HF. However, to confirm these results, future studies with a larger and diverse patient population are necessary.

Avaliação ecocardiográfica de centenários / Echocardiographic Assessment of Centenary Patients

Fundamento: O ecocardiograma é uma ferramenta diagnóstica capaz de detectar diversos parâmetros com potencial de auxiliar o cardiologista na conduta do paciente. O conhecimento desses parâmetros em centenários pode levar ao maior entendimento do processo saúde/doença nessa população.Objetivos: Avaliar os parâmetros ecocardiográficos em centenários, uma vez que não foi encontrado na literaturatrabalho que contemplasse tais dados nesse grupo. Métodos: Foram avaliados por meio de ecocardiograma transtorácico 16 pacientes centenários, com baixo estado de dependência e fragilidade e sem histórico de cardiopatia.Resultados: Diâmetros, áreas, volumes e volumes indexados do átrio esquerdo encontraram-se aumentados em 31,25%, 50%, 68,75% e 87,5% dos pacientes, respectivamente. Os diâmetros diastólicos absolutos e indexados do ventrículo esquerdo acharam-se aumentados em 6,25% e 68,75%, respectivamente. A massa ventricular esquerda absoluta eindexada estava aumentada em 37,5% e 75% dos idosos. Apresentaram padrão de hipertrofia excêntrica 62,5% dos indivíduos. Déficit de contratilidade segmentar ocorreu em 31,25% da amostra. Pressão sistólica em artéria pulmonar acima de 40 mmHg ocorreu em 61,5% dos pacientes. Conclusão: As dimensões aumentadas das câmaras esquerdas e massa ventricular esquerda principalmente quando quantificadas pela superfície corporal apontam para a necessidade de indexação dos valores nesses indivíduos. A presençade déficit segmentar em 31,25% dos pacientes sugere que isquemia silenciosa seja relativamente comum em centenários. Hipertensão pulmonar em 61,5% dos pacientes sem elevação da pressão capilar pulmonar faz suspeitar de doença pulmonar não diagnosticada.

Background: Echocardiography is a diagnostic tool capable of detecting different parameters with the potential to assist the cardiologists inpatients management. Being aware of these parameters in centenary patients may lead to greater understanding of the health/disease process in this population. Objectives: To evaluate echocardiographic parameters in centenary patients, since no study covering such data in that group was found in the literature. Methods: Sixteen centenary patients with low state of dependence and weakness and no history of heart disease were assessed by transthoracic echocardiography.Results: Diameters, areas, volumes and indexed left atrial volumes were found to be increased by 31.25%, 50%, 68.75% and 87.5% of patients, respectively. Absolute and indexed left ventricular diastolic diameters were found to be increased by 6.25% and 68.75%, respectively. Absolute and indexed left ventricular mass was increased by 37.5% and 75% of elderly patients. The study found that 62.5% of individuals presented a pattern of eccentric hypertrophy. Deficit of segmental contractility occurred in 31.25% of the sample. Pulmonary arterial systolic pressure above 40 mm Hg occurred in 61.5% of patients. Conclusion: Increased dimensions of left chambers and left ventricular mass especially when quantified by body surface point out to the need for indexing the values in these individuals. The presence of segmental deficit in 31.25% of patients suggests that silent ischemia is relativelycommon in centenarians. Pulmonary hypertension in 61.5% of patients without elevated pulmonary capillary pressure leads to suspectedundiagnosed lung disease.

Análise da função diastólica e função atrial em ciclistas de alto desempenho por meio da ecocardiografia tridimensional / Analysis of diastolic function and atrial function in high performance cyclists through three-dimensional echocardiography

