Effects on pre- and posttransplant pulmonary hemodynamics in patients with continuous-flow left ventricular assist devices

OBJECTIVE

Pulsatile left ventricular assist devices have been shown to effectively reduce pulmonary hypertension in patients with end-stage heart failure. However, it remains to be seen whether newer continuous-flow left ventricular assist devices have a similar effect on pulmonary hypertension. The objective of this study was to determine whether the HeartMate II (Thoratec Corp, Pleasanton, Calif), a continuous-flow left ventricular assist device, is effective in improving pulmonary hemodynamics in the period after left ventricular assist device support and posttransplant.

METHODS

Fifty patients with end-stage heart failure underwent HeartMate II left ventricular assist device placement as a bridge to transplant. We evaluated their pulmonary hemodynamics with right-sided heart catheterization at baseline, after left ventricular assist device placement, and after heart transplant.

RESULTS

The mean age of patients was 53.7 +/- 13.5 years. Ischemic etiology was present in 60% of the patients. After left ventricular assist device placement (mean duration, 135 +/- 60 days), mean systolic and diastolic pulmonary artery pressures decreased significantly from a baseline of 55.2 +/- 13.4 mm Hg and 27.3 +/- 6.8 mm Hg, respectively, to 35.9 +/- 10.8 mm Hg and 15.8 +/- 6.5 mm Hg, respectively (P < .001). Similarly, mean pulmonary vascular resistance decreased significantly from a baseline of 3.6 +/- 1.9 Woods units to 2.1 +/- 0.8 Woods units (P < .001). Posttransplant pulmonary hemodynamics also remained within normal limits, even in patients with previously severe pulmonary hypertension.

CONCLUSION

Continuous-flow left ventricular assist devices effectively improve pulmonary hemodynamics associated with end-stage heart failure. Moreover, pulmonary hemodynamics remain within normal limits in the posttransplant period, even in patients with severe pulmonary hypertension. Therefore, adequate left ventricular decompression achieved with newer left ventricular assist devices can reverse significant pulmonary hypertension in patients with end-stage heart failure, making them eligible for cardiac transplantation.

Effect of light exercise on valvular regurgitation in Standardbred trotters

REASONS FOR PERFORMING STUDY

Although valvular regurgitation is diagnosed frequently by colour Doppler echocardiography in racehorses at rest, there is currently no information about the effect of exercise on valvular regurgitation.

OBJECTIVES

To investigate the effect of light exercise on valvular regurgitation in a population of trotters.

METHODS

Standardbred trotters (n = 73) were examined by resting auscultation and echocardiography, of which 50 fullfilled the criteria of the study. Of these, 4 had reduced performance according to the trainers and were not included in the statistical analyses. Horses that showed valvular regurgitations diagnosed by colour Doppler echocardiography at rest, were light exercised and the regurgitant valves were then re-examined by colour Doppler echocardiography.

RESULTS

Of the 46 horses, 41 (89%) had one or more valvular regurgitations at rest with tricuspid regurgitation present in 83% of horses, mitral regurgitation 46%, pulmonary regurgitation 37% and aortic regurgitation 57%. After exercise, one or more valvular regurgitation persisted for 23 of the 41 horses (56%). The regurgitation decreased significantly for mitral, pulmonary and aortic valves; the mitral regurgitation persisted for 21% of the horses, pulmonary regurgitation persisted for 6% and aortic regurgitation persisted after exercise for 23 % with regurgitation diagnosed at rest. Half of those with tricuspid regurgitation at rest still had tricuspid regurgitation after exercise.

CONCLUSIONS

The results of this study showed that the majority of small valvular regurgitations disappear after light exercise. However, the severity of tricuspid regurgitation increased in 4 horses. Furthermore, these horses were not performing satisfactorily according to the trainers.

POTENTIAL RELEVANCE

Studies in man have shown that severity after exercise suggests pathological regurgitation. The present study indicates that echocardiographic examination of valvular regurgitation after exercise might be a relevant examination in horses. However, more studies are needed to evaluate the effect of strenuous exercise on valvular regurgitation in horses.

