A comparison between the heart of young athletes and of young healthy sedentary subjects: a morphometric and morpho-functional study by echo-color-doppler method

Morphologic and morpho-functional heart differences between healthy young athletes and healthy young subjects who do not practice agonistic sport have been studied using Color Doppler Echography (CDE). Overall, 68 subjects were enrolled in the study (age range: 19-26 yrs). Of them, 34 subjects (17 men and 17 women) were practicing sport agonistically; the 34 controls (17 men and 17 women) did not practice any sport on a regular basis. In each subject, age, height, weight, body mass index, practiced sport, systolic and diastolic blood pressure were recorded. CDE measures included telediastolic left and right ventricular diameters (LVDd and RVDd, respectively), interventricular septum thickness (IVSd), posterior wall thickness of the left ventricle (PLVWd), left and right atrium diameters during ventricular systole (LAD and RAD respectively), and continence of each heart valve (mitral; tricuspid; aortic; pulmonic). In women, LADd was significantly higher in the athletes than in the controls (35.04+/-4.13 vs 31.81+/-3.34; p<0.02). Physiological regurgitation in at least one heart valve was observed in 15 out of 17 (88.2%) of the athletes; in 12 cases only one valve was involved: the mitral valve presented physiological regurgitation in 8 women, the tricuspid in 4, the aortic in 2 and the pulmonic in 6. In the control female population (17 persons), only 2 women showed evidence of regurgitation. In men, except for RVDd, CDE measurements were all significantly higher in the athletes than in the controls: LVDd (49.4+/-3.13 vs 46.02+/-4.46; p<0.02); IVSd (9.79+/-1.24 vs 8.59+/-0.91; p<0.003); PLVWd (8.63+/-1.29 vs 7.48+/-0.66; p<0.002). Physiological regurgitation through one or more heart valves was demonstrated in all the 17 male athletes studied; in 9 cases (52.9%) only one valve was involved. Mitral regurgitation was ob- served in 8 cases (47%); tricuspid in 6 (35.3%). No physiological regurgitation through the aortic valve was found, while 15 cases (88.2%) presented a pulmonic regurgitation. Among male controls, physiological regurgitation was demonstrated only in 2 persons out of 17 (11.8%), both involving the pulmonic and the aortic valve. In the total population of athletes compared to controls, analyzing men and women jointly, we found that LAD (p<0.001),RAD (p<0.001), LIVD (p<0.01) were significantly larger in cases than in controls, while for RVD, IVSd and PLVWd such a difference did not reach statistical significance. No relationship was fouhd between CDE data and either age, height, weight or blood pressure.

[Volumetric analysis and visualization of cardiologic ultrasound data]

BACKGROUND

Echocardiography is a standard imaging technique for the assessment of heart valve disease. The good spatial and temporal resolution is the basis for different methods which provide information about the severity of such defects. Dynamic colour visualisation and volumetric measurements of regurgitant jets are a new evaluating tool for the assessment of heart valve insufficiencies.

METHODS

The regurgitant jet volume of 58 patients was evaluated on an external work-station after segmentation of the left atrium and compared to regurgitant volume; the correlation was good. This result is valid for central jets as well as for eccentric jets.

CONCLUSIONS

Measurement of regurgitant jet volume is a method which considers the three-dimensional shape of the examined volume. Real-time visualisation techniques which support the interactive clipping of morphological structures provide dynamic visualisation of intracardiac flow during the heart cycle. Dynamic colour visualisation of jets together with myocardial structures allows the assignment of intracardiac flow to morphological structures.

Long term follow-up of atrioventricular valve function after repair of atrioventricular septal defect