Objetivos: Avaliar a função diastólica e a função atrial esquerda por meio do estudo com Doppler e ecocardiograma tridimensional em ciclistas de alto desempenho; comparar as variáveis estudadas a controles não esportistas. Métodos: Foram estudados 18 ciclistas profissionais (homens, idade 29, 5±4, 3 anos) e 18 indivíduos controles não esportistas (homens, idade 28, 8±5, 8 anos). Todos os indivíduos foram submetidos a ecocardiograma bidimensional e tridimensional com medidas de variáveis de função diastólica e de esvaziamento atrial como volume atrial esquerdo máximo, mínimo e antes de sua contração. Com base nestes volumes fundamentais foram calculadas a função de esvaziamento ativo, passivo e total, bem como a força de contração atrial. Resultados: Os indivíduos de ambos grupos apresentaram variáveis antropométricas semelhantes. Foi observado no grupo ciclista em relação aos controles: menor velocidade da onda A’ (5,9cm/s ± 2,2 versus 7,6 ± 2,3cm/s, com P=0,03), menor força de contração atrial (4,7 ±1,4Kdyn Vs. 6,2 ± 2,1Kdyn, com P= 0,02) e maior fração de esvaziamento passivo (43,8 ± 12,8% versus 34,8 ± 10,4% com P=0,03). Foi observada correlação linear entre a velocidade da onda A’ e a força de contração atrial no grupo dos ciclistas (r=0,80, P<0,05), entre a força de contração atrial e a fração de esvaziamento passivo (r=-0,88, P<0,05) e entre a força de contração atrial e o volume atrial antes de sua contração (r=0,65, P<0,05). Conclusão: O grupo ciclistas apresentou aumento do componente passivo em detrimento de uma redução do componente ativo no esvaziamento atrial total, o que mostrou estar correlacionado à atividade diastólica supernormal nesse grupo.

Objectives: To assess left ventricular diastolic and atrial function by means of Doppler and three-dimensional echocardiography of high-performance cyclists; To compare the variables studied for non-athlete controls. Methods: The study included 18 professional cyclists (men, age 29, 5±4, 3 years) and 18 non-athlete control individuals (men, age 28, 8±5, 8 years). All individuals underwent two-dimensional and three-dimensional echocardiography including measures of diastolic function variables and atrial emptying, such as maximum, minimum and before contraction left atrial volume. Based on these fundamental volumes, active, passive and total emptying function, and atrial contraction strength were calculated. Results: The individuals of both groups had similar anthropometric variables. The following was observed in the cyclist group as for the controls: lower A’ wave velocity (5.9 cm/s ± 2.2 versus 7.6 ± 2.3 cm/s, with P = 0.03), smaller atrial contraction force (4.7 ± 1,4Kdyn vs. 6.2 ± 2.1Kdyn, P = 0.02) and greater passive emptying fraction (43.8% ± 12.8 versus 34.8 ± 10.4% with P = 0.03). A linear correlation was found between A’ wave velocity and atrial contraction force in the cyclists group (r = 0.65, P <0.05), between atrial contraction force and passive emptying fraction (r = 0.80, P <0.05) and between atrial contraction and volume before contraction (r = 0.65, P < 0.05). Conclusion: The cyclists group showed an increase in the passive component to the detriment of a reduction in the active component in total atrial emptying, which was showed to be correlated with supernormal diastolic activity in this group.

Baixa concordância entre diâmetro e volume do átrio esquerdo em pacientres com maior risco de fibrilação atrial / Low agreement between left atrial diameter and volume in patients with increased risk of atrial fibrillation

Introdução: O aumento do átrio esquerdo (AE) está diretamente relacionado a disfunção diastólica do VE(VD) e ambos estão associados a ocorrência de fibrilação atrial (FA). Embora o diâmetro (DAE) seja mundialmente usado como medida do AE, muitas evidencias mostram que o volume indexado para a superficie corporea (indVAE) é mais acurado. Objetivo: Avaliar a correlação entre DAE e IndVAE em pacientes (pt) com DD. Material e Métodos: Dentre 892 pacientes encaminhados ao ecocardiograma, (ECO) de uma clínica terciaria no DF, entre janeiro de 2008 a junho de 2009, foram selecionados 540 com addos clínicos e ecocardiograficos, dos quais foram excluidos 21, devido a idade < 18 anos e 18 pacientes com lesão valvar mitral > discreta. A função diastólica foi considerada, significativamente, anormal se E/e'>-15 (elevação das pressões de encihmento ventricular esquerdo). A concordância entre as medidas de DAE e IndVAE foi avaliada da seguinte forma concordante (IndVAE<- 40mm ou IndVAE > 40); e discordante (indVAE<- 32 e DAE > 40 ou IndVAE > 32 e DAE <- 40.). Resultados: Dos 501 pacientes estudados, 33 (6,6%) tinham E/e' >- 15 e 468 (93,4%) E/e' < 15. Houve boa correlação entre DAE e IndVAE tanto para pacientes com E/e' >- 15 (r=0,57), quando para pacientes com E/e' < 15 (r=0,62). A discordância entre DAF e IndVAE foi maior nos pacientes...

