Persistent Pulmonary Hypertension in Corrected Valvular Heart Disease: Hemodynamic Insights and Long-Term Survival

Background The determinants and consequences of pulmonary hypertension after successfully corrected valvular heart disease remain poorly understood. We aim to clarify the hemodynamic bases and risk factors for mortality in patients with this condition. Methods and Results We analyzed long-term follow-up data of 222 patients with pulmonary hypertension and valvular heart disease successfully corrected at least 1 year before enrollment who had undergone comprehensive hemodynamic and imaging characterization as per the SIOVAC (Sildenafil for Improving Outcomes After Valvular Correction) clinical trial. Median (interquartile range) mean pulmonary pressure was 37 mm Hg (32-44 mm Hg) and pulmonary artery wedge pressure was 23 mm Hg (18-26 mm Hg). Most patients were classified either as having combined precapillary and postcapillary or isolated postcapillary pulmonary hypertension. After a median follow-up of 4.5 years, 91 deaths accounted for 4.21 higher-than-expected mortality in the age-matched population. Risk factors for mortality were male sex, older age, diabetes mellitus, World Health Organization functional class III and higher pulmonary vascular resistance-either measured by catheterization or approximated from ultrasound data. Higher pulmonary vascular resistance was related to diabetes mellitus and smaller residual aortic and mitral valve areas. In turn, the latter correlated with prosthetic nominal size. Six-month changes in the composite clinical score and in the 6-minute walk test distance were related to survival. Conclusions Persistent valvular heart disease-pulmonary hypertension is an ominous disease that is almost universally associated with elevated pulmonary artery wedge pressure. Pulmonary vascular resistance is a major determinant of mortality in this condition and is related to diabetes mellitus and the residual effective area of the corrected valve. These findings have important implications for individualizing valve correction procedures. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00862043.

A Delphi consensus on the management of oral anticoagulation in patients with non-valvular atrial fibrillation in Spain: ACOPREFERENCE study

OBJECTIVE

To evaluate the level of agreement between cardiologists regarding the management of oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (NVAF) in Spain.

MATERIALS AND METHODS

A two-round Delphi study was performed using an online survey. In round 1, panel members rated their level of agreement with the questionnaire items on a 9-point Likert scale. Item selection was based on acceptance by ≥66.6% of panellists and the agreement of the scientific committee. In round 2, the same panellists evaluated those items that did not meet consensus in round 1.

RESULTS

A total of 238 experts participated in round 1; of these, 217 completed the round 2 survey. In round 1, 111 items from 4 dimensions (Thromboembolic and bleeding risk evaluation for treatment decision-making: 18 items; Choice of OAC: 39 items; OAC in specific cardiology situations: 12 items; Patient participation and education: 42 items) were evaluated. Consensus was reached for 92 items (83%). Over 80% of the experts agreed with the use of DOACs as the initial anticoagulant treatment when OAC is indicated. Panellists recommended the use of DOACs in patients at high risk of thromboembolic complications (CHA2DS2-VASc ≥3) (83%), haemorrhages (HAS-BLED ≥3) (89%) and poor quality of anticoagulation control (SAMe-TT2R2 >2) (76%), patients who fail to achieve an optimal therapeutic range after 3 months on VKA treatment (93%), and those who are to undergo cardioversion (80%). Panellists agreed that the efficacy and safety profile of each DOAC (98%), the availability of a specific reversal agent (72%) and patient's preference (85%) should be considered when prescribing a DOAC. A total of 97 items were ultimately accepted after round 2.

CONCLUSIONS

This Delphi panel study provides expert-based recommendations that may offer guidance on clinical decision-making for the management of OAC in NVAF. The importance of patient education and involvement has been highlighted.

Sildenafil for improving outcomes in patients with corrected valvular heart disease and persistent pulmonary hypertension: a multicenter, double-blind, randomized clinical trial

Aims

We aimed to determine whether treatment with sildenafil improves outcomes of patients with persistent pulmonary hypertension (PH) after correction of valvular heart disease (VHD).

Methods and results

The sildenafil for improving outcomes after valvular correction (SIOVAC) study was a multricentric, randomized, parallel, and placebo-controlled trial that enrolled stable adults with mean pulmonary artery pressure ≥ 30 mmHg who had undergone a successful valve replacement or repair procedure at least 1 year before inclusion. We assigned 200 patients to receive sildenafil (40 mg three times daily, n = 104) or placebo (n = 96) for 6 months. The primary endpoint was the composite clinical score combining death, hospital admission for heart failure (HF), change in functional class, and patient global self-assessment. Only 27 patients receiving sildenafil improved their composite clinical score, as compared with 44 patients receiving placebo; in contrast 33 patients in the sildenafil group worsened their composite score, as compared with 14 in the placebo group [odds ratio 0.39; 95% confidence interval (CI) 0.22–0.67; P < 0.001]. The Kaplan–Meier estimates for survival without admission due to HF were 0.76 and 0.86 in the sildenafil and placebo groups, respectively (hazard ratio 2.0, 95% CI = 1.0–4.0; log-rank P = 0.044). Changes in 6-min walk test distance, natriuretic peptides, and Doppler-derived systolic pulmonary pressure were similar in both groups.