Non-invasive imaging in percutaneous mitral valve procedures

Novel percutaneous techniques for the treatment of mitral valve (MV) disease have recently been developed and provide an alternative to surgery in patients with high operative risk. However, the complexity of MV anatomy and the variety of mitral regurgitation mechanisms require sophisticated procedures and accurate patient selection. Non-invasive imaging (echocardiography, multislice computed tomography) provides crucial anatomical details and exact characterisation of the mechanism underlying mitral regurgitation, thereby facilitating selection of potential candidates for these procedures. Furthermore, imaging is needed for procedural guidance and assessment of long-term results; for these purposes echocardiographic techniques are mainly used. In this review, a detailed discussion on the use of non-invasive imaging in selection, procedural guiding and follow-up of patients undergoing percutaneous MV interventions is provided.

Valvular heart disease: diagnosis and management

Valvular heart disease (VHD) encompasses a number of common cardiovascular conditions that account for 10% to 20% of all cardiac surgical procedures in the United States. A better understanding of the natural history coupled with the major advances in diagnostic imaging, interventional cardiology, and surgical approaches have resulted in accurate diagnosis and appropriate selection of patients for therapeutic interventions. A thorough understanding of the various valvular disorders is important to aid in the management of patients with VHD. Appropriate work-up for patients with VHD includes a thorough history for evaluation of causes and symptoms, accurate assessment of the severity of the valvular abnormality by examination, appropriate diagnostic testing, and accurate quantification of the severity of valve dysfunction and therapeutic interventions, if necessary. It is also important to understand the role of the therapeutic interventions vs the natural history of the disease in the assessment of outcomes. Prophylaxis for infective endocarditis is no longer recommended unless the patient has a history of endocarditis or a prosthetic valve.

[Clinical inertia and treatment adherence in the management of chronic valvular heart diseases]

Valvular heart diseases are of increasing importance among the general adult population. When compared with other heart diseases, there are few trials in the field of valvular heart disease and randomized clinical trials are particularly scarce. Two sets of guidelines exist: one in the USA and the other in Europe. However, they are not always consistent due to the lack of randomized data and it appears that, frequently, there is a gap between the existing guidelines and their effective application.

The role of cardiovascular computed tomographic angiography for coronary sinus mitral annuloplasty

BACKGROUND

The coronary sinus (CS) travels in close proximity to the left circumflex (LCX) artery. Percutaneously placed CS devices used to treat mitral regurgitation (MR) therefore have the potential to impinge upon the LCX arterial distribution and compromise coronary flow.

OBJECTIVES

In this study, we sought to analyze the anatomic relationship between the CS, LCX and mitral annulus (MA) in patients with right dominant (RCD), left dominant (LCD) and codominant (CCD) arterial systems using a novel systematic approach.

METHODS

We retrospectively studied 102 normal patients (46 females) and 27 consecutive patients (5 females) with ischemic severe MR. All patients underwent cardiovascular computed tomographic (CCT) angiography with a 64 multidetector scanner for clinical indications. Images were analyzed using a GE Advantage workstation, version 4.4, capable of advanced image processing and manipulation.

RESULTS

In patients with a normal mitral valve, the LCX initially crossed under the coronary sinus/great cardiac vein (CS/GCV) in 74% with RCD, 83% with LCD and 97% with CCD. In patients with ischemic severe MR, the LCX initially crossed under the CS/GCV in 96%.

CONCLUSIONS

The majority of patients, especially those with a CCD, have the LCX initially coursing under the CS/GCV. CCT data analysis using our newly established method is an excellent tool to evaluate the anatomic course of the LCX in patients being evaluated for percutaneous CS device placement.

An unusual case of endocarditis- a rare occurrence with unique etiology

The seeding of endocarditis directly to the non-valvular areas of the heart is extremely rare. We report a case of a 36-year-old woman presenting with sudden-onset lower-extremity pain and swelling, who was found to have mitral valve endocarditis with pulmonary vein vegetation. Echocardiography showed a large linear mitral valve mass coming into contact with the base of the left inferior pulmonary vein with each ventricular contraction. Spread into the atrium from mitral valve endocarditis is generally thought to be caused by jet lesions, whereas direct seeding as in this case is not well described. The location in the pulmonary vein is also unique, with no case reports being found in the literature, although the significance remains to be ascertained.