To elucidate the factors which are associated with early and late operative results of atrioventricular septal defects, 102 consecutive patients who underwent reparative operation of atrioventricular septal defects (AVSD) in our institution since 1968 were studied. Our operative technique was basically the same through this period. That is the two patch method in its complete form (the so-called Shirotani's method) and preferential use of cleft closure supplemented with Kay-Reed-Wooler type annuloplasty. Early mortality (< 30 days) rate was 18.6%. More than 80% of the early deaths were not related to atrioventricular valve malfunction. Non-complete closure of the cleft, high preoperative pulmonary vascular resistance, deficient atrioventricular valve, and complete form showed independent correlations with early mortality in multiple logistic regression analysis. For operative survivors, event-free survival curves, for atrioventricular valve related reoperations were drawn for various factors. Two late deaths and 3 late atrioventricular-valve-related reoperations occurred. The event-free actuarial survival for operative survivors at 5, 10, and 20 years were 97.0%, 89.4%, and 89.4%, respectively. The survival analysis revealed that preoperative high pulmonary vascular resistance, preoperative severe atrioventricular regurgitation, and preoperative large cardiothoracic ratio in chest radiogram were related with late event occurrence. Higher early mortality in our series may be attributable to relatively advanced pulmonary vascular occlusive disease rather than post repair atrioventricular valve malfunction. On the other hand, our late results were rather good. We concluded that the Shirotani's method and preferential use of cleft closure supplemented with Kay-Reed-Wooler type annuloplasty was effective for most of atrioventricular valves in atrioventricular septal defects. Early surgical intervention before pulmonary vascular disease progression or atrioventricular valve regurgitation development is also important.

Chorea as the presenting clinical feature of primary antiphospholipid syndrome in childhood

Three patients, aged five to 16 years, developed chorea as the only or main clinical manifestation of primary antiphospholipid syndrome. In two cases, complaints were self-limited five to eight months after onset. In one patient, the clinical course was complicated by valvulitis. Under corticosteroid treatment, chorea disappeared and cardiac involvement stabilised. Primary antiphospholipid syndrome is a probably under-recognised differential diagnosis of choreatic syndromes in childhood. Assessment of anticardiolipin antibodies and/or lupus anticoagulant should be an obligatory part of the diagnostic work-up of such patients. Early diagnosis of primary antiphospholipid syndrome may improve clinical management and prognosis.

Effects of obesity and weight loss on cardiac function and valvular performance

OBJECTIVE

To study the consequences of long-standing obesity on myocardial function and valvular performance and to determine the effects of weight loss on these cardiovascular features.

RESEARCH METHODS AND PROCEDURES

We included 41 patients with obesity referred for weight-reducing gastroplasty, 31 patients with obesity who received dietary recommendations, and 43 lean subjects. Body weight and blood pressure were measured, and cardiac function and valvular performance were estimated echocardiographically. Left ventricular ejection fraction was used to assess systolic heart function, and the ratio of transmitral early to atrial (E/A) peak flow velocity was used as an estimate of diastolic filling. All three study groups were investigated at baseline, and the two groups with obesity were re-examined at 1-year follow-up.

RESULTS

Patients with obesity had higher blood pressure, greater cardiac output, lower ejection fraction, and reduced E/A ratio, compared with lean subjects (p<0.01). Surgical treatment of obesity led to significant decreases in body weight, whereas body weight remained unchanged in the group treated with dietary recommendations (p<0.001). In the weight loss group, blood pressure and cardiac output decreased and the E/A ratio increased (p<0.001). Left ventricular ejection fraction tended to increase in the weight loss group and decrease in the obese control group (p<0.01). No significant valvular disease was observed in any of the subjects with obesity at baseline or after weight loss.

DISCUSSION

We conclude that weight reduction in subjects with obesity is associated with improvements in left ventricular diastolic filling and has favorable effects on left ventricular ejection fraction. Neither obesity nor weight loss seem to promote valvular heart disease.

Prosthetic ball valve endocarditis due to Gemella species

A case is presented of endocarditis that was affecting a prosthetic ball valve (Starr-Edwards) and which was caused by Gemella species. A 57-year-old man was admitted with a 3-day history of abdominal pain with fever. At the time of admission, his temperature was 37.7 degrees C and laboratory tests showed elevated inflammatory parameters and an increased neutrophil count. However, transthoracic echocardiogram showed no vegetation. During hospitalization, Gemella spp. were detected by blood culture, and a transesophageal echocardiogram showed vegetation on the prosthetic valve. He was treated with intravenous ampicillin and astromycin, and also underwent valve replacement. This is the first case in Japan of infective endocarditis of a prosthetic valve due to Gemella spp.

