Valvular regurgitation and stenosis: when is surgery required?

Valvular heart disease is a growing public health problem, with an increasing prevalence due to an ageing population. Despite advances, the medical management of symptomatic valvular heart diseases remains suboptimal, necessitating surgical correction. The challenge remains in identifying an asymptomatic or mildly symptomatic patient who will benefit from timely surgery before irreversible changes in cardiac function have occurred. The potential risks of surgery versus watchful expectancy require careful decision-making. This review is a focused update on the existing guidelines and identifies the knowledge gaps and avenues of future research in the management of patients with valvular heart diseases.

Comparison of intraoperative transesophageal echocardiographic examinations with the operative findings: prospective review of 1918 cases.

The purpose of this study was to prospectively compare the intraoperative transesophageal echocardiographic (IOTEE) findings with the operative findings in 1918 consecutive cardiac cases. Forty-eight discordant findings were found between the IOTEE and operative findings. Of the 48 discordant findings, most were related to valve pathology. Structural abnormalities that were missed by IOTEE included those of the aortic valve, 12 cases (25%), mitral valve, 13 cases (27%), and pulmonic and tricuspid valves, 5 cases (10%). Functional discrepancies occurred in 8% of cases. Overall, incidence of discrepant findings between IOTEE and operative findings was low (2.5%). This resulted in an alteration of the planned surgical procedure in a small number of cases (0.3%).

A simplified, practical approach to assessment of severity of mitral regurgitation by Doppler color flow imaging with proximal convergence: validation with concomitant cardiac catheterization.

OBJECTIVE: To compare the proximal convergence method for quantification of mitral regurgitation with findings on concomitant left ventriculography. MATERIAL AND METHODS: In 41 patients (22 men and 19 women, 63 +/- 13 years of age), mitral regurgitation was evaluated concomitantly by Doppler color flow jet area, proximal convergence method, and left ventriculography. A simplified measurement of the proximal convergence, consisting of the aliasing radius and velocity of the proximal isosurface (r2 x V), was used. RESULTS: Angiographic grade correlated well with the proximal convergence method (r2 x V) but had poor correlation with the Doppler color flow jet area method. All patients with a proximal convergence flow rate of less than 10 cm3/s had grade 1 or 2 mitral regurgitation, whereas patients with a proximal convergence flow rate of more than 20 cm3/s had grade 3 or 4 mitral regurgitation. The severity of mitral regurgitation was indeterminate in patients with proximal convergence flow rates from 10 to 20 cm3/s. CONCLUSION: Doppler color flow jet area correlates poorly with angiographic grade of mitral regurgitation. A simplified proximal convergence method is useful for separating grade 3 and 4 from grade 1 and 2 mitral regurgitation in most patients. A group of patients with indeterminate severity of mitral regurgitation remains, however, in whom further assessment is necessary.

Determination of left ventricular filling pressure by Doppler echocardiography in patients with coronary artery disease: critical role of left ventricular systolic function.

OBJECTIVES: This study was designed to determine the usefulness of transthoracic Doppler measurements in detecting increased left ventricular (LV) end-diastolic pressure in patients with coronary artery disease, specifically examining the influence of systolic function on the accuracy of these methods. BACKGROUND: Studies that have correlated Doppler indexes with LV filling pressures primarily involved patients with LV systolic dysfunction. The reliability of Doppler indexes in estimating filling pressures in patients with coronary artery disease and preserved systolic function is unclear. METHODS: Pulsed wave Doppler transmitral and pulmonary venous flow velocity curves and LV pressure were recorded in 83 patients with coronary artery disease. RESULTS: Conventional Doppler indexes (deceleration time of mitral E wave velocity, ratio of peak mitral E to A wave velocities and pulmonary venous systolic fraction) correlated with LV filling pressure in patients with an ejection fraction (EF) < or = 50% but not in those with an EF > 50%. Previously published regression analysis for prediction of LV filling pressure was accurate in patients with an EF < or = 50% but not in those with an EF > 50%. The difference between flow duration with atrial contraction in the pulmonary veins and transmitral flow duration with atrial contraction correlated with LV filling pressure in both groups. CONCLUSIONS: Analysis of the early diastolic portion of the transmitral or pulmonary venous flow velocity curves can be used to predict LV filling pressures in patients with systolic dysfunction, but are inaccurate in patients with preserved systolic function. The combined analysis of both flow velocity curves at atrial contraction is a reliable, feasible predictor of increased LV filling pressure, irrespective of systolic function.

Worsening left ventricular performance on serial exercise radionuclide angiography does not identify high-risk patients.

OBJECTIVE: To determine whether worsening exercise performance on serial exercise radionuclide angiography identifies patients at increased risk of future cardiac events. MATERIAL AND METHODS: One hundred nine medically treated patients with previous Q-wave myocardial infarction underwent two exercise radionuclide angiographic studies at least 6 months apart (median, 16 months) without an intervening clinical event. Worsening exercise performance between the two studies was defined by five criteria: (1) lower (5% or more) peak exercise ejection fraction; (2) worsening peak exercise wall motion score; (3) combination of criteria 1 and 2; (4) worsening serial delta (exercise - rest) ejection fraction; or (5) increasing exercise ST-segment depression of 1 mm or more. Patients were followed up for a median duration of 3.9 years after the second exercise study. RESULTS: Five cardiac deaths and 10 nonfatal myocardial infarctions occurred during follow-up. A Cox proportional hazards analysis failed to show an association between any of the aforementioned variables and cardiac events. Of the 15 patients with cardiac events, 4 (27%) had a lower (5% or more) exercise ejection fraction and 2 (13%) had a worsening exercise wall motion score. Of the 94 patients without cardiac events, 37 (39%) had a lower (5% or more) exercise ejection fraction and 28 (30%) had a worsening serial exercise wall motion score (not a statistically significant difference). CONCLUSION: Worsening exercise performance on serial exercise radionuclide angiography does not identify patients at increased risk of future cardiac events.