Conclusion

Treatment with sildenafil in patients with persistent PH after successfully corrected VHD is associated to worse clinical outcomes than placebo. Off-label usage of sildenafil for treating this source of left heart disease PH should be avoided.

The trial is registered with ClinicalTrials.gov, number NCT00862043.

Stable angina in Spain and its impact on quality of life. The AVANCE registry

INTRODUCTION AND OBJECTIVES

Mortality from acute coronary syndrome has fallen but a substantial number of chronic patients remain symptomatic. The present study was designed to determine the clinical characteristics and therapeutic treatment of patients with stable angina and its impact on their quality of life.

METHODS

A cross-sectional, multicenter, observational study of 2039 patients with stable angina attended in outpatient clinics was performed. Data were collected on clinical variables and on the subjective perception of the severity of angina and the resulting limitations. Patients completed questionnaires on their perception of severity and quality of life.

RESULTS

We analyzed data on 2024 patients; 73% were men (mean age 68[10] years). Some 50.3% were asymptomatic (<1 angina attack per week in the previous 4 weeks), 39.2% reported 1-3 attacks per week and 10.5% reported >3 attacks per week; 66% had previously undergone revascularization, and 59% of these developed recurrent angina. Patients rated the severity of their condition higher than did their physicians (4.5 [2.5] vs 4.3 [2.3]; P=.002). Physicians' and patients' perceptions of the repercussions of angina showed little concordance (kappa<0.3). The patients believed their condition was much more severe, more debilitating, and had a greater negative impact on their quality of life.

CONCLUSIONS

A high proportion of patients with stable angina remains symptomatic and their quality of life is impaired. Their perception of the condition is worse than that of their physicians.

[Advances in clinical cardiology: new approaches to old challenges]

This article provides cardiologists with a broad overview of recent advances in clinical cardiology that could affect their daily practice in the near future. It discusses new ways of interacting with primary care physicians, the most recent findings on the remote monitoring of chronic disease, and the latest publications on the drugs used in routine clinical practice. The article ends with a summary of the work carried out by the Clinical Cardiology Section of the Spanish Society of Cardiology during the last year.

[Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease]

OBJECTIVE

To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs).

DESIGN

Compare standard reference (Doppler-echocardiography) with contrast.

LOCATION

Echocardiography department.

PATIENTS

Ambulatory chronic obstructive patient disease (COPD).

INTERVENTION

Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10 mm Hg to the transtricuspid gradient, calculated from the TR peak velocity.

RESULTS

PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10 mm Hg vs. 56±15 mm Hg (p<0.01).

CONCLUSION

The use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value.

[Update on clinical cardiology: aortic diseases, hypertrophic cardiomyopathy, and prophylaxis of infective endocarditis]

Although clinical cardiology encompasses the full spectrum of heart disease, in order to avoid overlaps with other sections we have reviewed recent developments reported in two substantial subject areas: aortic diseases and hypertrophic cardiomyopathy, which are the focus of working groups in the Clinical and Outpatient Cardiology working group of the Spanish Society of Cardiology. In addition, this article contains a critical review of new guidelines for antibiotic prophylaxis against infective endocarditis published by American scientific societies.

[Clinical cardiology: update]

Clinical cardiology encompasses all forms of heart disease and their more general characteristics, and its sphere of activity includes practical aspects of prevention, diagnosis, and inpatient and outpatient treatment as applied to patients on an everyday basis. Since certain areas of cardiology have become highly specialized, this review of new developments reported in the past year has attempted to bring together all those advances that are not the subject of research in some particular specialization within cardiology and that have such a wide range of application that they should be familiar to all clinical cardiologists, irrespective of their daily responsibilities. For the purposes of this review, articles were classified according to their origin as either English-language, European, or domestic publications. The review concludes with a summary of registry data collected in the last two years by the Clinical and Outpatient Cardiology Section of the Spanish Society of Cardiology.