[Surgery of the heart valves: prosthetic replacement versus repair (1)]

The surgical management of valvular heart disease nowadays includes the use of various valvular substitutes and sophisticated reparative surgical techniques. Characteristics and indications of these different surgical options are discussed and the objective criteria that justify the use of a given technique in a given clinical situation are provided.

Atrioventricular valve function after single patch repair of complete atrioventricular septal defect in infancy: how early should repair be attempted?

BACKGROUND

Though repair of complete atrioventricular septal defect in infancy has become routine at most centers, it is not unusual for very young infants to be managed medically because of concerns about the fragility of the atrioventricular valve tissue.

METHODS

Since July 1992, seventy-two infants have undergone primary repair of complete atrioventricular septal defects at a median age of 3.9 months (40% < 3 months). A single-patch technique was used in all patients. The cleft was closed completely in 61 patients and partially (n = 10) or not at all (n = 1) in select patients at risk for valve stenosis. Left atrioventricular valve annuloplasty was performed in 18 patients. On the basis of transesophageal echocardiographic findings, 10 patients were returned to bypass for revision of the valve repair.

RESULTS

There was one early death in a patient with single left papillary muscle, no early reoperations, and no new permanent arrhythmias. Only three patients had moderate left atrioventricular valve regurgitation at discharge. During a median follow-up of 24 months, there was one late death and five reoperations for left atrioventricular valve regurgitation (n = 2) and/or systemic outflow obstruction (n = 4). Follow-up left atrioventricular valve regurgitation was moderate in three patients, mild in 14, and none/trace in 54. Age had no relation to postoperative atrioventricular valve regurgitation, death, or reoperation.

CONCLUSIONS

Despite concerns about fragility of valve tissue in very young patients, excellent results can be achieved with meticulous techniques. From neonates to older infants, age at repair does not influence outcome or valve function.

[The contribution of experimental models to the physiopathology and treatment of infectious endocarditis]

The model of experimental endocarditis can be used for the investigation of the different steps in the physiopathologic process leading to the formation of the infected cardiac vegetation. It has also greatly contributed to the knowledge of the characteristics of the infected vegetation. These data allow a better understanding of the therapeutic consequences (both preventive and curative) of the physiopathologic process.

[Cardiac ultrasonography in the diagnosis and monitoring of infectious endocarditis]

Transthoracic and transoesophageal doppler echocardiography has become an essential tool for the diagnosis of infective endocarditis. It detects valvular vegetations and destructions, evaluates regurgitations, and appreciates haemodynamic tolerance. Recognition of endocarditis, early identification of high-risk patients, and detection of mechanical complications are the most accurate informations derived from this technique. Transoesophageal echocardiography has the potential to avoid the difficulties encountered using the transthoracic approach, and it must be used particularly in the presence of non diagnostic transthoracic examination when clinical suspicion is high.

Trends in the management of truncal valve insufficiency

BACKGROUND

The single semilunar valve in patients with truncus arteriosus frequently is dysplastic and dysfunctional. Truncal valve insufficiency has been associated with poor outcome. Although the management of truncal valve insufficiency has evolved over the years, approaches to this problem vary considerably and remain a serious dilemma in many cases.

METHODS

We reviewed the records of 89 patients with unrepaired truncus arteriosus and mild (n = 37), moderate (n = 33), or severe (n = 19) truncal valve insufficiency who were admitted to our institution between 1975 and 1995. Eight patients (7 neonates) with moderate or severe insufficiency died before surgical intervention, and 4 patients underwent palliative pulmonary artery banding. The remaining 77 patients underwent repair. The median age at repair was 3.2 months (range, 2 days to 15 years; 83% infants), and it decreased from 4 months between 1975 and 1985 to 1 month between 1986 and 1995. Truncal valve replacement (mechanical = 6, allograft = 4) was performed in 10 patients, and 5 patients underwent valve repair.

RESULTS

All 4 patients who underwent pulmonary artery banding died either early or late. The hospital (or 30-day) mortality rate after repair was 34% (26/77). At a median follow-up of 10 years, 11 hospital survivors had died, with overall 1- and 10-year actuarial survival rates of 56% and 48%, respectively, and poorer survival among patients with severe truncal valve insufficiency (p = 0.02). Late truncal valve replacement (n = 24) had been performed in 21 patients. Freedom from truncal valve replacement was better in patients with mild truncal insufficiency than in those with moderate or severe preoperative insufficiency (p < 0.001). Four late deaths were related directly to reoperation for truncal valve replacement or to prosthetic valve dysfunction. Three of the 4 neonates who received allograft root replacements died within 7 months of repair, and severe allograft valve insufficiency requiring replacement 1 year after operation developed in the fourth.

