Clinical value of parameters derived by the application of the proximal isovelocity surface area method in the assessment of mitral regurgitation

To determine the clinical value of several parameters derived by application of the proximal isovelocity surface area method in the assessment of mitral regurgitation (MR), 28 consecutive patients with angiographic diagnosis of MR underwent color Doppler echocardiography within 48 h of cardiac catheterization. Aliasing velocities (V(N)) were baseline-shifted to 25 cm/s and the maximal radius (R) was measured from the first aliasing boundary to the tips of the mitral valve. By continuity, the regurgitant orifice area (ROA) and regurgitant stroke volume (RSV(PISA)) were obtained. We have related them to the angiographic grade, and with determination of the regurgitant stroke volume (RSV(DE)) and the regurgitant fraction (RF), we calculated the volume of the transmitral flow according to Fisher's method.

RESULTS

RSV(DE) correlated well with RSV(PISA) (r = 0.98). A clear relation existed between the isovelocity radius and the RSV(DE) and RF (r = 0.95 and 0.88, respectively). A radius of 8 mm or more was identified well with an RSV(DE) of 40 cm3 or more (sensitivity: 100%, specificity: 95%) and an RF of 35% or more (sensitivity: 88%, specificity: 94%). The ROA was closely related to the RSV(DE) and RF, with r = 0.92 and 0.88, respectively. An ROA of 20 mm2 or more identified well patients with RSV(DE) values of 40 cm3 or more and RF values of 35% or more. The radius, RSV(PISA) and ROA were closely related to the angiographic grade of MR (r = 0.91, 0.83 and 0.92, respectively). A radius of 7 mm or more identified patients with grade III or IV of regurgitation (sensitivity: 82%, specificity: 94%), while an ROA of 15 mm2 or more discriminated well significant regurgitation (sensitivity: 91%, specificity: 94%).

CONCLUSIONS

Parameters derived by application of the proximal isovelocity surface area method provide quantitative information that can be helpful in predicting the severity of mitral regurgitation noninvasively.

[The evolution of severe postvalvuloplasty mitral insufficiency]

Percutaneous mitral valvuloplasty has become the technique of choice for mitral stenosis with favorable anatomic features. However, mitral regurgitation is an important complication of this technique that has not reduced with Inoue technique. This study reports the clinical and echocardiographic follow-up (28 +/- 20 months) of 20 patients who developed severe mitral regurgitation after percutaneous mitral valvuloplasty with Inoue technique. The patients were divided into two groups on the basis of the need for mitral valve replacement during follow-up. We analyzed variables before and after percutaneous mitral valvuloplasty using univariate analysis. Multivariate analysis was performed to identify variables as independent predictors of the need for mitral valve replacement. Ten patients needed mitral valve replacement during follow-up. Multivariate analysis showed that suboptimal result of percutaneous mitral valvuloplasty (MVA < 1.5 cm2) was the only independent predictor of the need of mitral valve replacement. We concluded that the need for MVR in patients who develop severe mitral regurgitation after percutaneous mitral valvuloplasty was related to suboptimal result of procedure.

[The measurement of jet width at its origin in assessing mitral prosthetic regurgitation. The effect of the spatial disposition of the jet]

INTRODUCTION AND OBJECTIVES

The study was performed to test the influence of the jet spatial disposition on the correlation degree between the measurement of the jet width at its origin and the severity of mitral prosthetic regurgitation by transesophageal Doppler color flow imaging.

MATERIAL AND METHODS

In 165 patients with mitral valve prosthesis which were submitted for transesophageal echocardiography examination due to suspected prosthetic dysfunction, we studied 126 with pathological mitral regurgitation. On these patients, studies of jet spatial disposition, maximum width in its origin and severity quantification by means of maximum regurgitation area were performed.

RESULTS

For the free jet group of patients (90), jet width at its origin correlated with maximal regurgitation area (r = 0.75); whereas for the wall jet group (36), the correlation degree was 0.59. We observed a relationship (p < 0.05) between severe mitral regurgitation assessed by maximal regurgitant jet size and jet width > or = 5 mm in both groups: the sensitivity and specificity of 72.7% and 95% respectively for free jets, and 70.7% and 64.4% for wall jets.