[Clinical and Preclinical Heart Failure Research Network (REDINSCOR). Instituto de Salud Carlos III Cooperative Special Topic Research Networks]

Heart failure is a prevalent condition that is associated with high morbidity and mortality and that places a substantial demand on healthcare resources. As the condition often affects older individuals with comorbidities, its treatment requires the implementation of an integrated model of care that can be applied in primary care, in hospitals, and in the patient's home. The use of heart failure units has improved quality of life in these patients and has reduced hospital admissions. However, in Spain integrated care has not yet been widely implemented. Clinical and preclinical research on heart failure is complex and, consequently, it is essential for investigators to work together in research networks. As a result, 16 Spanish centers have organized themselves into a heart failure research network (REDINSCOR). This network is considering the establishment of a national heart failure registry and is involved in seven research projects, whose subjects range from molecular biology and cell physiology to diagnosis, treatment, and the development of integrated healthcare models.

Novedades en el síndrome metabólico, envejecimiento poblacional y visión del clínico de las nuevas guías en fibrilación auricular

This article reviews the main developments reported during the last year concerning metabolic syndrome, population aging, and new atrial fibrillation guidelines. The principal aim was to provide the clinical cardiologist with an overview of recent 2006 publications and conference reports on these topics, which have been selected for their broad clinical implications.

[Usefulness of hand-held echocardiography in emergency room]

BACKGROUND AND OBJECTIVE

Handheld echocardiography may be a powerful diagnostic tool in the emergency room. However, its usefulness in this environment when it is performed by medical personnel with a basic training in echocardiography remains to be clarified.

PATIENTS AND METHOD

A cardiologist with expertise in echocardiography and a cardiology fellow with basic training evaluated 33 patients admitted in emergency using a handheld device.

RESULTS

The echocardiogram led to a change in the diagnosis and treatment in 27% and 46% of patients, respectively, allowing an early discharge in 49% of cases. The agreement between the two observers was acceptable.

CONCLUSIONS

Portable echocardiography is a useful tool in emergency rooms and may be reliably performed by medical personnel with basic training in echocardiography.

Restrictive left ventricular filling and preserved ventricular function: a limitation in the noninvasive estimation of pulmonary wedge pressure by Doppler echocardiography

Pulmonary wedge pressure (PWP) can be estimated from the ratio of transmitral early peak flow velocity to flow propagation velocity measured by Doppler. Discrepancies observed in the application of the method prompted us to design this prospective study, aimed at detecting potential limitations of the method. We studied a total of 32 patients admitted to a cardiac intensive care unit, using a Swan-Ganz catheter. Correlation between invasive- and Doppler-estimated PWP was fairly good (r = 0.58). Analysis of discrepant cases led to the identification of a subgroup of 6 patients in whom PWP was largely underestimated because of unexpectedly high values of flow propagation velocity (71 +/- 15 cm/s vs 37 +/- 10 cm/s in the rest of the group; P =.0001). All of them had in common a restrictive Doppler filling pattern and preserved left ventricular systolic function. Exclusion of this group showed an improvement in the correlation coefficient to r = 0.72. In conclusion, PWP can be estimated by the Doppler early peak flow velocity to flow propagation velocity ratio, although a significant underestimation of PWP may be observed in patients with a restrictive filling pattern and preserved ventricular function.

[Comparative study of echocardiography and magnetic resonance imaging in the assessment of left ventricular mass]

AIM OF THE STUDY

Echocardiography is a widely applied technique for the estimation of left ventricular mass, although magnetic resonance is considered as a reference method for this purpose. Both techniques were compared in the present study and the usefulness of a simplified method of calculation by magnetic resonance was also tested.

METHODS

Left ventricular mass was determined in 42 patients by M-mode echocardiography by the application of two equations: the so-called Penn's convention and that proposed by the American Society of Echocardiography. Magnetic resonance studies were also performed, left ventricular mass being estimated from an anatomical method (summation of contiguous transverse ventricular slices) that was considered as a reference, and also by means of a geometrical method (planimetry on a single longitudinal view).

RESULTS

Echocardiographic studies were judged as technically inadequate in 3/42 (7%) patients, while magnetic resonance was performed in all cases. Comparison between each echocardiographic method and the anatomical method of magnetic resonance showed a coefficient correlation of r = 0.70 (Penn's convention formula), and r = 0.71 (American Society of Echocardiography), with an overestimation being observed, particularly with Penn's convention method. The geometrical method of magnetic resonance showed an excellent correlation with the anatomical technique (r =0.93).

CONCLUSIONS

Magnetic resonance is more applicable for the estimation of left ventricular mass than M-mode echocardiography, with the latter showing an overestimation when compared with magnetic resonance, particularly with the Penn's convention method. A simplified method of geometrical estimation of left ventricular mass by magnetic resonance is a reliable alternative to the anatomical method.

Myocardial cell damage in human hypertension

OBJECTIVES

The goal of this study was to investigate the presence of myocardial cell damage in patients with systemic hypertension and its relationship with left ventricular hypertrophy (LVH).

