Loperfido, F; Biasucci, L M; Pennestri, F; Laurenzi, F; Gimigliano, F; Vigna, C; Rossi, E; Favuzzi, A; Santarelli, P; Manzoli, U
In 72 patients with previous myocardial infarction (MI), mitral regurgitation (MR) was assessed by pulsed-wave Doppler echocardiography and compared with physical and 2-dimensional echocardiographic findings. MR was found by Doppler in 29 of 42 patients (62%) with anterior MI, 11 of 30 (37%) with inferior MI (p less than 0.01) and in none of 20 normal control subjects. MR was more frequent in patients who underwent Doppler study 3 months after MI than in those who underwent Doppler at discharge (anterior MI = 83% vs 50%, p less than 0.01; inferior MI = 47% vs 27%, p = not significant). Of 15 patients who underwent Doppler studies both times, 3 (all with anterior MI) had MR only on the second study. Of the patients with Doppler MR, 12 of 27 (44%) with a left ventricular (LV) ejection fraction (EF) greater than 30% and 1 of 13 (8%) with an EF of 30% or less (p less than 0.01) had an MR systolic murmur. Mitral prolapse or eversion and papillary muscle fibrosis were infrequent in MI patients, whether or not Doppler MR was present. The degree of Doppler MR correlated with EF (r = -0.61), LV systolic volume (r = 0.47), and systolic and diastolic mitral anulus circumference (r = 0.52 and 0.51, respectively). Doppler MR was present in 24 of 28 patients (86%) with an EF of 40% or less and in 16 of 44 (36%) with EF more than 40% (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Blanchard, D; Diebold, B; Peronneau, P; Foult, J M; Nee, M; Guermonprez, J L; Maurice, P
The value of Doppler echocardiography for the non-invasive diagnosis of mitral regurgitation was studied blindly in 161 consecutive invasively investigated adult patients. Regurgitation was graded from 0 to 3 at selective left ventricular angiography. The Doppler echocardiographic examination was considered to be positive when a disturbed systolic flow was found within the left atrium behind the aorta or the anterior leaflet of the mitral valve. The test was considered to be negative in the absence of a regurgitant jet. The level of the signal to noise ratio was checked by the recording of the ventricular filling flow. The study was performed in 131 cases from the left side of the sternum and in 101 cases from the apex. There were no false positives and thus the specificity was 100 per cent. The 20 false negatives were all in patients with grade 1 regurgitation. Thus only some (33%) instances of mild regurgitation were misdiagnosed, and the sensitivity for moderate to severe mitral regurgitation was 100 per cent. PMID:7236465
Temporelli, P. L.; Scapellato, F.; Corra, U.; Eleuteri, E.; Firstenberg, M. S.; Thomas, J. D.; Giannuzzi, P.
Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.
Khouzam, Rami N; D'Cruz, Ivan A; Minderman, Daniel; Kaiser, Jacqueline
Color flow Doppler has been useful in diagnosing the presence and severity of mitral regurgitation (MR). We noted a hitherto unreported sign of MR due to flail mitral leaflet: intense local mosaic pattern at the site of the flail leaflet. This sign was seen well in 11 of 14 patients (79%) with the two-dimensional echocardiographic features of flail mitral leaflet, all with moderate or severe MR. In 3 other patients, the sign was absent; two of those had flail mitral leaflet with severe MR. No local mosaic pattern was seen on color Doppler in 20 other patients with MR but no flail mitral leaflet. We speculate that the focal intense mosaic color Doppler morphology may have been caused by intrusion of the flail leaflet into the MR stream, or to a Coanda-like effect of the MR jet "adhering" to the flail leaflet.
Zuppiroli, A; Mori, F; Favilli, S; Barchielli, A; Corti, G; Montereggi, A; Dolara, A
Atrial and ventricular arrhythmias have been reported with variable incidence in symptomatic patients with mitral valve prolapse (MVP). The role of clinical and echocardiographic parameters as predictors for arrhythmias still needs to be clarified. One hundred nineteen consecutive patients (56 women and 63 men, mean age 40 +/- 17 years) with echocardiographically diagnosed MVP were examined. A complete echocardiographic study (M-mode, two-dimensional, and Doppler) and 24-hour electrocardiographic monitoring were performed in all patients. Complex atrial arrhythmias (CAAs) included atrial couplets, atrial tachycardia, and paroxysmal or sustained atrial flutter or fibrillation. Complex ventricular arrhythmias (CVAs) included multiform ventricular premature contractions (VPCs), VPC couplets, and runs of three or more sequential VPCs (salvos of ventricular tachycardia). The relation between complex arrhythmias and clinical parameters (age and gender) and echocardiographic parameters (left atrial and left ventricular dimensions, anterior mitral leaflet thickness [AMLT], and presence and severity of mitral regurgitation) was evaluated by multiple logistic regression analysis. CAA were present in 14% of patients and CVA in 30%. According to multiple logistic modeling, CAA correlated separately in the univariate analysis with age, presence of MR, and left ventricular and left atrial diameters; age was the only independent predictor (p < 0.001). CVA, in the univariate analysis, correlated with age, female gender, left ventricular end-diastolic diameter, and AMLT; only female gender and AMLT were independent predictors in the multivariate analysis (p < 0.01). The incidence of mitral regurgitation (59%) was higher than expected in a general population of MVP patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Bruch, C; Stypmann, J; Gradaus, R; Breithardt, G; Wichter, T
The aim of this study was to assess the impact of stroke volume (SV) on mitral annular velocities derived from tissue Doppler imaging (TDI). To this end, conventional echocardiographic variables and TDI derived mitral annular velocities (S', E', A') were obtained in 14 patients (pts) with increased SV (due to primary mitral (n=12) (ISV group)), in 41 pts with reduced SV (due to ischemic (n=27) or dilated cardiomyopathy (n=9) or hypertensive heart disease (n=5) (RSV group)) and 29 asymptomatic controls with normal SV (CON group). Systolic (S') and early diastolic (E') mitral annular velocities were elevated in the ISV group in the comparison to the CON group, but were significantly reduced in the RSV group. Late diastolic annular velocities (A') did not differ between the ISV and the CON group, but were lowest in the RSV group. On simple linear regression analysis, SV was significantly related to S' (r=0.74, p<0.001), to E' (r=0.74, p<0.001) and to A' (r=0.43, p<0.01). On multiple regression analysis, SV was a stronger independent predictor of S' and E' than conventional systolic or diastolic echocardiographic variables. Thus, stroke volume has a significant impact on TDI derived systolic (S') and early diastolic (E') mitral annular velocities. This should be considered, when TDI is used in the evaluation of LV performance or in the estimation of filling pressures.
Czer, L S; Maurer, G; Bolger, A F; DeRobertis, M; Chaux, A; Matloff, J M
To determine the effectiveness of revascularization alone or combined with mitral valve repair for ischemic mitral regurgitation, we performed color Doppler echocardiography intraoperatively before and after cardiopulmonary bypass in 49 patients (mean age, 70 +/- 9 years) with concomitant mitral regurgitation and coronary artery disease (triple vessel or left main in 88%; prior infarction in 90%). After revascularization alone (n = 25), the mitral annulus diameter (2.88 +/- 0.44 cm vs 2.88 +/- 0.44 cm), leaflet-to-annulus ratio (1.44 +/- 0.30 vs 1.44 +/- 0.29), and mitral regurgitation grade (1.7 +/- 0.9 vs 1.8 +/- 0.7) remained unchanged (p = NS, postpump vs prepump); mitral regurgitation decreased by 2 grades in only 1 patient (4%). After combined revascularization and mitral valve suture annuloplasty (Kay-Zubiate; n = 24), the annulus diameter decreased (to 2.57 +/- 0.45 cm from 3.11 +/- 0.43 cm), the leaflet-to-annulus ratio increased (to 1.46 +/- 0.25 from 1.20 +/- 0.21), and the mitral regurgitation grade decreased significantly (to 0.9 +/- 0.9 from 2.8 +/- 1.0) (p < 0.01); mitral regurgitation decreased by 2 grades or more (successful repair) in 75%. The origin of the jet correlated with the site of prior infarction (p < 0.05), being inferior in cases of posterior or inferior infarction (67%), and central or broad in cases of combined anterior and inferior infarction (70%). Despite a slightly higher 30-day mortality in the repair group (p = 0.10), there was no significant difference in survival between the 2 surgical groups at 5 years or 8 years. Therefore, in this study of patients with mitral regurgitation and coronary artery disease, reduction in regurgitation grade with revascularization alone was infrequent. Concomitant suture annuloplasty significantly reduced regurgitation by reestablishing a more normal relationship between the leaflet and annulus sizes. The failure rate after suture annuloplasty was 25%; alternative repair techniques such as ring
Leung, D. Y.; Wong, J.; Rodriguez, L.; Pu, M.; Vandervoort, P. M.; Thomas, J. D.
BACKGROUND: The effective orifice area (EOA) of a prosthetic valve is superior to transvalvular gradients as a measure of valve function, but measurement of mitral prosthesis EOA has not been reliable. METHODS AND RESULTS: In vitro flow across St Jude valves was calculated by hemispheric proximal isovelocity surface area (PISA) and segment-of-spheroid (SOS) methods. For steady and pulsatile conditions, PISA and SOS flows correlated with true flow, but SOS and not PISA underestimated flow. These principles were then used intraoperatively to calculate cardiac output and EOA of newly implanted St Jude mitral valves in 36 patients. Cardiac output by PISA agreed closely with thermodilution (r=0.91, Delta=-0.05+/-0.55 L/min), but SOS underestimated it (r=0.82, Delta=-1.33+/-0.73 L/min). Doppler EOAs correlated with Gorlin equation estimates (r=0.75 for PISA and r=0.68 for SOS, P<0.001) but were smaller than corresponding in vitro EOA estimates. CONCLUSIONS: Proximal flow convergence methods can calculate forward flow and estimate EOA of St Jude mitral valves, which may improve noninvasive assessment of prosthetic mitral valve obstruction.
Ha, Jong-Won; Ommen, Steve R; Tajik, A Jamil; Barnes, Marion E; Ammash, Naser M; Gertz, Morie A; Seward, James B; Oh, Jae K
This study evaluated the diagnostic role of early diastolic mitral annular velocity (E') by tissue Doppler echocardiography for differentiating constrictive pericarditis from restrictive cardiomyopathy (primary restrictive cardiomyopathy and cardiac amyloidosis). The study group consisted of 75 patients (53 men, 22 women; mean age 62 years, range 27 to 87). Of these, 23 patients had surgically confirmed constrictive pericarditis, 38 had biopsy-proved systemic amyloidosis and typical echocardiographic features of cardiac involvement, and 14 had primary restrictive cardiomyopathy. Standard mitral inflow characteristics were measured. Tissue Doppler echocardiography was used to measure E' at the septal annulus. E' was significantly higher in patients with constrictive pericarditis than in those with primary restrictive cardiomyopathy or cardiac amyloidosis (12.3 vs 5.1 cm/second, p <0.001). An E' cut-off value > or =8 cm/second resulted in 95% sensitivity and 96% specificity for the diagnosis of constrictive pericarditis. There was no overlap of E' between patients who had constrictive pericarditis and those who had cardiac amyloidosis. In a subgroup analysis of restrictive cardiomyopathy, E' of patients who had cardiac amyloidosis was significantly lower than that of patients who had primary restrictive cardiomyopathy (4.6 vs 6.3 cm/second, p <0.001). Thus, E' velocity can distinguish between constrictive pericarditis and restrictive cardiomyopathy with a specific cut-off value in patients with clinical and echocardiographic evidence of diastolic heart failure.
Salehi, Rezvaneh; Javanshir, Elnaz; Enamzadeh, Elgar
Background Tissue Doppler imaging (TDI) is a new echocardiographic imaging technique that is believed to be superior to older conventional techniques in assessing abnormalities of cardiac function in many conditions affecting the heart. There are very limited data regarding the role of TDI in evaluating patients with mitral valve prolapse (MVP). Current study evaluates diastolic function in patients with MVP by this method. Methods From November 2009 to April 2011, one hundred and ten adults matched for age and sex and without structural heart disease were studied in two groups, with and without MVP, at Madani Heart Center, Tabriz, Iran. TDI was performed at the basal-lateral wall and S, E, E’, A, and A’ velocities, as well as the E/A and E’/A’ ratios were measured. Mitral annular systolic velocity and early diastolic (E’) velocities were measured lateral corner of mitral valve in apical 4-chamber view. Results Patients with MVP had higher left atrium volume (42.31 ± 10.47 vs. 35.19 ± 9.15 cm3; P < 0.001) and deceleration time (186.70 ± 26.00 vs. 176.89 ± 20.36 ms; P = 0.03). Diastolic dysfunction, although seemed more prevalent in MVP group (14.54%) than normal subjects (5.45%), the difference was not statistically significant between groups (P = 0.11). Conclusion Left atrial volume and deceleration time of mitral valve inflow was significantly higher in MVP which could be indicative of early stages of diastolic dysfunction in patients with MVP. However, larger follow-up studies are required to evaluate clinical significance of our findings in these patients.
Zhang, Guimin; Shi, Yingkang; Tang, Hong; Zhang, Eryong; Guo, Zhongsan; Fan, Yubo; Pu, Fang; Zengzhi
In order to establish a method for measuring quantitatively turbulent shear stress (TSS) downstream of mitral stenosis in vivo based on Doppler echocardiography and computer-aided image analysis, we used doppler echocardiography to record the spectrum of flow velocity downstream of mitral valve at several locations in normal persons and in patients with mitral stenosis. With the computer-aided analysis of spectrum images, the magnitude of TSS was measured at the locations. The results demonstrate that no matter how severe the mitral stenosis is, the TSS and relative turbulent intensity(Irel) at the central locations of jet are lower than those at the marginal ones. A significant difference in the quantitative items of TSS, Irel and flow field uniformity between normal persons and patients with varying-degree of mitral stenosis was noticed (P < 0.05). There was a significant correlation between these items and effective orifice area (EOA), and we found that the smaller EOA is, the more severe the extent of stenosis is and the greater the magnitude of both TSS and Irel are, and that the highest magnitude of TSS is focused on the marginal area of jet. These results indicate that there is an obvious correlation between TSS(measured by Doppler echocardiography combined with computer-aided image analysis) and flow field uniformity. They can coincidently reveal the hemodynamic changes resulting from mitral stenosis of varied severeness, implying that our method could exactly depict the magnitude of TSS downstream of mitral stenosis in vivo and is non-invasive and good for anti-disturbance. The method can be used to analyze quantitatively TSS in the flow field of heart valve in patients with valvular diseases.
Sengupta, Partho P; Mohan, Jagdish C; Mehta, Vimal; Arora, Ramesh; Pandian, Natesa G; Khandheria, Bijoy K
Mitral annular velocities are reportedly useful in diagnosing constrictive pericarditis (CP); however, their exact efficacy in larger clinical settings remains unevaluated. This study reexamined the role of longitudinal tissue Doppler imaging in diagnosing CP in clinical practice. Tissue velocity imaging (GE Vingmed System Five) was performed in 122 subjects (87 referred with clinically suspected CP and 35 age- and sex-matched controls). Of the 87 subjects with suspected CP, 45 (51.7%) had CP confirmed at surgery, 11 (12.6%) had restrictive heart disease, 20 (23.0%) had right heart failure due to cor pulmonale, and the other 11 (12.6%) had old pericardial effusions and no hemodynamic evidence of constriction on follow-up echocardiography. Of the 45 patients with CP, mitral early diastolic (Ea) annular velocities from septal and lateral regions were normal (>/=8 cm/s) in 40 (88.9%) and decreased (<8 cm/s) in 1 or both regions in 5 (3 with left ventricular systolic dysfunction, 2 with extensive mitral annular calcification). Of 11 patients with restrictive cardiomyopathy, 8 (72.7%) had reduced Ea (<8 cm/s) and 3 showed normal Ea velocity in 1 or both corners of the mitral annulus. All except 2 patients with right-sided heart failure from cor pulmonale and those with previous pericardial effusion had normal Ea velocities. A normal Ea velocity improved recognition of CP, particularly in the presence of nondiagnostic 2-dimensional or transmitral flow-Doppler imaging. The overall sensitivity and specificity for diagnosing CP using tissue Doppler incrementally with M-mode, 2-dimensional, and transmitral flow Doppler were 88.8% and 94.8%, respectively. Mitral annular velocities help with diagnosis and differentiation of CP in most cases, except in the presence of extensive annular calcification, left ventricular systolic dysfunction, or segmental nonuniformity in myocardial velocities.
Kupari, M; Verkkala, K; Maamies, T; Härtel, G
The development of a left ventricular pseudoaneurysm is a rare complication of heart surgery. Until recently it has been impossible to detect without an angiographic study of the left ventricle. A combination of cross sectional and Doppler ultrasound studies led to the correct diagnosis in two patients with left ventricular pseudoaneurysms after mitral valve replacement. Cross sectional echocardiography showed a posterolateral echo-free space confined only by the pericardium and communicating with the left ventricle through a defect in the ventricular wall, and Doppler echocardiography confirmed the presence of blood flow in this cavity. This Doppler finding is critical if the perforation is too small to be identified reliably by cross sectional imaging. Surgical repair of the pseudoaneurysm can be undertaken without invasive studies if the echocardiographic findings are unequivocal and there is no reason to suspect the integrity of the circumflex coronary artery. Images Fig 1 Fig 2 Fig 3 Fig 4 Fig 5 PMID:3620242
Evin, Morgane; Guivier-Curien, Carine; Pibarot, Philippe; Kadem, Lyes; Rieu, Régis
Malfunction of bileaflet mechanical heart valves in the mitral position could either be due to patient-prosthesis mismatch (PPM) or leaflet obstruction. The aim of this article is to investigate the validity of current echocardiographic criteria used for diagnosis of mitral prosthesis malfunction, namely maximum velocity, mean transvalvular pressure gradient, effective orifice area, and Doppler velocity index. In vitro testing was performed on a double activation left heart duplicator. Both PPM and leaflet obstruction were investigated on a St. Jude Medical Master. PPM was studied by varying the St. Jude prosthesis size (21, 25, and 29 mm) and stroke volume (70 and 90 mL). Prosthesis leaflet obstruction was studied by partially or totally blocking the movement of one valve leaflet. Mitral flow conditions were altered in terms of E/A ratios (0.5, 1.0, and 1.5) to simulate physiologic panel of diastolic function. Maximum velocity, effective orifice area, and Doppler velocity index are shown to be insufficient to distinguish normal from malfunctioning St. Jude prostheses. Doppler velocity index and effective orifice area were 1.3 ± 0.49 and 1.83 ± 0.43 cm(2) for testing conditions with no malfunction below the 2.2 and 2 cm(2) thresholds (1.19 cm(2) for severe PPM and 1.23 cm(2) for fully blocked leaflet). The mean pressure gradient reached 5 mm Hg thresholds for several conditions of severe PPM only (6.9 mm Hg and mean maximum velocity value: 183.4 cm/s) whereas such value was never attained in the case of leaflet obstruction. In the case of leaflet obstruction, the maximum velocity averaged over the nine pulsed-wave Doppler locations increased by 38% for partial leaflet obstruction and 75% for a fully blocked leaflet when compared with normal conditions. Current echocardiographic criteria might be suboptimal for the detection of bileaflet mechanical heart valve malfunction. Further developments and investigations are required in order
Alam, M; Wardell, J; Andersson, E; Samad, B A; Nordlander, R
This study was undertaken to assess the effect of a first myocardial infarction (MI) on the systolic and diastolic velocity profiles of the mitral annulus determined by pulsed wave Doppler tissue imaging and thereby evaluate left ventricular (LV) function after MI. Seventy-eight patients with a first MI were examined before discharge. Peak systolic, peak early diastolic, and peak late diastolic velocities were recorded at 4 different sites on the mitral annulus corresponding to the septum, anterior, lateral, and inferior sites of the left ventricle. In addition, the amplitude of mitral annular motion at the 4 above LV sites, the ejection fraction, and conventional Doppler diastolic parameters were recorded. Nineteen age-matched healthy subjects served as controls. Compared with healthy subjects, the MI patients had a significantly reduced peak systolic velocity at the mitral annulus, especially at the infarction sites. A relatively good linear correlation was found between the ejection fraction and the mean systolic velocity from the 4 LV sites (r = 0.74, P <.001). The correlation was also good when the mean peak systolic mitral annular velocity was tested against the magnitude of the mean mitral annular motion (r = 0.77, P <.001). When the patients were divided into 2 different groups with respect to an ejection fraction > or =0.50 or <0.50, a cutoff point of mean systolic mitral annular velocity of > or =7.5 cm/s had a sensitivity of 79% and a specificity of 88% in predicting a preserved global LV systolic function. Similar to systolic velocities, the early diastolic velocity was also reduced, especially at the infarction sites. The peak mitral annular early diastolic velocity correlated well with both LV ejection fraction (r =.66, P <.001) and mean systolic mitral annular motion (r = 0.68, P <.001). However, no correlation existed between the early diastolic velocity and conventional diastolic Doppler parameters. The reduced peak systolic mitral annular velocity
Nakatani, S.; Firstenberg, M. S.; Greenberg, N. L.; Vandervoort, P. M.; Smedira, N. G.; McCarthy, P. M.; Thomas, J. D.
The pressure-velocity relationship across the normal mitral valve is approximated by the Bernoulli equation DeltaP = 1/2 rhoDeltav(2) + M. dv/dt, where DeltaP is the atrioventricular pressure difference, rho is blood density, v is transmitral flow velocity, and M is mitral inertance. Although M is indispensable in assessing transvalvular pressure differences from transmitral flow, this term is poorly understood. We measured intraoperative high-fidelity left atrial and ventricular pressures and simultaneous transmitral flow velocities by using transesophageal echocardiography in 100 beats (8 patients). We computed mean mitral inertance (M) by M = integral((DeltaP)-(1/2 x rho v(2))dt/integral(dv/dt)dt and we assessed the effect of the inertial term on the transmitral pressure-flow relation. ranged from 1.03 to 5.96 g/cm(2) (mean = 3.82 +/- 1.22 g/cm(2)). DeltaP calculated from the simplified Bernoulli equation (DeltaP = 1/2. rhov(2)) lagged behind (44 +/- 11 ms) and underestimated the actual peak pressures (2.3 +/- 1.1 mmHg). correlated with left ventricular systolic pressure (r = -0.68, P < 0.0001) and transmitral pressure gradients (r = 0.65, P < 0.0001). Because mitral inertance causes the velocity to lag significantly behind the actual pressure gradient, it needs to be considered when assessing diastolic filling and the pressure difference across normal mitral valves.
López-Candales, Angel; Edelman, Kathy; Gulyasy, Beth; Candales, Maria Dolores
Some data suggests that both left ventricular (LV) systolic and diastolic function are impaired in patients with chronic pulmonary hypertension (cPH); however, a clear understanding of these specific abnormalities remains poorly characterized. LV systolic and diastolic function as well as LV myocardial performance index (MPI) were obtained and compared to total duration of mitral annular (MA) TDI systolic (MASTDId) and diastolic (MADTDId) measurements, corrected for heart rate, in 20 controls (Group I: mean 53 ± 18 years) and 30 patients (Group II: mean 55 ± 14 years) with cPH. Group II patients had relatively faster heart rates (75 ± 14 bpm vs. 63 ± 12 bpm; P < 0.003), higher LV ejection fraction (78 ± 10% vs. 68 ± 6%; P < 0.0004), similar MA systolic excursion (1.4 ± 0.2), unchanged MA TDI Ea/Aa ratios (0.86 ± 0.46 vs. 1.05 ± 0.41; P = 0.15), significantly higher LV MPI (0.98 ± 0.56 vs. 0.60 ± 0.11; P < 0.004), with a significantly shorter heart rate corrected MASTDId (251 ± 66 ms vs. 305 ± 30 ms; P < 0.001) and MADTDId (378 ± 87 ms vs. 497 ± 114 ms; P < 0.0001) than Group I. It appears that cPH shortens the total duration of both MA systolic and diastolic TDI intervals. Whether this is a result of altered LV geometry and/or confounded by the presence of relatively faster heart rates in cPH patients will require further study.
Dori, Guy; Egbaria, Muhammad A; Jabaren, Mohamed
Trans-mitral flow velocity (TMFV) examination is a standard echocardiographic measure for assessing diastolic function of the heart. Typically, the Doppler signal representing the early rapid filling phase of the left ventricle (LV), termed: E wave, is triangular. The ascending arm of the E wave (EWAA) represents blood accelerating into the LV from the left atrium (LA), whereas the descending arm reflects blood decelerating as the LV fills and resists further filling. The slope of EWAA is linear, starting at TMFV of zero cm/s (prior to mitral valve opening) and building to peak E wave value. The physical meaning of a single slope is that blood acceleration is constant with time. Little data exist regarding the significance of the shape of EWAA. It is hypothesized that in heart failure with preserved ejection fraction (HFPEF) the EWAA displays 2 slopes. A first steeper slope followed by a second less steep slope reaching peak E wave. The different slopes represent a change in the composition of driving forces propelling blood from LA to LV. It is hypothesized that the first steeper slope of EWAA represents a set of driving force including a force termed: diastolic suction, whereas in the second slope diastolic suction has already dissipated. This 2-slope phenomenon is not expected in healthy subjects because the assumed underlying mechanism is not operative.
Sitges, Marta; Jones, Michael; Shiota, Takahiro; Qin, Jian Xin; Tsujino, Hiroyuki; Bauer, Fabrice; Kim, Yong Jin; Agler, Deborah A.; Cardon, Lisa A.; Zetts, Arthur D.; Panza, Julio A.; Thomas, James D.
BACKGROUND: Pitfalls of the flow convergence (FC) method, including 2-dimensional imaging of the 3-dimensional (3D) geometry of the FC surface, can lead to erroneous quantification of mitral regurgitation (MR). This limitation may be mitigated by the use of real-time 3D color Doppler echocardiography (CE). Our objective was to validate a real-time 3D navigation method for MR quantification. METHODS: In 12 sheep with surgically induced chronic MR, 37 different hemodynamic conditions were studied with real-time 3DCE. Using real-time 3D navigation, the radius of the largest hemispherical FC zone was located and measured. MR volume was quantified according to the FC method after observing the shape of FC in 3D space. Aortic and mitral electromagnetic flow probes and meters were balanced against each other to determine reference MR volume. As an initial clinical application study, 22 patients with chronic MR were also studied with this real-time 3DCE-FC method. Left ventricular (LV) outflow tract automated cardiac flow measurement (Toshiba Corp, Tokyo, Japan) and real-time 3D LV stroke volume were used to quantify the reference MR volume (MR volume = 3DLV stroke volume - automated cardiac flow measurement). RESULTS: In the sheep model, a good correlation and agreement was seen between MR volume by real-time 3DCE and electromagnetic (y = 0.77x + 1.48, r = 0.87, P <.001, delta = -0.91 +/- 2.65 mL). In patients, real-time 3DCE-derived MR volume also showed a good correlation and agreement with the reference method (y = 0.89x - 0.38, r = 0.93, P <.001, delta = -4.8 +/- 7.6 mL). CONCLUSIONS: real-time 3DCE can capture the entire FC image, permitting geometrical recognition of the FC zone geometry and reliable MR quantification.
Uemura, Kazunori; Inagaki, Masashi; Zheng, Can; Li, Meihua; Kawada, Toru; Sugimachi, Masaru
Assessing left ventricular (LV) filling pressure (pulmonary capillary wedge pressure, PCWP) is an important aspect in the care of patients with heart failure (HF). Physicians rely on right ventricular (RV) filling pressures such as central venous pressure (CVP) to predict PCWP, assuming concordance between CVP and PCWP. However, the use of this method is limited because discordance between CVP and PCWP is observed. We hypothesized that PCWP can be reliably predicted by CVP corrected by the relationship between RV and LV function, provided by the ratio of tissue Doppler peak systolic velocity of tricuspid annulus (S(T)) to that of mitral annulus (S(M)) (corrected CVP:CVP·S(T)/S(M)). In 16 anesthetized closed-chest dogs, S T and S M were measured by transthoracic tissue Doppler echocardiography. PCWP was varied over a wide range (1.8-40.0 mmHg) under normal condition and various types of acute and chronic HF. A significantly stronger linear correlation was observed between CVP·S(T)/S(M) and PCWP (R2 = 0.78) than between CVP and PCWP (R2 = 0.22) (P < 0.01). Receiver-operating characteristic (ROC) analysis indicated that CVP·S(T)/S(M) >10.5 mmHg predicted PCWP >18 mmHg with 85% sensitivity and 88% specificity. Area under ROC curve for CVP·S T/S M to predict PCWP >18 mmHg was 0.93, which was significantly larger than that for CVP (0.66) (P < 0.01). Peripheral venous pressure (PVP) corrected by S T/S M (PVP·S(T)/S(M) also predicted PCWP reasonably well, suggesting that PVP·S(T)/S (M) may be a minimally invasive alternative to CVP·S(T)/S(M) In conclusion, our technique is potentially useful for the reliable prediction of PCWP in HF patients.
Nagueh, Sherif F; Rao, Liyun; Soto, Julia; Middleton, Katherine J; Khoury, Dirar S
In the present study, we performed simultaneous epicardial echocardiography and left heart catheterization on ten adult dogs to investigate the effects of ischaemia and tachycardia on the mitral annulus early (E(a)) and late (A(a)) diastolic velocities and the haemodynamic mechanisms involved. Left atrial pressure and left ventricular (LV) volumes and pressures were measured with 5 French Millar catheters. In each dog, inferior vena cava occlusion was used to alter preload and circumflex coronary artery occlusion was applied to induce ischaemia at two different cycle lengths: 450 and 550 ms. At both cycle lengths, ischaemia resulted in a reduction in LV relaxation, LV global and ipsilateral systolic function, transmitral pressure gradient (TMG), E(a) and A(a) ( P <0.05). The shorter cycle length was associated with a shorter tau (time constant of LV relaxation), reduced TMG and reduced septal and lateral E(a) ( P <0.05 for all variables). Both septal and lateral A(a) were significantly increased ( P <0.05). Ischaemia influences E(a) through changes in LV relaxation, global and regional systolic function and TMG. An increase in heart rate reduces E(a), but increases A(a).
... may then collect in the lung tissue (pulmonary edema), making it hard to breathe. In adults, mitral ... kidneys, or other areas Congestive heart failure Pulmonary edema Pulmonary hypertension When to Contact a Medical Professional ...
Joseph Woo, Y; McCormick, Ryan C
We report transventricular mitral valve operations in 2 patients with severe mitral regurgitation and postinfarction left ventricular rupture and pseudoaneurysm. The first patient had direct papillary muscle involvement necessitating replacement of the mitral valve. The second patient had indirect mitral involvement allowing for placement of an atrial mitral annuloplasty ring via the left ventricle. Both patients showed no mitral valve regurgitation after replacement or repair and had uneventful postoperative recoveries. These cases demonstrate a feasible, alternative, transventricular approach to mitral valve replacement and repair.
Fujii, Taro; Kogure, Shuhei; Muro, Takashi; Okada, Yukikatsu
Mitral valve injury after blunt chest trauma is a rare clinical condition. We describe a case of mitral valve repair for severe mitral regurgitation due to blunt chest trauma 5 years previously. A 22-year-old man was referred to our hospital for surgical correction of severe mitral regurgitation. Echocardiography demonstrated a partial tear of the anterolateral papillary muscle which lacerated to the apex. The entire anterolateral part of the mitral valve including the anterior commissure and posterior leaflets had prolapsed. Reimplantation of the papillary muscle to the posterior left ventricular wall and ring annuloplasty were successfully performed without residual regurgitation.
de Agustin, Jose A; Nanda, Navin C; Gill, Edward A; de Isla, Leopoldo Pérez; Zamorano, Jose L
To date, mitral stenosis has been evaluated by both hemodynamic data derived from catheterization as well as 2D and Doppler echocardiography. However, the advent of real-time 3D echocardiography has allowed more precise measurement of the mitral valve orifice by planimetry. In addition, evaluation of the mitral commissures prior to and after percutaneous mitral valvuloplasty is greatly aided by 3D echocardiography. Here we discuss these subjects as well as provide specific clinical trials that support the use of real-time 3D echocardiography for the evaluation and treatment of mitral stenosis.
Mitral valve prolapse (MVP) occurs when one of your heart's valves doesn't work properly. The flaps of ... Migraine headaches Chest discomfort Most people who have mitral valve prolapse (MVP) don't need treatment because they ...
Rosser, Walter W.
The author discusses the pathophysiology of mitral valve prolapse and provides guidelines to identify and treat low-to high-risk mitral valve prolapse. An approach to diagnosing bacterial endocarditis and its prophylaxis are also discussed. The author reviews mitral valve prolapse syndrome and the risk of sudden death.
Mohebali, Jahan; Chen, Frederick Y
Mitral valve repair for ischemic mitral valve regurgitation remains controversial. In moderate mitral regurgitation (MR), controversy exists whether revascularization alone will be adequate to restore native valve geometry or whether intervention on the valve (repair) should be performed concomitantly. When MR is severe, the need for valve intervention is not disputed. Rather, the controversy is whether repair versus replacement should be undertaken. In contrast to degenerative or myxomatous disease that directly affects leaflet integrity and morphology, ischemic FMR results from a distortion and dilation of native ventricular geometry that normally supports normal leaflet coaptation. To address this, the first and most crucial step in successful valve repair is placement of an undersized, complete remodeling annuloplasty ring to restore the annulus to its native geometry. The following article outlines the steps for repair of ischemic mitral regurgitation.
Kalmanson, D; Veyrat, C; Bernier, A; Witchitz, S; Chiche, P
In 15 patients with pure or predominant mitral stenosis and in a control group of 11 patients without mitral stenosis the blood flow velocity through the mitral valve orifice was recorded by means of a directional Doppler ultrasound velocity catheter introduced transeptally and positioned in the orifice of the mitral valve. A simultaneous surface phonocardiogram was obtained. The timing of the mitral opening snap in relation to the blood velocity record of the flow through the valve supported the hypothesis that the opening snap is due to a sudden tensing of the valve leaflets by the chordae tendineae. Determination of the exact time of mitral valve opening, made possible by the blood velocity record, led to the division of the classical A2-0S interval (aortic valve closure to opening snap) into two components representing respectively the diastolic isovolumic relaxation period and the time of excursion of the mitral valve cusps. The durations of the isovolumic relaxation period were compared with those in the control patients and were found to correlate with the severity of the mitral stenosis, whereas those of the excursion time of the mitral cusps were influenced by the presence or absence of mitral valve calcification. PMID:1259828
Hoit, B D; Rashwan, M; Verba, J; Pretorius, T; Sahn, D J; Bhargava, V
To improve the accuracy of Doppler echocardiographic indices of left ventricular filling, we derived two indices of instantaneous transmitral flow with the use of Doppler velocities and M-mode echocardiography. These indices were calculated from the product of pulsed Doppler mitral velocities and either the excursion of the anterior mitral leaflet or the separation of both mitral leaflets as measures of the changing mitral orifice area. The derived flow indices and the mitral velocities alone were compared to left ventricular filling as determined by radionuclide ventriculography in 24 patients. When compared as areas under the matched decile divisions of the derived filling sequences by linear regression analysis, the relationship for combined Doppler and M-mode versus radionuclide left ventricular filling was closer to the line of identity (slope = 0.98 and 0.94 using the anterior mitral leaflet and both mitral leaflets, respectively, both p = NS versus the line of identity) than was the relationship for mitral velocities alone versus radionuclide left ventricular filling (slope = 0.74, p less than 0.05 versus the line of identity). The instantaneous mitral volume flow indices more closely resemble the time course and shape of radionuclide left ventricular filling curves than do mitral velocities alone, and the application of these indices should assist the quantitative description by Doppler echocardiography of left ventricular filling.
Bothe, W; Beyersdorf, F
At the beginning of the 20th century, Cutler and Levine performed the first successful surgical treatment of a stenotic mitral valve, which was the only treatable heart valve defect at that time. Mitral valve surgery has evolved significantly since then. The introduction of the heart-lung machine in 1954 not only reduced the surgical risk, but also allowed the treatment of different mitral valve pathologies. Nowadays, mitral valve insufficiency has become the most common underlying pathomechanism of mitral valve disease and can be classified into primary and secondary mitral insufficiency. Primary mitral valve insufficiency is mainly caused by alterations of the valve (leaflets and primary order chords) itself, whereas left ventricular dilatation leading to papillary muscle displacement and leaflet tethering via second order chords is the main underlying pathomechanism for secondary mitral valve regurgitation. Valve reconstruction using the "loop technique" plus annuloplasty is the surgical strategy of choice and normalizes life expectancy in patients with primary mitral regurgitation. In patients with secondary mitral regurgitation, implanting an annuloplasty is not superior to valve replacement and results in high rates of valve re-insufficiency (up to 30 % after 3 months) due to ongoing ventricular dilatation. In order to improve repair results in these patients, we add a novel subvalvular technique (ring-noose-string) to the annuloplasty that aims to prevent ongoing ventricular remodeling and re-insufficiency. In modern mitral surgery, a right lateral thoracotomy is the approach of choice with excellent repair and cosmetic results.
Choi, Jin-Oh; Shin, Mi-Seung; Kim, Mi-Jeong; Jung, Hae Ok; Park, Jeong Rang; Sohn, Il Suk; Kim, Hyungseop; Park, Seong-Mi; Yoo, Nam Jin; Choi, Jung Hyun; Kim, Hyung-Kwan; Cho, Goo-Yeong; Lee, Mi-Rae; Park, Jin-Sun; Shim, Chi Young; Kim, Dae-Hee; Shin, Dae-Hee; Shin, Gil Ja; Shin, Sung Hee; Kim, Kye Hun; Park, Jae-Hyeong; Lee, Sang Yeub; Kim, Woo-Shik
Background Hemodynamic and functional evaluation with Doppler and tissue Doppler study as a part of comprehensive echocardiography is essential but normal reference values have never been reported from Korean normal population especially according to age and sex. Methods Using Normal echOcaRdiographic Measurements in a KoreAn popuLation study subjects, we obtained normal reference values for Doppler and tissue Doppler echocardiography including tricuspid annular velocities according to current guidelines and compared values according to gender and age groups. Results Mitral early diastolic (E) and late diastolic (A) velocity as well as E/A ratio were significantly higher in women compared to those in men. Conversely, mitral peak systolic and late diastolic annular velocity in both septal and lateral mitral annulus were significantly lower in women compared to those in men. However, there were no significant differences in both septal and lateral mitral early diastolic annular (e') velocity between men and women. In both men and women, mitral E velocity and its deceleration time as well as both E/A and E/e' ratio considerably increased with age. There were no significant differences in tricuspid inflow velocities and tricuspid lateral annular velocities between men and women except e' velocity, which was significantly higher in women compared to that in men. However, changes in both tricuspid inflow and lateral annular velocities according to age were similar to those in mitral velocities. Conclusion Since there were significant differences in Doppler and tissue Doppler echocardiographic variables between men and women and changes according to age were even more considerable in both gender groups, normal Doppler echocardiographic values should be differentially applied based on age and sex. PMID:27358707
... Kawasaki Disease Long Q-T Syndrome Marfan Syndrome Metabolic Syndrome Mitral Valve Prolapse Myocardial Bridge Myocarditis Obstructive Sleep Apnea Pericarditis Peripheral Vascular Disease Rheumatic Fever Sick Sinus Syndrome Silent Ischemia Stroke Sudden ...
Bergy, Gordon G.
Mitral valve prolapse is the most common heart disease seen in college and university health services. It underlies most arrhythmia and many chest complaints. Activity and exercise restrictions are usually unnecessary. (Author/CJ)
... Heart Disease Diseases of the arteries, valves, and aorta, as well as cardiac rhythm disturbances Aortic Valve ... are two main types of mitral valve disease: Stenosis – the valve does not open enough to allow ...
Block, Peter C
Mitral regurgitation (MR) associated with, ischemic, and degenerative (prolapse) disease, contributes to left ventricular (LV) dysfunction due to remodeling, and LV dilation, resulting in worsening of MR. Mitral valve (MV) surgical repair has provided improvement in survival, LV function and symptoms, especially when performed early. Surgical repair is complex, due to diverse etiologies and has significant complications. The Society for Thoracic Surgery database shows that operative mortality for a 1st repair is 2% and for re-do repair is 4 times that. Cardiopulmonary bypass and cardiac arrest are required. The attendant morbidity prolongs hospitalization and recovery. Alfieri simplified mitral repair using an edge-to-edge technique which subsequently has been shown to be effective for multiple etiologies of MR. The MV leaflers are typically brought together by a central suture producing a double orifice MV without stenosis. Umana reported that MR decreased from grade 3.6 +/- 0.5 to 0.8 +/- 0.4 (P < 0.0001) and LV ejection fraction increased from 33 +/- 13% to 45 +/- 11% (P = 0.0156). In 121 patients, Maisano reported freedom from re-operation of 95 +/- 4.8% with up to 6 year follow-up. Oz developed a MV "grasper" that is directly placed via a left ventriculotomy and coapts both leaflets which are then fastened by a graduated spiral screw. An in-vitro model using explanted human valves showed significant reduction in MR and in canine studies, animals followed by serial echo had persistent MV coaptation. At 12 weeks the device was endothelialized. These promising results have paved the way for a percutaneous or minimally invasive-off pump mitral repair. Evalve has developed catheter-based technology, which, by apposing the edges of a regurgitant MV, results in edge-to-edge repair. Release of the device is done after echo and fluoroscopic evaluation under normal loading conditions. If the desired effect is not produced the device can be repositioned or retrieved
Mice allow biologists to study various genes playing a role in cardiac function and pathophysiological situations. Echocardiography is a non-invasive tool for assessing cardiac phenotype. Because of load dependence of conventional parameters (left ventricular shortening fraction, left ventricular ejection fraction and mitral pulsed Doppler), we have to perform Doppler tissular velocity imaging and strain imaging for the characterization of cardiomyopathies mice models.
Attari, M; Legrand, M; Philippe, C; Rosak, P
We here report the case of a 67-year-old woman with moderate mitral regurgitation without significant structural abnormalities that get worse during severe recurrent heart failures and preserved ejection fraction with concomitant paroxysmal atrial fibrillation. Atrial fibrillation became permanent and despite a well-controlled cardiac frequency, new heart failure episodes occurred. Exercise doppler echocardiography showed that the mechanism of this mitral regurgitation was a two leaflet mitral tenting. We discuss here the different mechanisms that could induce these kinds of mitral regurgitation with excessive tenting. We emphasize the interest of early detection by exercise doppler echocardiography even when a triggering factor like atrial fibrillation seems to be involved. We also discuss the interest of mitral valve replacement for these patients.
Freund, W. R.; Beaver, W. L.; Meindl, J. D.
Studies were made of (1) blood flow redistribution during lower body negative pressure (LBNP), (2) the profile of blood flow across the mitral annulus of the heart (both perpendicular and parallel to the commissures), (3) testing and evaluation of a number of pulsed Doppler systems, (4) acute calibration of perivascular Doppler transducers, (5) redesign of the mitral flow transducers to improve reliability and ease of construction, and (6) a frequency offset generator designed for use in distinguishing forward and reverse components of blood flow by producing frequencies above and below the offset frequency. Finally methodology was developed and initial results were obtained from a computer analysis of time-varying Doppler spectra.
Alehan, D; Doğan, R; Ozkutlu, S; Elshershari, H; Gümrük, F
Two cases are described in which severe mechanical hemolytic anemia developed after surgical repair of primum atrial septal defect (ASD) and cleft mitral valve. In both cases there was residual mitral regurgitation after repair. Moderate mitral regurgitation and collision of the regurgitant jet with the teflon patch used for repair of the primum ASD were detected by color-Doppler echocardiography imaging. Laboratory tests showed normochromic normocytic anemia, increased indirect serum bilirubin, decreased plasma haptoglobin and hemoglobinuria. The peripheral blood smear contained numerous fragmented red cells. Following another surgical correction of the mitral valve (repair or mitral valve replacement), there was no more hemolysis. The two presented cases show that foreign materials in association with localized intracardiac turbulence may cause severe hemolysis.
Smedema, J P
A middle-aged African lady, who presented with ventricular tachycardias, mitral valve regurgitation and congestive heart failure, was diagnosed with cardiac sarcoidosis. Tissue Doppler imaging demonstrated abnormalities suggestive of myocardial scar, which was confirmed by contrast-enhanced cardiac magnetic resonance.
Misumi, Ikuo; Nagao, Asako; Iwamoto, Katsuya; Honda, Tsuyoshi; Ishii, Masanobu; Ueyama, Hidetsugu; Maeda, Yasushi; Ishizaki, Masatoshi; Kurisaki, Ryoichi; Okazaki, Toshio; Yamashita, Tetsuji; Fujimoto, Akiko; Honda, Yumi
A 96-year-old woman developed hemiparesis 2 weeks after orthopedic surgery. Magnetic resonance imaging revealed multiple cerebral infarctions in the bilateral hemisphere. Transthoracic echocardiography revealed a mobile structure attached to the anterior mitral leaflet that protruded toward the left ventricular outflow tract. The structure was identified as an accessory mitral valve. Doppler echocardiography showed that there was no significant left ventricular outflow obstruction. This is a rare case of a silent accessory mitral valve that was detected after multiple cerebral infarctions. PMID:28090044
... Saunders; 2012:chap 61. Otto CM, Bonow RO. Valvular heart disease. In: Mann DL, Zipes DP, Libby P, Bonow ... Editorial team. Related MedlinePlus Health Topics Heart Surgery Heart Valve Diseases Mitral Valve Prolapse Browse the Encyclopedia A.D. ...
Cristiano, Spadaccio; Nenna, Antonio; Chello, Massimo
Ischemic mitral prolapse (IMP) is a pathologic entity encountered in about one-third among the patients undergoing surgery for ischemic mitral regurgitation (IMR). IMP is generally the result of a papillary muscle injury consequent to myocardial, but the recent literature is progressively unveiling a more complex pathogenesis. The mechanisms underlying its development regards the impairment of one or more components of the mitral apparatus, which comprises the annulus, the chordae tendineae, the papillary muscle and the left ventricular wall. IMP is not only a disorder of valvular function, but also entails coexistent aspects of a geometric disturbance of the mitral valve configuration and of the left ventricular function and dimension and a correct understanding of all these aspects is crucial to guide and tailor the correct therapeutic strategy to be adopted. Localization of prolapse, anatomic features of the prolapsed leaflets and the subvalvular apparatus should be carefully evaluated as also constituting the major determinants defining patient’s outcomes. This review will summarize our current understanding of the pathophysiology and clinical evidence on IMP with a particular focus on the surgical treatment. PMID:28149574
Hertwig, Christine; Haas, Nikolaus A; Habash, Sheeraz; Hanslik, Andreas; Kececioglu, Deniz; Sandica, Eugen; Laser, Kai-Thorsten
Mitral valve stenosis caused by a discrete supravalvular membrane is a rare congenital malformation haemodynamically leading to significant mitral valve stenosis. When the supravalvular mitral stenosis consists of a discrete supravalvular membrane adherent to the mitral valve, it is usually not clearly detectable by routine echocardiography. We report about the typical echocardiographic finding in three young patients with this rare form of a discrete membranous supravalvular stenosis caused by a membrane adherent to the mitral valve. These cases present a typical echocardiographic feature in colour Doppler generated by the pathognomonic supramitral flow acceleration. Whereas typical supravalvular mitral stenosis caused by cor triatriatum or a clearly visible supravalvular ring is easily detectable by echocardiography, a discrete supravalvular membrane adjacent to the mitral valve leaflets resembling valvular mitral stenosis is difficult to differentiate by routine echocardiography. In our opinion, this colour phenomenon does resemble the visual impression of polar lights in the northern hemisphere; owing to its typical appearance, it may therefore be named as "Polar Light Sign". This phenomenon may help to detect this anatomical entity by echocardiography in time and therefore improve the prognosis for repair.
Lindeboom, J.E.; Jaarsma, W.; Kelder, J.C.; Morshuis, W.J.; Visser, C.A.
Background and aim Functional mitral regurgitation (FMR) is defined as mitral regurgitation in the absence of intrinsic valvular abnormalities. We prospectively evaluated the effect of coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR), without additional mitral valve repair, on the degree of moderate or severe FMR. Study design and methods From a cohort of 2829 patients undergoing CABG and/or AVR in the St. Antonius Hospital, 67 patients were identified with moderate or severe FMR by transthoracic and transoesophageal Doppler echocardiography. Results Two out of the 67 patients (3%) died perioperatively. During follow-up (3-18 months) mitral regurgitation decreased by one grade in 29 patients, by two grades in 28, by three grades in five patients and remained unchanged in one patient (p=0.0001). Of all patients, 85% had grade I mitral regurgitation or less. Grade II mitral regurgitation remained in nine patients with a previous large myocardial infarction and/or annular calcifications. NYHA class improved from 3.1+0.5 to 1.4+0.4 (p=0.0001). Ejection fraction increased from 46 to 55% (p=0.0001). Overall, left atrial and left ventricular end-diastolic dimensions decreased significantly. In contrast, no decrease in dimensions was seen in patients with postoperative grade II mitral regurgitation. Conclusion FMR may improve significantly following CABG and/or AVR, although a previous large myocardial infarction and/or annular calcifications may affect outcome. PMID:25696484
Yalcin, Fatih; El-Amrousy, Mahmoud; Muderrisoglu, Haldun; Korkmaz, Mehmet; Flachskampf, Frank; Tuzcu, Murat; Garcia, Mario G.; Thomas, James D.
Patients with mitral stenosis have usually blunted pulmonary venous (PV) flow, because of decreased mitral valve area and diastolic dysfunction. The authors compared changes in Doppler PV velocities by using transesophageal echocardiography (TEE) against hemodynamics parameters before and after mitral balloon valvotomy to observe relevance of PV velocities and endsystolic left atrial (LA) pressure-volume relationship. In 25 patients (aged 35 +/- 17 years) with mitral stenosis in sinus rhythm, changes in LA pressure and volumes were compared with PV velocities before and after valvotomy. Mitral valve area, mitral gradients, and deceleration time were obtained. Mitral valve area and mitral gradients changed from 1 +/- 0.2 cm2 and 14.6 +/- 5.4 mmHg to 1.9 +/- 0.3 cm2 and 6.3 +/- 1.7 mmHg, respectively (p<0.001). AR peak reverse flow velocity and AR duration decreased from 29 +/- 13 cm/s and 110 =/- 30 msec to 19 +/- 6 cm/s and 80 +/- 29 msec respectively (p<0.001). Transmitral Doppler E wave deceleration time decreased from 327 +/- 85 to 209 +/- 61 s and cardiac output increased from 4.2 +/- 1.0 to 5.2 +/- 1.1 L/minute (p<0.001). The changes in LA pressure were correlated with changes in S/D (r=0.57, p<0.05). The changes in endsystolic LA pressure-volume relationship were also correlated with changes in S/D (r=0.52, p<0.05). Endsystolic LA pressure-volume relationship decreased after mitral balloon valvotomy, as a result of a large decrease in pressure. PV systolic/diastolic (S/D) waves ratio reflects endsystolic LA pressure-volume relationship and may be used as another indicator of successful valvotomy.
... page from the NHLBI on Twitter. How Is Mitral Valve Prolapse Treated? Most people who have mitral valve ... all hospitals offer this method. Valve Repair and Valve Replacement In mitral valve surgery, the valve is repaired or replaced. ...
Basso, Cristina; De Lazzari, Manuel; Rizzo, Stefania; Cipriani, Alberto; Giorgi, Benedetta; Lacognata, Carmelo; Rigato, Ilaria; Migliore, Federico; Pilichou, Kalliopi; Cacciavillani, Luisa; Bertaglia, Emanuele; Frigo, Anna Chiara; Bauce, Barbara; Corrado, Domenico; Thiene, Gaetano; Iliceto, Sabino
Background— Arrhythmic mitral valve prolapse (MVP) is characterized by myxomatous leaflets and left ventricular (LV) fibrosis of papillary muscles and inferobasal wall. We searched for morphofunctional abnormalities of the mitral valve that could explain a regional mechanical myocardial stretch. Methods and Results— Thirty-six (27 female patients; median age: 44 years) arrhythmic MVP patients with LV late gadolinium enhancement on cardiac magnetic resonance and no or trivial mitral regurgitation, and 16 (6 female patients; median age: 40 years) MVP patients without LV late gadolinium enhancement were investigated by morphofunctional cardiac magnetic resonance. Mitral annulus disjunction (median: 4.8 versus 1.8 mm; P<0.001), end-systolic mitral annular diameters (median: 41.2 versus 31.5; P=0.004) and end-diastolic mitral annular diameters (median: 35.5 versus 31.5; P=0.042), prevalence of posterior systolic curling (34 [94%] versus 3 [19%]; P<0.001), and basal to mid LV wall thickness ratio >1.5 (22 [61%] versus 4 [25%]; P=0.016) were higher in MVP patients with late gadolinium enhancement than in those without. A linear correlation was found between mitral annulus disjunction and curling (R=0.85). A higher prevalence of auscultatory midsystolic click (26 [72%] versus 6 [38%]; P=0.018) was also noted. Histology of the mitral annulus showed a longer mitral annulus disjunction in 50 sudden death patients with MVP and LV fibrosis than in 20 patients without MVP (median: 3 versus 1.5 mm; P<0.001). Conclusions— Mitral annulus disjunction is a constant feature of arrhythmic MVP with LV fibrosis. The excessive mobility of the leaflets caused by posterior systolic curling accounts for a mechanical stretch of the inferobasal wall and papillary muscles, eventually leading to myocardial hypertrophy and scarring. These mitral annulus abnormalities, together with auscultatory midsystolic click, may identify MVP patients who would need arrhythmic risk stratification. PMID
The mitral valve is one of four valves in the human heart. The valve opens to allow oxygenated blood from the lungs to fill the left ventricle, and closes when the ventricle contracts to prevent backflow. The valve is composed of two fibrous leaflets which hang from a ring. These leaflets are supported like a parachute by a system of strings called chordae tendineae. In this talk, I will describe a new computational model of the mitral valve. To generate geometry, general information comes from classical anatomy texts and the author's dissection of porcine hearts. An MRI image of a human heart is used to locate the tips of the papillary muscles, which anchor the chordae tendineae, in relation to the mitral ring. The initial configurations of the valve leaflets and chordae tendineae are found by solving solving an equilibrium elasticity problem. The valve is then simulated in fluid (blood) using the immersed boundary method over multiple heart cycles in a model valve tester. We aim to identify features and mechanisms that influence or control valve function. Support from National Science Foundation, Graduate Research Fellowship Program, Grant DGE 1342536.
Muscholl, M; Dennig, K; Kraus, F; Rudolph, W
For noninvasive assessment of diastolic ventricular function, in addition to echocardiography, more recently, in particular, Doppler echocardiography has been employed. M-mode echocardiogram velocity curves for diameter changes as well as Doppler-echocardiographically registered velocity curves of mitral flow characterize the temporal changes of diastolic flow into the left ventricle. They represent the overall result of factors which influence diastolic filling and are functions of the temporal course of the pressure difference between left atrium and left ventricle. Registration of M-mode and Doppler echocardiograms: For determination of M-mode parameters which should describe left ventricular diastolic function, in addition to the motion of the mitral valve, the left ventricular contours of septum and posterior wall between mitral leaflets and papillary muscles are recorded together with the ECG. For evaluation of the index of atrial emptying, an M-mode registration is obtained from the region of the aortic root. Determination of the Doppler echocardiographic parameters is based on analysis of the blood flow velocity in the region of the mitral valve in the apical four-chamber view with the pulsed Doppler method. Additionally, simultaneous to the Doppler curve, a phonocardiogram is registered or, alternatively, a continuous-wave Doppler registration is obtained which delineates the left ventricular outflow signal and the artefact of mitral valve opening. Parameters for characterization of left ventricular diastolic filling: The first peak of the velocity curve of the diameter change in the M-mode echocardiogram corresponds with the maximal diameter change resulting from early-diastolic filling and the second peak with the maximal diameter change of the left ventricle associated with atrial filling. From this curve as well as the diameter curve relative to time and the mitral valve motion, the times for isovolumetric relaxation as well as the rapid, slow and
Bhat, Seetharama P S; Gowda, Girish S L; Chikkatur, Raghavendra; Nanjappa, Manjunath C
Primary cardiac tumors are very rare, and tumors arising from cardiac valves are extremely rare. We present a case of lipomatous hamartoma of the mitral valve in a young female. This is the 6th case of lipomatous hamartoma of the mitral valve to be reported. We discuss the operative and histopathological findings.
McLeod, A. Jonathan; Moore, John; Lang, Pencilla; Bainbridge, Dan; Campbell, Gordon; Jones, Doug L.; Guiraudon, Gerard M.; Peters, Terry M.
Conventional mitral valve replacement requires a median sternotomy and cardio-pulmonary bypass with aortic crossclamping and is associated with significant mortality and morbidity which could be reduced by performing the procedure off-pump. Replacing the mitral valve in the closed, off-pump, beating heart requires extensive development and validation of surgical and imaging techniques. Image guidance systems and surgical access for off-pump mitral valve replacement have been previously developed, allowing the prosthetic valve to be safely introduced into the left atrium and inserted into the mitral annulus. The major remaining challenge is to design a method of securely anchoring the prosthetic valve inside the beating heart. The development of anchoring techniques has been hampered by the expense and difficulty in conducting large animal studies. In this paper, we demonstrate how prosthetic valve anchoring may be evaluated in a dynamic phantom. The phantom provides a consistent testing environment where pressure measurements and Doppler ultrasound can be used to monitor and assess the valve anchoring procedures, detecting pararvalvular leak when valve anchoring is inadequate. Minimally invasive anchoring techniques may be directly compared to the current gold standard of valves sutured under direct vision, providing a useful tool for the validation of new surgical instruments.
Boudoulas, Konstantinos Dean; Pitsis, Antonios A; Boudoulas, Harisios
Mitral valve prolapse (MVP) results from the systolic movement of a portion(s) or segment(s) of the mitral valve leaflet(s) into the left atrium during left ventricular (LV) systole. It should be emphasised that MVP alone, as defined by imaging techniques, may comprise a non-specific finding because it also depends on the LV volume, myocardial contractility and other LV hemodynamics. Thus, a floppy mitral valve (FMV) should be the basis for the diagnosis of MVP. Two types of symptoms may be defined in these patients. In one group, symptoms are directly related to progressive mitral regurgitation and its complications. In the other group, symptoms cannot be explained only by the degree of mitral regurgitation alone; neuroendocrine dysfunction has been implicated for the explanation of symptoms in this group of patients that today is referred as the FMV/MVP syndrome. When significant mitral regurgitation is present in a patient with FMV/MVP, surgical intervention is recommended. In patients with a prohibitive risk for surgery, transcatheter mitral valve repair using a mitraclip device may be considered. Furthermore, transcatheter mitral valve replacement may represent an option in the near future as clinical trials are underway. In this brief review, the current concepts related to FMV/MVP and FMV/MVP syndrome will be discussed.