CONCLUSIONS

The correlation between the area measurement and the width in its origin is better for free jets than for wall jets. A statistically significant relationship between the presence of severe mitral regurgitation and width in its origin > or = 5 mm could be observed, independently of the jet spatial disposition.

[Long-term results of percutaneous mitral valvuloplasty]

OBJECTIVES

The aim of this study was to assess the long-term results of percutaneous transvenous mitral commisurotomy in our institution, and to evaluate potential predictors of long-term event-free survival.

PATIENTS AND METHODS

Between 1990 and 1996, 204 patients underwent percutaneous transvenous mitral commisurotomy with an Inoue balloon. One hundred and thirty two patients were followed for up to 9 months. Mean time of follow-up was 2.6-1.5 years (7 days-5.7 years). End points were considered mitral surgery, death and functional class III-IV. Long-term event-free survival analysis was performed to determine independent predictors of event-free survival.

RESULTS

At the end of the study, 88% of patients were classified as New York Heart Association class I-II. Multivariate analysis revealed that independent predictors of major events were stiffness and thickening of the valve, presence of severe left atrial enlargement as factors pre-procedure; with suboptimal results and significant mitral regurgitation after percutaneous transvenous mitral commisurotomy.

CONCLUSIONS

Percutaneous transvenous mitral commisurotomy with Inoue balloon is a safe and effective technique. Good results are maintained at long-term follow-up and the best results are obtained in patients with flexible and thin valves, with mild or moderate enlargement of left auricle and in cases with optimal results and without severe mitral regurgitation as a complication of the procedure.

[Cardiac transplant in single ventricle]

Univentricular heart is an uncommon congenital heart disease. A select group of these patients (those with severe pulmonary stenosis or atresia) can reach adult age with different degrees of heart failure and severe chronic hypoxemia. Patients with adequate pulmonary tree development are likely to undergo heart transplantation when usual palliative techniques are contraindicated. Three cases of univentricular heart with pulmonary stenosis in which heart transplantation was the optimal choice are reported. Different techniques used to assess pulmonary tree development are analysed.

[Predictive variables of early mortality after orthotopic heart transplant in adults]

OBJECTIVE

The purpose of the study was to analyze some variables of donors, recipients and surgical procedures in order to discover factors that could predict mortality during the early stage (< 30 days) of orthotopic heart transplants.

MATERIAL AND METHOD

125 consecutive orthotopic heart transplants in adults were analyzed. The average age was 51 +/- 11 (range: 12-67), 109 (87%) were men, 16 were women (13%). Two groups were compared: 15 patients who died within 30 days after heart transplant and 110 who survived during that period. Immunosuppressive protocol: preoperative: Cyclosporin + Azathioprine. Intraoperative: Methylprednisolone Postoperative: Methylprednisolone (first 24 h), antilymphocyte monoclonal antibodies (7-10 days after heart transplant) + Cyclosporin + Azathioprine + Corticoids. The following parameters of the recipient were analyzed: sex, age, weight, size, thoracic perimeter, pretransplant cardiopathy, previous thoracic operations, functional stage or need for catecholamines during the days prior to the transplant, pulmonary artery pressure and resistance, history of systemic arterial hypertension, elevation of creatinine, blood type, urgent transplant indication, receptor/donor weight relationship. The following parameters of donors and operation were analyzed: sex, age, weight, thoracic perimeter, period in intensive care unit, dose of dopamine and dobutamine, blood type, origin of the organ, cause of death, ischaemia time, cardiopulmonary by-pass time and cardioplegia type.

RESULTS

The rate of early mortality was 12%. The univariate analysis showed differences in: prior cardiovascular surgery, receptor blood type, need for urgent transplantation, pulmonary artery resistance > 2.5 Wood Units, cardiopulmonary by-pass time, weight relationship between receptor and donor. The death cause of the donor proved significant. On multivariate analysis, the following parameters independently predicted early mortality: history of operation with extracorporeal circulation, high pulmonary artery resistance, urgent transplant, receptor/donor weight relation and time of extracorporeal circulation.