BACKGROUND

Although initially compensatory, LVH adversely affects myocellular integrity and contributes to congestive heart failure in hypertensive patients. Noninvasive detection of myocardial damage can be of value.

METHODS

We performed imaging studies with 111In-labeled monoclonal antimyosin antibodies to identify myocardial damage in 39 patients with systemic hypertension and variable degrees of LVH. Three groups were considered: 16 asymptomatic patients with normal echocardiographic left ventricular mass (LVM) (group I); 14 asymptomatic patients with LVH (group II) and 9 patients with symptomatic hypertensive heart disease and advanced LVH (group III). The severity of myocardial damage was represented as heart-to-lung (target-to-background) antibody uptake ratio (normal: <1.55).

RESULTS

Mean LVM index was 105+/-14 g/m2 in group I, 124+/-24 in group II and 174+/-29 in group III. Heart-to-lung ratios of antimyosin uptake were: 1.45+/-0.14 in group I, 4 of the 16 (25%) patients showing an abnormal scan; 1.50+/-0.07 in group II with abnormal scans in 2 of the 14 (16%) patients and 1.77+/-0.16 (p < 0.001) in group III, all 9 patients presenting with abnormal antimyosin scans. On multivariate regression analysis LVM index was the main variable that independently correlated with the degree of myocardial uptake of antimyosin (r = 0.815; p = 0.001).

CONCLUSIONS

This study provides the first in vivo evidence of myocyte damage in patients with hypertension. The severity of myocardial damage can be related to the magnitude of LVH.

Usefulness of the I/D angiotensin-converting enzyme genotype for detecting the risk of left ventricular hypertrophy in pharmacologically treated hypertensive men

The insertion/deletion polymorphism (I/D) of the angiotensin-converting enzyme (ACE) gene has been associated in some studies with a higher prevalence of left ventricular hypertrophy (LVH), but few of them were performed on pharmacologically treated hypertensive patients. The present study was undertaken to determine whether ACE genotype determination could help in the identification of pharmacologically treated hypertensive patients at a higher risk of LVH. Ninety-six consecutive men with essential hypertension were selected for the study. Left ventricular mass (LVM) was assessed by echocardiography and indexed by body surface area and 82 patients were considered suitable for the study. Three groups of patients were defined on the basis of their I/D ACE genotype: DD (n = 39), ID (n = 33) and II (n = 10). There were no statistically significant differences between the three groups regarding to the severity of hypertension at diagnosis, degree of control of blood pressure or type of antihypertensive drug therapy used. No statistically significant differences were found between the three groups regarding to LVM index (total 124 +/- 31, DD 121 +/- 29, ID 127 +/- 35 and II 122 +/- 18 g/m2), relative wall thickness (total 0.5 +/- 0. 2, DD 0.5 +/- 0.3, ID 0.48 +/- 0.07 and II 0.47 +/- 0.04) or prevalence of LVH (total 34%, DD 31%, ID 39% and II 30% by Cornell criteria and total 39%, DD 33%, ID 45% and II 40% by Framingham criteria). Furthermore, the I and D allele frequency distribution was similar in the whole group of patients, in patients with LVH, and in a control group of healthy volunteers. Our data do not support that the I/D ACE genotype determination helps in identifying treated hypertensive patients at higher risk of LVH. Journal of Human Hypertension (2000) 14, 327-331

[Patency study of internal mammary artery grafts: the usefulness of echo-enhancers for identifying the flow signal by color Doppler echocardiography]

OBJECTIVES

a) To study the capacity of the technique of high-frequency color Doppler to detect flow signal of left internal mammary artery grafts; b) to assess the usefulness of an echo-enhancer agent to facilitate the detection of the signal, and c) to evaluate the patency of the graft according to its pulsed Doppler velocity profile pattern.

METHODS

39 consecutive patients were studied. A Hewlett-Packard 5500 echocardiograph was used, with a high-frequency probe (S12) applied at the high left parasternal border. When a graft signal was not elicited after a predetermined 5-minute check period, an intravenous dose of 4 g of Levovist (Schering España) at 400 mg/ml was administrated. According to previous studies, a pulsed Doppler flow profile with a predominantly diastolic pattern was considered a normal graft patency, while a systolic one was deemed as abnormal.

RESULTS

Graft flow was identified by color Doppler in 33/39 patients (85%). The additional use of an echo-enhancer in 6 patients with no detected signal increased this proportion to 38/39 (97%). Normal flow patterns were seen in 34/38 (89%). Among the four patients with abnormal pattern, 1 case of early myocardial infarction was observed, while angiographic studies showed distal occlusion of the graft in 1 or the presence of competitive flow in 2 patients.