Percutaneous closure of mitral paravalvular leak via retrograde approach: with use of the Amplatzer duct occluder II and without a wire loop

The gold-standard treatment for prosthetic-valve paravalvular leakage is surgery to repair or replace the valve; however, the morbidity and mortality rates cannot be ignored, and some patients are poor surgical candidates. The percutaneous closure of such defects is possible, and different devices are being used for this purpose. In almost all instances, a femorofemoral or femorojugular wire loop is constructed to deliver the closure device. Herein, we present the case of a 61-year-old man in whom a mitral paravalvular leak was successfully closed with use of the Amplatzer Duct Occluder II, via retrograde approach under 3-dimensional transesophageal echocardiographic guidance, without the use of a wire loop. To the best of our knowledge, this is the 1st report of retrograde device deployment without the construction of an arteriovenous wire loop, and the 1st case in which the Amplatzer Duct Occluder II was used for the percutaneous closure of a mitral paravalvular leak.

[The most common heart valve diseases: aortic stenosis and mitral regurgitation. A few comments on guidelines and recommendations by societies of cardiology]

Recommendations of professional societies, frequently called guidelines as per the English translation, provide help to the general practice as well as specialized physicians. These are recommendations, not a legislative norm. Societies of cardiology have issued 3 new guidelines over the recent years; American ACC/AHA in 2006 and European ESC and Czech CSC in 2007. Guidelines for diagnostics and therapy are presented as Class I to III according to the suitability of the procedure and the level of evidence is classified in groups A to C. Emphasised is the effort of societies of cardiology to provide unbiased guidelines. They request the authors to provide a statement confirming they are not in any way related to any organization, institution or company that could be at present or in the future considered as a conflict of interests. Mentioned is the rapid growth of knowledge that does not allow the guidelines to consider the latest advances to trans-catheter therapy of the both most frequently occurring valve disorders.

Percutaneous mitral annuloplasty for functional mitral regurgitation: results of the CARILLON Mitral Annuloplasty Device European Union Study

BACKGROUND

Functional mitral regurgitation (FMR), a well-recognized component of left ventricular remodeling, is associated with increased morbidity and mortality in heart failure patients. Percutaneous mitral annuloplasty has the potential to serve as a therapeutic adjunct to standard medical care.

METHODS AND RESULTS

Patients with dilated cardiomyopathy, moderate to severe FMR, an ejection fraction <40%, and a 6-minute walk distance between 150 and 450 m were enrolled in the CARILLON Mitral Annuloplasty Device European Union Study (AMADEUS). Percutaneous mitral annuloplasty was achieved through the coronary sinus with the CARILLON Mitral Contour System. Echocardiographic FMR grade, exercise tolerance, New York Heart Association class, and quality of life were assessed at baseline and 1 and 6 months. Of the 48 patients enrolled in the trial, 30 received the CARILLON device. Eighteen patients did not receive a device because of access issues, insufficient acute FMR reduction, or coronary artery compromise. The major adverse event rate was 13% at 30 days. At 6 months, the degree of FMR reduction among 5 different quantitative echocardiographic measures ranged from 22% to 32%. Six-minute walk distance improved from 307+/-87 m at baseline to 403+/-137 m at 6 months (P<0.001). Quality of life, measured by the Kansas City Cardiomyopathy Questionnaire, improved from 47+/-16 points at baseline to 69+/-15 points at 6 months (P<0.001).

CONCLUSIONS

Percutaneous reduction in FMR with a novel coronary sinus-based mitral annuloplasty device is feasible in patients with heart failure, is associated with a low rate of major adverse events, and is associated with improvement in quality of life and exercise tolerance.

[Functional mitral regurgitation]

Functional mitral regurgitation (FMR) is the mitral regurgitation that occurs due to myocardial disease in the presence of normal mitral valve leaflets. This scenario has the different characteristics than the organic mitral regurgitation. Functional mitral regurgitation is a disease of the ventricle and occurs by the deformation of the mitral valve leaflets. This morbid entity is frequent and has bad prognosis. Functional mitral regurgitation is the result of complex pathophysiologic process including left ventricular local and global remodeling, mitral annular and papillary muscle dysfunction, and left ventricular dysfunction. The dynamic behavior of FMR complicates the quantification of the regurgitation. Exercise stress echocardiography is of particular importance in the evaluation of the hemodynamic burden of FMR. Particular pathophysiological properties of the FMR necessitate different therapeutic approaches than the current ones for classical mitral regurgitation.