Rausch, Manuel K.; Bothe, Wolfgang; Kvitting, John-Peder Escobar; Swanson, Julia C.; Miller, D. Craig; Kuhl, Ellen
Mitral valve annuloplasty is a common surgical technique used in the repair of a leaking valve by implanting an annuloplasty device. To enhance repair durability, these devices are designed to increase leaflet coaptation, while preserving the native annular shape and motion; however, the precise impact of device implantation on annular deformation, strain, and curvature is unknown. Here we quantify how three frequently used devices significantly impair native annular dynamics. In controlled in vivo experiments, we surgically implanted eleven flexible-incomplete, eleven semi-rigid-complete, and twelve rigid-complete devices around the mitral annuli of 34 sheep, each tagged with 16 equally-spaced tantalum markers. We recorded four-dimensional marker coordinates using biplane videofluoroscopy, first with device and then without, which were used to create mathematical models using piecewise cubic splines. Clinical metrics (characteristic anatomical distances) revealed significant global reduction in annular dynamics upon device implantation. Mechanical metrics (strain and curvature fields) explained this reduction via a local loss of anterior dilation and posterior contraction. Overall, all three devices unfavorably reduced annular dynamics. The flexible-incomplete device, however, preserved native annular dynamics to a larger extent than the complete devices. Heterogeneous strain and curvature profiles suggest the need for heterogeneous support, which may spawn more rational design of annuloplasty devices using design concepts of functionally graded materials. PMID:22037916
Güler, Inan; Hardalaç, Firat; Barişçi, Necaattin
Doppler signals, recorded from the output of tricuspid, mitral, and aorta valves of 60 patients, were transferred to a personal computer via 16-bit sound card. The fast Fourier transform (FFT) method was applied to the recorded signal from each patient. Since FFT method inherently cannot offer a good spectral resolution at highly turbulent blood flows, it sometimes leads to wrong interpretation of cardiac Doppler signals. In order to avoid this problem, firstly six known diseased heart signals such as hypertension, mitral stenosis, mitral failure, tricuspid stenosis, aorta stenosis, aorta insufficiency were introduced to fuzzy algorithm. Then, the unknown heart diseases from 15 patients were applied to the same fuzzy algorithm in order to detect the kinds of diseases. It is observed that the fuzzy algorithm gives true results for detecting the kind of diseases.
... Atrial Septal Defect Ventricular Septal Defect Heart and Circulatory System Congenital Heart Defects Getting an EKG (Video) Your Heart & Circulatory System Heart Murmurs Marfan Syndrome Mitral Valve Prolapse EKG ( ...
Sharif, Dawod; Sharif-Rasslan, Amal; Shahla, Camilia
Background Longitudinal systolic left ventricular contraction is complementary to the radial performance and can be assessed using tissue Doppler imaging (TDI). This study was performed to evaluate the contribution of mitral annular systolic velocities using TDI after dobutamine stress echocardiography (DSE). Methods and Results Fifty subjects with suspected coronary artery disease and chest pain were examined, using DSE as usual, as well as TDI imaging of the mitral annulus at the septal, lateral, inferior, anterior, posterior regions and the proximal anteroseptal region from the apical views, before and immediately after DSE. In 24 subjects the study was normal, while wall motion abnormality was seen in 26, 9 of them only after DSE. Mitral annular systolic velocity at the 6 locations increased significantly after DSE both in normal subjects and in those with wall motion abnormality (WMA). After DSE mitral annular septal systolic velocity in normals, 19.2 ± 3.8 cm/sec, was higher than in those with WMA, 14.6 ± 2.5 cm/sec, P < 0.0003. Post-DSE mitral systolic velocity was senstive and accurate in predicting WMA. Conclusions Systolic mitral TDI velocities increase after DSE, however to a lesser extent in those with wall motion abnormality, and can differentiate them from normal subjects.
Aortic Valve Insufficiency; Aortic Valve Regurgitation; Aortic Valve Stenosis; Aortic Valve Incompetence; Mitral Valve Insufficiency; Mitral Valve Regurgitation; Mitral Valve Stenosis; Mitral Valve Incompetence
Picard, F; Tadros, V-X; Millán, X; Asgar, A W
Mitral repair using the MitraClip device is on ongoing expansion and has been evaluated in different patterns of mitral regurgitation. Nevertheless, surgical approaches to mitral regurgitation remain the standard of care, at least in absence of contraindication. We report the first Canadian experience of mitral valve repair with the MitraClip following surgical mitral annuloplasty failure. Therapeutic considerations and potential challenges are discussed.
Wolfe, J. Alan; Malaisrie, S. Chris; Farivar, R. Saeid; Khan, Junaid H.; Hargrove, W. Clark; Moront, Michael G.; Ryan, William H.; Ailawadi, Gorav; Agnihotri, Arvind K.; Hummel, Brian W.; Fayers, Trevor M.; Grossi, Eugene A.; Guy, T. Sloane; Lehr, Eric J.; Mehall, John R.; Murphy, Douglas A.; Rodriguez, Evelio; Salemi, Arash; Segurola, Romualdo J.; Shemin, Richard J.; Smith, J. Michael; Smith, Robert L.; Weldner, Paul W.; Lewis, Clifton T. P.; Barnhart, Glenn R.; Goldman, Scott M.
Abstract Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery. PMID:27654406
Stengel, S; Allemann, Y; Zimmerli, M; Lipp, E; Kucher, N; Mohacsi, P; Seiler, C
OBJECTIVE—To test the hypothesis that diastolic mitral annular motion velocity, as determined by Doppler tissue imaging and left ventricular diastolic flow propagation velocity, is related to the histological degree of heart transplant rejection according to the International Society of Heart and Lung Transplantation (ISHLT). METHODS—In 41 heart transplant recipients undergoing 151 myocardial biopsies, the following Doppler echocardiographic measurements were performed within one hour of biopsy: transmitral and pulmonary vein flow indices; mitral annular motion velocity indices; left ventricular diastolic flow propagation velocity. RESULTS—Late diastolic mitral annular motion velocity (ADTI) and mitral annular systolic contraction velocity (SCDTI) were higher in patients with ISHLT < IIIA than in those with ISHLT ⩾ IIIA (ADTI, 8.8 cm/s v 7.7 cm/s (p = 0.03); SCDTI, 19.3 cm/s v 9.3 cm/s (p < 0.05)). Sensitivity and specificity of ADTI < 8.7 cm/s (the best cut off value) in predicting significant heart transplant rejection were 82% and 53%, respectively. Early diastolic mitral annular motion velocity (EDTI) and flow propagation velocity were not related to the histological degree of heart transplant rejection. CONCLUSIONS—Doppler tissue imaging of the mitral annulus is useful in diagnosing heart transplant rejection because a high late diastolic mitral annular motion velocity can reliably exclude severe rejection. However, a reduced late diastolic mitral annular motion velocity cannot predict severe rejection reliably because it is not specific enough. Keywords: heart transplant rejection; diastolic function; Doppler tissue imaging; echocardiography PMID:11559685
Labovitz, A.J.; Williams, G.A.
The authors are successful in presenting a basic book on clinical quantitative Doppler echocardiography. It is not intended to be a comprehensive text, but it does cover clinical applications in a succinct fashion. Only the more common diseases in the adult are considered. The subjects are presented logically and are easy to comprehend. The illustrations are good, and the book is paperbound. The basic principles of Doppler echocardiography are presented briefly. The book ends with chapters on left ventricular function (stroke volume and cardiac output), congenital heart disease, and color Doppler echo-cardiography. There are numerous references and a good glossary and index.
David, Tirone E
Degenerative diseases of the mitral valve (MV) are the most common cause of mitral regurgitation in the Western world and the most suitable pathology for MV repair. Several studies have shown excellent long-term durability of MV repair for degenerative diseases. The best follow-up results are obtained with isolated prolapse of the posterior leaflet, however even with isolated prolapse of the anterior leaflet or prolapse of both leaflets the results are gratifying, particularly in young patients. The freedom from reoperation on the MV at 15 years exceeds 90% for isolated prolapse of the posterior leaflet and it is around 70-85% for prolapse of the anterior leaflet or both leaflets. The degree of degenerative change in the MV also plays a role in durability of MV repair. Most studies have used freedom from reoperation to assess durability of the repair but some studies that examined valve function late after surgery suggest that recurrent mitral regurgitation is higher than estimated by freedom from reoperation. We can conclude that MV repair for degenerative mitral regurgitation is associated with low probability of reoperation for up to two decades after surgery. However, almost one-third of the patients develop recurrent moderate or severe mitral regurgitation suggesting that surgery does not arrest the degenerative process.
Vörös, Károly; Szilvási, Viktória; Manczur, Ferenc; Máthé, Ákos; Reiczigel, Jenő; Nolte, Ingo; Hungerbühler, Stephan
Chronic degenerative valve disease (CDVD) is the most common cardiac disease in dogs, usually resulting in mitral valve insufficiency (MVI). The goal of this study was to investigate the occurrence of MVI in clinically healthy Beagle populations. A total of 79 adult healthy Beagles (41 females and 38 males; age: 5.6 ± 2.7 years, range 1.4 to 11.7 years) were examined. The diagnosis of MVI was based on the detection of a systolic murmur heard above the mitral valve, and was confirmed by colour flow Doppler (CFD) echocardiography. Systolic mitral valve murmurs were detected in 20/79 dogs (25.3%), of them 11 males and 9 females with no statistically significant gender difference (P = 0.6059). The strength of the murmur on the semi-quantitative 0/6 scale yielded intensity grade 1/6 in 10 dogs, grade 2/6 in 4 dogs, and grade 3/6 in 6 dogs. Mild to moderate MVI was detected by CFD in all these 20 dogs with systolic murmurs. Of them, 17 dogs had mild and 3 demonstrated moderate MVI, showing 10-30% and 30-50% regurgitant jets compared to the size of the left atrium, respectively. The age of dogs with MVI was 7.1 ± 2.3 years, which was significantly different from that of dogs without MVI (5.1 ± 2.7 years, P = 0.0029). No significant differences in body weight (P = 0.1724) were found between dogs with MVI (13.8 ± 2.8 kg) and those without MVI (12.8 ± 3.0 kg). Mitral valve disease causing MVI is relatively common in Beagle dogs, just like in other small breed dogs reported in the literature.
Berroya, Renato B.; Escano, Fernando B.
This report deals with a rare complication of disc-valve prosthesis in the mitral area. A significant disc poppet and struts destruction of mitral Beall valve prostheses occurred 20 and 17 months after implantation. The resulting valve incompetence in the first case contributed to the death of the patient. The durability of Teflon prosthetic valves appears to be in question and this type of valve probably will be unacceptable if there is an increasing number of disc-valve variance in the future. Images PMID:5017573
La Canna, Giovanni; Denti, Paolo; Buzzatti, Nicola; Alfieri, Ottavio
In recent years, various percutaneous techniques have been introduced for the treatment of mitral regurgitation (MR), including direct leaflet repair, annuloplasty and left ventricular remodeling. Percutaneous mitral repair targets both primary degenerative and secondary mitral valve regurgitation and may be considered in selected high-surgical-risk patients. The assessment of mitral functional anatomy by echocardiography and computed tomography is crucial when selecting the appropriate repair strategy, according to the regurgitant valve lesion and the surrounding anatomy. The ongoing clinical use of new devices in annuloplasty and percutaneous mitral valve replacement is a promising new scenario in the treatment of MR that goes beyond the conventional surgical approach.
Shah, Jainil; Jain, Tarun; Shah, Sunay; Mawri, Sagger; Ananthasubramaniam, Karthikeyan
Unileaflet mitral valve is the rarest of the congenital mitral valve anomalies and is usually life threatening in infancy due to severe mitral regurgitation (MR). In most asymptomatic individuals, it is mostly due to hypoplastic posterior mitral leaflet. We present a 22-year-old male with palpitations, who was found to have an echocardiogram revealing an elongated anterior mitral valve leaflet with severely hypoplastic posterior mitral valve leaflet appearing as a unileaflet mitral valve without MR. Our case is one of the 11 reported cases in the literature so far. We hereby review those cases and conclude that these patients are likely to be at risk of developing worsening MR later in their lives.
Ha, Jong-Won; Oh, Jae K; Ommen, Steve R; Ling, Lieng H; Tajik, A Jamil
Respiratory variation of 25% or more in transmitral early diastolic filling (E) velocity is a well-recognized diagnostic feature of constrictive pericarditis (CP) that is useful for distinguishing it from restrictive cardiomyopathy. However, a subset of patients with CP do not exhibit the typical respiratory change. Recent data showed that mitral annular (E') velocity measured by Doppler tissue echocardiography (DTE) is markedly reduced in patients with restrictive cardiomyopathy whereas E' velocity is well-preserved in CP. This study evaluated the role of DTE for the diagnosis of CP when there is no characteristic respiratory variation of E velocity. From September 1999 to March 2001, 19 patients (17 men, 2 women; mean age, 57 +/- 13 years) with surgically confirmed CP underwent comprehensive echocardiography preoperatively, including pulsed wave and DTE examination with simultaneous recording of respiration. Nine (47%) of the 19 patients had less than 25% respiratory variation in E velocity. There was no significant difference in mitral inflow peak velocity, deceleration time, early-to-late ventricular filling ratio, and E' velocity between patients with and patients without respiratory variation of E velocity of 25% or more. Regardless of the presence or absence of a significant respiratory variation of E velocity, E' velocity was relatively normal (mean, 12 +/- 4 cm/s) in all patients with CP. In conclusion, E' velocity is well preserved in patients with isolated CP even when there is no characteristic respiratory variation of E velocity. Thus, when the respiratory variation in Doppler E velocity is blunted or absent during the evaluation of suspected CP in patients with restrictive mitral inflow velocity, preserved E' velocity shown by DTE should support the diagnosis of CP over a primary myocardial disease.
Oktay, Ahmet Afşşin; Gilliland, Yvonne E; Lavie, Carl J; Ramee, Stephen J; Parrino, Patrick E; Bates, Michael; Shah, Sangeeta; Cash, Michael E; Dinshaw, Homeyar; Qamruddin, Salima
Degenerative mitral stenosis (DMS) is characterized by decreased mitral valve (MV) orifice area and increased transmitral pressure gradient due to chronic noninflammatory degeneration and subsequent calcification of the fibrous mitral annulus and the MV leaflets. The "true" prevalence of DMS in the general population is unknown. DMS predominantly affects elderly individuals, many of whom have multiple other comorbidities. Transcatheter MV replacement techniques, although their long-term outcomes are yet to be tested, have been gaining popularity and may emerge as more effective and relatively safer treatment option for patients with DMS. Echocardiography is the primary imaging modality for evaluation of DMS and related hemodynamic abnormalities such as increased transmitral pressure gradient and pulmonary arterial pressure. Classic echocardiographic techniques used for evaluation of mitral stenosis (pressure half time, proximal isovelocity surface area, continuity equation, and MV area planimetry) lack validation for DMS. Direct planimetry with 3-dimensional echocardiography and color flow Doppler is a reasonable technique for determining MV area in DMS. Cardiac computed tomography is an essential tool for planning potential interventions or surgeries for DMS. This article reviews the current concepts on mitral annular calcification and its role in DMS. We then discuss the epidemiology, natural history, differential diagnosis, mechanisms, and echocardiographic assessment of DMS.
... Saunders; 2012:chap 61. Otto CM, Bonow RO. Valvular heart disease. In: Mann DL, Zipes DP, Libby P, Bonow ... Editorial team. Related MedlinePlus Health Topics Heart Surgery Heart Valve Diseases Mitral Valve Prolapse Browse the Encyclopedia A.D. ...
Ren, J F; Kotler, M N; DePace, N L; Mintz, G S; Kimbiris, D; Kalman, P; Ross, J
Several noninvasive techniques, including radionuclide angiography and Doppler echocardiography, have attempted to measure the regurgitant volume in patients with mitral regurgitation; however, none of these techniques are entirely satisfactory. Utilizing a computerized light pen method for tracing the left atrial endocardial border during systole and diastole in two orthogonal planes (apical four and two chamber views), biplane volume determinations were calculated in 12 normal subjects and 30 patients with nonrheumatic mitral regurgitation. Left atrial emptying volume determinations were performed by subtracting the left atrial end-diastolic volume from the left atrial end-systolic volume. The degree of mitral regurgitation was visually assessed as normal (0, trivial, Group I, 12 patients), mild (1+, Group II, 4 patients), moderate (2+, Group III, 8 patients), moderately severe (3+, Group IV, 12 patients) and severe (4+, Group V, 6 patients) by contrast left ventricular angiography and also quantitatively by regurgitant fraction at cardiac catheterization. All 18 patients with moderately severe (Group IV) and severe (Group V) mitral regurgitation had a left atrial emptying volume greater than 40 ml compared with none of the normal subjects and patients with mild (Group II) or moderate (Group III) mitral regurgitation. There was good correlation between left atrial emptying volume and mitral regurgitant fraction (r = 0.85, p less than 0.01). Thus, in patients with nonrheumatic mitral regurgitation, left atrial emptying volume is useful in separating mild from severe mitral regurgitation.
Nishida, Hidefumi; Kasegawa, Hitoshi; Kin, Hajime; Takanashi, Shuichiro
Here we report the early outcome of mitral valve replacement using a newly designed stentless mitral valve for failure of initial mitral valve repair. Mitral valve plasty (MVP) for mitral regurgitation is currently a standard technique performed worldwide. However, whether mitral valve repair should be performed for patients with advanced leaflet damage or complicated pathology remains controversial. Mitral valve replacement might be feasible for patients who have undergone failed initial MVP; however, it is not an optimal treatment because of poor valve durability and the need for anticoagulative therapy. We report two cases of successful mitral valve replacement using a newly designed stentless mitral valve made of fresh autologous pericardium, which may have a potential benefit over mitral valve repair or mitral valve replacement with a mechanical or bioprosthetic valve.
Kumagai, H; Hamanaka, Y; Hirai, S; Mitsui, N; Kobayashi, T
A 21 year-old woman was admitted to our hospital because of chest and back pain after blunt chest trauma. On admission, consciousness was clear and a physical examination showed labored breathing. Her vital signs were stable, but her breathing gradually worsened, and artificial respiration was started. The chest roentgenogram and a subsequent chest computed tomographic scans revealed contusions, hemothorax of the left lung and multiple rib fractures. A transthoracic echocardiography (TTE) revealed normal left ventricular wall motion and mild mitral regurgitation (MR). TTE was carried out repeatedly, and revealed gradually progressive MR and prolapse of the posterior medial leaflet, although there was no congestive heart failure. After her general condition had recovered, surgery was performed. Intraoperative transesophageal echocardiography (TEE) revealed torn chordae at the posterior medial leaflet. The leaflet where the chorda was torn was cut and plicated, and posterior mitral annuloplasty was performed using a prosthetic ring. One month later following discharge, the MR had disappeared on TTE.
Roberts, William C; Moore, Meagan; Ko, Jong Mi; Hamman, Baron L
Mitral repair operations for correction of pure mitral regurgitation (MR) are generally quite successful. Occasionally, however, the reparative procedure incompletely corrects the MR or the MR recurs. From March 1993 to January 2016, twenty nine patients had mitral valve replacement after the initial mitral repair operation, and observations in them were analyzed. All 29 patients at the repair operation had an annular ring inserted and later (<1 year in 6 and >1 year in 21) mitral valve replacement. The cause of the MR before the repair operation appears to have been prolapse in 16 patients (55%), secondary (functional) in 12 (41%) (ischemic in 5), and infective endocarditis which healed in 1 (3%). At the replacement operation the excised anterior mitral leaflet was thickened in all 29 patients. Some degree of stenosis appeared to have been present in 16 of the 29 patients before the replacement operation, although only 10 had an echocardiographic or hemodynamic recording of a transvalvular gradient; at least 11 patients had restricted motion of the posterior mitral leaflet; 10, ring dehiscence; 2, severe hemolysis; and 2, left ventricular outflow obstruction. In conclusion, there are multiple reasons for valve replacement after earlier mitral repair. Uniformly, at the time of the replacement, the mitral leaflets were thickened by fibrous tissue. Measurement of the area enclosed by the 360° rings and study of the excised leaflet suggest that the ring itself may have contributed to the leaflet scarring and development of some transmitral stenosis.
Sidhu, Navdeep Singh; Kondethimmanahally Rangaiah, Sunil Kumar; Ramesh, Dwarikaprasad; Manjunath, Cholenahally Nanjappa
Co-existence of Ebstein's anomaly of the tricuspid valve with rheumatic mitral stenosis is a very rare occurrence. We report the case of a young man who presented with progressive dyspnoea and was found to have rheumatic mitral stenosis with pulmonary hypertension and Ebstein's anomaly of the tricuspid valve. The patient underwent successful balloon mitral valvotomy resulting in marked improvement of symptoms.
Incremental value of combining systolic mitral annular velocity and time difference between mitral inflow and diastolic mitral annular velocity to early diastolic annular velocity for differentiating constrictive pericarditis from restrictive cardiomyopathy.
Choi, Eui-Young; Ha, Jong-Won; Kim, Jin-Mi; Ahn, Jeong-Ah; Seo, Hye-Sun; Lee, Jee-Hyun; Rim, Se-Joong; Chung, Namsik
Although normal or exaggerated early diastolic mitral annular velocity (E') provides an excellent specificity for differentiating constrictive pericarditis (CP) from restrictive cardiomyopathy (RCM), its sensitivity has been shown to be lower, especially in patients with CP who had underlying myocardial abnormality. This study sought to evaluate the incremental value of systolic mitral annular velocity (S') and time difference between onset of mitral inflow and onset of E' (T(E'-E)) for differentiation between CP and RCM. This study included 44 participants (28 male, 16 female; mean age 47 years, range 10-76): 17 patients with CP, 12 with RCM, and 15 control subjects. Standard mitral inflow Doppler and tissue Doppler echocardiography were performed. E' (9.5 +/- 1.7 vs 4.7 +/- 1.6 cm/s, P < .001) and S' (7.7 +/- 1.3 vs 4.6 +/- 1.9 cm/s, P < .001) were significantly higher, whereas T(E'-E) (21.0 +/- 32.0 vs 53.1 +/- 30.4 milliseconds, P = .02) was significantly shorter in patients with CP than with RCM. Diagnostic accuracy of E' for differentiation of CP from RCM was higher than S' or T(E'-E) (area under curve 0.99 vs 0.87 vs 0.74, respectively). E' of 8 cm/s had excellent specificity (100%) for differentiation of CP from RCM but sensitivity (70%) was relatively low. However, when combining E' with S' and T(E'-E), the sensitivity could be increased when compared with E' alone (70% with E', 88% with E' + S', and 94% with E' + S' + T(E'-E)), P = .001). In conclusion, the measurement of S' and T(E'-E) can be helpful for differentiating between CP and RCM by providing incremental diagnostic information to E'.
Kim, Hyun-Jin; Kim, Kyung-Hee; Choi, Jae-Sung; Kim, Jun-Sung; Kim, Myung-A
Preservation of the subvalvular apparatus has the merits of postoperative outcomes during mitral valve replacement for mitral regurgitation. We performed mitral valve replacement with anterior and posterior leaflet chordal preservation in a 65-year-old woman. On the 2nd postoperative day, routine postoperative trans-thoracic echocardiography showed an unknown aortic subvalvular mobile mass. We report a case of a remnant mitral subvalvular apparatus detected by echocardiography after chordal preserving mitral valve replacement which was confused with postoperative aortic valve vegetation. PMID:22509443
Salenger, Rawn; Diao, Xavier; Dawood, Murtaza Y; Herr, Daniel L; Sample, George A; Pichard, Augusto; Gammie, James S
We report a case of catastrophic hemodynamic compromise secondary to pannus ingrowth and severe mitral stenosis occurring years after repair of a nonrheumatic mitral valve. The initial repair included closure of a posterior leaflet cleft and implantation of an annuloplasty ring. We describe a hybrid treatment strategy for this severely compromised patient, which included initial placement of a right ventricular assist device followed by percutaneous balloon mitral valvuloplasty and, eventually, a definitive mitral valve reoperation. This case report reinforces the importance of routine clinical and echocardiographic follow-up for patients after mitral valve repair, and it includes the description of a novel therapeutic approach.
Condado, Jose F; Babaliaros, Vasilis C; Thourani, Vinod H; Jensen, Hanna K; Kim, Dennis W; Kaebnick, Brian W; Block, Peter C; Lerakis, Stamatios
Hybrid transcatheter Mitral Valve-in-Ring and Mitral Valve-in-Valve procedures can be an alternative to traditional surgical valve replacement in patients with high surgical risk. We present a case of a 65-year-old male with recurrent severe mitral regurgitation (MR) that failed two traditional surgical attempts due to severe chest fibrosis. We performed a mitral valve-in ring replacement with a Sapien valve followed by a mitral valve-in-valve replacement with a Melody valve. Patient had a residual paravalvular leak that was closed with a vascular plug. Our case proves that is feasible to treat selected patients with MR using a hybrid transcatheter approach.
Levine, Robert A.; Hagége, Albert A.; Judge, Daniel P.; Padala, Muralidhar; Dal-Bianco, Jacob P.; Aikawa, Elena; Beaudoin, Jonathan; Bischoff, Joyce; Bouatia-Naji, Nabila; Bruneval, Patrick; Butcher, Jonathan T.; Carpentier, Alain; Chaput, Miguel; Chester, Adrian H.; Clusel, Catherine; Delling, Francesca N.; Dietz, Harry C.; Dina, Christian; Durst, Ronen; Fernandez-Friera, Leticia; Handschumacher, Mark D.; Jensen, Morten O.; Jeunemaitre, Xavier P.; Le Marec, Hervé; Le Tourneau, Thierry; Markwald, Roger R.; Mérot, Jean; Messas, Emmanuel; Milan, David P.; Neri, Tui; Norris, Russell A.; Peal, David; Perrocheau, Maelle; Probst, Vincent; Pucéat, Michael; Rosenthal, Nadia; Solis, Jorge; Schott, Jean-Jacques; Schwammenthal, Ehud; Slaugenhaupt, Susan A.; Song, Jae-Kwan; Yacoub, Magdi H.
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but—even in adult life—remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular–ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease. PMID:26483167
Levine, Robert A; Hagége, Albert A; Judge, Daniel P; Padala, Muralidhar; Dal-Bianco, Jacob P; Aikawa, Elena; Beaudoin, Jonathan; Bischoff, Joyce; Bouatia-Naji, Nabila; Bruneval, Patrick; Butcher, Jonathan T; Carpentier, Alain; Chaput, Miguel; Chester, Adrian H; Clusel, Catherine; Delling, Francesca N; Dietz, Harry C; Dina, Christian; Durst, Ronen; Fernandez-Friera, Leticia; Handschumacher, Mark D; Jensen, Morten O; Jeunemaitre, Xavier P; Le Marec, Hervé; Le Tourneau, Thierry; Markwald, Roger R; Mérot, Jean; Messas, Emmanuel; Milan, David P; Neri, Tui; Norris, Russell A; Peal, David; Perrocheau, Maelle; Probst, Vincent; Pucéat, Michael; Rosenthal, Nadia; Solis, Jorge; Schott, Jean-Jacques; Schwammenthal, Ehud; Slaugenhaupt, Susan A; Song, Jae-Kwan; Yacoub, Magdi H
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.
Ailawadi, Gorav; Agnihotri, Arvind K.; Mehall, John R.; Wolfe, J. Alan; Hummel, Brian W.; Fayers, Trevor M.; Farivar, R. Saeid; Grossi, Eugene A.; Guy, T. Sloane; Hargrove, W. Clark; Khan, Junaid H.; Lehr, Eric J.; Malaisrie, S. Chris; Murphy, Douglas A.; Rodriguez, Evelio; Ryan, William H.; Salemi, Arash; Segurola, Romualdo J.; Shemin, Richard J.; Smith, J. Michael; Smith, Robert L.; Weldner, Paul W.; Goldman, Scott M.; Lewis, Clifton T. P.; Barnhart, Glenn R.
Abstract Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection. PMID:27654407
Reimann, M J; Møller, J E; Häggström, J; Markussen, B; Holen, A E W; Falk, T; Olsen, L H
Mitral regurgitation (MR) due to myxomatous mitral valve disease (MMVD) is a frequent finding in Cavalier King Charles Spaniels (CKCSs). Sinus arrhythmia and atrial premature complexes leading to R-R interval variations occur in dogs. The aim of the study was to evaluate whether the duration of the R-R interval immediately influences the degree of MR assessed by echocardiography in dogs. Clinical examination including echocardiography was performed in 103 privately-owned dogs: 16 control Beagles, 70 CKCSs with different degree of MR and 17 dogs of different breeds with clinical signs of congestive heart failure due to MMVD. The severity of MR was evaluated in apical four-chamber view using colour Doppler flow mapping (maximum % of the left atrium area) and colour Doppler M-mode (duration in ms). The influence of the ratio between present and preceding R-R interval on MR severity was evaluated in 10 consecutive R-R intervals using a linear mixed model for repeated measurements. MR severity was increased when a short R-R interval was followed by a long R-R interval in CKCSs with different degrees of MR (P<0.005 when adjusted for multiple testing). The relationship was not significant in control dogs with minimal MR and in dogs with severe MR and clinical signs of heart failure. In conclusion, MR severity increases in long R-R intervals when these follow a short R-R interval in CKCSs with different degrees of MR due to asymptomatic MMVD. Thus, R-R interval variations may affect the echocardiographic grading of MR in CKCSs.
Joong, Anna; Lai, Wyman W; Ferris, Anne
An infant with residual severe mitral regurgitation following mitral commissurotomy developed cardiogenic unilateral pulmonary oedema and subsegmental atelectasis that resolved with mechanical mitral valve replacement.
Karplus, Henry H. B.; Raptis, Apostolos C.
A Doppler flowmeter impulses an ultrasonic fixed-frequency signal obliquely into a slurry flowing in a pipe and a reflected signal is detected after having been scattered off of the slurry particles, whereby the shift in frequencies between the signals is proportional to the slurry velocity and hence slurry flow rate. This flowmeter filters the Doppler frequency-shift signal, compares the filtered and unfiltered shift signals in a divider to obtain a ratio, and then further compares this ratio against a preset fractional ratio. The flowmeter utilizes a voltage-to-frequency convertor to generate a pulsed signal having a determinable rate of repetition precisely proportional to the divergence of the ratios. The pulsed signal serves as the input control for a frequency-controlled low-pass filter, which provides thereby that the cutoff frequency of the filtered signal is known. The flowmeter provides a feedback control by minimizing the divergence. With the cutoff frequency and preset fractional ratio known, the slurry velocity and hence flow will also be determinable.
Karplus, H.H.B.; Raptis, A.C.
A Doppler flowmeter impulses an ultrasonic fixed-frequency signal obliquely into a slurry flowing in a pipe and a reflected signal is detected after having been scattered off of the slurry particles, whereby the shift in frequencies between the signals is proportional to the slurry velocity and hence slurry flow rate. This flowmeter filters the Doppler frequency-shift signal, compares the filtered and unfiltered shift signals in a divider to obtain a ratio, and then further compares this ratio against a preset fractional ratio. The flowmeter utilizes a voltage-to-frequency convertor to generate a pulsed signal having a determinable rate of repetition precisely proportional to the divergence of the ratios. The pulsed signal serves as the input control for a frequency-controlled low-pass filter, which provides thereby that the cutoff frequency of the filtered signal is known. The flowmeter provides a feedback control by minimizing the divergence. With the cutoff frequency and preset fractional ratio known, the slurry velocity and hence flow will also be determinable.
Al Amri, Ibtihal; van der Kley, Frank; Schalij, Martin J; Ajmone Marsan, Nina; Delgado, Victoria
Mitral regurgitation is one of the most prevalent valvular heart diseases and its prevalence is related to population aging. Elderly patients with age-associated co-morbidities have an increased risk for conventional mitral valve surgery. Transcatheter mitral valve repair has emerged as a feasible and safe alternative in patients with contraindications for surgery or high operative risk. Several transcatheter mitral repair technologies have been developed during the last decade. While the development of some devices was abandoned due to suboptimal results, others demonstrated to be safe and effective and have been included in current practice guidelines. Not all technologies are suitable for all mitral anatomies and regurgitation mechanisms. Therefore, accurate evaluation of mitral valve anatomy and function are pivotal to the success of these therapies. Cardiac imaging plays a central role in selecting patients, guiding the procedure and evaluating the durability of the repair at follow-up.
Bedzra, Edo; Don, Creighton W; Reisman, Mark; Aldea, Gabriel S
A 71-year-old man presented with New York Heart Association (NYHA) class IV heart failure. He had undergone transapical mitral valve replacement for mixed mitral stenosis and mitral regurgitation. At the 1 month follow-up, the patient reported symptom resolution. An echocardiogram revealed a low gradient and no regurgitation. Our case shows that with careful multidisciplinary evaluation, preoperative planning, and patient selection, percutaneous mitral intervention can become an alternative therapy for high-risk patients who cannot undergo conventional surgical therapy.
Yamasaki, Manabu; Misumi, Hiroyasu; Abe, Kohei; Kawazoe, Kohei
Double-orifice mitral valve (DOMV) is a relatively rare cardiac anomaly. Although usually associated with various cardiac anomalies, co-presence of DOMV and noncompaction of left ventricular myocardium (NCLVM) is extremely rare. Here, we present a 24-year-old male who underwent mitral valve repair using artificial chordae and annuloplasty at the posterior commissure for severe mitral regurgitation (MR), resulting from flail anterior leaflet of the larger postero-medial orifice and dilatation of left ventricle with NCLVM. One year later, he underwent second mitral valve repair for recurrence of MR. Further endoscopic evaluation of the left ventricle, and reinforcement via artificial ring, enabled us to achieve repair.
Ansari, Mohammed T.; Ahmadzai, Nadera; Coyle, Kathryn; Coyle, Doug; Moher, David
Background Many of the 500,000 North American patients with chronic mitral regurgitation may be poor candidates for mitral valve surgery. Objective The objective of this study was to investigate the comparative effectiveness, harms, and cost-effectiveness of percutaneous mitral valve repair using mitral valve clips in candidates at prohibitive risk for surgery. Data Sources We searched articles in MEDLINE, Embase, and the Cochrane Library published from 1994 to February 2014 for evidence of effectiveness and harms; for economic literature we also searched NHS EED and Tufts CEA registry. Grey literature was also searched. Review Methods Primary studies were sought from existing systematic reviews that had employed reliable search and screening methods. Newer studies were sought by searching the period subsequent to the last search date of the review. Two reviewers screened records and assessed study validity. We used the Cochrane risk of bias tool for randomized, generic assessment for non-randomized studies, and the Phillips checklist for economic studies. Results Ten studies including 1 randomized trial were included. The majority of the direct comparative evidence compared the mitral valve clip repair with surgery in patients not particularly at prohibitive surgical risk. Irrespective of degenerative or functional chronic mitral regurgitation etiology, evidence of effectiveness and harms is inconclusive and of very low quality. Very-low-quality evidence indicates that percutaneous mitral valve clip repair may provide a survival advantage, at least during the first 1 to 2 years, particularly in medically managed chronic functional mitral regurgitation. Because of limitations in the design of studies, the cost-effectiveness of mitral valve clips in patients at prohibitive risk for surgery also could not be established. Limitations Because of serious concerns of risk of bias, indirectness, and imprecision, evidence is of very low quality. Conclusions No meaningful
Varghese, Thomas George; Revankar, Vinod Raghunath; Papanna, Monica; Srinivasan, Harshini
Double-orifice mitral valve is an rare anomaly characterized by a mitral valve with a single fibrous annulus and 2 orifices that open into the left ventricle. It is often associated with other congenital anomalies, most commonly atrioventricular canal defects, and rarely associated with a stenotic or regurgitant mitral valve. A patient who was diagnosed with congenital double-orifice mitral valve with severe mitral stenosis was treated successfully by percutaneous balloon mitral valvotomy rather than the conventional open surgical approach, demonstrating the utility of percutaneous correction of this anomaly.
Elevli, M; Celebi, A; Tombul, T; Gökalp, A S
Sydenham's chorea is often encountered in pure form, but it may also occur in association with carditis. Recently, it has been reported that silent, mild valvular regurgitation has been encountered in patients with rheumatic fever manifested by isolated polyarthritis and pure chorea. We studied 22 children with Sydenham's chorea to determine clinical and subclinical heart involvement at the time of the initial diagnosis. Ages of the patients ranged from 6-19 y (mean 13.14+/-3.0), and the female/male ratio was 3.4:1. All patients were evaluated by clinical and echocardiographic examination with respect to heart involvement. Carditis was detected in only 5 of 22 patients (23%) by auscultation. Clinical valvular involvement was determined: mitral regurgitation in three and combined mitral and aortic regurgitation in two. The frequency of valvular involvement increased significantly to 63% 2(14/22) after adding silent mitral regurgitation detected by colour Doppler echocardiography (chi2=7.50, p=0.0062). We found that clinically inaudible, but echocardiographically significant, mild valvular regurgitation was frequent in patients with pure chorea. It is concluded that colour Doppler echocardiography may be useful in detecting silent valvular regurgitation and in deciding the duration of prophylaxis.
Tencate, F J; Mayala, A P; Vletter, W B; Roelandt, J
We studied 11 patients with hypertrophic cardiomyopathy by color Doppler echocardiography (Group I: 6 patients with outflow obstruction, and Group II: 5 patients without outflow obstruction) to assess systolic structure and function as observed by cross-sectional echocardiography in relation to the flow dynamics. The structure and function included systolic anterior motion of mitral valve (SAM), midsystolic aortic valve closure (AoC), systolic cavity obliteration and the presence and timing of mitral incompetence. Their occurrence and timing was related to presence of aortic systolic flow and presence of turbulence. While all patients in Group I had SAM and turbulence, none of the patients in Group II had SAM nor turbulence. Early mitral incompetence appearing before SAM and turbulence, occurred in all patients of Group I and in none of Group II. Midsystolic aortic valve closure was only present in Group I and blood flow was unilaterally directed so that only 60% of aortic cross-sectional area showed blood flow. We conclude that mitral incompetence in hypertrophic cardiomyopathy in early systole is common when outflow gradient is present and is independent of mitral incompetence of mid- and late systole. During SAM, turbulence in the subaortic area and mid and late mitral incompetence occurred simultaneously. The midsystolic aortic valve closure was related to the unilaterally directed blood flow through the aortic cross-sectional area.
Billy, F.; Coisne, D.; Sanchez, L.; Perrault, R.
Color Doppler is routinely used for visualisation of intra cardiac flows and quantification of valvular heart disease, Nevertheless the 2D visualization of a complex 3D phenomenon is the major limitation of this technique, In particular, in clinical setting, the flow rate calculation upstream a regurgitant orifice (i,e, mitral valve insufficiency), assumes that the velocity field in the convergent region have hemispheric shapes and introduce miscalculation specially in case of prolaps regurgitant orifices, The main objective of this study was to characterize the dynamic 3D velocity field of the convergent region upstream a prolaps model of regurgitant orifice based on 2D time dependent PIV reconstruction.
Zito, Concetta; Carerj, Scipione; Todaro, Maria Chiara; Cusmà-Piccione, Maurizio; Caprino, Alessandra; Di Bella, Gianluca; Oreto, Lilia; Oreto, Giuseppe; Khandheria, Bijoy K
We studied whether evaluation of overall left ventricular (LV) and left atrial (LA) mechanics would be useful to detect subclinical dysfunction in patients with mitral valve prolapse (MVP), mitral regurgitation (MR), and normal LV ejection fraction (EF). Fifty consecutive patients (27 men, mean age 61 ± 19 years) with MVP, MR, and normal systolic function (LVEF ≥60%) were prospectively enrolled and compared with 40 age- and gender-matched healthy subjects (22 men, mean age: 59 ± 16 years). At baseline, 2-dimensional and color-flow Doppler transthoracic echocardiography were performed for MR quantification and analysis of left-chambers mechanics. Patients were divided into groups by severity of MR: mild (n = 14), moderate (n = 19), and severe (n = 17). Left ventricular dimensions, volume and mass, and LA area and volume indices were significantly increased in patients with moderate and severe MR compared with control subjects. Circumferential strain, basal/apical rotations, and twist were significantly enhanced in patients with moderate MR compared with controls; with the exception of basal rotation, they decreased in those with severe MR. Furthermore, LA strain and untwisting rate were progressively and significantly reduced from normal subjects to patients with severe MR. Effective regurgitant orifice area and MR vena contracta were significantly related to most systolic and diastolic function parameters and LA volume as well as LA strain and LV untwisting rate in all patients. In conclusion, cardiac mechanics indices, particularly LA deformation and LV rotational parameters, could help unmask incipient myocardial dysfunction in patients with MVP, especially in those with severe MR and yet normal LVEF.
Tabata, Tomotsugu; Cardon, Lisa A.; Armstrong, Guy P.; Fukamach, Kiyotaka; Takagaki, Masami; Ochiai, Yoshie; McCarthy, Patrick M.; Thomas, James D.
BACKGROUND: Doppler tissue echocardiography and color M-mode Doppler flow propagation velocity have proven useful in evaluating cross-sections of patients with left ventricular (LV) dysfunction, but experience with serial changes is limited. Purpose and methods: We tested their use by evaluating the temporal changes of LV function in a pacing-induced congestive heart failure model. Rapid ventricular pacing was initiated and maintained in 20 dogs for 4 weeks. Echocardiography was performed at baseline and weekly during brief pacing cessation. RESULTS: With rapid pacing, LV volume significantly increased and ejection fraction (57%-28%), stroke volume (37-18 mL), and mitral annulus systolic velocity (16.1-6.6 cm/s) by Doppler tissue echocardiography significantly decreased, with ejection fraction and mitral annulus systolic velocity closely correlated (r = 0.706, P <.0001). In contrast to the mitral inflow velocities, mitral annulus early diastolic velocity decreased steadily (12.3-7.3 cm/s) resulting in a dramatic decrease in mitral annulus early/late (1.22-0.57) diastolic velocity with no tendency toward pseudonormalization. The color M-mode Doppler flow propagation velocity also showed significant steady decrease (57-24 cm/s) throughout the pacing period. Multiple regression analysis chose mitral annulus systolic velocity (r = 0.895, P <.0001) and propagation velocity (r = 0.782, P <.0001) for the most important factor predicting LV systolic and diastolic function, respectively. CONCLUSIONS: Doppler tissue echocardiography and color M-mode Doppler flow could evaluate the serial deterioration in LV dysfunction throughout the pacing period. These were more useful in quantifying progressive LV dysfunction than conventional ehocardiographic techniques, and were probably relatively independent of preload. These techniques could be suitable for longitudinal evaluation in addition to the cross-sectional study.
Mullens, Wilfried; Borowski, Allen G; Curtin, Ronan J; Thomas, James D; Tang, W. H. Wilson
Background Early transmitral velocity / tissue Doppler mitral annular early diastolic velocity (E/Ea) has been correlated with pulmonary capillary wedge pressure (PCWP) in a wide variety of cardiac conditions. The objective of this study was to determine the reliability of mitral E/Ea for predicting PCWP in patients admitted for advanced decompensated heart failure (ADHF). Methods and Results Prospective consecutive patients with ADHF (ejection fraction [EF] ≤30%, NYHA class III-IV symptoms) underwent simultaneous echocardiographic and hemodynamic evaluation on admission and after 48 hours of intensive medical therapy. A total of 106 patients were included (mean age 57 ±12 years, EF 24 ±8%, PCWP 21 ±7 mmHg, mitral E/Ea 20 ±12). There was a lack of correlation between mitral E/Ea and PCWP, particularly in those with larger LV volumes, more impaired cardiac indices, and the presence of cardiac resynchronization therapy. Overall, mitral E/Ea was similar among patients with PCWP > and ≤ 18 mmHg, and sensitivity and specificity for mitral E/Ea > 15 to identify a PCWP > 18 mmHg was 66% and 50%, respectively. Contrary to prior reports, we did not observe any direct association between changes in PCWP and changes in mitral E/Ea. Conclusion In decompensated patients with advanced systolic heart failure, tissue Doppler derived mitral E/Ea may not be as reliable in predicting intracardiac filling pressures, particularly in those with larger LV volumes, more impaired cardiac indices, and the presence of cardiac resynchronization therapy. PMID:19075104
Woo, Y Joseph; Rodriguez, Evelio; Atluri, Pavan; Chitwood, W Randolph
A significant transformation is occurring in the management of mitral valve disease. Earlier surgery is now recommended. Mitral valve repair is the standard of care, and newer methods of reconstructing the mitral valve are developing. Surgery with videoscopic assistance can be effectively performed without sternotomy. Robotics systems are gaining wider adoption. Implantable devices to repair or replace the mitral valve off-pump and percutaneously are emerging.
DePace, N L; Nestico, P F; Morganroth, J
Acute severe mitral regurgitation often goes unrecognized as an emergency requiring prompt, lifesaving treatment. Its causes, physical signs, natural history, echocardiographic features, and findings on chest roentgenography, electrocardiography, and nuclear scintigraphic scanning are reviewed. Acute severe mitral insufficiency can be differentiated from chronic severe mitral insufficiency by noninvasive two-dimensional echocardiography. M-mode echocardiography is a valuable tool in evaluating mitral prosthetic paravalvular regurgitation.
Matsuno, Yukihiro; Mori, Yoshio; Umeda, Yukio; Takiya, Hiroshi
Mitral valve replacement with preservation of the mitral leaflets and subvalvular apparatus is considered to maintain left ventricular geometry and function and reduce the risk of myocardial rupture. However, the routine use of this technique may lead to early complications such as left ventricular outflow tract obstruction and even mitral inflow obstruction, requiring reoperation. We describe a rare case of bioprosthetic mitral valve dysfunction caused by a native valve preserving procedure.
Garcia-Villarreal, Ovidio A; Fernández-Ceseña, Ernesto; Solano-Ricardi, Mercedes; Aguilar-García, Alma L; Vega-Hernández, Raquel; Del Angel-Soto, Gustavo
We report the case of 23-year-old man with mitral valve regurgitation and Glanzmann thrombasthenia, who underwent mechanical mitral valve replacement. Warfarin therapy was devastating, causing bilateral hemothorax, pericardial effusion, gastrointestinal bleeding, and hematuria. Redo mitral valve replacement with a biological prosthesis was required to resolve this critical situation. To our knowledge, this is the first report of mitral valve replacement in Glanzmann thrombasthenia, highlighting the danger of oral anticoagulation in this pathology.
Fassbender, D; Schmidt, H K; Seggewiss, H; Mannebach, H; Bogunovic, N
Clinical symptoms and diagnostic findings in patients with mitral stenosis are usually determined by the extent of the stenosis. Compared to a normal mitral valve area (MVA) of > 4 cm2, MVA in patients with severe mitral stenosis is usually reduced to < 1.5 cm2. In older patients symptoms are frequently influenced by concomitant diseases (e.g. atrial fibrillation, arterial hypertension or lung disease). An important diagnostic element besides anamnesis, auscultation, ECG and chest X-ray is echocardiography, which is required in order to measure non-invasively and reliably the mitral valve gradient (MVG), the MVA and morphologic changes to the valves, as well as concomitant valvular disease, ventricular functions and, where appropriate, left-atrial thrombi. In addition to the surgical treatment of patients with severe mitral stenosis, which has been an established procedure for 50 years, percutaneous balloon mitral valvuloplasty (MVP) has recently established itself as an alternative option. At the current time, the Inoue technique seems to display the most advantages. Following transseptal puncture, the Inoue balloon is guided transvenously into the left atrium and then into the left ventricle using a special support wire. The balloon is short and soft. Its special unfolding character enables it to be placed securely in the mitral valve without any risk of ventricular perforation (Figure 1). As with surgical commissurotomy, balloon valvuloplasty leads to a separation of fused commissures. This results in a significant reduction of MVG, accompanied by an increase in the MVA (Figure 2). The results and success of MVP are influenced by the morphology of the valves and the changes to the subvalvular apparatus. In randomized studies, the results of surgical commissurotomy were comparable with those of balloon mitral valvulotomy. In our hospital, an increase in MVA from 1.0 to 1.8 cm2 could be achieved in 899 patients (mean age 56 +/- 3 years). In younger patients with
Ateş, Ahmet Hakan; Aksakal, Aytekin; Yücel, Huriye; Atasoy Günaydın, İlksen; Ekbul, Adem; Yaman, Mehmet
Mitral balloon valvuloplasty which has been used for the treatment of rheumatic mitral stenosis (MS) for several decades can cause serious complications. Herein, we presented right atrial clot formation early after percutaneous mitral balloon valvuloplasty which was treated successfully with unfractioned heparin infusion. PMID:28105049
Pueschel, Siegfried M.; Werner, John Christian
Examination of 36 home-reared young adults with Down's syndrome found that 20 had abnormal echocardiographic findings. Thirteen had mitral valve prolapse, three had mitral valve prolapse and aortic insufficiency, two had only aortic insufficiency, and two had other mitral valve disorders. Theories of pathogenesis and relationship to exercise and…
... sof-uh-JEE-ul) echocardiography, or TEE . Doppler Ultrasound A Doppler ultrasound is part of an echo ... heart's electrical activity. An EKG can show how fast your heart is beating and whether its rhythm ...
Fan, P; Nanda, N C; Gatewood, R P; Cape, E G; Yoganathan, A P
Due to the unavoidable problem of aliasing, color flow signals from high blood flow velocities cannot be measured directly by conventional color Doppler. A new technology termed Quantitative Un-Aliased Speed Algorithm Recognition (Quasar) has been developed to overcome this limitation. Employing this technology, we used transesophageal color Doppler echocardiography to investigate whether the velocities detected by the Quasar would correlate with those obtained by continuous-wave Doppler both in vitro and in vivo. In the in vitro study, a 5.0 MHz transesophageal transducer of a Kontron Sigma 44 color Doppler flow system was used. Fourteen different peak velocities calculated and recorded by color Doppler-guided continuous-wave Doppler were randomly selected. In the clinical study, intraoperative transesophageal echocardiography was performed using the same transducer 18 adults (13 aortic valve stenosis, 2 aortic and 2 mitral stenosis, 2 hypertrophic obstructive cardiomyopathy and 1 mitral valve stenosis). Following each continuous-wave Doppler measurement, the Quasar was activated, and a small Quasar marker was placed in the brightest area of the color flow jet to obtain the maximum mean velocity readout. The maximum mean velocities measured by Quasar closely correlated with maximum peak velocities obtained by color flow guided continuous-wave Doppler in both in vitro (0.53 to 1.65 m/s, r = 0.99) and in vivo studies (1.50 to 6.01 m/s, r = 0.97). We conclude that the new Quasar technology can accurately measure high blood flow velocities during transesophageal color Doppler echocardiography. This technique has the potential of obviating the need for continuous-wave Doppler.
Tavil, Yusuf; Ozturk, Mehmet Akif; Sen, Nihat; Kaya, Mehmet Gungor; Hizal, Fatma; Poyraz, Fatih; Turfan, Murat; Onder, Meltem; Gurer, Mehmet Ali; Cengel, Atiye
Vascular involvement is one of the major characteristics of Behcet's disease (BD). However, there are controversial findings regarding cardiac involvement in BD. Although early reports demonstrated that there is diastolic dysfunction in BD, conflicting results were found in the following trials. Hence, a new method for more objectively estimating the cardiac functions is needed. For this aim, we used high-usefulness tissue Doppler echocardiography for detailed analysis of cardiac changes in BD patients because this method was superior to other conventional echocardiographic techniques. The study population included 42 patients with BD (19 men, 23 women; mean age, 35 +/- 10 years, mean disease duration, 2.7 +/- 1.6 years) and 30 healthy subjects (14 men, 16 women; mean age, 38 +/- 7 years). Cardiac functions were determined using echocardiography, comprising standard two-dimensional and conventional Doppler and tissue Doppler imaging (TDI). Peak systolic myocardial velocity at mitral annulus, early diastolic mitral annular velocity (Em), late diastolic mitral annular velocity (Am), Em/Am, and myocardial performance index (MPI) were calculated by TDI. The conventional echocardiographic parameters and tissue Doppler measurements were similar between the groups. Tissue Doppler derived mitral relaxation time was longer (75 +/- 13 vs 63 +/- 16 msn, p = 0.021) in patients with BD. There was statistically significant difference between the two groups regarding left ventricular MPI (0.458 +/- 0.072 vs 0.416 +/- 0.068%, p = 0.016), which were calculated from tissue Doppler systolic time intervals. There was also significant correlation between the disease duration and MPI (r = 0.38, p = 0.017). We have demonstrated that tissue Doppler-derived myocardial left ventricular relaxation time and MPI were impaired in BD patients, although systolic and diastolic function parameters were comparable in the patients and controls.
Rajagopalan, N; Garcia, M J; Rodriguez, L; Murray, R D; Apperson-Hansen, C; Stugaard, M; Thomas, J D; Klein, A L
This study assesses how the newer modalities of tissue Doppler echocardiography and color M-mode flow propagation compare with respiratory variation of Doppler flow in distinguishing between constrictive pericarditis and restrictive cardiomyopathy. We studied 30 patients referred for further evaluation of diastolic function who had a diagnosis of constrictive pericarditis or restrictive cardiomyopathy established by diagnostic tests, including clinical assessment, magnetic resonance imaging, cardiac catheterization, endomyocardial biopsy, and surgical findings. Nineteen patients had constrictive pericarditis and 11 had restrictive cardiomyopathy. We performed 2-dimensional transesophageal echocardiography combined with pulsed-wave Doppler of the pulmonary veins and mitral inflow with respiratory monitoring, tissue Doppler echocardiography of the lateral mitral annulus, and color M-mode flow propagation of left ventricular filling. Respiratory variation of the mitral inflow peak early (peak E) velocity of > or =10% predicted constrictive pericarditis with 84% sensitivity and 91% specificity and variation in the pulmonary venous peak diastolic (peak D) flow velocity of > or =18% distinguished constriction with 79% sensitivity and 91% specificity. Using tissue Doppler echocardiography, a peak early velocity of longitudinal expansion (peak Ea) of > or =8.0 cm/s differentiated patients with constriction from restriction with 89% sensitivity and 100% specificity. A slope of > or =100 cm/s for the first aliasing contour in color M-mode flow propagation predicted patients with constriction with 74% sensitivity and 91% specificity. Thus, the newer methods of tissue Doppler echocardiography and color M-mode flow propagation are equivalent and complimentary with Doppler respiratory variation in distinguishing between constrictive pericarditis and restrictive cardiomyopathy. The additive role of the new methods needs to be established in difficult cases of constrictive
Francis, Loren; Finley, Alan; Hessami, Walead
Mitral stenosis is often managed percutaneously with an interventional procedure such as balloon commissurotomy. Although this often results in an increased mitral valve area and improved clinical symptoms, this procedure is not benign and may have serious complications including the development of hemodynamically significant mitral valve regurgitation. Multiple scoring systems have been developed to attempt to risk stratify these patients prior to their procedure.
Bouabdallaoui, Nadia; Wang, Zhen; Lecomte, Milena; Ennezat, Pierre V; Blanchard, Didier
Takotsubo cardiomyopathy (TTC) is a well-recognised entity that commonly manifests with chest pain, ST segment abnormalities and transient left ventricular apical ballooning without coronary artery obstructive disease. This syndrome usually portends a favourable outcome. In the rare haemodynamically unstable TTC patients, acute mitral regurgitation (MR) related to systolic anterior motion (SAM) of the mitral valve and left ventricular outflow tract obstruction (LVOTO) is to be considered. Bedside echocardiography is key in recognition of this latter condition as vasodilators, inotropic agents or intra-aortic balloon counter-pulsation worsen the patient's clinical status. We discuss here a case of TTC where nitrate-induced subaortic obstruction and mitral regurgitation led to haemodynamic instability.
Mylotte, Darren; Piazza, Nicolo
In the last year transcatheter mitral valve implantation (TMVI) has seen a major jump in development. This technique offers the potential to treat a great number of elderly and/or high-risk patients with severe mitral regurgitation (MR). Such patients are declined surgical intervention either because the institutional Heart Team considers the risk of intervention to exceed the potential benefit, or because the patients and their families believe the morbidity of mitral surgery to be excessive. The advent of a less invasive transcatheter treatment could, therefore, potentially appeal to both clinicians and patients alike. In this overview paper, we describe briefly these recent developments in TVMI technologies as an introduction to the dedicated TVMI technical device parade later in this supplement.
Lutter, G; Frank, D
Approximately 30 % of patients suffering from severe valvular heart disease, such as mitral valve regurgitation are non-compliant to the gold standard of minimally invasive surgery, reconstruction or valve replacement. The number of these mostly old patients with severe comorbidities is increasing; therefore, transcatheter interventions have been developed to address an unmet clinical need and may be an alternative therapeutic option to the reference standard. Apart from the successful MitraClip therapy, alternative transcatheter reconstruction technologies are being developed. As with transcatheter aortic valve implantation (TAVI) procedures, the off-pump implantation of a valved stent into the mitral position mainly via a transapical approach will be of great benefit. Recently, the feasibility of transcatheter mitral valved stent implantation in high-risk patients has already been reported.
Maselli, Daniele; Pizio, Raffaella; Borelli, Gabriele; Musumeci, Francesco
To evaluate micro embolic events occurrence during minimally invasive mitral valve procedures, comparing balloon endovascular aortic occlusion (Group I) and transthoracic aortic clamping technique (Group II), 36 patients (20 in Group I and 16 in Group II) undergoing minimally invasive mitral valve surgery were selected by CT scan and Doppler studies for absence of atherosclerotic disease at aortic, coronary or peripheral level. Assignment to one of the two groups was made on the basis of surgeon's preference. Continuous automated intra-operative transcranial Doppler was used to monitor micro embolic events during five operative steps: cardiopulmonary bypass (CPB) setup, time interval from CPB start until aortic clamp positioning, first minute after clamp-on, first minute after clamp-off, first ten minutes after CPB weaning start. More embolic events were observed in Group II than in Group I (total 143.4+/-30.6 per patient vs. 78.9+/-28.6 per patient). A large amount of embolic events occurring mainly when the aortic clamp was positioned and released accounted for the observed differences. In a low risk population for embolic events occurrence, endovascular balloon aortic clamping determined less embolic signals than transthoracic aortic clamping.
It has become evident that mitral valve (MV) repair is the preferable treatment for the majority of patients presenting with severe mitral regurgitation (MR). This success clearly testifies that the surgical procedure is accessible, reproducible and is carrying excellent long-lasting results. From the pre-extracorporeal circulation’s era to the last percutaneous approaches, a large variety of techniques have been proposed to address the different features of MV diseases. This article aimed at reviewing chronologically the development of these dedicated techniques through their origins and the debates that they generated in the literature. PMID:26309841
García-Ropero, Álvaro; Cortés García, Marcelino; Aldamiz Echevarría, Gonzalo; Farré Muncharaz, Jerónimo
A previously non-described cause of mitral regurgitation is presented. An asymptomatic 50-year old male who was casually diagnosed of mitral valve Barlow's disease underwent cardiac surgery due to severe mitral regurgitation. In the operating theatre, a longitudinal fissure of 1.5-2.0 cm length, along the posterior mitral leaflet, was found responsible for the insufficiency. This defect had features of a potential congenital origin and it was successfully repaired with direct suture. Whether it is an atypical mitral cleft, a variation of Barlow's morphology spectrum or a new congenital heart defect remains unclear.
Grosset, D G; Georgiadis, D; Kelman, A W; Cowburn, P; Stirling, S; Lees, K R; Faichney, A; Mallinson, A; Quin, R; Bone, I; Pettigrew, L; Brodie, E; MacKay, T; Wheatley, D J
Doppler ultrasound detection of abnormally high-pitched signals within the arterial waveform offers a new method for diagnosis, and potentially for prediction, of embolic complications in at-risk patients. The nature of Doppler "microembolic" signals is of particular interest in patients with prosthetic heart valves, where a high prevalence of these signals is observed. Monitoring the middle cerebral artery with 2-MHz transcranial Doppler ultrasound (TC-2000, Nicolet Biomedical; Warwick, UK), we looked for microemboli signals in 150 patients (95 women and 55 men), and found 1 or more signals during a 30-min recording in 89% of 70 patients with Bjork-Shiley valves (principally monostrut), 54% of 50 patients with Medtronic-Hall valves, and 50% of 30 patients with Carpentier-Edwards valves (p < 0.001, chi 2). In the patients with Bjork-Shiley valves, the mean number of signals per hour was 59 (range, 42-86; 95% confidence interval), which was significantly higher than the mean in patients with Medtronic-Hall and Carpentier-Edwards valves (1.5[range, 0.5-2.5] and 1 [range, 0-5.3], respectively; both p < 0.04, multiple comparisons. Bonferroni correction). In the patients undergoing serial pre- and postoperative studies, the causative role of the valve implant was emphasized. There was no correlation between the number of emboli signals and a prior history of neurologic deficit, cardiac rhythm, previous cardiac surgery, or the intensity of oral anticoagulation, in patients with prosthetic heart valves. In Bjork-Shiley patients, dual (mitral and aortic) valves were associated with more signals than were single valves. In Medtronic-Hall patients, the signal count was greater for valves in the aortic position than it was for valves in the mitral position. Comparative studies of Doppler emboli signals in other clinical settings suggest a difference in composition or size of the underlying maternal between prosthetic valve patients and patients with carotid stenosis. These
Berlin, Gary J.
