Longitudinal echocardiographic and clinical follow-up of patients undergoing mitral valve surgery without concomitant tricuspid valve repair.

BACKGROUND: In patients with mild to moderate functional tricuspid regurgitation (TR) and absence of right ventricular dysfunction or tricuspid annulus (TA) dilatation, there is currently no indication for concomitant tricuspid valve (TV) repair during elective mitral valve (MV) surgery. However, long-term results are conflicting. Here, we sought to determine the clinical outcome of this cohort, the rate of TR progression after MV surgery and the role of MV aetiology. METHODS: Patients for elective MV surgery without concomitant TV repair were retrospectively analysed with longitudinal echocardiographic and clinical follow-up, focusing on TR progression and MV aetiology. Linear regression analysis was performed for change in TR at follow-up, using pre-determined variables and confounders. RESULTS: In total 204 patients without TV repair were analysed. Development of more than moderate TR after a median of 3.1 [1.6-4.6] years was rarely seen: only in 2 out of 161 patients (1.2%) with known TR grade at follow-up. Overall, median preoperative and late postoperative TR grade were equal (p = 0.116). Subanalysis showed no significant difference in MV aetiology subgroups. Preoperative TR grade and male gender were inversely correlated to change in TR. Mortality was not influenced by the 1­year postoperative TR severity. CONCLUSION: Our data showed that in a study population of patients with mild to moderate TR undergoing MV surgery without concomitant TV repair, significant late TR was rarely seen. Based on our study, it is safe to waive concomitant TV repair in this specific patient cohort.

Stent thrombosis in real-world patients: a comparison of drug-eluting with bare metal stents.

BACKGROUND: Although the introduction of drugeluting stents (DES) has been associated with an impressive reduction in target vessel revascularisation, there has been concern about the safety profile. The aim of this study was to determine the incidence of stent thrombosis in real-world patients and evaluate the contribution of drug-eluting stents. METHODS: A prospective observational cohort study was conducted at a high-volume centre in Utrecht, the Netherlands. All patients who underwent a percutaneous coronary intervention (PCI) between 1 January and 31 December 2005 were evaluated. The patients were pretreated with aspirin and clopidogrel, which was continued for six months in bare metal stents (BMS) and 12 months in DES. RESULTS: In 2005, 1309 patients underwent a percutaneous coronary intervention procedure with stent implantation. After a median follow-up of nine months, 1.8% (n=23) of the patients had suffered from stent thrombosis. Two cases could be attributed to incorrect use of antiplatelet agents. In 8/23 cases, a technical reason was found such as an unrecognised dissection or stent underexpansion. The timing of stent thrombosis was acute in 1/23 patients, subacute in 20/23 patients and late in 2/23 patients. In both cases of late stent thrombosis, a BMS had been used. There were no differences in stent thrombosis rates between DES and BMS (1.4 vs. 1.9%, ns.). This is remarkable since DES were used in more complex and longer lesions. CONCLUSION: The use of DES in routine daily practice does not appear to be associated with a higher rate of stent thrombosis than BMS. (Neth Heart J 2007;15:382-6.Neth Heart J 2007;15:382-6).

Traumatic papillary muscle rupture.

Papillary muscle rupture caused by blunt chest trauma is a relatively rare cause of mitral incompetence. To date only 25 cases of surgically corrected posttraumatic mitral regurgitation have been reported, of which only eight resulted from rupture of the anterolateral papillary muscle.

Biventricular pacing in end-stage heart failure improves functional capacity and left ventricular function.