CONCLUSIONS

The high-frequency color Doppler technique allows the detection of a flow signal from internal mammary artery grafts in most patients. The administration of an echo-enhancer agent is useful in those with non detectable signals. An abnormal pulsed Doppler velocity pattern indicates graft malfunction.

[Acute myocardial infarct studied by magnetic resonance with gadolinium-DTPA contrast compared to echocardiography]

INTRODUCTION AND OBJECTIVES

Gadolinium-DTPA used as a contrast agent in magnetic resonance imaging allows the detection and quantification of the necrotic area in acute myocardial infarction. The aim of the present study is to assess the value of this method for the diagnosis of myocardial infarction in comparison with clinical and echocardiographic data.

METHODS

Contrast magnetic resonance imaging and echocardiographic studies were performed on 16 patients during the first week after admission for acute myocardial infarction. Necrotic and total myocardial mass were calculated from magnetic resonance images and this was compared to the extension of the myocardial infarction assessed by electrocardiography and the peak level of total creatinine-phosphokinase serum enzyme. The number and localization of myocardial segments showing contrast uptake was related to segments with contractile abnormalities at the echocardiographic exam.

RESULTS

The mean value of the mass of myocardial necrosis calculated from the total area of gadolinium-DTPA uptake in each patient was 25 g (range: 2-67 g), corresponding to 17% of the total myocardial mass (range: 1-45%). This value correlated with the peak serum level of total creatinine-phosphokinase enzyme (r = 0.714; p < 0.003) and with the number of Q waves present at the electrocardiogram (r = 0.69; p < 0.005). A very good agreement between the location of the myocardial infarction by ECG, echocardiography and magnetic resonance was evidenced, and a satisfactory correlation existed between myocardial segments with gadolinium-DTPA uptake and akinetic echocardiographic segments (kappa = 0.65).

CONCLUSIONS

The detection and quantitation of the necrotic area in the acute myocardial infarction with gadolinium-DTPA contrast magnetic resonance shows a good correlation with clinical and echocardiographic data.

[Evaluation of the patency of left internal mammary artery graft by transcutaneous Doppler flow velocity analysis]

OBJECTIVE

To analyze the features of Doppler flow velocity curve of left internal mammary artery by-pass grafts in relation with their permeability as assessed by selective angiography.

METHODS

Twenty-five consecutive patients with a left mammary artery graft were studied by angiography and transcutaneous Doppler technique. From the Doppler tracings, peak velocity and time-velocity integral of the systolic and diastolic components were determined. Patency of the graft and the characteristics of the distal native coronary artery were evaluated at angiography.

RESULTS

Doppler flow signal was obtained in 23 (92%) of 25 analyzed patients. The graft was angiographically patent in 17 (68%) of 25 patients; in 15 (88%) of them the Doppler flow velocity signal was mainly diastolic and in only 2 (12%) it was predominantly systolic. In 8 (32%) of the 25 patients the graft was angiographically occluded, 6 (75%) of these patients showing a predominantly systolic Doppler signal, while the remaining 2 (25%) patients were those in whom the signal could not be elicited. Sensitivity and specificity of a predominantly diastolic Doppler flow pattern for the presence of graft patency was 88% and 100% respectively, with a predictive positive value of 100% and a negative one of 80%.

CONCLUSIONS

Doppler flow velocity pattern of internal mammary artery by-pass grafts is related with patency of the graft, the presence of a predominantly diastolic curve being highly indicative of a patent graft.

Short-course thrombolysis as the first line of therapy for cardiac valve thrombosis

OBJECTIVE

To retrospectively evaluate the clinical and echocardiographic criteria of thrombolytic therapy for mechanical heart valve thrombosis.

METHODS

Nineteen consecutive patients with 22 instances of prosthetic heart valve thrombosis (14 mitral, 2 aortic, 3 tricuspid, and 3 pulmonary) were treated with short-course thrombolytic therapy as first option of treatment in absence of contraindications. The thrombolytic therapy protocol consisted of streptokinase (1,500,000 IU in 90 minutes) (n = 18) in one (n = 7) or two (n = 11) cycles or recombinant tissue-type plasminogen activator (100 mg in 90 minutes) (n = 4).

RESULTS

Overall success was seen in 82%, immediate complete success in 59%, and partial success in 23%. Six patients without total response to thrombolytic therapy underwent surgery, and pannus was observed in 83%. Six patients showed complications: allergy, stroke, transient ischemic attack, coronary embolism, minor bleeding, and one death. At diagnosis, 10 patients evidenced atrial thrombus by transesophageal echocardiography, 3 of whom experienced peripheral embolism during thrombolysis. Four episodes of rethrombosis were observed (16%). The survivorship was 84% with a mean follow-up of 42.6 months.