The SRS Doppler Weather System consists of a Doppler Server, A Master Server (also known as the Weather Server), several Doppler Slave Servers, and client-side software program called the Doppler Radar Client. This system is used to display near rel-time images taken from the SRS Weather Center's Doppler Radar computer. The Doppler Server is software that resides on the SRS Doppler Computer. It gathers raw data, 24-bit color weather images via screen scraping ever five minutes as requested by the Master Server. The Doppler Server then reduces the 24-bit color images to 8-bit color using a fixed color table for analysis and compression. This preserves the fidelity of the image color and arranges the colors in specific order for display. At the time of color reduction, the white color used for the city names on the background images are remapped to a different index (color) of white that the white on the weather scale. The Weather Server places a time stamp on the image, then compresses the image and passes it to all Doppler Slave servers. Each of the Doppler Slave servers mainitain a circular buffer of the eight most current images representing the last 40 minutes of weather data. As a new image is added, the oldest drops off. The Doppler Radar Client is an optional install program for any site-wide workstation. When a Client session is started, the Client requests Doppler Slave server assignment from the Master Server. Upon its initial request to the Slave Server, the Client obtains all eight current images and maintains its own circular buffer, updating its images every five minutes as the Doppler Slave is updated. Three background reference images are stored as part of the Client. The Client brings up the appropriate background image, decompresses the doppler data, and displays the doppler data on the background image.
Shabsigh, Muhammad; Lawrence, Cassidy; Rosero-Britton, Byron R.; Kumar, Nicolas; Kimura, Satoshi; Durda, Michael Andrew; Essandoh, Michael
Mitral stenosis (MS) after mitral valve (MV) repair is a slowly progressive condition, usually detected many years after the index MV surgery. It is defined as a mean transmitral pressure gradient (TMPG) >5 mmHg or a mitral valve area (MVA) <1.5 cm2. Pannus formation around the mitral annulus or extending to the mitral leaflets is suggested as the main mechanism for developing delayed MS after MV repair. On the other hand, early stenosis is thought to be a direct result of an undersized annuloplasty ring. Furthermore, in MS following ischemic mitral regurgitation (MR) repair, subvalvular tethering is the hypothesized pathophysiology. MS after MV repair has an incidence of 9–54%. Several factors have been associated with a higher risk for developing MS after MV repair, including the use of flexible Duran annuloplasty rings versus rigid Carpentier–Edwards rings, complete annuloplasty rings versus partial bands, small versus large anterior leaflet opening angle, and anterior leaflet tip opening length. Intraoperative echocardiography can measure the anterior leaflet opening angle, the anterior leaflet tip opening dimension, the MVA and the mean TMPG, and may help identify patients at risk for developing MS after MV repair. PMID:27148540
Shabsigh, Muhammad; Lawrence, Cassidy; Rosero-Britton, Byron R; Kumar, Nicolas; Kimura, Satoshi; Durda, Michael Andrew; Essandoh, Michael
Mitral stenosis (MS) after mitral valve (MV) repair is a slowly progressive condition, usually detected many years after the index MV surgery. It is defined as a mean transmitral pressure gradient (TMPG) >5 mmHg or a mitral valve area (MVA) <1.5 cm(2). Pannus formation around the mitral annulus or extending to the mitral leaflets is suggested as the main mechanism for developing delayed MS after MV repair. On the other hand, early stenosis is thought to be a direct result of an undersized annuloplasty ring. Furthermore, in MS following ischemic mitral regurgitation (MR) repair, subvalvular tethering is the hypothesized pathophysiology. MS after MV repair has an incidence of 9-54%. Several factors have been associated with a higher risk for developing MS after MV repair, including the use of flexible Duran annuloplasty rings versus rigid Carpentier-Edwards rings, complete annuloplasty rings versus partial bands, small versus large anterior leaflet opening angle, and anterior leaflet tip opening length. Intraoperative echocardiography can measure the anterior leaflet opening angle, the anterior leaflet tip opening dimension, the MVA and the mean TMPG, and may help identify patients at risk for developing MS after MV repair.
McFaul, Richard C.
A review of research regarding mitral valve prolapse in young children indicates that up to five percent of this population have the condition, with the majority being asymptomatic and requiring reassurance that the condition usually remains mild. Beta-blocking drugs are prescribed for patients with disabling chest pain, dizziness, palpitation, or…
Lehr, Eric J.; Guy, T. Sloane; Smith, Robert L.; Grossi, Eugene A.; Shemin, Richard J.; Rodriguez, Evelio; Ailawadi, Gorav; Agnihotri, Arvind K.; Fayers, Trevor M.; Hargrove, W. Clark; Hummel, Brian W.; Khan, Junaid H.; Malaisrie, S. Chris; Mehall, John R.; Murphy, Douglas A.; Ryan, William H.; Salemi, Arash; Segurola, Romualdo J.; Smith, J. Michael; Wolfe, J. Alan; Weldner, Paul W.; Barnhart, Glenn R.; Goldman, Scott M.; Lewis, Clifton T. P.
Abstract Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program. PMID:27662478
Babuty, D; Charniot, J C; Delhomme, C; Fauchier, L; Fauchier, J P; Cosnay, P
In order to determine the predictive value for ventricular arrhythmias of ventricular late potentials (LP) in mitral valve prolapse (MVP) the authors performed high amplification signal-averaging ECG (SA) and 24 hours ambulatory ECG (Holter) monitoring in 68 consecutive patients (34 men, 34 women, average age 48 +/- 17.7 years) with echocardiographically diagnosed MVP. Patients with bundle branch block or associated cardiac disease were excluded. Echocardiography showed 26 patients to have floppy mitral valves (38.2%), 50 patients to have posterior deplacement > or = 5 mm of the mitral valves in systole (73.5%) and 35 patients to have mitral regurgitation (51.4%). Holter monitoring showed 17 patients without ventricular extrasystoles (VES), 15 had Lown Grade I, 6 had Lown Grade II, 3 had Lown Grade III, 15 had Lown Grade IV A and 12 had Lown Grade IV B ventricular arrhythmias. Therefore, 30 patients had complex ventricular arrhythmias (> or = Lown Grade III) and 13 patients had spontaneous non-sustained ventricular tachycardia (NSVT) (one patient had NSVT on resting ECG but not on Holter monitoring). Eighteen patients had LP (26.5%). The incidence of complex ventricular arrhythmias was higher in patients with mitral regurgitation (62.8% versus 27.7%; p < 0.005) whereas the incidence of NSVT was not significantly different (25.7% versus 17.1%; p = 0.15). On the other hand, the frequency of complex ventricular arrhythmias was not significantly different in the presence or absence of LP (61.1% versus 40%: NS) whereas the incidence of NSVT was higher in patients with LP (44.4% versus 10%; p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)
A summary is given of Doppler's life and career. He was born 180 years ago on November 29, 1803, in Salzburg, Austria. He died on March 17, 1853 in Venice. The effect bearing his name was first announced in a presentation before the Royal Bohemian Society of the Sciences in Prague on May 25, 1842. Doppler considered his work a generalization of the aberration theorem as discovered by Bradley. With it came the inference that the perception of physical phenomena can change with the state of motion of the observer. Acceptance of the principle was not without controversy. In 1852, the mathematician Petzval claimed that no useful scientific deductions can be made from Doppler's elementary equations. In 1860, Ernst Mach resolved the misunderstanding that clouded this controversy. The Doppler effect is alive and well. Its role in radio science and related disciplines is enumerated.
Thankavel, Poonam P; Ramaciotti, Claudio
Congenital cardiac anomalies are common in trisomy 21, and transthoracic echocardiogram within the first month of life is recommended. While a cleft mitral valve associated with atrioventricular septal defect has been well defined in this population, the prevalence of isolated mitral valve cleft has not been previously reported. The aim of our study was to define the occurrence of isolated mitral cleft in the first echocardiogram of patients with trisomy 21. This retrospective chart review examined echocardiographic data on all Trisomy 21 patients <1 year of age obtained during January 1, 2010, to May 1, 2014, at our institution. Images were reviewed by one of the authors with no knowledge of the official diagnosis. In addition to evaluation for isolated mitral valve cleft, data obtained included presence of additional congenital heart defects and need for surgical intervention. A total of 184 patients (median age 5 days) were identified. Isolated mitral cleft was identified in 12 patients (6.5 %). Four were diagnosed retrospectively (33 %). Only one had mitral regurgitation on initial echocardiogram. Seven required surgery for closure of ventricular septal defects. Isolated mitral cleft is present in an important number of neonates with Trisomy 21. Mitral regurgitation is often absent in the neonatal period and should not be used as a reliable indicator of absence of valve abnormality. Careful attention should be directed toward the mitral valve during the first echocardiogram to exclude an isolated cleft, which can lead to progressive mitral regurgitation.
Silverman, Norman H
I surveyed our echocardiographic database of the years between 1998 and 2012 for congenital abnormalities of the mitral valve in patients over 14 years. A total of 249 patients with mitral valve abnormalities were identified. Abnormalities included clefts in the mitral valve in 58 patients, double orifice of the mitral valve in 19, mitral stenosis with two papillary muscles in 72, and mitral stenosis with one papillary muscle in 51 patients. Supravalvar rings were found in 35 patients with a single papillary muscle, and mitral stenoses with two papillary muscles were found in 22 patients. Mitral prolapse occurred in 44 patients and mitral valvar straddle in five patients. The patients were evaluated by all modalities of ultrasound available over the course of time. Although some lesions were isolated, there were many lesions in which more than one mitral deformity presented in the same patient. The patients are presented showing anatomical correlation with autopsy specimens, some of which came from the patients in this series, and others matched to show correlative anatomy. These lesions remain rare as a group and continue to have high morbidity and mortality.
MacLeod, D; Fananapazir, L; de Bono, D; Bloomfield, P
Eight patients who developed a ventricular septal defect after myocardial infarction were assessed by cross sectional echocardiography and pulsed wave Doppler scanning. Cross sectional echocardiography visualised the defect in four patients and gave an accurate assessment of global and regional left ventricular function in all eight. In all patients pulsed wave Doppler scanning detected turbulent flow at the apex of the right ventricle or adjacent to a wall motion abnormality affecting the interventricular septum. Pulsed wave Doppler detected coexisting mitral regurgitation in one patient and tricuspid regurgitation in another two. In all patients a left to right shunt was confirmed by oximetry and the location of the defect was identified by angiography or at operation or necropsy. Cross sectional echocardiography in combination with pulsed wave Doppler scanning is useful in the rapid bedside evaluation of patients with ventricular septal defect after myocardial infarction. Images Fig PMID:3663420
Urban, Marian; Pirk, Jan; Szarszoi, Ondrej; Skalsky, Ivo; Maly, Jiri; Netuka, Ivan
BACKGROUND: Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated. METHODS: A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival. RESULTS: The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival. CONCLUSIONS: In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulation-related complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation. PMID:24294032
Guedes, Marco Antônio Vieira; Pomerantzeff, Pablo Maria Alberto; Brandão, Carlos Manuel de Almeida; Vieira, Marcelo Luiz Campos; Tarasoutchi, Flávio; Spinola, Pablo da Cunha; Jatene, Fábio Biscegli
Introduction Mitral valve repair is the treatment of choice to correct mitral insufficiency, although the literature related to mitral valve annulus behavior after mitral repair without use of prosthetic rings is scarce. Objective To analyze mitral annulus morphology and function using real time tridimensional echocardiography in individuals submitted to mitral valve repair with Double Teflon technique. Methods Fourteen patients with mitral valve insufficiency secondary to mixomatous degeneration that were submitted to mitral valve repair with the Double Teflon technique were included. Thirteen patients were in FC III/IV. Patients were evaluated in preoperative period, immediate postoperative period, 6 months and 1 year after mitral repair. Statistical analysis was made by repeated measures ANOVA test and was considered statistically significant P<0.05. Results There were no deaths, reoperation due to valve dysfunction, thromboembolism or endocarditis during the study. Posterior mitral annulus demonstrated a significant reduction in immediate postoperative period (P<0.001), remaining stable during the study, and presents a mean of reduction of 25.8% comparing with preoperative period. There was a significant reduction in anteroposterior and mediolateral diameters in the immediate postoperative period (P<0.001), although there was a significant increase in mediolateral diameter between immediate postoperative period and 1 year. There was no difference in mitral internal area variation over the cardiac cycle during the study. Conclusion Segmentar annuloplasty reduced the posterior component of mitral annulus, which remained stable in a 1-year-period. The variation in mitral annulus area during cardiac cycle remained stable during the study. PMID:26313723
Liu, Gangjun; Chen, Zhongping
We review the principle and some recent applications of Doppler optical coherence tomography (OCT). The advances of the phase-resolved Doppler OCT method are described. Functional OCT algorithms which are based on an extension of the phase-resolved scheme are also introduced. Recent applications of Doppler OCT for quantification of flow, imaging of microvasculature and vocal fold vibration, and optical coherence elastography are briefly discussed. PMID:24443649
Armstrong, J. W.
The Doppler tracking method is currently the only technique available for broadband gravitational wave searches in the approx. 10(exp -4) to 10(exp -1) Hz low frequency band. A brief review is given of the Doppler method, a discussion of the main noise sources, and a review of experience with current spacecraft and the prospects for sensitivity improvements in an advanced Doppler tracking experiment.
Li, Chi-Hion; Arzamendi, Dabit; Carreras, Francesc
Mitral regurgitation is the most prevalent valvular heart disease in the United States and the second most prevalent in Europe. Patients with severe mitral regurgitation have a poor prognosis with medical therapy once they become symptomatic or develop signs of significant cardiac dysfunction. However, as many as half of these patients are inoperable because of advanced age, ventricular dysfunction, or other comorbidities. Studies have shown that surgery increases survival in patients with organic mitral regurgitation due to valve prolapse but has no clinical benefit in those with functional mitral regurgitation. In this scenario, percutaneous repair for mitral regurgitation in native valves provides alternative management of valvular heart disease in patients at high surgical risk. Percutaneous repair for mitral regurgitation is a growing field that relies heavily on imaging techniques to diagnose functional anatomy and guide repair procedures.
Yalcin, F.; Kaftan, A.; Muderrisoglu, H.; Korkmaz, M. E.; Flachskampf, F.; Garcia, M.; Thomas, J. D.
BACKGROUND: Transmitral Doppler flow indices are used to evaluate diastolic function. Recently, velocities measured by Doppler tissue imaging have been used as an index of left ventricular relaxation. OBJECTIVE: To determine whether Doppler tissue velocities are influenced by alterations in preload. METHODS: Left ventricular preload was altered in 17 patients (all men, mean (SD) age, 49 (8) years) during echocardiographic measurements of left ventricular end diastolic volume, maximum left atrial area, peak early Doppler filling velocity, and left ventricular myocardial velocities during early filling. Preload altering manoeuvres included Trendelenberg (stage 1), reverse Trendelenberg (stage 2), and amyl nitrate (stage 3). Systolic blood pressure was measured at each stage. RESULTS: In comparison with baseline, left ventricular end diastolic volume (p = 0.001), left atrial area (p = 0.003), peak early mitral Doppler filling velocity (p = 0.01), and systolic blood pressures (p = 0.001) were all changed by preload altering manoeuvres. Only left ventricular myocardial velocity during early filling remained unchanged by these manoeuvres. CONCLUSIONS: In contrast to standard transmitral Doppler filling indices, Doppler tissue early diastolic velocities are not significantly affected by physiological manoeuvres that alter preload. Thus Doppler tissue velocities during early left ventricular diastole may provide a better index of diastolic function in cardiac patients by providing a preload independent assessment of left ventricular filling.
Li, Feng P.; Rajchl, Martin; Moore, John; Peters, Terry M.
Mitral regurgitation (MR) occurs when the mitral valve cannot close properly during systole. The NeoChordtool aims to repair MR by implanting artificial chordae tendineae on flail leaflets inside the beating heart, without a cardiopulmonary bypass. Image guidance is crucial for such a procedure due to the lack of direct vision of the targets or instruments. While this procedure is currently guided solely by transesophageal echocardiography (TEE), our previous work has demonstrated that guidance safety and efficiency can be significantly improved by employing augmented virtuality to provide virtual presentation of mitral valve annulus (MVA) and tools integrated with real time ultrasound image data. However, real-time mitral annulus tracking remains a challenge. In this paper, we describe an image-based approach to rapidly track MVA points on 2D/biplane TEE images. This approach is composed of two components: an image-based phasing component identifying images at optimal cardiac phases for tracking, and a registration component updating the coordinates of MVA points. Preliminary validation has been performed on porcine data with an average difference between manually and automatically identified MVA points of 2.5mm. Using a parallelized implementation, this approach is able to track the mitral valve at up to 10 images per second.
Mihos, Christos G; Santana, Orlando
Approximately 30% to 50% of patients will develop ischemic mitral regurgitation (MR) after a myocardial infarction, which is a result of progressive left ventricular remodeling and dysfunction of the subvalvular apparatus, and portends a poor long-term prognosis. Surgical treatment is centered on mitral valve repair utilizing a restrictive annuloplasty, or valve replacement with preservation of the subvalvular apparatus. In the recent Cardiothoracic Surgical Trials Network (CSTN) study, patients with severe ischemic MR were randomized to mitral valve repair with a restrictive annuloplasty versus chordal-sparing valve replacement, and concomitant coronary artery bypass grafting, if indicated. At 2-year follow-up, mitral valve repair was associated with a significantly higher incidence of moderate or greater recurrent MR and heart failure, with no difference in the indices of left ventricular reverse remodeling, as compared with valve replacement. The current appraisal aims to provide insight into the CSTN trial results, and discusses the evidence supporting a pathophysiologic-guided repair strategy incorporating combined annuloplasty and subvalvular repair techniques to optimize the outcomes of mitral valve repair in ischemic MR.
Mahmood, Feroze; Warraich, Haider Javed; Shahul, Sajid; Qazi, Aisha; Swaminathan, Madhav; Mackensen, G Burkhard; Panzica, Peter; Maslow, Andrew
A 3-dimensional echocardiographic view of the mitral valve, called the "en face" or "surgical view," presents a view of the mitral valve similar to that seen by the surgeon from a left atrial perspective. Although the anatomical landmarks of this view are well defined, no comprehensive echocardiographic definition has been presented. After reviewing the literature, we provide a definition of the left atrial and left ventricular en face views of the mitral valve. Techniques used to acquire this view are also discussed.
Tchantchaleishvili, Vakhtang; Rajab, Taufiek K.
The first successful mitral valve repair was performed by Elliot Cutler at Brigham and Women’s Hospital in 1923. Subsequent evolution in the surgical techniques as well as multi-disciplinary cooperation between cardiac surgeons, cardiologists and cardiac anesthesiologists has resulted in excellent outcomes. In spite of this, the etiology of mitral valve pathology ultimately determines the outcome of mitral valve repair. PMID:26309840
Labrosse, Michel; Mesana, Thierry; Baxter, Ian; Chan, Vincent
Although finite element analysis has been used to model simple mitral repair, it has not been used to model complex repair. A virtual mitral valve model was successful in simulating normal and abnormal valve function. Models were then developed to simulate an edge-to-edge repair and repair employing quadrangular resection. Stress contour plots demonstrated increased stresses along the mitral annulus, corresponding to the annuloplasty. The role of finite element analysis in guiding clinical practice remains undetermined.
Bernabeu, Eduardo; Mestres, Carlos A; Loma-Osorio, Pablo; Josa, Miguel
Traumatic rupture of intracardiac structures is an uncommon phenomenon although there are a number of reports with regards to rupture of the tricuspid, mitral and aortic valves. We report the case of a 25-year-old patient who presented with acute aortic and mitral valve regurgitation of traumatic origin. Both lesions were seen separated by 2 weeks. Pathophysiology is reviewed. The combination of both aortic and mitral lesions following blunt chest trauma is almost exceptional.
Seo, Jung Hee; Vedula, Vijay; Mittal, Rajat; Abraham, Theodore; Dawoud, Fady; Luo, Hongchang; Lardo, Albert C.
The leaflets of the mitral valve interact with the mitral jet and significantly impact diastolic flow patterns, but the effect of mitral valve morphology and kinematics on diastolic flow and its implications for left ventricular function have not been clearly delineated. In the present study, we employ computational hemodynamic simulations to understand the effect of mitral valve leaflets on diastolic flow. A computational model of the left ventricle is constructed based on a high-resolution contrast computed-tomography scan, and a physiological inspired model of the mitral valve leaflets is synthesized from morphological and echocardiographic data. Simulations are performed with a diode type valve model as well as the physiological mitral valve model in order to delineate the effect of mitral-valve leaflets on the intraventricular flow. The study suggests that a normal physiological mitral valve promotes the formation of a circulatory (or “looped”) flow pattern in the ventricle. The mitral valve leaflets also increase the strength of the apical flow, thereby enhancing apical washout and mixing of ventricular blood. The implications of these findings on ventricular function as well as ventricular flow models are discussed.
Natarajan, Navin; Patel, Parag; Bartel, Thomas; Kapadia, Samir; Navia, Jose; Stewart, William; Tuzcu, E. Murat
Mitral regurgitation (MR) has a high prevalence in older patient populations of industrialized nations. Common etiologies are structural, degenerative MR and functional MR secondary to myocardial remodeling. Because of co-morbidities and associated high surgical risk, open surgical mitral repair/replacement is deferred in a significant percentage of patients. For these patients transcatheter repair/replacement are emerging as treatment options. Because of the lack of direct visualization, pre- and intra-procedural imaging is critical for these procedures. In this review, we summarize mitral valve anatomy, trans-catheter mitral valve replacement (TMVR) options, and imaging in the context of TMVR. PMID:27054104
Yoshida, Takeshi; Ohashi, Takeki; Furui, Masato; Kageyama, Souichirou; Kodani, Noriko; Kobayashi, Yutaka; Hirai, Yasutaka; Sakakura, Reo
Coffin-Lowry syndrome is a rare X-linked disorder characterized by craniofacial and skeletal abnormalities, mental retardation, short stature, and hypotonia. An 18-year-old man with morphologic features characteristic of Coffin-Lowry syndrome was referred to our institution for valve disease surgery for worsening cardiac failure. Echocardiography showed severe mitral valve regurgitation associated with tricuspid valve regurgitation. Mitral valve implantation with a biological valve and tricuspid annular plication with a ring was performed. The ascending aorta was hypoplastic. Both the mitral papillary muscle originating near the mitral annulus and the chordae were shortened. The patient's postoperative course was uneventful and his cardiac failure improved.
Algarni, Khaled D; Suri, Rakesh M; Daly, Richard C
Robotic-assisted mitral valve repair represents the least invasive surgical approach currently available for anatomical mitral valve repair in patients with myxomatous mitral valve disease. Standard mitral valve repair techniques utilized during conventional sternotomy/right thoracotomy are exactly replicated with the robotic instrumentation through 1-2 cm port-like incisions with superior 3D visualization. This is performed on cardiopulmonary bypass by peripheral cannulation of the femoral vessels/right internal jugular vein. The ascending aorta is occluded with a transthoracic aortic cross-clamp. Antegrade cardioplegia is delivered centrally into the aortic root through a cardioplegia vent catheter. By replicating conventional mitral valve repair done via an open sternotomy approach, the quality of mitral valve repair is ensured while providing the patients with advantages of less invasive surgery including shorter hospital stay, rapid recovery and return to normal activities, less blood transfusion, superior cosmesis and complete elimination of sternotomy-related morbidities such as deep sternal wound infection and sternal dehiscence. We reviewed the first consecutive 200 patients undergoing robotic mitral valve repair at Mayo Clinic Rochester between 24 January 2008 and 28 January 2011. Successful mitral valve repair was completed in all patients. There were no early (30-day) deaths. One patient suffered a stroke (0.5%). One patient required reoperation for bleeding (0.5%). Two patients (1%) required reoperation for recurrent mitral regurgitation. Twelve patients (6%) required transfusion of allogeneic blood products. We have noted a significant reduction in operative times and resource utilization over time.
Espiritu, Daniella; Onohara, Daisuke; Kalra, Kanika; Sarin, Eric L; Padala, Muralidhar
Mitral regurgitation is a common cardiac valve lesion, developing from primary lesions of the mitral valve or secondary to cardiomyopathies. Moderate or higher severity of mitral regurgitation imposes significant volume overload on the left ventricle, causing permanent structural and functional deterioration of the myocardium and heart failure. Timely correction of regurgitation is essential to preserve cardiac function, but surgical mitral valve repair is often delayed due to the risks of open heart surgery. Since correction of mitral regurgitation can provide symptomatic relief and halt progressive cardiac dysfunction, transcatheter mitral valve repair technologies are emerging as alternative therapies. In this approach, the mitral valve is repaired either with sutures or implants that are delivered to the native valve on catheters introduced into the cardiovascular system under image guidance, through small vascular or ventricular ports. Several transcatheter mitral valve technologies are in development, but limited clinical success has been achieved. In this review, we present a historical perspective of mitral valve repair, review the transcatheter technologies emerging from surgical concepts, the challenges they face in achieving successful clinical application, and the increasing rigor of safety and durability standards for new transcatheter valve technologies.
González Rocafort, Álvaro; Aroca, Ángel; Polo, Luz; Rey, Juvenal; Villagrá, Fernando
Severe mitral stenosis is unusual in children, but it represents an important challenge for surgeons because of the scarcity of solutions. Several mitral percutaneous and surgical valvuloplasties are performed repetitively to delay mitral valve replacement. Most of the time these procedures show discouraging results. When mitral valve replacement is performed, the annulus may not be large enough to fit a substitute. We present, to our best knowledge, a new technique to implant a large prosthesis in a small annulus without negatively affecting the opening of the leaflets.
Sun, J. P.; Yang, X. S.; Qin, J. X.; Greenberg, N. L.; Zhou, J.; Vazquez, C. J.; Griffin, B. P.; Stewart, W. J.; Thomas, J. D.
OBJECTIVES: To develop and validate an automated noninvasive method to quantify mitral regurgitation. BACKGROUND: Automated cardiac output measurement (ACM), which integrates digital color Doppler velocities in space and in time, has been validated for the left ventricular (LV) outflow tract but has not been tested for the LV inflow tract or to assess mitral regurgitation (MR). METHODS: First, to validate ACM against a gold standard (ultrasonic flow meter), 8 dogs were studied at 40 different stages of cardiac output (CO). Second, to compare ACM to the LV outflow (ACMa) and inflow (ACMm) tracts, 50 normal volunteers without MR or aortic regurgitation (44+/-5 years, 31 male) were studied. Third, to compare ACM with the standard pulsed Doppler-two-dimensional echocardiographic (PD-2D) method for quantification of MR, 51 patients (61+/-14 years, 30 male) with MR were studied. RESULTS: In the canine studies, CO by ACM (1.32+/-0.3 liter/min, y) and flow meter (1.35+/-0.3 liter/min, x) showed good correlation (r=0.95, y=0.89x+0.11) and agreement (deltaCO(y-x)=0.03+/-0.08 [mean+/-SD] liter/min). In the normal subjects, CO measured by ACMm agreed with CO by ACMa (r=0.90, p < 0.0001, deltaCO=-0.09+/-0.42 liter/min), PD (r=0.87, p < 0.0001, deltaCO=0.12+/-0.49 liter/min) and 2D (r=0.84, p < 0.0001, deltaCO=-0.16+/-0.48 liter/min). In the patients, mitral regurgitant volume (MRV) by ACMm-ACMa agreed with PD-2D (r= 0.88, y=0.88x+6.6, p < 0.0001, deltaMRV=2.68+/-9.7 ml). CONCLUSIONS: We determined that ACM is a feasible new method for quantifying LV outflow and inflow volume to measure MRV and that ACM automatically performs calculations that are equivalent to more time-consuming Doppler and 2D measurements. Additionally, ACM should improve MR quantification in routine clinical practice.
Poyner, Jennifer; Olson, Ewan; Henriksen, Peter; Koch, Oliver
Introduction: Staphylococcus caprae is a rare cause of infective endocarditis. Here, we report a case involving the native mitral valve in the absence of an implantable cardiac electronic device. Case presentation: A 76-year-old man presented with a 2 week history of confusion and pyrexia. His past medical history included an open reduction and internal fixation of a humeral fracture 17 years previously, which remained non-united despite further revision 4 years later. There was no history of immunocompromise or farm-animal contact. Two sets of blood culture bottles, more than 12 h apart, were positive for S. caprae. Trans-thoracic echocardiography revealed a 1×1.2 cm vegetation on the mitral valve, with moderate mitral regurgitation. Due to ongoing confusion, he had a magnetic resonance imaging brain scan, which showed a subacute small vessel infarct consistent with a thromboembolic source. A humeral SPECT-CT (single-photon emission computerized tomography-computerized tomography) scan showed no clear evidence of acute osteomyelitis. Surgical vegetectomy and mitral-valve repair were considered to reduce the risk of further systemic embolism and progressive valve infection. However, the potential risks of surgery to this patient led to a decision to pursue a cure with antibiotic therapy alone. He remained well 3 months after discharge, with repeat echocardiography demonstrating a reduction in the size of the vegetation (0.9 cm). Conclusion: Management of this infection was challenging due to its rarity and its unclear progression, complicated by the dilemma surrounding surgical intervention in a patient with a complex medical background. PMID:28348787
Sá, Michel Pompeu Barros de Oliveira; Ferraz, Paulo Ernando; Escobar, Rodrigo Renda; Martins, Wendell Santos; de Araújo e Sá, Frederico Browne Correia; Lustosa, Pablo César; Vasconcelos, Frederico Pires; Lima, Ricardo Carvalho
Resection of the chordopapillary apparatus during mitral valve replacement has been associated with a negative impact on survival. Mitral valve replacement with the preservation of the mitral valve apparatus has been associated with better outcomes, but surgeons remain refractory to its use. To determine if there is any real difference in preservation vs non-preservation of mitral valve apparatus during mitral valve replacement in terms of outcomes, we performed a systematic review and meta-analysis using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for clinical studies that compared outcomes (30-day mortality, postoperative low cardiac output syndrome or 5-year mortality) between preservation vs non-preservation during mitral valve replacement from 1966 to 2011. The principal summary measures were odds ratios (ORs) with 95% confidence interval and P-values (that will be considered statistically significant when <0.05). The ORs were combined across studies using a weighted DerSimonian–Laird random-effects model. The meta-analysis was completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, NJ, USA). Twenty studies (3 randomized and 17 non-randomized) were identified and included a total of 3835 patients (1918 for mitral valve replacement preservation and 1917 for mitral valve replacement non-preservation). There was significant difference between mitral valve replacement preservation and mitral valve replacement non-preservation groups in the risk of 30-day mortality (OR 0.418, P <0.001), postoperative low cardiac output syndrome (OR 0.299, P <0.001) or 5-year mortality (OR 0.380, P <0.001). No publication bias or important heterogeneity of effects on any outcome was observed. In conclusion, we found evidence that argues in favour of the preservation of mitral valve apparatus during mitral valve replacement. PMID:23027596
MacArthur, John W.; Cohen, Jeffrey E.; Goldstone, Andrew B.; Fairman, Alexander S.; Edwards, Bryan B.; Hornick, Matthew A.; Atluri, Pavan; Woo, Y. Joseph
Background Both leaflet resection and neochordal construction are effective mitral repair techniques, but they may become incrementally time-consuming when using minimally invasive approaches. We have used a single-suture leaflet-remodeling technique of inverting the prolapsed or flail segment tissue into the left ventricle. This repair is straightforward, expeditious, and facilitates a minimally invasive approach. Methods Ninety-nine patients with degenerative mitral regurgitation (MR) underwent a minimally invasive single-suture repair of the mitral valve from May 2007 through December 2012. Preoperative and perioperative echocardiograms as well as patient outcomes were analyzed and compared with those obtained from patients undergoing minimally invasive mitral valve repair using quadrangular resection at the same institution during the same period. Results All 99 patients had a successful mitral repair through a sternal-sparing minimally invasive approach. Ninety-one of the 99 patients had zero MR on postoperative echocardiogram, and 8 of 99 had trace to mild MR. Patients in the nonresectional group had significantly shorter cardiopulmonary bypass and cross-clamp times compared with the quadrangular resection group (115.8 ± 41.7 minutes versus 144.9 ± 38.2 minutes; p < 0.001; 76.2 ± 28.1 minutes versus 112.6 ± 33.5 minutes; p < 0.001, respectively). The mean length of stay was 7.5 ± 3 days. All patients were discharged alive and free from clinical symptoms of MR. There have been no reoperations for recurrent MR on subsequent average follow-up of 1 year. Conclusions An effective, highly efficient, and thus far durable single-suture mitral leaflet-remodeling technique facilitates minimally invasive repair of degenerative MR. PMID:23932318
Casamian-Sorrosal, Domingo; Saunders, Richard; Browne, William; Elliot, Sarah; Fonfara, Sonja
This paper reports radial colour and longitudinal mitral annulus pulsed-wave tissue Doppler findings in a large cohort of healthy, adult pet rabbits. Thirty-nine rabbits (22 Dwarf Lops, 14 French Lops and three Alaskans) underwent conscious echocardiography. The median age of the rabbits was 22 months and the median weight was 2.8 kg (Dwarf Lop 2.4 kg/French Lop 6.0 kg). Adequate radial colour and longitudinal pulsed-wave tissue Doppler traces were obtained in 100% and 85% of cases, respectively. Most systolic tissue Doppler parameters were significantly higher in French Lops than in Dwarf Lops. Separation of mitral inflow diastolic waves was present in 40% of cases using conventional spectral Doppler and in >60% of cases using pulsed-wave tissue Doppler which could be beneficial when evaluating diastolic function in rabbits. This study can be used as a reference for normal echocardiographic tissue Doppler values for adult rabbits undergoing conscious echocardiography in clinical practice.
Kozoil, Micah E.
Discusses the learning needs of students in the concrete operational stage in mathematics. Identifies the phenomenon of reduced cognitive performance in an out-of-class environment as the "Cognitive Doppler." Suggests methods of reducing the pronounced effects of the Cognitive Doppler by capitalizing on the students' ability to memorize…
Docker, M F
Developments in the signal processing of Doppler ultrasound used for the detection of fetal heart rate (FHR) have improved the operation of cardiotocographs. These developments are reviewed and the advantages and disadvantages of the various Doppler and signal processing methods are compared.
Iwasaki, Y; Kojima, T; Yasui, W; Nagasawa, N; Yashiki, M
A 51-year-old male, who had been driving a motor bicycle, was involved in a traffic accident with a trailer, and he died immediately after the accident. According to the external examination of the victim, no fatal injuries were found. The medico-legal autopsy revealed a rupture of the left side of the pericardium, and a tear of the posterior leaflet of the mitral valve. There were no injuries of the papillary muscles and chordae. The cause of death was due to traumatic mitral regurgitation.
Wise, J R
The slope of the posterior left ventricular wall motion in diastole (LVDS) was determined by echocardiography in 25 normal subjects and 21 patients with mitral stenosis. Patients with mitral stenosis had reduced LVDS that was related to the degree of mitral stenosis determined by calculated mitral valve area (r = 0.92). The mitral valve area correlated more closely with the LVDS than with the left atrial emptying index derived from the posterior aortic wall motion. Three patients with mitral stenosis had an increased LVDS after mitral valvotomy or mitral valve replacement. One patient with a stenotic mitral valve prosthesis had reduced LVDS. The results of this study suggest that analysis of the LVDS would be useful in predicting the severity of mitral stenosis and may be beneficial in evaluating patients with suspected prosthetic mitral valve malfunction.
Samad, Zainab; Velazquez, Eric J
Functional mitral regurgitation (MR) is the most common type of MR encountered in clinical practice. Because the disease arises from the ventricular aspect of the mitral valve apparatus, treatment therapies are less defined and outcomes are poor. In this review, the state of evidence for medical and surgical therapy in functional MR is appraised. Future directions for research in this area are also defined.
Fan, Jerry; Timbrook, Alexa; Said, Sarmad; Babar, Kamran; Teleb, Mohamed; Mukherjee, Debabrata; Abbas, Aamer
Summary Background Myxomatous mitral valve with prolapse are classically seen with abnormal leaflet apposition during contraction of the heart. Hemodynamic disorders can result from eccentric mitral regurgitation usually caused by chordae tendinae rupture or papillary muscle dysfunction. Echocardiography is the gold standard for evaluation of leaflet flail and prolapse due to high sensitivity and specificity. Though most mitral valve prolapse are asymptomatic those that cause severe regurgitation need emergent surgical intervention to prevent disease progression. Case Report We report a 54 year old Hispanic male who presented with progressively worsening dyspnea and palpitations. Initial evaluation was significant for atrial fibrillation on electrocardiogram with subsequent echocardiography revealing myxomatous mitral valve with prolapse. Following surgical repair of the mitral valve, the dyspnea and palpitations resolved. Conclusions Mitral valve prolapse is a common valvular abnormality but the pathogenic cause of myxomatous valves has not been elucidated. Several theories describe multiple superfamilies of proteins to be involved in the process. Proper identification of these severe mitral regurgitation due to these disease valves will help relieve symptomatic mitral valve prolapse patients. PMID:27279924
Park, Jong Myung; Je, Hyung Gon; Lee, Sang Kwon
The single-suture neochorda-folding plasty technique is a modification of existing mitral valve repair techniques. In the authors’ experience, its simplicity, reliability, and versatility make it a useful technique for mitral valve repair, especially when a minimally invasive approach is used. PMID:26889453
Petlevich, Walter J.; Sverdrup, Edward F.
A Doppler radar flowmeter comprises a transceiver which produces an audio frequency output related to the Doppler shift in frequency between radio waves backscattered from particulate matter carried in a fluid and the radiated radio waves. A variable gain amplifier and low pass filter are provided for amplifying and filtering the transceiver output. A frequency counter having a variable triggering level is also provided to determine the magnitude of the Doppler shift. A calibration method is disclosed wherein the amplifier gain and frequency counter trigger level are adjusted to achieve plateaus in the output of the frequency counter and thereby allow calibration without the necessity of being able to visually observe the flow.
Arita, Makoto; Tono, Sumihiro; Kasegawa, Hitoshi; Umezu, Mitsuo
An in vitro pulsatile simulator with a porcine mitral valve was developed in order to simulate physiologic and diseased mitral valve conditions. Evaluation of these conditions was conducted from a hydrodynamic and annulus behavior point of view. We found it possible to simulate mild "mitral valve prolapse" and to obtain quantitative data related to the condition. The diseased condition produced a 40% greater regurgitant volume than that observed under the normal condition (p < 0.0001). Regarding the leakage volume, the diseased condition exhibited about 2.6 times more leakage than the normal condition. The mitral valve simulator proposed in this study is considered fairly stable with respect to both hemodynamics and the behavior of the annulus, and it is an adequate simulator for modeling various types of normal and diseased mitral valve conditions.
Schantz, Daryl; Benson, Lee; Windram, Jonathan; Wong, Derek; Dragulescu, Andreea; Yoo, Shi-Joon; Mertens, Luc; Friedberg, Mark; Al Nafisi, Bahiyah; Grosse-Wortmann, Lars
The hearts of patients with hypertrophic cardiomyopathy (HCM) show structural abnormalities other than isolated wall thickening. Recently, adult HCM patients have been found to have longer mitral valve leaflets than control subjects. The aim of the current study was to assess whether children and adolescents with HCM have similar measureable differences in mitral valve leaflet dimensions when compared to a healthy control group. Clinical and echocardiographic data from 46 children with myocardial hypertrophy and a phenotype and/or genotype consistent with sarcomeric HCM were reviewed. Cardiac magnetic resonance imaging studies were evaluated. The anterior and posterior mitral valve leaflet lengths and myocardial structure were compared to 20 healthy controls. The anterior mitral valve was longer in the HCM group than in the control group (28.4 ± 4.9 vs. 25.2 ± 3.6 mm in control patients, p = 0.013) as was the posterior mitral valve leaflet (16.3 ± 3.0 vs. 13.1 ± 2.3 mm for controls <0.0001). There was no correlation between the resting left ventricular outflow tract gradient and anterior mitral valve leaflet length, nor was the anterior mitral valve leaflet longer in those with systolic anterior motion of the mitral valve compared to those without (28.9 ± 6.1 vs. 28.1 ± 4.5 mm, p = 0.61). Children and adolescents with HCM have abnormally long mitral valve leaflets when compared with healthy control subjects. These abnormalities do not appear to result in, or be due to, obstruction to left ventricular outflow. The mechanism of this mitral valve elongation is not clear but appears to be independent of hemodynamic disturbances.
Breburda, C. S.; Griffin, B. P.; Pu, M.; Rodriguez, L.; Cosgrove, D. M. 3rd; Thomas, J. D.
OBJECTIVES: We sought to validate direct planimetry of mitral regurgitant orifice area from three-dimensional echocardiographic reconstructions. BACKGROUND: Regurgitant orifice area (ROA) is an important measure of the severity of mitral regurgitation (MR) that up to now has been calculated from hemodynamic data rather than measured directly. We hypothesized that improved spatial resolution of the mitral valve (MV) with three-dimensional (3D) echo might allow accurate planimetry of ROA. METHODS: We reconstructed the MV using 3D echo with 3 degrees rotational acquisitions (TomTec) using a transesophageal (TEE) multiplane probe in 15 patients undergoing MV repair (age 59 +/- 11 years). One observer reconstructed the prolapsing mitral leaflet in a left atrial plane parallel to the ROA and planimetered the two-dimensional (2D) projection of the maximal ROA. A second observer, blinded to the results of the first, calculated maximal ROA using the proximal convergence method defined as maximal flow rate (2pi(r2)va, where r is the radius of a color alias contour with velocity va) divided by regurgitant peak velocity (obtained by continuous wave [CW] Doppler) and corrected as necessary for proximal flow constraint. RESULTS: Maximal ROA was 0.79 +/- 0.39 (mean +/- SD) cm2 by 3D and 0.86 +/- 0.42 cm2 by proximal convergence (p = NS). Maximal ROA by 3D echo (y) was highly correlated with the corresponding flow measurement (x) (y = 0.87x + 0.03, r = 0.95, p < 0.001) with close agreement seen (AROA (y - x) = 0.07 +/- 0.12 cm2). CONCLUSIONS: 3D echo imaging of the MV allows direct visualization and planimetry of the ROA in patients with severe MR with good agreement to flow-based proximal convergence measurements.
Sharif, Dawod; Sharif-Rasslan, Amal; Shahla, Camilia; Rosenschein, Uri
Background Mitral annular systolic displacement from M-mode echocardiography and velocity from tissue Doppler imaging reflect subendocardial longitudinal systolic LV performance and may precede radial abnormalities. The aim of this study is to evaluate the utility of mitral annular systolic displacement (D) and velocity (V) during dobutamine stress echocardiography (DSE) in detecting left ventricular (LV) functional reserve and wall motion abnormality (WMA). Methods and Results Fifty-nine subjects, 15 with resting WMA, underwent DSE and measurement of mitral systolic (D) and (V) before and immediately after DSE. Annular septal (D) was lower in those with WMA than in those without, at rest 10.5 ± 4 cm versus 13.2 ± 2 cm, p = 0.015, and after DSE, 11.7 ± 3.8 cm versus 14 ± 2.25 cm, p = 0.036, but without significant change after stress. Annular systolic (V) at rest with WMA was 9.7 ± 1.8 cm/sec and similar to those without, 11.25 ± 2.7 cm/sec. In both groups the velocity increased after DSE, 14.5 ± 4.5 cm/sec, p = 0.025 with WMA and 17.8 ± 3.2 cm/sec, p = 1.99 x 10-10 in those without WMA. Velocities after DSE were lower in those with WMA, p = 2.25 x 10-6. Conclusions To evaluate LV systolic performance mitral annular systolic longitudinal displacement is valuable at rest, but for assessment of LV functional reserve after stress velocities are better.
Lester, W; Rosenthal, A; Granton, B; Gotlieb, A I
There are connective tissue cells present within the interstitium of the heart valves. This study was designed to isolate and characterize mitral valve interstitial cells from the anterior leaflet of the mitral valve. Explants obtained from the distal part of the leaflet, having been scraped free of surface endocardial cells, were incubated in medium 199 supplemented with 10% fetal bovine serum. Cells grew out of the explant after 3 to 5 days and by 3 weeks these cells were harvested and passaged. Passages 1 to 22 were characterized in several explant sets. The cells showed a growth pattern reminiscent of fibroblasts. Growth was dependent on serum concentration. Cytoskeletal localization of actin and myosin showed prominent stress fibers. Ultrastructural studies showed many elongated cells with prominent stress fibers and some gap junctions and few adherens junctions. There were as well cells with fewer stress fibers containing prominent Golgi complex and dilated endoplasmic reticulum. In the multilayered superconfluent cultures, the former cells tended to be on the substratum of the dish or surface of the multilayered culture, whereas the latter was generally located within the layer of cells. Extracellular matrix was prominent in superconfluent cultures, often within the layers as well. Labeling of the cells with antibody HHF 35 (Tsukada T, Tippens D, Gordon D, Ross R, Gown AM: Am J Pathol 126:51, 1987), which recognizes smooth muscle cell actin, showed prominent staining of the elongated stress fiber-containing cells and much less in the secretory type cells. These studies show that interstitial mitral valve cells can be grown in culture and that either two different cell types or one cell type with two phenotypic expressions is present in culture.
The Doppler lidar (DL) is an active remote sensing instrument that provides range- and time-resolved measurements of radial velocity and attenuated backscatter. The principle of operation is similar to radar in that pulses of energy are transmitted into the atmosphere; the energy scattered back to the transceiver is collected and measured as a time-resolved signal. From the time delay between each outgoing transmitted pulse and the backscattered signal, the distance to the scatterer is inferred. The radial or line-of-sight velocity of the scatterers is determined from the Doppler frequency shift of the backscattered radiation. The DL uses a heterodyne detection technique in which the return signal is mixed with a reference laser beam (i.e., local oscillator) of known frequency. An onboard signal processing computer then determines the Doppler frequency shift from the spectra of the heterodyne signal. The energy content of the Doppler spectra can also be used to determine attenuated backscatter.
Mahue, Veronique; Mari, Jean Martial; Eckersley, Robert J.; Caro, Colin G.; Tang, Meng-Xing
Recent advances have demonstrated the feasibility of molecular imaging using targeted microbubbles and ultrasound. One technical challenge is to selectively detect attached bubbles from those freely flowing bubbles and surrounding tissue. Pulse Inversion Doppler is an imaging technique enabling the selective detection of both static and moving ultrasound contrast agents: linear scatterers generate a single band Doppler spectrum, while non-linear scatterers generate a double band spectrum, one being uniquely correlated with the presence of contrast agents and non-linear tissue signals. We demonstrate that similar spectrums, and thus the same discrimination, can be obtained through a Doppler implementation of Pulse Subtraction. This is achieved by reconstructing a virtual echo using the echo generated from a short pulse transmission. Moreover by subtracting from this virtual echo the one generated from a longer pulse transmission, it is possible to fully suppress the echo from linear scatterers, while for non-linear scatterers, a signal will remain, allowing classical agent detection. Simulations of a single moving microbubble and a moving linear scatterer subject to these pulses show that when the virtual echo and the long pulse echo are used to perform pulsed Doppler, the power Doppler spectrum allows separation of linear and non-linear moving scattering. Similar results are obtained on experimental data acquired on a flow containing either microbubble contrast agents or linear blood mimicking fluid. This new Doppler method constitutes an alternative to Pulse Inversion Doppler and preliminary results suggest that similar dual band spectrums could be obtained by the combination of any non-linear detection technique with Doppler demodulation.
Goldstone, Andrew B.
The treatment of mitral valve disease remains dynamic; surgeons and patients must now choose between many different surgical options when addressing mitral regurgitation and mitral stenosis. Notably, advances in imaging and surgical instrumentation allow surgeons to perform less invasive mitral valve surgery that spares the sternum. With favorable long-term data now emerging, we compare the benefits and risks of thoracoscopic mitral valve surgery with that through conventional sternotomy or surgery that is robot-assisted. PMID:27942489
Watts, E; Nomeir, A M; Barnes, R
Thirty-three patients with mitral valve prostheses were studied with echocardiography in an effort to determine if this technique could be useful in detecting significant abnormalities. Recordings were obtained in the supine position with the transducer directed to record maximum excursion of the prosthesis. Echoes from the struts, poppet and sewing ring were readily recorded. Amplitude of excursion and opening and closing velocities of the poppet were measured. Fifty echocardiographic recordings were obtained from the 33 patients. Of the 33 patients studied, 22 were thought to have "normal" echo tracings while in 11, the tracings were considered "abnormal." Apparent abnormalities consisted of: 1) abnormal diastolic separation between the poppet and strut, 2) increased echoes near the poppet, strut or sewing ring and 3) a combination of both. There was only one instance of suspected "sticking" of the prosthesis. All patients who had "abnormal" studies except one developed complications associated with their prosthesis (90%) compared to only 36% in patients with "normal" tracings. Five patients in each group died. Autopsy studies are described and correlations with the echocardiographic findings are made. In low profile valves reduction in excursion of the disc may be an indication of malfunction. Echocardiography appears to be of value in the assessment of function of mitral valve prostheses.
Expósito, Víctor; García-Camarero, Tamara; Bernal, José M; Arnáiz, Elena; Sarralde, Aurelio; García, Iván; Berrazueta, José R; Revuelta, José M
Prosthetic heart valve dysfunction is an acquired condition that carries a significant risk of emergency surgery. However, the long-term natural history of the condition is not well understood. Between 1974 and 2006, 1535 isolated mitral valve replacements were performed at our hospital (in-hospital mortality 5%). In total, 369 patients needed a second operation (in-hospital mortality 8.1%), while 80 (age 59.8+/-11.4 years) needed a third. The reasons for the third intervention were structural deterioration (67.5%), paravalvular leak (20%) and endocarditis (6.3%). Some 15 patients died in hospital (18.8%). After a mean follow-up period of 17.8 years, 21 patients needed another intervention (i.e., a fourth intervention). The actuarial reoperation-free rate at 20 years was 40.1+/-13.8%. The late mortality rate was 58.5% (18-year survival rate 15.4+/-5.4%). Indications for repeat mitral valve replacement must be judged on an individual basis given the high risk associated with surgery.
Ramlawi, Basel; Gammie, James S.
The mitral valve is a highly complex structure, the competency and function of which relies on the harmonious action of its component parts. Minimally invasive cardiac surgery (MICS) for mitral valve repair or replacement (MVR/r) has been performed successfully with incremental improvements in techniques over the past decade. These minimally invasive procedures, while attractive to patients and referring physicians, should meet the same high bar for optimal clinical outcomes and long-term durability of valve repair as traditional sternotomy procedures. The majority of MICS MVR/r procedures are performed via a right minithoracotomy approach with direct or camera-assisted visualization, with a minority of centers performing robotic MVR/r. Outcomes with MICS MVR/r have been shown to have similar morbidity and mortality rates as traditional sternotomy MV procedures but with the advantage of reduced transfusions, postoperative atrial fibrillation, and time to recovery. More recently, transcatheter mitral valve repair and replacement (TMVR/r) has become a reality. Percutaneous MV repair technology is currently FDA approved for patients with nonsurgical high-risk degenerative mitral regurgitation. Other TMVR/r technology is at various levels of preclinical and clinical investigation, although these devices are proving to be more challenging compared to transcatheter aortic valve replacement (TAVR) due to the significantly more complex mitral anatomy and the greater heterogeneity of mitral disease requiring treatment. In this article, we review current techniques for MICS MVR/r and upcoming catheter-based therapies for the mitral valve. PMID:27127558
Ramlawi, Basel; Gammie, James S
The mitral valve is a highly complex structure, the competency and function of which relies on the harmonious action of its component parts. Minimally invasive cardiac surgery (MICS) for mitral valve repair or replacement (MVR/r) has been performed successfully with incremental improvements in techniques over the past decade. These minimally invasive procedures, while attractive to patients and referring physicians, should meet the same high bar for optimal clinical outcomes and long-term durability of valve repair as traditional sternotomy procedures. The majority of MICS MVR/r procedures are performed via a right minithoracotomy approach with direct or camera-assisted visualization, with a minority of centers performing robotic MVR/r. Outcomes with MICS MVR/r have been shown to have similar morbidity and mortality rates as traditional sternotomy MV procedures but with the advantage of reduced transfusions, postoperative atrial fibrillation, and time to recovery. More recently, transcatheter mitral valve repair and replacement (TMVR/r) has become a reality. Percutaneous MV repair technology is currently FDA approved for patients with nonsurgical high-risk degenerative mitral regurgitation. Other TMVR/r technology is at various levels of preclinical and clinical investigation, although these devices are proving to be more challenging compared to transcatheter aortic valve replacement (TAVR) due to the significantly more complex mitral anatomy and the greater heterogeneity of mitral disease requiring treatment. In this article, we review current techniques for MICS MVR/r and upcoming catheter-based therapies for the mitral valve.
Tri, Terry B.; Gregoratos, Gabriel
Although the Davila-Sierra mitral valve prosthesis was removed from the market nearly a decade ago, a number of patients still have this valve in place. We recently studied the echocardiographic features of a malfunctioning Davila-Sierra mitral valve prosthesis. Abnormalities that suggested improper functioning of the prosthesis included a markedly delayed poppet opening and an early diastolic hump believed to represent motion of the mitral annulus. Previously described echocardiographic indications of dys-function were not observed in our patient. We report the first known echocardiographic evaluation of a Davila-Sierra prosthesis.
Tri, Terry B.; Gregoratos, Gabriel
Although the Davila-Sierra mitral valve prosthesis was removed from the market nearly a decade ago, a number of patients still have this valve in place. We recently studied the echocardiographic features of a malfunctioning Davila-Sierra mitral valve prosthesis. Abnormalities that suggested improper functioning of the prosthesis included a markedly delayed poppet opening and an early diastolic hump believed to represent motion of the mitral annulus. Previously described echocardiographic indications of dys-function were not observed in our patient. We report the first known echocardiographic evaluation of a Davila-Sierra prosthesis. Images PMID:15216230
Masutani, Satoshi; Taketazu, Mio; Mihara, Chihiro; Mimura, Yuko; Ishido, Hirotaka; Matsunaga, Tamotsu; Kobayashi, Toshiki; Senzaki, Hideaki
Device closure of atrial septal defect (ASD) is sometimes followed by elevation of plasma brain natriuretic peptide (BNP), a marker of heart failure, and progression to heart failure. This study tested the hypothesis that the underlying diastolic dysfunction, assessed on tissue Doppler images (TDI) before device closure, can predict BNP level after ASD closure. The study subjects were 39 consecutive patients (age 27.5 +/- 16.3 years, range 5 to 63) who underwent device closure for ASD. Echocardiographic evaluation using TDI and 2-dimensional and pulse wave Doppler were performed, together with plasma BNP measurement 1 day before and 2 days after ASD closure. Before ASD closure, an age-dependent decrease was noted in left ventricular relaxation, assessed by early diastolic mitral annular velocity. ASD closure resulted in a decrease in early diastolic mitral annular velocity (from 14.7 to 12.3 cm/s, p <0.05) despite an increase in the left ventricular dimension (84% to 92% vs normal, p <0.05). These changes were associated with a parallel increase in BNP (17.9 to 48.4 pg/ml, p <0.05). Stepwise multivariate linear regression identified early diastolic mitral annular velocity before ASD closure and age as independent predictors of BNP levels after ASD closure (p <0.05). Consistent with this result, 2 patients with the lowest early diastolic mitral annular velocity developed exertional dyspnea after the procedure. In conclusion, our results indicate that TDI measurements could be useful to detect underlying diastolic dysfunction that can potentially cause heart failure after ASD closure and emphasize the importance of ASD closure at a young age before impairment of left ventricular relaxation.
Tomino, Mikiko; Miyata, Kazuto; Takeshita, Yuji; Kaneko, Koki; Kanazawa, Hiroko; Uchino, Hiroyuki
A 54-year-old woman was admitted for mitral valvular repair. After folding plasty to A3, a 30 mm Cosgrove-Edwards ring was placed. There was no mitral regurgitation jet observed by transesophageal echocardiography (TEE) during the operation. However, high blood pressure was monitored and treated in the intensive care unit, hemolytic anemia developed, and the serum lactate dehydrogenase level was elevated. Two weeks after the operation, serum lactate dehydrogenase was again elevated. TEE showed mild mitral regurgitation and the regurgitation jet colliding with the annuloplasty ring. Multiple transfusions of red blood cells were required. Repeat surgery was therefore undertaken. Lam and associates previously studying patients on hemolysis after mitral valvular repair noted high grade mitral regurgitation jets fragmented or accelerated. In the present case, mitral regurgitation was mild, but the high velocity and manner of regurgitation (collision with the annuloplasty ring) could cause hemolytic anemia. In the present case, high blood pressure might have caused chordae rupture. Furthermore, a flexible ring, such as the Cosgrove-Edwards ring, is likely to cause hemolytic anemia. As contributing factors to hemolysis after mitral valvular repair, perioperative blood pressure management and type of ring are significant.
Li, Yuechun; Lin, Jiafeng; Peng, Chen
Abstract Rationale: Data on nonvitamin K antagonist oral anticoagulant being used for the treatment of LAA thrombi are limited only in nonvalvular atrial fibrillation. There are no data on the antithrombotic efficacy and safety of nonvitamin K antagonist oral anticoagulant in the resolution of left atrial appendage (LAA) thrombi in patients with rheumatic mitral stenosis. Patient concerns: A 49-year-old woman with known rheumatic mitral stenosis and atrial fibrillation was referred for percutaneous transvenous mitral commissurotomy because of progressive dyspnea on exertion over a period of 3 months. Diagnoses: Transesophageal echocardiography (TEE) demonstrated a large LAA thrombus protruding into left atria cavity before the procedure. Interventions: Direct factor Xa (FXa) inhibitor rivaroxaban (20 mg/d) was started for the patient. After 3 weeks of rivaroxaban treatment TEE showed a relevantly decreased thrombus size, and a complete thrombus resolution was achieved after 5 weeks of anticoagulant therapy with the FXa inhibitor. Outcomes: To the best of our knowledge, this is the first documented case of large LAA thrombus resolution with nonvitamin K antagonist oral anticoagulant in severe mitral stenosis, and in which percutaneous transvenous mitral commissurotomy was performed subsequently. Lessons: The report indicated that rivaroxaban could be a therapeutic option for mitral stenosis patients with LAA thrombus. Further study is required before the routine use of rivaroxaban in patients with rheumatic mitral stenosis and atrial fibrillation. PMID:27930571
Joshi, Hasit Sureshbhai; Deshmukh, Jagjeet Kishanrao; Prajapati, Jayesh Somabhai; Sahoo, Sibasis Shahsikant; Vyas, Pooja Maheshbhai
Introduction In pregnant women mitral stenosis is the commonest cardiac valvular lesion. When it is present in majorly severe condition it leads to maternal and fetal morbidity and mortality. In mitral stenosis pregnancy can lead to development of heart failure. Aim To evaluate the safety and efficacy of balloon mitral valvulotomy (BMV) in pregnant females with severe mitral stenosis. Materials and Methods A total of 30 pregnant patients who underwent BMV were included in the study from July 2011 to November 2013. Clinical follow-up during pregnancy was done every 3 months until delivery and after delivery. The mean follow up time after BMV was 6.72±0.56 months. Results From the 30 pregnant females 14 (46.67%) and 16 (53.3%) patients underwent BMV during the third and second trimester of pregnancy respectively. The mean mitral valve area was 0.85+0.16 cm2 before BMV that increased to 1.60+0.27 cm2 (p<0.0001) immediately after BMV. Peak and mean diastolic gradients had decreased significantly within 48 hours after the procedure (p<0.001) but remained very much unchanged at 6.72 month period of follow-up. Two patients had an increase in mitral regurgitation by 2 grades. Conclusion During pregnancy BMV technique is safe and effective in patients with severe mitral stenosis. This results in marked symptomatic relief along with long term maternal and fetal outcomes. PMID:26816932
Yeo, Khung Keong; Ding, Zee Pin; Chua, Yeow Leng; Lim, Soo Teik; Sin, Kenny Yoong Kong; Tan, Jack Wei Chieh; Chiam, Paul Toon Lim; Hwang, Nian Chih; Koh, Tian Hai
A 67-year-old Chinese woman with comorbidities of chronic obstructive lung disease, hypertension and prior coronary artery bypass surgery presented with severe functional mitral regurgitation (MR) and severely depressed left ventricular function. She was in New York Heart Association (NYHA) Class II-III. Due to high surgical risk, she was referred for percutaneous treatment with the MitraClip valve repair system. This procedure is typically performed via the femoral venous system and involves a transseptal puncture. A clip is delivered to grasp the regurgitant mitral valve leaflets and reduce MR. This was performed uneventfully in our patient, with reduction of MR from 4+ to 1+. She was discharged on post-procedure Day 2 and her NYHA class improved to Class I. This was the first successful MitraClip procedure performed in Asia and represents a valuable treatment option in patients with severe MR, especially those with functional MR or those at high surgical risk.