Papillary muscle dyssynchrony as a cause of functional mitral regurgitation in non-ischemic dilated cardiomyopathy patients with narrow QRS complexes

OBJECTIVE

Mitral regurgitation (MR) increases mortality in dilated cardiomyopathy (DCM). We investigated the prevalence of functional MR in non-ischemic DCM patients with narrow QRS intervals and its association with papillary muscle dyssynchrony.

METHODS

Ninety-three patients were enrolled consecutively in this cross-sectional study. Patients were evaluated for the presence of intraventricular (DYS Sep-Lat Sys) and papillary muscle (DYS Inter PAP Sys) systolic dyssynchrony using tissue Doppler echocardiographic imaging (TDI). Two-dimensional and Doppler echocardiography were used for quantification of MR. Statistical analyses were performed using unpaired t test, Mann-Whitney U test, correlation and logistic regression analyses.

RESULTS

Thirty-seven patients (39%) had significant DYS Sep-Lat Sys and 25 patients (26%) had DYS Inter PAP Sys. Patients with DYS Inter PAP Sys had lower basal septum systolic (p=0.007) and late diastolic velocities (p=0.049), greater MR volume (p=0.01), effective regurgitant orifice (ERO) (p=0.01), and E/A ratios (p=0.03) than the patients without DYS Inter PAP Sys. Fifty-five patients with narrow QRS intervals were also evaluated for DYS Inter PAP Sys. Patients with DYS Inter PAP Sys and narrow QRS had lower basal septum TDI peak systolic velocities (p=0.038), higher MR volume (p=0.03) and ERO (p=0.03). Logistic regression analysis revealed that NYHA Class III-IV (OR=6.4, 95% CI: 1.1-37.1, p=0.038) and DYS Inter PAP Sys (OR=9.5, 95% CI: 1.17-75.78, p=0.034) were the independent predictors of functional MR >20 ml.

CONCLUSION

Papillary muscle systolic dyssynchrony is common and correlated with functional MR in non-ischemic DCM patients with sinus rhythm and narrow QRS. Papillary muscle systolic dyssynchrony may help predict patients who will benefit from cardiac resynchronization therapy.

Deleterious effects of cardiac pacing in a patient with mitral insufficiency

A 70-year-old, artificially paced women with dizziness and extremely low physical capacity exhibited a systolic BP varying from one moment to another; in standing position it was not measurable. With the aid of a strain gauge technique, the amplitude of the pulse wave of her left thumb was recorded and shown to vary widely. The variations were correlated to synchrony or asynchrony between atrial and ventricular activity. Pronounced decreases in stroke volume and peripheral pulse volume were recorded with pacemaker-induced beats compared with idioventricular beats. With artifical stimulation at a rate of 45/min, thus avoiding competition but still protecting her from syncopes, she was free from symptoms.

Mitral regurgitation

Mitral regurgitation affects more than 2 million people in the USA. The main causes are classified as degenerative (with valve prolapse) and ischaemic (ie, due to consequences of coronary disease) in developed countries, or rheumatic (in developing countries). This disorder generally progresses insidiously, because the heart compensates for increasing regurgitant volume by left-atrial enlargement, causes left-ventricular overload and dysfunction, and yields poor outcome when it becomes severe. Doppler-echocardiographic methods can be used to quantify the severity of mitral regurgitation. Yearly mortality rates with medical treatment in patients aged 50 years or older are about 3% for moderate organic regurgitation and about 6% for severe organic regurgitation. Surgery is the only treatment proven to improve symptoms and prevent heart failure. Valve repair improves outcome compared with valve replacement and reduces mortality of patient with severe organic mitral regurgitation by about 70%. The best short-term and long-term results are obtained in asymptomatic patients operated on in advanced repair centres with low operative mortality (<1%) and high repair rates (>/=80-90%). These results emphasise the importance of early detection and assessment of mitral regurgitation.