CONCLUSIONS

The prospects for patients with truncal valve insufficiency have been improving over time. Nevertheless, the results in patients with severe insufficiency continue to be poor.

Ventricular tachycardia in valvular heart disease: facilitation of sustained bundle-branch reentry by valve surgery

BACKGROUND

The clinical characteristics of sustained monomorphic ventricular tachycardia (SMVT), when it develops after valve surgery, have not been described.

METHODS AND RESULTS

Between 1985 and 1996, 31 patients (30 men and 1 woman) who had undergone valve surgery were found to have inducible SMVT. Nine patients (29%) had sustained VT due to bundle-branch reentry (BBR) (group 1). Four of these patients had normal left ventricular function, and VT with a right bundle-branch morphology was inducible in 4 patients. Group 2 included 20 patients with inducible myocardial (ie, non-BBR) VT. Coronary artery disease was present in 15 group 2 patients (75%) due to atherosclerotic (n=12) and nonatherosclerotic (n=3) causes. Two patients had both inducible sustained BBR and myocardial VT (group 3). Sustained BBR VT occurred significantly earlier after valve surgery (median, 10 days) than the onset of postoperative myocardial VT (median, 72 months; P<.005).

CONCLUSIONS

Myocardial VT was the most common type of inducible SMVT in patients with valvular heart disease. The majority of these patients had underlying coronary artery disease and significant left ventricular dysfunction. However, in almost one third of the patients, sustained BBR VT was the only type of inducible SMVT. This type of VT was facilitated by the valve procedure occurring within 4 weeks after surgery in most patients. In these patients, left ventricular function was relatively well preserved, and the right bundle-branch block type of BBR was frequently induced. Because a curative therapy can be offered to these patients (ie, bundle-branch ablation), BBR should be seriously considered as the mechanism of VT in patients with valvular heart disease, particularly if the arrhythmia occurs soon after valve surgery.

Double-homograft repair of truncus arteriosus with severe truncal valve dysfunction

An infant with truncus arteriosus and severe dysfunction of the truncal valve including both stenosis and insufficiency successfully underwent primary repair. This included the insertion of two separate valved homograft conduits. Early outcome has been excellent and the patient is doing well after 6 months with only echocardiographic evidence of mild aortic valve regurgitation. Double-homograft repair is a realistic option in cases of truncus arteriosus with severe malformation of the truncal valve.

Evaluation of the proximal flow field to circular and noncircular orifices of different aspect ratios

Investigations of valvular regurgitation attempt to specify flow field characteristics and apply them to the proximal isovelocity surface area (PISA) method for quantifying regurgitant flow. Most investigators assume a hemispherical shape to these equivelocity shells proximal to an axisymmetric (circular) orifice. However, in vivo flow fields are viscous and regurgitant openings vary in shape and size. By using centerline profiles and isovelocity surfaces, this investigation describes the flow field proximal to circular and elliptical orifices. Steady, proximal flow fields are obtained with two- and three-dimensional computational fluid dynamic (CFD) simulations. These simulations are verified by in vitro, laser-Doppler velocimetry (LDV) experiments. The data show that a unique, normalized proximal flow field results for each orifice shape independent of orifice flow or size. The distinct differences in flow field characteristics with orifice shape may provide a mechanism for evaluating orifice characteristics and regurgitant flows. Instead of the hemispherical approximation technique, this study attempts to show the potential to define a universal flow evaluation method based on the details of the flowfield according to orifice shape. Preliminary results indicate that Magnetic Resonance (MR) and Color Doppler (CD) may reproduce these flow details and allow such a procedure in vivo.