BACKGROUND: Asynchronous patterns of contraction and relaxation may contribute to hemodynamic and functional impairment in heart failure. In 1993, we introduced biventricular pacing as a novel method to treat heart failure by synchronous stimulation of the right and left ventricles after an appropriate atrioventricular delay. The objectives of this study were to assess the early and long-term effects of this therapy on functional capacity and left ventricular function in patients with severe heart failure and left bundle branch block. METHODS AND RESULTS: Twelve patients with end-stage congestive heart failure, sinus rhythm and complete left bundle branch block were treated with biventricular stimulation at optimized atrioventricular delay. The NYHA functional class and maximal bicycle exercise capacity were assessed. Systolic and diastolic left ventricular function were studied with echocardiography and radionuclide angiography. Data was collected at various intervals during 1-year follow-up. Cumulative survival [95% CI] was 66.7% [40.0,93.4] at 1 year and 50 % [21.8, 78.2] at 2 and 3 years. Median NYHA class improved from class IV to class II at 1 year (p=0.008). After 6 weeks an increase in exercise capacity occurred, which was sustained. A less restrictive left ventricular filling pattern, an increase in dP/dt and left ventricular ejection fraction, and a decrease in mitral regurgitation were observed early and long-term. CONCLUSIONS: Biventricular pacing at optimized atrioventricular delay results in improvement in functional capacity, which is associated with improved systolic and diastolic left ventricular function, and a decrease in mitral regurgitation during short- and long-term follow-up.

Revascularization of patients with coronary artery disease: the interventional cardiologist's perspective.

In the majority of patients with chronic coronary artery disease, treatment is aimed at palliation or prolongation of disease-free intervals and consists of either pharmacologic therapy or coronary revascularization. As a result of continuous refinements and improvements in both surgical and catheter-based revascularization techniques, modalities, and adjunctive pharmacologic therapy, an increasing number of patients may benefit from coronary revascularization. This also engenders difficult choices for the physicians responsible for selecting the most appropriate treatment. To achieve and provide optimal patient care an open and principled discussion with all parties involved is mandatory and must be based on the integration of clinical experience and data from both basic and clinical research. The purpose of this article is to provide the interventional cardiologist's view on the treatment of patients with atherosclerotic coronary artery disease.

Pulmonary venous flow as assessed by Doppler echocardiography: potential clinical applications.

During the past few years Doppler assessment of pulmonary venous flow has gained increasing interest. The growing experience with the use of transesophageal echocardiography, the approach that nearly always yields registrations adequate for quantitative analysis, has markedly contributed in this respect. The Doppler-derived pulmonary venous flow pattern can be regarded as a measure of left atrial inflow and it augments the clinical significance of Doppler transmitral flow in the evaluation of diastolic left ventricular function. This article summarizes physiological background, possible applications, and limitations of Doppler echocardiography of pulmonary venous flow in clinical cardiology.

Clinical relevance of Doppler pulmonary venous flow characteristics in constrictive pericarditis.

The purpose of this study was to determine the diagnostic value of Doppler pulmonary venous flow in constrictive pericarditis, as assessed by transoesophageal echocardiography. It has been demonstrated previously that increased respiratory variation in Doppler pulmonary venous, but not in transmitral flow velocities, can identify patients with constrictive pericarditis, when transoesophageal echocardiography is used. In the present study we compared a group of 10 patients with constrictive pericarditis and a control group of 15 normal subjects with respect to pulmonary venous and transmitral flow velocities and their respiratory variation. Peak velocities and velocity time integrals of the systolic, early diastolic and late diastolic reversed pulmonary venous flow waves were measured. Peak velocities and velocity time integrals of the early and late diastolic transmitral flow waves were also measured. Measurements were made irrespective of the respiratory cycle, at the onset of inspiration and at the onset of expiration. Values for inspiration and expiration were expressed as percent difference of those obtained irrespective of the respiratory cycle. Peak velocity and velocity time integral of the pulmonary venous systolic and diastolic waves were significantly lower than in normal subjects. Furthermore, the difference between peak velocities of the diastolic wave obtained at the onset of inspiration and obtained irrespective of the respiratory cycle was significantly larger in constrictive pericarditis than in the control group (-20% vs -9%, P < 0.05). This also applied to the difference between velocity time integrals of the diastolic wave obtained at the onset of inspiration and obtained irrespective of the respiratory cycle (-22% vs -12%, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Transesophageal pulsed-Doppler echocardiographic evaluation of transmitral and pulmonary venous flow during ventilation with positive end-expiratory pressure.