Matsubara, T; Yamazoe, M; Tamura, Y; Tanabe, Y; Hori, T; Konno, T; Higuchi, K; Ida, T; Takemoto, M; Aizawa, Y
Progression to moderate or severe mitral regurgitation (MR) was studied after Inoue balloon percutaneous transvenous mitral commissurotomy (PTMC) using the stepwise inflation technique, performed at increments of 1 mm of balloon diameter, in 49 consecutive patients with rheumatic mitral stenosis (aged from 32-73 years; 8 males, 41 females). The patients were classified on the basis of the degree of MR after PTMC, compared with that before PTMC, into either Group A, development of moderate or more severe (> or = grade 2) MR (n = 8) or Group B, no increase in MR or development of mild (grade 1) MR (n = 41). Progression to moderate or severe MR was significantly associated only with advanced age (60 +/- 8 vs 52 +/- 10 years, p < 0.05) and narrower mitral valve area (0.87 +/- 0.35 vs 1.11 +/- 0.29 cm2, p < 0.05), but other characteristics before PTMC were similar in both groups. There was no difference between the two groups in the total number and degree of balloon inflation. Immediately before the final inflation, the left atrial mean pressure and v wave pressure were decreased in smaller degrees in Group A compared with Group B (-2 +/- 2 vs -5 +/- 4 mmHg, p < 0.05; -2 +/- 2 vs -6 +/- 6 mmHg, p < 0.05, respectively). Thus, the stepwise inflations require careful monitoring of changes in the left atrial pressure and waveform to recognize the aggravation of MR, especially in older patients with severe stenosis. Patients who do not have a significant drop in left atrial mean pressure and v wave pressure during stepwise inflations of the balloon might be at risk of development of moderate or severe MR after further dilations.
Aquila, Iolanda; Fernández-Golfín, Covadonga; Rincon, Luis Miguel; González, Ariana; García Martín, Ana; Hinojar, Rocio; Jimenez Nacher, Jose Julio; Indolfi, Ciro; Zamorano, Jose Luis
Abstract Three-dimensional (3D) transesophageal echocardiography (TEE) is the gold standard for mitral valve (MV) anatomic and functional evaluation. Currently, dedicated MV analysis software has limitations for its use in clinical practice. Thus, we tested here a complete and reproducible evaluation of a new fully automatic software to characterize MV anatomy in different forms of mitral regurgitation (MR) by 3D TEE. Sixty patients were included: 45 with more than moderate MR (28 organic MR [OMR] and 17 functional MR [FMR]) and 15 controls. All patients underwent TEE. 3D MV images obtained using 3D zoom were imported into the new software for automatic analysis. Different MV parameters were obtained and compared. Anatomic and dynamic differences between FMR and OMR were detected. A significant increase in systolic (859.75 vs 801.83 vs 607.78 mm2; P = 0.002) and diastolic (1040.60 vs. 1217.83 and 859.74 mm2; P < 0.001) annular sizes was observed in both OMR and FMR compared to that in controls. FMR had a reduced mitral annular contraction compared to degenerative cases of OMR and to controls (17.14% vs 32.78% and 29.89%; P = 0.007). Good reproducibility was demonstrated along with a short analysis time (mean 4.30 minutes). Annular characteristics and dynamics are abnormal in both FMR and OMR. Full 3D software analysis automatically calculates several significant parameters that provide a correct and complete assessment of anatomy and dynamic mitral annulus geometry and displacement in the 3D space. This analysis allows a better characterization of MR pathophysiology and could be useful in designing new devices for MR repair or replacement. PMID:27930514
Shukla, Anand N; Shah, Saurin; Nayak, Vidya; Prabhu, Sridevi; Pai, Umesh
Introduction Atrial Fibrillation (AF) is largely present in patients with rheumatic valvular disease, leading to hospitalizations. Aim We aimed to study the restoration and maintenance of Sinus Rhythm (SR) in rheumatic patients with Mitral Stenosis (MS) and AF after Balloon Mitral Valvotomy (BMV) and evaluated the factors which affect the maintenance of SR. Materials and Methods A total of 50 patients who underwent BMV at U. N. Mehta Institute of Cardiology and Research Centre from 2010 November to 2013 January were included in the study. Subsequently, all patients were treated with amiodarone and electrical cardioversion was applied in patients in whom it was necessary. The patients were followed for six months for conversion and maintenance of SR. Results Total 34 (68%) patients reverted to SR. Twelve patients reverted to SR with amiodarone and 22 patients with electrical cardioversion and amiodarone. Out of the total, 29 patients and 26 patients remained in SR at the end of follow up at 3 months and 6 months respectively. Conclusion Smaller Left Atrial (LA) size and greater Mitral Valve Area (MVA) are the chief predictors of restoration and maintenance of SR. Combining BMV with an aggressive anti-arrhythmic strategy offers the best prospect of rhythm control. PMID:28384905
The Doppler spectrometer is a conventional Czerny-Turner grating spectrometer with a 1024 channel multiple detector. Light is dispersed across the detector, and its output yields a spectrum covering approximately 200 A. The width of the spectral peak is directly proportional to the temperature of the emitting ions, and determination of the impurity ion temperature allows one to infer the plasma ion temperature. The Doppler ion software system developed at General Atomic uses a TRACOR Northern 1710-31 and an LSI-11/2. The exact configuration of Doublet III is different from TRACOR Northern systems at other facilities.
Badhwar, Vinay; Smith, Anson J C; Cavalcante, João L
Mitral regurgitation remains the most common global valvular heart disease. From otherwise unsuspecting healthy patients without overt symptoms to those with recalcitrant heart failure, mitral valve (MV) disease touches millions of patients per year. While MV prolapse without regurgitation remains benign, once regurgitation begins, quantification of severity is related to prognosis. Understanding the mechanism of regurgitation guides appropriate treatment. Current management guidelines emphasize early therapy after careful assessment of both anatomy and severity of mitral regurgitation. The objective of this review is to provide an update on the treatment of MV disease and to offer additional granularity on pathoanatomic decision making that may aid a more precise application of optimal guideline-directed therapy of primary and secondary mitral regurgitation.
Jönsson, Anders; Settergren, Magnus
The ongoing evolution of transcatheter valve technology is impressive. Mitral valve regurgitation is the most common type of heart valve insufficiency and mitral valve surgery is, next to aortic valve surgery, the second leading valvular surgical procedure in the western world. However, there is a large patient population suffering from mitral valve regurgitation that is currently not treated with heart surgery because of significant morbidity and mortality risks. This large underserved patient population could benefit from a less invasive treatment. The MitraClip system (Abbott Vascular, Menlo Park, CA, USA) is the first commercially available medical technology providing a catheter-based nonsurgical repair alternative for patients suffering from mitral valve regurgitation and has the greatest clinical experience compared with other alternative devices. The device is currently in late-stage clinical trials in the USA and has received the CE mark.
Suri, Rakesh; Mick, Stephanie; Mihaljevic, Tomislav
Use of the surgical robot facilitates less invasive mitral valve surgery. Although multiple single center studies confirmed excellent results with robotically-assisted mitral valve surgery, both real and perceived limitations have slowed adoption of this technology. Some still question the safety and efficacy of robotically-assisted mitral valve surgery. However, present data suggests that robotic operations can be performed by specialized surgeons in appropriately selected patients without compromising results. That said, the robot does introduce additional procedural complexity related to management of cardiopulmonary bypass and myocardial protection. A direct approach to these challenges combined with careful patient selection enables the surgeon to obtain excellent results with robotically-assisted mitral valve surgery. PMID:27942490
Udoji, Timothy N; Force, Seth D; Pelaez, Andres
Abstract A 33-year-old female patient with advanced idiopathic pulmonary artery hypertension underwent bilateral lung transplantation. The postsurgical course was complicated by prolonged mechanical ventilation and acute hypoxemia with recurrent episodes of pulmonary edema. An echocardiogram revealed improved right-sided pressures along with a dilated left atrium, a structurally normal mitral valve, and a new posterior-oriented severe mitral regurgitation. The patient's condition improved after treatment with arterial vasodilators and diuretics, and she has remained in World Health Organization functional class I after almost 36 months of follow-up. We hypothesize that cardiac ventricle remodeling and a geometric change in mitral valve apparatus after transplantation led to the hemodynamic changes and recurrent pulmonary edema seen in our patient. Our case is, to our knowledge, the second report of severe valvular regurgitation in a structurally normal mitral valve apparatus in the postoperative period and the first of a patient to be treated without valve replacement.
Lukács, L; Kassai, I; Lengyel, M
We describe an unusual sequela of mitral valve replacement in a 50-year-old woman who had undergone a closed mitral commissurotomy in 1975. She was admitted to our hospital because of mitral restenosis in November 1993, at which time her mitral valve was replaced with a mechanical prosthesis. On the 8th postoperative day, the patient developed symptoms of heart failure; transesophageal echocardiography revealed dissection and rupture of the left atrial wall. At prompt reoperation, we found an interlayer dissection and rupture of the atrial wall into the left atrium. We repaired the ruptured atrial wall with a prosthetic patch. The postoperative course was uneventful, and postoperative transesophageal echocardiography showed normal prosthetic valve function and no dissection. Images PMID:8680278
Das, Mrinalendu; Mahindrakar, Pallavi; Das, Debasis; Behera, Sukanta Kumar; Chowdhury, Saibal Roy; Bandyopadhyay, Biswajit
The usual presentation of anomalous left coronary artery from pulmonary artery is severe left-sided heart failure and mitral valve insufficiency presenting during the first months of life. The manifestations of left heart failure may be masked if pulmonary artery pressure remains high. We believe this is a rarest of rare case of anomalous left coronary artery from pulmonary artery with severe mitral stenosis and pulmonary hypertension in which pulmonary hypertension, along with good collateral circulation helped to preserve left ventricular function.
Carrilho-Ferreira, Pedro; Pedro, Monica Mendes; Varela, Manuel Gato; Diogo, Antonio Nunes
Although the prevalence of rheumatic fever has greatly decreased in developed countries, rheumatic mitral stenosis still causes significant morbidity and mortality. Symptomatic patients have a poor prognosis, with a 0 to 15% 10-year survival rate, particularly if percutaneous or surgical intervention are contraindicated or considered high risk. We present a case of severe rheumatic mitral stenosis with an evolution over 4 decades, in which exceptional venous distention has established.
Reade, Clifton C; Bower, Curtis E; Kypson, Alan P; Nifong, L Wiley; Wooden, William A; Chitwood, W Randolph
Historically, contraindications to minimally invasive or robotic mitral valve surgery have included prior mastectomy, thoracic reconstruction, or chest radiation. However, we believe that by granting flexibility in the choice of skin incision site while performing careful dissection, surgeons can provide these patients the outstanding results afforded by a minithoracotomy. We present a patient who had undergone a prior mastectomy and radiation treatment in whom we performed a minimally invasive mitral valve repair through a right-sided minithoracotomy using the previous mastectomy incision.
Lambrechts, David L.; Wellens, Francis; Vercoutere, Rik A.; De Geest, Raf
We report a case of life-threatening aortic transection with concomitant mitral papillary muscle rupture and severe lung contusion caused by a failed parachute jump. This blunt thoracic injury was treated by early stabilization with extracorporeal membrane oxygenation followed by successful delayed graft repair of the descending aorta and mitral valve replacement with a mechanical prosthesis. (Tex Heart Inst J 2003;30:65–7) PMID:12638675
Robotic mitral valve repair began in 1998 and has advanced remarkably. It arose from an interest in reducing patient trauma by operating through smaller incisions with videoscopic assistance. In the United States, following two clinical trials, the FDA approved the daVinci Surgical System in 2002 for intra-cardiac surgery. This device has undergone three iterations, eventuating in the current daVinci XI. At present it is the only robotic device approved for mitral valve surgery. Many larger centers have adopted its use as part of their routine mitral valve repair armamentarium. Although these operations have longer perfusion and arrest times, complications have been either similar or less than other traditional methods. Preoperative screening is paramount and leads to optimal patient selection and outcomes. There are clear contraindications, both relative and absolute, that must be considered. Three-dimensional (3D) echocardiographic studies optimally guide surgeons in operative planning. Herein, we describe the selection criteria as well as our operative management during a robotic mitral valve repair. Major complications are detailed with tips to avoid their occurrence. Operative outcomes from the author’s series as well as those from the largest experiences in the United States are described. They show that robotic mitral valve repair is safe and effective, as well as economically reasonable due to lower costs of hospitalization. Thus, the future of this operative technique is bright for centers adopting the “heart team” approach, adequate clinical volume and a dedicated and experienced mitral repair surgeon. PMID:27942486
This doppler lidar system provides co-polar and cross polar attenuated backscatter coefficients,signal strength, and doppler velocities in the cloud and in the boundary level, including uncertainties for all parameters. Using the doppler beam swinging DBS technique, and Vertical Azimuthal Display (VAD) this system also provides vertical profiles of horizontal winds.
Lee, C. K.; Wong, H. K.
An experiment to verify the Doppler effect of sound waves is described. An ultrasonic source is mounted at the end of a simple pendulum. As the pendulum swings, the rapid change of frequency can be recorded by a stationary receiver using a simple frequency-to-voltage converter. The experimental results are in close agreement with the Doppler…
Arnold, J. E.
The data collection phase of a Doppler wind measurement experiment supported by high-resolution Jimsphere/FPS-16 wind data and Windsonde data was carried out at the Kennedy Space Center in February, March and early April of 1985. The Doppler wind measurements were made using a hybrid doppler profiler put in place by the Johnson Space Center and a SOUSY profiler operated by Radian Corporation. Both systems operated at 50 Mhz. Although the doppler profiler systems were located 10 km apart to enable concurrent operation of the systems for data comparison, little concurrent data were obtained due to set-up delays with the SOUSY system, and system problems with the WPL system during the last month of the test. During the test period, special serial Jimsphere soundings were taken at two-hour intervals on six days in March and April in addition to balloon soundings taken in support of the Shuttle launch operations. In addition, there is temperature, moisture and wind information available from the daily morning Radiosonde sounding taken at the Kennedy site. The balloon release point was at the same location as the SOUSY profiler. Vertical resolution of the SOUSY profiler was 150 M to approximately 20 km. The vertical resolution of the WPL profiler was 290 M to 10 km and 870 M to 17 km. Winds determined form the Jimsphere balloon have a vertical resolution of 30 M.
Komoda, Takeshi; Huebler, Michael; Berger, Felix; Hetzer, Roland
When mitral annuloplasty is performed in small children, room for annular growth should be allowed. However, it has not been reported how the valve develops after mitral annuloplasty of the entire posterior annulus. We report a case showing traces of annular growth at redo surgery. A female patient suffering from mitral valve insufficiency due to annular dilatation underwent modified Paneth plasty with Kay-Wooler commissural plication annuloplasty at the age of two years one month. In redo surgery 8.4 years after initial repair, enlargement of the commissural portion of the posterior annulus in addition to enlargement of the anterior leaflet and anterior annulus was observed. Modified Paneth plasty reinforced with a pericardial strip and Kay-Wooler annuloplasty of the posteromedial commissure were performed. Mitral orifice size measured with the Hegar dilator was 18 mm after the re-repair, increasing from 16 mm after the initial repair. Taking into account the normal mitral annulus diameter related to body surface area (BSA) of 16 mm at initial operation and 20 mm at redo surgery, the increase in mitral orifice size from 16 mm to 18 mm in this patient may be regarded as the annular growth in 8.4 years.
Rinkevichius, Bronius S.
The current state of the optical metrology based on the Doppler effect has been reviewed. Some historical and scientific information is given, in addition the contemporary optical methods of the velocity measurement using the Doppler effect are analyzed. The Doppler effect applications in astrophysics, plasma physics, investigations of gas and liquid flows, acoustics, mechanics of the deforming solid body and of the rotational motion are considered. The description is presented for the following techniques of the velocity measurement: laser Doppler anemometry, laser Doppler vibrometry, laser gyroscopy.
Kovalova, Sylva; Necas, Josef
Aim To assess the changes of mitral valve (MV) in ischemic mitral regurgitation (IMR) using Mitral Valve Quantification (MVQ) program. Methods We examined 46 patients (18 women) with IMR aged 45-86 and a control group of 33 healthy individuals (14 women) aged 18-88. Following parameters were assessed: Area of minimal surface spanning annulus (A3), annulus height (h), tenting height (Th), exposed area of anterior (AL), posterior (PL) and both leaflets (BL), ejection fraction of the left ventricle (LV EF), regurgitation volume (RV) and BL/A3, AL/A3, PL/A3 ratios. The normal range of BL/A3 ratio was defined as the average ± 2SD of control group. The study group was separated into subgroup 1 with BL/A3 ratio within normal values and subgroup 2 with pathological BL/A3 ratio. Corresponding parameters of IMR group were compared to the controls and both subgroups were compared to each other using Student t-test. Results In IMR group, as compared to the controls, A3, AL, PL, BL as well as BL/A3, AL/A3, PL/A3 ratios and Th were significantly increased, conversely, h and LV EF was significantly decreased. In the subgroup 2 as compared to the subgroup 1 there was significant increase of Th, BL, AL and PL, while EF LV was significantly decreased. There was no significant difference between these subgroups in A3, h and RV. Conclusion In ischemic MV remodeling two stages were identified without relation to the severity of IMR. The first stage was mainly influenced by the LV dilatation while LV remodeling was more important in the second stage.
Durst, Ronen; Sauls, Kimberly; Peal, David S; deVlaming, Annemarieke; Toomer, Katelynn; Leyne, Maire; Salani, Monica; Talkowski, Michael E; Brand, Harrison; Perrocheau, Maëlle; Simpson, Charles; Jett, Christopher; Stone, Matthew R; Charles, Florie; Chiang, Colby; Lynch, Stacey N; Bouatia-Naji, Nabila; Delling, Francesca N; Freed, Lisa A; Tribouilloy, Christophe; Le Tourneau, Thierry; LeMarec, Hervé; Fernandez-Friera, Leticia; Solis, Jorge; Trujillano, Daniel; Ossowski, Stephan; Estivill, Xavier; Dina, Christian; Bruneval, Patrick; Chester, Adrian; Schott, Jean-Jacques; Irvine, Kenneth D; Mao, Yaopan; Wessels, Andy; Motiwala, Tahirali; Puceat, Michel; Tsukasaki, Yoshikazu; Menick, Donald R; Kasiganesan, Harinath; Nie, Xingju; Broome, Ann-Marie; Williams, Katherine; Johnson, Amanda; Markwald, Roger R; Jeunemaitre, Xavier; Hagege, Albert; Levine, Robert A; Milan, David J; Norris, Russell A; Slaugenhaupt, Susan A
Mitral valve prolapse (MVP) is a common cardiac valve disease that affects nearly 1 in 40 individuals. It can manifest as mitral regurgitation and is the leading indication for mitral valve surgery. Despite a clear heritable component, the genetic aetiology leading to non-syndromic MVP has remained elusive. Four affected individuals from a large multigenerational family segregating non-syndromic MVP underwent capture sequencing of the linked interval on chromosome 11. We report a missense mutation in the DCHS1 gene, the human homologue of the Drosophila cell polarity gene dachsous (ds), that segregates with MVP in the family. Morpholino knockdown of the zebrafish homologue dachsous1b resulted in a cardiac atrioventricular canal defect that could be rescued by wild-type human DCHS1, but not by DCHS1 messenger RNA with the familial mutation. Further genetic studies identified two additional families in which a second deleterious DCHS1 mutation segregates with MVP. Both DCHS1 mutations reduce protein stability as demonstrated in zebrafish, cultured cells and, notably, in mitral valve interstitial cells (MVICs) obtained during mitral valve repair surgery of a proband. Dchs1(+/-) mice had prolapse of thickened mitral leaflets, which could be traced back to developmental errors in valve morphogenesis. DCHS1 deficiency in MVP patient MVICs, as well as in Dchs1(+/-) mouse MVICs, result in altered migration and cellular patterning, supporting these processes as aetiological underpinnings for the disease. Understanding the role of DCHS1 in mitral valve development and MVP pathogenesis holds potential for therapeutic insights for this very common disease.
St John Sutton, M G; Traill, T A; Ghafour, A S; Brown, D J; Gibson, D G
In order to investigate the functional effects of mitral valve surgery, echocardiograms showing left ventricular dimension were recorded and digitised in 14 normal subjects and 129 patients after mitral valve surgery. Measurements were made of peak rate of increase of dimension (dD/dt) and duration of rapid filling, studies on left ventriculograms in 36 patients having shown close correlation between these values and changes in cavity volume. In 14 patients with mitral stenosis, peak dD/dt was reduced to 7-2 +/ 1-5 cm/s, and filling period prolonged to 330 +/- 65 ms, compared with normal (16-0 +/- 3-2 cm/s, and 160 +/- 50 ms, respectively), and after mitral valvotomy, these values improved significantly (10-4 +/- 2-7 cm/s and 245 +/- 55 ms). Characteristic abnormalities were found in 67 patients with mitral prostheses. Values for the Björk-Shiley (10-5 +/- 4-2 cm/s and 180 +/- 80 ms) and Hancock (10-3 +/- 3-7 cm/s, 245 +/- 80 ms) values were similar, and both superior to the Starr-Edwards (7-4 +/- 3-0 cm/s, 295 +/- 105 ms). Results after mitral valve repair in 30 cases were not significantly different from normal (14-4 +/- 5-0 cm/s, 170 +/- 50 ms). Values outside the 95 per cent confidence limits for the valve in question allowed diagnosis of value malfunction in 18 cases. The method is value in comparing different operative procedures and in following up patients after mitral valve surgery. PMID:603728
Durst, Ronen; Sauls, Kimberly; Peal, David S; deVlaming, Annemarieke; Toomer, Katelynn; Leyne, Maire; Salani, Monica; Talkowski, Michael E.; Brand, Harrison; Perrocheau, Maëlle; Simpson, Charles; Jett, Christopher; Stone, Matthew R.; Charles, Florie; Chiang, Colby; Lynch, Stacey N.; Bouatia-Naji, Nabila; Delling, Francesca N.; Freed, Lisa A.; Tribouilloy, Christophe; Le Tourneau, Thierry; LeMarec, Hervé; Fernandez-Friera, Leticia; Solis, Jorge; Trujillano, Daniel; Ossowski, Stephan; Estivill, Xavier; Dina, Christian; Bruneval, Patrick; Chester, Adrian; Schott, Jean-Jacques; Irvine, Kenneth D.; Mao, Yaopan; Wessels, Andy; Motiwala, Tahirali; Puceat, Michel; Tsukasaki, Yoshikazu; Menick, Donald R.; Kasiganesan, Harinath; Nie, Xingju; Broome, Ann-Marie; Williams, Katherine; Johnson, Amanda; Markwald, Roger R.; Jeunemaitre, Xavier; Hagege, Albert; Levine, Robert A.; Milan, David J.; Norris, Russell A.; Slaugenhaupt, Susan A.
SUMMARY Mitral valve prolapse (MVP) is a common cardiac valve disease that affects nearly 1 in 40 individuals1–3. It can manifest as mitral regurgitation and is the leading indication for mitral valve surgery4,5. Despite a clear heritable component, the genetic etiology leading to non-syndromic MVP has remained elusive. Four affected individuals from a large multigenerational family segregating non-syndromic MVP underwent capture sequencing of the linked interval on chromosome 11. We report a missense mutation in the DCHS1 gene, the human homologue of the Drosophila cell polarity gene dachsous (ds) that segregates with MVP in the family. Morpholino knockdown of the zebrafish homolog dachsous1b resulted in a cardiac atrioventricular canal defect that could be rescued by wild-type human DCHS1, but not by DCHS1 mRNA with the familial mutation. Further genetic studies identified two additional families in which a second deleterious DCHS1 mutation segregates with MVP. Both DCHS1 mutations reduce protein stability as demonstrated in zebrafish, cultured cells, and, notably, in mitral valve interstitial cells (MVICs) obtained during mitral valve repair surgery of a proband. Dchs1+/− mice had prolapse of thickened mitral leaflets, which could be traced back to developmental errors in valve morphogenesis. DCHS1 deficiency in MVP patient MVICs as well as in Dchs1+/− mouse MVICs result in altered migration and cellular patterning, supporting these processes as etiological underpinnings for the disease. Understanding the role of DCHS1 in mitral valve development and MVP pathogenesis holds potential for therapeutic insights for this very common disease. PMID:26258302
Rużyłło, Witold; Chmielak, Zbigniew; Opalińska-Ciszek, Ewa; Janas, Jadwiga; Hoffman, Piotr; Hryniewiecki, Tomasz; Grzybowski, Jacek
Introduction Atrial (ANP) and B-type (BNP) natriuretic peptides are hormones secreted by the heart as a response to volume expansion and pressure overload. Aim To assess the changes of ANP and BNP after percutaneous balloon mitral valvuloplasty (PBMV) and to investigate factors associated with endpoints. Material and methods The study included 96 patients (90.7% females, age 51.6 ±12.2 years) with rheumatic mitral valve stenosis (mitral valve area (MVA) 1.18 (1.01–1.33) cm2, mean mitral gradient (MMG) 8.2 (7.1–9.2) mm Hg, NYHA 2.09 (1.9–2.5)). Patients were followed up for 29.1 months for the search of endpoints. Results The PBMV was successful in all cases. After the procedure MVA increased (1.18–1.78 cm2, p < 0.01) and pulmonary capillary wedge pressure (PCWP) decreased (29.8–21.8 mm Hg, p < 0.01). Concentration of ANP significantly rose 30 min after the PBMV (79.2 vs. 134.2 pg/ml, p = 0.012) and dropped significantly after 24 h (134.2 vs. 70.4 pg/ml, p = 0.01). Furthermore, after 36 months concentration of ANP did not differ from the baseline value (p = NS). BNP concentration at day 1 was lower than at baseline (94.5 vs. 80.2 pg/ml, p = 0.032). Moreover, during the follow-up period BNP continued to fall at all time points. In univariate analysis parameters associated with endpoint occurrence were baseline PAP (p = 0.023), baseline PCWP (p = 0.022), baseline NYHA (p = 0.041) and increase in 6-minute walk test (6MWT) (p = 0.043). In multivariate analysis the only factor associated with endpoint occurrence was baseline NYHA (HR = 1.52, 95% CI: –1.3–1.91, p = 0.022). Conclusions Patients with MS had increased levels of both BNP and ANP. Baseline NYHA class was found to be associated with outcomes after the procedure. PMID:28344613
Le Goffic, Caroline; Toledano, Manuel; Ennezat, Pierre-Vladimir; Binda, Camille; Castel, Anne-Laure; Delelis, François; Graux, Pierre; Tribouilloy, Christophe; Maréchaux, Sylvestre
The present prospective study was designed to evaluate the accuracy of quantitative assessment of mitral regurgitant fraction (MRF) by echocardiography and cardiac magnetic resonance imaging (cMRI) in the modern era using as reference method the blinded multiparametric integrative assessment of mitral regurgitation (MR) severity. 2-Dimensional (2D) and 3-dimensional (3D) MRF by echocardiography (2D echo MRF and 3D echo MRF) were obtained by measuring the difference in left ventricular (LV) total stroke volume (obtained from either 2D or 3D acquisition) and aortic forward stroke volume normalized to LV total stroke volume. MRF was calculated by cMRI using either (1) (LV stroke volume - systolic aortic outflow volume by phase contrast)/LV stroke volume (cMRI MRF [volumetric]) or (2) (mitral inflow volume - systolic aortic outflow volume)/mitral inflow volume (cMRI MRF [phase contrast]). Six patients had 1 + MR, 6 patients had 2 + MR, 12 patients had 3 + MR, and 10 had 4 + MR. A significant correlation was observed between MR grading and 2D echo MRF (r = 0.60, p <0.0001) and 3D echo MRF (r = 0.79, p <0.0001), cMRI MRF (volumetric) (r = 0.87, p <0.0001), and cMRI MRF (phase contrast r = 0.72, p <0.001). The accuracy of MRF for the diagnosis of MR ≥3+ or 4+ was the highest with cMRI MRF (volumetric) (area under the receiver-operating characteristic curve [AUC] = 0.98), followed by 3D echo MRF (AUC = 0.96), 2D echo MRF (AUC = 0.90), and cMRI MRF (phase contrast; AUC = 0.83). In conclusion, MRF by cMRI (volumetric method) and 3D echo MRF had the highest diagnostic value to detect significant MR, whereas the diagnostic value of 2D echo MRF and cMRI MRF (phase contrast) was lower. Hence, the present study suggests that both cMRI (volumetric method) and 3D echo represent best approaches for calculating MRF.
Dworakowski, R; Kogoj, P; Reiken, J; Kenny, C; MacCarthy, P; Wendler, O; Monaghan, M J
Objective To assess the impact of mitral geometry, left ventricular (LV) remodelling and global LV afterload on mitral regurgitation (MR) after trans-catheter aortic valve implantation (TAVI). Methods In this study, 60 patients who underwent TAVI were evaluated by 3D echocardiography at baseline, 1 month and 6 months after procedure. The proportional change in MR following TAVI was determined by examining the percentage change in vena contracta (VC) at 6 months. Patients having a significant reduction of at least 30% in VC were defined as good responders (GR) and the remaining patients were defined as poor responders (PR). Results After 6 months of TAVI, 27 (45%) patients were GR and 33 (55%) were PR. There was a significant decrease in 3DE-derived mitral annular diameter and area (P = 0.001), mitral valve tenting area (TA) (P = 0.05), and mitral papillary muscle dyssynchrony index (DSI) (P = 0.05) in the GR group. 3DE-derived LVESV (P = 0.016), LV mass (P = 0.001) and LV DSI, (P = 0.001) were also improved 6 months after TAVI. In addition, valvulo-arterial impedance (ZVA) was significantly higher at baseline in patients with PR (P = 0.028). 3DE-derived mitral annular area (β: 0.47, P = 0.04), mitral papillary DSI (β: −0.65, P = 0.012) and ZVA (β: 0.45, P = 0.028) were the strongest independent parameters that could predict the reduction of functional MR after TAVI. Conclusion GR patients demonstrate more regression in mitral annulus area and diameter after significant decrease in high LVEDP and trans-aortic gradients with TAVI. PR patients appear to have increased baseline ZVA, mitral valve tenting and restriction in mitral valve coaptation. These factors are important for predicting the impact of TAVI on pre-existing MR. PMID:27457965
Schaffer, R A; McAnulty, J H; Starr, A; Rahimtoola, S H
Diastolic murmurs associated with the Starr-Edwards mitral prosthesis have not been described previously. In this report, five patients with mitral prostheses are described in whom apical mid-diastolic and presystolic murmurs resulted from two different causes. Three patients had clots obstructing the prosthetic orifice. The other two had normally functioning protheses and moderately severe aortic insufficiency. The occurrence of mid-diastolic and presystolic murmurs in the presence of a normally functioning prosthetic mitral valve demonstrates that 1) the mid-diastolic Austin Flint murmur can occur in the absence of incomplete mitral valve opening, premature mitral valve closure, vibrating mitral leaflets, or relative mitral stenosis and 2) the presystolic Austin Flint murmur can occur in the absence of incomplete valve opening or presystolic mitral regurgitation. However, the presystolic murmur was associated with early closure movement of the presthetic poppet.
Tan, Timothy C.
The mitral valve is the most commonly diseased heart valve and the prevalence of mitral valve disease increases proportionally with age. Echocardiography is the primary diagnostic imaging modality used in the assessment of patients with mitral valve disease. It is a noninvasive method which provides accurate anatomic and functional information regarding the mitral valve and can identify the mechanism of mitral valve pathology. This is especially useful as it may guide surgical repair. This is increasingly relevant given the growing trend of patients undergoing mitral valve repair. Collaboration between cardiac surgeons and echocardiographers is critical in the evaluation of mitral valve disease and for identification of complex valvular lesions that require advanced surgical skill to repair. This article will provide an overview of transthoracic and transesophageal assessment of common mitral valve pathology that aims to aid surgical decision making. PMID:26539350
Johnson, Dennis A.
The material in this NASA TM is to appear as a chapter on Laser Doppler Anemometry (LDA) in the AGARDograph entitled, A Survey of Measurements and Measuring Techniques in Rapidly Distorted Compressible Turbulent Boundary Layers. The application of LDA (specifically, the dual-beam, burst-counter approach) to compressible flows is discussed. Subjects treated include signal processing, particle light scattering and tracking, data reduction and sampling bias, and three-dimensional measurements.
Keltai, M; Palik, I; Rozsa, Z; Szente, A
Left ventriculography and coronary arteriography were performed in 47 patients with hyperacute myocardial infarction prior to recanalization of the infarct-related vessel. Mitral regurgitation was found in ten patients. After successful recanalization, left ventriculography was repeated in eight of the ten patients with mitral incompetence, and the mitral regurgitation had disappeared in seven. Selective intracoronary thrombolysis resulted in improved left ventricular function and disappearance of mitral incompetence.
Leitgeb, Rainer A.; Werkmeister, René M.; Blatter, Cedric; Schmetterer, Leopold
Optical Coherence Tomography (OCT) has revolutionized ophthalmology. Since its introduction in the early 1990s it has continuously improved in terms of speed, resolution and sensitivity. The technique has also seen a variety of extensions aiming to assess functional aspects of the tissue in addition to morphology. One of these approaches is Doppler OCT (DOCT), which aims to visualize and quantify blood flow. Such extensions were already implemented in time domain systems, but have gained importance with the introduction of Fourier domain OCT. Nowadays phase-sensitive detection techniques are most widely used to extract blood velocity and blood flow from tissues. A common problem with the technique is that the Doppler angle is not known and several approaches have been realized to obtain absolute velocity and flow data from the retina. Additional studies are required to elucidate which of these techniques is most promising. In the recent years, however, several groups have shown that data can be obtained with high validity and reproducibility. In addition, several groups have published values for total retinal blood flow. Another promising application relates to non-invasive angiography. As compared to standard techniques such as fluorescein and indocyanine-green angiography the technique offers two major advantages: no dye is required and depth resolution is required is provided. As such Doppler OCT has the potential to improve our abilities to diagnose and monitor ocular vascular diseases. PMID:24704352
Poffo, L.; Goujon, J.-M.; Le Page, R.; Lemaitre, J.; Guendouz, M.; Lorrain, N.; Bosc, D.
The Laser Doppler flowmetry (LDF) is a non-invasive method for estimating the tissular blood flow and speed at a microscopic scale (microcirculation). It is used for medical research as well as for the diagnosis of diseases related to circulatory system tissues and organs including the issues of microvascular flow (perfusion). It is based on the Doppler effect, created by the interaction between the laser light and tissues. LDF measures the mean blood flow in a volume formed by the single laser beam, that penetrate into the skin. The size of this measurement volume is crucial and depends on skin absorption, and is not directly reachable. Therefore, current developments of the LDF are focused on the use of always more complex and sophisticated signal processing methods. On the other hand, laser Double Doppler Flowmeter (FL2D) proposes to use two laser beams to generate the measurement volume. This volume would be perfectly stable and localized at the intersection of the two laser beams. With FL2D we will be able to determine the absolute blood flow of a specific artery. One aimed application would be to help clinical physicians in health care units.
Schneider, Robert J; Tenenholtz, Neil A; Perrin, Douglas P; Marx, Gerald R; del Nido, Pedro J; Howe, Robert D
Segmenting the mitral valve during closure and throughout a cardiac cycle from four dimensional ultrasound (4DUS) is important for creation and validation of mechanical models and for improved visualization and understanding of mitral valve behavior. Current methods of segmenting the valve from 4DUS either require extensive user interaction and initialization, do not maintain the valve geometry across a cardiac cycle, or are incapable of producing a detailed coaptation line and surface. We present a method of segmenting the mitral valve annulus and leaflets from 4DUS such that a detailed, patient-specific annulus and leaflets are tracked throughout mitral valve closure, resulting in a detailed coaptation region. The method requires only the selection of two frames from a sequence indicating the start and end of valve closure and a single point near a closed valve. The annulus and leaflets are first found through direct segmentation in the appropriate frames and then by tracking the known geometry to the remaining frames. We compared the automatically segmented meshes to expert manual tracings for both a normal and diseased mitral valve, and found an average difference of 0.59 +/- 0.49 mm, which is on the order of the spatial resolution of the ultrasound volumes (0.5-1.0 mm/voxel).
Dina, Christian; Bouatia-Naji, Nabila; Tucker, Nathan; Delling, Francesca N; Toomer, Katelynn; Durst, Ronen; Perrocheau, Maelle; Fernandez-Friera, Leticia; Solis, Jorge; Le Tourneau, Thierry; Chen, Ming-Huei; Probst, Vincent; Bosse, Yohan; Pibarot, Philippe; Zelenika, Diana; Lathrop, Mark; Hercberg, Serge; Roussel, Ronan; Benjamin, Emelia J; Bonnet, Fabrice; Lo, Su Hao; Dolmatova, Elena; Simonet, Floriane; Lecointe, Simon; Kyndt, Florence; Redon, Richard; Le Marec, Hervé; Froguel, Philippe; Ellinor, Patrick T; Vasan, Ramachandran S; Bruneval, Patrick; Markwald, Roger R; Norris, Russell A; Milan, David J; Slaugenhaupt, Susan A; Levine, Robert A; Schott, Jean-Jacques; Hagege, Albert A; Jeunemaitre, Xavier
Nonsyndromic mitral valve prolapse (MVP) is a common degenerative cardiac valvulopathy of unknown etiology that predisposes to mitral regurgitation, heart failure and sudden death. Previous family and pathophysiological studies suggest a complex pattern of inheritance. We performed a meta-analysis of 2 genome-wide association studies in 1,412 MVP cases and 2,439 controls. We identified 6 loci, which we replicated in 1,422 cases and 6,779 controls, and provide functional evidence for candidate genes. We highlight LMCD1 (LIM and cysteine-rich domains 1), which encodes a transcription factor and for which morpholino knockdown of the ortholog in zebrafish resulted in atrioventricular valve regurgitation. A similar zebrafish phenotype was obtained with knockdown of the ortholog of TNS1, which encodes tensin 1, a focal adhesion protein involved in cytoskeleton organization. We also showed expression of tensin 1 during valve morphogenesis and describe enlarged posterior mitral leaflets in Tns1(-/-) mice. This study identifies the first risk loci for MVP and suggests new mechanisms involved in mitral valve regurgitation, the most common indication for mitral valve repair.
Echocardiographic imaging of the mitral valve before and immediately after repair is crucial to the immediate and long-term outcome. Prior to mitral valve repair, echocardiographic imaging helps determine the feasibility and method of repair. After the repair, echocardiographic imaging displays the new baseline anatomy, assesses function, and determines whether or not further management is necessary. Three-dimensional imaging has improved the assessment of the mitral valve and facilitates communication with the surgeon by providing the surgeon with an image that he/she might see upon opening up the atrium. Further advancements in imaging will continue to improve the understanding of the function and dysfunction of the mitral valve both before and after repair. This information will improve treatment options, timing of invasive therapies, and advancements of repair techniques to yield better short- and long-term patient outcomes. The purpose of this review was to connect the echocardiographic evaluation with the surgical procedure. Bridging the pre- and post-CPB imaging with the surgical procedure allows a greater understanding of mitral valve repair.
Smith, R; Brender, D; McCredie, M
Pregnancy can cause life threatening complications in women with mitral stenosis, and there is a substantial risk of fetal death if valvotomy under cardiopulmonary bypass is required. A patient is described in whom pulmonary oedema developed after delivery of her first child by caesarean section 13 months previously. Subsequent cardiac catheterisation showed severe mitral stenosis (valve area 0.96 cm2, valve gradient 12 mm Hg, pulmonary artery pressure 30/16 mm Hg). Before valvotomy could be performed the patient again became pregnant and presented in pulmonary oedema at twenty two weeks' gestation. Medical treatment was unsuccessful and she underwent percutaneous transluminal balloon dilatation of the mitral valve. This increased the valve area to 1.78 cm2 and reduced the transmitral gradient to 6 mm Hg. The procedure was uncomplicated, and she remained symptom free on no medication. She delivered vaginally at 37 weeks' gestation. Percutaneous transluminal balloon dilatation of the mitral valve is a safe and effective alternative to mitral valvotomy in pregnancy. PMID:2757867
Burns, R.J.; Armitage, D.L.; Fountas, P.N.; Tremblay, P.C.; Druck, M.N.
Fifteen patients with pure mitral stenosis (MS) underwent high-temporal-resolution radionuclide angiocardiography for calculation of the ratio of peak left ventricular (LV) filling rate divided by mean LV filling rate (filling ratio). Whereas LV filling normally occurs in 3 phases, in MS it is more uniform. Thus, in 13 patients the filling ratio was below the normal range of 2.21 to 2.88 (p less than 0.001). In 11 patients in atrial fibrillation, filling ratio divided by mean cardiac cycle length and by LV ejection fraction provided good correlation (r = 0.85) with modified Gorlin formula derived mitral area and excellent correlation with echocardiographic mitral area (r = 0.95). Significant MS can be detected using radionuclide angiocardiography to calculate filling ratio. In the absence of the confounding influence of atrial systole calculation of 0.14 (filling ratio divided by cardiac cycle length divided by LV ejection fraction) + 0.40 cm2 enables accurate prediction of mitral area (+/- 4%). Our data support the contention that the modified Gorlin formula, based on steady-state hemodynamics, provides less certain estimates of mitral area for patients with MS and atrial fibrillation, in whom echocardiography and radionuclide angiocardiography may be more accurate.
Dina, Christian; Bouatia-Naji, Nabila; Tucker, Nathan; Delling, Francesca N.; Toomer, Katelynn; Durst, Ronen; Perrocheau, Maelle; Fernandez-Friera, Leticia; Solis, Jorge; Le Tourneau, Thierry; Chen, Ming-Huei; Probst, Vincent; Bosse, Yohan; Pibarot, Philippe; Zelenika, Diana; Lathrop, Mark; Hercberg, Serge; Roussel, Ronan; Benjamin, Emelia J.; Bonnet, Fabrice; Su Hao, LO; Dolmatova, Elena; Simonet, Floriane; Lecointe, Simon; Kyndt, Florence; Redon, Richard; Le Marec, Hervé; Froguel, Philippe; Ellinor, Patrick T.; Vasan, Ramachandran S.; Bruneval, Patrick; Norris, Russell A.; Milan, David J.; Slaugenhaupt, Susan A.; Levine, Robert A.; Schott, Jean-Jacques; Hagege, Albert A.; Jeunemaitre, Xavier
Non-syndromic mitral valve prolapse (MVP) is a common degenerative cardiac valvulopathy of unknown aetiology that predisposes to mitral regurgitation, heart failure and sudden death1. Previous family and pathophysiological studies suggest a complex pattern of inheritance2–5. We performed a meta-analysis of two genome-wide association studies in 1,442 cases and 2,439 controls. We identified and replicated in 1,422 cases and 6,779 controls six loci and provide functional evidence for candidate genes. We highlight LMCD1 encoding a transcription factor6, for which morpholino knockdown in zebrafish results in atrioventricular (AV) valve regurgitation. A similar zebrafish phenotype was obtained for tensin1 (TNS1), a focal adhesion protein involved in cytoskeleton organization. We also show the expression of tensin1 during valve morphogenesis and describe enlarged posterior mitral leaflets in Tns1−/− mice. This study identifies the first risk loci for MVP and suggests new mechanisms involved in mitral valve regurgitation, the most common indication for mitral valve repair7. PMID:26301497
Katsi, Vasiliki; Raftopoulos, Leonidas; Aggeli, Constantina; Vlasseros, Ioannis; Felekos, Ioannis; Tousoulis, Dimitrios; Stefanadis, Christodoulos; Kallikazaros, Ioannis
The tricuspid valve (TV) is inseparably connected with the mitral valve (MV) in terms of function. Any pathophysiological condition concerning the MV is potentially a threat for the normal function of the TV as well. One of the most challenging cases is functional tricuspid regurgitation (TR) after surgical MV correction. In the past, TR was considered to progressively revert with time after left-sided valve restoration. Nevertheless, more recent studies showed that TR could develop and evolve postoperatively over time, as well as being closely associated with a poorer prognosis in terms of morbidity and mortality. Pressure and volume overload are usually the underlying pathophysiological mechanisms; structural alterations, like tricuspid annulus dilatation, increased leaflet tethering and right ventricular remodelling are almost always present when regurgitation develops. The most important risk factors associated with a higher probability of late TR development involve the elderly, female gender, larger left atrial size, atrial fibrillation, right chamber dilatation, higher pulmonary artery systolic pressures, longer times from the onset of MV disease to surgery, history of rheumatic heart disease, ischaemic heart disease and prosthetic valve malfunction. The time of TR manifestation can be up to 10 years or more after an MV surgery. Echocardiography, including the novel 3D Echo techniques, is crucial in the early diagnosis and prognosis of future TV disease development. Appropriate surgical technique and timing still need to be clarified.
Significant technological advances have led to an impressive evolution in mitral valve surgery over the last two decades, allowing surgeons to safely perform less invasive operations through the right chest. Most new technology comes with an increased upfront cost that must be measured against postoperative savings and other advantages such as decreased perioperative complications, faster recovery, and earlier return to preoperative level of functioning. The Da Vinci robot is an example of such a technology, combining the significant benefits of minimally invasive surgery with a “gold standard” valve repair. Although some have reported that robotic surgery is associated with increased overall costs, there is literature suggesting that efficient perioperative care and shorter lengths of stay can offset the increased capital and intraoperative expenses. While data on current cost is important to consider, one must also take into account future potential value resulting from technological advancement when evaluating cost-effectiveness. Future refinements that will facilitate more effective surgery, coupled with declining cost of technology will further increase the value of robotic surgery compared to traditional approaches. PMID:28203539
Katsi, Vasiliki; Raftopoulos, Leonidas; Aggeli, Constantina; Vlasseros, Ioannis; Felekos, Ioannis; Tousoulis, Dimitrios; Stefanadis, Christodoulos; Kallikazaros, Ioannis
The tricuspid valve (TV) is inseparably connected with the mitral valve (MV) in terms of function. Any pathophysiological condition concerning the MV is potentially a threat for the normal function of the TV as well. One of the most challenging cases is functional tricuspid regurgitation (TR) after surgical MV correction. In the past, TR was considered to progressively revert with time after left-sided valve restoration. Nevertheless, more recent studies showed that TR could develop and evolve postoperatively over time, as well as being closely associated with a poorer prognosis in terms of morbidity and mortality. Pressure and volume overload are usually the underlying pathophysiological mechanisms; structural alterations, like tricuspid annulus dilatation, increased leaflet tethering and right ventricular remodelling are almost always present when regurgitation develops. The most important risk factors associated with a higher probability of late TR development involve the elderly, female gender, larger left atrial size, atrial fibrillation, right chamber dilatation, higher pulmonary artery systolic pressures, longer times from the onset of MV disease to surgery, history of rheumatic heart disease, ischaemic heart disease and prosthetic valve malfunction. The time of TR manifestation can be up to 10 years or more after an MV surgery. Echocardiography, including the novel 3D Echo techniques, is crucial in the early diagnosis and prognosis of future TV disease development. Appropriate surgical technique and timing still need to be clarified. PMID:22457188
Memon, Sarfaraz; Chhabra, Lovely; Krainski, Felix; Parker, Matthew W; Swales, Heather
Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification that maybe easily misdiagnosed or confused with an abscess, a tumor, or infective vegetation. The main pathophysiological mechanism leading to CCMA involves degeneration and calcium deposition on the mitral valve. We present a case of CCMA to help understand this clinical entity.
Derkx, Salomé; Nguyen, Virginia; Cimadevilla, Claire; Verdonk, Constance; Lepage, Laurent; Raffoul, Richard; Nataf, Patrick; Vahanian, Alec; Messika-Zeitoun, David
Recurrence of mitral regurgitation after mitral valve repair is correlated with unfavourable left ventricular remodelling and poor outcome. This pictorial review describes the echocardiographic features of three types of acute mitral valve repair dysfunction, and the additional value of three-dimensional echocardiography.
Sedacca, Cassidy D; Bright, Janice M; Boon, June
Univentricular atrioventricular (AV) connections are rare and complex congenital cardiac anomalies in which both AV valves communicate into a large, common (single) receiving chamber. The common chamber can be of left, right, or mixed ventricular morphology. Although well documented in people, reports of the double-inlet ventricle malformation are rare in the veterinary literature. This report provides description of an Arabian horse with a double-inlet univentricular connection of left ventricular type, a hypoplastic subpulmonary right ventricle, two muscular ventricular septal defects, and a stenotic mitral valve. Transthoracic Doppler echocardiography enabled antemortem diagnosis, and provided an assessment of intracardiac hemodynamics. The findings indicate that Doppler echocardiography is a useful, noninvasive tool for evaluating equine patients with congenital univentricular AV connections, such as a double-inlet left ventricle.
Chandra, S.; Thomas, J. D.
Color Doppler flow mapping has played an important role in clinical echocardiography. Most of the clinical work, however, has been primarily qualitative. Although qualitative information is very valuable, there is considerable quantitative information stored within the velocity map that has not been extensively exploited so far. Recently, many researchers have shown interest in using the encoded velocities to address the clinical problems such as quantification of valvular regurgitation, calculation of cardiac output, and characterization of ventricular filling. In this article, we review some basic physics and engineering aspects of color Doppler echocardiography, as well as drawbacks of trying to retrieve velocities from video tape data. Digital storage, which plays a critical role in performing quantitative analysis, is discussed in some detail with special attention to velocity encoding in DICOM 3.0 (medical image storage standard) and the use of digital compression. Lossy compression can considerably reduce file size with minimal loss of information (mostly redundant); this is critical for digital storage because of the enormous amount of data generated (a 10 minute study could require 18 Gigabytes of storage capacity). Lossy JPEG compression and its impact on quantitative analysis has been studied, showing that images compressed at 27:1 using the JPEG algorithm compares favorably with directly digitized video images, the current goldstandard. Some potential applications of these velocities in analyzing the proximal convergence zones, mitral inflow, and some areas of future development are also discussed in the article.
Taylor, K.J.W.; Burns, P.N.; Well, P.N.T.
This book introduces a guide to the physical principles and instrumentation of duplex Doppler ultrasound and its applications in obstetrics, gynecology, neonatology, gastroentology, and evaluation of peripheral vascular disease. The book provides information needed to perform Doppler ultrasound examinations and interpret the results. An introduction to Doppler physics and instrumentation is followed by a thorough review of hemodynamics, which explains the principles underlying interpretation of Doppler signals. Of special note is the state-of-the-art coverage of new applications of Doppler in recognition of high-risk pregnancy, diagnosis of intrauterine growth retardation, investigation of neonatal blood flow, evaluation of first-trimester pregnancy, and diagnosis of gastrointestinal disease. The book also offers guidelines on the use of Doppler ultrasound in diagnosing carotid disease, deep venous thrombosis, and aorta/femoral disease.
Mihos, Christos G; Yucel, Evin; Santana, Orlando
SummarySecondary mitral regurgitation (MR) is present in up to half of patients with dilated cardiomyopathy, and is associated with a poor prognosis. It primarily results from progressive left ventricular remodelling, papillary muscle displacement and tethering of the mitral valve leaflets. Mitral valve repair with an undersized ring annuloplasty is the reparative procedure of choice in the treatment of secondary MR. However, this technique is associated with a 30-60% incidence of recurrent moderate or greater MR at mid-term follow-up, which results in progressive deterioration of left ventricular function and increased morbidity. Combined mitral valve repair and papillary muscle approximation has been applied in order to address both the annular and subvalvular dysfunction that coexist in secondary MR, which include graft and suture-based techniques. Herein, we provide a systematic review of the published literature regarding the technical aspects, clinical application, and outcomes of mitral valve repair with combined ring annuloplasty and papillary muscle approximation for the treatment of secondary MR.
Sinha, Santosh Kumar; Thakur, Ramesh; Jha, Mukesh Jitendra; Sayal, Karandeep Singh; Sachan, Mohit; Krishna, Vinay; Kumar, Ashutosh; Mishra, Vikas; Varma, Chandra Mohan
Situs inversus totalis is a rare congenital disorder where the heart being a mirror image is situated on the right side of the body. Distorted cardiac anatomy makes fluoroscopy-guided percutaneous mitral valvotomy (PMV) technically challenging and there are only few reports of PMV in situs inversus totalis. Here we report a case where PMV was successfully done for situs inversus totalis with rare coincidence of juvenile rheumatic severe mitral stenosis in a 12-year-old boy with a few modifications of standard Inoue technique. He had exertional dyspnea of NYHA class III with initial mitral valve area (MVA) of 0.6 cm2 and severe pulmonary arterial hypertension with features suitable for PMV. Femoral vein was accessed from the left side to align the septal puncture needle and balloon to facilitate left ventricular entry. Septal descent and puncture by Brockenbrough needle was performed in the right anterior oblique view with the needle facing 5 o’clock position. Accura balloon was negotiated across mitral valve in left anterior oblique and procedure was successfully executed. Echocardiography showed a well-divided anterior commissure with an MVA of 2.0 cm2 and mild mitral regurgitation. In summary, PMV is safe and feasible in the rare patient with situs inversus totalis with few modifications of the Inoue technique. PMID:26985259
McLeod, A. Jonathan; Moore, John; Guiraudon, Gerard M.; Jones, Doug L.; Campbell, Gordon; Peters, Terry M.
Off-pump, intracardiac, beating heart surgery has the potential to improve patient outcomes by eliminating the need for cardiopulmonary bypass and aortic cross clamping but it requires extensive image guidance as well as the development of specialized instrumentation. Previously, developments in image guidance and instrumentation were validated on either a static phantom or in vivo through porcine models. This paper describes the design and development of a surgical phantom for simulating off-pump mitral valve replacement inside the closed beating heart. The phantom allows surgical access to the mitral annulus while mimicking the pressure inside the beating heart. An image guidance system using tracked ultrasound, magnetic instrument tracking and preoperative models previously developed for off-pump mitral valve replacement is applied to the phantom. Pressure measurements and ultrasound images confirm the phantom closely mimics conditions inside the beating heart.
Madesis, Athanasios; Tsakiridis, Kosmas; Katsikogiannis, Nikolaos; Machairiotis, Nikolaos; Kougioumtzi, Ioanna; Kesisis, George; Tsiouda, Theodora; Beleveslis, Thomas; Koletas, Alexander; Zarogoulidis, Konstantinos
Mitral valve (MV) dysfunction is the second-most common clinically significant form of valvular defect in adults. MV regurgitation occurs with the increasing frequency of degenerative changes of the aging process. Moreover, other causes of clinically significant MV regurgitation include cardiac ischemia, infective endocarditis and rhematic disease more frequently in less developed countries. Recent evidence suggests that the best outcomes after repair of severe degenerative mitral regurgitation (MR) are achieved in asymptomatic or minimally symptomatic patients, who are selected for surgery soon after diagnosis on the basis of echocardiography. This review will focus on the surgical management of mitral insufficiency according to its aetiology today and will give insight to some of the perspectives that lay in the future. PMID:24672698
Athanasiou, Thanos; Cherian, Ashok; Ross, Donald
The surgical management of mitral valve disease in women of childbearing age, young patients, and children with congenital mitral valve defects is made difficult by the prospect of lifelong anticoagulation. We suggest the use of a pulmonary autograft in the mitral position (Ross II procedure) as an alternative surgical technique. We present a review of the literature, historical perspectives, indications, selection criteria, and surgical technique for the Ross II procedure. Our literature search identified 14 studies that reported results from the Ross II operation. Performed in 103 patients, the overall in-hospital mortality was 7 (6.7%), with a late mortality of 10 (9%). Although further research is needed, current evidence suggests the Ross II operation is a valuable alternative in low-risk young patients where valve durability and the complication rate from other procedures is unsatisfactory and anticoagulation not ideal.
Tu, Yan; Zeng, Qing-Chun; Huang, Ying; Li, Jian-Yong
Ischemic mitral regurgitation (IMR) is a common complication of acute myocardial infarction (AMI). Current evidences suggest that revascularization of the culprit vessels with percutaneous coronary artery intervention (PCI) or coronary artery bypass grafting can be beneficial for relieving IMR. A 2.5-year follow-up data of a 61-year-old male patient with ST-segment elevation AMI complicated with IMR showed that mitral regurgitation area increased five days after PCI, and decreased to lower steady level three months after PCI. This finding suggest that three months after PCI might be a suitable time point for evaluating the possibility of IMR recovery and the necessity of surgical intervention of the mitral valve for AMI patient. PMID:27582769
Erhard, W; Reichmann, M; Delius, W; Sebening, H; Herrmann, G
210 patients were followed up by the actuary method for over 5 years after isolated mitral valve replacement or a double valve replacement. After isolated valve replacement the one month survival including the operative mortality was 92+/-2%. The survival after one year was 83+/-3% and after 5 years 66+/-7%. The five year survival of patients in preoperative class III (according to the NYHA) was 73+/-8% and of class IV 57+/-8% (P less than or equal to 0.1). A comparison of valve replacements for pure mitral stenosis or mitral insufficiency showed no statistically significant differences. In the 37 patients who had a double valve replacement the survival risk was not increased in comparison with those patients who had had a single valve replacement. Age above 45 years and a preoperative markedly raised pulmonary arteriolar resistance reduced the chances of survival.
Ryzhkova, Anastasia V.; Lebedeva, Nina G.; Sedykh, Alexey V.; Ulyanov, Sergey S.; Lepilin, Alexander V.; Kharish, Natalia A.
The results of statistical analysis of Doppler spectra of intensity fluctuations of light, scattered from mucous membrane of oral cavity of healthy volunteers and patients, abused by the orthodontic diseases, are presented. Analysis of Doppler spectra, obtained from tooth pulp of patients, is carried out. New approach to monitoring of blood microcirculation in orthodontics is suggested. Influence of own noise of Doppler measuring system on formation of the output signal is studied.