[Heart valve diseases]

Although valvular stenosis may be evaluated adequately by measuring transvalvular pressure gradients with Doppler echocardiography and cardiac catheterization, these methods have failed to provide reliable and accurate quantification of valvular regurgitation. In recent years the development of magnetic resonance imaging has broadened the diagnostic spectrum in cardiology, since it allows assessment of ventricular volumes without geometrical assumptions and the non-invasive quantification of blood flow within the heart and great vessels. The purpose of this overview is to evaluate "established" diagnostic tools and to show the capabilities of magnetic resonance imaging in the assessment of valvular heart disease.

[Echocardiographic findings in primary Sjögren syndrome]

Primary Sjögren's syndrome is an autoimmune disorder characterized by an increased cellular and humoral activity, which determines immune-complex deposition at multisystemic level. The main morphologic and functional alterations associated with this syndrome at cardiovascular level have been described only in isolated cases. In this paper, 23 patients with primary Sjögren's syndrome were studied by transthoracic echocardiography. The aim of this study was to determine the relationship between the duration of the syndrome, sex and age with the type of cardiovascular abnormalities. All patients were women with mean age of 58 years (range from 39 to 76 years). The longest disease duration was 20 years and the shortest, 2 years. The main alterations were localized at valve level and are characterized by two patterns of thickening: 1) the first one involves the whole extension of one or more leaflets, 2) the other one is nodular and involves only the edge of one or more leaflets. The abnormal valves were mitral, aortic and tricuspid, but none of them showed a significant dysfunction. We did not find any association between the type of valve abnormalities and age or disease duration. It was concluded that the wide variety of morphologic abnormalities at valvular level were related with degenerative factors associated with the age in some cases, but in others its development probably depends on immunopathologic features of the primary Sjögren's syndrome. It must be proved in future studies whether the affected tissue can be assessed by immunohistochemical tests.

Studies on prosthetic valve function--a transesophageal echocardiographic assessment

Haemodynamic assessment was done by colour flow mapping and Doppler interrogation by both Transthoracic (TTE) and Transesophageal echocardiography (TEE) in 40 consecutive patients (mean age 36.6 +/- 12.35 years) with prosthetic valves. There were 30 cases of mitral (MVR) and 12 aortic (AVR) valve replacement. Major purpose of the study was to detect the sensitivity of TEE in detecting prosthetic valve malfunction particularly in comparison to TTE. Pannus was detected in 3 and 8 cases of MVR (p < 0.01) by TTE and TEE respectively; however, TEE was found to be of equal status in detecting pannus over AV (2 cases). Physiological regurgitation in MVR and AVR was detected in 13% and 25% by TTE and 20% and 33% by TEE respectively. Paravalvular leak was detected in 3 cases of MVR by TEE compared to only case by TTE. Though it is difficult to deduce any specific conclusion from this small number of patients, there is definite trend to higher sensitivity in detecting disorders with TEE specially for mitral prostheses.

[Color Doppler echocardiography of the flow convergence region in vitro: effect of the orifice shape on proximal velocity profile]

The flow convergence method serves to determine flow across orifices (like valve leaks) by color Doppler. Both the PISA method (proximal isovelocity surface areas) and the PVP method (proximal velocity profile) were developed in vitro at circular orifice plates. Therefore, we studied the influence of a non-circular orifice shape on the color map of the flow convergence. Steady flow across orifices of the following shapes was imaged by color Doppler: Oval (6 x 2 mm), slit (12 x 1.5 mm), three-star (diameter 100, area 30 mm2), circular twin-orifice (two circular orifices diameter 2 mm at 10 mm distance from each other) and oval twin-orifice (two ovals 6 x 2 mm at 10 mm distance). As reference we imaged circular orifices with a similar opening area. The alias method was used to locate discrete velocities within the color map, and the proximal velocity profile along the flow center line was analyzed (mean of 24 subsequent images). The local velocity was plotted (y-axis) against its distance to the orifice (x-axis) providing proximal velocity profile curves. The more the orifice shape differed from circular, the more the proximal velocity profile was shifted downward: The profile proximal to the oval was not different from the reference profile proximal to the circular orifice. The profile proximal to the slit was considerably slowed, and proximal to the three-star was even slightly slower (local velocity -12 %, -23 % and -29 % at 14, 8 and 5 mm distance to the orifice). If the circular reference orifice corresponded to total flow across the twin-orifice, the proximal velocity profile of the latter was also shifted markedly downward (-20 %, -18 % and -23 % at 14, 8 and 5 mm distance to the circular twin-orifice). However, if the reference profile corresponded to flow across only one opening of the twin-orifice, the proximal velocity profile of the latter was shifted considerably upwards (+60 %, +71 % and +50 % at 14, 8, and 5 mm distance). Deviation of the orifice shape from circular leads to lower local velocities within the flow convergence; thus neglecting this orifice shape would result in underestimation of flow by the flow convergence method. However, presence of parallel neighboring flow increases the local velocities; neglecting this effect would lead to corresponding overestimation of flow.

