Prognostic value of exercise left ventricular end-systolic volume index in patients with asymptomatic aortic regurgitation: an exercise echocardiography study.

BACKGROUND: Surgical timing of chronic aortic regurgitation (AR) remains a matter of debate because of limited data. This study assessed the prognostic value of exercise echocardiography in asymptomatic AR. METHODS: This prospective study included 60 consecutive asymptomatic patients with isolated moderate or severe AR (mean regurgitant volume 56.7 ± 11.8 ml) and preserved ejection fraction who underwent exercise echocardiography. The clinical outcomes were defined by the presence of major adverse cardiovascular events (MACE) and the indication for aortic valve replacement (AVR) with class I or IIa classification in the current guidelines. RESULTS: During the average follow-up of 731 days, 12 patients suffered from the clinical events, including two patients developing MACE (3%) and ten patients indicating for AVR (17%). No difference in left ventricular (LV) ejection fraction at rest was found between the patients with and without the clinical events. The indexed LV diameters and LV volumes were significantly dilated in the patients with the clinical events. The Cox proportional hazards regression analysis resulted that the exercise LV end-systolic volume index (LVESVi) was significantly associated with the clinical outcomes [hazard ratio, 1.116; 95% CI (1.032-1.205); p = 0.006]. The Kaplan-Meier analysis showed that exercise LVESVi was clearly stratified the event-free survival. CONCLUSIONS: Exercise LVESVi might be an independent predictor of prognosis in patients with asymptomatic moderate or severe AR.

Value of anatomical aortic valve area using real-time three-dimensional transoesophageal echocardiography in patients with aortic stenosis: a comparison between tricuspid and bicuspid aortic valves.

AIMS: Accurate assessment of disease severity is critical for appropriate treatment of patients with aortic stenosis (AS). This study investigated the influence of aortic-valve morphology on the determination of anatomical aortic-valve area (AVA) in patients with AS. METHODS AND RESULTS: This prospective study included 126 patients with AS who underwent transoesophageal echocardiography (TEE). Aortic-valve area was measured using (i) planimetric two-dimensional (2D) TEE, (ii) volumetric three-dimensional (3D) TEE, and (iii) the continuity equation (CE) obtained with transthoracic echocardiography. Of these, 20 patients also underwent contrast-enhanced multidetector computed tomography (MDCT). Aortic-valve area was measured from multiplanar reconstruction of the MDCT images. Of the 126 patients, 20 (15.9%) were diagnosed with bicuspid AS and 106 were diagnosed with tricuspid AS. There was an excellent correlation between AVAADCT and AVA3DTEE (r = 0.83, P < 0.001) and a somewhat lower correlation between AVAADCT and AVA2DTEE (r = 0.63, P = 0.006). In the tricuspid AS group, both AVA2DTEE and AVA3DTEE significantly correlated with AVACE (r = 0.63, mean difference 0.13 ± 0.24 cm(2), and r = 0.83, mean difference 0.03 ± 0.12 cm(2), respectively, both P < 0.001). In contrast, in the bicuspid AS group, AVA3DTEE significantly correlated with AVACE (r = 0.83, mean difference 0.10 ± 0.18 cm(2), P < 0.001), whereas AVA2DTEE did not (r = 0.42, mean difference 0.48 ± 0.32 cm(2), P = 0.066). CONCLUSION: Aortic-valve morphology influenced the assessment of anatomical AVA in patients with AS, and 3D TEE is useful for assessing anatomical AVA regardless of aortic-valve morphology.