CONCLUSIONS

We believe that the results of our experience can help to stratify the risk in the orthotopic heart transplant recipient and even to contraindicate the procedure in some cases showing an accumulation of poor prognostic factors in borderline recipients.

[Coronary involvement in Takayasu's arteritis]

Takayasu's arteritis is a chronic inflammatory disease that primarily affects young women. Cardiac involvement is infrequent and it includes aortic regurgitation, pericarditis, angor pectoris or myocardial infarction due to coronary narrowing and cardiac heart failure due to coronary involvement and/or high blood pressure. A patient with Takayasu's aortitis and angina pectoris due to severe narrowing of the left coronary arterial ostia is described.

[Heart angiosarcoma and heart transplantation. Report of a case]

We present the case of a 29-year-old women with a cardiac primary angiosarcoma diagnosis. The initial symptom was a cardiac tamponade. The tests for screening metastasis proved negative. She was preoperatively treated with chemotherapy, followed by a heart transplant. There were no incidents related to surgery nor to the transplant except for a rejection in the second week biopsy. Four weeks after the transplant, the patient had a sudden dyspnea, the radiological tests confirmed the existence of a massive pleural overflow and lung and pleural metastasis. All types of therapeutical approaches were rejected except for pleurodesis. The patient died 60 days after the heart transplant.

[Obstructive and non-obstructive hypertrophic cardiomyopathy: clinical, electrocardiographic, and echocardiographic differences]

AIM

The purpose of the study was to analyse echocardiographic, electrocardiographic and clinical variables in patients with hypertrophic cardiomyopathy, as well as to compare the possible differences between the non-obstructive (NOHCM) and the obstructive form (OHCM).

METHOD

44 consecutive patients were studied and diagnosed with hypertrophic cardiomyopathy (NOHCM 26 and OHCM 18). The following variables were analysed: 1) echocardiographic: right ventricle (RV), interventricular septum (IVS), posterior wall (pW), telediastolic and telesystolic diameter of the left ventricle (TDD-LV and TSD-LV), size of the left atrium (LA), systolic anterior motion of the mitral valve (SAM), mitral insufficiency and direction of the jet (MI and MIpW), mitral anular calcium (MAC), filling pattern (A > E); 2) electrocardiographic: repolarization disorders (RD), left ventricular hypertrophy (LVH), negative "T" waves in the precordial leads (T-), pathological "q" waves, super or ventricular arrhythmias (SA or VA), short PR, right or left bundle branch block (RBBB and LBBB), and 3) clinical: presence of dyspnea, angina, syncope, palpitations and response to treatment with beta-blockers (B-b) or Calcium-antagonists (C-A).

RESULTS

There were no differences in age or sex between the obstructive and non-obstructive groups: 1) echocardiographic differences: there were none in RV, pW, TDD-LV, LA nor A > E wave. Significant differences were found (p < 0.05) in the rest of the variables; IVS (16 +/- 3 mm in NOHCM vs 22 +/- 5 mm in OHCM), TSD-LV (26 +/- 5 mm in NOHCM vs 22 +/- 6 mm in OHCM), SAM (38% in NOHCM vs 89% in OHCM), MI (19% in NOHCM vs 78% in OHCM), MIpW (20% in NOHCM vs 79% in OHCM), MAC (15% in NOHCM vs 44% in OHCM); 2) electrocardiographic differences: there were none in the presence of RD, pathological "q", VA, short PR, RBBB nor LBBB. The presence of "T" negatives was on the limit of significance in the precordial leads (31% in NOHCM vs 11% in OHCM; p = 0.09). Differences were found in the rest of the variables; LVH (58% in NOHCM vs 83% in OHCM), SA (50% in NOHCM vs 17% in OHCM); 3) clinical differences: there were none in the presence of dyspnea, angina, syncope or palpitations. Differences were found in the improvement with treatment; B-b (60% in NOHCM vs 57% in OHCM), C-A (100% in NOHCM vs 100% in OHCM).