[Incidence of intervention-related heart valve lesions after high-frequency catheter ablation of the left-side accessory atrioventricular conduction pathways]

The aim of this study was to evaluate the incidence of valve lesions after radiofrequency catheter ablation of accessory atrioventricular pathways using the retrograde transaortic approach. Patients who presented no preexisting detectable valve lesion prior to catheter ablation and who underwent a comparable echocardiographic examination prior to and after catheter ablation were included for data analysis. From January 1991 until May 1993, 113 patients underwent radiofrequency catheter ablation of a left-sided accessory atrioventricular pathways at our institution. Fifty-nine patients were included in this study. Five patients (8.4%) developed new valve lesions after radiofrequency catheter ablation. There were two cases (3.3%) of aortic regurgitation and four cases (6.7%) of mitral regurgitation. In the majority of cases only mild valve regurgitation was detected. A hemodynamically significant valve lesion was observed in a single patient (1.6%). We speculate that the new onset of valve lesions is mostly due to catheter manipulations rather than due to tissue injury related to radiofrequency current application. Echocardiographic examinations prior to and after radiofrequency catheter ablation of accessory pathways may contribute to a further reduction in intervention-related complications.

Colour flow Doppler echocardiography in horses with cardiac murmurs

Thirty-two horses with cardiac murmurs typical of tricuspid, mitral and aortic regurgitation were studied using colour flow Doppler echocardiography. The dimensions and duration of any regurgitant signals, recorded at the cardiac valve suspected as being the site of origin of the murmur, were measured. Results were compared with flow signals described at the valves of normal horses (Blissitt and Bonagura 1995). Horses with murmurs suggestive of tricuspid (n = 8) and aortic (n = 8) regurgitation showed larger regurgitant signals at the tricuspid and aortic valves respectively, than has been reported in normal horses. Horses with murmurs suggestive of mitral regurgitation (n = 8) had a regurgitant signal of longer duration than occurs in normal horses, but the jets were not larger. Comparison of two groups of horses with low and high grade murmurs of tricuspid regurgitation, showed that horses with louder murmurs had significantly longer jets of larger area than those with low grade murmurs. This study demonstrates that colour flow Doppler echocardiography is a sensitive technique for the detection of valvular regurgitation in horses. However, quantification of jet size and duration are important for distinguishing physiological backflow which occurs in normal horses (Blissitt and Bonagura 1995) from valvular regurgitation associated with cardiac murmurs.

Physiological valvular regurgitation in clinically normal young racehorses: prevalence and two-dimensional colour flow Doppler echocardiographic characteristics

Colour flow Doppler echocardiographic examinations were performed on 15 horses; 10 Thoroughbreds and 5 Standardbreds; 9 mares, 5 geldings and 1 stallion; mean +/- s.d. 3.4 +/- 1.1 years. Cardiac murmurs were audible in 12 horses (80%), but these had characteristics consistent with functional murmurs in all horses. A standardised two-dimensional (2-D) and M-mode echocardiographic examination was unremarkable in all horses except that aortic valve prolapse was identified in 3 horses, tricuspid valve prolapse in 2 horses and mitral valve prolapse was present in one horse. Colour flow Doppler echocardiography revealed laminar antegrade flow in most sites but variance was noted in the right ventricular outflow tract in some horses. Small regurgitant jets associated with the aortic valve were seen in 12 horses (80%), with the tricuspid valve in 7 horses (46%), with the pulmonary valve in 4 horses (26%) and the mitral valve in 4 horses (26%). It was concluded that with colour flow Doppler echocardiography, as in other species, small regurgitant jets could be detected in many normal horses.