The deceleration [correction of declaration] time of pulmonary venous diastolic flow is more accurate than the pulmonary artery occlusion pressure in predicting left atrial pressure.

OBJECTIVES: This study compared a prediction of mean left atrial pressure (P(LA)) ascertained by Doppler echocardiography of pulmonary venous flow (PVF), with predicted P(LA) using the pulmonary artery occlusion pressure (P(PAO)). BACKGROUND: In select patient groups, PVF variables correlate with P(PAO)) an indirect measure of P(LA). METHODS: In 93 patients undergoing cardiac surgery, we recorded with transesophageal echocardiography mitral valve early (E) and late (A) wave velocities, deceleration time (DT) of E (DT(E)), and pulmonary vein systolic (S) and diastolic (D) wave velocities, DT of D (DT(D)) and systolic fraction. The P(PAO) was measured using a pulmonary artery catheter zeroed to midaxillary level. A further catheter was held at midatrial level to zero a transducer and was then inserted into the left atrium. A prediction rule for P(LA) from DT(D) was developed in 50 patients and applied prospectively to estimate P(LA) in 43 patients. RESULTS: A close correlation (r = -0.92) was found between P(LA) and DT(D). Systolic fraction (r = -0.63), DT(E) (r = -0.61), D wave (r = 0.57), E wave (r = 0.52), and E/A ratio (r = 0.13) correlated less closely with P(LA). The mean difference between predicted and measured P(LA) was 0.58 mm Hg for DT(D) method and 1.72 mm Hg for P(PAO), with limits of agreement (mean +/- 2 SE) of -2.94 to 4.10 mm Hg and -2.48 to 5.92 mm Hg, respectively. A DT(D)) of <175 ms had 100% sensitivity and 94% specificity for a P(LA) of >17 mm Hg. CONCLUSIONS: Deceleration time of pulmonary vein diastolic wave is more accurate than P(PAO) in estimating left atrial pressure in cardiac surgical patients.

Tricuspid valve replacement using a cryopreserved mitral homograft. Surgical technique and initial results.

BACKGROUND AND AIM OF THE STUDY: The surgical management of tricuspid valve endocarditis, especially in patients with positive serology for HIV and hepatitis C, is complicated by the inappropriateness of reconstruction and the late complications of mechanical prostheses and bioprostheses. Late results of mitral homograft replacement of the tricuspid valve have been satisfactory, but evidence of moderate and severe regurgitation appears in some patients. This report presents a novel approach to implantation of a mitral homograft in the tricuspid position. METHODS: Five patients with complications of native tricuspid valve endocarditis underwent mitral homograft replacement of the tricuspid valve, the homograft being implanted with the anterior leaflet orientated to the septum, the papillary muscles exteriorized and sutured to the right ventricular wall, the posteromedial muscle anteriorly, and the anterolateral muscle inferiorly. The annular attachment was reinforced with a rigid mitral annuloplasty ring in the anti-anatomical relationship. RESULTS: There was no early mortality. Among three patients available for echocardiographic assessment during the first year, regurgitation was absent in two cases, and trivial in one case. The latter patient died of a drug overdose after nine months. Two patients required insertion of atrioventricular pacemakers for complete heart block. CONCLUSION: This novel extension to the technique of mitral homograft replacement of the tricuspid valve for uncontrollable native endocarditis in drug abusers makes the procedure more technically feasible, and should be considered a procedure of choice.

Left ventricular shape analysis from three-dimensional echocardiograms.

The objective of this study was to develop and validate a three-dimensional technique of left ventricular shape analysis. Geometric phantoms and left ventricles of excised calf hearts, normal human subjects, and one subject each with aortic stenosis and dilated cardiomyopathy were reconstructed from three-dimensional echocardiograms. The fit between the reconstructions and true surfaces of the geometric phantoms and excised ventricles was determined. To evaluate in vivo left ventricular shape, a center axis was constructed from the centroid of the mitral annulus to the furthest endocardial point. Regional shape was evaluated as the relative distances of 16 separate myocardial segments from the center axis compared with a population-derived mean value. Global shape was evaluated as the average standard deviation from the normal value over the 16 segments. The system precisely reproduced the shapes of the phantoms and excised left ventricles (root-mean-square error between true and reconstructed surface 1.0 0.2 mm and 1.2 0.8 mm, respectively). The in vivo shape analysis differentiated the pathological from normal left ventricles.