Early diastolic function during exertion influences exercise intolerance in patients with hypertrophic cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) patients with preserved left ventricular ejection fraction (LVEF) often develop dyspnea and exercise intolerance. Diastolic dysfunction may contribute to exercise intolerance in these patients. This study aimed to clarify our hypothesis as to whether diastolic function rather than systolic function would be associated with exercise intolerance in HCM using two-dimensional (2D) speckle tracking echocardiography during exercise. METHODS: Thirty-three HCM patients (mean age 59.3 ± 15.7 years) underwent 2D speckle tracking echocardiography at rest and during submaximal semi-supine bicycle exercise. Global longitudinal strain (LS), LS rate during systole (LSRs), early diastole (LSRe), and late diastole (LSRa) were measured. The symptom-limited cardiopulmonary exercise testing was performed using a cycle ergometer for measuring the peak oxygen consumption (peak [Formula: see text]). RESULTS: In the multivariate linear regression analysis, peak [Formula: see text] did not associate with strain or strain rate at rest. However, peak [Formula: see text] correlated with LS (ß = -0.403, p = 0.007), LSRe (ß = 6.041, p = 0.001), and LSRa (ß = 5.117, p = 0.021) during exercise after adjustment for age, gender, and heart rate. The first quartile peak [Formula: see text] (14.2 mL/min/kg) was assessed to predict exercise intolerance. The C-statistic of delta LSRe was 0.74, which was relatively greater than that of delta LS (0.70) and delta LSRa (0.58), indicating that early diastolic function rather than systolic and late diastolic function affects exercise intolerance. CONCLUSIONS: LSRe during exercise is closely associated with the peak [Formula: see text]. Early diastolic function during exercise is an important determinant of exercise capacity in patients with HCM.

Relationship between left ventricular ejection fraction and mitral annular displacement derived by speckle tracking echocardiography in patients with different heart diseases.

BACKGROUND: Speckle tracking echocardiography (STE)-derived mitral annular displacement (MAD) utilizes the speckle tracking technique to measure strain vectors, which provides accurate estimates of left ventricular ejection fraction (LVEF). Here, we investigated a link between STE-derived MAD and LVEF in patients with different heart diseases and evaluated its clinical usefulness. METHODS: This study included 266 outpatients and 84 controls. Of the study patients, 52 patients had ischemic heart disease (IHD), 37 patients had dilated cardiomyopathy (DCM), 34 patients had hypertrophic cardiomyopathy (HCM), 74 patients had valvular heart disease (VHD), and 69 patients had hypertensive heart disease (HHD). STE continuously tracked annular motion throughout the cardiac cycle in the apical 4- and 2-chamber views. RESULTS: In all participants, the curvilinear relationship was found between STE-derived MAD and LVEF (R(2)=0.642). The strong correlation between STE-derived MAD and LVEF was also found in the patients with IHD (R(2)=0.733, p=0.001) and in those with DCM (R(2)=0.614, p=0.008). However, such a correlation was not found in the patients with HCM, VHD, or HHD. CONCLUSION: The specificity in the correlation between STE-derived MAD and LVEF was found in patients with each heart disease, which should be taken into account when assessing these parameters.

Changes in mitral regurgitation and left ventricular geometry during exercise affect exercise capacity in patients with systolic heart failure.

AIMS: exercise may dramatically change the extent of functional mitral regurgitation (MR) and left ventricular (LV) geometry in patients with chronic heart failure (CHF). We hypothesized that dynamic changes in MR and LV geometry would affect exercise capacity. METHODS AND RESULTS: this study included 30 CHF patients with functional MR who underwent symptom-limited bicycle exercise stress echocardiography and cardiopulmonary exercise testing for quantitative assessment of MR (effective regurgitant orifice; ERO), and pulmonary artery systolic pressure (PASP). LV sphericity index was obtained from real-time three-dimensional echocardiograms. The patients were stratified into exercised-induced MR (EMR; n = 10, an increase in ERO by ≥13 mm(2)) or non-EMR (NEMR; n = 20, an increase in ERO by <13 mm(2)) group. At rest, no differences in LV volume and function, ERO, and PASP were found between the two groups. At peak exercise, PASP and sphericity index were significantly greater (all P < 0.01) in the EMR group. The EMR group revealed lower peak oxygen uptake (peak VO(2); P = 0.018) and greater minute ventilation/carbon dioxide production slope (VE/VCO(2) slope; P = 0.042) than the NEMR group. Peak VO(2) negatively correlated with changes in ERO (r = -0.628) and LV sphericity index (r = -0.437); meanwhile, VE/VCO(2) slope was well correlated with these changes (r = 0.414 and 0.364, respectively). A multivariate analysis identified that the change in ERO was the strongest predictor of peak VO(2) (P = 0.001). CONCLUSION: dynamic changes in MR and LV geometry contributed to the limitation of exercise capacity in patients with CHF.