Kherada, Nisharahmed; Brenes, Juan Carlos; Kini, Annapoorna S; Dangas, George D
Accurate evaluation of trans-aortic valvular pressure gradients is challenging in cases where dual mechanical aortic and mitral valve prostheses are present. Non-invasive Doppler echocardiographic imaging has its limitations due to multiple geometric assumptions. Invasive measurement of trans-valvular gradients with cardiac catheterization can provide further information in patients with two mechanical valves, where simultaneous pressure measurements in the left ventricle and ascending aorta must be obtained. Obtaining access to the left ventricle via the mitral valve after a trans-septal puncture is not feasible in the case of a concomitant mechanical mitral valve, whereas left ventricular apical puncture technique is associated with high procedural risks. Retrograde crossing of a bileaflet mechanical aortic prosthesis with standard catheters is associated with the risk of catheter entrapment and acute valvular regurgitation. In these cases, the assessment of trans-valvular gradients using a 0.014˝ diameter coronary pressure wire technique has been described in a few case reports. We present the case of a 76-year-old female with rheumatic valvular heart disease who underwent mechanical aortic and mitral valve replacement in the past. She presented with decompensated heart failure and echocardiographic findings suggestive of elevated pressure gradient across the mechanical aortic valve prosthesis. The use of a high-fidelity 0.014˝ diameter coronary pressure guidewire resulted in the detection of a normal trans-valvular pressure gradient across the mechanical aortic valve. This avoided a high-risk third redo valve surgery in our patient. © 2017 Wiley Periodicals, Inc.
A 37-year-old male with known intravenous drug use was admitted with an acute onset of worsening confusion and speech impairment. His vitals and biochemical profile demonstrated severe sepsis, with a brain CT showing several lesions suspicious for cerebral emboli. He then went on to have a bedside transthoracic echocardiogram that was positive for vegetation on the mitral valve, with associated severe mitral regurgitation. Unfortunately, before he was stable enough to be transferred for valve surgery, he suffered an episode of acute pulmonary oedema requiring intubation and ventilation on intensive care unit. PMID:26120312
Bachalo, William D.
Advanced research in experimental fluid dynamics required a familiarity with sophisticated measurement techniques. In some cases, the development and application of new techniques is required for difficult measurements. Optical methods and in particular, the laser Doppler velocimeter (LDV) are now recognized as the most reliable means for performing measurements in complex turbulent flows. And such, the experimental fluid dynamicist should be familiar with the principles of operation of the method and the details associated with its application. Thus, the goals of this primer are to efficiently transmit the basic concepts of the LDV method to potential users and to provide references that describe the specific areas in greater detail.
Greenberg, N. L.; Castro, P. L.; Drinko, J.; Garcia, M. J.; Thomas, J. D.
Color M-mode echocardiography has recently been utilized to describe diastolic flow propagation velocity (Vp) in the left ventricle. While increasing temporal resolution from 15 to 200 Hz, this M-mode technique requires the user to select a single scanline, potentially limiting quantification of Vp due to the complex three-dimensional inflow pattern. We previously performed computational fluid dynamics simulations to demonstrate the insignificance of the scanline orientation, however geometric complexity was limited. The purpose of this study was to utilize high frame-rate 2D color Doppler images to investigate the importance of scanline selection in patients for the quantification of Vp. 2D color Doppler images were digitally acquired at 50 frames/s in 6 subjects from the apical 4-chamber window (System 5, GE/Vingmed, Milwaukee, WI). Vp was determined for a set of scanlines positioned through 5 locations across the mitral annulus (from the anterior to posterior mitral annulus). An analysis of variance was performed to examine the differences in Vp as a function of scanline position. Vp was not effected by scanline position in sampled locations from the center of the mitral valve towards the posterior annulus. Although not statistically significant, there was a trend to slower propagation velocities on the anterior side of the valve (60.8 +/- 16.7 vs. 54.4 +/- 13.6 cm/s). This study clinically validates our previous numerical experiment showing that Vp is insensitive to small perturbations of the scanline through the mitral valve. However, further investigation is necessary to examine the impact of ventricular geometry in pathologies including dilated cardiomyopathy.
Little, Sherard G
Between January, 2009 and December, 2013, 84 patients were identified who underwent isolated mitral valve surgery in Jamaica at The University Hospital of the West Indies and The Bustamante Hospital for Children. The most common pathology requiring surgery was rheumatic heart disease, accounting for 84% of the procedures performed. The majority of patients had regurgitation of the mitral valve (67%), stenosis of the mitral valve (22%), and mixed mitral valve disease (11%). The most common procedure performed was replacement of the mitral valve (69%), followed by mitral valve repair (29%). Among the patients, one underwent closed mitral commissurotomy. The choice of procedure differed between age groups. In the paediatric population (<18 years of age), the majority of patients underwent repair of the mitral valve (89%). In the adult population (18 years and above), the majority of patients underwent mitral valve replacement (93%). Overall, of all the patients undergoing replacement of the mitral valve, 89% received a mechanical valve prosthesis, whereas 11% received a bioprosthetic valve prosthesis. Of the group of patients who underwent mitral valve repair for rheumatic heart disease, 19% required re-operation. The average time between initial surgery and re-operation was 1.2 years. Rheumatic fever and rheumatic heart disease remain significant public health challenges in Jamaica and other developing countries. Focus must remain on primary and secondary prevention strategies in order to limit the burden of rheumatic valvulopathies. Attention should also be directed towards improving access to surgical treatment for young adults.
Mahmood, Feroze; Matyal, Robina
Intraoperative echocardiography of the mitral valve has evolved from a qualitative assessment of flow-dependent variables to quantitative geometric analyses before and after repair. In addition, 3-dimensional echocardiographic data now allow for a precise assessment of mitral valve apparatus. Complex structures, such as the mitral annulus, can be interrogated comprehensively without geometric assumptions. Quantitative analyses of mitral valve apparatus are particularly valuable for identifying indices of left ventricular and mitral remodeling to establish the chronicity and severity of mitral regurgitation. This can help identify patients who may be unsuitable candidates for repair as the result of irreversible remodeling of the mitral valve apparatus. Principles of geometric analyses also have been extended to the assessment of repaired mitral valves. Changes in mitral annular shape and size determine the stress exerted on the mitral leaflets and, therefore, the durability of repair. Given this context, echocardiographers may be expected to diagnose and quantify valvular dysfunction, assess suitability for repair, assist in annuloplasty ring sizing, and determine the success and failure of the repair procedure. As a result, anesthesiologists have progressed from being mere service providers to participants in the decision-making process. It is therefore prudent for them to acquaint themselves with the principles of intraoperative quantitative mitral valve analysis to assist in rational and objective decision making.
Gabriel, Joseph; Göbölös, László; Miskolczi, Szabolcs; Barlow, Clifford
A best evidence topic was constructed according to a structured protocol. The enquiry: In [patients undergoing mitral valve surgery] are [postoperative morbidity and mortality outcomes] acceptable when patients are operated on by [residents]? Four hundred and twenty-three were identified from the search strategy. Six articles selected as best evidence were tabulated. All current published evidence, encompassing open and minimally invasive mitral valve repair in addition to mitral valve replacement, supports the involvement of trainees in mitral procedures. Although trainees may experience longer aortic cross-clamp and cardiopulmonary bypass times than specialist surgeons, they are not associated with significantly worse perioperative or postoperative outcomes in comparable mitral procedures. Important factors in the viability of mitral valve training and its quality include the volume of cases per institution and the expertise of the supervising surgeon, and these remain largely unexplored. Overall, mitral valve surgery remains a valuable potential training opportunity, one which is perhaps underexploited.
Pulido, Juan N; Lynch, James J; Mauermann, William J; Michelena, Hector I; Rehfeldt, Kent H
Diastolic mitral valve regurgitation is a rare phenomenon described in patients with atrioventricular conduction abnormalities, severe left ventricular systolic or diastolic dysfunction with regional wall motion dyssynchrony, or severe acute aortic valve regurgitation. The presence of diastolic mitral valve regurgitation in acute aortic regurgitation due to endocarditis suggests critical severity requiring urgent surgical valve replacement. We describe a case of diastolic mitral regurgitation in the setting of complex native mitral-aortic valve endocarditis in a patient in normal sinus rhythm and review the etiologic mechanisms of this phenomenon, echocardiographic assessment, and therapeutic implications for hemodynamic management.
Karplus, H. B.; Raptis, A. C.; Lee, S.; Simpson, T.
A flowmeter has been developed for measuring flow velocity in hot slurries. The flowmeter works on an ultrasonic Doppler principle in which ultrasound is injected into the flowing fluid through the solid pipe wall. Isolating waveguides separate the hot pipe from conventional ultrasonic transducers. Special clamp-on high-temperature transducers also can be adapted to work well in this application. Typical flows in pilot plants were found to be laminar, giving rise to broad-band Doppler spectra. A special circuit based on a servomechanism sensor was devised to determine the frequency average of such a broad spectrum. The device was tested at different pilot plants. Slurries with particulates greater than 70 microns (0.003 in.) yielded good signals, but slurries with extremely fine particulates were unpredictable. Small bubbles can replace the coarse particles to provide a good signal if there are not too many. Successful operation with very fine particulate slurries may have been enhanced by the presence of microbubbles.
Rammos, Christos; Zeus, Tobias; Balzer, Jan; Kubatz, Laura; Hendgen-Cotta, Ulrike B.; Veulemans, Verena; Hellhammer, Katharina; Totzeck, Matthias; Luedike, Peter; Kelm, Malte; Rassaf, Tienush
Background and Objective Endothelial dysfunction is predictive for cardiovascular events and may be caused by decreased bioavailability of nitric oxide (NO). NO is scavenged by cell-free hemoglobin with reduction of bioavailable NO up to 70% subsequently deteriorating vascular function. While patients with mitral regurgitation (MR) suffer from an impaired prognosis, mechanisms relating to coexistent vascular dysfunctions have not been described yet. Therapy of MR using a percutaneous mitral valve repair (PMVR) approach has been shown to lead to significant clinical benefits. We here sought to investigate the role of endothelial function in MR and the potential impact of PMVR. Methods and Results Twenty-seven patients with moderate-to-severe MR treated with the MitraClip® device were enrolled in an open-label single-center observational study. Patients underwent clinical assessment, conventional echocardiography, and determination of endothelial function by measuring flow-mediated dilation (FMD) of the brachial artery using high-resolution ultrasound at baseline and at 3-month follow-up. Patients with MR demonstrated decompartmentalized hemoglobin and reduced endothelial function (cell-free plasma hemoglobin in heme 28.9±3.8 μM, FMD 3.9±0.9%). Three months post-procedure, PMVR improved ejection fraction (from 41±3% to 46±3%, p = 0.03) and NYHA functional class (from 3.0±0.1 to 1.9±1.7, p<0.001). PMVR was associated with a decrease in cell free plasma hemoglobin (22.3±2.4 μM, p = 0.02) and improved endothelial functions (FMD 4.8±1.0%, p<0.0001). Conclusion We demonstrate here that plasma from patients with MR contains significant amounts of cell-free hemoglobin, which is accompanied by endothelial dysfunction. PMVR therapy is associated with an improved hemoglobin decompartmentalization and vascular function. PMID:26986059
Kelly, Paul S.
Discusses the following: another version of Doppler beats; alternate proof of spin-1 sin-1/2 problems; some mechanisms related to Dirac's strings; Doppler redshift in oblique approach of source and observer; undergraduate experiment on noise thermometry; use of the time evolution operator; resolution of an entropy maximization controversy;…
MIKAWA, Shoma; MIYAGAWA, Yuichi; TODA, Noriko; TOMINAGA, Yoshinori; TAKEMURA, Naoyuki
Pulmonary hypertension (PH) often occurs due to a left heart disease, such as myxomatous mitral valve disease (MMVD), in dogs and is diagnosed using Doppler echocardiography and estimated pulmonary arterial pressure. Diagnosis of PH in dogs requires expertise in echocardiography: however, the examination for PH is difficult to perform in a clinical setting. Thus, simple and reliable methods are required for the diagnosis of PH in dogs. The purpose of this study was to develop models using multiple logistic regression analysis to detect PH due to left heart disease in dogs with MMVD without echocardiography. The medical records of dogs with MMVD were retrospectively reviewed, and 81 dogs were included in this study and classified into PH and non-PH groups. Bivariate analysis was performed to compare all parameters between the groups, and variables with P values of <0.25 in bivariate analysis were included in multiple logistic regression analysis to develop models for the detection of PH. In multiple logistic regression analysis, the model included a vertebral heart scale short axis of >5.2 v, and a length of sternal contact of >3.3 v was considered suitable for the detection of PH. The predictive accuracy of this model (85.9%) was judged statistically adequate, and therefore, this model may be useful to screen for PH due to left heart disease in dogs with MMVD without echocardiography. PMID:25319513
Background Celiac artery stenosis (CAS) may be caused by atherosclerotic degeneration or compression exerted by the arched ligament of the diaphragm. Mitral valve prolapse (MVP) is the most common valvular disorder. There are no reports on an association between CAS and MVP. Methods 1560 (41%) out of 3780 consecutive patients undergoing echocardiographic assessment of MVP, had Doppler sonography of the celiac tract to detect CAS. Results CAS was found in 57 (3.7%) subjects (23 males and 34 females) none of whom complained of symptoms related to visceral ischemia. MVP was observed in 47 (82.4%) subjects with and 118 (7.9%) without CAS (p < 0.001). The agreement between MVP and CAS was 39% (95% CI 32–49%). PSV (Peak Systolic Velocity) was the only predictor of CAS in MPV patients (OR 0.24, 95% CI 0.08–0.69) as selected in a multivariate logistic model. Conclusion CAS and MVP seem to be significantly associated in patients undergoing consecutive ultrasonographic screening. PMID:15588321
Gaillard, E; Kadem, L; Pibarot, P; Durand, L-G
Intra- and inter-observer variability in Doppler velocity echocardiographic measurements (DVEM) is a significant issue. Indeed, imprecisions of DVEM can lead to diagnostic errors, particularly in the quantification of the severity of heart valve dysfunction. To minimize the variability and rapidity of DVEM, we have developed an automatic method of Doppler velocity wave contour detection, based on active contour models. To validate our new method, results obtained with this method were compared to those obtained manually by an experienced echocardiographer on Doppler echocardiographic images of left ventricular outflow tract and transvalvular flow velocity signals recorded in 30 patients, 15 with aortic stenosis and 15 with mitral stenosis. We focused on three essential variables that are measured routinely by Doppler echocardiography in the clinical setting: the maximum velocity, the mean velocity and the velocity-time integral. Comparison between the two methods has shown a very good agreement (linear correlation coefficient R(2) = 0.99 between the automatically and the manually extracted variables). Moreover, the computation time was really short, about 5s. This new method applied to DVEM could, therefore, provide a useful tool to eliminate the intra- and inter-observer variabilities associated with DVEM and thereby to improve the diagnosis of cardiovascular disease. This automatic method could also allow the echocardiographer to realize these measurements within a much shorter period of time compared to standard manual tracing method. From a practical point of view, the model developed can be easily implanted in a standard echocardiographic system.
Silbiger, Jeffrey J
Ischemic mitral regurgitation (MR) is a common complication of myocardial infarction thought to result from leaflet tethering caused by displacement of the papillary muscles that occurs as the left ventricle remodels. The author explores the possibility that left atrial remodeling may also play a role in the pathogenesis of ischemic MR, through a novel mechanism: atriogenic leaflet tethering. When ischemic MR is hemodynamically significant, the left ventricle compensates by dilating to preserve forward output using the Starling mechanism. Left ventricular dilatation, however, worsens MR by increasing the mitral valve regurgitant orifice, leading to a vicious cycle in which MR begets more MR. The author proposes that several structural adaptations play a role in reducing ischemic MR. In contrast to the compensatory effects of left ventricular enlargement, these may reduce, rather than increase, its severity. The suggested adaptations involve the mitral valve leaflets, the papillary muscles, the mitral annulus, and the left ventricular false tendons. This review describes the potential role each may play in reducing ischemic MR. Therapies that exploit these adaptations are also discussed.
Gariboldi, Vlad; Jop, Bertrand; Grisoli, Dominique; Jaussaud, Nicolas; Kerbaul, François; Collart, Frédéric
Takotsubo syndrome is characterized by transient and acute left ventricular dysfunction and apical ballooning, with electrocardiographic abnormalities, but without coronary disease. We report a case of Takotsubo syndrome occurring after emergent mitral valve replacement for acute infective endocarditis. The patient is a 66-year-old woman who regained complete recovery of left ventricular function.
Schrire, Velva; Barnard, Christiaan N.
We describe seven years' experience with the University of Cape Town lenticular mitral valve prosthesis in 122 patients. All the patients had severe mitral valve disease. In 98 severe mitral stenosis was present with or without incompetence and in 24 the dominant or sole lesion was mitral incompetence. Other valves, particularly the tricuspid, were also frequently affected. The disability was severe or total in almost every patient. One hundred and five patients were discharged from hospital, and in 90 per cent of these the clinical improvement was most gratifying, with the disappearance of pulmonary oedema, paroxysmal dyspnoea, angina pectoris, and congestive cardiac failure. Return to full normal activity including physical work was the rule. The hospital mortality was 14 per cent and a further 38 per cent died during the follow-up period. The major post-operative complication was systemic embolism which could occur at any time after operation. The most important factor influencing the frequency of this complication was the nature of the valve seat. A bare steel seat was associated with a 100 per cent embolism, and a significant reduction occurred when a cloth-covered seat of Dacron-velour was introduced. Anticoagulant therapy appeared to prevent large or fresh clots but had no effect on the deposition of fibrin or platelet thrombi. The only other factor of importance was the age of the patient: after the age of 50 life expectancy and trouble-free long-term survival was reduced. Images PMID:5440520
Mihos, Christos G; Santana, Orlando
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Is an adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation effective in preventing recurrent regurgitation? Altogether, 353 studies were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The best evidence regarding adjunctive subvalvular repair during mitral annuloplasty for secondary mitral regurgitation was from retrospective analyses. The studies reported outcomes of mitral valve repair (MVr) with annuloplasty alone (ring MVr) versus adjunctive papillary muscle approximation (PMA; n = 3), papillary muscle relocation (PMR; n = 3), secondary chordal cutting (n = 2) and PMA + PMR (n = 1). All but one study included concomitant coronary artery bypass grafting, whereas additional ventriculoplasty was performed in three studies. Follow-up ranged from 1 month to 5 years. The performance of PMA was associated with a lower mitral regurgitation (MR) grade when combined with ventriculoplasty in one study, whereas a greater improvement in left ventricular end-diastolic diameter and left ventricular ejection fraction at follow-up was observed with PMA alone in a separate study. Three studies of ring + PMR reported a reduction in ≥ 2+ recurrent MR, whereas two studies also observed a greater reduction in left ventricular end-diastolic diameter. The two studies on secondary chordal cutting reported a lower MR grade, lower recurrence of ≥ 2+ MR and a greater left ventricular ejection fraction at follow-up. Combining PMA + PMR + ventriculoplasty significantly reduced left ventricular end-systolic volume index at short-term follow-up in one study. Finally, none of the studies reported a significant difference in
Cui, Yong-Chun; Li, Kai; Tian, Yi; Yuan, Wei-Min; Peng, Peng; Yang, Jian-Zhong; Zhang, Bao-Jie; Zhang, Hui-Dong; Wu, Ai-Li; Tang, Yue
A miniature pig model of ischemic mitral regurgitation (IMR) was developed by posterior mitral chordae tendinae rupture and implantation of an ameroid constrictor. A 2.5-mm ameroid constrictor was placed around the left circumflex coronary artery (LCX) of male Tibetan miniature pigs to induce ischemia, while the posterior mitral chordae tendinae was also ruptured. X-ray coronary angiography, ECG analysis, echocardiography, and magnetic resonance imaging (MRI) were used to evaluate heart structure and function in pigs at baseline and one, two, four and eight weeks after the operation. Blood velocity of the mitral regurgitation was found to be between medium and high levels. Angiographic analyses revealed that the LCX closure was 10-20% at one week, 30-40% at two weeks and 90-100% at four weeks subsequent ameroid constrictor implantation. ECG analysis highlighted an increase in the diameter of the left atria (LA) at two weeks post-operation as well as ischemic changes in the left ventricle (LV) and LA wall at four weeks post-operation. Echocardiography and MRI further detected a gradual increase in LA and LV volumes from two weeks post-operation. LV end diastolic and systolic volumes as well as LA end diastolic and systolic volume were also significantly higher in pig hearts post-operation when compared to baseline. Pathological changes were observed in the heart, which included scar tissue in the ischemic central area of the LV. Transmission electron microscopy highlighted the presence of contraction bands and edema surrounding the ischemia area, including inflammatory cell infiltration within the ischemic area. We have developed a pig model of IMR using the posterior mitral chordae tendineae rupture technique and implantation of an ameroid constrictor. The pathological features of this pig IMR model were found to mimic the natural history and progression of IMR in patients.
Gotzmann, Michael; Sprenger, Isabell; Ewers, Aydan; Mügge, Andreas; Bösche, Leif
AIM To investigate one-year outcomes after percutaneous mitral valve repair with MitraClip® in patients with severe mitral regurgitation (MR). METHODS Our study investigated consecutive patients with symptomatic severe MR who underwent MitraClip® implantation at the University Hospital Bergmannsheil from 2012 to 2014. The primary study end-point was all-cause mortality. Secondary end-points were degree of MR and functional status after percutaneous mitral valve repair. RESULTS The study population consisted of 46 consecutive patients (mean logistic EuroSCORE 32% ± 21%). The degree of MR decreased significantly (severe MR before MitraClip® 100% vs after MitraClip® 13%; P < 0.001), and the NYHA functional classes improved (NYHA III/IV before MitraClip® 98% vs after MitraClip® 35%; P < 0.001). The mortality rates 30 d and one year after percutaneous mitral valve repair were 4.3% and 19.5%, respectively. During the follow-up of 473 ± 274 d, 11 patients died (90% due to cardiovascular death). A pre-procedural plasma B-type natriuretic peptide level > 817 pg/mL was associated with all-cause mortality (hazard ratio, 6.074; 95%CI: 1.257-29.239; P = 0.012). CONCLUSION Percutaneous mitral valve repair with MitraClip® has positive effects on hemodynamics and symptoms. Despite the study patients’ multiple comorbidities and extremely high operative risk, one-year outcomes after MitraClip® are favorable. Elevated B-type natriuretic peptide levels indicate poorer mid-term survival. PMID:28163835
Jong, Rudiyanto P.; Osman, Kahar; Adib, M. Azrul Hisham M.
Mitral valve prolapse without proper monitoring might lead to a severe mitral valve failure which eventually leads to a sudden death. Additional information on the mitral valve leaflet condition against the backflow volume would be an added advantage to the medical practitioner for their decision on the patients' treatment. A study on two dimensional echocardiography images has been conducted and the correlations between the backflow volume of the mitral regurgitation and mitral valve leaflet Young modulus have been obtained. Echocardiogram images were analyzed on the aspect of backflow volume percentage and mitral valve leaflet dimensions on different rates of backflow volume. Young modulus values for the mitral valve leaflet were obtained by using the principle of elastic deflection and deformation on the mitral valve leaflet. The results show that the backflow volume increased with the decrease of the mitral valve leaflet Young modulus which also indicate the condition of the mitral valve leaflet approaching failure at high backflow volumes. Mitral valve leaflet Young modulus values obtained in this study agreed with the healthy mitral valve leaflet Young modulus from the literature. This is an initial overview of the trend on the prediction of the behaviour between the fluid and the structure of the blood and the mitral valve which is extendable to a larger system of prediction on the mitral valve leaflet condition based on the available echocardiogram images.
The Doppler difference method as applied to track the GEOS 3 spacecraft is discussed. In this method a pair of 2 GHz ground tracking stations simultaneously track a spacecraft beacon to generate an observable signal in which bias and instability of the carrier frequency cancel. The baselines are formed by the tracking sites at Bermuda, Rosman, and Merritt Island. Measurements were made to evaluate the effectiveness of the Doppler differencing procedure in tracking a beacon target with the high dynamic rate of the GEOS 3 orbit. Results indicate the precision of the differenced data to be at a level comparable to the conventional precise two way Doppler tracking.
Kinman, Peter W.; Hinedi, Sami M.; Labelle, Remi C.; Bevan, Roland P.; Del Castillo, Hector M.; Chong, Dwayne C.
Digital and analog phase-locked loop (PLL) receivers were operated in parallel, each tracking the residual carrier from a spacecraft. The PLL tracked the downlink carrier and measured its instantaneous phase. This information, combined with a knowledge of the uplink carrier and the transponder ratio, permitted the computation of a Doppler observable. In this way, two separate Doppler measurements were obtained for one observation window. The two receivers agreed on the magnitude of the Doppler effect to within 1 mHz. There was less jitter on the data from the digital receiver. This was due to its smaller noise bandwidth. The demonstration and its results are described.
Bouma, Wobbe; Lai, Eric K.; Levack, Melissa M.; Shang, Eric K.; Pouch, Alison M.; Eperjesi, Thomas J.; Plappert, Theodore J.; Yushkevich, Paul A.; Mariani, Massimo A.; Khabbaz, Kamal R.; Gleason, Thomas G.; Mahmood, Feroze; Acker, Michael A.; Woo, Y. Joseph; Cheung, Albert T.; Jackson, Benjamin M.; Gorman, Joseph H.; Gorman, Robert C.
Background Valve repair for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings is characterized by high IMR recurrence rates. Patient-specific preoperative imaging-based risk stratification for recurrent IMR would optimize results. We sought to determine if pre-repair three-dimensional (3D) echocardiography combined with a novel valve modeling algorithm would be predictive of IMR recurrence 6 months after repair. Methods Intraoperative transesophageal real-time 3D echocardiography was performed in 50 patients undergoing undersized ring annuloplasty for IMR (and in 21 patients with normal mitral valves). A customized image analysis protocol was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥grade 2) was assessed with two-dimensional transthoracic echocardiography 6 months after repair. Results Preoperative annular geometry was similar in all IMR patients; and preoperative leaflet tethering was significantly higher in patients with recurrent IMR (n=13) as compared with patients in whom IMR did not recur IMR (n=37) (tethering index 3.91±1.01 vs. 2.90±1.17, P=0.008; tethering angles of A3 (23.5±8.9° vs. 14.4± 11.4°, P=0.012), P2 (44.4±8.8° vs. 28.2±17.0°, P=0.002), and P3 (35.2±6.0° vs. 18.6±12.7°, P<0.001)). Multivariate logistic regression analysis revealed preoperative P3 tethering angle as an independent predictor of IMR recurrence with an optimal cut-off value of 29.9° (AUC 0.92, 95%CI 0.84–1.00, P<0.001). Conclusions 3D echocardiography combined with valve modeling is predictive of recurrent IMR. Preoperative regional leaflet tethering of segment P3 is a strong independent predictor of IMR recurrence after undersized ring annuloplasty. In patients with a preoperative P3 tethering angle ≥29.9° chordal-sparing valve replacement rather than valve repair should be strongly considered. PMID:26688087
Hildebrand, P. H.; Mueller, C. K.
This paper will discuss the capabilities of airborne Doppler radar for atmospheric sciences research. The evaluation is based on airborne and ground based Doppler radar observations of convective storms. The capability of airborne Doppler radar to measure horizontal and vertical air motions is evaluated. Airborne Doppler radar is shown to be a viable tool for atmospheric sciences research.
Botta, Luca; Cannata, Aldo; Bruschi, Giuseppe; Fratto, Pasquale; Taglieri, Corrado; Russo, Claudio Francesco; Martinelli, Luigi
Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these
Cannata, Aldo; Bruschi, Giuseppe; Fratto, Pasquale; Taglieri, Corrado; Russo, Claudio Francesco; Martinelli, Luigi
Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining “mitral valve” with the following terms: ‘minimally invasive’, ‘reoperation’, and ‘alternative approach’. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed “mini” thoracotomy or “port access”. The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and
Sebag, Igal A; Morgan, John G; Handschumacher, Mark D; Marshall, Jane E; Nesta, Francesca; Hung, Judy; Picard, Michael H; Levine, Robert A
Two-dimensional (2-D) planimetry is limited by the technical demands, time, and observer variability required to locate the minimal orifice area, limiting the confident clinical reporting of mitral valve area (MVA). In 27 consecutive patients, MVA was determined independently by 2 observers using the conventional 2-D method and a new 3-D-guided method. Using a matrix-array probe, the valve was visualized in a long-axis view and a cursor steered to intersect the leaflet tips and provide a perpendicular short-axis plane viewed side-by-side. Two-dimensional and 3-D-guided methods allowed planimetry in 24 patients. Consistent with better orifice localization, 3-D guidance eliminated the overestimation of internal orifice diameters in the planimetered short-axis view relative to the limiting diameter defined by the long-axis view (for 3-D guidance, 0.73 +/- 0.20 vs 0.73 +/- 0.21 cm, p = 0.98, vs 0.90 +/- 0.27 cm in the 2-D short-axis view, p <0.01). Accordingly, mean values for the smallest orifice area by 3-D guidance were less than by 2-D imaging (1.4 +/- 0.5 vs 1.5 +/- 0.5 cm(2), p <0.01), changing the clinical severity classification in 11 of 24 patients (46%). The 2-D method also overestimated MVA relative to 3-D guidance compared with Doppler pressure halftime and (n = 6) Gorlin areas. Phantom studies verified no differences in resolution for the 2 acquisition modes. Three-dimensional guidance reduced intraobserver variability from 9.8% to 3.8% (SEE 0.14 to 0.06 cm(2), p <0.01) and interobserver variability from 10.6% to 6.1% (SEE 0.15 to 0.09 cm(2), p <0.02). In conclusion, matrix-array technology provides a feasible and highly reproducible direct 3-D-guided method for measuring the limiting mitral orifice area.
Jain, Surendra K.; Pechacek, Leonard W.; Decastro, Carlos M.; Garcia, Efrain; Hall, Robert J.
Two-dimensional echocardiographic imaging of the mitral valve orifice was attempted in 26 patients with isolated mitral stenosis. The intention was to examine further the clinical usefulness and limitations of this technique for estimating the severity of mitral stenosis. Technically adequate recordings of the mitral orifice were obtained in 20 patients (77%). Mitral valve area calculated from echocardiography compared favorably to the valve area derived from cardiac catheterization with the use of the Gorlin formula (r = 0.95). The average difference between the two methods was 0.109 cm2. Two-dimensional echocardiography does provide clinically useful data for predicting the degree of mitral stenosis in the majority of patients provided that critical technical limitations are recognized. Images PMID:15216223
Koprivanac, Marijan; Kelava, Marta; Alansari, Shehab; Javadikasgari, Hoda; Tappuni, Bassman; Mick, Stephanie; Marc, Gillinov A; Suri, Rakesh; Mihaljevic, Tomislav
Given the increasing age of the US population and the accompanying rise in cardiovascular disease, we expect to see an increasing number of patients affected by degenerative mitral valve disease in a more complex patient population. Therefore, increasing the overall rate of mitral valve repair will become even more important than it is today, and the capability to provide a universally and uniformly accepted quality of repair will have important medical, economic, and societal implications. This article will describe preoperative and intraoperative considerations and the currently practiced mitral valve repair approaches and techniques. The aim of the article is to present our contemporary approach to mitral valve repair in the hope that it can be adopted at other institutions that may have low repair rates. Adoption of simple and reproducible mitral valve repair techniques is of paramount importance if we as a profession are to accomplish overall higher rates of mitral valve repair with optimal outcomes.
Kelava, Marta; Alansari, Shehab; Javadikasgari, Hoda; Tappuni, Bassman; Mick, Stephanie; Marc, Gillinov A.; Suri, Rakesh; Mihaljevic, Tomislav
Given the increasing age of the US population and the accompanying rise in cardiovascular disease, we expect to see an increasing number of patients affected by degenerative mitral valve disease in a more complex patient population. Therefore, increasing the overall rate of mitral valve repair will become even more important than it is today, and the capability to provide a universally and uniformly accepted quality of repair will have important medical, economic, and societal implications. This article will describe preoperative and intraoperative considerations and the currently practiced mitral valve repair approaches and techniques. The aim of the article is to present our contemporary approach to mitral valve repair in the hope that it can be adopted at other institutions that may have low repair rates. Adoption of simple and reproducible mitral valve repair techniques is of paramount importance if we as a profession are to accomplish overall higher rates of mitral valve repair with optimal outcomes. PMID:28203540
Huddleston, Lisa L.
When two or more Doppler weather radar systems are monitoring the same region, the Doppler velocities can be combined to form a three-dimensional (3-D) wind vector field thus providing for a more intuitive analysis of the wind field. A real-time display of the 3-D winds can assist forecasters in predicting the onset of convection and severe weather. The data can also be used to initialize local numerical weather prediction models. Two operational Doppler Radar systems are in the vicinity of Kennedy Space Center (KSC) and Cape Canaveral Air Force Station (CCAFS); these systems are operated by the 45th Space Wing (45 SW) and the National Weather Service Melbourne, Fla. (NWS MLB). Dual-Doppler applications were considered by the 45 SW in choosing the site for the new radar. Accordingly, the 45th Weather Squadron (45 WS), NWS MLB and the National Aeronautics and Space Administration tasked the Applied Meteorology Unit (AMU) to investigate the feasibility of establishing dual-Doppler capability using the two existing systems. This study investigated technical, hardware, and software requirements necessary to enable the establishment of a dual-Doppler capability. Review of the available literature pertaining to the dual-Doppler technique and consultation with experts revealed that the physical locations and resulting beam crossing angles of the 45 SW and NWS MLB radars make them ideally suited for a dual-Doppler capability. The dual-Doppler equations were derived to facilitate complete understanding of dual-Doppler synthesis; to determine the technical information requirements; and to determine the components of wind velocity from the equation of continuity and radial velocity data collected by the two Doppler radars. Analysis confirmed the suitability of the existing systems to provide the desired capability. In addition, it is possible that both 45 SW radar data and Terminal Doppler Weather Radar data from Orlando International Airport could be used to alleviate any
Raynal, Ann Marie; Doerry, Armin Walter
Doppler radars can distinguish targets from clutter if the target's velocity along the radar line of sight is beyond that of the clutter. Some targets of interest may have a Doppler shift similar to that of clutter. The nature of sea clutter is different in the clutter and exo-clutter regions. This behavior requires special consideration regarding where a radar can expect to find sea-clutter returns in Doppler space and what detection algorithms are most appropriate to help mitigate false alarms and increase probability of detection of a target. This paper studies the existing state-of-the-art in the understanding of Doppler characteristics of sea clutter and scattering from the ocean to better understand the design and performance choices of a radar in differentiating targets from clutter under prevailing sea conditions.
Kinman, Peter W.
This article concerns the measurement of Doppler shift on microwave links that connect planetary spacecraft with the Deep Space Network. Such measurements are made by tracking the Doppler effect with phase-locked loop receivers. A description of equipment and techniques as well as a summary of the appropriate mathematical models are given. The two-way Doppler shift is measured by transmitting a highly-stable microwave (uplink) carrier from a ground station, having the spacecraft coherently transpond this carrier, and using a phase-locked loop receiver at the ground station to track the returned (downlink) carrier. The largest sources of measurement error are usually plasma noise and thermal noise. The plasma noise, which may originate in the ionosphere or the solar corona, is discussed; and a technique to partially calibrate its effect, involving the use of two simultaneous downlink carriers that are coherently related, is described. Range measurements employing Doppler rate-aiding are also described.
Lear, William M.
Error analysis increases precision of navigation. Report presents improved mathematical models of analysis of Doppler measurements and measurement errors of spacecraft navigation. To take advantage of potential navigational accuracy of Doppler measurements, precise equations relate measured cycle count to position and velocity. Drifts and random variations in transmitter and receiver oscillator frequencies taken into account. Mathematical models also adapted to aircraft navigation, radar, sonar, lidar, and interferometry.
Avidor, J M
A laser Doppler velocimeter capable of directly measuring instantaneous velocities is described. The new LDV uses a novel detection technique based on the utilization of a static slightly defocused spherical Fabry-Perot interferometer used in conjunction with a special mask for the detection of instantaneous Doppler frequency shifts. The essential characteristics of this LDV are discussed, and such a system recently developed is described. Results of turbulent flow measurements show good agreement with data obtained using hot wire anemometry.
Gran, Fredrik; Jakobsson, Andreas; Jensen, Jørgen Arendt
In this paper, 2 adaptive spectral estimation techniques are analyzed for spectral Doppler ultrasound. The purpose is to minimize the observation window needed to estimate the spectrogram to provide a better temporal resolution and gain more flexibility when designing the data acquisition sequence. The methods can also provide better quality of the estimated power spectral density (PSD) of the blood signal. Adaptive spectral estimation techniques are known to provide good spectral resolution and contrast even when the observation window is very short. The 2 adaptive techniques are tested and compared with the averaged periodogram (Welch's method). The blood power spectral capon (BPC) method is based on a standard minimum variance technique adapted to account for both averaging over slow-time and depth. The blood amplitude and phase estimation technique (BAPES) is based on finding a set of matched filters (one for each velocity component of interest) and filtering the blood process over slow-time and averaging over depth to find the PSD. The methods are tested using various experiments and simulations. First, controlled flow-rig experiments with steady laminar flow are carried out. Simulations in Field II for pulsating flow resembling the femoral artery are also analyzed. The simulations are followed by in vivo measurement on the common carotid artery. In all simulations and experiments it was concluded that the adaptive methods display superior performance for short observation windows compared with the averaged periodogram. Computational costs and implementation details are also discussed.
This Grant supported the development of an incoherent lidar system to measure winds and aerosols in the lower atmosphere. During this period the following activities occurred: (1) an active feedback system was developed to improve the laser frequency stability; (2) a detailed forward model of the instrument was developed to take into account many subtle effects, such as detector non-linearity; (3) a non-linear least squares inversion method was developed to recover the Doppler shift and aerosol backscatter without requiring assumptions about the molecular component of the signal; (4) a study was done of the effects of systematic errors due to multiple etalon misalignment. It was discovered that even for small offsets and high aerosol loadings, the wind determination can be biased by as much as 1 m/s. The forward model and inversion process were modified to account for this effect; and (5) the lidar measurements were validated using rawinsonde balloon measurements. The measurements were found to be in agreement within 1-2 m/s.
Hays, Paul B.
This report summarizes the accomplishments of the High Resolution Doppler Imager (HRDI) on UARS spacecraft during the period 4/l/96 - 3/31/99. During this period, HRDI operation, data processing, and data analysis continued, and there was a high level of vitality in the HRDI project. The HRDI has been collecting data from the stratosphere, mesosphere, and lower thermosphere since instrument activation on October 1, 1991. The HRDI team has stressed three areas since operations commenced: 1) operation of the instrument in a manner which maximizes the quality and versatility of the collected data; 2) algorithm development and validation to produce a high-quality data product; and 3) scientific studies, primarily of the dynamics of the middle atmosphere. There has been no significant degradation in the HRDI instrument since operations began nearly 8 years ago. HRDI operations are fairly routine, although we have continued to look for ways to improve the quality of the scientific product, either by improving existing modes, or by designing new ones. The HRDI instrument has been programmed to collect data for new scientific studies, such as measurements of fluorescence from plants, measuring cloud top heights, and lower atmosphere H2O.
Andreas, Martin; Doll, Nicolas; Livesey, Steve; Castella, Manuel; Kocher, Alfred; Casselman, Filip; Voth, Vladimir; Bannister, Christina; Encalada Palacios, Juan F.; Pereda, Daniel; Laufer, Guenther; Czesla, Markus
OBJECTIVES Recurrent mitral regurgitation is a significant problem after mitral valve repair in patients with functional valve disease. We report the safety and feasibility of a novel adjustable mitral annuloplasty device that permits downsizing of the anterior–posterior diameter late after initial surgery. METHODS In this multicentre, non-randomized, observational register, patients with moderate or severe mitral regurgitation undergoing surgical mitral valve repair with the MiCardia EnCorSQ™ Mitral Valve Repair system were evaluated. Patient characteristics, operative specifications and results as well as postoperative follow-up were collected for all five centres. RESULTS Ninety-four patients with a median age of 71 (64–75) years (EuroSCORE II 6.7 ± 6.3; 66% male, 48% ischaemic MR, 37% dilated cardiomyopathy and 15% degenerative disease) were included. Operative mortality was 1% and the 1-year survival was 93%. Ring adjustment was attempted in 12 patients at a mean interval of 9 ± 6 months after surgery. In three of these attempts, a technical failure occurred. In 1 patient, mitral regurgitation was reduced two grades, in 2 patients mitral regurgitation was reduced one grade and in 6 patients, mitral regurgitation did not change significantly. The mean grade of mitral regurgitation changed from 2.9 ± 0.9 to 2.1 ± 0.7 (P = 0.02). Five patients were reoperated after 11 ± 9 months (Ring dehiscence: 2; failed adjustment: 3). CONCLUSION We conclude that this device may provide an additional treatment option in patients with functional mitral regurgitation, who are at risk for reoperation due to recurrent mitral regurgitation. Clinical results in this complex disease were ambiguous and patient selection seems to be a crucial step for this device. Further trials are required to estimate the clinical value of this therapeutic concept. PMID:25694471
The Mitral Valve Prolapsus : Quantification of the Regurgitation Flow Rate by Experimental Time-Dependant PIV. F. Billy1, D. Coisne1,2, L. Sanchez1... mitral valve insufficiency), assumes that the velocity field in the convergent region have hemispheric shapes and introduce miscalculation specially...upstream a prolaps model of regurgitant orifice based on 2D time dependent PIV reconstruction. Keywords- Mitral Valve , Prolapsus, Regurgitation Flow
Lee, T. M.; Su, S. F.; Chen, M. F.; Liau, C. S.; Lee, Y. T.
OBJECTIVES: To investigate the effects of transvalvar flow rate on aortic valve resistance and valve area after percutaneous transvenous balloon dilatation of the mitral valve in a homogeneous group of patients with rheumatic heart disease. DESIGN: Retrospective analysis of 12 patients with combined aortic and mitral stenosis who had undergone balloon dilatation of the mitral valve over a period of 9 years. SETTING: Tertiary referral centre. PATIENTS: Twelve (8 women, 4 men; mean (SD) age 37 (9) of 227 consecutive patients with critical mitral stenosis undergoing transvenous balloon dilation of the mitral valve in the centre also had aortic stenosis, defined as a transaortic pressure gradient of more than 25 mm Hg measured at a catheterisation study before valvuloplasty. INTERVENTIONS: Echocardiographic variables (mitral valve area measured by the pressure half-time method and planimetry, and the aortic valve area derived from the continuity equation) and haemodynamic measurements (cardiac output, left ventricular mean systolic pressure, aortic mean pressure, transaortic valve pressure gradient, mitral valve and aortic valve areas derived from the Gorlin formula, and aortic valve resistance) were assessed before and after transvenous balloon dilatation of the mitral valve. Follow up catheterisation to measure haemodynamic variables was performed one week after mitral valvuloplasty. RESULTS: Mean transaortic flow rate increased 33% after mitral valvuloplasty (from 198 (68) to 254 (41) ml/s, P = 0.002). Aortic valve areas derived from the Gorlin formula were significantly increased from 0.57 (0.12) to 0.73 (0.14) cm2 (P = 0.006) after mitral valvuloplasty. However, aortic valve area and valve resistance derived from the continuity equation were independent of the increase in flow rate after mitral valvuloplasty (from 1.29 (0.35) to 1.30 (0.29) cm2 and from 317 (65) to 259 (75) dyn.s.cm-5, both P = NS). CONCLUSION: The Gorlin-derived aortic valve area tends to be flow
McLeod, A. Jonathan; Moore, John T.; Peters, Terry M.
Beating heart valve therapies rely extensively on image guidance to treat patients who would be considered inoperable with conventional surgery. Mitral valve repair techniques including the MitrClip, NeoChord, and emerging transcatheter mitral valve replacement techniques rely on transesophageal echocardiography for guidance. These images are often difficult to interpret as the tool will cause shadowing artifacts that occlude tissue near the target site. Here, we integrate ultrasound imaging directly into the NeoChord device. This provides an unobstructed imaging plane that can visualize the valve lea ets as they are engaged by the device and can aid in achieving both a proper bite and spacing between the neochordae implants. A proof of concept user study in a phantom environment is performed to provide a proof of concept for this device.
Hisatomi, Kazuki; Hashizume, Koji; Tanigawa, Kazuyoshi; Miura, Takashi; Matsukuma, Seiji; Yokose, Shogo; Sumi, Mizuki; Eishi, Kiyoyuki
Accessory mitral valve (AMV) tissue is a congenital anomaly that occurs in association with other congenital anomalies, and is an uncommon cause of left ventricular outflow tract obstruction. It is usually detected in early childhood when accompanied by symptoms of obstruction of the left ventricular outflow tract, and is rarely diagnosed in adults. We present a case of a 53-year-old man who was referred to our institution for evaluation of a systolic heart murmur. Echocardiography disclosed a diagnosis of AMV tissue. This case was uncommon because of the lack of severe obstruction of left ventricular outflow, cardiac symptoms, or other cardiac anomalies. We were able to carry out surgical resection of AMV tissue to avert possible progression of aortic insufficiency and the risk of a cerebrovascular embolization. The patient's postoperative course was uneventful, and postoperative echocardiography showed no residual accessory mitral tissue.
Morokuma, H; Nakayama, Y; Minematsu, N
Sheehan' syndrome is caused by pituitary apoplexy occurring during parturition and results in hypopituitarism, adrenal insufficiency and hypothyroidism. A 66-year-old woman with Sheehan's syndrome had received corticosteroids and thyroid hormones for about 18 years. The patient underwent mitral valve replacement for mitral regurgitation. Intraoperatively, just after the initiation of cardiopulmonary bypass, hypotension and severe edema suddenly occurred. Crystalloid fluid was rapidly administered to increase intravascular volumes. Postoperatively the body weight increased by 9.4 kg. The patient was intubated for 64 hours, stayed in the intensive care unit (ICU) for 7 days and was discharged from hospital on the postoperative day 36. Careful perioperative hormone supplementation is necessary for patients with Sheehan's syndrome.
Kumar, Bhupesh; Raj, Ravi; Jayant, Aveek; Kuthe, Sachin
Mitral regurgitation is uncommon with left atrial myxoma. The echocardiographic assessment of presence of mitral regurgitation and its severity are impaired by the presence of left atrial myxoma. We describe an uncommon association of left atrial myxoma with coronary artery disease and mitral regurgitation. MR was reported as mild on pre-operative transthoracic echocardiography but found to be severe due to ruptured chordae tendinae during intra-operative transesophageal echocardiography, which lead to change in the surgical plan to mitral valve replacement in addition to excision of myxoma.
Tomsic, Anton; Li, Wilson W L; van Paridon, Marieke; Bindraban, Navin R; de Mol, Bas A J M
Mitral valve leaflet aneurysm is a rare and potentially devastating complication of aortic valve endocarditis. We report the case of a 48-year-old man who had endocarditis of the native aortic valve and a concomitant aneurysm of the anterior mitral valve leaflet. Severe mitral regurgitation occurred after the aneurysm perforated. The patient showed no signs of heart failure and completed a 6-week regimen of antibiotic therapy before undergoing successful aortic and mitral valve replacement. In addition to the patient's case, we review the relevant medical literature.
Gómez, Ricardo; Verduras, María José; Lopez-Quintana, Alfonso; Riera, Luis; Zerolo, Ignacio; Martinez-Bordiu, Cristóbal
Three cases of severe disc variance and erosion of the Teflon-disc Beall mitral valve prosthesis (Models 103 and 104) are reported. In two patients, the Beall mitral valves were excised and replaced with two Björk-Shiley mitral valves. The remaining patient did not survive, and at autopsy, the lens was found at the aortic bifurcation level. Because of this potentially lethal complication, careful follow-up of patients with Beall mitral valve prostheses (Models 103 and 104) is recommended. Images PMID:15216211
Tada, Norio; Enta, Yusuke; Sakurai, Mie; Ootomo, Tatsushi; Hata, Masaki
An 82-year-old woman had a history of mitral valve replacement with a 25-mm MOSAIC (Medtronic, USA) for severe mitral regurgitation (MR) 8 years previously. Recently, she developed heart failure due to MR secondary to prosthetic valve failure. She underwent transcatheter valve-in-valve implantation with a 23-mm SAPIEN XT (Edwards Lifesciences, USA) to the prosthetic mitral valve by transapical approach. To our knowledge, this is the first reported case of transcatheter valve implantation for failed mitral prosthetic valve using valve-in-valve technique in Japan.
The Cardiothoracic Surgery Trials Network has reported results of the one-year follow up of their randomized trial "Surgical Treatment of Moderate Ischemic Mitral Regurgitation". They studied 301 patients with moderate ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting (CABG) with or without mitral repair with the primary end-point of change in left ventricular end-diastolic volume index (LVEDVI) at one year and multiple clinical and echocardiographic secondary endpoints. Although their results were against repairing the mitral valve, the debate on surgical management of moderate IMR remains unsettled.
The Cardiothoracic Surgery Trials Network has reported results of the one-year follow up of their randomized trial “Surgical Treatment of Moderate Ischemic Mitral Regurgitation”. They studied 301 patients with moderate ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting (CABG) with or without mitral repair with the primary end-point of change in left ventricular end-diastolic volume index (LVEDVI) at one year and multiple clinical and echocardiographic secondary endpoints. Although their results were against repairing the mitral valve, the debate on surgical management of moderate IMR remains unsettled. PMID:26779511
Strelkovska, V. Y.
In hypokinesia, edema of all the layers of the mitral value was observed, which resulted in morphological changes of the cellular and noncellular components. An increase in ratio of elastic and collagenic fibers in the value was also observed along with and changes in their structural and staining properties. The observed changes can limit valve mobility and can result in manifestations of cardiac valve insufficiency, which is found clinically.
Rahmani, Azadeh; Rasmussen, Ann Q.; Honge, Jesper L.; Ostli, Bjorn; Levine, Robert A.; Hagège, Albert; Nygaard, Hans; Nielsen, Sten L.; Jensen, Morten O.
Background and aim of the study Attention towards the optimization of mitral valve repair methods is increasing. Patch augmentation is one strategy used to treat functional ischemic mitral regurgitation (FIMR). The study aim was to investigate the force balance changes in specific chordae tendineae emanating from the posterior papillary muscle in a FIMR-simulated valve, following posterior leaflet patch augmentation. Methods Mitral valves were obtained from 12 pigs (body weight 80 kg). An in vitro test set-up simulating the left ventricle was used to hold the valves. The left ventricular pressure was regulated with water to simulate different static pressures during valve closure. A standardized oval pericardial patch (17 × 29 mm) was introduced into the posterior leaflet from mid P2 to the end of the P3 scallop. Dedicated miniature transducers were used to record the forces exerted on the chordae tendineae. Data were acquired before and after 12 mm posterior and 5 mm apical posterior papillary muscle displacement to simulate the effect from one of the main contributors of FIMR, before and after patch augmentation. Results The effect of displacing the posterior papillary muscle induced tethering on the intermediate chordae tendineae to the posterior leaflet, and resulted in a 39.8% force increase (p = 0.014). Posterior leaflet patch augmentation of the FIMR valve induced a 31.1% force decrease (p = 0.007). There was no difference in force between the healthy and the repaired valve simulations (p = 0.773). Conclusion Posterior leaflet patch augmentation significantly reduced the forces exerted on the intermediate chordae tendineae from the posterior papillary muscle following FIMR simulation. As changes in chordal tension lead to a redistribution of the total stress exerted on the valve, patch augmentation may have an adverse long-term influence on mitral valve function and remodeling. PMID:23610985
Sakata, K; Ishikawa, S; Ohtaki, A; Otani, Y; Suzuki, M; Kawashima, O; Morishita, Y
Two cases of malfunctioning Starr-Edwards cloth-covered mitral valve prostheses requiring reoperation are presented. Both cases underwent successful surgical repair 21 years after the valve replacement. The causes were a disturbance of the poppet during the opening movement due to excessive tissue ingrowth and a paravalvular leak associated with a tear of the valve seat. Replacement of the Starr-Edwards valve prosthesis more than 20 years after the initial installation has not been reported.
Behi, F; Chang, S; Welch, T
Progression of intermittent partial or total impaction of the poppet from a prosthetic mitral valve may be difficult to evaluate in patients with chronic obstructive pulmonary disease and atrial fibrillation. Heart sounds may be distant; opening and closing clicks of the poppet are muffled and irregular. Echocardiography provides a noninvasive method to detect early prosthetic malfunction at a time when the patient is clinically asymptomatic.
Cooper, D K; Sturridge, M F
Two cases of prosthetic valve dysfunction resulting in acute massive mitral regurgitation are reported; emergency operation was successful in both cases. Survival following complete dislodgement of the occluder of a disc valve, as occurred in one case, does not appear to have been reported before. The diffculty in diagnosis of sudden cardiac decompensation in patients with prosthetic valves is stressed, as is the need for urgent operation. Images PMID:973894
Surgical ablation for atrial fibrillation is most frequently done in the concomitant setting, and most commonly with mitral valve surgery. Minimally invasive surgical techniques for the treatment of atrial fibrillation have developed contemporaneously with techniques for minimally invasive mitral valve surgery. As in traditional surgery for atrial fibrillation, there are many different permutations of ablations for the less invasive approaches. Lesion sets can vary from simple pulmonary vein isolation (PVI) to full bi-atrial lesions that completely reproduce the traditional cut-and-sew Cox Maze III procedure with variable efficacy in restoring sinus rhythm. Additionally, treatment of the atrial appendage can be done through minimally invasive approaches without any ablation at all in an attempt to mitigate the risk of stroke. Finally, hybrid procedures combining minimally invasive surgery and catheter-based ablation are being developed that might augment surgical treatment of atrial fibrillation at the time of minimally invasive mitral valve repair. These various permutations and their results are reviewed. PMID:26539352
Mihaljevic, Tomislav; Koprivanac, Marijan; Kelava, Marta; Goodman, Avi; Jarrett, Craig; Williams, Sarah J.; Gillinov, A. Marc; Bajwa, Gurjyot; Mick, Stephanie L.; Bonatti, Johannes; Blackstone, Eugene H.
Importance The value of robotically assisted surgery for mitral valve disease is questioned because the high cost of care associated with robotic technology may outweigh its clinical benefits. Objective To investigate conditions under which benefits of robotic surgery mitigate high technology costs. Design Clinical cohort study comparing costs of robotic vs. three contemporaneous conventional surgical approaches for degenerative mitral disease. Surgery was performed from 2006–2011, and comparisons were based on intent-to-treat, with propensity-matching used to reduce selection bias. Setting Large multi-specialty academic medical center. Participants 1,290 patients aged 57±11 years, 27% women, underwent mitral repair for regurgitation from posterior leaflet prolapse. Robotic surgery was used in 473, complete sternotomy in 227, partial sternotomy in 349, and anterolateral thoracotomy in 241. Three propensity-matched groups were formed based on demographics, symptoms, cardiac and noncardiac comorbidities, valve pathophysiology, and echocardiographic measurements: robotic vs. sternotomy (n=198 pairs) vs. partial sternotomy (n=293 pairs) vs. thoracotomy (n=224 pairs). Interventions Mitral valve repair. Main Outcome Measures Cost of care, expressed as robotic capital investment, maintenance, and direct technical hospital cost, and benefit of care, based on differences in recovery time. Results Median cost of care for robotically assisted surgery exceeded the cost of alternative approaches by 27% (−5%, 68%), 32% (−6%, 70%), and 21% (−2%, 54%) (median [15th, 85th percentiles]) for complete sternotomy, partial sternotomy, and anterolateral thoracotomy, respectively. Higher operative costs were partially offset by lower postoperative costs and earlier return to work: median 35 days for robotic surgery, 49 for complete sternotomy, 56 for partial sternotomy, and 42 for anterolateral thoracotomy. Resulting net differences in cost of robotic surgery vs. the three
Elnady, Basant M.; Abdelghafar, Ayman Saeed Mohamed; Khalik, El Shazly Abdul; Algethami, Mohammed Mesfer; Basiony, A.S.; Al-otaibi, Mona Dhaif Allah; Al-otaibi, Maram Eidhah
Objective Systemic lupus erythematosus (SLE) can present limitations to exercise capacity and quality of life (QoL) because of various clinical conditions, such as pulmonary disease or heart disease. Tissue Doppler echocardiography (TDE) offers the promise of an objective measurement to quantify regional and global ventricular function through the assessment of myocardial velocity data. This study aimed to assess the intensity of left ventricular (LV) and right ventricular (RV) systolic and diastolic dysfunction in SLE patients by means of TDE and cardiopulmonary exercise (CPX) testing to determine their impact on QoL. Material and Methods Overall, 56 SLE patients within two tertiary healthcare centers as well as 50 healthy controls were examined with TDE after the exclusion of cardiovascular risk factors. TDE was performed for maximal systolic (S), early diastolic (E′), and late diastolic (A′) velocities of the mitral and tricuspid annulus. Pulsed wave (PW) Doppler of mitral and tricuspid valve inflow was performed in addition to the estimation of the left ventricle ejection fraction and assessment of right ventricle systolic function by tricuspid annular plane systolic excursion (TAPSE). Disease activity was assessed by the Systemic Lupus Activity Measure (SLAM), and the damage index was assessed by the Systemic Lupus International Collaborating Clinics (SLICC)/American College of Rheumatology (ACR) Damage Index (SDI). CPX tests according to the modified Bruce protocol were performed. Results SLE patients in both subgroups had more or less similar laboratory data and statistically higher values of ESR, CRP, and anticardiolipin (aCL) antibodies compared to the control group. LV function showed statistically insignificant EF compared to the control group, being lower in the patient group. Tissue Doppler image revealed that E′ and A′ of the mitral annulus were lower in the patient group than in the control group. Concerning RV, TAPSE in the patient group was
Wagner, K J; Unterbuchner, C; Bogdanski, R; Martin, J; Kochs, E F; Tassani-Prell, P
This report describes the case of a 59-year-old man who was scheduled for general anesthesia with propofol, sufentanil and sevoflurane for removal of a metal implant. The patient was classified as American Society of Anesthesiologists (ASA) II status because of an asymptomatic mitral valve prolapse and medically treated arterial hypertension. During induction of narcosis a pulsoxymetrically measured inadequate increase in oxygen saturation after preoxygenation was noticed and a moderate respiratory obstruction occurred intraoperatively, but anesthesia was uneventfully completed and the patient was extubated. However, 3 h later the patient developed severe dyspnea, hypoxia, tachycardia and arterial hypotension. Physical examination revealed a new grade 4/6 systolic murmur radiating to the axilla and X-ray showed bilateral pulmonary edema. Neither electrocardiographic nor biochemical manifestations of acute myocardial infarction were identified but transthoracic echocardiography revealed fluttering of the posterior leaflet of the mitral valve with grade III regurgitation and dilation of the left atrium. Coronary angiography was normal and left ventriculography confirmed severe mitral regurgitation. Mitral valve repair was successfully performed 22 h after presentation of symptoms. Mitral regurgitation is a common finding on echocardiography, seen to some degree in over 75% of the population. The etiology of mitral valve insufficiency which can be caused by pathologic changes of one or more of the components of the mitral valve, including the leaflets, annulus, chordae tendineae, papillary muscles, or by abnormalities of the surrounding left ventricle and/or atrium are discussed. Rupture of mitral chordae tendineae is infrequent and causes acute hemodynamic deterioration and needs corrective surgery. Valve replacement should be performed only if mitral valve repair is not possible. Echocardiography is an invaluable tool in determining the severity of regurgitation
Kim, Jong Hun; Kim, Tae Youn; Choi, Jong Bum; Kuh, Ja Hong
Patients requiring redo cardiac surgery for diseased heart valves other than mitral valves may show increased pressure gradients and reduced valve areas of previously placed mechanical mitral valves due to subvalvular pannus formation. We treated four women who had mechanical mitral valves inserted greater than or equal to 20 years earlier and who presented with circular pannus that protruded into the lower margin of the valve ring but did not impede leaflet motion. Pannus removal improved the haemodynamic function of the mitral valve.