CONCLUSIONS

1) in our patients, the most frequent cardiomyopathy is the non-obstructive one, with no predominance of age or sex; 2) in OHCM, IVS is much wider, with smaller TSD-LV, there is a greater incidence of MI, generally directed towards the posterior wall of the left atrium, and a larger tendency to calcify the mitral annulus; 3) the most frequent electrocardiographic abnormality is the alteration of repolarization. NOHCM has a greater incidence of SA and a lower degree of LVH with more prevalence of negative "T" waves in the precordial leads; 4) there are no clinical parameters differentiating the two groups, although the sustained improvement obtained with treatment is more likely to be produced by the calcium-antagonists than by beta-blockers in both types of cardiomyopathy.

[The usefulness of the isovolumetric relaxation time of both ventricles in detecting acute rejection in the heart transplant patient]

AIMS

The purpose of our study was to evaluate the usefulness of the isovolumetric relaxation time in both ventricles when diagnosing acute rejection in transplanted patients.

METHOD

68 endomyocardial biopsies were performed on a total of 38 patients. An echocardiographic study was carried out within the first 24 hours of each biopsy. All registrations were made by the same person. The isovolumetric relaxation time was measured in the left and right ventricles. The patients were divided according to two criteria: according to the degree of rejection (0-I, II, III) and according to whether the rejection was treatable (III) or non-treatable (0, I and II).

RESULTS

In both ventricles, there was a progressive decrease of the isovolumetric relaxation time corresponding to higher degrees of rejection: in the left ventricle (0-I = 90 +/- 16; II = 74 +/- 16; III = 70 +/- 26; significant differences of II and III in relation to 0-I) as well as in right ventricle (0-I = 43 +/- 16; II = 37 +/- 14; III = 29 +/- 8; significant difference of III in relation to 0-I). The patients with treatable and non-treatable rejection were compared: no differences were found in the isovolumetric relaxation time of the left ventricle (0, I and II = 85 +/- 16 vs III = 70 +/- 26), but they were found in the right ventricle (0, I and II = 41 +/- 15 vs III = 29 +/- 8).

CONCLUSIONS

Acute heart rejection induces a decrease of the isovolumetric relaxation time in both the left ventricle and the right ventricle. However, the isovolumetric relaxation time of the right ventricle seems to be a more useful parameter than isovolumetric relaxation time of the left ventricle, as it permits to detect whether an acute heart rejection is treatable or non-treatable.

[The incidence of major histocompatibility system antigens in dilated and ischemic myocardiopathies]

AIM

The purpose of this study was to analyze the frequency of the different antigens of HLA in patients with diagnosis of very advanced dilated cardiomyopathy and ischemic heart disease by comparing them with a control group of supposedly healthy subjects.

MATERIAL AND METHOD

The group of dilated cardiomyopathy consisted of 35 patients (8 women and 27 men) aged between 14 and 60 years. The group of ischemic heart disease included 32 patients (4 women and 28 men) aged between 34 and 64 years. The control group comprised 1337 subjects of the Spanish Mediterranean area, supposedly healthy and recruited from paternity studies.

RESULTS

In dilated cardiomyopathy we found a higher incidence in comparison with the control group of the A-2 (62.86% vs 46.22%), B-12 (60.00% vs 32.38%) and DQ-3 (82.86 vs 49.96%) antigens, and a lower incidence of B-51 (0.00% vs 12.49%). In ischemic heart disease we found, when comparing to the control group, a higher incidence of A-11 (31.25% vs 13.08%) and A-29 (34.38% vs 14.58%) antigens and a lower incidence of DQ-2 (15.63% vs 49.88%).

CONCLUSIONS

In the Spanish Mediterranean area, the presence of A-2, B-12 and DQ-3 antigens, as well as the absence of B-51 would favour the appearance of advanced dilated cardiomyopathy. The presence of the A-11 and A-29 antigens would predispose to ischemic cardiomyopathy while the presence of DQ-2 would have a protective effect on the appearance of this cardiopathy.

[Changes in lipoprotein(a) after heart transplantation]

AIM

The purpose of this study was to analyze the evolutionary changes of lipoprotein (a) levels occurring in heart transplant and to evaluate the possible relationship between the plasma concentration of this lipoprotein and the immunosuppressor drugs normally used in this type of transplant.