Cardiac mucormycosis with T-cell immunodeficiency

We present a case of a 2 year old apparently healthy child who presented with fever and mass on the mitral valve. Excision histopathology of the mass revealed mucormycosis. After 4 months, she had CNS embolisation with recurrence of cardiac lesion when investigations revealed associated T-cell immunodeficiency.

Percutaneous transvenous mitral commissurotomy versus surgical commissurotomy in the treatment of mitral stenosis

There is no doubt that percutaneous transvenous mitral commissurotomy (PTMC) in experienced centers is associated with a low risk of major complications and yields excellent immediate and long-term outcome. Although previous observational studies on both PTMC and surgical commissurotomy have indicated similar outcome between the two treatment strategies in terms of valve area improvement and risk of major complication (death, thromboembolism and significant resultant mitral regurgitation), it was not until recently that several prospective randomized trials comparing the two procedures and involving > 470 patients with favorable valve characteristics (pliable, noncalcified valve with mild subvalvular disease and no or mild mitral regurgitation), have confirmed that PTMC is indeed just as, if not more, effective as surgical commissurotomy. The late restenosis rate at up to 3-year follow-up appears comparable. Furthermore, PTMC has other additional benefits. It is nontraumatic, may be repeated without additional risk, and has been shown to be an extremely useful and efficacious palliative tool in those with end-stage mitral stenosis or with unfavorable valve anatomy who refuse surgery, and in certain subset of patients at high surgical risk because of medical comorbidities.

Three-dimensional echocardiography. New possibilities in mitral valve assessment

Recent developments in three-dimensional echocardiography have made it possible to obtain images in real time, without the need for off-line reconstruction. These developments have enabled the technique to become an important tool for both research and daily clinical practice. A substantial proportion of the studies carried out using three-dimensional echocardiography have focused on the mitral valve, the pathophysiology of mitral valve disease and, in particular, functional mitral regurgitation. The aims of this article were to review the contribution of three-dimensional echocardiography to understand the functional anatomy of the mitral valve and to summarize the resulting clinical applications and therapeutic implications.

Cogan's syndrome with left main coronary artery occlusion

Cogan's syndrome is a rare idiopathic chronic inflammatory disease of the eye and the inner ear in young adults. Cogan's syndrome can be associated with large vessel vasculitis. We report a young female, with a history of interstitial keratitis and audiovestibular disease, who presents with large vessel vasculitis with left main coronary artery occlusion and develops heart failure. Cogan's syndrome was diagnosed on the basis of the presence of large vessel vasculitis with the typical inner ear and ocular involvement.

Isolated cleft of the mitral valve: clinical spectrum and course

We have reviewed the clinical presentations, courses, and outcomes of 90 patients seen at Texas Children's Hospital from 1983 through 2008 who had an isolated cleft of the mitral valve without some form of endocardial cushion defect. Additional congenital cardiac defects were present in 61 of the 90 patients, 35 of whom had a congenital syndrome. Seven patients had isolated cleft of the mitral valve without other intracardiac defects, and in these 7 there was a progressive increase in the degree of mitral regurgitation during a median time of 26.5 months from diagnosis to surgery. The patients ranged from a gestational age of approximately 32 weeks to 21.9 years of age. No death was observed among the 39 surgical patients, including 32 who had additional cardiac defects. There was a significant reduction in the degree of mitral regurgitation in all patients who underwent surgery. Among the 51 patients who did not have surgery, the degree of regurgitation did not change significantly over the course of 1 to 27 years' observation. Isolated cleft of the mitral valve is an uncommon (but not rare) congenital malformation of the mitral valve that can cause all degrees of mitral regurgitation but can be managed medically or surgically.

Strategies for endovascular mitral valve repair

Technological advances have recently enabled mitral valve repair to be performed using endovascular techniques and thus open the possibility of nonsurgical treatment of mitral valve disease. While balloon valvotomy has been applied to mitral stenosis for over 20 years, a number of devices aimed at correcting mitral regurgitation are currently in preclinical and clinical development. While some of these, such as edge-to-edge repair, are catheter adaptations of established surgical techniques, others represent true departures from the current surgical paradigms of correcting mitral regurgitation. This review will summarize the current status of percutaneous transcatheter techniques for mitral valve repair. Included are balloon mitral valvotomy, indirect annuloplasty, direct annuloplasty, ventricular shape change, and edge-to-edge repair. These techniques certainly represent a new interdisciplinary paradigm between cardiac surgery and interventional cardiology and may be the next frontier in minimally-invasive cardiac surgery.