CONCLUSIONS

A short-course of thrombolytic therapy may be considered first-line therapy for prosthetic heart valve thrombosis. The risk of peripheral embolism may be evaluated for the presence of atrial thrombus by transesophageal echocardiography at diagnosis.

Comparison of morphologic assessment of hypertrophic cardiomyopathy by magnetic resonance versus echocardiographic imaging

To compare the value of echocardiography and magnetic resonance imaging (MRI) in the assessment of the amount and extent of hypertrophy in hypertrophic cardiomyopathy (HC) and, second, to correlate the degree of hypertrophy, as assessed by MRI, with clinical and electrocardiographic parameters, 30 consecutive patients (16 men and 14 women, aged 20 to 74 years) with HC were studied. Measurements of left ventricular wall thickness were performed at 11 predetermined segments (5 basal, 5 midventricular, and 1 apical) by 2-dimensional echocardiography and MRI. Two parameters derived from MRI studies were considered as indicators of the degree and extent of hypertrophy: (1) mean of the measured wall thickness at the 11 segments, and (2) the number of segments with thickness > 15 mm. Results showed that, from a total of 330 myocardial segments, thickness could be measured by echocardiography in 221 (67%), whereas MRI allowed measurement of 320 segments (97%). When compared with clinical and electrocardiographic data, no correlation was found regarding mean wall thickness and number of hypertrophied segments by MRI except for the presence of an abnormal electrocardiographic repolarization pattern. It is concluded that MRI allows a better assessment of the degree and extension of left ventricular hypertrophy than echocardiography in HC. Despite the precise information on hypertrophy provided by MRI, the amount and degree of hypertrophy bears no correlation with most of the clinical data in these patients.

Doppler-derived gradients in normally functioning Monostrut Björk-Shiley prostheses

In summary, reference values of Doppler gradients obtained in a large number of patients with normal-functioning mitral and aortic Monostrut Björk-Shiley prostheses are reported. It is shown that the value of the transprosthetic gradient increases with decreasing valve size in patients with aortic prostheses. No individual significant variations of the transprothetic Doppler gradient during a 3-year follow-up were observed.

[Conservative mitral surgery for a tear of the valvular leaflets post-percutaneous mitral commissurotomy]

A case of a 32-year-old woman who developed acute mitral insufficiency after percutaneous mitral dilatation is presented. In spite the fact of having torn both leaflets, successful plastic repair of her valve was performed.

The Monostrut Björk-Shiley valve. Seven years' experience

The results of cardiac valve replacement with the Monostrut Björk-Shiley prosthesis (Shiley, Inc., Irvine, Calif.) during a 7-year period are presented. A total of 984 valves were implanted in 820 patients from May 1983 to April 1990. Aortic valve replacement was performed in 378 patients, mitral replacement in 294, and multiple replacement in 148. In addition, 180 patients (22%) underwent associated procedures. Mean age was 52.6 +/- 11 years. Operative (30 days) mortality was 5.9% (49 patients): 3.9% (15 patients) for aortic, 7.8% (23 patients) for mitral, and 7.4% (11 patients) for multiple valve replacement. All patients were given long-term anticoagulation therapy. Follow-up was 99% complete (eight patients were lost to follow-up), with a closing interval of 3 months, and totaled 2422 patient-years. Valve-related complications, expressed as percentage event-free (+/- standard error) at seven years were as follows: structural deterioration, 100%; nonstructural dysfunction, 98.3% +/- 0.6%; thromboembolism, 90.2% +/- 1.7%; anticoagulant-related hemorrhage, 88.7% +/- 2.8%; and prosthetic valve endocarditis, 98.1% +/- 0.8%. There were no cases of valve thrombosis. Actuarial survival (free from operative, valve-related, and sudden death) was 88.4% +/- 1.2% at 7 years. Freedom from reoperation was 96.8% +/- 0.1%. Probability of being free from all valve-related morbidity and mortality was 70% +/- 3%, and 708 (93%) of the survivors were in New York Heart Association class I or II. Serial Doppler echocardiograms were done prospectively in 243 patients (with 154 aortic and 120 mitral prostheses), both postoperatively and at regular intervals up to 3 years. Mean prosthetic gradients ranged from an average of 20.9 to 7 mm Hg in the aortic prostheses (21 to 29 mm) and from 6.1 to 4.8 mm Hg in the mitral prostheses (25 to 31 mm). The gradients in each patient did not change significantly during the follow-up period. Our 7 year's experience with the Monostrut valve shows a low rate of valve-related complications, a durable design, and good hemodynamic and functional results.