METHOD

17 patients undergoing heart transplant and with no history of dyslipemia or dysglucemia were studied. Patients with metabolic alterations after the transplant were excluded (except when these alterations occurred during the first week), as well as those who showed intercurrent processes near to the determinations. These were performed before the transplant, and 1, 2, 4 and 6 months later.

RESULTS

An increase of lipoprotein (a) was observed after the transplant, with a subsequent progressive decrease. Significant differences were found between the levels prior to the transplant (9.18 +/- 8.66) and 6 months later (7.53 +/- 8.86), with no differences found between the previous concentrations and the determinations after one month (10.29 +/- 7.58), two months (8.06 +/- 7.90) and four months (8.82 +/- 7.84). Differences were also observed between the values of the first month in relation to the subsequent months, as well as between the 4th and the 6th month. No relationship was noticed between the levels of this lipoprotein and those of cyclosporin (r = 0.10), azatioprine (r = 0.17) and deflazacort (r = 0.19).

CONCLUSIONS

The lipoprotein (a) levels increase after heart transplant, with a subsequent gradual decrease even below the previous figures. These levels bear no relationship with the dose of immunosupressors normally used in heart transplant.

[Prolonged treatment with isosorbide-5-mononitrate in patients with silent ischemia]

INTRODUCTION AND PURPOSES: The purpose of this study was to check the beneficial effect of isosorbide-5-mononitrate (IS-5-MN) in patients with myocardial postinfarction silent ischemia, and to evaluate the possible appearance of tolerance after prolonged treatment.

METHODS

We have studied 20 patients, all males, with a history of infarction (11 with inferoposterior infarction and 9 with anterior infarction) and having a positive effort test by electrocardiographic criteria (ischemic S-T depression > 1 mm). The study was designed in two parts, first crossover with placebo, double-blind and then open during 100 days; until day 20, 40 mg/12 hours of IS-5-MN were administered and from then on 40 mg/8 hours of the drug. Effort tests were carried on days, 1, 20, 34 and 100, first basal ones and then at 3 and 6 hours after the administration of the medication.

RESULTS

The time of S-T segment depression was prolonged in relation to the tests carried out with placebo and to its basal values (Placebo-basal: 235 +/- 97, Placebo-3 hours: 196 +/- 92, Placebo-6 hours: 201 +/- 80, day 1-basal: 197 +/- 84, day 1-3 hours: 420-96, day 1-6 hours: 381 +/- 93, day 20-basal: 221 +/- 81, day 20-3 hours: 384 +/- 121, day 20-6 hours: 389 +/- 112, day 34-basal: 272 +/- 91, day 34-3 hours: 437 +/- 102, day 34-6 hours: 362 +/- 100, day 100-basal: 269 +/- 102, day 100-3 hours: 389 +/- 112, day 100-6 hours 369 +/- 111). The duration of the effort was prolonged in relation to the placebo values (Placebo-basal: 480 +/- 100, Placebo-3 hours: 445 +/- 73, Placebo-6 hours: 430 +/- 79, day 1-basal: 450 +/- 95, day 1-3 hours: 510 +/- 79, day 1-6 hours: 532 +/- 86, day 20-basal: 524 +/- 93, day 20-3 hours: 535 +/- 77, day 20-6 hours: 519 +/- 77, day 34-basal: 517 +/- 85, day 34-3 hours: 567 +/- 87, day 34-6 hours: 558 +/- 94, day 100-basal: 520 +/- 89, day 100-3 hours: 593 +/- 91, day 100-6 hours: 590 +/- 92). This effect lasted throughout the 100 days of the study.

CONCLUSIONS

Therefore, in patients with silent ischemia after myocardial infarction, the administration of 40 mg/12 hours as well as of 40 mg/8 hours of IS-5-MN shows an obvious anti-ischemic effect; with long-term treatment, the effect persists without evidence of tolerance phenomenon.