Three-dimensional measurement of the mitral annulus by multiplane transesophageal echocardiography: in vitro validation and in vivo demonstration.

Ten phantoms were scanned with a multiplane transesophageal echocardiographic probe in a water bath to assess a new method for three-dimensional modeling of the mitral annulus. The annulus was reconstructed from manually outlined borders with Fourier series in each of the three spatial coordinates. Comparisons with direct measurements by least-squares linear regression gave coefficients of determination of 0.99 for annular height, area, and circumference. Expressed as a percentage of their true values, the mean +/- SD of the errors were -0.1% +/- 3.0% for annular height, -2.8% +/- 3.1% for area, and -0.2% +/- 1.7% for circumference. The mean residual error length for phantoms was 0.64 mm compared with 1.21 mm in nine patients studied during general anesthesia. This method gives accurate and precise measurements of the mitral annulus in vitro and should be valuable for studying its morphology and dynamics in vivo.

Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome.

BACKGROUND: Only limited data on the rate of hemodynamic progression and predictors of outcome in asymptomatic patients with valvular aortic stenosis (AS) are available. METHODS AND RESULTS: In 123 adults (mean age, 63 +/- 16 years) with asymptomatic AS, annual clinical, echocardiographic, and exercise data were obtained prospectively (mean follow-up of 2.5 +/- 1.4 years). Aortic jet velocity increased by 0.32 +/- 0.34 m/s per year and mean gradient by 7 +/- 7 mm Hg per year; valve area decreased by 0.12 +/- 0.19 cm2 per year. Kaplan-Meier event-free survival, with end points defined as death (n = 8) or aortic valve surgery (n = 48), was 93 +/- 5% at 1 year, 62 +/- 8% at 3 years, and 26 +/- 10% at 5 years. Univariate predictors of outcome included baseline jet velocity, mean gradient, valve area, and the rate of increase in jet velocity (all P < or = .001) but not age, sex, or cause of AS. Those with an end point had a smaller exercise increase in valve area, blood pressure, and cardiac output and a greater exercise decrease in stroke volume. Multivariate predictors of outcome were jet velocity at baseline (P < .0001), the rate of change in jet velocity (P < .0001), and functional status score (P = .002). The likelihood of remaining alive without valve replacement at 2 years was only 21 +/- 18% for a jet velocity at entry > 4.0 m/s, compared with 66 +/- 13% for a velocity of 3.0 to 4.0 m/s and 84 +/- 16% for a jet velocity < 3.0 m/s (P < .0001). CONCLUSIONS: In adults with asymptomatic AS, the rate of hemodynamic progression and clinical outcome are predicted by jet velocity, the rate of change in jet velocity, and functional status.

Effects of aortic valve replacement on exercise duration and functional status in adults with valvular aortic stenosis.

OBJECTIVE: To evaluate the effect of aortic valve replacement on left ventricular function, functional status and exercise duration in an adult population with valvular aortic stenosis. DESIGN: Prospective study of initially asymptomatic patients with pre- and postvalve replacement echocardiography, functional status score and exercise data. SETTING: University-affiliated, tertiary care teaching hospital. PATIENTS: Valvular aortic stenosis patients referred from academic and private practice internists and cardiologists (n = 34, 65% men, mean age 68 +/- 11 years, preoperative aortic valve area 0.9 +/- 0.4 cm2). INTERVENTIONS: Annual Doppler echocardiography, functional status questionnaires and, if possible, Bruce protocol maximal exercise tolerance tests. MAIN RESULTS: Aortic valve replacement resulted in a decrease in maximum jet velocity (pre 4.7 +/- 0.7 versus post 2.9 +/- 0.7 m/s, P = 0.0001) and left ventricular mass (pre 167 +/- 37 versus post 134 +/- 32 g, P = 0.0001) and an increase in left ventricular ejection fraction (pre 65 +/- 11 versus post 69 +/- 10%, P = 0.05) at rest. However, there was no change in the ratio of early to atrial diastolic filling velocities (pre 1.2 +/- 0.5 versus post 1.4 +/- 0.8, not significant), exercise tolerance as assessed by estimated functional aerobic impairment (pre 26 +/- 32 versus post 22 +/- 27%, not significant) or functional status score (pre 89 +/- 13 versus post 91 +/- 11, not significant). CONCLUSIONS: When the aortic valve is replaced promptly at symptom onset, despite improvement in resting left ventricular systolic performance, there is no evidence of improvement in exercise capacity or functional status.