Global longitudinal strain by two-dimensional speckle tracking imaging predicts exercise capacity in patients with chronic heart failure.

BACKGROUND: Left ventricular ejection fraction (LVEF) predicts mortality in patients with chronic heart failure (CHF). However, a weak correlation was found between LVEF and peak oxygen uptake ([Formula: see text]) in CHF patients. Global longitudinal strain measured by two-dimensional (2D) strain is regarded as a more useful predictor of cardiac events than LVEF. We investigated whether 2D strain obtained at rest could predict peak [Formula: see text] in patients with CHF. METHODS: Fifty-one patients (mean age of 54.0 ± 12.0 years, 14 females, LVEF 46.0 ± 15.0%) with stable CHF underwent resting echocardiography and cardiopulmonary exercise testing. Leg muscle strength was measured for the evaluation of peripheral factors. Global longitudinal strain (GLS) in the apical 4-, 3-, and 2-chamber views and global circumferential strain (GCS) in the parasternal mid short-axis view were measured. RESULTS: In all patients, peak [Formula: see text] correlated with leg muscle strength (r = 0.55, p < 0.0001), LVEF (r = 0.46, p < 0.001), GLS (r = -0.45, p < 0.001), and GCS (r = -0.41, p = 0.005), respectively. No significant correlation was found between the ratio of early transmitral velocity to peak early diastolic mitral annulus velocity (E/E') and peak [Formula: see text]. In the patients with heart failure and reduced LVEF, a multiple stepwise linear regression analysis based on leg muscle strength, LVEF, E/E', GLS, and GCS was performed to identify independent predictors of peak [Formula: see text], resulting in leg muscle strength and GLS (R (2) = 0.888) as independent predictors of peak [Formula: see text]. CONCLUSION: Global longitudinal strain at rest could possibly predict exercise capacity, which appeared to be more useful than LVEF, E/E', and GCS in CHF patients with reduced LVEF.

Cardiac function and structure in longitudinal analysis of echocardiography in peritoneal dialysis patients.

BACKGROUND: Echocardiography is widely used for the evaluation of cardiac structures and function. The prognostic value of assessment of left cardiac atrium (LA) size in peritoneal dialysis (PD) patients is still unclear. The objective of the present study is to investigate prospectively a longitudinal monitoring of echocardiography parameters after start of PD. We also investigated a correlation study among plasma atrial natriuretic peptide (ANP) level, LA size, and cardiac function undergoing aggressive treatment. METHODS: Correlation among plasma ANP, LA size, and cardiac function was prospectively analyzed by Doppler echocardiography in 32 PD patients in Juntendo University Hospital, Tokyo. Measurement of these parameters was performed at 0, 6, 12, 18, and 24 months after start of PD. All patients were treated with an angiotensin type 1 receptor blocker to control blood pressure to less than 140/90 mmHg. Other antihypertensive drugs such as diuretics and/or calcium channel blockers were added if blood pressure rose to over 140/90 mmHg. Hemoglobin and hematocrit levels were targeted at 10.0 g/dL and 30.0% respectively with recombinant human erythropoietin treatment. A diuretic was added or patients decreased their water intake if ANP was more than 43.0 pg/mL or LA diameter (LAD) more than 39 mm, and for other basic markers of volume status. Cardiac function was measured before and after drainage of PD fluid to evaluate the influence of cardiac function. RESULTS: LAD at start of dialysis (36 +/- 4.6 mm) decreased significantly to 33 +/- 3.3 mm (p < 0.05), 33 +/- 3.2 mm (p < 0.05), and 33 +/- 3.6 mm (p < 0.05) after 6, 12, and 24 months, respectively. Ejection fraction after 6 months was significantly increased compared with that at start of dialysis (p < 0.05). Left ventricular mass index (LVMI) after 6, 12, and 24 months was significantly decreased compared with that at start of dialysis (p < 0.05). ANP was 56 +/- 39 pg/mL at start of dialysis and decreased significantly to 33 +/- 19 pg/mL after 24 months (p < 0.05). ANP was significantly correlated with LAD (r = 0.412, p < 0.01), transmitral A wave flow velocity (r = 0.429, p < 0.01), and LVMI (r = 0.426, p < 0.01). Instillation of the dialysis fluid did not affect any parameters except inferior vena cava dimension. CONCLUSION: This study demonstrates a reduction in LA size and LVMI in PD patients followed over 24 months. Left ventricular structure, contraction, and compliance were well preserved in PD patients undergoing aggressive treatment based on measurements of plasma ANP and LAD.