An unusual manifestation of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy typically presents with chest pain, ST changes, and transient left ventricular apical ballooning in the absence of epicardial coronary artery disease. This process is reversible and usually benign. An unusual manifestation is that of left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve. Recognition of this finding is critical in patient management especially in the setting of cardiogenic shock, as inotropes are likely to aggravate and worsen the clinical condition. We provide a systematic review and an illustrative case and discuss treatment strategies.

Comparison of Inoue balloon, metallic commissurotome and multi-track double-balloon valvuloplasty in the treatment of rheumatic mitral stenosis

BACKGROUND Percutaneous mitral valvuloplasty (PMV) is a well known non-surgical technique for treating patients with rheumatic mitral stenosis (MS). There are very few studies that have compared the 3 techniques together for their safety and efficacy.

METHODS

To compare the three different techniques for percutaneous mitral valvuloplasty (PMV) using Inoue balloon (IB), metallic commissurotome (PMMC), or multi-track double balloon (MTDB) in patients with MS.

RESULTS

A total of 486 patients were subjected to PMV using any of the 3 techniques, IB, PMMC or MTDB. The overall success rate was 97.3% (n = 473); 95.7% for IB, 97.6% for PMMC, and 98.3% for MTDB. Overall, the transmitral gradient decreased from 20.7 +/- 7.2 mmHg to 6.5 +/- 3.7 mmHg (p < 0.001) and mitral valve area (MVA) increased from 0.87 +/- 0.2 cm(2) to 1.9 +/- 0.4 cm(2) (p < 0.001). Left atrial pressure decreased from 29.3 +/- 8.4 mmHg to 16.1 +/- 11.5 mmHg (p < 0.001) and pulmonary arterial pressure decreased from 76.9 +/- 41.8 mmHg to 45.2 +/- 17.6 mmHg (p < 0.001). Thirteen patients (2.7%) required mitral valve replacement (MVR) for severe mitral regurgitation (MR) while one patient (0.2%) developed cardiac tamponade requiring urgent pericardiocentesis followed by surgical repair of the tear and open mitral valvotomy. There was no statistical difference among the 3 techniques used.

CONCLUSION

In conclusion, percutaneous mitral valvuloplasty is an effective procedure for MS with any of the three above techniques.

[From premature birth to cardiac surgery - severe heart failure due to infective endocarditis in pregnancy - a case report]

A 25-year-old woman, gravida 2, para 1, without any previous medical history was admitted to the hospital because of the signs and symptoms of fetal distress. After a caesarean section the woman developed an acute heart failure. Echocardiography demonstrated massive vegetations attached to aortic and mitral valves with their destruction. Surgical treatment was performed immediately. The postoperative period was complicated by chronic atrioventricular third degree heart block, requiring implantation of a pacemaker. Finally the woman was discharged from hospital and is followed regularly in the out-patient cardiac clinic.

Percutaneous mitral valvuloplasty through a Carpentier-Edwards ring

The authors report the case of a young girl with a Carpentier-Edwards annuloplasty ring for severe rheumatic mitral disease who presented 4 years later with mitral restenosis due to commissural fusion. She underwent successful percutaneous mitral commissurotomy with an Inoue balloon. Technical specificities and the safety of the procedure are briefly discussed.

Effects of interruption of long-term cardiac resynchronization therapy on left ventricular function and dyssynchrony

Interruption of short-term cardiac resynchronization therapy (CRT) has been shown to acutely worsen left ventricular (LV) function, mitral regurgitation, and LV dyssynchrony. The present study aims to assess whether LV reverse remodeling influences interruption of CRT, and, more practically, whether long-term continuous pacing is necessary in patients with reverse LV remodeling. A total of 135 recipients of CRT were selected after showing LV reverse remodeling defined as a decrease in LV end-systolic volume > or =15% after 6 months of CRT ("responders"). Echocardiography was performed at baseline and after 6 months with intermittent CRT on and off. LV dyssynchrony was determined using tissue Doppler imaging. During interruption of CRT, an acute deterioration in LV function, mitral regurgitation, and LV desynchronization were noted in responder patients. Of note, worsening of these echocardiographic measurements was observed, but they did not return to baseline values. For comparison, 100 nonresponder patients (without LV reverse remodeling) showed no significant echocardiographic changes during interruption. In conclusion, despite the presence of LV reverse remodeling, interruption of CRT resulted in worsening of LV function and desynchronization. Therefore, continuous long-term pacing is warranted to maintain the beneficial effects.