[Heparinoids versus nitroglycerin in the treatment of superficial phlebitis]

The purpose of this study was to evaluate the beneficial effects of transdermal nitroglycerine (TNG) in the treatment of superficial phlebitis caused by endovenous catheters and to compare them with the effects from the application of heparinoid substances. The study performed was prospective, randomized during a six-day period. One hundred patients (73 male and 27 female), aged 28-89 years (mean 67.3), participated in the study; all presented phlebitis, diagnosed by the presence of pain, erythema, edema, and fibrous cord in the area around the catheter. Among 50 subjects, two cm of NTG gel were administered to the affected zone once a day, and for the other 50 subjects, heparinoid substances were applied three times a day. The value parameters were: time for the disappearance of pain and time for reducing erythema, edema, and fibrous cord in half (all measured in hours). We found significant differences between the two treatments with TNG yielding greater improvement in terms of disappearance of pain (TNG: 50.2 +/- 39.7, heparinoids: 72.0 +/- 39.9), time for reducing erythema in half (TNG: 28.0 +/- 24.2, heparinoids: 54.6 +/- 34.5), and time for reducing fibrous cord in half (TNG: 58.3 +/- 38.4, heparinoids: 84.5 +/- 41.5). Edema was reduce before with TNG; however, this difference was not significant (TNG: 31.2 +/- 20.3, heparinoids: 33.0 +/- 25.7). We conclude that transcutaneous TNG should be applied systematically in patients with superficial phlebitis, given that it is more effective than the usual treatment with heparinoid substances.

[Clinical evaluation of the changes produced by nitrates in patients with chronic heart insufficiency]

The aim for this study was to evaluate the hemodynamic changes that appear in patients with myocardiopathy at functional stage II (NYHA) subjected to standard treatment (digital+diuretics) plus nitrates. We used isosorbide-5-mononitrate (IS-5-MN). We studied 20 patients for 100 days in different phases. The placebo-controlled, crossover, double-blind stage random distribution was from day 2 to 5. From day 6 to 20 all the patients took 40 mg/12 hours of IS-5-MN, taking 40 mg/8 hours of active ingredient from day 21 to 100. We performed basal cycloergometrics 3 and 6 hours after administration on days 2, 5, 20, 34 and 100 of the treatment, as well as echocardiograms on these same days. We compared the results obtained versus placebo (p < 0.05). There were no significant differences in heart rate at rest or systolic arterial tension at rest or maximum. Maximum heart rate increased significantly in the tests at days 34 (basal: 143 +/- 9; 3 hours: 139 +/- 8; 6 hours: 140 +/- 7) and 100 (basal: 145 +/- 7; 3 hours: 141 +/- 8; 6 hours: 142 +/- 6) versus the tests carried out with placebo (basal: 136 +/- 8; 3 hours: 135 +/- 7; 6 hours: 136 +/- 7). There were no differences in the tests after acute dose or at treatment day 20.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac rhabdomyosarcoma. Its echographic diagnosis]

We report a case of cardiac rhabdomyosarcoma whose initial clinical features were fever and palpitations due to documented ventricular tachycardia. Sequential two-dimensional echocardiographic studies pointed out the presumed diagnosis, showing intracavitary masses at multiple sites appearing within a short period of time. The postmortem examination confirmed the diagnosis of rhabdomyosarcoma.

[Doppler echocardiography assessment of cardiac abnormalities in parenteral drug addicts]

We studied by Echocardiographic-Doppler 114 consecutive intravenous drugs addicts (IVDA); 91 were positive human immunodeficiency virus (HIV+) and 23 negatives. We classified them in five groups; beginning the negative HIV as group 0, and groups I to IV stratified according the Central Disease Control (CDC) classification. We compared the cardiac abnormalities founded between themselves and a control group presumed healthy persons of similar age. The cardiac cavities dimensions showed a statistic significant increased left ventricular end-systolic and diastolic diameters, right ventricular diameter, posterior wall and interventricular septum thickness and aortic root diameter compared with the control group; but all were in the normal range for age. The left ventricular fractional shortening was statistically different from control group related the other groups, and the group IV related other. The existence and severity of pericardial effusions were directly related to the illness stage. We founded moderate pericardial effusions in 25% patients in the 0 to III groups, increasing until 50% in the group IV. The presence of valvular vegetations, nearly 30% in our series, ought to the IVDA. We did not found relationship between the severity of valvular incompetence and the illness stage. We recorded a excellent correlation between the ratio T4/T8 lymphocytes with the progress of illness and the existence and severity of cardiac abnormalities.