Acute myocardial infarction in a young adult patient with simultaneous total occlusion of double coronary arteries.

We report an otherwise healthy 16-year-old male patient with simultaneous double vessel acute myocardial infarction. Coronary angiography (CAG) showed simultaneous total occlusion of the left anterior descending artery (LAD) and the left circumflex artery (LCX). Emergent percutaneous coronary intervention (PCI) was performed on the diseased lesions. After PCI, coronary artery aneurysms were found in both the LAD and LCX. The patient was discharged after a 56-day hospitalization. The New York Heart Association (NYHA) Functional Classification at discharge was II. Medical therapy became ineffective over time because of exacerbated ischemic mitral regurgitation; successful mitral annuloplasty was performed. The post-operative course was uneventful.

Recurrent takotsubo cardiomyopathy with variant forms of left ventricular dysfunction.

A 78-year-old man presented to our emergency department with dyspnea. The patient was diagnosed as having pneumonia from the chest X-ray which depicted mass-like opacity in the left lower lobe. On the 5th hospital day, electrocardiography showed giant negative T waves in pericardial leads and echocardiography demonstrated left ventricular apical akinesis and basal hyperkinesis. Accordingly, the patient was retrospectively diagnosed as having typical takotsubo cardiomyopathy. Two years later, the patient was admitted again to our hospital with pneumonia. On the 2nd hospital day, echocardiography showed left ventricular basal and mid-ventricular akinesis combined with normal apical wall motion. Ventricular wall motion was normalized within two months. The patient was finally diagnosed as having inverted takotsubo cardiomyopathy. Here, we report the patient who had recurrent takotsubo cardiomyopathy with variant forms of left ventricular dysfunction caused by repeated physical stress in two years.

Hyperventilation and cold-pressor stress echocardiography combined with automated functional imaging non-invasively detected vasospastic angina.

A 47-year-old male presented with chest discomfort while sleeping. The patient was suspected of having vasospastic angina (VSA) and underwent hyperventilation and cold-pressor stress echocardiography. No chest pain, ECG changes or decreased wall motion was found. However, automated function imaging (AFI) showed decreased peak systolic strain at the apex and postsystolic shortening at both the apex and inferior wall, which was not found before the test. The provocation test revealed 99% stenosis in the right coronary artery #2 at a dose of 50 µg acetylcholine and 90% stenosis in the left coronary artery #8 at a dose of 100 µg. The patient was thus diagnosed as having VSA. The present case demonstrates the usefulness of AFI combined with hyperventilation and cold-pressor stress echocardiography as a screening examination for VSA.

Three-dimensional echocardiographic assessments of exercise-induced changes in left ventricular shape and dyssynchrony in patients with dynamic functional mitral regurgitation.

AIMS: Left ventricular (LV) shape and LV dyssynchrony are two cofactors associated with functional mitral regurgitation (MR) in patients with heart failure. Both can be accurately examined by real-time three-dimensional echocardiography (3DE). We examined the relationship between dynamic MR and exercise-induced changes in LV shape and synchronicity using 3DE. METHODS AND RESULTS: Fifty patients with systolic LV dysfunction underwent 2D and 3D quantitative assessment of LV function, shape, and synchronicity at rest and during symptom-limited exercise test. According to the magnitude of change in MR, patients were divided into EMR group (15 patients, 30%), if the degree of MR increased during test, and NEMR group. During exercise, the changes in LV volumes and ejection fraction were similar in both groups, whereas changes in mitral valvular deformation parameters, in LV sphericity index, and in the extent of LV dyssynchrony were more pronounced in the EMR group. At rest, only the 3D sphericity index could distinguish the two groups. By stepwise multiple regression model, dynamic changes in the systolic dyssynchrony index, sphericity index, and coaptation distance were associated with dynamic MR (r(2) = 0.45, P = 0.012). CONCLUSION: Dynamic MR during exercise is related to the 3D changes in LV shape and in LV synchronicity.

