Is a good perioperative echocardiographic result predictive of durability in ischemic mitral valve repair?

BACKGROUND: Chronic ischemic mitral regurgitation is associated with poor long-term survival. Despite the increasing popularity of valve repair, its durability and long-term outcome for ischemic mitral regurgitation have recently been questioned. METHODS: Seventy-eight patients underwent repair for ischemic mitral regurgitation between 1996 and 2002 at our institution. Of these patients, 73 had complete clinical and echocardiographic follow-up. Preoperative, intraoperative, and postoperative clinical data were obtained, and the results of echocardiograms were reviewed to assess the rate of recurrence of regurgitation after repair and to identify predictive factors. RESULTS: The mean preoperative mitral regurgitation grade, New York Heart Association class, and left ventricular ejection fraction were 2.72, 2.65, and 39.4%, respectively. Mortality was 12.3% at 30 days and 30.1% at a mean follow-up of 39 +/- 25 months. Immediate postoperative echocardiography showed absent or mild mitral regurgitation in 89.4% of patients and showed moderate mitral regurgitation in 10.6%. Freedom from reoperation was 93.2%. Recurrent moderate mitral regurgitation (2+) was present in 36.7% of patients, and severe mitral regurgitation (3+ to 4+) was present in 20.0% at mean follow-up of 28.1 +/- 22.5 months. Only age (P = .0130) and less marked preoperative posterior tethering (P = .0362) were predictive of recurrent mitral regurgitation. Patients with a preoperative New York Heart Association class greater than II and recurrent mitral regurgitation greater than 2+ had decreased survival (P = .0152 and P = .0450, respectively). CONCLUSIONS: Significant recurrent mitral regurgitation occurs following repair for ischemic mitral regurgitation, despite good early results. This finding raises questions about the need for improved repair techniques, better patient selection, or eventual mitral valve replacement in selected patients.

Contrast echocardiography improves the accuracy and reproducibility of left ventricular remodeling measurements: a prospective, randomly assigned, blinded study.

OBJECTIVES: We sought to assess the impact of contrast injection and harmonic imaging, on the measure by echocardiography of left ventricular (LV) remodeling. BACKGROUND: Left ventricular remodeling is a precursor of LV dysfunction, but the impact of contrast injection and harmonic imaging on the accuracy or reproducibility of echocardiography is unclear. METHODS: We prospectively collected LV images by using simultaneous methods. Then, LV volumes were measured off-line, in blinded manner and in random order. The accuracy of echocardiography was determined in comparison to electron beam computed tomography (EBCT) in 26 patients. The reproducibility of echocardiography was assessed by three blinded observers with different training levels in 32 patients. RESULTS: End-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV) and ejection fraction (EF), as measured by EBCT (195 +/- 55, 58 +/- 24 and 137 +/- 35 ml and 71 +/- 5%, respectively) and echocardiography with harmonic imaging and contrast injection (194 +/- 51, 55 +/- 20 and 140 +/- 35 ml and 72 +/- 4%, respectively), showed no differences (all p > 0.15) and excellent correlations (all r > 0.87). In contrast, echocardiography using harmonic imaging without contrast injection underestimated the EBCT results (all p < 0.01). Reproducibility was superior with rather than without contrast injection for intraobserver and interobserver variabilities (all p < 0.001). Values measured by different observers were different without contrast injection, but were similar with contrast injection (all p > 0.18). Consequently, intrinsic patient differences represented a larger and almost exclusive proportion of global variability with contrast injection for EDV (94 vs. 79%), ESV (93 vs. 82%), SV (87 vs. 53%) and EF (84 vs. 41%), as compared with harmonic imaging without contrast injection (all p < 0.005). CONCLUSIONS: For assessment of LV remodeling, echocardiography with harmonic imaging and contrast injection improved the accuracy and reproducibility, as compared with imaging without contrast injection. With contrast injection, variability was almost exclusively due to intrinsic patient differences. Therefore, when evaluation of LV remodeling is deemed important, assessment after contrast injection should be the preferred echocardiographic approach.

Obstruction of left ventricular outflow tract by vegetation and periaortic abscess.

Echocardiography is the modality of choice for the noninvasive recognition of vegetations and abscesses that complicate endocarditis. Vegetation size is highly variable, and it has been suggested that large vegetations are related to a more complicated course. The case we present is unusual in that the echocardiographically detected vegetation was very large, highly mobile, and caused severe obstruction of the left ventricular outflow tract, which led to impaction and cardiac arrest.

Progression of mitral regurgitation: a prospective Doppler echocardiographic study.

OBJECTIVES: This study was performed to define the rates and determinants of progression of organic mitral regurgitation (MR). BACKGROUND: Severe MR has major clinical consequences, but the rates and determinants of progression of the degree of regurgitation are unknown. Quantitative Doppler echocardiographic methods allow the quantitation of regurgitant volume (RVol), regurgitant fraction (RF) and effective regurgitant orifice (ERO) to define progression of MR. METHODS: In a prospective study of MR progression, 74 patients had two quantitative Doppler echocardiographic examinations of MR (with at least two methods) 561 +/- 423 days apart without an intervening event. RESULTS: Progression of MR was observed, with increase in RVol (77 +/- 46 ml vs. 65 +/- 40 ml, p < 0.0001), RF (47 +/- 16% vs. 43% +/- 15%, p < 0.0001), and ERO (50 +/- 35 mm2 vs. 41 +/- 28 mm2, p < 0.0001). Annual rates (95% confidence interval) were, respectively, 7.4 ml/year (5.1, 9.7), 2.9%/year (1.9, 3.9) and 5.9 mm2/year (3.9, 7.8). However, wide individual variation was observed, and regression and progression of RVol >8 ml was found in 11% and 51%, respectively. In multivariate analysis, independent predictors of progression of RVol were progression of the lesions, particularly a new flail leaflet (p = 0.0003), and progression of mitral annulus diameter (p = 0.0001). Regression of MR was associated with marked changes in afterload, particularly decreased blood pressure (p = 0.008). No significant effect of treatment was detected. CONCLUSIONS: Organic MR tends to progress over time with increase in volume overload (RVol) due to increase in ERO. Progression of MR is variable and determined by progression of lesions or mitral annulus size. These data should help plan follow up of patients with organic MR and future intervention trials.