Su, Ho-Ming; Lin, Tsung-Hsien; Voon, Wen-Chol; Lee, Kun-Tai; Chu, Chih-Sheng; Cheng, Kai-Hung; Yen, Hsueh-Wei; Lai, Wen-Ter; Sheu, Sheng-Hsiung
Diastolic mitral annular motion may terminate earlier in patients with higher left ventricular end-diastolic pressure (LVEDP). It was therefore hypothesized that the time interval measured from the end of the diastolic mitral annular velocity pattern to the onset of QRS (the AQ interval) would be a useful parameter in predicting LVEDP. The aim of this study was to evaluate the relation between the AQ interval and LVEDP. Forty-six patients with suspected coronary artery disease who underwent Doppler echocardiographic studies and cardiac catheterization were included. LVEDP was determined using a micromanometer-tipped catheter. On univariate analysis, the AQ interval had positive correlations with the PR interval (r = 0.405, p = 0.005), transmitral E-wave velocity (r = 0.502, p <0.001), isovolumic contraction time (r = 0.635, p <0.001), and LVEDP (r = 0.514, p <0.001) and a negative correlation with E-wave deceleration time (r = -0.430, p = 0.003). After stepwise multiple linear regression analysis, the PR interval, transmitral E-wave velocity, and LVEDP were the independent predictors of the AQ interval (beta = 0.234, p = 0.033; beta = 0.331, p = 0.004; and beta = 0.350, p = 0.003, respectively). In conclusion, the AQ interval is a novel, simple, and easily obtained index in the prediction of LVEDP.
Ziyrek, Murat; Tayyareci, Yelda; Yurdakul, Selen; Sahin, Sükrü Taylan; Yıldırımtürk, Ozlem; Aytekin, Saide
AMAÇ: Mitral anüler kalsifikasyon (MAK), mitral kapak anulusunun dejeneratif kalsifikasyonu ile karakterize bir hastalıktır. MAK gelişiminde aterosklerotik mekanizmaların rol oynadığı düşünülmektedir. Fetuin-A, patolojik kalsifikasyonun inhibitörlerindendir. Çalışmamızda; MAK ile, endotel fonksiyon bozukluğu, karotis intima media kalınlığı (KİMK) ve serum fetuin-A düzeyleri arasındaki ilişkiyi inceledik. YÖNTEMLER: Bu gözlemsel, kesitsel çalışmaya, transtorasik ekokardiyografide MAK saptanan 40 hasta ile saptanmayan 40 hasta dahil edildi. Tüm hastalar koroner arter hastası idi. Endotel fonksiyonları brakiyal arter ultrasonografisi (USG), karotis arter Doppler USG ile değerlendirildi. Hastaların Fetuin A düzeyi ölçüldü. Lineer regresyon analizi ve "ROC" analizi ile istatistiki değerlendirmeler yapıldı.
Rose, David; Irace, Francesco; Frati, Giacomo
Optimal exposure of the mitral valve is paramount in minimally invasive surgery (MIS) and a prerequisite for successful mitral valve repair or replacement. We report the concept of a new left atrial retractor (Karl Storz GmbH, Tuttlingen, Germany) dedicated to MIS. The effectiveness of the device was evaluated in a prospective series of 40 patients successfully operated at our institution. PMID:28149570
Hamasaki, Azumi; Uchida, Tetsuro; Sadahiro, Mitsuaki
We report a 56-year-old hemodialysis patient with a spontaneously ruptured caseous calcification of the mitral annulus resulting in multiple cerebral emboli. The mass was resected without replacing the mitral valve. The patient has remained symptom-free 3.5 years following surgery.
Ponasenko, Anastasia V.; Khutornaya, Maria V.; Kutikhin, Anton G.; Rutkovskaya, Natalia V.; Tsepokina, Anna V.; Kondyukova, Natalia V.; Yuzhalin, Arseniy E.; Barbarash, Leonid S.
Severe bioprosthetic mitral valve calcification is a significant problem in cardiovascular surgery. Unfortunately, clinical markers did not demonstrate efficacy in prediction of severe bioprosthetic mitral valve calcification. Here, we examined whether a genomics-based approach is efficient in predicting the risk of severe bioprosthetic mitral valve calcification. A total of 124 consecutive Russian patients who underwent mitral valve replacement surgery were recruited. We investigated the associations of the inherited variation in innate immunity, lipid metabolism and calcium metabolism genes with severe bioprosthetic mitral valve calcification. Genotyping was conducted utilizing the TaqMan assay. Eight gene polymorphisms were significantly associated with severe bioprosthetic mitral valve calcification and were therefore included into stepwise logistic regression which identified male gender, the T/T genotype of the rs3775073 polymorphism within the TLR6 gene, the C/T genotype of the rs2229238 polymorphism within the IL6R gene, and the A/A genotype of the rs10455872 polymorphism within the LPA gene as independent predictors of severe bioprosthetic mitral valve calcification. The developed genomics-based model had fair predictive value with area under the receiver operating characteristic (ROC) curve of 0.73. In conclusion, our genomics-based approach is efficient for the prediction of severe bioprosthetic mitral valve calcification. PMID:27589735
Ponasenko, Anastasia V; Khutornaya, Maria V; Kutikhin, Anton G; Rutkovskaya, Natalia V; Tsepokina, Anna V; Kondyukova, Natalia V; Yuzhalin, Arseniy E; Barbarash, Leonid S
Severe bioprosthetic mitral valve calcification is a significant problem in cardiovascular surgery. Unfortunately, clinical markers did not demonstrate efficacy in prediction of severe bioprosthetic mitral valve calcification. Here, we examined whether a genomics-based approach is efficient in predicting the risk of severe bioprosthetic mitral valve calcification. A total of 124 consecutive Russian patients who underwent mitral valve replacement surgery were recruited. We investigated the associations of the inherited variation in innate immunity, lipid metabolism and calcium metabolism genes with severe bioprosthetic mitral valve calcification. Genotyping was conducted utilizing the TaqMan assay. Eight gene polymorphisms were significantly associated with severe bioprosthetic mitral valve calcification and were therefore included into stepwise logistic regression which identified male gender, the T/T genotype of the rs3775073 polymorphism within the TLR6 gene, the C/T genotype of the rs2229238 polymorphism within the IL6R gene, and the A/A genotype of the rs10455872 polymorphism within the LPA gene as independent predictors of severe bioprosthetic mitral valve calcification. The developed genomics-based model had fair predictive value with area under the receiver operating characteristic (ROC) curve of 0.73. In conclusion, our genomics-based approach is efficient for the prediction of severe bioprosthetic mitral valve calcification.
LaPar, Damien J; Acker, Michael A; Gelijns, Annetine C; Kron, Irving L
Ischemic mitral regurgitation (IMR) is a subset of functional mitral regurgitation (MR) that has the potential to impact an increasing number of patients in the future. This is in the context of a worldwide population, which continues to live longer with improved survival after myocardial infarction. Substantial data have accumulated over the past few decades demonstrating the negative effects of IMR. Further, significant research has been done to define the optimal surgical approach and several studies have compared mitral repair versus replacement for patients with severe mitral regurgitation (SMR). Studies supporting performance of mitral repair cite superior operative morbidity and mortality rates, while proponents of mitral replacement cite improved long-term durability and correction of MR. Lack of clinically robust Level I randomized controlled trial data have curtailed attempts to better define appropriate surgical treatment allocation over the past few decades. Recently, however, the Cardiothoracic Surgical Trials Network (CTSN) conducted the first randomized controlled trial, funded by the National Heart, Lung, and Blood Institute, the National Institute for Neurological Diseases and Stroke and the Canadian Institute for Health Research, to compare the performance of mitral repair versus replacement for SMR. Herein, the present review describes the design, results and implications of the CTSN SMR trial and its efforts to identify the most efficacious surgical approach to SMR. This review also describes CTSN investigation to predict the recurrence of MR after mitral repair.
Staphylococcus epidermidis Bacterial Endocarditis Complicated byMitral- Aortic Intervalvular Fibrosa Pseudoaneurysm Diane Elegino-Steffens,1 Amy Stratton,1...hypertension and congestive heart failure who underwent a bioprosthetic aortic valve replacement secondary to acute onset of aortic insufficiency...severe regurgitation, anterior and posterior leaflet vegetations, and scallop prolapse. There was also evidence of a mitral- aortic intervalvular fibrosa
Lambrechts, David L; Wellens, Francis; Vercoutere, Rik A; De Geest, Raf
We report a case of life-threatening aortic transection with concomitant mitral papillary muscle rupture and severe lung contusion caused by a failed parachute jump. This blunt thoracic injury was treated by early stabilization with extracorporeal membrane oxygenation followed by successful delayed graft repair of the descending aorta and mitral valve replacement with a mechanical prosthesis.
Kazama, S; Kurata, A; Yamashita, Y
An aortic valve replacement was successfully performed employing the Nicks annulus enlargement procedure in a case of aortic valve stenosis with small annulus 12 years after mitral valve replacement. Previous mitral valve replacement does not preclude feasibility of the Nicks procedure.
Sack, Stefan; Kahlert, Philipp; Erbel, Raimund
Functional mitral regurgitation in heart failure limits survival in a severity-graded fashion. Even mild mitral regurgitation doubles mortality risk. We report the use of a non-stented coronary sinus device to reduce mitral annulus dimension in order to re-establish mitral valve competence. The device (PTMA, Viacor, Inc., Wilmington, MA, USA) consists of a multi-lumen PTFE (Teflon) PTMA catheter in which Nitinol (nickel-titanium alloy) treatment rods are advanced. For individual use up to three rods of different length and stiffness can be used. Therefore dimension reduction can be performed in an incremental fashion. Fluoroscopy and 3 D echocardiography are performed throughout the procedure to visiualize the positioning and confirm maximum treatment effect. The case describes the use and the effect of PTMA treatment. Safety and efficacy of the PTMA device will be investigated in the upcoming PTOLEMY 2 trial.
Ersoy, Burak; Yeniterzi, Mehmet
We describe a case of mitral valve annular dilatation caused by a huge left atrial myxoma obstructing the mitral valve orifice. A 50-year-old man presenting with palpitation was found to have a huge left atrial myxoma protruding into the left ventricle during diastole, causing severe mitral regurgitation. The diagnosis was made with echocardiogram. Transoesophageal echocardiography revealed a solid mass of 75 × 55 mm. During operation, the myxoma was completely removed from its attachment in the atrium. We preferred to place a mechanical heart valve after an annuloplasty ring because of severely dilated mitral annulus and chordae elongation. The patient had an uneventful recovery. Our case suggests that immediate surgery, careful evaluation of mitral valve annulus preoperatively is recommended. PMID:26702283
Sherrid, Mark V; Balaram, Sandhya; Kim, Bette; Axel, Leon; Swistel, Daniel G
Mitral valve abnormalities were not part of modern pathological and clinical descriptions of hypertrophic cardiomyopathy in the 1950s, which focused on left ventricular (LV) hypertrophy and myocyte fiber disarray. Although systolic anterior motion (SAM) of the mitral valve was discovered as the cause of LV outflow tract obstruction in the M-mode echocardiography era, in the 1990s structural abnormalities of the mitral valve became appreciated as contributing to SAM pathophysiology. Hypertrophic cardiomyopathy mitral malformations have been identified at all levels. They occur in the leaflets, usually elongating them, and also in the submitral apparatus, with a wide array of malformations of the papillary muscles and chordae, that can be detected by transthoracic and transesophageal echocardiography and by cardiac magnetic resonance. Because they participate fundamentally in the predisposition to SAM, they have increasingly been repaired surgically. This review critically assesses imaging and measurement of mitral abnormalities and discusses their surgical relief.
Jain, Sonia; Malouf, Joseph F
Transesophageal echocardiography provides excellent visualization of the posteriorly located mitral valve. Over the last decade, 3-dimensional transesophageal echocardiography (3D TEE) has emerged as an exciting imaging modality, particularly of the mitral valve. The current generation matrix array technology allows the operator to perform 2D and 3D imaging with a single transducer. 3D TEE affords the unique ability to view the mitral valve and its surrounding structures "en face" in real time (RT), and provide contextual anatomical guidance during surgical and transcatheter interventions. Additionally, offline quantification has made significant contributions to our mechanistic understanding of the normal and diseased mitral valve, and alterations induced by therapeutic intervention such as surgical repair. This review will address recent advances in the incremental role of 3D TEE in mitral valve imaging.
... in your neck (carotid artery stenosis) A Doppler ultrasound can estimate how fast blood flows by measuring the rate of change in its pitch (frequency). During a Doppler ultrasound, a technician trained in ultrasound imaging (sonographer) presses ...
Garcia, Kathleen M.; Hamilton, Douglas R.; Sargsyan, Ashot E.; Ebert, Douglas; Martin, David S.; Barratt, Michael R.; Martin, David S.; Bogomolov, Valery V.; Dulchavsky, Scott A.; Duncan, J. Michael
The presentation slides review normal physiology of the right ventricle in space, general physiology of the right ventricle; difficulties in imaging the heart in space, imaging methods, tissue Doppler spectrum, right ventricle tissue Doppler, and Rt Tei Index.
Arques, S; Roux, E
Acute heart failure is a common condition that leads to hospital admission, with important mortality and readmission rates. A prompt and accurate diagnosis of this condition by hospitalists is essential for an early and tailored medical management. The use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as the first-line diagnostic complement to the initial clinical evaluation in the acute care setting. Transthoracic Doppler echocardiography is an other noninvasive method that can be used at bedside, especially in patients with intermediate, inconclusive natriuretic peptides levels. In this regard, left ventricular ejection fraction and several simple Doppler indexes (restrictive mitral filling pattern, spectral tissue Doppler E/e' ratio), have been validated in the emergency diagnosis of acute heart failure. The aim of the present review is to overview the respective contribution of natriuretic peptides and Doppler echocardiography at bedside to the diagnosis of acute heart failure in the acute care setting.
Sengupta, Partho P; Krishnamoorthy, Vijay K; Abhayaratna, Walter P; Korinek, Josef; Belohlavek, Marek; Sundt, Thoralf M; Chandrasekaran, Krishnaswamy; Seward, James B; Tajik, A Jamil; Khandheria, Bijoy K
Brain (B-type) natriuretic peptide (BNP) and tissue Doppler imaging may distinguish restrictive cardiomyopathy (RCMP) from idiopathic constrictive pericardial disease (CP). However, their comparative efficacy is unknown for patients with CP from secondary causes (e.g., surgery or radiotherapy). We compared the efficacy of tissue Doppler imaging and BNP for differentiation of RCMP (n = 15) and CP (n = 16) were compared. BNP was higher in patients with RCMP than CP (p = 0.008), but the groups overlapped, particularly for BNP <400 pg/ml. BNP was lower with idiopathic CP than secondary CP (139 +/- 50 vs 293 +/- 69 pg/ml; p <0.001) or RCMP (139 +/- 50 vs 595 +/- 499 pg/ml; p <0.001), but not significantly different between those with secondary CP and RCMP (293 +/- 69 vs 595 +/- 499 pg/ml; p = 0.1). Patients with CP and RCMP had less overlap in early diastolic and isovolumic contraction tissue Doppler imaging velocities compared with BNP, with clear separation of groups evident with mean early diastolic annular velocities (averaged from 4 walls). Early diastolic tissue Doppler imaging velocity was superior to BNP for differentiation of CP and RCMP (area under the curve 0.97 vs 0.76, respectively; p = 0.01). In conclusion, mean early diastolic mitral annular velocity correctly distinguished CP from RCMP even when there was a large overlap of BNP between the 2 groups.
Rawool-Sullivan, Mohini; Sullivan, John P.
Doppler-broadened gamma ray peaks are observed routinely in the collection and analysis of gamma-ray spectra. If not recognized and understood, the appearance of Doppler broadening can complicate the interpretation of a spectrum and the correct identification of the gamma ray-emitting material. We have conducted a study using a simulation code to demonstrate how Doppler broadening arises and provide a real-world example in which Doppler broadening is found. This report describes that study and its results.
Reece, T Brett; Tribble, Curtis G.; Ellman, Peter I.; Maxey, Thomas S.; Woodford, Randall L.; Dimeling, George M.; Wellons, Harry A.; Crosby, Ivan K.; Kern, John A.; Kron, Irving L.
Objective: To compare the outcomes of mitral repair and replacement in revascularized patients with ischemic mitral regurgitation. Summary Background Data: Combined coronary bypass (CABG) and mitral procedures have been associated with the highest mortality (>10%) in cardiac surgery. Recent studies have suggested that mitral valve replacement (MVR) with sparing of the subvalvular apparatus had comparable results to mitral repair when associated with CABG. Methods: Over the past 7 years, 54 patients had CABG/mitral repair versus 56 who had CABG/MVR with preservation of the subvalvular apparatus. The groups were similar in age at 69.2 years in the replacement group versus 67.0 in the repair group. We compared these 2 groups based on hospital mortality, incidence of complications including nosocomial infection, neurologic decompensation (stroke), pulmonary complication (pneumonia, atelectasis, and prolonged ventilation), and renal complications (acute renal failure or insufficiency). Results: The mitral repair group had a hospital mortality of 1.9% versus 10.7% in the replacement group (P = 0.05). Infection occurred in 9% of repairs compared with 13% of replacements (P = 0.59). The incidence of stroke was no different between groups (2 of 54 repairs vs. 2 of 56 replacements, P = 1.00). Pulmonary complication rate was 39% in repairs versus 32% in replacements (P = 0.59). Worsening renal function occurred in 15% of repairs versus 18% of replacements (P = 0.67). Conclusions: Mitral repair is superior to mitral replacement when associated with coronary artery disease in terms of perioperative morbidity and hospital mortality. Although preservation of the subvalvular apparatus with MVR has a theoretical advantage in terms of ventricular function, mitral repair clearly adds a survival benefit in patients with concomitant ischemic cardiac disease. PMID:15082971
Dal-Bianco, Jacob P.; Aikawa, Elena; Bischoff, Joyce; Guerrero, J. Luis; Hjortnaes, Jesper; Beaudoin, Jonathan; Szymanski, Catherine; Bartko, Philipp E.; Seybolt, Margo M.; Handschumacher, Mark D.; Sullivan, Suzanne; Garcia, Michael L.; Mauskapf, Adam; Titus, James S.; Wylie-Sears, Jill; Irvin, Whitney S.; Chaput, Miguel; Messas, Emmanuel; Hagège, Albert A.; Carpentier, Alain; Levine, Robert A.
BACKGROUND In patients with myocardial infarction (MI), leaflet tethering by displaced papillary muscles induces mitral regurgitation (MR), which doubles mortality. Mitral valves (MVs) are larger in such patients but fibrosis sets in counterproductively. The investigators previously reported that experimental tethering alone increases mitral valve area in association with endothelial-to-mesenchymal transition. OBJECTIVES This study explored the clinically relevant situation of tethering and MI, testing the hypothesis that ischemic milieu modifies MV adaptation. METHODS Twenty-three adult sheep were examined. Under cardiopulmonary bypass, the PM tips in 6 sheep were retracted apically to replicate tethering, short of producing MR (tethered-alone). PM retraction was combined with apical MI created by coronary ligation in another 6 sheep (tethered + MI), and left ventricular (LV) remodeling was limited by external constraint in 5 additional sheep (LV constraint). Six sham-operated sheep were controls. Diastolic MV surface area was quantified by 3-dimensional echocardiography at baseline and after 58 ± 5 days, followed by histopathology and flow cytometry of excised leaflets. RESULTS Tethered + MI leaflets were markedly thicker than tethered-alone valves and sham controls. Leaflet area also increased significantly. EMT, detected as α-smooth muscle actin-positive endothelial cells, significantly exceeded that in tethered-alone and control valves. Transforming growth factor-β, matrix metalloproteinase expression, and cellular proliferation were markedly increased. Uniquely, tethering + MI showed endothelial activation with vascular adhesion molecule expression, neovascularization, and cells positive for CD45, considered a hematopoietic cell marker. Tethered + MI findings were comparable with external ventricular constraint. CONCLUSIONS MI altered leaflet adaptation, including a profibrotic increase in valvular cell activation, CD45-positive cells, and matrix turnover
Webb, Rachel H; Culliford-Semmens, Nicola; Sidhu, Karishma; Wilson, Nigel J
Objective We aimed to define the normal range of aortic and mitral valve thickness in healthy schoolchildren from a high prevalence rheumatic heart disease (RHD) region, using a standardised protocol for imaging and measurement. Methods Measurements were performed in 288 children without RHD. Anterior mitral valve leaflet (AMVL) thickness measurements were performed at the midpoint and tip of the leaflet in the parasternal long axis (PSLA) in diastole, when the AMVL was approximately parallel to the ventricular septum. Thickness of the aortic valve was measured from PSLA imaging in systole when the leaflets were at maximum excursion. The right coronary and non-coronary closure lines of the aortic valve were measured in diastole in parasternal short axis (PSSA) imaging. Results were compared with 51 children with RHD classified by World Heart Federation diagnostic criteria. Results In normal children, median AMVL tip thickness was 2.0 mm (IQR 1.7–2.4) and median AMVL midpoint thickness 2.0 mm (IQR 1.7–2.4). The median aortic valve thickness was 1.5 mm (IQR 1.3–1.6) in the PSLA view and 1.4 mm (IQR 1.2–1.6) in the PSSA view. The interclass correlation coefficient for the AMVL tip was 0.85 (0.71 to 0.92) and for the AMVL midpoint was 0.77 (0.54 to 0.87). Conclusions We have described a standardised method for mitral and aortic valve measurement in children which is objective and reproducible. Normal ranges of left heart valve thickness in a high prevalence RHD population are established. These results provide a reference range for school-age children in high prevalence RHD regions undergoing echocardiographic screening.
Schoch, Nicolai; Philipp, Patrick; Weller, Tobias; Engelhardt, Sandy; Volovyk, Mykola; Fetzer, Andreas; Nolden, Marco; De Simone, Raffaele; Wolf, Ivo; Maleshkova, Maria; Rettinger, Achim; Studer, Rudi; Heuveline, Vincent
For cardiac surgeons, mitral valve reconstruction (MVR) surgery is a highly demanding procedure, where an artificial annuloplasty ring is implanted onto the mitral valve annulus to re-enable the valve's proper closing functionality. For a successful operation the surgeon has to keep track of a variety of relevant impact factors, such as patient-individual medical history records, valve geometries, or tissue properties of the surgical target, and thereon-based deduce type and size of the best-suitable ring prosthesis according to practical surgery experience. With this work, we aim at supporting the surgeon in selecting this ring prosthesis by means of a comprehensive information processing pipeline. It gathers all available patient-individual information, and mines this data according to 'surgical rules', that represent published MVR expert knowledge and recommended best practices, in order to suggest a set of potentially suitable annuloplasty rings. Subsequently, these rings are employed in biomechanical MVR simulation scenarios, which simulate the behavior of the patient-specific mitral valve subjected to the respective virtual ring implantation. We present the implementation of our deductive system for MVR ring selection and how it is integrated into a cognitive data processing pipeline architecture, which is built under consideration of Linked Data principles in order to facilitate holistic information processing of heterogeneous medical data. By the example of MVR surgery, we demonstrate the ease of use and the applicability of our development. We expect to essentially support patient-specific decision making in MVR surgery by means of this holistic information processing approach.
Okafor, Ikechukwu U.; Santhanakrishnan, Arvind; Raghav, Vrishank S.; Yoganathan, Ajit P.
The mitral valve (MV) is a bileaflet valve positioned between the left atrium and ventricle of the heart. The annulus of the MV has been observed to undergo geometric changes during the cardiac cycle, transforming from a saddle D-shape during systole to a flat (and less eccentric) D-shape during diastole. Prosthetic MV devices, including heart valves and annuloplasty rings, are designed based on these two configurations, with the circular design of some prosthetic heart valves (PHVs) being an approximation of the less eccentric, flat D-shape. Characterizing the effects of these geometrical variations on the filling efficiency of the left ventricle (LV) is required to understand why the flat D-shaped annulus is observed in the native MV during diastole in addition to optimizing the design of prosthetic devices. We hypothesize that the D-shaped annulus reduces energy loss during ventricular filling. An experimental left heart simulator (LHS) consisting of a flexible-walled LV physical model was used to characterize the filling efficiency of the two mitral annular geometries. The strength of the dominant vortical structure formed and the energy dissipation rate (EDR) of the measured fields, during the diastolic period of the cardiac cycle, were used as metrics to quantify the filling efficiency. Our results indicated that the O-shaped annulus generates a stronger (25% relative to the D-shaped annulus) vortical structure than that of the D-shaped annulus. It was also found that the O-shaped annulus resulted in higher EDR values throughout the diastolic period of the cardiac cycle. The results support the hypothesis that a D-shaped mitral annulus reduces dissipative energy losses in ventricular filling during diastole and in turn suggests that a symmetric stent design does not provide lower filling efficiency than an equivalent asymmetric design. PMID:26502376
Okafor, Ikechukwu U; Santhanakrishnan, Arvind; Raghav, Vrishank S; Yoganathan, Ajit P
The mitral valve (MV) is a bileaflet valve positioned between the left atrium and ventricle of the heart. The annulus of the MV has been observed to undergo geometric changes during the cardiac cycle, transforming from a saddle D-shape during systole to a flat (and less eccentric) D-shape during diastole. Prosthetic MV devices, including heart valves and annuloplasty rings, are designed based on these two configurations, with the circular design of some prosthetic heart valves (PHVs) being an approximation of the less eccentric, flat D-shape. Characterizing the effects of these geometrical variations on the filling efficiency of the left ventricle (LV) is required to understand why the flat D-shaped annulus is observed in the native MV during diastole in addition to optimizing the design of prosthetic devices. We hypothesize that the D-shaped annulus reduces energy loss during ventricular filling. An experimental left heart simulator (LHS) consisting of a flexible-walled LV physical model was used to characterize the filling efficiency of the two mitral annular geometries. The strength of the dominant vortical structure formed and the energy dissipation rate (EDR) of the measured fields, during the diastolic period of the cardiac cycle, were used as metrics to quantify the filling efficiency. Our results indicated that the O-shaped annulus generates a stronger (25% relative to the D-shaped annulus) vortical structure than that of the D-shaped annulus. It was also found that the O-shaped annulus resulted in higher EDR values throughout the diastolic period of the cardiac cycle. The results support the hypothesis that a D-shaped mitral annulus reduces dissipative energy losses in ventricular filling during diastole and in turn suggests that a symmetric stent design does not provide lower filling efficiency than an equivalent asymmetric design.
Discusses the Doppler effect as it applies to different situations, such as a stationary source of sound with the observer moving, a stationary observer, and the sound source and observer both moving. Police radar, satellite surveillance radar, radar astronomy, and the Doppler navigator, are discussed as applications of Doppler shift. (JR)
Scherrer, P. H.
Daily observations of the photospheric equatorial rotation rate using the Doppler effect mode at the Sanford Solar Observatory are presented. These observations show no variations in the rotation rate that exceed the observational error of about one percent. The average rotation rate is indistinguishable from that of sunspots and large scale magnetic field structures.
Scherrer, P. H.; Wilcox, J. M.
Daily observations of the photospheric equatorial rotation rate using the Doppler effect are made at the Stanford Solar Observatory. These observations show no variations in the rotation rate that exceed the observational error of about 1%. The average rotation rate is indistinguishable from that of sunspots and large-scale magnetic field structures.
Washuettl, Albert; Strassmeier, Klaus G.; Collier-Cameron, Andrew
We present Doppler images of the rapidly rotating active close binary star EI Eridani. Several Doppler images have been produced since 1984 making use of different versions of the Doppler imaging technique. They all show high-latitude spots surrounding or covering the rotational pole as well as some smaller spots on lower latitudes. The high-latitude/polar spot seems to be long-lived (at least a decade) but changes its shape on comparatively short timescales (of the order of one month). From time to time spots along the stellar equator also occur, but their lifetimes tend to be relatively short (weeks). Furthermore, long-term photometric observations revealed the existence of a magnetic cycle which has been estimated to be around 11 years. We also present time-resolved Doppler images from EI Eri obtained at McMath/NSO in fall 1996 during 70 consecutive nights. The final aim of this program is to investigate the spot evolution over the whole activity cycle.
Nair, Krishna Kumar Mohanan; Pillai, Harikrishnan Sivadasan; Titus, Thomas; Varaparambil, Ajitkumar; Sivasankaran, Sivasubramonian; Krishnamoorthy, Kavassery Mahadevan; Namboodiri, Narayanan; Sasidharan, Bijulal; Thajudeen, Anees; Ganapathy, Sanjay; Tharakan, Jaganmohan
Pulmonary artery pressure (PAP) is known to regress after successful balloon mitral valvotomy (BMV). Data of persistent pulmonary artery hypertension (PPAH) following BMV is scarce. We analyzed the clinical, echocardiographic, and hemodynamic data of 701 consecutive patients who have undergone successful BMV in our institute from 1997 to 2003. Data of 287 patients who had PPAH (defined by pulmonary artery systolic pressure [PASP] of ≥ 40 mmHg at one year following BMV) were compared to the data of 414 patients who did not have PPAH. Patients who had PPAH were older (39.9 ± 9.9 years vs. 29.4 ± 10.1; P < 0.001). They had higher prevalence of atrial fibrillation (AF; 21.9 vs. 12.1%, P < 0.05), moderate or severe pulmonary artery hypertension (PAH) defined as PASP more than 50 mmHg (43.5 vs. 33.8%, P = 0.00), anatomically advanced mitral valve disease as assessed by Wilkin's echocardiographic score > 8 (33.7 vs. 23.2%, P < 0.001), and coexistent aortic valve disease (45.6 vs. 37.9%, P < 0.001) at the baseline. Those patients with PPAH had comparatively lower immediate postprocedural mitral valve area (MVA). On follow-up of more than five years, the occurrence of restenosis (39.3 vs. 10.1%, P = 0.000), new onset heart failure (14% vs. 4%, P < 0.05) and need for reinterventions (9.5% vs. 2.8%, P < 0.05) were higher in the PPAH group. Patients with PPAH were older, sicker, and had advanced rheumatic mitral valve disease. They had higher incidence of restenosis, new onset heart failure, and need for reinterventions on long term follow-up. PPAH represents an advanced stage of rheumatic valve disease and indicates chronicity of the disease, which may be the reason for the poorer prognosis of these patients. Patients with PPAH requires intense and more frequent follow-up. PMID:24015345
Akbari, Jayesh G; Varma, Praveen K; Gadhinglajkar, Shrinivas V; Neelakandhan, Kurur S
A 32-year-old female underwent mitral valve replacement with total chordal preservation (Miki's technique) using 26 mm (1M) Starr-Edward prosthesis (SEP) in 1988. The patient was in NYHA class-I until 2001. She progressed to NYHA class-III with paroxysmal nocturnal dyspnoea. Transthoracic echocardiogram showed increased prosthetic valve gradient, and cardiac catheterization confirmed the findings. Intraoperatively, the poppet movement in the cage was found to be restricted due to the preserved subvalvular apparatus entrapping the poppet inside the prosthetic valve cage.
Gillinov, A. Marc; Gelijns, Annetine C.; Parides, Michael K.; DeRose, Joseph J.; Moskowitz, Alan J.; Voisine, Pierre; Ailawadi, Gorav; Bouchard, Denis; Smith, Peter K.; Mack, Michael J.; Acker, Michael A.; Mullen, John C.; Rose, Eric A.; Chang, Helena L.; Puskas, John D.; Couderc, Jean-Philippe; Gardner, Timothy J.; Varghese, Robin; Horvath, Keith A.; Bolling, Steven F.; Michler, Robert E.; Geller, Nancy L.; Ascheim, Deborah D.; Miller, Marissa A.; Bagiella, Emilia; Moquete, Ellen G.; Williams, Paula; Taddei-Peters, Wendy C.; O’Gara, Patrick T.; Blackstone, Eugene H.; Argenziano, Michael
Background Among patients undergoing mitral-valve surgery, 30 to 50% present with atrial fibrillation, which is associated with reduced survival and increased risk of stroke. Surgical ablation of atrial fibrillation has been widely adopted, but evidence regarding its safety and effectiveness is limited. Methods We randomly assigned 260 patients with persistent or long-standing persistent atrial fibrillation who required mitral-valve surgery to undergo either surgical ablation (ablation group) or no ablation (control group) during the mitral-valve operation. Patients in the ablation group underwent further randomization to pulmonary-vein isolation or a biatrial maze procedure. All patients underwent closure of the left atrial appendage. The primary end point was freedom from atrial fibrillation at both 6 months and 12 months (as assessed by means of 3-day Holter monitoring). Results More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P<0.001). There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure (61.0% and 66.0%, respectively; P = 0.60). One-year mortality was 6.8% in the ablation group and 8.7% in the control group (hazard ratio with ablation, 0.76; 95% confidence interval, 0.32 to 1.84; P = 0.55). Ablation was associated with more implantations of a permanent pacemaker than was no ablation (21.5 vs. 8.1 per 100 patient-years, P = 0.01). There were no significant between-group differences in major cardiac or cerebrovascular adverse events, overall serious adverse events, or hospital readmissions. Conclusions The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-standing persistent atrial fibrillation, but the
Jawad, Maadh; Cardozo, Shaun
Mural endocarditis is a very rare condition. This entity involves bacterial growth on cardiac walls. In addition, concomitant valvular endocarditis, along with mural endocarditis, is an extremely rare combination. The diagnosis of mural endocarditis is difficult and requires more advanced cardiac imaging, such as a transesophageal echocardiogram. The differential diagnoses of mural masses include vegetations, thrombi, metastasis, and benign and malignant tumors. We present a rare and unusual case of Methicillin-Resistant Staphylococcus aureus bacteremia with findings of both right ventricular outflow tract mural endocarditis and valvular endocarditis involving the mitral valve.
Jawad, Maadh; Cardozo, Shaun
Mural endocarditis is a very rare condition. This entity involves bacterial growth on cardiac walls. In addition, concomitant valvular endocarditis, along with mural endocarditis, is an extremely rare combination. The diagnosis of mural endocarditis is difficult and requires more advanced cardiac imaging, such as a transesophageal echocardiogram. The differential diagnoses of mural masses include vegetations, thrombi, metastasis, and benign and malignant tumors. We present a rare and unusual case of Methicillin-Resistant Staphylococcus aureus bacteremia with findings of both right ventricular outflow tract mural endocarditis and valvular endocarditis involving the mitral valve. PMID:26702695
Musumeci, Francesco; Mariscalco, Giovanni; Ranocchi, Federico; Tosi, Daniele; Persichetti, Paolo
During the past years, a rapid development and refinements of robotic heart valve techniques have led to consider robotic mitral valve (MV) surgery safe, effective, and durable. Robotic MV surgery has proven to be a cost-effective and cost-saving strategy in MV operations, being associated with reduced morbidity and mortality rates. We present a novel video-assisted transareolar approach to access the MV using the da Vinci Si HD telemanipulation system (Intuitive Surgical, Inc, Sunnyvale, CA USA). This technique is effective and reproducible, providing maximum patient satisfaction from both the clinical and cosmetic points of view.
Sawazaki, Masaru; Tomari, Shiro; Tsunekawa, Tomohiro; Izawa, Naoto
A wide and redundant prolapse of the posterior mitral leaflet in active infective endocarditis cannot be easily repaired. A sliding plasty can be attempted, but the range of annular plication is often too large. Chordal replacement is another option, but is prone to long-term degeneration because the redundant leaflet still exists. Here, we describe a simple resection technique that utilizes only two small triangular resections. The resections are sutured with no need to shorten the annulus. The leaflet tissue between the two triangular resections must be preserved to make an appropriately shaped posterior leaflet. PMID:23223672
Valtuille, Lucas; Choy, Jonathan B; Becher, Harald
Various Doppler-derived parameters of left atrial electrical remodeling have been demonstrated to predict recurrence of atrial fibrillation (AF) after AF ablation. The aim of this study was to compare three Doppler-derived measures of atrial conduction time in patients undergoing AF ablation, and to investigate their predictive value for successful procedure. In 32 prospectively enrolled patients undergoing the first AF ablation, atrial conduction time was estimated by measuring the time delay between the onset of P-wave on the surface ECG to the peak of the a′-wave on the pulsed-wave Doppler and color-coded tissue Doppler imaging of the left atrial lateral wall, and to the peak of the A-wave on the pulsed-wave Doppler of the mitral inflow. There was a significant difference in the baseline atrial conduction time measured by different echocardiographic techniques. Most (88%) patients had normal or only mildly dilated left atrium. At 6 months, 12 patients (38%) had recurrent AF/atrial tachycardia. The duration of history of AF was the only predictor of AF/atrial tachycardia recurrence following the first AF ablation (P=0.024; OR 1.023, CI 1.003–1.044). A combination of normal left atrial volume and history of paroxysmal AF of ≤48 months was associated with the best outcome. Predictive value of the Doppler derived parameters of atrial conduction time may be reduced in the early stages of left atrial remodeling. Future studies may determine which echocardiographic parameter correlates best with the extent of left atrial remodeling and is most predictive of successful AF ablation. PMID:26795694
Gaillard, Emmanuel; Kadem, Lyes; Clavel, Marie-Annick; Pibarot, Philippe; Durand, Louis-Gilles
Intra- and interobserver variability in Doppler echocardiographic velocity measurements (DEVM) is a significant issue. Indeed, imprecisions of DEVM can lead to diagnostic errors, particularly in the quantification of the severity of heart valve dysfunctions. To reduce the variability and rapidity of DEVM, we have developed an automatic method of Doppler velocity wave contour detection, based on active contour models. To validate our new method, results obtained with this method were compared with those obtained manually by two experienced echocardiographers on Doppler echocardiographic images of left ventricular outflow tract and transvalvular flow velocity signals recorded in 30 patients with aortic or mitral stenosis, 20 with normal sinus rhythm and 10 with atrial fibrillation. We focused on the three essential variables that are measured routinely using Doppler echocardiography in the clinical setting: the maximum velocity (Vmax), the mean velocity (Vmean) and the velocity-time integral (VTI). Comparison between the two methods has shown a very good agreement. A small bias value was found between the two methods (between -3.9% and 0.5% for Vmax, between -4.6% and -1.4% for Vmean and between -3.6% and 4.4% for VTI). Moreover, the computation time was short, approximately 5 s. This new method applied to DEVM could, therefore, provide a useful tool to eliminate the intra- and interobserver variabilities associated with DEVM and thereby to improve the accuracy of the diagnosis of cardiovascular disease. This automatic method could also allow the echocardiographer to realize these measurements within a much shorter period of time compared with the standard manual tracing method. From a practical point of view, the model developed can be easily implemented in a standard echocardiographic system.
Holmes, Anthony A; Hung, Tawny; Human, Derek G; Campbell, Andrew I M
Kingella kingae, a HACEK (Haemophilus parainfluenzae, Aggregatibacter actinomycetemcomitans, Aggregatibacter aphrophilus, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae) organism, is a common resident of the upper airway in children; it has been associated with endocarditis in children with pre-existing heart conditions. This case report describes K. kingae endocarditis leading to valvular damage in a previously healthy 18-month-old child. Our patient developed a K. kingae bacteremia that was later complicated by meningitis, septic embolic stroke, and endocarditis of the mitral valve, leading to perforation of the posterolateral leaflet. The patient was initially treated conservatively with cefotaxime but, subsequently, required a mitral valve repair with a pericardial patch and annuloplasty. This report draws attention to the need for clinicians to be aware of the potentially serious complications of K. kingae infection in young children. If K. kingae infection is suspected then therapy should be initiated promptly with a β-lactam, followed by early echocardiographic assessment. This case also highlights the lack of specific guidelines available for K. kingae endocarditis. PMID:21976892
Holmes, Anthony A; Hung, Tawny; Human, Derek G; Campbell, Andrew I M
Kingella kingae, a HACEK (Haemophilus parainfluenzae, Aggregatibacter actinomycetemcomitans, Aggregatibacter aphrophilus, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae) organism, is a common resident of the upper airway in children; it has been associated with endocarditis in children with pre-existing heart conditions. This case report describes K. kingae endocarditis leading to valvular damage in a previously healthy 18-month-old child. Our patient developed a K. kingae bacteremia that was later complicated by meningitis, septic embolic stroke, and endocarditis of the mitral valve, leading to perforation of the posterolateral leaflet. The patient was initially treated conservatively with cefotaxime but, subsequently, required a mitral valve repair with a pericardial patch and annuloplasty. This report draws attention to the need for clinicians to be aware of the potentially serious complications of K. kingae infection in young children. If K. kingae infection is suspected then therapy should be initiated promptly with a β-lactam, followed by early echocardiographic assessment. This case also highlights the lack of specific guidelines available for K. kingae endocarditis.
Amano, K; Sakamoto, T; Hada, Y; Hasegawa, I; Takahashi, T; Suzuki, J; Takahashi, H
Four cases of anorexia nervosa recently encountered were reported in respect to their cardiovascular manifestations including prolapse of the cardiac valves and other poorly recognized cardiac findings. All four patients, aged 13 to 32 years, were women and had marked emaciation (35 to 44% weight loss of the ideal body weight) with typical hormone abnormalities. Chest radiographs showed a small cardiac shadow, and sinus bradycardia with low voltage was present in their electrocardiograms. One case, 13-year-old, had a mid-systolic click and occasionally a late systolic murmur, and also an abdominal continuous hum. Echocardiography including two-dimensional color flow-mapping disclosed mitral valve prolapse in all, and tricuspid valve prolapse in two. Mild to moderate pericardial effusion was noted in all between the right ventricle and diaphragm, and pericardiocentesis in one case had no effect on the valve movements. No inflammatory changes were observed in the specimen of the pericardium and also of the fluid. An association of mitral valve prolapse and anerexia nervosa was discussed based on the previous studies, but the final conclusion remains unknown.
Feldman, Ted; Young, Amelia
Percutaneous therapy has emerged as an option for treatment of mitral regurgitation for selected, predominantly high-risk patients. Most of the percutaneous approaches are modifications of existing surgical approaches. Catheter-based devices mimic these surgical approaches with less procedural risk, due to their less-invasive nature. Percutaneous annuloplasty can be achieved indirectly via the coronary sinus or directly from retrograde left ventricular access. Catheter-based leaflet repair with the MitraClip (Abbott Laboratories, Abbott Park, Illinois) is accomplished with an implantable clip to mimic the surgical edge-to-edge leaflet repair technique. A large experience with MitraClip has been reported, and several other percutaneous approaches have been successfully used in smaller numbers of patients to demonstrate proof of concept, whereas others have failed and are no longer under development. There is increasing experience in both trials and practice to begin to define the clinical utility of percutaneous leaflet repair, and annuloplasty approaches are undergoing significant development. Transcatheter mitral valve replacement is still in early development.
Araujo, C; Chaves, C
Background: Mitral valve prolapse (MVP) is common in women. Other clinical features such as flexibility and hyperlaxity are often associated with MVP, as there is a common biochemical and histological basis for collagen tissue characteristics, range of joint motion, and mitral leaflet excursion. Objective: To confirm whether adult women with MVP are more flexible and hypermobile than those without. Methods: Data from 125 women (mean age 50 years), 31 of them with MVP, were retrospectively analysed with regard to clinical and kinanthropometric aspects. Passive joint motion was evaluated in 20 body movements using Flexitest and three laxity tests. Flexitest individual movements (0 to 4) and overall Flexindex scores were obtained in all subjects by the same investigator. Results: Women with MVP were lighter, less endomorphic and mesomorphic, and more linear. The Flexindex was significantly higher in the women with MVP, both absolute (48 (1.6) v 41 (1.3); p<0.01) and centile for age (67 v 42; p<0.01) values. In 13 out of 20 movements, the Flexitest scores were significantly higher for the women with MVP. Signs of hyperlaxity were about five times more common in these women: 74% v 16% (p<0.01). Scores of 0 and 1 in elbow extension, absence of hyperlaxity, and a Flexindex centile below 65 were almost never found in women with MVP. Conclusion: Flexitest, alone or combined with hyperlaxity tests, may be useful in the assessment of adult women with MVP. PMID:16183767
Elkharbotly, Ali; Delago, Augustin; El-Hajjar, Mohammad
Transcatheter aortic valve replacement (TAVR) is well established for patients who cannot undergo surgery (Leon et al., N Engl J Med 2010;363:1597) or are high risk for surgery (Smith et al., N Engl J Med 2011;364:2187-2198). Experience with the TAVR procedure has led to recent reports of successful transcatheter mitral valve replacement (TMVR) procedures (Cheung et al., J Am Coll Cardiol 2014;64:1814; Seiffert et al., J Am Coll Cardiol Interv 2012;5:341-349) separately or simultaneously with the TAVR. However, these reports were of simultaneous valve-in-valve procedures (Cheung Anson, et al. J Am Coll Cardiol 2013;61:1759-1766). A recent report from Portugal also reported simultaneous transpical implantation of an inverted transcatheter aortic valve-in-ring in the mitral position and transcatheter aortic valve (Hasan et al., Circulation 2013;128:e74-e76). There has been an experience of TMVR only in native mitral valve for mitral valve stenosis, but none in both aortic and mitral valves. We report the first in human case of simultaneous transapical TAVR and TMVR in native valves secondary to valvular stenosis. Our patient was not a candidate for percutaneous balloon mitral valvuloplasty secondary to a high Wilkins Score. Sizing of the aortic valve was based on the transesophageal echocardiogram (TEE), whereas sizing of the mitral valve was based on TEE measurements and balloon inflation during left ventriculography. © 2015 Wiley Periodicals, Inc.
Richards, Andrew L.; Cook, Richard C.; Bolotin, Gil; Buckner, Gregory D.
Objective The development of a novel surgical tool or technique for mitral valve repair can be hampered by cost, complexity, and time associated with performing animal trials. A dynamically pressurized model was developed to control pressure and flowrate profiles in intact porcine hearts in order to quantify mitral regurgitation and evaluate the quality of mitral valve repair. Methods A pulse duplication system was designed to replicate physiological conditions in explanted hearts. To test the capabilities of this system in measuring varying degrees of mitral regurgitation, the output of eight porcine hearts was measured for two different pressure waveforms before and after induced mitral valve failure. Four hearts were further repaired and tested. Measurements were compared with echocardiographic images. Results For all trials, cardiac output decreased as left ventricular pressure was increased. After induction of mitral valve insufficiencies, cardiac output decreased, with a peak regurgitant fraction of 71.8%. Echocardiography clearly showed increases in regurgitant severity from post-valve failure and with increased pressure. Conclusions The dynamic heart model consistently and reliably quantifies mitral regurgitation across a range of severities. Advantages include low experimental cost and time associated with each trial, while still allowing for surgical evaluations in an intact heart. PMID:19224369
Ostli, B; Vester-Petersen, J; Askov, JB; Honge, JL; Levine, RA; Hagège, A; Nielsen, SL; Hasenkam, JM; Nygaard, H; Jensen, MO
Background Attention towards optimization of mitral valve repair methods is increasing. Patch augmentation is one strategy utilized to correct functional mitral regurgitation or systolic anterior motion in complex mitral valve repairs. This article describes a system for investigating the redistribution of chordae tendineae tension as a reflection of altered stress distribution of the valve leaflet following patch augmentation. Methods and materials An in vitro test setup was constructed to hold native porcine mitral valves containing an annulus and papillary muscle positioning system. The alterations caused by patch augmentation should be visual from both the atrial and ventricular views. Ventricular pressure was regulated stepwise in a range of 0-150 mmHg. To test the system, the anterior mitral leaflet was extended by a pericardial patch sutured to the mid/basal part of the leaflet, and the chordae tendineae force was measured as the ventricular pressure was applied. Results The system demonstrated the capacity to hold native porcine mitral valves and introducing patch repairs according to clinical practice. The porcine mitral valve test setup indicated strong correlation between the forces in the mitral valve secondary chordae tendineae and the applied transvalvular pressure (R2 = 0.95). Conclusion This test setup proved the ability to obtain normal mid-systolic mitral valve function, secondary chordae force measurements, and important preservation of the visual access: Hence, obtaining the pressure-force relationship as well as identifying any shift of the secondary chordae insertion point on the anterior leaflet relative to the coaptation zone was made possible. PMID:26273417
Kaza, Aditya K.; Patel, Mayank R.; Fiser, Steven M.; Long, Stewart M.; Kern, John A.; Tribble, Curtis G.; Kron, Irving L.
Introduction Surgical restoration of the left ventricular wall (Dor procedure) has been advocated as a therapy for left ventricular dysfunction due to ischemic cardiomyopathy. This procedure involves placement of an endoventricular patch through a ventriculotomy. Methods We reviewed our series of patients that underwent the Dor procedure within the past 4 years and examined their pre and postoperative ventricular function and mitral valve function. Pre and postoperative ejection fraction and degree of mitral regurgitation were analyzed using the paired Student t-test. We hypothesized that this procedure would result in improved ventricular function and that it would also help improve mitral valve function. Results Thirty-four patients underwent this procedure, with one death. Of these, 30 patients underwent concomitant coronary artery bypass grafting and 8 patients had mitral intervention (seven had an Alfieri repair of the mitral valve, and one had mitral valve annuloplasty). The average preoperative ejection fraction among these patients was 26.8% (range 10–45%). The postoperative ejection fraction was significantly higher at 35.4% (range 25–52%) (P < .001). We noted an improvement in ejection fraction in 27 patients (82%). We also noted that 21 of 33 patients (64%) had improvement in the degree of mitral regurgitation based on echocardiography data (P < .001). Conclusions We conclude that the Dor procedure results in improvement in the left ventricular function. Furthermore, we also note that this procedure ameliorates mitral regurgitation in a majority of these patients even in the absence of associated mitral valve procedures, probably due to reduction in the size of the ventricle and improved orientation of the papillary muscles. PMID:12035039
Nakano, K; Swindle, M M; Spinale, F; Ishihara, K; Kanazawa, S; Smith, A; Biederman, R W; Clamp, L; Hamada, Y; Zile, M R
It is known that long-standing volume overload on the left ventricle due to mitral regurgitation eventually leads to contractile dysfunction. However, it is unknown whether or not correction of the volume overload can lead to recovery of contractility. In this study we tested the hypothesis that depressed contractile function due to volume overload in mitral regurgitation could return toward normal after mitral valve replacement. Using a canine model of mitral regurgitation which is known to produce contractile dysfunction, we examined contractile function longitudinally in seven dogs at baseline, after 3 mo of mitral regurgitation, 1 mo after mitral valve replacement, and 3 mo after mitral valve replacement. After 3 mo of mitral regurgitation (regurgitant fraction 0.62 +/- 0.04), end-diastolic volume had nearly doubled from 68 +/- 6.8 to 123 +/- 12.1 ml (P less than 0.05). All five indices of contractile function which we examined were depressed. For instance, maximum fiber elastance (EmaxF) obtained by assessment of time-varying elastance decreased from 5.95 +/- 0.71 to 2.25 +/- 0.18 (P less than 0.05). The end-systolic stiffness constant (k) was also depressed from 4.2 +/- 0.4 to 2.1 +/- 0.3. 3 mo after mitral valve replacement all indexes of contractile function had returned to or toward normal (e.g., EmaxF 3.65 +/- 0.21 and k 4.2 +/- 0.3). We conclude that previously depressed contractile function due to volume overload can improve after correction of the overload. PMID:1828252
Roberts, Brad J; Grayburn, Paul A
Qualitative grading of mitral regurgitation severity has significant pitfalls secondary to hemodynamic variables, sonographic technique, blood pool entrainment, and the Coanda effect. Volumetric and proximal isovelocity surface area methods can be used to quantitate regurgitant orifice area, regurgitant volume, and regurgitant fraction, but have several limitations and can pose technical challenges. The vena contracta width method provides a rapid and accurate quantitative assessment of mitral regurgitation severity, but is clinically underused. This article is intended to generate an understanding of the flow mechanics of the vena contracta and the sonographic technique required to provide consistent and accurate measurements of vena contracta width in patients with mitral regurgitation.
Vega, Julián; Gabrielli, Luigi; Olivares, Gabriel; Córdova, Samuel; Méndez, Manuel; González, Rodrigo
We report a 23-year-old woman, with three recent exertional syncopes. Transthoracic (TTE) and transesophageal (TEE) echocardiography found a large heterogeneous mass (38 x 35 mm) arising from the posterior mitral annulus, protruding in systole through the left ventricular outflow tract (LVOT). Heart MRI confirmed the echocardiography findings, suggesting a cardiac myxoma. Cardiac surgery accomplished the complete resection of the lesion, confirming a mass arising from the posterior mitral annulus and preserving mitral anatomy and function. Pathology was positive for a myxoma. Uneventful evolution allowed the discharge of the patient at the fifth postoperative day. Control TTE discarded any complication.
Sabbagh, Adib H.; O'Hare, James E.; Schocket, Lee I.; Pinckley, James N.
A 51-year-old male with acute fulminating pulmonary edema and cardiogenic shock secondary to severe mitral insufficiency from dislodgment of the disc occluder in a Wada-Cutter valve was treated by immediate open heart procedure with a Bjork-Shiley mitral valve replacement. The patient survived and remains well. This is the second patient reported to survive operation and replacement of a malfunctioning prosthetic mitral valve from which the poppet escaped and embolized. The first case was reported by Hughes et al1 in February, 1975. Some striking similarities, as well as differences, in these two cases are discussed. Images PMID:15215920
Hughes, D A; Leatherman, L L; Norman, J C; Cooley, D A
Embolization of the occluder from a prosthetic mitral valve is an extremely rare event. Previous reports in the literature have described the uniformly fatal outcome of this complication. A case in which the occluder from a Wada-Cutter mitral prosthesis embolized five years following implantation is presented. The patient survived following emergency reoperation. Several unique features of escaped mitral poppet are discussed. Depending upon cardiac reserves, patients who have this complication may live long enough to allow emergency operative intervention and eventual recovery.
Sabbagh, Adib H.; O'Hare, James E.; Schocket, Lee I.; Pinckley, James N.
A 51-year-old male with acute fulminating pulmonary edema and cardiogenic shock secondary to severe mitral insufficiency from dislodgment of the disc occluder in a Wada-Cutter valve was treated by immediate open heart procedure with a Bjork-Shiley mitral valve replacement. The patient survived and remains well. This is the second patient reported to survive operation and replacement of a malfunctioning prosthetic mitral valve from which the poppet escaped and embolized. The first case was reported by Hughes et al(1) in February, 1975. Some striking similarities, as well as differences, in these two cases are discussed.
Dottori, V; Barberis, L; Lijoi, A; Giambuzzi, M; Maccario, M; Faveto, C
We compared a series of 7 consecutive patients who underwent mitral valve replacement with preservation of both leaflets to a control group of 97 patients who underwent standard mitral valve replacement at our institution during the same period. Use of inotropic drugs and duration of postoperative intensive care were compared and shown to be markedly reduced in the study group; however, statistical analysis was not applied due to the small number of patients. Comparison of the available pre- and postoperative echocardiographic values showed a decrease in left ventricular end-diastolic and end-systolic diameters in patients with preserved leaflets, particularly in those with mitral regurgitation of degenerative origin. PMID:8000269
Segreto, Antonio; De Salvatore, Sergio; Chiusaroli, Alessandro; Bizzarri, Federico; Van Wyk, Cornelius; Congiu, Stefano
The case is described of an eight-year-old boy who required an operation for moderate mitral regurgitation due to a double-orifice mitral valve (DOMV). The DOMV, which was clearly demonstrated by transthoracic echocardiography, had a central fibrous bridge. Mitral valve repair using a 5/0 Prolene suture placed at the level of the superior commissure of each hole to stabilize the valve, and ring annuloplasty with Edwards Physio ring, was successfully performed. Intraoperative real-time transesophageal echocardiography showed the repaired DOMV to be without regurgitation or stenosis.
Iagnocco, A; Epis, O; Delle Sedie, A; Meenagh, G; Filippucci, E; Riente, L; Scirè, C A; Montecucco, C; Bombardieri, S; Grassi, W; Valesini, G
The use of Doppler ultrasound in rheumatology has grown in recent years. This is partly due to the increasing number of rheumatologists who perform US in their daily clinical practise and also to the technological advances of US systems. Both colour Doppler and power Doppler are used to evaluate the degree of intra- and peri-articular soft tissue inflammation. Moreover, Doppler US has been found to be of help in the assessment of vascular pathologies such as the vasculitides. In this review we provide an update of the data regarding the use of colour Doppler and power Doppler in rheumatology.
Vaquerizo, Beatriz; Theriault-Lauzier, Pascal; Piazza, Nicolo
Mitral regurgitation is the most prevalent valvular heart disease worldwide. Despite the widespread availability of curative surgical intervention, a considerable proportion of patients with severe mitral regurgitation are not referred for treatment, largely due to the presence of left ventricular dysfunction, advanced age, and comorbid illnesses. Transcatheter mitral valve replacement is a promising therapeutic alternative to traditional surgical valve replacement. The complex anatomical and pathophysiological nature of the mitral valvular complex, however, presents significant challenges to the successful design and implementation of novel transcatheter mitral replacement devices. Patient-specific 3-dimensional computer-based models enable accurate assessment of the mitral valve anatomy and preprocedural simulations for transcatheter therapies. Such information may help refine the design features of novel transcatheter mitral devices and enhance procedural planning. Herein, we describe a novel medical image-based processing tool that facilitates accurate, noninvasive assessment of the mitral valvular complex, by creating precise three-dimensional heart models. The 3-dimensional computer reconstructions are then converted to a physical model using 3-dimensional printing technology, thereby enabling patient-specific assessment of the interaction between device and patient. It may provide new opportunities for a better understanding of the mitral anatomy-pathophysiology-device interaction, which is of critical importance for the advancement of transcatheter mitral valve replacement.
Huang, Chih-Chung; Chou, Hung-Lung; Chen, Pay-Yu
Measurement of the Doppler power of signals backscattered from flowing blood (henceforth referred to as the Doppler power of flowing blood) and the echogenicity of flowing blood have been used widely to assess the degree of red blood cell (RBC) aggregation for more than 20 y. Many studies have used Doppler flowmeters based on an analogue circuit design to obtain the Doppler shifts in the signals backscattered from flowing blood; however, some recent studies have mentioned that the analogue Doppler flowmeter exhibits a frequency-response problem whereby the backscattered energy is lost at higher Doppler shift frequencies. Therefore, the measured Doppler power of flowing blood and evaluations of RBC aggregation obtained using an analogue Doppler device may be inaccurate. To overcome this problem, the present study implemented a field-programmable gate array-based digital pulsed-wave Doppler flowmeter to measure the Doppler power of flowing blood, in the aim of providing more accurate assessments of RBC aggregation. A clinical duplex ultrasound imaging system that can acquire pulsed-wave Doppler spectrograms is now available, but its usefulness for estimating the ultrasound scattering properties of blood is still in doubt. Therefore, the echogenicity and Doppler power of flowing blood under the same flow conditions were measured using a laboratory pulser-receiver system and a clinical ultrasound system, respectively, for comparisons. The experiments were carried out using porcine blood under steady laminar flow with both RBC suspensions and whole blood. The experimental results indicated that a clinical ultrasound system used to measure the Doppler spectrograms is not suitable for quantifying Doppler power. However, the Doppler power measured using a digital Doppler flowmeter can reveal the relationship between backscattering signals and the properties of blood cells because the effects of frequency response are eliminated. The measurements of the Doppler power and
Johannessen, K.A.; Cerqueira, M.D.; Stratton, J.R. )
To assess the relation between myocardial infarction size and diastolic function as measured by radionuclide ventriculography and Doppler echocardiography, 83 patients (aged 58 +/- 9 years) without significant valvular disease were studied 8 to 12 weeks after an acute myocardial infarction. Myocardial infarction size was measured by resting thallium-201 tomography. Peak early filling rate (in end-diastolic volumes/s) was measured by gated blood pool scintigraphy. Doppler measures of mitral inflow were peak early (E) and atrial (A) filling velocities, slopes of E and A, percent E and A filling, E/A ratio and diastolic filling period. In univariate analyses, there was a significant inverse correlation between infarction size and the peak early filling rate (r = -0.59, p less than 0.001), and this remained significant (r = -0.63, p less than 0.0001) in an analysis that included 2 other determinants of the filling rate, age and diastolic filling period. Infarction size was directly correlated to the peak E velocity (r = 0.37, p less than 0.01), deceleration of E (r = 0.41, p less than 0.01) and percent E filling (r = 0.31, p less than 0.01), and was inversely correlated to peak A (r = -0.27, p less than 0.05) and percent A filling (r = -0.26, p less than 0.05).