The echocardiographic determinants of functional mitral regurgitation differ in ischemic and non-ischemic cardiomyopathy.

BACKGROUND: Functional mitral regurgitation (MR) is one of the common and severe complications in patients with dilated cardiomyopathy. The detailed mechanisms that cause functional MR remain to be elucidated. Using two-dimensional transthoracic echocardiography, we investigated the differences in major determinants of MR severity between ischemic cardiomyopathy (ICM) and non-ICM patients. METHODS: We enrolled 103 patients (91 males; age 64+/-12 years) with significant left ventricular (LV) dilatation. They were divided into ICM group (n=69) with significant coronary disease, and non-ICM (n=34) group without coronary disease. We devised a novel and simple parameter; the short-axis sphericity index (SI), to evaluate global LV remodeling, and used coaptation depth (CD) and tenting area (TA) to evaluate mitral deformity. RESULTS: In all cases, CD, TA and left atrium diameter (LAD) correlated positively with maximum regurgitation area (MRA) (r=0.54, 0.57, 0.57; P<0.0001). A negative correlation was observed between MRA and SI (r=-0.33, P=0.0008). There was no significant relationship between MRA and LV ejection fraction (EF). In non-ICM cases, SI tended to be lower with reduced EF. Multivariate stepwise linear regression analysis showed the following equations; ICM: MRA=-9.4+0.81CD+0.21LAD (r2=0.47, P<0.0001), non-ICM: MRA=-7.2+0.17LVDs (LV end systolic diameter) -8.7SI+0.27LAD (r2=0.63, P<0.0001). CONCLUSIONS: The strongest determinants of functional MR severity differ in ICM and non-ICM. While LV diameter and SI (global LV remodeling index) mainly determine the severity in non-ICM, CD that reflects mitral deformity is the major determinant in ICM.

Pre-operative atrial fibrillation as the key determinant of outcome of mitral valve repair for degenerative mitral regurgitation.

AIMS: To examine the impact of pre-operative atrial fibrillation (AF) on the outcome of mitral valve repair (MVR) for degenerative mitral regurgitation (MR). METHODS AND RESULTS: Among 392 patients with moderate to severe MR who underwent MVR between 1991 and 2002, 283 patients with isolated degenerative MR were followed for 4.7+/-3.3 years. Of 27 deaths, nine were due to cardioembolic events and four were due to left ventricular (LV) dysfunction. When compared with patients with pre-operative AF, those with sinus rhythm (SR) had better survival (96+/-2.1 vs. 87+/-3.2% at 5 years, P=0.002) and higher cardiac event-free rates (96+/-2.0 vs. 75+/-4.4% at 5 years, P<0.001). In patients with pre-operative SR, observed and expected survival were similar (P=0.811). Cox multivariable regression analysis confirmed AF [P=0.027, adjusted hazard ratio (AHR) 2.9] and age as independently predictive of survival, and AF (P=0.002, AHR 3.1), New York Heart Association Class, and LV fractional shortening as independently predictive of cardiac event. CONCLUSION: Death due to LV dysfunction was not frequent and cardioembolic events due to AF were the leading cause for cardiac death. Pre-operative AF became a strong independent predictor of survival and morbidity. Patients with pre-operative SR had excellent prognosis. The benefits of preventing cardioembolic events due to AF validate the indication of MVR for patients with high risk for AF.

Pulmonary thromboembolism in a patient with an anomalous right coronary artery as a cause of unusual biventricular myocardial infarction.