Findings on Doppler echocardiography in asymptomatic intravenous heroin users

To detect potential cardiac abnormalities induced by intravenous heroin use, 68 persons without a previous episode of infective endocarditis were studied by Doppler echocardiography. A control group of 41 normal subjects was studied for comparison. The following measurements were considered: (1) diameter of heart chambers, (2) systolic left ventricular function, (3) morphologic valvular abnormalities, (4) presence of valve regurgitations, (5) Doppler indexes of diastolic function, and (6) estimation of pulmonary arterial resistances. Results showed no significant differences regarding the size of the heart chambers or systolic left ventricular function. A significantly higher incidence of valvular abnormalities (focal thickening or valve prolapse) was found in drug addicts (p = 0.0009) at the mitral and tricuspid valves, as was valvular regurgitation detected by Doppler (p = 0.04). Also, a significantly prolonged deceleration time of mitral and tricuspid early diastolic Doppler flow was found in the study group (p = 0.0001 and 0.027, respectively) although a different hemodynamic condition in the study group (pharmacologically reduced preload) precluded these findings to be attributable to an actual diastolic dysfunction. No differences were observed in pulmonary arterial resistances. It is concluded that mitral and tricuspid valve abnormalities can be detected by echocardiography in asymptomatic intravenous heroin users, whereas no apparent effects are observed in morphologic or functional parameters of cardiac structures other than the valves.

[Ambulatory transesophageal echocardiography: 2 years of experience]

In this report we study the value of ambulatory transesophageal echocardiography (TEE) in the clinical setting after a 2-year experience at our department. Since December 1988 until February 1991, 470 TEE examinations were indicated in 430 patients. Excluded were 8 cases, two out of them due to a formal contraindication and six who did not tolerate the procedure. The clinical indications for the examination, in the 462 studies performed, were as follows: possible cardiac source of emboli in 165 (35%); native mitral valve disease in 91 (20%); prosthetic valve dysfunction in 54 (12%); diseases of the aorta in 44 (10%); suspected infective endocarditis in 41 (9%); study of left ventricular function in 26 (6%); congenital heart disease in 18 (4%); tumor or intracardiac mass in 11 (2%); miscellaneous in 12 (2%). Based on this experience, we can conclude that TEE is a clinically useful technique for: 1) the study of mitral regurgitation, either native or prosthetic; 2) the detection of vegetations and abscesses in infective endocarditis; 3) the evaluation of a possible cardiac source of emboli; 4) the examination of the aorta in cases of suspected dissection; 5) the completion of the anatomic study in some congenital heart diseases, particularly after a surgical correction; 6) the study of patients with a technically inadequate transthoracic approach.

[Short-term treatment of thrombosis of heart valve prostheses with high doses of streptokinase. Presentation of 5 cases]

Five cases of thrombosis of cardiac prosthetic valves were treated with high dose fibrinolytic drugs during a short period of time. There were 3 mitral, one tricuspid and one pulmonary prosthetic valves. In 3 cases the treatment was successful without significant complications. Another patient, a woman in early pregnancy, died shortly after the treatment. The last patient required surgery as the cause of valve obstruction was a fibrous pannus virtually without thrombus formation. This diagnosis was intraoperative. The reported therapeutic modality permits a rapid resolution of valve obstruction. If this is not the case, surgery may be immediately carried out when the hemodynamic condition of the patient is still adequate.

[Intraoperative transesophageal echocardiography: initial experience with 60 patients]

To assess the usefulness of intraoperative transesophageal echocardiography (ITE), this technique was applied in 60 non-selected cardiac patients operated on in our hospital by the surgical team. Only one case was excluded because it was not possible to introduce the probe, and no complications were observed in any patient. ITE permitted: 1) to obtain images without interruption and with no interference with the surgeons or anesthesiologists; 2) to confirm the preoperative diagnosis; 3) to facilitate the surgical approach; 4) the monitoring of left ventricular function, and 5) to evaluate the immediate results of the surgical procedures, particularly the assessment by Doppler technique of residual valvular regurgitations after valve repair. A minor but not disdainable inconvenience of ITE relates to the strategy of its application, as it requires a completely dedicated equipment and operator in the surgical area.