Background: Increased left atrial (LA) is directly related to LV diastolic dysfunction (DD), and both are associated with atrial fibrillation (AF). Although the diameter (LAD) is used as a measure of LA, many evidences show that LA volume index (iLAV) is more accurate. Objective: To evaluate the correlation between LAD and iLAV in patients (pt) with DD. Material and Methods: Among 892 pt referred to the echocardiography laboratory of a tertiary clinic, from Jan/08 to June/09, 540 pt with clinical and echocardiographic data were selected and 21 were excluded for being <18yo and 18 pt presenting more than mild mitral valve lesion. Diastolic function was considered abnormal when E/e¡¯ ratio ¡Ý 15 (elevated left ventricular filling pressures). Agreement between measures of LAD and iLAV was evaluated: agreement if iLAV ¡Ü 32ml/m2 and LAD ¡Ü 40mm or iLAV > 32 and LAD > 40; and disagreement if iLAV ¡Ü 32 and LAD > 40 or iLAV > 32 and LAD ¡Ü 40. Results: Of 501 pt, 33 (6.6%) presented E/e¡¯ ratio ¡Ý 15 and 468 (93.4%) < 15. There was a good correlation between LAD and iLAV in both patients with E/e¡¯ ¡Ý 15 (r = 0.57), and E/e¡¯ < 15 (r = 0.62). The disagreement between LAD and iLAV was higher in p with E/e¡¯ ¡Ý 15 (21.2% vs 9% - p <0.0001). Clinical and echocardiographic data were, respectively, for E/e¡¯ ¡Ý15 and E/e¡¯ < 15: male 54.5% vs 45.5% (p = ns), age 73.2 ¡À 12.4 vs 50.1 ¡À 16.5 (p <0.0001), LAD (cm) 38.8 ¡À 6.3 vs 35.2 ¡À 5.2 (p <0.0001); iLAV (ml/m2) 35 ¡À 16.2 x 21.9 ¡À 7 (p <0.0001), EF (%) 60.7 ¡À 16.2 vs 70.7 ¡À 6.9 (p <0.0001), E/e¡¯ 21 , 1 ¡À 8.1 vs 16.5 ¡À 2.4 (p <0.0001), HBP 81.8% vs. 50.2% (p <0.0001), DM 21.2% vs. 9.4% (p = 0.04); CHF 24.2% vs. 3.2% (p <0.0001), CAD 33.3% versus 9% (p <0.0001). Conclusion: Patients with elevated left ventricular filling pressures are older, have larger LA diameter and volume, worse EF and higher incidence of HBP, diabetes, CHF and CAD. There is less agreement between LAD and iLAV in these patients.

Alterações hemodinâmicas devido ao uso de estabilizadores em revascularização do miocárdio: estudo experimental / Hemodynamic disorders related to beating heart surgery using cardiac stabilizers: experimental study

OBJETIVO: Estudar, em suínos, as alterações hemodinâmicas secundárias ao uso de estabilizadores para operações de revascularização do miocárdio sem circulação extracorpórea, um por sucção (Octopus) e outro por compressão (Speroni). MÉTODOS: Dez suínos submetidos à esternotomia e monitorizados com eletrocardiograma, débito cardíaco contínuo e pressões: arterial média, pulmonar média, atriais médias direita e esquerda, ventriculares diastólicas direita e esquerda, calculando-se volume sistólico e resistência vascular sistêmica. Estudaram-se os estabilizadores posicionados em três artérias: interventricular anterior, interventricular posterior e ramo marginal da circunflexa. Para cada animal foi sorteada a ordem de aplicação do estabilizador com relação ao tipo e à artéria. As mensurações foram realizadas antes e após aplicar-se o estabilizador. RESULTADOS: Na artéria interventricular anterior, ocorreram alterações somente com o Speroni, havendo queda do débito cardíaco, do volume sistólico e da pressão arterial média, com aumento da resistência vascular sistêmica. Na artéria interventricular posterior, constatamos alterações com o Speroni, havendo queda do débito cardíaco e do volume sistólico, com aumento da freqüência cardíaca. Com o Octopus houve aumento da freqüência cardíaca e da resistência vascular sistêmica, com queda do volume sistólico. No ramo marginal da circunflexa, ocorreu queda do débito cardíaco, do volume sistólico e da pressão arterial média com os dois estabilizadores, havendo também queda na pressão arterial pulmonar média e aumento da pressão atrial direita média com o estabilizador por compressão. CONCLUSÕES: Ambos os estabilizadores causaram alterações hemodinâmicas. O que atua por compressão provocou mais alterações do que o que atua por sucção.