During mechanical ventilation with high levels of positive end-expiratory pressure (PEEP) several hemodynamic changes occur, the mechanism of which has been the subject of various previous studies. The effects of increasing levels of PEEP during mechanical ventilation were measured on left atrial and left ventricular filling dynamics, as assessed by pulmonary venous and transmitral flow velocities, respectively. Using transesophageal echocardiography in 12 patients, Doppler flow velocities of pulmonary venous and transmitral flow were studied at baseline (0 cmH2O PEEP) and at 5, 10, 15, and 20 cm H2O with 10-minute intervals, and once more after removal of PEEP. In 2 of the 12 patients, PEEP could not be increased beyond 15 cmH2O, because cardiac index fell below 2.0 L/min/m2. Pulmonary venous flow velocity and velocity time integral during systole significantly decreased from 48 +/- 7 cm/s and 10.3 +/- 2.2 cm at baseline to 35 +/- 6 cm/s and 5.7 +/- 2.5 cm at 20 cmH2O PEEP, respectively (P < 0.01). In contrast, early and late diastolic velocities and velocity time integrals did not change. In regard to transmitral flow, both early and late diastolic velocities significantly decreased from 51 +/- 7 cm/s and 50 +/- 9 cm/s at baseline to 38 +/- 7 cm/s at 20 cmH2O PEEP, respectively (P < 0.01). Early and late diastolic velocity time integrals decreased from 6.1 +/- 1.8 cm and 4.7 +/- 1.0 cm to 4.5 +/- 1.0 cm (NS) and 3.4 +/- 0.7 cm (P < 0.05), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Normal pulmonary venous flow characteristics as assessed by transesophageal pulsed Doppler echocardiography.

Twenty-seven subjects without apparent cardiac abnormalities underwent transesophageal echocardiography to evaluate normal Doppler characteristics of pulmonary venous flow. In particular, the effects of normal respiration and straining during the Valsalva maneuver were analyzed. Pulmonary venous flow during systole consisted of one forward flow wave in 15 cases (56%) and of two forward flow waves in 12 cases (44%). In all instances one forward flow wave was seen during early diastole and in 23 subjects (85%) a retrograde wave related to atrial contraction was present. Maximal velocity during systole was 57 +/- 13 cm/sec (mean +/- SD), during early diastole was 58 +/- 19 cm/sec, and during late diastole was 16 +/- 9 cm/sec. Velocity time integral during systole was significantly higher than during early diastole (11.8 +/- 4.9 vs 9.5 +/- 3.9 cm, p < 0.05), while velocity time integral during late diastole was 1.1 +/- 0.7 cm. During normal inspiration both early diastolic velocity and velocity time integral significantly decreased from 59 +/- 15 to 54 +/- 15 cm/sec (p < 0.01) and from 9.5 +/- 3.9 to 8.5 +/- 4.2 cm (p < 0.05), respectively. During normal expiration, systolic and early diastolic velocity time integral significantly increased, from 11.0 +/- 4.1 to 11.8 +/- 4.5 cm (p < 0.001) and from 9.5 +/- 3.9 to 10.1 +/- 4.3 cm (p < 0.05), respectively. Although statistically significant, the differences were small and do not seem of clinical importance. Straining during the Valsalva maneuver, however, obviously decreased pulmonary venous flow velocities. Systolic and early diastolic velocity decreased from 57 +/- 15 to 32 +/- 10 cm/sec and from 59 +/- 18 to 34 +/- 15 cm/sec, respectively, while velocity time integral during systole, early, and late diastole decreased from 12.0 +/- 5.6 to 4.3 +/- 2.6 cm, from 9.9 +/- 4.4 to 5.2 +/- 3.7 cm, and from 1.3 +/- 0.8 to 0.8 +/- 0.7 cm, respectively. In conclusion, pulmonary venous Doppler characteristics can adequately be analyzed with transesophageal echocardiography. Normal respiration only minimally influences pulmonary venous flow velocities in contrast to straining during the Valsalva maneuver; this should be considered when these variables are applied for clinical purposes.

Valsalva termination of ventricular tachycardia in myocardial infarction.

A 66-yr-old patient with recurrent monomorphic ventricular tachycardias subsequent to a previous myocardial infarction is reported. The tachycardia could repeatedly be terminated by the Valsalva manoeuvre. Procainamide, infused shortly before, possibly had an additional effect. As far as we know, this is the first report of ventricular tachycardias, as a result of an old myocardial infarction, that could be terminated by the Valsalva manoeuvre.