Kossaify, Antoine; Nicolas, Nayla
Background Diastolic dysfunction is a common cause of heart failure with preserved systolic function in obese patients. Objective To assess diastolic function in a series of overweight and obese patients using conventional and tissue Doppler echocardiography. Setting and method University hospital; left ventricular diastolic function was evaluated in 99 patients (mean age 61.59 ± 13.9 years); body mass index and waist circumference were assessed, and patients were subdivided into three groups according to their body mass index (kg/m2): [normal, (18.5–24.9); overweight, (25–29.9); obese, (>29.9)]. Peak early (E) and late (A) transmitral flow and peak early (E′) diastolic mitral annulus velocities were measured. Results Diastolic dysfunction was significantly higher in the overweight/obese groups compared to the normal body mass index group. The analysis was made with regard to waist circumference and other clinical characteristics, and multivariate regression analysis showed a direct and independent effect of body mass index on diastolic function [OR: 2.75; CI: 1.34–5.67; P = 0.006]. Discussion was made in view of the latest clinical data. Also, an insight into normal weight obesity is presented and discussed. Conclusion Overweight and obesity are found to have an independent negative impact on diastolic function as assessed by tissue Doppler imaging. PMID:23471126
Ramasamy, Ramona; Kaliappan, Tamilarasu; Gopalan, Rajendiran; Palanimuthu, Ramasmy; Anandhan, Premkrishna
Introduction Rheumatic mitral stenosis is the most common Valvular Heart Disease encountered during pregnancy. Balloon Mitral Valvuloplasty (BMV) is one of the treatment option available if the symptoms are refractory to the medical management and the valve anatomy is suitable for balloon dilatation. BMV with Inoue balloon is the most common technique being followed worldwide. Over the wire BMV is a modified technique using Joseph Mitral Valvuloplasty (JOMIVA) balloon catheter which is being followed in certain centres. Aim To assess the immediate post procedure outcome of over the wire BMV with JOMIVA balloon. Materials and Methods Clinical and echocardiographic parameters of pregnant women with significant mitral stenosis who underwent elective BMV with JOMIVA balloon in our institute from 2005 to 2015 were analysed retrospectively. Severity of breathlessness (New York Heart Association Functional Class), and duration of pregnancy was included in the analysis. Pre procedural echocardiographic parameters which included severity of mitral stenosis and Wilkin’s scoring were analysed. Clinical, haemodynamic and echocardiographic outcomes immediately after the procedure were analysed. Results Among the patients who underwent BMV in our Institute 38 were pregnant women. Twenty four patients (63%) were in New York Heart Association (NYHA) Class III. All of them were in sinus rhythm except two (5%) who had atrial fibrillation. Thirty four patients (89.5%) were in second trimester of pregnancy at the time of presentation and four (10.5%) were in third trimester. Echocardiographic analysis of the mitral valve showed that the mean Wilkin’s score was 7.3. Mean mitral valve area pre procedure was 0.8 cm2. Mean gradient across the valve was 18 mmHg. Ten patients (26.5%) had mild mitral regurgitation and none had more than mild mitral regurgitation. Thirty six patients had pulmonary hypertension as assessed by tricuspid regurgitation jet velocity. All of them underwent BMV
Ananthanarayanan, Chandrasekaran; Bishnoi, Arvind Kumar; Ramani, Jayadip; Gandhi, Hemang
Cardiac myxomas are rare intracardiac tumors, and the majority are benign myxomas involving the left atrium. We report a case of the very rare occurrence of biatrial myxoma associated with mitral regurgitation, which was successfully treated.
Murugesan, Chinnamuthu; Raghu, Bheemaiah; Rao, Parachuri Venkateshwara
A 16-year-old woman with severe mitral regurgitation as a result of rheumatic heart disease underwent mitral valve repair with posterior mitral annuloplasty. ST elevation was observed in leads II, III and aVF after weaning from cardiopulmonary bypass. On transesophageal echocardiography, the stenosis of the circumflex artery was suggested by a modified midesophageal long axis. Since the patient was hemodynamically unstable, an emergency coronary angiography could not be considered. An urgent cardiopulmonary bypass was re-instituted; the first two sutures in the P1 region of the posterior mitral annulus were translocated more superficially. Transesophageal echocardiography revealed good opening of the circumflex artery and improvement in regional wall motion abnormality following the corrected procedure.
Anyanwu, Ani C; Adams, David H
In this review we summarize the data on epidemiology and natural history of functional tricuspid valve regurgitation as it applies to surgery for mitral valve disease. Tricuspid regurgitation in the context of mitral valve disease is frequent and is associated with substantial reduction in survival and quality of life. In many patients, the correction of left-sided cardiac lesions does not lead to resolution of tricuspid regurgitation. Significant tricuspid regurgitation after mitral valve surgery portends a poor prognosis, a course that is often not altered by subsequent surgical therapy. Although a liberal approach to tricuspid annuloplasty is widely practiced, the evidence that this approach alters the natural history of functional tricuspid regurgitation is not yet available, so it is not certain how much of the negative impact of tricuspid regurgitation is causative, rather than confounding, and to what degree we will improve long-term outcomes of mitral valve surgery by liberal tricuspid annuloplasty.
Various devices have been developed to facilitate mitral valve surgery, including those that improve mitral valve exposure and assist surgeons with associated procedures. Choosing appropriate supporting devices when performing minimally invasive mitral valve surgery (MIMVS) through a minithoracotomy with endoscopic assistance is critical. Depending on the surgeon’s preference, trans-thoracic or trans-working-port left atrial retractors can be utilized. Although the trans-thoracic retractors provide a simple and orderly working space around the minithoracotomy working port, the positioning of the shaft is difficult and there is an implicit risk of chest wall bleeding. On the other hand, the trans-working-port type provides excellent exposure, is easily handled and manipulated, and facilitates surgeries involving various anatomical structures without special training. A great deal of understanding and knowledge about retractors is necessary to achieve the optimal exposure required to facilitate surgical techniques, and to maintain a reproducible and safe surgical system during mitral valve surgery. PMID:26309847
Bruschi, Giuseppe; De Marco, Federico; Oreglia, Jacopo; Colombo, Paola; Fratto, Pasquale; Lullo, Francesca; Paino, Roberto; Frigerio, Maria; Martinelli, Luigi; Klugmann, Silvio
Concerns exist in the field of transcatheter aortic valve implantation regarding the treatment of patients with mechanical mitral valve for possible interference between the percutaneous aortic valve and the mechanical mitral prosthesis. We report our experience with percutaneous aortic valve implantation in 4 patients with severe aortic stenosis, previously operated on for mitral valve replacement with a mechanical prosthesis. All patients underwent uneventful percutaneous retrograde CoreValve implantation (CoreValve Inc, Irvine, CA). No deformation of the nitinol tubing of the prostheses (ie, neither distortion nor malfunction of the mechanical valve in the mitral position) occurred in any of the patients. All patients are alive and asymptomatic at a mean follow-up of 171 days.
Toufan, Mehrnoush; Mahmoudi, Seyed Sajjad
A 29-year old female patient was referred to our hospital for evaluation of dyspnea NYHA class I which begun from several months ago. The only abnormal sign found on physical examination was a grade 2/6 systolic murmur at the apex position without radiation. Echocardiography revealed normal left and right ventricular sizes and systolic function, and only one papillary muscle in left ventricular (LV) cavity which all chordae tendineae inserted into that muscle. The mitral valve orifice was eccentrically located at the lateral side with mild to moderate mitral regurgitation but without significant mitral stenosis. No other congenital heart anomalies were identified. Thus, the final diagnosis was isolated parachute mitral valve (IPMV). She was one of the very rare IPMV cases have ever been reported in adults PMID:27069567
Okamoto, Kazuma; Yozu, Ryohei
Various devices have been developed to facilitate mitral valve surgery, including those that improve mitral valve exposure and assist surgeons with associated procedures. Choosing appropriate supporting devices when performing minimally invasive mitral valve surgery (MIMVS) through a minithoracotomy with endoscopic assistance is critical. Depending on the surgeon's preference, trans-thoracic or trans-working-port left atrial retractors can be utilized. Although the trans-thoracic retractors provide a simple and orderly working space around the minithoracotomy working port, the positioning of the shaft is difficult and there is an implicit risk of chest wall bleeding. On the other hand, the trans-working-port type provides excellent exposure, is easily handled and manipulated, and facilitates surgeries involving various anatomical structures without special training. A great deal of understanding and knowledge about retractors is necessary to achieve the optimal exposure required to facilitate surgical techniques, and to maintain a reproducible and safe surgical system during mitral valve surgery.
Sunami, Y; Shimura, A; Miyazawa, Y; Nishimoto, Y; Masuda, Y; Inagaki, Y
In view of the close relationship of mitral valve prolapse (MVP) and chest deformity, seven patients of MVP associated with flat chest were echocardiographically evaluated, and the results were compared with those of 43 normal control subjects, 29 cases with flat chest, and patients with MVP either of the anterior (25 cases) or posterior (21 cases) leaflet. MVP associated with flat chest was observed in the anterior leaflet in all cases. MVP was related to the dislocation of the two mitral leaflets caused by the displaced posterior mitral ring observed by two-dimensional echocardiography. The transition type was observed among the cases with or without dislocation of the mitral ring in cases with flat chest.
Goldstein, D.; Moskowitz, A.J.; Gelijns, A.C.; Ailawadi, G.; Parides, M.K.; Perrault, L.P.; Hung, J.W.; Voisine, P.; Dagenais, F.; Gillinov, A.M.; Thourani, V.; Argenziano, M.; Gammie, J.S.; Mack, M.; Demers, P.; Atluri, P.; Rose, E.A.; O’Sullivan, K.; Williams, D.L.; Bagiella, E.; Michler, R.E.; Weisel, R.D.; Miller, M.A.; Geller, N.L.; Taddei-Peters, W.C.; Smith, P.K.; Moquete, E.; Overbey, J.R.; Kron, I.L.; O’Gara, P.T.; Acker, M.A.
BACKGROUND In a randomized trial comparing mitral-valve repair with mitral-valve replacement in patients with severe ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI), survival, or adverse events at 1 year after surgery. However, patients in the repair group had significantly more recurrences of moderate or severe mitral regurgitation. We now report the 2-year out-comes of this trial. METHODS We randomly assigned 251 patients to mitral-valve repair or replacement. Patients were followed for 2 years, and clinical and echocardiographic outcomes were assessed. RESULTS Among surviving patients, the mean (±SD) 2-year LVESVI was 52.6±27.7 ml per square meter of body-surface area with mitral-valve repair and 60.6±39.0 ml per square meter with mitral-valve replacement (mean changes from baseline, −9.0 ml per square meter and −6.5 ml per square meter, respectively). Two-year mortality was 19.0% in the repair group and 23.2% in the replacement group (hazard ratio in the repair group, 0.79; 95% confidence interval, 0.46 to 1.35; P = 0.39). The rank-based assessment of LVESVI at 2 years (incorporating deaths) showed no significant between-group difference (z score = −1.32, P = 0.19). The rate of recurrence of moderate or severe mitral regurgitation over 2 years was higher in the repair group than in the replacement group (58.8% vs. 3.8%, P<0.001). There were no significant between-group differences in rates of serious adverse events and overall readmissions, but patients in the repair group had more serious adverse events related to heart failure (P = 0.05) and cardiovascular readmissions (P = 0.01). On the Minnesota Living with Heart Failure questionnaire, there was a trend toward greater improvement in the replacement group (P=0.07). CONCLUSIONS In patients undergoing mitral-valve repair or replacement for severe ischemic mitral regurgitation, we observed no significant between
Smith, R A; Kerber, R E; Snyder, J W
Phonocardiography and echocardiography were used to examine 20 patients with a normally functioning Beall disc mitral valve prosthesis. Phonocardiographic intervals were: Q-S1 interval 67 +/- 3 msec; A2-OC interval 118 +/- 8 msec. Maximal variation of the Q-S1 interval within one examination was 21 +/- 2 msec, for A2-OC interval it was 31 +/- 5 msec. Echocardiographic disc velocities were: opening velocity 296 +/- 30 mm/sec, closing velocity 414 +/- 44 mm/sec. Maximal variation of the opening velocity was 126 +/- 25 msec; maximal variation of the closing velocity was 334 +/- 57 msec. Abnormal poppet function was suspected in one patient with unusual prolongation and variability of A2-OC interval.
Parker, Heidi G.; Kilroy-Glynn, Paul
Myxomatous mitral valve disease (MMVD) is the most commonly diagnosed cardiovascular disease in the dog accounting for more than 70% of all cardiovascular disease in dogs. As are most canine diseases with genetic underpinnings, risk of MMVD is greatly increased in a subset of breeds. What is uncommon is that the vast majority of the breeds at elevated risk for MMVD are small or toy breeds with average adult weights under 9 kg. These breeds appear to have little in common other than their diminutive size. In the following review we propose a number of mechanisms by which relatively unrelated small breeds may have developed a predisposition for chronic valvular disorders. Although factors such as age are key in the expression of MMVD, taking a comprehensive look at the commonalities, as well as the differences, between the susceptible breeds may assist in finding the causal variants responsible for MMVD and translating them to improved treatments for both dogs and humans. PMID:22356836
Depenbrock, Sarah M; Visser, Lance C; Kohnken, Rebecca A; Russell, Duncan S; Simpson, Katharine M; Bonagura, John D
A 5-week-old Holstein heifer calf presented for emergency treatment of signs referable to gastrointestinal disease and hypovolemic shock. Fluid resuscitation uncovered clinical signs of primary cardiac disease and echocardiography revealed multiple congenital cardiac defects. Malformations included a cleft anterior mitral valve leaflet resembling an isolated cleft mitral valve and an apically-located muscular ventricular septal defect. The echocardiographic and postmortem findings associated with these defects are presented and discussed in this report.
Secondary or functional mitral regurgitation (FMR) represents an increasing feature of mitral valve disease characterized by abnormal function of anatomically normal leaflets in the context of the impaired function of remodelled left ventricles. The anatomic and pathophysiological basis of FMR are briefly analyzed; in addition, the role of exercise echocardiography for the assessment of FMR is discussed in view of its relevance to clinical practice. PMID:20003417
Roberts, W C; Sullivan, M F
Clinical and necropsy findings are described in 54 patients, aged 25 to 83 years (mean 53), who died within 60 days of simultaneous replacements of both mitral and aortic valves. The patients were separated into 4 groups on the basis of the presence of stenosis (with or without associated regurgitation) or pure regurgitation of each valve: 30 patients (56%) had combined mitral and aortic valve stenosis; 12 patients (22%) had mitral stenosis and pure aortic regurgitation; 8 patients (15%) had pure regurgitation of both valves; and 4 patients (7%) had pure aortic regurgitation and mitral stenosis. Necropsy examination in the 54 patients disclosed a high frequency (48%) of anatomic evidence of interference to poppet or disc movement in either the mitral or aortic valve position or both. Anatomic evidence of interference to movement of a poppet or disc in the aortic valve position was twice as common as anatomic evidence of interference to poppet or disc movement in the mitral position. Interference to poppet movement is attributable to the prosthesis's being too large for the ascending aorta or left ventricular cavity in which it resided. The ascending aorta is infrequently enlarged in patients with combined mitral and aortic valve dysfunction irrespective of whether the aortic valve is stenotic or purely regurgitant. Likewise, the left ventricular cavity is usually not dilated in patients with combined mitral and aortic valve stenosis, the most common indication for replacement of both left-sided cardiac valves. Of the 54 patients, 12 (22%) had 1 mechanical and 1 bioprosthesis inserted. It is recommended that both substitute valves should be mechanical prostheses or both should be bioprostheses.
Brubakk, O; Simonsen, S; Källman, L; Fredriksen, A
The case of a patient with the new type Bjørk-Shiley aortic and mitral valve prosthesis is described. Three months after implant she suffered acute heart failure and died. Post-mortem examination revealed a fractured outlet strut in the mitral valve prosthesis with dislocation of the disc. The fracture was regarded as due to excessive brittleness caused by demonstrated deposition of chromium-tungsten-carbide.
Leddet, P; Couppié, P; De Poli, F; Uhry, S; Hanssen, M
We report the case of an asymptomatic 70-year-old woman with a liquefaction necrosis of mitral annulus calcification. This mass was discovered incidentally during an echocardiographic examination. Additional treatment was not performed because liquefaction necrosis of mitral calcification usually has a benign prognosic. A scheduled clinical review with an echocardiographic examination and cardiac MRI was planified. The patient is actually healthy without any complication.
Kunzelman, K. S.; Einstein, Daniel R.; Cochran, R. P.
Successful mitral valve repair is dependent upon a full understanding of normal and abnormal mitral valve anatomy and function. Computational analysis is one such method that can be applied to simulate mitral valve function in order to analyze the roles of individual components, and evaluate proposed surgical repair. We developed the first three-dimensional, finite element (FE) computer model of the mitral valve including leaflets and chordae tendineae, however, one critical aspect that has been missing until the last few years was the evaluation of fluid flow, as coupled to the function of the mitral valve structure. We present here our latest results for normal function and specific pathologic changes using a fluid-structure interaction (FSI) model. Normal valve function was first assessed, followed by pathologic material changes in collagen fiber volume fraction, fiber stiffness, fiber splay, and isotropic stiffness. Leaflet and chordal stress and strain, and papillary muscle force was determined. In addition, transmitral flow, time to leaflet closure, and heart valve sound were assessed. Model predictions in the normal state agreed well with a wide range of available in-vivo and in-vitro data. Further, pathologic material changes that preserved the anisotropy of the valve leaflets were found to preserve valve function. By contrast, material changes that altered the anisotropy of the valve were found to profoundly alter valve function. The addition of blood flow and an experimentally driven microstructural description of mitral tissue represent significant advances in computational studies of the mitral valve, which allow further insight to be gained. This work is another building block in the foundation of a computational framework to aid in the refinement and development of a truly noninvasive diagnostic evaluation of the mitral valve. Ultimately, it represents the basis for simulation of surgical repair of pathologic valves in a clinical and educational
Dübbers, H W; Neuhaus, K L; Spiller, P; Tebbe, U
Left ventricular and myocardial performance were analyzed in 9 patients with chronic volume overload by mitral regurgitation from biplane cineventriculograms, simultaneous pressure recordings and cardiac output (thermodilution method) determinations. In spite of a considerable regurgitant fraction (49 +/- 17% of total stroke volume) cardiac index on the average is normal (CI = 3.3 +/- 0.7 l . min-1). The main compensatory mechanism to maintain cardiac ouput in hypertorphy (WED = 1.1 +/- 0.2 cm; LVMI = 216 +/- 62 g . m-2; LVMI/EDVI = 1.3 +/- 0.3 g . ml-1) and dilatation (EDVI = 163 +/- 37 ml . m-2). An increase of preload is of minor importance (PLVED = 15 +/- 7 mmHg; sigma ED = (40 +/- 19) x 10(3) dyn . cm-2). Left ventricular enlargement and wall mass are related to the degree of clinical heart failure (NYHA). Enddiastolic volume on the average is more increased than total stroke volume (89 +/- 31 ml . m-2). Ejection fraction (EF = 54 +/- 7%) was depressed despite a normal afterload (sigma tej = (171 +/- 37 x 10(3) dyn. cm-2; sigma max = (247 +/- 48 x 10(3) dyn . cm-2). The reduced ejection fraction and diminished myocardial power are related to an impairment of myocardial function (VMW . sigma tej = (83 +/- 39) x 10(3) dyn . cm-2 . s-1; VMW . sigma tej/ln sigma ED = 7.9 +/- 3.6 x 10(3) dyn . cm-2 . s-1). In comparable degrees of heart failure myocardial function is more compromised in patients with mitral than with aortic regurgitation.
Vannelli, Claire; Moore, John; McLeod, Jonathan; Ceh, Dennis; Peters, Terry
Cardiac valvular stenosis, prolapse and regurgitation are increasingly common conditions, particularly in an elderly population with limited potential for on-pump cardiac surgery. NeoChord©, MitraClipand numerous stent-based transcatheter aortic valve implantation (TAVI) devices provide an alternative to intrusive cardiac operations; performed while the heart is beating, these procedures require surgeons and cardiologists to learn new image-guidance based techniques. Developing these visual aids and protocols is a challenging task that benefits from sophisticated simulators. Existing models lack features needed to simulate off-pump valvular procedures: functional, dynamic valves, apical and vascular access, and user flexibility for different activation patterns such as variable heart rates and rapid pacing. We present a left ventricle phantom with these characteristics. The phantom can be used to simulate valvular repair and replacement procedures with magnetic tracking, augmented reality, fluoroscopy and ultrasound guidance. This tool serves as a platform to develop image-guidance and image processing techniques required for a range of minimally invasive cardiac interventions. The phantom mimics in vivo mitral and aortic valve motion, permitting realistic ultrasound images of these components to be acquired. It also has a physiological realistic left ventricular ejection fraction of 50%. Given its realistic imaging properties and non-biodegradable composition—silicone for tissue, water for blood—the system promises to reduce the number of animal trials required to develop image guidance applications for valvular repair and replacement. The phantom has been used in validation studies for both TAVI image-guidance techniques1, and image-based mitral valve tracking algorithms2.
Javadikasgari, Hoda; Suri, Rakesh M.; Tappuni, Bassman; Lowry, Ashley M.; Mihaljevic, Tomislav; Mick, Stephanie
Background Robotic mitral valve (MV) repair is the least invasive surgical approach to the MV and provides unparalleled access to the valve. We sought to assess technical aspects and clinical outcomes of robotic MV repair for isolated posterior leaflet prolapse by examining the first 623 such cases performed in a tertiary care center. Methods We reviewed the first 623 patients (mean age 56±9.7 years) with isolated posterior leaflet prolapse who underwent robotic primary MV repair from 01/2006 to 11/2013. All procedures were performed via right chest access with femoral perfusion for cardiopulmonary bypass. Results MV repair was attempted in all patients; 622 (99.8%) underwent MV repair and only 1 (0.2%) converted to replacement. After an initial attempt at robotic MV repair, 8 (1.3%) patients were converted to sternotomy as a result of management of residual mitral regurgitation (n=3), bleeding (n=1), difficulties with surgical exposure (n=2), aortic valve injury (n=1), and aortic dissection (n=1). Intraoperative post-repair echocardiography confirmed that all patients left the operating room with MR graded as mild or less, and pre-discharge echocardiography confirmed mild or less MR in 573 (99.1%). There was no hospital death, sternal wound infection, or renal failure. Seven (1.1%) patients suffered a stroke, 11 (1.8%) patients underwent re-exploration for bleeding, and 111 (19%) experienced new-onset atrial fibrillation. The mean intensive care unit length of stay and hospital length of stay were 29±17 hours and 4.6±1.6 days, respectively. Conclusions At a large tertiary care referral center, robotic MV repair for posterior prolapse is associated with zero mortality, infrequent operative morbidity, and near 100% successful repair. The combination of a patient selection algorithm and increased experience improved clinical outcomes and procedural efficiency. PMID:28203538
Doukas, G; Oc, M; Alexiou, C; Sosnowski, A W; Samani, N J; Spyt, T J
Objective To describe the clinical and echocardiographic outcome after mitral valve (MV) repair for active culture positive infective MV endocarditis. Patients and methods Between 1996 and 2004, 36 patients (mean (SD) age 53 (18) years) with positive blood culture up to three weeks before surgery (or positive culture of material removed at operation) and intraoperative evidence of endocarditis underwent MV repair. Staphylococci and streptococci were the most common pathogens. All patients had moderate or severe mitral regurgitation (MR). Mean New York Heart Association (NYHA) class was 2.3 (1.0). Follow up was complete (mean 38 (19) months). Results Operative mortality was 2.8% (one patient). At follow up, endocarditis has not recurred. One patient developed severe recurrent MR and underwent valve replacement and one patient had moderate MR. There were two late deaths, both non‐cardiac. Kaplan‐Meier five year freedom from recurrent moderate to severe MR, freedom from repeat operation, and survival were 94 (4)%, 97 (3)%, and 93 (5)%, respectively. At the most recent review the mean NYHA class was 1.17 (0.3) (p < 0.0001). At the latest echocardiographic evaluation, left atrial diameters, left ventricular end diastolic diameter, and MV diameter were significantly reduced (p < 0.05) compared with preoperative values. Conclusions MV repair for active culture positive endocarditis is associated with low operative mortality and provides satisfactory freedom from recurrent infection, freedom from repeat operation, and survival. Hence, every effort should be made to repair infected MVs and valves should be replaced only when repair is not possible. PMID:15951395
Nguyen, Tien M.; Jedrey, Thomas C.; Hinedi, Sami; Agan, Martin J.
Report presents theoretical analysis of effect of rate of change of Doppler shift of received multiple-differential-phase-shift-keyed (MDPSK) radio signal on performance of Doppler-corrected differential detector. In particular detector, phase of received signal corrected for Doppler shift by use of Doppler estimator designed to operate in presence of negligibly small Doppler rate.
Equations are given for the doppler shift and rate of change of doppler shift for the bistatic case where an orbiting, nontransmitting earth... of change of doppler shift, satellite height, earth-center angle between the receiver and the satellite, and zenith angle from receiver to satellite are shown for a typical satellite, 1958 Alpha, Explorer I....have been computed, using transmitting and receiving sites of the Space Surveillance System. Plots of various relationships between doppler shift, rate
Mochizuki, Yasuhide; Tanaka, Hidekazu; Fukuda, Yuko; Hirata, Ken-Ichi
A 31-year-old asymptomatic male was referred to hospital for an examination of right bundle brunch block. Both, transthoracic and transesophageal echocardiography revealed normal left ventricular function, and two different-sized papillary muscles; the anterolateral muscle was more pronounced, with almost major chordae tendineae inserted into this dominant muscle, whereas the immature, flat posteromedial papillary muscle had very short chordae tendineae and was located higher in the left ventricle, inserted directly into the mitral annulus. The mitral valve orifice was eccentrically located at the lateral side, but no significant mitral stenosis or regurgitation was observed. No other congenital heart anomalies were identified. Thus, the final diagnosis was isolated parachute-like asymmetric mitral valve (PLAMV), without any other congenital heart anomalies. The patient was followed up closely with periodic echocardiographic examinations. Parachute mitral valve is a rare congenital cardiac defect characterized by focalized attachment of the chordae tendineae of both leaflets to a single papillary muscle. In contrast to true parachute mitral valve, PLAMV has two separate papillary muscles, one of which is more pronounced and into which all chordae are inserted. PLAMV was highly associated with other congenital heart anomalies, and the involved dominant muscle was most frequently a posteromedial papillary muscle. Isolated PLAMV in an adult is even more rare, while the presence of an immature posteromedial papillary muscle--as in the present case--is extremely rare.
Schoen, F J; Goodenough, S H; Ionescu, M I; Braunwald, N S
Interrelationships among silicone poppet wear, cloth wear, and tissue ingrowth were investigated in 14 retrieved Braunwald-Cutter heart valve prostheses following implantation of 37 to 118 (mean 83) months. Six aortic valves (mean 81 months) had severe cloth and poppet wear. In three the poppet had escaped. The lesser wear of the strut covering on the eight mitral valves (mean 84, range 37 to 108 months) was generally functionally insignificant. Mean decrease in mitral poppet diameter was 0.4% (range 0% to 1.5%), in contrast to a mean of 5.8% for aortic poppets. Histologic examination of the cloth/tissue complex demonstrated well-collagenized tissue ingrowth in areas of intact fabric with focal endothelial lining. Functionally trivial calcific deposits were often noted deep in the tissue coating, adjacent to cloth fibers or the strut metal. These results suggest that the mitral Braunwald-Cutter prosthesis need not be electively replaced without specific indication. A model is presented which explains the favorable clinical course demonstrated for mitral recipients and provides a rationale for the disparate clinicopathological behavior of mitral and aortic Braunwald-Cutter prostheses. Although inconsequential in this setting, the focal microcalcification noted in all mitral prostheses implanted for more than 72 months may have implications for the development of clinical cardiac assist devices for long-term application.
Engelhardt, Sandy; De Simone, Raffaele; Wald, Diana; Zimmermann, Norbert; Al Maisary, Sameer; Beller, Carsten J.; Karck, Matthias; Meinzer, Hans-Peter; Wolf, Ivo
Mitral valve reconstruction is a widespread surgical method to repair incompetent mitral valves. During reconstructive surgery the judgement of mitral valve geometry and subvalvular apparatus is mandatory in order to choose for the appropriate repair strategy. To date, intraoperative analysis of mitral valve is merely based on visual assessment and inaccurate sizer devices, which do not allow for any accurate and standardized measurement of the complex three-dimensional anatomy. We propose a new intraoperative computer-assisted method for mitral valve measurements using a pointing instrument together with an optical tracking system. Sixteen anatomical points were defined on the mitral apparatus. The feasibility and the reproducibility of the measurements have been tested on a rapid prototyping (RP) heart model and a freshly exercised porcine heart. Four heart surgeons repeated the measurements three times on each heart. Morphologically important distances between the measured points are calculated. We achieved an interexpert variability mean of 2.28 +/- 1:13 mm for the 3D-printed heart and 2.45 +/- 0:75 mm for the porcine heart. The overall time to perform a complete measurement is 1-2 minutes, which makes the method viable for virtual annuloplasty during an intervention.
Napoleone, Carlo Pace; Oppido, Guido; Angeli, Emanuela; Giardini, Alessandro; Gargiulo, Gaetano
Background. Mitral valve replacement can be very difficult to obtain in infants because the valve annulus diameter can be smaller than the available prosthesis. Case Report. We describe the case of a 2-month-old female weighing 3.5 kg affected by mitral valve dysplasia leading to severe valve stenosis. Despite full medication, the clinical conditions were critical and surgery was undertaken. The mitral valve was unsuitable for repair and the orifice of mitral anulus was 12 mm, too small for a mechanical prosthesis. Therefore, a Ross-Kabbani operation was undertaken, replacing the mitral valve with the pulmonary autograft and reconstructing the right ventricular outflow tract with an etherograft. Results. The postoperative course was uneventful and the clinical conditions are good at 4-month follow-up. Conclusion. The Ross-Kabbani operation can be an interesting alternative to mitral valve replacement in infants when valve repair is not achievable and there is little space for an intra-annular mechanical prosthesis implant. PMID:20049318
Krieger, Eric V; Lee, James; Branch, Kelley R; Hamilton-Craig, Christian
In this review discuss the application of cardiac magnetic resonance (CMR) to the evaluation and quantification of mitral regurgitation and provide a systematic literature review for comparisons with echocardiography. Using the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology, we searched Medline and PubMed for original research articles published since 2000 that provided data on the quantification of mitral regurgitation by CMR. We identified 220 articles of which 33 were included. Four main techniques of mitral regurgitation quantification were identified. Reproducibility varied substantially between papers but was high overall for all techniques. However, quantification differed between the techniques studied. When compared with two-dimensional echocardiography, mitral regurgitation fraction and regurgitant volume measured by CMR were comparable but typically lower. CMR has high reproducibility for the quantification of mitral regurgitation in experienced centres, but further technological refinement is needed. An integrated and standardised approach that combines multiple techniques is recommended for optimal reproducibility and precise mitral regurgitation quantification. Definitive outcome studies using CMR as a basis for treatment are lacking but needed.
Cottini, E; Giacone, G; Cosentino, M; Cirino, A; Rando, G; Vintaloro, G
More and more older people exercise endurance training. Physical activity regularly exercised has been proven to exert beneficial effects on the cardiovascular system. The aim of the present study was to investigate left ventricular diastolic function by analysis of the pulmonary venous flow velocity pattern (PVFVP) in conjunction with the mitral flow velocity pattern (MFVP) in endurance veteran athletes. The study was performed in 15 trained veteran athletes (mean age 60 +/- 10) and 15 sedentary older subjects (mean age 61 +/- 7). Between the two groups there were no differences of age, body surface area and blood pressure. All subjects were without evidence of cardiovascular diseases. They underwent transthoracal pulsed Doppler echocardiography and the following parameters were measured: early (E) and late (A) peak diastolic filling velocities from mitral flow and E/A ratio; peak forward flow velocities during systole (S) and diastole (D) and peak reverse flow velocity at atrial contraction (Ar) from right upper pulmonary vein. The peak early diastolic filling and E/A ratio resulted significantly increased in the veteran athletes compared with the older sedentary subjects (E 80.0 +/- 13.6 and 62.2 +/- 8.2, respectively, p < 0.01; E/A 1.20 +/- 0.1 and 0.90 +/- 0.1, respectively, p < 0.001), whereas there were no significant differences m the PVFVP between the two groups. Heart rate at rest was significantly lower in the veteran athletes compared with sedentary older subjects (58.3 +/- 8 and 72.8 +/- 7.6, respectively, p < 0.001). These data demonstrate an improvement of left ventricle diastolic function in endurance veteran athletes (E/A ratio > 1 ) in comparison with sedentary older subjects (E/A ratio > 1). Analysis of PVFVP suggests that the left atrial contribution to left ventricular filling increases with aging without any significant differences between the two groups. Therefore, left atrial function, i.e., the main determinant of PVFVP is not likely
Snow, F R; Gorcsan, J; Lewis, S A; Cowley, M J; Vetrovec, G W; Nixon, J V
The effect of percutaneous transluminal coronary angioplasty (PTCA) on left ventricular (LV) diastolic function has not been systematically investigated in patients treated for unstable angina or ischemia after acute myocardial infarction (AMI). To assess the relation between reduction of stenosis severity and improvement in diastolic function in this setting, 42 patients with either unstable angina (n = 22) or post-AMI ischemia (n = 20) were serially monitored by Doppler echocardiography 8 +/- 5 hours before and 2 +/- 1 days after PTCA. Doppler LV filling indexes included isovolumic relaxation time, mitral deceleration time, E/A peak velocity ratio and atrial filling fraction. Eighteen aged-matched control subjects served to establish normal values for comparison. Before PTCA, both groups exhibited abnormal diastolic function demonstrated by prolonged isovolumic relaxation time and mitral deceleration time, decreased E/A ratio and increased atrial filling fraction. After PTCA isovolumic relaxation time and deceleration time decreased 18 +/- 28 (p less than 0.005) and 33 +/- 43 ms (p less than 0.002) in the unstable angina group and 18 +/- 23 (p less than 0.003) and 14 +/- 34 ms (difference not significant), respectively, in the post-AMI ischemia group. An increase in E/A ratio and a decrease in atrial filling fraction occurred in both groups; however, these changes were significant only in patients with post-AMI ischemia (+21%, p less than 0.03 and -11.4%, p less than 0.005, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)
Palecek, Tomas; Linhart, Ales; Lubanda, Jean Claude; Magage, Sudheera; Karetova, Debora; Bultas, Jan; Aschermann, Michael
Fabry disease is an X-linked genetic disorder characterized by progressive intracellular accumulation of neutral glycosphingolipids. Cardiac involvement is frequent and left ventricular (LV) diastolic dysfunction is present in most of the affected subjects. Pulsed-wave tissue Doppler echocardiography (PW-TDE) and color M-mode are new Doppler methods for LV diastolic function evaluation. Their role in the assessment of Fabry disease-related cardiomyopathy remains to be established. In this study we aimed to determine the utility of PW-TDE and color M-mode-derived parameters in the assessment of LV diastolic function in patients with Fabry disease. Eighty-one echocardiographic examinations performed in 35 patients affected by Fabry disease were retrospectively analyzed. Early diastolic lateral mitral annular velocity (E(m)) determined by PW-TDE and color M-mode flow propagation velocity (V(p)) were measured and compared to LV filling patterns obtained using standard Doppler indexes. The receiver operating characteristics (ROC) curves method was used to determine the summary measure of relative accuracy for E(m) and V(p). A comparison of ROC curves showed a significant difference for areas under the curve in favor of E(m) (P < 0.001). Pseudonormal filling pattern, higher LV mass index, higher relative wall thickness, larger left atrial diameter, and older age were more frequent (all P < 0.001) in patients with incorrect diagnosis of normal LV diastolic function based on the measurement of V(p). E(m) appears to be superior to V(p) in the assessment of LV diastolic function in patients with Fabry disease. V(p) fails to detect abnormal LV diastolic function in subjects with pronounced concentric LV remodeling and pseudonormal filling pattern.
Wang, Xiaozhi; Wang, Liang; Miao, Liping; Zhao, Rong; Wu, Yanhu; Kong, Xiangqing
The effect of CC-chemokine receptor 7 (CCR7) and CC-chemokine ligand 19 (CCL19) on rheumatic mitral stenosis is unknown. This study aimed to explore the roles of CCR7 and CCL19 in rheumatic mitral stenosis by measuring the expression of CCR7 and CCL19 in human mitral valves from rheumatic mitral stenosis patients. Additionally, we examined their effects on human mitral valve interstitial cells (hMVICs) proliferation, apoptosis and wound repair. CCR7 and CCL19 expression was measured in the mitral valves from rheumatic mitral stenosis patients (n = 10) and compared to normal mitral valves (n = 5). CCR7 was measured in cultured hMVICs from rheumatic mitral stenosis patients and normal donors by RT-PCR and immunofluorescence. The cells were also treated with exogenous CCL19, and the effects on wound healing, proliferation and apoptosis were assayed. In the rheumatic mitral valves, valve interstitial cells expressed CCR7, while mononuclear cells and the endothelium expressed CCL19. Healthy mitral valves did not stain positive for CCR7 or CCL19. CCR7 was also detected in cultured rheumatic hMVICs or in normal hMVICs treated with CCL19. In a wound healing experiment, wound closure rates of both rheumatic and normal hMVICs were significantly accelerated by CCL19. These effects were abrogated by a CCR7 neutralizing antibody. The CCR7/CCL19 axis did not influence the proliferation or apoptosis of hMVICs, indicating that wound healing was due to increased migration rates rather than increased proliferation. In conclusion, CCR7 and CCL19 were expressed in rheumatic mitral valves. The CCR7/CCL19 axis may regulate remodeling of rheumatic valve injury through promoting migratory ability of hMVICs.
Hodges, Ryan; Endo, Masayuki; La Gerche, Andre; Eixarch, Elisenda; DeKoninck, Philip; Ferferieva, Vessilina; D'hooge, Jan; Wallace, Euan M.; Deprest, Jan
Fetal intrauterine growth restriction (IUGR) results in abnormal cardiac function that is apparent antenatally due to advances in fetoplacental Doppler ultrasound and fetal echocardiography. Increasingly, these imaging modalities are being employed clinically to examine cardiac function and assess wellbeing in utero, thereby guiding timing of birth decisions. Here, we used a rabbit model of IUGR that allows analysis of cardiac function in a clinically relevant way. Using isoflurane induced anesthesia, IUGR is surgically created at gestational age day 25 by performing a laparotomy, exposing the bicornuate uterus and then ligating 40-50% of uteroplacental vessels supplying each gestational sac in a single uterine horn. The other horn in the rabbit bicornuate uterus serves as internal control fetuses. Then, after recovery at gestational age day 30 (full term), the same rabbit undergoes examination of fetal cardiac function. Anesthesia is induced with ketamine and xylazine intramuscularly, then maintained by a continuous intravenous infusion of ketamine and xylazine to minimize iatrogenic effects on fetal cardiac function. A repeat laparotomy is performed to expose each gestational sac and a microultrasound examination (VisualSonics VEVO 2100) of fetal cardiac function is performed. Placental insufficiency is evident by a raised pulsatility index or an absent or reversed end diastolic flow of the umbilical artery Doppler waveform. The ductus venosus and middle cerebral artery Doppler is then examined. Fetal echocardiography is performed by recording B mode, M mode and flow velocity waveforms in lateral and apical views. Offline calculations determine standard M-mode cardiac variables, tricuspid and mitral annular plane systolic excursion, speckle tracking and strain analysis, modified myocardial performance index and vascular flow velocity waveforms of interest. This small animal model of IUGR therefore affords examination of in utero cardiac function that is
Domoto, Satoru; Morita, Kozo; Koike, Hiroyuki; Iguchi, Atsushi; Uwabe, Kazuhiko; Niinami, Hiroshi
Systolic anterior motion (SAM) of the mitral apparatus is a relatively frequent complication of mitral valve repair. When significant SAM persists despite intraoperative medical therapies, a second repair is generally required. We describe a rare case of SAM due to a hypertrophic septum in a patient who underwent mitral valve repair, with no preoperative obstruction of the left ventricular outflow tract. The present case of SAM was successfully treated only with transaortic septal myectomy. Therefore, myectomy might be considered as an alternative solution for SAM that is suspected to be caused by a hypertrophic septum after mitral valve repair.
Solis, Jorge; Sitges, Marta; Levine, Robert A.; Hung, Judy
Recent developments in three-dimensional echocardiography have made it possible to obtain images in real time, without the need for off-line reconstruction. These developments have enabled the technique to become an important tool for both research and daily clinical practice. A substantial proportion of the studies carried out using three-dimensional echocardiography have focused on the mitral valve, the pathophysiology of mitral valve disease and, in particular, functional mitral regurgitation. The aims of this article were to review the contribution of three-dimensional echocardiography to understanding of the functional anatomy of the mitral valve and to summarize the resulting clinical applications and therapeutic implications. PMID:19232192
Meneghini, R.; Bidwell, S.; Liao, L.; Rincon, R.; Heymsfield, G.; Hildebrand, Peter H. (Technical Monitor)
The Precipitation Radar aboard the Tropical Rain Measuring Mission (TRMM) Satellite has shown the potential for spaceborne sensing of snow and rain by means of an incoherent pulsed radar operating at 13.8 GHz. The primary advantage of radar relative to passive instruments arises from the fact that the radar can image the 3-dimensional structure of storms. As a consequence, the radar data can be used to determine the vertical rain structure, rain type (convective/stratiform) effective storm height, and location of the melting layer. The radar, moreover, can be used to detect snow and improve the estimation of rain rate over land. To move toward spaceborne weather radars that can be deployed routinely as part of an instrument set consisting of passive and active sensors will require the development of less expensive, lighter-weight radars that consume less power. At the same time, the addition of a second frequency and an upgrade to Doppler capability are features that are needed to retrieve information on the characteristics of the drop size distribution, vertical air motion and storm dynamics. One approach to the problem is to use a single broad-band transmitter-receiver and antenna where two narrow-band frequencies are spaced apart by 5% to 10% of the center frequency. Use of Ka-band frequencies (26.5 GHz - 40 GHz) affords two advantages: adequate spatial resolution can be attained with a relatively small antenna and the differential reflectivity and mean Doppler signals are directly related to the median mass diameter of the snow and raindrop size distributions. The differential mean Doppler signal has the additional property that this quantity depends only on that part of the radial speed of the hydrometeors that is drop-size dependent. In principle, the mean and differential mean Doppler from a near-nadir viewing radar can be used to retrieve vertical air motion as well as the total mean radial velocity. In the paper, we present theoretical calculations for the
Background The aim of the study was to investigate the relationship between the ejection fraction (EF) and the mitral annular systolic velocity (Sm) in patients with preserved left ventricular systolic function (EF>55%). The study task was to evaluate whether the assessment of Sm(avg) can be used as an alternative to the Simpson’s method in assessment of the EF. The expected benefit was that Sm could be used to predict EF, when EF is difficult to assess due to poor image quality (IQ). Method Sm was obtained by spectral pulse wave Tissue Doppler Imaging (pwTDI) from the lateral and septal sites of the mitral annulus (MA) and an averaged value was calculated - Sm(avg). EF was assessed using Simpson’s rule. Participants were divided into controls (n=70), hypertensive (HTN, n=56), HTN with diastolic dysfunction (HTN/DD, n=65), HTN with diabetes mellitus (HTN/DM, n=52) and HTN with DD and DM (HTN/DD/DM, n=65). Results Sm(avg) showed strong correlation with EF (r=0.978; p<0.0001). There were no significant differences between the correlation coefficients between the subgroups and the controls. The mathematical model that the study recommended to assess the EF is: EF=45.0 + 2 × Sm(avg). Conclusion The assessment of Sm(avg) could be used as an alternative to EF. This approach may be useful especially when the IQ is poor. The method maintains high accuracy and reproducibility in prediction of the EF. PMID:24160570
Firstenberg, M. S.; Vandervoort, P. M.; Greenberg, N. L.; Smedira, N. G.; McCarthy, P. M.; Garcia, M. J.; Thomas, J. D.
OBJECTIVES: We hypothesized that color M-mode (CMM) images could be used to solve the Euler equation, yielding regional pressure gradients along the scanline, which could then be integrated to yield the unsteady Bernoulli equation and estimate noninvasively both the convective and inertial components of the transmitral pressure difference. BACKGROUND: Pulsed and continuous wave Doppler velocity measurements are routinely used clinically to assess severity of stenotic and regurgitant valves. However, only the convective component of the pressure gradient is measured, thereby neglecting the contribution of inertial forces, which may be significant, particularly for nonstenotic valves. Color M-mode provides a spatiotemporal representation of flow across the mitral valve. METHODS: In eight patients undergoing coronary artery bypass grafting, high-fidelity left atrial and ventricular pressure measurements were obtained synchronously with transmitral CMM digital recordings. The instantaneous diastolic transmitral pressure difference was computed from the M-mode spatiotemporal velocity distribution using the unsteady flow form of the Bernoulli equation and was compared to the catheter measurements. RESULTS: From 56 beats in 16 hemodynamic stages, inclusion of the inertial term ([deltapI]max = 1.78+/-1.30 mm Hg) in the noninvasive pressure difference calculation significantly increased the temporal correlation with catheter-based measurement (r = 0.35+/-0.24 vs. 0.81+/-0.15, p< 0.0001). It also allowed an accurate approximation of the peak pressure difference ([deltapc+I]max = 0.95 [delta(p)cathh]max + 0.24, r = 0.96, p<0.001, error = 0.08+/-0.54 mm Hg). CONCLUSIONS: Inertial forces are significant components of the maximal pressure drop across the normal mitral valve. These can be accurately estimated noninvasively using CMM recordings of transmitral flow, which should improve the understanding of diastolic filling and function of the heart.
Ran, Jia; Zhang, Yewen; Chen, Xiaodong; Fang, Kai; Zhao, Junfei; Chen, Hong
The normal Doppler effect has well-established applications in many areas of science and technology. Recently, a few experimental demonstrations of the inverse Doppler effect have begun to appear in negative-index metamaterials. Here we report an experimental observation of the zero Doppler effect, that is, no frequency shift irrespective of the relative motion between the wave signal source and the detector in a zero-index metamaterial. This unique phenomenon, accompanied by the normal and inverse Doppler effects, is generated by reflecting a wave from a moving discontinuity in a composite right/left-handed transmission line loaded with varactors when operating in the near zero-index passband, or the right/left-handed passband. This work has revealed a complete picture of the Doppler effect in metamaterials and may lead to potential applications in electromagnetic wave related metrology.
Reu, Phillip L.
Measurement of dynamic events at the nano-scale is currently impossible. This paper presents the theoretical underpinnings of a method for making these measurements using electron microscopes. Building on the work of Moellenstedt and Lichte who demonstrated Doppler shifting of an electron beam with a moving electron mirror, further work is proposed to perfect and utilize this concept in dynamic measurements. Specifically, using the concept of ''fringe-counting'' with the current principles of transmission electron holography, an extension of these methods to dynamic measurements is proposed. A presentation of the theory of Doppler electron wave shifting is given, starting from the development of the de Broglie wave, up through the equations describing interference effects and Doppler shifting in electron waves. A mathematical demonstration that Doppler shifting is identical to the conceptually easier to understand idea of counting moving fringes is given by analogy to optical interferometry. Finally, potential developmental experiments and uses of a Doppler electron microscope are discussed.
Zhai, S. L.; Zhao, X. P.; Liu, S.; Shen, F. L.; Li, L. L.; Luo, C. R.
The Doppler effect refers to the change in frequency of a wave source as a consequence of the relative motion between the source and an observer. Veselago theoretically predicted that materials with negative refractions can induce inverse Doppler effects. With the development of metamaterials, inverse Doppler effects have been extensively investigated. However, the ideal material parameters prescribed by these metamaterial design approaches are complex and also challenging to obtain experimentally. Here, we demonstrated a method of designing and experimentally characterising arbitrary broadband acoustic metamaterials. These omni-directional, double-negative, acoustic metamaterials are constructed with ‘flute-like’ acoustic meta-cluster sets with seven double meta-molecules; these metamaterials also overcome the limitations of broadband negative bulk modulus and mass density to provide a region of negative refraction and inverse Doppler effects. It was also shown that inverse Doppler effects can be detected in a flute, which has been popular for thousands of years in Asia and Europe.
Zhai, S L; Zhao, X P; Liu, S; Shen, F L; Li, L L; Luo, C R
The Doppler effect refers to the change in frequency of a wave source as a consequence of the relative motion between the source and an observer. Veselago theoretically predicted that materials with negative refractions can induce inverse Doppler effects. With the development of metamaterials, inverse Doppler effects have been extensively investigated. However, the ideal material parameters prescribed by these metamaterial design approaches are complex and also challenging to obtain experimentally. Here, we demonstrated a method of designing and experimentally characterising arbitrary broadband acoustic metamaterials. These omni-directional, double-negative, acoustic metamaterials are constructed with 'flute-like' acoustic meta-cluster sets with seven double meta-molecules; these metamaterials also overcome the limitations of broadband negative bulk modulus and mass density to provide a region of negative refraction and inverse Doppler effects. It was also shown that inverse Doppler effects can be detected in a flute, which has been popular for thousands of years in Asia and Europe.
Brick, Alexandre Visconti; Braile, Domingo M.
Objective To evaluate surgical treatment of chronic atrial fibrillation with ultrasound in patients with mitral valve disease, considering preoperative clinical characteristics of patients undergoing surgical procedure and follow-up in the immediate postoperative period, in hospital and up to 60 months after discharge. Methods We studied 100 patients with chronic atrial fibrillation and mitral valve disease who underwent surgical treatment using ultrasound ablation. Patient data were reviewed by consulting the control reports, including signs and symptoms, underlying disease, functional class, hospital stay, surgical procedure time, ablation time, immediate complications, and complications at discharged and up to 60 months later. Actuarial curve (Kaplan-Meier) was used for the study of permanence without recurrence after 12, 24, 36, 48 and 60 months. Results 86% of the patients had rheumatic mitral valve disease, 14% had degeneration of the mitral valve, 40% had mitral regurgitation, and 36% had mitral stenosis. Main symptoms included palpitations related to tachycardia by chronic atrial fibrillation (70%), congestive heart failure (70%), and previous episodes of acute pulmonary edema (27%). Early results showed that 94% of the patients undergoing ultrasound ablation reversed the rate of chronic atrial fibrillation, 86% being in sinus rhythm and 8% in atrioventricular block. At hospital discharge, maintenance of sinus rhythm was observed in 86% of patients and there was recurrence of chronic atrial fibrillation in 8% of patients. At follow-up after 60 months, 83.8% of patients maintained the sinus rhythm. Conclusion Surgical treatment of chronic atrial fibrillation with ultrasound concomitant with mitral valve surgery is feasible and satisfactory, with maintenance of sinus rhythm in most patients (83.8%) after 60 months of follow-up.
Khan, M N
Significant progress has been achieved in cardiac surgery in the last 50 years. Mitral valve surgery (especially for the relief of mitral stenosis) has paralleled the innovations and trends of cardiac surgery and often has served as the benchmark of the latest procedures and techniques. A chronological survey of mitral valve surgery is presented, with emphasis on parallels to cardiac surgery in general and with highlights of key figures and events that have conclusively altered the surgeon's approach to and success with cardiac dysfunction. A few surgeons promulgated the idea of cardiac surgery in the late 19th century, but mitral valve surgeries were not performed in earnest until Souttar's and Cutler's initial attempts in the 1920s and were not successful on large groups of patients until Bailey and Harken made independent breakthroughs in the 1940s, finally laying to rest the idea of the "inviolable heart." Cardiopulmonary bypass provided cardiac surgeons with the time to implant mechanical and bioprosthetic valves for palliative benefit to patients. The "perfect" valve has yet to be found, but the Starr-Edwards mechanical valve since its inception in 1961 has been one of the most successful and widely used prosthetic valves. Gradual improvement in surgical technique and growing knowledge of valve function enabled the re-emergence of mitral valve repair in the 1980s as the preferred surgical method of treating mitral stenosis. In the last 10 years, mitral valve balloon dilation has provided a nonsurgical technique for relief of stenosis and represents the broader trend towards interventional techniques. Images PMID:8969024
Deborde, Christopher; Simionescu, Dan Teodor; Wright, Cristopher; Liao, Jun; Sierad, Leslie Neil; Simionescu, Agneta
There is a significant clinical need for new approaches to treatment of mitral valve disease. The aim of this study was to develop a tissue-engineered mitral valve scaffold possessing appropriate composition and structure to ensure ideal characteristics of mitral valves, such as large orifice, rapid opening and closure, maintenance of mitral annulus-papillary muscle continuity, in vivo biocompatibility and extended durability. An extracellular matrix-based scaffold was generated, based on the native porcine mitral valve as starting material and a technique for porcine cell removal without causing damage to the matrix components. To stabilize these structures and slow down their degradation, acellular scaffolds were treated with penta-galloyl glucose (PGG), a well-characterized polyphenol with high affinity for collagen and elastin. Biaxial mechanical testing presented similar characteristics for the PGG-treated scaffolds compared to fresh tissues. The extracellular matrix components, crucial for maintaining the valve shape and function, were well preserved in leaflets, and in chordae, as shown by their resistance to collagenase and elastin. When extracted with strong detergents, the PGG-treated scaffolds released a reduced amount of soluble matrix peptides, compared to untreated scaffolds; this correlated with diminished activation of fibroblasts seeded on scaffolds treated with PGG. Cell-seeded scaffolds conditioned for 5 weeks in a valve bioreactor showed good cell viability. Finally, rat subdermal implantation studies showed that PGG-treated mitral valve scaffolds were biocompatible, nonimmunogenic, noninflammatory, and noncalcifying. In conclusion, a biocompatible mitral valve scaffold was developed, which preserved the biochemical composition and structural integrity of the valve, essential for its highly dynamic mechanical demands, and its biologic durability.
Mornoş, Cristian; Petrescu, Lucian; Ionac, Adina; Cozma, Dragoş
It has been shown a good accuracy to predict high left ventricular end-diastolic pressure for a value >1.6 of a new tissue Doppler index, E/(E' × S'), including the ratio between early diastolic transmitral and mitral annulus velocity (E/E'), and the systolic mitral annulus velocity (S'). Our aim was to evaluate the prognostic value of E/(E' × S') > 1.6 in patients with heart failure (HF). Echocardiography was performed in 345 consecutive hospitalized patients with HF, in sinus rhythm, at hospital discharge and after 1 month. Worsening of E/(E' × S') was defined as any increase of baseline value. The primary end point consisted of cardiac death or readmission due to HF worsening in long term follow-up. At discharge, 153 patients (44.3%) presented E/(E' × S') ≤ 1.6 (group I) while 192 patients (55.7%) presented E/(E' × S') > 1.6 (group II). During the follow-up period (35.1 ± 8.7 months) the first cardiac event was cardiac death in 11 patients (3.1%) and readmission for HF in 179 patients (51.9%). The composite end point was significantly higher in group II than in group I (163 events, 84.9 % vs. 27 events, 17.6%, p < 0.001). By multivariate Cox regression analysis, E/(E' × S') > 1.6 was the best independent predictor of cardiac events (hazard ratio = 4.46, 95% CI = 2.44-8.13, p = 0.001). Patients with E/(E' × S') > 1.6 at discharge and its worsening after 1 month have presented the worst prognosis (all p < 0.05). In patients with HF, E/(E' × S') > 1.6 at hospital discharge is a powerful predictor of clinical outcome particularly if it is associated with worsening.
Phadke, Daniel; Patel, Sonali S; Dominguez, Samuel R; Heizer, Heather; Anderson, Marsha S; Glode, Mary P; Jone, Pei-Ni
Kawasaki disease (KD) is characterized by myocarditis and left ventricular dysfunction during the acute phase of the illness. Despite treatment with intravenous immunoglobulin (IVIG), a significant number of patients are IVIG resistant. We evaluated KD patients in the acute phase of illness using tissue Doppler imaging (TDI) to assess whether myocardial dysfunction may predict IVIG resistance. All patients with acute KD presenting to Children's Hospital Colorado from February 2007 through March 2014 were included in this study and underwent echocardiograms with TDI evaluation at diagnosis. Patients were divided into two groups: IVIG resistant and IVIG responder. Group differences were assessed using Wilcoxon-Mann-Whitney and Chi-square testing. Receiver operating characteristic (ROC) curve analysis was utilized to determine threshold values of TDI measurements associated with IVIG resistance. Fifty-one age-matched IVIG resistant patients were compared to 51 IVIG responder patients [median age, IQR 44.57 (20.13-77.07) vs. 33.49 (17.30-62.89) months, p < 0.44]. There were significant differences in the septal and mitral early diastolic velocities (E') (p < 0.001 and p < 0.01), respectively. ROC analysis demonstrated that tricuspid E' <0.15 cm/s, septal E' <0.12 cm/s, and mitral E' <0.16 cm/s were good predictors of IVIG unresponsiveness (AUC = 0.66, 0.66, and 0.70, respectively). There were no differences between the systolic velocities and late diastolic velocities (A'). IVIG resistant KD patients present with significantly greater diastolic dysfunction compared to responders in patients with KD. TDI may be a useful tool to differentiate KD patients at higher risk of IVIG resistance.
Ascione, L; Antonini-Canterin, F; Macor, F; Cervesato, E; Chiarella, F; Giannuzzi, P; Temporelli, P L; Gentile, F; Lucci, D; Maggioni, A P; Tavazzi, L; Badano, L; Stoian, I; Piazza, R; Bosimini, E; Pavan, D; Nicolosi, G L
Objective: To evaluate the prevalence and correlates of left ventricular thrombosis in patients with acute myocardial infarction, and whether the occurrence of early mitral regurgitation has a protective effect against the formation of left ventricular thrombus. Design and setting: Multicentre clinical trial carried out in 47 Italian coronary care units. Patients and methods: 757 patients from the GISSI-3 echo substudy population with their first acute myocardial infarct were studied by echocardiography at 24–48 hours from symptom onset (S1), at discharge (S2), at six weeks (S3), and at six months (S4). The diagnosis of left ventricular thrombosis was based on the detection of an echo dense mass with defined margins visible throughout the cardiac cycle in at least two orthogonal views. Results: In 64 patients (8%), left ventricular thrombosis was detected in one or more examinations. Compared with the remaining 693 patients, subjects with left ventricular thrombosis were older (mean (SD) age: 64.6 (13.0) v 59.8 (11.7) years, p < 0.005), and had larger infarcts (extent of wall motion asynergy: 40.9 (11.5)% v 24.9 (14)%, p < 0.001), greater depression of left ventricular ejection fraction at S1 (43.3 (6.9)% v 48.1 (6.8)%, p < 0.001), and greater left ventricular volumes at S1 (end diastolic volume: 87 (22) v 78 (18) ml/m2, p < 0.001; end systolic volume: 50 (17) v 41 (14) ml/m2, p < 0.001). The prevalence of moderate to severe mitral regurgitation on colour Doppler at S1 was greater in patients who had left ventricular thrombosis at any time (10.2% v 4.2%, p < 0.05). On stepwise multiple logistic regression analysis the only independent variables related to the presence of left ventricular thrombosis were the extent of wall motion asynergy and anterior site of infarction. Conclusions: Left ventricular thrombosis is not reduced, and may even be increased, by early moderate to severe mitral regurgitation after acute myocardial infarction. The only independent
Atsumi, Yosuke; Tokunaga, Shigehiko; Yasuda, Shota; Fushimi, Kenichi; Masuda, Munetaka
We report a case of severe mitral regurgitation (MR) with dextrocardia and 180° counterclockwise rotated situs solitus heart. We describe the technique for mitral valve surgery in a patient with dextrocardia and agenesis of the right lung.