OBJECTIVE: To study in swine the hemodynamic changes secondary to the use of stabilizers for off-pump coronary artery bypass graft surgeries by means of both a suction device "Octopus" and a compression device (Speroni). METHODS: Ten swine underwent median sternotomy. Monitoring of ECG, continuous cardiac output, mean arterial pressure, mean pulmonary artery pressure, mean right and left atrial pressures, and right and left ventricular diastolic pressure were performed. Stroke volume and systemic vascular resistance were calculated. Both stabilizers were studied placed on three vessels: anterior interventricular branch, posterior interventricular branch, and marginal branch of the circumflex branch. Each animal was randomly designed to application regarding the type of stabilizer and the target artery. The measurements were carried out 5 minutes before and after the stabilizer application. RESULTS: In the anterior interventricular branch changes have occurred only with the compression device, thus reducing cardiac output, stroke volume, and mean arterial pressure, but increasing the systemic vascular resistance. In the posterior interventricular branch changes have occurred with the compression device (Speroni), reducing cardiac output and stroke volume, but increasing the heart rate. With the suction device (octopus) there was an increase of both heart rate and systemic vascular resistance, but a decrease in stroke volume. In the marginal branch of the circumflex branch there was a decrease of cardiac output, stroke volume, and mean arterial pressure with both stabilizers. Also, there was a decrease in the mean pulmonary artery pressure and an increase in the mean right atrial pressure with the compression device (Speroni). CONCLUSION: Both stabilizers have caused hemodynamic changes. The compression device (Speroni) is more associated with changes than the suction device (Octopus).

O eletrocardiograma de alta resolução da ativação atrial em pacientes com ou sem fibrilação atrial paroxística / The signal-averaged electrocardiogram of atrial activation in patients with or without paroxysmal atrial fibrillation

OBJETIVO: Analisar os parâmetros do eletrocardiograma de alta resolução da onda P no domínio do tempo (ECGAR-P) e compará-los com: a duração da onda P no eletrocardiograma clássico (P no ECG), o diâmetro atrial esquerdo (AE) e a fração de ejeção do ventrículo esquerdo (FE) obtidos no ecocardiograma, para avaliar pacientes com fibrilação atrial paroxística (FAP). MÉTODOS: Foram estudados 181 pacientes: 117 com FAP comprovada e 64 sem FAP. Os parâmetros do ECGAR-P foram: a duração da onda P filtrada (DPF), as voltagens da raiz quadrada média dos últimos 40, 30 e 20 ms da onda P filtrada (RMS 40, RMS 30 e RMS 20), a voltagem da raiz quadrada média dos potenciais da onda P filtrada (RMS P), a integral dos potenciais da onda P filtrada (Integral P) e a duração dos potenciais tardios da onda P filtrada abaixo de 3 æV (PT<3). RESULTADOS: Os parâmetros que apresentaram diferenças estatisticamente significantes entre os grupos foram: DPF, RMS 40, 30 e 20, PT<3, P no ECG e AE. Os cálculos pela curva ROC mostraram, para cada parâmetro, o melhor valor de corte e os estimadores de desempenho: sensibilidade, especificidade, área sob a curva e p-value (p) ou nível descritivo. CONCLUSÃO: O ECGAR-P no domínio do tempo mostrou-se melhor que o eletrocardiograma clássico e o ecocardiograma para identificar pacientes com fibrilação atrial paroxística.

OBJECTIVE: To analyze the parameters of the time domain P-wave signal-averaged electrocardiogram (P-SAECG) and compare them with the P-wave duration on the conventional electrocardiogram (P on ECG) as well as the left atrium diameter (LAD) and left ventricular ejection fraction (EF) obtained on the echocardiogram in order to evaluate patients with paroxysmal atrial fibrillation (PAF). METHODS: One hundred and eighty-one patients were included in the study: 117 with confirmed PAF and 64 without PAF. The P-SAECG parameters used were: the filtered P-wave duration (FPD), the root mean square (RMS) voltages in the last 40, 30 and 20 ms of the filtered P-wave (RMS 40, RMS 30 and RMS 20), the root mean square voltage of the filtered P-wave potentials (RMS P), the integral of the potentials during the filtered P-wave (Integral P) and the filtered P-wave late potential durations below 3 æV (PL<3). RESULTS: The parameters that presented significant statistical differences between the groups were: FPD, RMS 40, 30 and 20, PL<3, P on ECG and LAD. The ROC curve calculations demonstrated the best cut-off points and performance estimates for each parameter: sensitivity, specificity, area under the curve and p-value (p). CONCLUSION: The time domain P-SAECG proved to be a superior method to identify patients with paroxysmal atrial fibrillation than the conventional electrocardiogram and echocardiogram.