[Long-term results in patients with tricuspid prosthesis]

A retrospective study was undertaken of 31 patients submitted to tricuspid valve replacement between 1977 and 1988, either alone or associated to mitral or aortic replacement. The cause of the tricuspid lesion was rheumatic in 19 patients, congenital in seven, prosthetic valve thrombosis in two and miscellaneous in the remaining 3 patients (endocarditis, carcinoid syndrome, iatrogenic operative tricuspid regurgitation). Of the 31 tricuspid prostheses reviewed, 26 were mechanical (St Jude, Björk-Shiley) and five of the biological type (Ionescu, Hancock). Results showed that 25% of patients died in the hospital; 75% of them had been operated previously. With a follow-up averaging 3.9 years the complications related with the prosthesis were: thrombosis of the tricuspid prostheses in 1 patient (1.2% patients-year) and hemolytic anemia in another. Ninety percent of patient included in the follow-up were in NYHA class I or II. Three patients (14%) died due to a cause not directly related to the prosthesis. An actuarial analysis showed intrahospital survival rates of 55%, 100% and 75% in patient with 3, 2 and 1 prostheses, respectively; at 6 months postoperatively the figures were 55%, 87% and 75%, and at a follow-up of 3 years, 55%, 67% and 66%. In conclusion, in patients submitted to a tricuspid valve replacement mortality is high before hospital discharge, and is related to the clinical situation. A sustained improvement is observed in survivors once discharged, independently of the number of prostheses implanted. Complications related to the tricuspid prosthesis are comparable to those observed with prostheses in mitral or aortic position.

Prospective validation of detection and quantitative assessment of chronic aortic regurgitation by a combined echocardiographic and Doppler method

To establish the accuracy of Doppler echocardiography in the assessment of chronic aortic regurgitation (AR), 87 patients were included in a two-step prospective study. In a first consecutive series of 56 patients, two-dimensional directed M-mode echocardiography and pulsed wave Doppler (PWD) studies were performed within a 24-hour interval of a conventional contrast aortic angiography, which showed AR in 46 patients. Sensitivity and specificity of PWD in the detection of AR were both 100%. To quantitate AR, a left ventricular outflow tract (LVOT) PWD mapping was scored. Significant differences between 1, 2, and 3 to 4 angiographic grades of AR were obtained. As some overlap existed between groups, a multifactorial analysis of PWD and echocardiographic measurements was performed: optimal discrimination was obtained when a new score combining LVOT mapping by PWD, diastolic left ventricular diameter, and aortic root dimension was considered. A prospective validation of this combined echocardiographic-Doppler method was then applied on a second group of 31 catheterized patients with AR. Correlation obtained (r = 0.86; p less than 0.001) confirmed the accuracy of this new method in the prediction of the severity of AR.

Pulsed Doppler assessment of tricuspid regurgitation: usefulness of regurgitant signal patterns for estimation of severity

A study on the value of pulsed Doppler in the detection and quantitative assessment of tricuspid regurgitation (TR) has been conducted on 33 consecutive adult patients with valvular heart disease. Only 1 patient had to be excluded owing to a technically inadequate Doppler examination. Data for comparison were obtained from a right heart catheterization performed within a twenty-four-hour interval from the Doppler study. Sensitivity and specificity in the detection of the lesion were 88% and 100%, respectively. A previously undescribed pulsed Doppler method for the estimation of the degree of TR was tested, based on the consideration of two distinctive patterns of the regurgitant Doppler signal: type I: a protosystolic regurgitant signal with progressively fading intensity along systole; and type II: a homogeneously intense pansystolic signal. Correlation between these patterns and the angiographic degrees of TR showed that milder lesions correspond to the type I Doppler pattern, whereas significant regurgitations present a type II pattern, this allowing a clinically useful method of assessment of TR.

Non-invasive preoperative assessment of chronic valvular heart disease by Doppler ultrasound

Between February 1986 and June 1987, 306 consecutive patients were included in a programme of non-invasive preoperative assessment of valvular heart disease using M-mode and cross-sectional echocardiography and Doppler ultrasound. In 285 cases (93%), echocardiography provided all the necessary preoperative information. Coronary angiography was performed in 74 patients because of angina and in 55 because of their age. Invasive investigation was needed in 21 cases because of discrepancies between clinical data and echo-Doppler results. The results were definitely misleading in six patients, mainly due to erroneous assessment of valvular regurgitation. One hundred and ninety one patients underwent valve surgery (179 evaluated exclusively by echocardiography, 79 with coronary angiography as the sole invasive procedure). No discrepancies were observed between echo-Doppler diagnosis and macroscopic evaluation of valvular heart disease at surgery. Operative mortality (3.6%) was not significantly different from that observed during the preceeding period when preoperative catheterisation was performed (3.3%). It is concluded that echo-Doppler techniques are perfectly satisfactory for the preoperative assessment of patients with valvular heart disease. Cardiac catheterisation is only infrequently required, although coronary angiography remains mandatory in a selected group of these patients.

Patency of internal mammary artery grafts in no-flow situations

We report two cases in which an internal mammary artery graft was found to be nonfunctional in the early postoperative period, but repeat catheterization at 6 months revealed the graft to be patent. These two cases substantiate that closure of an internal mammary artery graft may be reversible.