This report presents the first case of an unusual biventricular myocardial infarction caused by pulmonary thromboembolism in a 55-year-old woman who had an anomalous origin of the right coronary artery (RCA) from the left coronary sinus. The RCA consequently courses between the aorta and pulmonary trunk, and dilatation of the pulmonary artery because of elevated pulmonary artery pressure compressed the proximal portion of the RCA. The consequent reduced right coronary oxygen supply and sudden increase in right ventricular afterload contributed to the characteristic right ventricular infarction, in addition to a left ventricular infero-posterior infarction. Her anginal symptoms disappeared following successful anticoagulation therapy and insertion of an inferior vena caval filter, without coronary bypass. This pathophysiologic phenomenon is rare, but can be fatal.

Impact of mitral regurgitation on long-term survival in patients with ischemic cardiomyopathy: efficacy of combined mitral valve repair and revascularization.

Ischemic cardiomyopathy complicated by severe mitral regurgitation (MR) has a poor prognosis. In such cases, whether mitral valve repair for MR improves the prognosis of survival remains unclear. In this study, 50 patients diagnosed with ischemic cardiomyopathy at our hospital between August 1991 and August 1996 were studied to examine the long-term prognosis and factors determining the prognosis. Among 17 patients with the complication of severe MR, 11 underwent mitral valve repair (repair group) and 6 did not (nonrepair group). Among the 33 patients without MR, 15 underwent revascularization (revascularization group) and 18 received medical treatment alone (medical group). Patients with MR showed significantly poorer baseline activities of daily living (ADL) [New York Heart Association (NYHA) class III or above: MR(+) vs MR(-) = 14 vs 8; P = 0.0001] and survival rate [MR(+) vs MR(-); log rank = 3.8, P = 0.05]. In contrast, patients in whom mitral valve repair was actively performed to resolve MR had favorable outcomes for both ADL (NYHA class improved from 3.9 +/- 0.3 to 2.7 +/- 1.0; P = 0.0004) and survival rate (MV repair vs nonrepair: long rank = 10.1, P = 0.0015). In addition, among patients without MR, the revascularization group showed more favorable results in terms of ADL (NYHA class improved from 3.5 +/- 0.7 to 2.5 +/- 0.8; P = 0.0059) and survival rate (revascularization vs medical: log rank = 3.7, P = 0.05), irrespective of improvement of left ventricular function. When the factors determining the prognosis for ischemic cardiomyopathy were examined by multivariate analysis, whether or not revascularization was conducted, the presence or absence of mitral regurgitation, and if present, whether or not mitral valve repair was performed were identified as independent factors determining the prognosis (revascularization: hazard ratio = 0.121, P = 0.012; absence of MR: hazard ratio = 0.104, P = 0.050; mitral valve repair: hazard ratio = 0.018, P = 0.005). These results showed that revascularization should be conducted as actively as possible in patients with ischemic cardiomyopathy; in addition, for those patients with mitral regurgitation, mitral valve repair should be conducted actively to relieve it.

Acute myocardial infarction caused by embolism of thrombus in the right coronary sinus of Valsalva: a case report and review of the literature.

A 56-year-old man presented with sustained chest pain. Coronary angiography revealed total occlusion of the distal right coronary artery and left anterior descending branch. Left ventriculography depicted a mobile mass in the right sinus of Valsalva originating from the ostium of the right coronary artery. Transesophageal echocardiography (TEE) showed a mobile mass in the sinus of Valsalva and another mobile mass in the aortic arch. The mass at the right sinus of Valsalva was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study showed protein S deficiency. This is the first case of acute myocardial infarction as a result of multiple coronary embolism caused by thrombosis in the right sinus of Valsalva with a second aortic arch thrombosis, contributed by protein S deficiency.

Impact of a preoperative mitral regurgitation scoring system on outcome of surgical repair for mitral valve prolapse.