Leukocytoclastic vasculitis with severe cardiac involvement in an infant: a case report

Severe visceral involvement in leukocytoclastic vasculitis is rare. We report here the case of a 2-month-old male infant with leukocytoclastic vasculitis who initially presented with fever and skin purpura. Endomyocarditis with mitral valve regurgitation, multiple hepatic infarction, and pulmonary hemorrhage developed later. The patient was successfully managed with an aggressive treatment of high frequency oscillation ventilation and extracorporeal membrane oxygenation together with corticosteroid and azathioprine therapy for 3 months. Valvuloplasty was also performed due to irreversible damage of the mitral valve, although long-term oral anticongestive medications were also needed.

In vitro mitral chordal cutting by high intensity focused ultrasound

Mitral regurgitation, when it arises from functional restriction of mitral leaflet closure, can be relieved by surgical cutting of the mitral tendineae chordae. We hypothesized that high intensity focused ultrasound (HIFU) might be useful as a noninvasive extracorporeal technique for cutting mitral chordae. As a pilot study to test this hypothesis, we examined the in vitro feasibility of using HIFU to cut calf mitral chordae with diameters from 0.2 to 1.6 mm. Sixty-seven percent of chordae were completely cut with HIFU, operated at 4.67 MHz and 45 W acoustic power, with up to 120 pulses of 0.3-s duration at 2-s intervals. Forty-five percent were completely cut when the pulse duration was reduced to 0.2 s. The average diameter of those chordae, which were completely cut, was significantly smaller than that of incompletely cut chordae (0.59 +/- 0.30 versus 1.14 +/- 0.30 mm with a pulse duration of 0.2 s, p < 0.0001; 0.68 +/- 0.29 versus 1.32 +/- 0.20 mm with a pulse duration of 0.3 s, p < 0.0001). For each pulse duration, the number of pulses required for complete cutting exhibited a strong positive correlation with the chordae diameter. In conclusion, in vitro feasibility of mitral chordal cutting by HIFU depended on the diameter of chordae but was controllable by HIFU settings. (E-mail: abeyukio@aol.com).

Multivessel coronary drug-eluting stenting alone in patients with significant ischemic mitral regurgitation: a 4-year follow up

OBJECTIVE

Is there a role for multivessel drug-eluting stenting alone in the treatment of patients with concomitant significant ischemic mitral regurgitation and coronary artery disease?

METHODS

In 2003, a single medical center in Honolulu, Hawaii, performed a total of 6 cases of coronary revascularization in patients with concomitant significant ischemic mitral regurgitation (MR). All 6 patients had at least 3-4+ grade MR by echocardiography. All 6 patients had clinical presentation of myocardial ischemia. Of the 6 patients, 2 underwent percutaneous coronary intervention (PCI) alone, 2 had coronary artery bypass graft surgery (CABG) alone, and 2 had combined CABG + mitral valve repair (MVR). The patients were followed for 4 years for cardiac death, myocardial infarction or target lesion revascularization.

RESULTS

Clinical follow up after the index procedure showed significant improvement in MR in all patients. Left ventricular ejection fraction improved in both the PCI-only patients, in 1 of 2 CABG-only patients and no improvement in the CABG + MVR group. Incomplete revascularization occurred in 1 patient in the PCI-only arm, both patients in the CABG arm and in 1 of 2 in the combined surgical arm. At 48 months, the only endpoint observed was 1 cardiac death in the CABG-only arm.

CONCLUSIONS

Multivessel PCI with drug-eluting stents appears to be an acceptable first treatment for patients with concomitant severe multivessel coronary artery disease and ischemic MR. For those with no improvement in MR after PCI, MVR can be a later hybrid procedure.