Mitral balloon valvuloplasty by inoue technique A new emerging indications

Mitral balloon Valvuloplasty [MBV] by Inoue technique [1] was performed in 164 patients [MS]. 64patients were male and 100 patients were female. The age range was 9-62 years [mean28]. All patients were subjected to echocardiographic and Doppler examinations before and one day after the procedure. The first57 patients were subjected to exercise tolerance test [ETT] few days before and few days after the procedure. An echocardiographic score was measured regarding valve thickening, leaflet mobility, degree of calcification and the severity of involvement of the subvalvular apparatus [2], patients with> grade 2/4 mitral regurgitation [MR] and fresh mobile left atrial thrombus [LAT] were excluded. Patients with commissural calcifications, resolved or organized thrombus were also subjected to [MBV]. No echocardiographic stand by was needed during the procedure. [3] Mitral valve area [MVA] increased from 0.9 +/- 0.2 cm° to 1.9 +/- 0.45 cm° [P<.001]. Mitral gradient [MG] decreased from 20.85 +/- 8.4mmHg to 11.05 +/- 5.4 mmHg [P<.0001]. [ETT] increased from 5.6 +/- 1.3 to 11.75 +/- 1.5 minute [P<.001]. Complications included severe [MR] in 4 patients [2.5%],cardial tamponade in 1 patient [0.6%],bacterial endocarditis in 1 patient [0.6%]. In the first 57 patients mild left to right shunt measured by green dye dilution technique has occurred in 40% of patients, no patient needed surgery for the shunt. In conclusion, [MBV] by Inoue balloon is a safe and good alternative to surgical commissurotomy and a new emerging indications will be discussed in this study

Atrial contribution to left ventricular filling in mitral stenosis: effects of balloon mitral valvuloplasty.

Doppler echocardiographic contribution of atrial systole to left ventricular filling (AC) was studied in 20 patients with mitral stenosis and compared with that obtained from 15 matched controls in a prospective study. AC in mitral stenosis as a percentage of total filling volume was 8 +/- 2.8% compared to 12.5 +/- 3.3% in control subjects (p < 0.001) and was weakly correlated to diastolic filling period (r = -0.45), mitral valve orifice resistance (r = -0.36) and heart rate (r = 0.36). An increase in mitral valve orifice area following balloon mitral valvuloplasty (0.78 +/- 0.12 to 1.72 +/- 0.4 cm2, p < 0.0001) resulted in an increase in AC to near normal values (8 +/- 2.8% to 12.5 +/- 3.8%, p < 0.001) coupled with an increase in cardiac index and a significant decrease in diastolic filling period and left atrial size. In conclusion, AC in young patients with severe mitral stenosis is decreased proportionately less than that reported in the older patients, is weakly correlated to mitral orifice resistance and normalises following a successful mitral valvuloplasty.

Percutaneous transseptal left atrial monitoring in open heart surgery [PTLAM] - a new technique

Between January and August 1991, 37 patients who underwent open mitral valve repair or replacement had left atrial monitoring by a new technique. A percutaneons transvenous line, similar to the one used to measure the central venous pressure, was used to monitor left atrial pressure after penetrating the atrial septum during heart surgery. This technique was useful in the postoperative period for evaluation of the left ventricular function in a similar manner to that obtained by measuring pulmonary capillary wedge pressure. It was also useful in cases of mitral valve repair to evaluate mitral valve function just after the patient is off bypass. Useful information was also obtained after mitral valve replacement. This technique was useful in the postoperative period for evaluation of the left ventricular function in a similar manner to that obtained by measuring pulmonary capillary wedge pressure. It was also useful in cases of mitral valve repair to evaluate mitral valve function just after the patient is off bypass. Useful information was also obtained after mitral valve replacement. Evaluation of the patients before discharge from hospital by colored flow Doppler cardiography was done. In all occasions the septum was intact sand no delectable shunt could be demonstrated. Percutaneous Transseptal left atrial Monitoring [PTLAM] is a simple technique, can be done in all cases in whom the evaluation of left ventricular function is needed; and/or in cases of mitral valve repair or replacement. PTLAM is more accurate than the indirect methods of measuring pulmonary capillary wedge pressure which can be affected by the pressure of pathological changes in the pulmonary vasculature. It also avoids the complications of insertion of Swan Ganz catheter, furthermore it is safer than the use of superior pulmonary vein