The optimal timing of surgical correction of severe mitral regurgitation (MR) is important for improved morbidity and mortality. We utilized a scoring system to decide the timing of procedures. Based on clinical features and echocardiographic data, we hypothesized that preoperative semi-quantitation of MR using this scoring system may be useful for predicting prognosis after repair. The MR score was composed of 6 parameters associated with disease severity (i.e., history of heart failure, atrial fibrillation, pulmonary hypertension, left ventricular end-systolic dimension, fractional shortening, and left atrial dimension). The maximum score was 6. Of 267 patients who underwent mitral valve repair in the last 10 years, 191 patients with mitral valve prolapse were studied. Patients were categorized into 2 groups according to MR score (group low [L] : 0 to 2.5 and group high [H]: >/=3.0) irrespective of New York Heart Association functional class. A significant difference in postoperative event-free survival was observed between both groups (p = 0.0014); the adjusted risk ratio was 3.4 (95% confidence interval 1.6 to 7.2). Postoperative echocardiography showed larger left ventricular systolic dimensions (p <0.0001), lower fractional shortening (p = 0.0016), and larger left atrial dimensions (p <0.0001) in group H than group L. Thus, an MR score is a simple way to predict the prognosis of severe MR independently of subjective symptoms in patients undergoing mitral valve repair.

Echocardiographic prediction of left ventricular dysfunction after mitral valve repair for mitral regurgitation as an indicator to decide the optimal timing of repair.

OBJECTIVES: This study sought to determine whether echocardiography before mitral valve repair (MVR) for mitral regurgitation (MR) was predictive of postoperative left ventricular (LV) dysfunction and useful for deciding the optimal timing of repair. BACKGROUND: Some reports have shown that the preoperative echocardiographic data of left ventricular ejection fraction (LVEF) and left ventricular end-systolic diameter (LVDs) were good predictors of postoperative LV dysfunction. However, few reports were based on long-term follow-up data of large numbers of patients who underwent MVR in the last decade. METHODS: A total of 274 patients with moderate or severe MR underwent MVR between October 1, 1991, and September 30, 2000. Among them, 171 patients who had both an operation for isolated MR due to degenerative pathology and a postoperative echocardiogram were studied. Postoperative echocardiograms were performed 3.9 +/- 2.4 years after the operation. The LVEF decreased from 66 +/- 10% before surgery to 63 +/- 11% after surgery (p < 0.0001). On univariate analysis, preoperative LVEF and LVDs correlated with postoperative LVEF (r = 0.41 and r = -0.39, respectively). Overall, postoperative LV dysfunction (defined as LVEF <50%) was not frequent (12%). However, the incidence of postoperative LV dysfunction was high in patients with preoperative LVEF <55% (38%) or LVDs > or =40 mm (23%). CONCLUSIONS: In patients with MR, the echocardiographic data of LVEF and LVDs were good predictors of postoperative LV dysfunction. When a decrease in LVEF or an increase in LVDs is detected, MVR should be considered to preserve postoperative LV function.

Infective endocarditis associated with quadricuspid aortic valve.

A 26-year old Japanese woman experienced new aortic valve regurgitation associated with a preceding high fever of unknown cause. During the fever episode, although bacteremia or fungemia was not evident despite frequent blood cultures, intravenous panipenem/betamipron (PAPM/BP) gradually resulted in decline of the fever. Echocardiography and operative procedures revealed a quadricuspid aortic valve (QAV), which was composed of two equal larger cusps and two unequal smaller cusps (type f). A smaller accessory cusp was damaged but showed no active vegetation. A Medtronic Freestyle bioprosthesis was implanted using a subcoronary technique. Although the risk of endocarditis for this rare valve abnormality is not well documented, the present case may support the conventional assumption that patients with unequal small cusps are prone to endocarditis.

Rubella-associated perimyocarditis--a case report.

Perimyocarditis represents an inflammation of both the myocardium and pericardium. Although several causative agents have been recognized, pericarditis or myocarditis associated with rubella is an unusual complication. In a 29-year-old woman, left ventricular function transiently deteriorated accompanied by ongoing cardiac inflammation a few days after illness. The titer of rubella virus increased from seronegative to more than 32-fold during the admission, and a rise in specific antirubella virus antibody was present. The patient was suspected of having perimyocarditis associated with the rubella infection. The authors also present clinical features of rubella-associated perimyocarditis and myocarditis in the literature.