[Ischemic mitral regurgitation]

Mitral regurgitation (MR) is a serious complication of coronary heart disease. The functional form is the most frequent, often presenting with a dynamic character. The presence, and in particular the severity of MR and its dynamic character have a major impact on the medium and long term prognosis. The mechanisms responsible for MR are complex and occur in a state of disequilibrium between traction forces and closing forces, for which the significance is partly affected by the presence of asynchrony in left ventricular contraction. The therapeutic management of these patients is difficult. In cases of proven asynchrony, implantation of a biventricular pacemaker is justified. A mitral surgical procedure may be envisaged in cases of severe MR where bypass surgery is planned. In cases of moderate MR at rest, an evaluation of its dynamic character on effort can assist with the decision to undertake combined surgery. Mitral regurgitation (MR) is a common and serious complication of ischemic heart disease. Three general forms are distinguished: MR related to acute rupture of the mitral pillar, ischemic MR and functional MR.

Treatment of severe functional mitral regurgitation: is cardiac surgery always indicated?

Severe functional mitral regurgitation associated with myocardial ischemia is conventionally a Class I indication for cardiac surgery. Mitral annuloplasty or mitral valve replacement are performed during coronary bypass surgery with the aim of improving the patient's ventricular function and symptoms. With the advancement of stent technology, sustained myocardial perfusion and improvement of ventricular function could be achieved by revascularization alone, leading to a reduction in the severity of mitral regurgitation. The purpose of this case is to review the role of transcatheter coronary revascularization in the management of myocardial ischemia associated with severe functional mitral regurgitation and heart failure.

The frequency, impact, and management of mitral regurgitation in patients with heart failure

Management of severe chronic mitral regurgitation (MR) in severe heart failure is challenging. There are controversies over the efficacy of surgical correction of MR in the presence of severely depressed left ventricular (LV) function. The etiology of MR plays an important role in clinical decision making. In organic MR, surgical correction should be performed even if patients have an LV ejection fraction of less than or equal to 30%. In functional MR, treatment of myocardial damage should be considered as the priority. The long-term mortality benefit of surgical correction of functional MR associated with severe LV dysfunction caused by cardiomyopathy (ischemic or dilated) likely depends on whether myocardial dysfunction can be reversed or improved by treatments (eg, coronary artery revascularization, pharmacologic treatment). Preoperative examination of viable myocardium (ischemic and hibernating myocardium) helps to identify a surgical candidate with ischemic MR associated with ischemic cardiomyopathy. The role of device treatment of MR in heart failure needs further investigation with outcome data.

Repercussion of functional mitral regurgitation on reverse remodelling in cardiac resynchronization therapy

AIMS

Cardiac resynchronization therapy (CRT) reduces the degree of functional mitral regurgitation (FMR). However, FMR has also been associated with a lack of clinical response to CRT. We undertook this study to determine whether the presence of FMR influences the reverse remodelling induced by CRT.

METHODS AND RESULTS

We used Doppler echocardiography to assess 20 patients with dilated cardiomyopathy before and 6 months after undergoing CRT. We evaluated the effect of reverse remodelling (reduction > or = 10% in end-systolic volume) according to the presence or absence of important FMR, defined as a regurgitant orifice area (ROA) of > or = 0.20 cm(2). Of the 20 patients (mean age, 64.7 +/- 8.2 years, eight women), 9 had marked FMR (ROA 0.40 +/- 0.12 cm(2)), 6 mild FMR (ROA 0.15 +/- 0.02 cm(2)), and 5 had trivial or no FMR. CRT reduced the presence of mitral regurgitation by 33.3% and induced reverse remodelling in 60% of the patients. A ROA > or = 0.20 cm(2) was associated with a lack of reverse remodelling, despite presenting similar baseline characteristics and a reduction in asynchrony to the other patients. Reverse remodelling was produced in all the other patients, with a significant reduction in end-systolic volume (41.7 +/- 21%; P = 0.003), accompanied by improvement in the ejection fraction (P = 0.003) and myocardial performance index (P = 0.027).

CONCLUSION

CRT improved FMR, although the baseline presence of important mitral regurgitation, with a ROA > or = 0.20 cm(2), in patients undergoing CRT was associated with a lack of response in reverse remodelling.