Ie, Eric H Y; Vletter, Wim B; ten Cate, Folkert J; Nette, Robert W; Weimar, Willem; Roelandt, Jos R T C; Zietse, Robert
Left ventricular (LV) hypertrophy leads to diastolic dysfunction. Standard Doppler transmitral and pulmonary vein (PV) flow velocity measurements are preload dependent. New techniques such as mitral annulus velocity by Doppler tissue imaging (DTI) and LV inflow propagation velocity measured from color M-mode have been proposed as relatively preload-independent measurements of diastolic function. These parameters were studied before and after hemodialysis (HD) with ultrafiltration to test their potential advantage for LV diastolic function assessment in HD patients. Ten patients (seven with LV hypertrophy) underwent Doppler echocardiography 1 h before, 1 h after, and 1 d after HD. Early (E) and atrial (A) peak transmitral flow velocities, peak PV systolic (s) and diastolic (d) flow velocities, peak e and a mitral annulus velocities in DTI, and early diastolic LV flow propagation velocity (V(p)) were measured. In all patients, the E/A ratio after HD (0.54; 0.37 to 1.02) was lower (P < 0.01) than before HD (0.77; 0.60 to 1.34). E decreased (P < 0.01), whereas A did not. PV s/d after HD (2.15; 1.08 to 3.90) was higher (P < 0.01) than before HD (1.80; 1.25 to 2.68). Tissue e/a after HD (0.40; 0.26 to 0.96) was lower (P < 0.01) than before HD (0.56; 0.40 to 1.05). Tissue e decreased (P < 0.02), whereas a did not. V(p) after HD (30 cm/s; 16 to 47 cm/s) was lower (P < 0.01) than before HD (45 cm/s; 32 to 60 cm/s). Twenty-four hours after the initial measurements values for E/A (0.59; 0.37 to 1.23), PV s/d (1.85; 1.07 to 3.38), e/a (0.41; 0.27 to 1.06), and V(p) (28 cm/s; 23 to 33 cm/s) were similar as those taken 1 h after HD. It is concluded that, even when using the newer Doppler techniques DTI and color M-mode, pseudonormalization, which was due to volume overload before HD, resulted in underestimation of the degree of diastolic dysfunction. Therefore, the advantage of these techniques over conventional parameters for the assessment of LV diastolic function in HD
Bilbro, J. W.; Jeffreys, H. B.; Kaufman, J. W.; Weaver, E. A.
A scanning laser doppler velocimeter (SLDV) system was used to detect, track, and measure the velocity flow field of naturally occurring tornado-like flows (dust devils) in the atmosphere. A general description of the dust devil phenomenon is given along with a description of the test program, measurement system, and data processing techniques used to collect information on the dust devil flow field. The general meteorological conditions occurring during the test program are also described, and the information collected on two selected dust devils are discussed in detail to show the type of information which can be obtained with a SLDV system. The results from these measurements agree well with those of other investigators and illustrate the potential for the SLDV in future endeavors.
da Rocha Araújo, Fátima Derlene; de Andrade Goulart, Eugênio Marcos; Meira, Zilda Maria Alves
Secondary prophylaxis remains the safest way to prevent or minimize heart valve damage in patients with rheumatic fever. However, criteria to determine the duration of prophylaxis have not been well established. This study aimed to evaluate the clinical and Doppler echocardiographic profile of patients with rheumatic fever and a normal clinical examination at least 5 years after the first episode and to discuss the contribution of Doppler echocardiography in supporting the decision to discontinue secondary prophylaxis. An observational longitudinal study analyzing 183 patients with rheumatic fever and a normal clinical examination 5 years or more after the initial attack was conducted. The patients underwent Doppler echocardiography to study the severity of mitral or aortic valvular disease. Of the 183 patients, 77 (42 %) had clinical carditis. Subclinical chronic heart disease occurred for 79 % of the patients with previous clinical carditis and for 25 % of the patients without clinical carditis. Of the 35 patients with previous clinical carditis who were in the period of discontinued prophylaxis, residual valvular heart disease was observed in all, whereas of the 62 patients without clinical carditis, only 27 % showed residual valvular heart disease. Considering Doppler echocardiographic criteria, prophylaxis would be continued for 13 (34 %) of the patients with previous clinical carditis and for only 2 (3 %) of those without clinical carditis. Return of cardiac auscultation to normal is not always accompanied by return of Doppler echocardiographic findings to normal. Criteria regarding Doppler echocardiographic findings and valve morphology should be evaluated by the time secondary prophylaxis is discontinued. However, further studies are needed to demonstrate whether prolonged prophylaxis provides any benefit to patients with persistent echocardiographic findings.
Kwan, Jun; Shiota, Takahiro; Agler, Deborah A.; Popovic, Zoran B.; Qin, Jian Xin; Gillinov, Marc A.; Stewart, William J.; Cosgrove, Delos M.; McCarthy, Patrick M.; Thomas, James D.
BACKGROUND: This study was conducted to elucidate the geometric differences of the mitral apparatus in patients with significant mitral regurgitation caused by ischemic cardiomyopathy (ICM-MR) and by idiopathic dilated cardiomyopathy (DCM-MR) by use of real-time 3D echocardiography (RT3DE). METHODS AND RESULTS: Twenty-six patients with ICM-MR caused by posterior infarction, 18 patients with DCM-MR, and 8 control subjects were studied. With the 3D software, commissure-commissure plane and 3 perpendicular anteroposterior (AP) planes were generated for imaging the medial, central, and lateral sides of the mitral valve (MV) during mid systole. In 3 AP planes, the angles between the annular plane and each leaflet (anterior, Aalpha; posterior, Palpha) were measured. In ICM-MR, Aalpha measured in the medial and central planes was significantly larger than that in the lateral plane (39+/-5 degrees, 34+/-6 degrees, and 27+/-5 degrees, respectively; P<0.01), whereas Palpha showed no significant difference in any of the 3 AP planes (61+/-7 degrees, 57+/-7 degrees, and 56+/-7 degrees, P>0.05). In DCM-MR, both Aalpha (38+/-8 degrees, 37+/-9 degrees, and 36+/-7 degrees, P>0.05) and Palpha (59+/-6 degrees, 58+/-5 degrees, and 57+/-6 degrees, P>0.05) revealed no significant differences in the 3 planes. CONCLUSIONS: The pattern of MV deformation from the medial to the lateral side was asymmetrical in ICM-MR, whereas it was symmetrical in DCM-MR. RT3DE is a helpful tool for differentiating the geometry of the mitral apparatus between these 2 different types of functional mitral regurgitation.
Dark, J H; Bain, W H
Possible aetiological factors, presentation, and management were reviewed in 18 patients with posterior left ventricular rupture complicating mitral valve replacement seen at one centre over six and a half years. The patients were elderly (mean age 57), predominantly women (16 of the 18), and suffering from mitral stenosis. Rupture was much more common after isolated replacement of the mitral valve (16 out of 797 operations) than after double valve replacement (one out 236) or mitral valve replacement and coronary artery bypass graft (one out of 70). A total of 1221 mitral valve replacements were performed over this period, with an overall incidence of rupture of 1.47%. Damage to the valve annulus occurred five times. On four occasions haemorrhage followed a vigorous response to a bolus dose of an inotrope. With the exception of these features, it was difficult to define specific risk factors. Eleven patients bled while still in theatre; one of them survived long term and another four lived for four to 10 days. Repair after restarting cardiopulmonary bypass made short term survival much more likely. In seven rupture developed after return to the intensive therapy unit; again only one survived long term. In nearly all cases bleeding was at, or just below, the atrioventricular groove. Rupture probably occurs after endocardial damage to a thin myocardium that has lost the internal buttress of the subvalvar apparatus. With the rise in intraventricular pressure at the end of bypass blood dissects into the myocardium, resulting in a large haematoma and eventual rupture. Images PMID:6515596
Connell, Patrick S; Azimuddin, Anam F; Kim, Seulgi E; Ramirez, Fernando; Jackson, Matthew S; Little, Stephen H; Grande-Allen, K Jane
Mitral valve regurgitation is a challenging clinical condition that is frequent, highly varied, and poorly understood. While the causes of mitral regurgitation are multifactorial, how the hemodynamics of regurgitation impact valve tissue remodeling is an understudied phenomenon. We employed a pseudo-physiological flow loop capable of long-term organ culture to investigate the early progression of remodeling in living mitral valves placed in conditions resembling mitral valve prolapse (MVP) and functional mitral regurgitation (FMR). Valve geometry was altered to mimic the hemodynamics of controls (no changes from native geometry), MVP (5 mm displacement of papillary muscles towards the annulus), and FMR (5 mm apical, 5 mm lateral papillary muscle displacement, 65% larger annular area). Flow measurements ensured moderate regurgitant fraction for regurgitation groups. After 1-week culture, valve tissues underwent mechanical and compositional analysis. MVP conditioned tissues were less stiff, weaker, and had elevated collagen III and glycosaminoglycans. FMR conditioned tissues were stiffer, more brittle, less extensible, and had more collagen synthesis, remodeling, and crosslinking related enzymes and proteoglycans, including decorin, matrix metalloproteinase-1, and lysyl oxidase. These models replicate clinical findings of MVP (myxomatous remodeling) and FMR (fibrotic remodeling), indicating that valve cells remodel extracellular matrix in response to altered mechanical homeostasis resulting from disease hemodynamics.
Magilligan, D J; Oyama, C; Alam, M
We reviewed the incidence of dysfunction of the Smeloff-Cutter mechanical prosthetic valve and the Hancock porcine prosthetic valve in the mitral position. The Smeloff-Cutter valve was implanted from 1966 to 1972; 107 patients were discharged from the hospital and were at risk for dysfunction. Follow-up averaged 10 +/- 0.7 years SD. The Hancock valve was implanted from 1971 through 1984; 473 patients were at risk and follow-up averaged 4.7 +/- 3.4 years SD. Dysfunction of the Smeloff-Cutter valve occurred as thrombosis with incomplete poppet opening in 13 patients. Dysfunction of the Hancock valve occurred as primary tissue failure in 47 patients. At 10 years the freedom from dysfunction of the Smeloff-Cutter valve was 84 +/- 5% SE and that for the Hancock valve was 71 +/- 4% SE (p greater than .06). The mortality associated with dysfunction of the Smeloff-Cutter valve was 46%; mortality associated with dysfunction of the Hancock valve was 15% (p less than .02). At 10 years the Hancock valve had a greater incidence of dysfunction than the Smeloff-Cutter valve but this difference was not statistically significant. The mortality associated with dysfunction of the Smeloff-Cutter valve, however, was three times that associated with dysfunction of the Hancock valve.
Chandran, Krishnan B.; Kim, Hyunggun
The mitral valve (MV) apparatus consists of the two asymmetric leaflets, the saddle-shaped annulus, the chordae tendineae, and the papillary muscles. MV function over the cardiac cycle involves complex interaction between the MV apparatus components for efficient blood circulation. Common diseases of the MV include valvular stenosis, regurgitation, and prolapse. MV repair is the most popular and most reliable surgical treatment for early MV pathology. One of the unsolved problems in MV repair is to predict the optimal repair strategy for each patient. Although experimental studies have provided valuable information to improve repair techniques, computational simulations are increasingly playing an important role in understanding the complex MV dynamics, particularly with the availability of patient-specific real-time imaging modalities. This work presents a review of computational simulation studies of MV function employing finite element (FE) structural analysis and fluid-structure interaction (FSI) approach reported in the literature to date. More recent studies towards potential applications of computational simulation approaches in the assessment of valvular repair techniques and potential pre-surgical planning of repair strategies are also discussed. It is anticipated that further advancements in computational techniques combined with the next generations of clinical imaging modalities will enable physiologically more realistic simulations. Such advancement in imaging and computation will allow for patient-specific, disease-specific, and case-specific MV evaluation and virtual prediction of MV repair. PMID:25134487
Li, Guixin; Zentgraf, Thomas; Zhang, Shuang
The translational Doppler effect of electromagnetic and sound waves has been successfully applied in measurements of the speed and direction of vehicles, astronomical objects and blood flow in human bodies, and for the Global Positioning System. The Doppler effect plays a key role for some important quantum phenomena such as the broadened emission spectra of atoms and has benefited cooling and trapping of atoms with laser light. Despite numerous successful applications of the translational Doppler effect, it fails to measure the rotation frequency of a spinning object when the probing wave propagates along its rotation axis. This constraint was circumvented by deploying the angular momentum of electromagnetic waves--the so-called rotational Doppler effect. Here, we report on the demonstration of rotational Doppler shift in nonlinear optics. The Doppler frequency shift is determined for the second harmonic generation of a circularly polarized beam passing through a spinning nonlinear optical crystal with three-fold rotational symmetry. We find that the second harmonic generation signal with circular polarization opposite to that of the fundamental beam experiences a Doppler shift of three times the rotation frequency of the optical crystal. This demonstration is of fundamental significance in nonlinear optics, as it provides us with insight into the interaction of light with moving media in the nonlinear optical regime.
Brugger, Nicolas; Wustmann, Kerstin; Hürzeler, Michael; Wahl, Andreas; de Marchi, Stefano F; Steck, Hélène; Zürcher, Fabian; Seiler, Christian
The aim of our study was to evaluate 3-dimensional (3D) color Doppler proximal isovelocity surface area (PISA) as a tool for quantitative assessment of mitral regurgitation (MR) against in vitro and in vivo reference methods. A customized 3D PISA software was validated in vitro against a flowmeter MR phantom. Sixty consecutive patients, with ≥mild MR of any cause, were recruited and the regurgitant volume (RVol) was measured by 2D PISA, 3D peak PISA, and 3D integrated PISA, using transthoracic (TTE) and transesophageal echocardiography (TEE). Cardiac magnetic resonance imaging (CMR) was used as reference method. Flowmeter RVol was associated with 3D integrated PISA as follows: y = 0.64x + 4.7, r(2) = 0.97, p <0.0001 for TEE and y = 0.88x + 4.07, r(2) = 0.96, p <0.0001 for TTE. The bias and limit of agreement in the Bland-Altman analysis were 6.8 ml [-3.5 to 17.1] for TEE and -0.059 ml [-6.2 to 6.1] for TTE. In vivo, TEE-derived 3D integrated PISA was the most accurate method for MR quantification compared to CMR: r(2) = 0.76, y = 0.95x - 3.95, p <0.0001; 5.1 ml (-14.7 to 26.5). It was superior to TEE 3D peak PISA (r(2) = 0.67, y = 1.00x + 6.20, p <0.0001; -6.3 ml [-33.4 to 21.0]), TEE 2D PISA (r(2) = 0.54, y = 0.76x + 0.18, p <0.0001; 8.4 ml [-20.4 to 37.2]), and TTE-derived measurements. It was also most accurate by receiver operating characteristic analysis (area under the curve 0.99) for the detection of severe MR, RVol cutoff = 48 ml, sensibility 100%, and specificity 96%. RVol and the cutoff to define severe MR were underestimated using the most accurate method. In conclusion, quantitative 3D color Doppler echocardiography of the PISA permits a more accurate MR assessment than conventional techniques and, consequently, should enable an optimized management of patients suffering from MR.
in cases in which, for one or another reason, a number -the typical traits of pre dominant stenosis in the mitral valve are lost....Results are presented of combined studies of 58 patients with mitral lesions. It is concluded that combined studies which yield interdependent
Hartley, Craig J.; Reddy, Anilkumar K.; Madala, Sridhar; Michael, Lloyd H.; Entman, Mark L.; Taffet, George E.
Aortic banding produces pressure overload cardiac hypertrophy in mice leading to decompensated heart failure in 4–8 wks, but the effects on coronary blood flow velocity and reserve are unknown. To determine whether coronary flow reserve (CFR) was reduced, we used noninvasive 20 MHz Doppler ultrasound to measure left main coronary flow velocity at baseline (B) and at hyperemia (H) induced by low (1%) and high (2.5%) concentrations of isoflurane gas anesthesia. Ten mice were studied before (Pre) and at 1d, 7d, 14d, and 21d after constricting the aortic arch to 0.4 mm diameter distal to the innominate artery. We also measured cardiac inflow and outflow velocities at the mitral and aortic valves and velocity at the jet distal to the aortic constriction. The pressure drop as estimated by 4V2 at the jet was 51 ± 5.1 (mean ± SE) mmHg at 1d increasing progressively to 74 ± 5.2 mmHg at 21d. Aortic and mitral blood velocities were not significantly different after banding (p = NS), but CFR, as estimated by H/B, dropped progressively from 3.2 ± 0.3 before banding to 2.2 ± 0.4, 1.7 ± 0.3, 1.4 ± 0.2, and 1.1 ± 0.1 at 1d, 7d, 14d, and 21d respectively (all P < 0.01 vs Pre). There was also a significant and progressive increase the systolic/diastolic velocity ratio (0.17 Pre to 0.92 at 21d, all P < 0.01 vs Pre) suggesting a redistribution of perfusion from subendocardium to subepicardium. We show for the first time that CFR, as estimated by the hyperemic response to isoflurane and measured by Doppler ultrasound, can be measured serially in mice and conclude that CFR is virtually eliminated in banded mice after 21 days of remodeling and hypertrophy. These results demonstrate that CFR is reduced in mice as in humans with cardiac disease but before the onset of decompensated heart failure. PMID:18255218
Ramnarine, K V; Hoskins, P R; Routh, H F; Davidson, F
The Doppler backscatter properties of a blood-mimickig fluid (BMF) were studied to evaluate its suitability for use in a Doppler flow test object. Measurements were performed using a flow rig with C-flex tubing and BMF flow produced by a roller pump or a gear pump. A SciMed Doppler system was used to measure the backscattered Doppler power with a root-mean-square power meter connected to the audio output. Studies investigated the dependence of the backscattered Doppler power of the BMF with: circulation time; batch and operator preparations; storage; sieve size; flow speed; and pump type. A comparison was made with human red blood cells resuspended in saline. The backscatter properties are stable and within International Electrotechnical Commission requirements. The BMF is suitable for use in a test object for Doppler performance assessment.
Villalba, Claudia N; Mouratian, Mariela; Lafuente, María V; Barretta, Jorge; Capelli, Horacio
Recurrent wheezing is a very common clinical ailment throughout infancy and childhood. The most common diagnosis in children with wheezing is asthma. However, some other causes should be considered in the differential diagnosis such as a congenital cardiac defect. We present a case of a four year old boy presenting with recurrent wheezing who was referred to our institution for cardiac evaluation. Severe mitral stenosis secondary to an anomalous mitral arcade was diagnosed by physical examination, chest X-ray, electrocardiogram and mainly transthoracic and transesophageal echocardiography. Anomalous mitral arcade is a rare congenital malformation of the mitral tensor apparatus which comprises the chordae tendineae and papillary muscles. This abnormal anatomy leads to increased filling pressure of the left ventricle, a retrograde post capillary pulmonary hypertension and interstitial aedema. The patient was referred to cardiac surgery and underwent a successful procedure with complete removal of the obstructive mitral lesion.
Testa, Luca; Gelpi, Guido; Bedogni, Francesco
We hereby present the case of a patient with severe aortic stenosis who underwent in her previous medical history a mitral valve replacement with a mechanical valve (Omnicarbon 27), and progressively developed a severe aortic stenosis. This patient was judged inoperable and then scheduled for CoreValve Revalving System implantation. Despite a good positioning of the CoreValve, an acute, severe mitral regurgitation developed soon after implantation as a consequence of the impaired movement of the mitral prosthesis leaflet. A condition of cardiogenic shock quickly developed. A good mitral prosthesis function was restored disengaging the CoreValve from the aortic annulus. After few months, the patients underwent successful Edwards-Sapien valve implantation through the Corevalve. This case strongly demonstrates how much a careful evaluation of the features of the mitral prosthesis and patient anatomy is crucial to select which specific transcatheter bioprosthesis would better perform.
Buyse, G; Kuchler, H; Crittin, J; Sekarski, N; Hurni, M; Cotting, J; Payot, M
An infant with frequent upper airways infections presented syncopes during meals and weeping since the age of eleven months. Cardiac examination was always normal. At 14 months of age, an echocardiogram with colour Doppler demonstrated a severely stenotic isolated supramitral membrane with severe pulmonary hypertension. The membrane was immediately excised curing the malformation and suppressing definitively the syncopes, probably due to decreased cerebral blood flow during exertion. An echocardiogram should always be performed when syncopes remain unexplained in small children. It allows early diagnosis and treatment of congenital heart defects which do not have auscultatory findings especially those resulting in severe pulmonary venous obstruction.
Chen, Zhang-Qiang; Hong, Lang; Wang, Hong; Lu, Lin-Xiang; Yin, Qiu-Lin; Lai, Heng-Li; Li, Hua-Tai; Wang, Xiang
Background: Tricuspid regurgitation (TR) is frequently associated with severe mitral stenosis (MS), the importance of significant TR was often neglected. However, TR influences the outcome of patients. The aim of this study was to investigate the efficacy and safety of percutaneous balloon mitral valvuloplasty (PBMV) procedure in rheumatic heart disease patients with mitral valve (MV) stenosis and tricuspid valve regurgitation. Methods: Two hundred and twenty patients were enrolled in this study due to rheumatic heart disease with MS combined with TR. Mitral balloon catheter made in China was used to expand MV. The following parameters were measured before and after PBMV: MV area (MVA), TR area (TRA), atrial pressure and diameter, and pulmonary artery pressure (PAP). The patients were followed for 6 months to 9 years. Results: After PBMV, the MVAs increased significantly (1.7 ± 0.3 cm2 vs. 0.9 ± 0.3 cm2, P < 0.01); TRA significantly decreased (6.3 ± 1.7 cm2 vs. 14.2 ± 6.5 cm2, P < 0.01), right atrial area (RAA) decreased significantly (21.5 ± 4.5 cm2 vs. 25.4 ± 4.3 cm2, P < 0.05), TRA/RAA (%) decreased significantly (29.3 ± 3.2% vs. 44.2 ± 3.6%, P < 0.01). TR velocity (TRV) and TR continue time (TRT) as well as TRV × TRT decreased significantly (183.4 ± 9.4 cm/s vs. 254.5 ± 10.7 cm/s, P < 0.01; 185.7 ± 13.6 ms vs. 238.6 ± 11.3 ms, P < 0.01; 34.2 ± 5.6 cm vs. 60.7 ± 8.5 cm, P < 0.01, respectively). The postoperative left atrial diameter (LAD) significantly reduced (41.3 ± 6.2 mm vs. 49.8 ± 6.8 mm, P < 0.01) and the postoperative right atrial diameter (RAD) significantly reduced (28.7 ± 5.6 mm vs. 46.5 ± 6.3 mm, P < 0.01); the postoperative left atrium pressure significantly reduced (15.6 ± 6.1 mmHg vs. 26.5 ± 6.6 mmHg, P < 0.01), the postoperative right atrial pressure decreased significantly (13.2 ± 2.4 mmHg vs. 18.5 ± 4.3 mmHg, P < 0.01). The pulmonary arterial pressure decreased significantly after PBMV (48.2 ± 10.3 mmHg vs. 60.6 ± 15
Abuzaid, Ahmed AbdulAziz; Zaki, Mahmood; Tarif, Habib
A 64-year-old female operated 1 month previous for mitral valve repair presented with acute respiratory distress and dyspnea. Echocardiography showed large echogenic valvular mass measuring 2.3 × 1.3 cm with severe mitral regurgitation and dehiscence of the mitral ring posteriorly. The mass was attached subvalvularly to the ventricular septal-free wall and eroding through it, which required complete aggressive dissection of the infected tissues. Diagnosis was confirmed after resection of the valve by multiple negative blood cultures and positive valvular tissue for Aspergillus fumigatus endocarditis. She was treated with high dose of voriconazole for 3 months. Her postoperative period was complicated by acute-on-chronic renal failure. She responded very well to the management. PMID:25838877
Matamala-Morillo, Miguel Ángel; Rodríguez-González, Moisés; Segado-Arenas, Antonio
Chest pain is rare and usually benign in pediatrics. Cardiac etiology is even rarer. However, it is a symptom associated with ischemic heart disease and it imposes great social alarm, even in health care workers. Therefore, it is necessary to know the most common causes of this symptom in children, as well as serious diseases that can cause it, which require prompt medical attention. We report a case of chest pain associated with ischemic electrocardiographic changes in a patient with mitral valve prolapse and MASS phenotype (mitral valve prolapse, aortic root enlargement, and skeletal and skin alterations), we review the mitral valve prolapse and stress the importance of knowing it in the pediatric setting.
Neves, Paulo C; Paulo, Nelson Santos; Gama, Vasco; Vouga, Luís
Transcatheter valve implantation offers a new treatment modality to those patients whose general condition makes conventional surgery very risky. However, the transcatheter option has only been available for the aortic valve. We describe a case of a successful implantation of two Edwards SAPIEN(®) 26 and 29 mm transapical valves, respectively, in aortic and mitral positions, on a 74-year-old patient with severe aortic and mitral stenosis. The procedure progressed uneventfully. Predischarge echocardiogram showed a peak aortic gradient of 20 mmHg, mild periprosthetic regurgitation, peak and mean mitral gradients of 12 and 4, respectively, and moderate (II/IV) periprosthetic regurgitation. Indications for transapical valve implantation will rapidly increase in the near future. It is essential to individualize the treatment be applied for each patient, in order to optimize the success of the procedure.
Srinivas, K H; Sharma, Rajni; Agrawal, Navin; Manjunath, C N
Klebsiella endocarditis rarely affects the native valve especially in the immunocompromised and the elderly. We report a case of Klebsiella endocarditis in a 60-year-old man who had a nidus of infection on the aortic valve which led to severe aortic regurgitation. This possibly spread to the anterior mitral leaflet (AML) leading to AML perforation therefore causing moderate mitral regurgitation. The reason for this suspicion was that there was perforation of the AML in the absence of vegetation. Noteworthy is that he was asymptomatic apart from generalised fatigue. This case draws our attention to the nature of Klebsiella valvular affection due to the fact that it had bitten the aortic and mitral valve silently and compelled the patient to undergo double valve replacement without having a prolonged duration of symptomatic illness thereby calling for high suspicion especially in individuals in the extremes of ages where the symptoms are less-guiding than the signs. PMID:24057412
A 5 year-old spayed female Cavalier King Charles Spaniel was presented after a 3- to 5-day onset of severe respiratory distress. The dog also had a history of several episodes of syncope prior to presentation. A comprehensive diagnostic investigation revealed a midsystolic click sound on cardiac auscultation, signs of left sided cardiac enlargement in ECG and thoracic radiography, mitral valvular leaflet protrusion into left the atrium, decreased E-point-to septal separation (EPSS) and mitral regurgitated flow in echocardiography, all of which are characteristic signs of mitral valvular prolapse. After intensive care with diuretics [corrected] and a vasodilator with oxygen supplement, the condition of the dog was stabilized. The dog was then released and is being medicated with angiotensin converting enzyme (ACE) inhibitor with regular follow-up.
Depace, N L; Rohrer, A H; Kotler, M N; Brezin, J H; Parry, W R
Calcification of the mitral annulus developed in a patient while undergoing dialysis. The rapid onset of events corresponded to the onset of end-stage renal failure and uncontrolled secondary hyperparathyroidism. Sequential echocardiograms verified the progression of calcification of the annulus as well as the valve. A new systolic and diastolic murmur and reduced valve orifice on two-dimensional echocardiography suggested acquired nonrheumatic mitral stenosis and insufficiency. We propose that metastatic calcium deposition rather than long-term hypertensive and degenerative effects was the predominant mechanism for massive calcification of the annulus and valve. It is suggested that M-mode echocardiography be used sequentially to follow both the occurrence and progression of calcification of the mitral annulus or valve in patients with chronic renal failure, secondary hyperparathyroidism, or both.
Chidambarathanu, Shanthi; Raja, Vijayalakshmi; Suresh, Indrani
A 28-week-old fetus was detected to have a single left atrial mass in prenatal ultrasound. Postnatal echocardiography showed an aneurysm between the anterior mitral leaflet and aortic valve, to the left of atrioventricular junction and communicating with the left ventricle through a narrow mouth. It probably originated from the mitral-aortic intervalvular fibrous tissue and an inherent weakness at this site might be the cause. Reported cases of pseudoaneurysm of mitral-aortic intervalvular fibrosa and subvalvular ventricular aneurysms seen following infective endocarditis, surgery, or trauma seem to have a similar anatomical background. This case explains the possibility of congenital aneurysm in this location which needs to be considered a differential diagnosis in similar cases. PMID:28163433
Rohani, Atooshe; Kargar, Shahram; Fazlinejad, Afsoon; Ghaderi, Fereshte; Vakili, Vida; Falsoleiman, Homa; Bagheri, Ramin Khamene
Aim: Peak atrial longitudinal strain (PALS) is used to evaluate left atrium (LA) function in patients with mitral stenosis (MS), before and after percutaneous transmitral commissurotomy (PTMC) and mitral valve replacement (MVR). Methods: Patients with severe symptomatic MS, who were referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery or PTMC from October of 2014 to October of 2015, were included in the study. Result: The peak systolic global LA strain improved post-PTMC (P < 0.001) and post-MVR (P = 0.012). This difference was statistically highly significant. Conclusion: PALS is impaired in patients with severe symptomatic MS and improved acutely after treatment and may be a good indicator of LA function and may predict the right time for intervention on mitral valve. PMID:28074794
During mitral valve surgery right pulmonary veins injury, subsequent to excessive traction (for better exposure of the mitral apparatus), is often unavoidable. This is more likely in patients with small left atrium. This common complication may cause severe intraoperative bleeding, while its surgical repair may lead to complications such as late stenosis or obstruction of the pulmonary veins. This injury should be early detected, before left atriotomy closing, and it is suggested to be repaired using a patch so as to avoid any possible late constriction. We describe a case -to our knowledge, the first reported in the literature- of intraoperatively injured right inferior pulmonary vein in a patient who underwent mitral valve replacement. As outlined we propose that the ostium of the right inferior pulmonary vein can be repaired by using autologous pericardial patch, incorporated in the completion of left atriotomy closure. PMID:19895700
Zhu, Jiasi; Sin, Yoong Kong; Chua, Yeow Leng
Most mitral paravalvular leaks (PVLs) occur during the first year after mitral valve replacement (MVR). This report describes the surgical management of 6 patients who developed very late mitral PVLs. The median interval between MVR and initial diagnosis of PVL was 16.5 years. All patients presented with congestive cardiac failure and haemolytic anaemia. The median EuroSCORE II was 9.5%. Two patients (33%) had failed attempts at transcatheter closure. Five patients underwent suture repair of the PVL. One patient underwent MVR after removal of the previous prosthesis. No in-hospital mortalities occurred. At latest follow-up (median 3.3 years), 5 patients (83%) were asymptomatic with no residual PVL. Haemolytic anaemia persisted in 1 patient with a mild residual PVL. PVL occurring decades after MVR is a rare but serious complication. Reoperative surgery can be performed in these high-risk patients with satisfactory early and midterm outcomes. PMID:27747034
Purser, Molly F.; Richards, Andrew L.; Cook, Richard C.; Osborne, Jason A.; Cormier, Denis R.; Buckner, Gregory D.
Purpose An in vitro study using explanted porcine hearts was conducted to evaluate a novel annuloplasty band, reinforced with a two-phase, shape memory alloy, designed specifically for minimally invasive mitral valve repair. Description In its rigid (austenitic) phase, this band provides the same mechanical properties as the commercial semi-rigid bands. In its compliant (martensitic) phase, this band is flexible enough to be introduced through an 8-mm trocar and is easily manipulated within the heart. Evaluation In its rigid phase, the prototype band displayed similar mechanical properties to commercially available semi-rigid rings. Dynamic flow testing demonstrated no statistical differences in the reduction of mitral valve regurgitation. In its flexible phase, the band was easily deployed through an 8-mm trocar, robotically manipulated and sutured into place. Conclusions Experimental results suggest that the shape memory alloy reinforced band could be a viable alternative to flexible and semi-rigid bands in minimally invasive mitral valve repair. PMID:19766827
Edwards, Nicola C; Ray, Simon; Steeds, Richard P
Mitral regurgitation (MR) is the second most common form of valvular disease requiring surgery. Correct identification of surgical candidates and optimising the timing of surgery are key in management. For primary MR, this relies upon a balance between the peri-operative risks and rates of successful repair in patients undergoing early surgery when asymptomatic with the potential risk of irreversible left ventricular dysfunction if intervention is performed too late. For secondary MR, recognition that this is a highly dynamic condition where MR severity may change is key, although data on outcomes in determining whether concomitant valve intervention is performed with revascularisation has raised questions regarding timing of surgery. There has been substantial interest in the use of stress echocardiography to risk stratify patients in mitral regurgitation. This article reviews the role of stress echocardiography in both primary and secondary mitral regurgitation and discusses how this can help clinicians tackle the challenges of this prevalent condition. PMID:27737905
Kavaya, Michael J.; Koch, Grady J.; Yu, Jirong; Trieu, Bo C.; Amzajerdian, Farzin; Singh, Upendra N.; Petros, Mulugeta
The state-of-the-art 2-micron coherent Doppler wind lidar breadboard at NASA/LaRC will be engineered and compactly packaged consistent with future aircraft flights. The packaged transceiver will be integrated into a coherent Doppler wind lidar system test bed at LaRC. Atmospheric wind measurements will be made to validate the packaged technology. This will greatly advance the coherent part of the hybrid Doppler wind lidar solution to the need for global tropospheric wind measurements.
Groundstroem, K; Rittoo, D; Hoffman, P; Bloomfield, P; Sutherland, G R
OBJECTIVES--To determine whether biplane transoesophageal imaging offers advantages in the evaluation of mitral prostheses when compared with standard single transverse plane imaging or the precordial approach in suspected prosthetic dysfunction. DESIGN--Prospective mitral valve prosthesis in situ using precordial and biplane transoesophageal ultrasonography. SETTING--Tertiary cardiac referral centre. SUBJECTS--67 consecutive patients with suspected dysfunction of a mitral valve prosthesis (16 had bioprostheses and 51 mechanical prostheses) who underwent precordial, transverse plane, and biplane transoesophageal echocardiography. Correlative invasive confirmation from surgery or angiography, or both, was available in 44 patients. MAIN OUTCOME MEASURES--Number, type, and site of leak according to the three means of scanning. RESULTS--Transverse plane transoesophageal imaging alone identified all 31 medial/lateral paravalvar leaks but only 24/30 of the anterior/posterior leaks. Combining the information from both imaging planes confirmed that biplane scanning identified all paravalvar leaks. Five of the six patients with prosthetic valve endocarditis, all three with valvar thrombus or obstruction, and all three with mitral annulus rupture were diagnosed from transverse plane imaging alone. Longitudinal plane imaging alone enabled diagnosis of the remaining case of prosthetic endocarditis and a further case of subvalvar pannus formation. CONCLUSIONS--Transverse plane transoesophageal imaging was superior to the longitudinal imaging in identifying medial and lateral lesions around the sewing ring of a mitral valve prosthesis. Longitudinal plane imaging was superior in identifying anterior and posterior lesions. Biplane imaging is therefore an important development in the study of mitral prosthesis function. Images PMID:8398497
Sinha, Santosh Kumar; Mishra, Vikas; Singh, Karandeep; Asif, Mohammad; Sachan, Mohit; Kumar, Ashutosh; Jha, Mukesh Jitendra; Khanra, Dibbendhu; Singh, Avinash Kumar; Singh, Shravan; Razi, Mahamdula; Thakur, Ramesh; Pandey, Umeshwar; Varma, Chandra Mohan
Objective The aim of the study was to know the incidence, clinical features, associated anomaly and echocardiographic evaluation of bi-luminal mitral valve (also known as double orifice mitral valve or DOMV) in patients with suspected mitral valve disease, continous murmur or left-to-right shunt. Methods Twenty-eight patients with DOMV were diagnosed by transthoracic echocardiography (TTE) in a retrospective review of 52,256 echocardiographic studies in 45,898 patients performed between 2000 and 2015. Results The mean age was 20.1 years (15 - 34 years) with female preponderance (M/F: 1:1.8). Dyspnea and diastolic murmur were the most common symptoms found in 19 (67.8%) and 19 (67.8%) of patients, respectively. Normal sinus rhythm was the most common electrocardiographic finding. Twenty-five (89%) patients had complete bridge, while three (11%) had incomplete bridge type of DOMV. Twenty-one (75%) had severe mitral stenosis (MS) including severe tricuspid regurgitation (n = 13, 61%), ventricular septal defect (VSD, n = 3, 14%), complete endocardial cushion defect (ECD, n = 3, 14%), and mild to moderate mitral regurgitation (MR) (n = 2, 11%), moderate MS and moderate MR were found in four (16%) patients among complete bridge type of DOMV, while all patients with incomplete bridge type had severe MS and patent ductus arteriosus (PDA) as associated lesions. Overall, 24 (85%) had severe and four (15%) had moderate MS. Conclusions DOMV as a cause of symptomatic mitral valve disease was seen in young and middle-aged patients with estimated incidence of 0.06%. Dyspnea and diastolic murmur were the most common symptoms. Mostly, it was an isolated anomaly but in majority, associated with VSD, complete ECD and PDA. TTE examination is a reliable and sufficient means of diagnosing DOMV and determining its type. PMID:27829956
Yan, Tao; Zhang, Guan-xin; Li, Bai-lin; Zhong, Keng; Xu, Zhi-yun; Han, Lin
We sought to explore the pulmonary haemodynamic changes in rheumatic mitral stenosis patients with secondary pulmonary hypertension. The pulmonary artery resistance and compliance of 35 patients with rheumatic mitral stenosis and 12 controls without cardiopulmonary vascular disease were evaluated by using an improved method, which is based on making calculations with parameters obtained from right heart catheterisation. The results are as follows: (1) pulmonary artery compliance in patients with secondary pulmonary hypertension was significantly lower than that of the control group (P<0.01); (2) linear correlation analyses showed that preoperative mean pulmonary artery pressure (mPAP) closely correlated with zero-pressure compliance in the mitral stenosis group (r=-0.745, P<0.05); (3) PAP and pulmonary vascular resistance decreased significantly in both groups with mitral stenosis after infusing 0.5 μg kg(-1) min(-1) of sodium nitroprusside (P<0.01). The pulmonary zero pressure compliance and mean pressure compliance increased significantly in the group with mild pulmonary hypertension; whereas in the severe group, the mean compliance changed with significance as the mPAP decreased (1.51 ± 0.59 vs 1.81 ± 0.77 ml/mmHg), however no significant change occurred in the pulmonary zero pressure compliance (2.35 ± 1.24 ml/mmHg vs. 2.24 ± 1.53 ml/mmHg, P>0.05) The walls of pulmonary artery vessels in patients with pulmonary hypertension secondary to rheumatic mitral stenosis appeared to be remodelled by varying degrees as indicated by their haemodynamic properties. Structural remodelling may be a factor affecting preoperative pulmonary artery pressure. Mitral stenosis patients with severe pulmonary hypertension have significantly lower responses to sodium nitroprusside possibly due to aggradation and deposition of collagen in the artery walls, decreasing constriction and dilation, or atrophy of smooth muscle cells.
Hughes, Stephen W.; Cowley, Michael
The Doppler effect is a shift in the frequency of waves emitted from an object moving relative to the observer. By observing and analysing the Doppler shift in electromagnetic waves from astronomical objects, astronomers gain greater insight into the structure and operation of our Universe. In this paper, a simple technique is described for teaching the basics of the Doppler effect to undergraduate astrophysics students using acoustic waves. An advantage of the technique is that it produces a visual representation of the acoustic Doppler shift. The equipment comprises a 40 kHz acoustic transmitter and a microphone. The sound is bounced off a computer fan and the signal collected by a DrDAQ ADC and processed by a spectrum analyser. Widening of the spectrum is observed as the fan power supply potential is increased from 4 to 12 V.
Gross, Peter G.
Derives the general Doppler formula in a nonstatic universe using assumptions of special relativity, homogeneity and isotropy of the universe. Examples of applications to physical cosmology are given. (SL)
Weber, F. Neff; And Others
Described is the use of the Doppler Effect with microwaves in the measurement of the acceleration due to gravity of falling objects. The experiments described add to the repertoire of quantitative student microwave experiments. (Author/DS)
Poulsen, S H
LV systolic function and dilation after Ml have been extensively studied and have been related to heart failure and cardiac mortality. In recent years, it has been increasingly apparent that LV diastolic dysfunction contributes to signs and symptoms of heart failure and LV diastolic dysfunction is associated with increased mortality rates in patients chronic heart failure independent of systolic function. LV diastolic dysfunction is difficult to assess on basis of clinical examination including chest radiography and electrocardiography. LV diastolic filling has traditionally been evaluated by cardiac catherization with direct measurement of filling pressures and relaxation. However, the invasive approach describing LV compliance and relaxation as the major determinants of LV diastolic function, is not feasible and suitable for routine investigations of diastolic function. Two-dimensional and Doppler echocardiography has become a well accented practical and safe non-invasive method for diagnosis of LV diastolic dysfunction. Combined invasive and echocardiographic studies have shown that analysis of mitral and pulmonary venous flow velocities relate to invasively measured filling pressures and relaxation rate in cardiac diseases. Based on Doppler analysis of mitral and pulmonary venous flow three abnormal LV filling patterns are identified: impaired relaxation, "pseudonormalization" and restrictive. These LV filling patterns have been related to symptoms, relaxation rate, filling pressure and prognosis in patients with restrictive and dilated cardiomyopathy. The Doppler flow profiles are influenced by several factors including age, heart rate, load conditions and valve heart diseases which must be taken into consideration during evaluation. During the last decade information about LV diastolic function assessed non-invasively by Doppler echocardiography has gained in patients with CAD. Myocardial ischemia induced by brief coronary artery occlusion or pacing leads to
Yokoyama, Yuichiro; Satoh, Harumitsu; Abe, Mitsunori; Nagashima, Mitsugi; Kurata, Akira; Higashino, Hiroshi
We report a surgical case of dextrocardia complicated with annuloaortic ectasia (AAE) and mitral regurgitation, which induced congestive heart failure. Preoperative electrocardiography-gated multidetector-row computed tomography (MDCT) showed the following complex cardiovascular abnormalities without motion artifacts: dextrocardia, situs inversus, polysplenia, AAE, absence of the inferior vena cava, azygos vein continuation, drainage of the hepatic vein into the right atrium, and bilateral superior venae cavae. On the basis of the MDCT data, we established a cardiopulmonary bypass; and a modified Bentall procedure (Piehler method) and mitral valve replacement were performed without complications.
Gisbert, Alejandro; Soulière, Vicky; Denault, André Y; Bouchard, Denis; Couture, Pierre; Pellerin, Michel; Carrier, Michel; Levesque, Sylvie; Ducharme, Anique; Basmadjian, Arsène J
Hemodynamic modifications induced by general anesthesia could lead to underestimation of mitral regurgitation (MR) severity in the operating department and potentially serious consequences. The intraoperative severity of MR was prospectively compared with the preoperative baseline evaluation using dynamic quantitative transesophageal echocardiography in 25 patients who were stable with MR 2/4 or greater undergoing coronary bypass, mitral valve operation, or both. Significant changes in the severity of MR using transesophageal echocardiographic criteria occurred after the induction of general anesthesia and with phenylephrine. Quantitative transesophageal echocardiographic evaluation of MR using effective orifice area and vena contracta, and the use of phenylephrine challenge, were useful to avoid underestimating MR severity in the operating department.
Botta, Luca; Merati, Roberto; Vignati, Gabriele; Orcese, Carlo Andrea; De Chiara, Benedetta; Cannata, Aldo; Bruschi, Giuseppe; Fratto, Pasquale
Infective endocarditis during pregnancy carries a high mortality risk, both for the mother and for the foetus and requires a multidisciplinary team in the management of complicated cases. We report our experience with a 39-year old patient, affected by an acute active mitral endocarditis due to Abiotrophia defectiva at the 14th gestational week, strongly motivated to continue the pregnancy. Our patient successfully underwent mitral valve replacement with a normothermic high-flow cardiopulmonary bypass under continuous intraoperative foetal monitoring. Caesarean section occurred at the 38th gestational week. The delivery was uneventful and both the mother and child are doing well at the 16-month follow-up.
Yarnoz, Michael D.; Hueter, David; McCormick, John R.; Black, Harrison; Berger, Robert L.
Four cases of severe mitral regurgitation due to disc variance of the Harken disc prosthesis in the mitral position are described. The valve occluder actually escaped into the left atrium in two patients, and neither survived despite emergency valve replacement. In the other two, disc malfunction was identified by flouroscopy, the prosthesis was replaced, and both patients survived. All four patients had associated aortic regurgitation, which most likely contributed to erosion of the disc edges. It is suggested that patients with the Harken disc prosthesis undergo periodic evaluation to detect abnormal disc motion. Images PMID:15216088
Sladek, Eric H; Accola, Kevin D
This report describes one the first cases of antiphospholipid syndrome and Libman-Sacks endocarditis in a bioprosthetic valve. A redo mitral valve replacement was carried out owing to early deterioration of the prior valve. Initially it was considered secondary to rheumatic heart disease; however, pathology analysis and autoimmune workup revealed antiphospholipid syndrome with Libman-Sacks endocarditis. We believe certain populations with mitral valve stenosis may have an underlying antiphospholipid syndrome. As a result, there needs to be a lower threshold for identifying this disease.
Curcio Ruigómez, A; Martín Jiménez, J; Wilhelmi Ayza, M; Soria Delgado, J L
We present a case of double post acute myocardial infarction complication: ventricular septal defect and acute and severe mitral insufficiency. As a consequence of the delay in the diagnosis, the patient developed pulmonary hypertension with values at the systemic level. The patient underwent surgery in order to close the ventricular septal defect and aneurysmectomy, resulting in posterior regression of mitral insufficiency and pulmonary circuit values became normal. The ethology, diagnosis, evolution and treatment of this exceptional association of acute post myocardial infarction complications are discussed.
Iwazawa, Jin; Nakamura, Kenji; Hamuro, Masao; Nango, Mineyoshi; Sakai, Yukimasa; Nishida, Norifumi
We present the case of a 60-year-old woman with symptomatic mitral regurgitation caused by a left-to-right shunt via anastomoses consisting of microfistulae, most likely of inflammatory origin, between the right subclavian artery and the right pulmonary artery. The three arteries responsible for fistulous formation, including the internal mammary, thyrocervical, and lateral thoracic arteries, were successfully occluded by transcatheter embolization using superabsorbent polymer microsphere (SAP-MS) particles combined with metallic coils. No complications have been identified following treatment with SAP-MS particles. This approach significantly reduced the patient's mitral regurgitation and she has remained asymptomatic for more than 4 years.
Lette, J.; Gagnon, A.; Lapointe, J.; Cerino, M.
A patient developed transient exacerbation of a mitral insufficiency murmur and a reversible posterior wall perfusion defect during dipyridamole-thallium imaging. Coronary angiography showed significant stenoses of both the right and the circumflex coronary arteries that supply the posterior papillary muscle. Cardiac auscultation for transient mitral incompetence, a sign of reversible papillary muscle dysfunction, is a simple and practical adjunctive test for myocardial ischemia during dipyridamole-thallium imaging. It may confirm that an isolated reversible posterior wall myocardial perfusion defect is truly ischemic in nature as opposed to an artifact resulting from attenuation by the diaphragm.
Wilke, Andreas; Wende, Christian M.; Horst, Michael; Steverding, Dietmar
Patients with prosthetic heart valves require lifelong oral anticoagulant therapy based on vitamin K antagonists. These patients may need interruption of their anticoagulant therapy if they have to undergo surgery. The clinical challenge is to identify patients who can safely undergo surgery while continuing their vitamin K antagonist treatment and those who have to take short-acting heparin as part of a bridging therapy. Here we present a case of a patient with a prosthetic mitral valve whose oral anticoagulant therapy was unnecessarily discontinued by the GP prior to an upcoming cataract surgery. As a result, the patient developed thrombosis of the prosthetic mitral valve which needed to be surgically replaced.
Vukicevic, Marija; Puperi, Daniel S; Jane Grande-Allen, K; Little, Stephen H
As catheter-based structural heart interventions become increasingly complex, the ability to effectively model patient-specific valve geometry as well as the potential interaction of an implanted device within that geometry will become increasingly important. Our aim with this investigation was to combine the technologies of high-spatial resolution cardiac imaging, image processing software, and fused multi-material 3D printing, to demonstrate that patient-specific models of the mitral valve apparatus could be created to facilitate functional evaluation of novel trans-catheter mitral valve repair strategies. Clinical 3D transesophageal echocardiography and computed tomography images were acquired for three patients being evaluated for a catheter-based mitral valve repair. Target anatomies were identified, segmented and reconstructed into 3D patient-specific digital models. For each patient, the mitral valve apparatus was digitally reconstructed from a single or fused imaging data set. Using multi-material 3D printing methods, patient-specific anatomic replicas of the mitral valve were created. 3D print materials were selected based on the mechanical testing of elastomeric TangoPlus materials (Stratasys, Eden Prairie, Minnesota, USA) and were compared to freshly harvested porcine leaflet tissue. The effective bending modulus of healthy porcine MV tissue was significantly less than the bending modulus of TangoPlus (p < 0.01). All TangoPlus varieties were less stiff than the maximum tensile elastic modulus of mitral valve tissue (3697.2 ± 385.8 kPa anterior leaflet; 2582.1 ± 374.2 kPa posterior leaflet) (p < 0.01). However, the slopes of the stress-strain toe regions of the mitral valve tissues (532.8 ± 281.9 kPa anterior leaflet; 389.0 ± 156.9 kPa posterior leaflet) were not different than those of the Shore 27, Shore 35, and Shore 27 with Shore 35 blend TangoPlus material (p > 0.95). We have demonstrated that patient-specific mitral valve models can be
DePace, N L; Burke, W; Kotler, M N; Glazier, E E
A case of Bjork-Shiley mitral valve dysfunction is presented. The patient has not responded to anticoagulant therapy and had hypotension, dyspnea, chest pain, and a pulse deficit but normal sinus rhythm. Simultaneous echocardiogram, ECG, and arterial pulse tracing were used as noninvasive means of monitoring. Nonsurgical correction of a clinical emergency restored the patient to prior normal baseline cardiovascular function. This case illustrates the possibility of restoring normal prosthetic function by supporting the patient medically while undertaking diagnostic testing and arranging surgical intervention. To our knowledge, this is the first reported case of a malfunctioning Bjork-Shiley mitral valve corrected without surgery.
Vandenberg, R. A.; Williams, J. C. P.; Sturm, R. E.; Wood , E. H.
Mitral regurgitant indexes were measured by roentgen videodensitometry in anesthetized dogs without thoracotomy before, during and after extrasystolic potentiation of ventricular contraction while the atria and ventricles were driven in normal temporal sequence simultaneously or in such a way as to induce atrial fibrillation. Small amounts of mitral reflux were observed with simultaneous atrial and ventricular driving and with atrial fibrillation in the control measurements before initiation of extrasystolic potentiation. Reflux became negligible during extrasystolic potentiation and increased beyond control levels after termination of extrasystolic potentiation.
Bullock, R E; Hall, R J
M-mode echocardiograms are demonstrated from a patient with subacute massive pulmonary embolism before and after thrombolytic treatment and clinical recovery. Severely impaired left ventricular contraction returned to normal. A reversible reduction in mitral valve opening velocity was also seen and was thought to be in part the result of diminished left atrial filling. This hypothesis was tested experimentally; mitral valve opening velocity was measured in normal subjects and found to be significantly reduced when pulmonary blood flow was impeded during the Valsalva manoeuvre. Images PMID:7126394
Malcić, I; Zavrsnik, J; Kancler, K; Kokol, P
The authors studied the prevalence of mitral valve prolapse (MVP) in the group of 656 children and adolescents (329 males and 327 females), who were a representative sample (obtained with the Monte Carlo method of statistical trials) of all newborns in the city of Maribor, Republic of Slovenia, in the period of 18 years (1976-1992). The results were considered positive in children and adolescents who in addition to possible history (chest pain, palpitations, dizziness, loss of consciousness, headaches, perspiration), probable auscultatory finding (mezzosystolic click and late systolic murmur), and suspected phonocardiographic and ECG findings, also had a positive M-mode echocardiographic finding. The criteria for MVP on M-mode echocardiography were taken from the literature: descending of mitral cusp, either anterior or posterior, of at least 3 mm below the line connecting points C and D. Children and adolescents were divided into six age groups (infants, toddlers, preschool children, early school age, children in puberty, adolescents). Assuming MVP as a cause of cardiac arrhythmias, beside standard ECG we also performed holter ECG monitoring in 61 children and adolescents (29 with MVP, 32 without MVP). The results were tested with standard statistical tools (chi 2-test, Student t-test, 2 x 2 Fisher chi 2-test). MVP was found in 71 patients (10.8%, 32 males and 39 females). As regards age and sex we found lower prevalence of MVP in male children (9.7%) compared to female children (11.9%). The highest prevalence was found in early school age, more so in females (14.2 vs 13.7). The differences were not statistically significant (p > 0.05). In both sexes most frequent was endosystolic prolapse (males 59.3%, females 51.3%). Most commonly both cusps are involved in the prolapse (males 78.1%, females 66.7%). Most frequently measured descending of the cusps was 3-4.5 mm (males 56.2%, females 48.7%). Negative auscultatory finding (silent MVP) was detected in 47.8% of the
Luciano, R; Velardi, F
Following the first study of Bada et al. (1979), Doppler assessment of cerebral blood flow has increasingly been used in newborn infants, matching the technical progress in the available equipment. The experience gathered in recent years has confirmed that Doppler US is a reliable and reproducible examination while precising the limitations and the methodology to be followed in order to prevent gross errors of assessment and interpretation. The interest this procedure has arisen, among other things, stems from being noninvasive and feasible at the patient's bed. These features enable its repeated use in newborn infants in poor clinical condition. The diagnostic and prognostic role of Doppler velocimetry has been shown in a number of neonatal diseases and the cerebral hemodynamics has been assessed in physiologic conditions as well as after drug administration. The most common equipment used in newborn infants is at present Duplex Doppler consisting of a pulsed Doppler combined with bidimensional scanner, which, with visualization of study arteries, enables precise positioning of sample volume and correction of the ultrasonic angle of incidence with respect to the direction of blood flow in the examined vessel. In this report, after a survey of the techniques and modalities of cerebral Doppler examination in newborns, a review of the present state of the art, in neonatal cerebral as well as extracranial disease, is presented.
Gorwara, Ashok; Molchanov, Pavlo; Asmolova, Olga
There is a need for small Sense and Avoid (SAA) systems for small and micro Unmanned Aerial Systems (UAS) to avoid collisions with obstacles and other aircraft. The proposed SAA systems will give drones the ability to "see" close up and give them the agility to maneuver through tight areas. Doppler radar is proposed for use in this sense and avoid system because in contrast to optical or infrared (IR) systems Doppler can work in more harsh conditions such as at dusk, and in rain and snow. And in contrast to ultrasound based systems, Doppler can better sense small sized obstacles such as wires and it can provide a sensing range from a few inches to several miles. An SAA systems comprised of Doppler radar modules and an array of directional antennas that are distributed around the perimeter of the drone can cover the entire sky. These modules are designed so that they can provide the direction to the obstacle and simultaneously generate an alarm signal if the obstacle enters within the SAA system's adjustable "Protection Border". The alarm signal alerts the drone's autopilot to automatically initiate an avoidance maneuver. A series of Doppler radar modules with different ranges, angles of view and transmitting power have been designed for drones of different sizes and applications. The proposed Doppler radar micro SAA system has simple circuitry, works from a 5 volt source and has low power consumption. It is light weight, inexpensive and it can be used for a variety of small unmanned aircraft.
Simon, Marvin K. (Inventor); Divsalar, Dariush (Inventor)
Doppler in a communication system operating with a multiple differential phase-shift-keyed format (MDPSK) creates an adverse phase shift in an incoming signal. An open loop frequency estimation is derived from a Doppler-contaminated incoming signal. Based upon the recognition that, whereas the change in phase of the received signal over a full symbol contains both the differentially encoded data and the Doppler induced phase shift, the same change in phase over half a symbol (within a given symbol interval) contains only the Doppler induced phase shift, and the Doppler effect can be estimated and removed from the incoming signal. Doppler correction occurs prior to the receiver's final output of decoded data. A multiphase system can operate with two samplings per symbol interval at no penalty in signal-to-noise ratio provided that an ideal low pass pre-detection filter is employed, and two samples, at 1/4 and 3/4 of the symbol interval T sub s, are taken and summed together prior to incoming signal data detection.
Kutikhin, Anton G; Yuzhalin, Arseniy E; Brusina, Elena B; Ponasenko, Anastasia V; Golovkin, Alexey S; Barbarash, Olga L
Valvular calcification precedes the development of valvular stenosis and may represent an important early phenotype for valvular heart disease. It is known that development of valvular calcification is likely to occur among members of a family. However, the knowledge about the role of genomic predictive markers in valvular calcification is still elusive. Aims of this review are to assess the impact of gene polymorphisms on risk and severity of aortic stenosis and mitral annular calcification. According to the results of the investigations carried out, all polymorphisms may be divided into the three groups conferring the level of evidence of their association with valvular stenosis. It is possible to conclude that apoB (XbaI, rs1042031, and rs6725189), ACE (rs4340), IL10 (rs1800896 and rs1800872), and LPA (rs10455872) gene polymorphisms may be associated with valvular calcific stenosis with a relatively high level of evidence. A number of other polymorphisms, such as PvuII polymorphism within the ORα gene, rs1042636 polymorphism within the CaSR gene, rs3024491, rs3021094, rs1554286, and rs3024498 polymorphisms within the IL10 gene, rs662 polymorphism within the PON1 gene, rs2276288 polymorphism within the MYO7A gene, rs5194 polymorphism within the AGTR1 gene, rs2071307 polymorphism within the ELN gene, rs17659543 and rs13415097 polymorphisms within the IL1F9 gene may correlate with a risk of calcific valve stenosis with moderate level of evidence. Finally, rs1544410 polymorphism within the VDR gene, E2 and E4 alleles within the apoE gene, rs6254 polymorphism within the PTH gene, and rs1800871 polymorphism within the IL10 gene may be associated with aortic stenosis with low level of evidence.
Szymański, Piotr; Hryniewiecki, Tomasz; Dąbrowski, Maciej; Sorysz, Danuta; Kochman, Janusz; Jastrzębski, Jan; Kukulski, Tomasz; Zembala, Marian
Objective To analyse the impact of postprocedural mitral regurgitation (MR), in an interaction with aortic regurgitation (AR), on mortality following transcatheter aortic valve implantation (TAVI). Methods To assess the interaction between MR and AR, we compared the survival rate of patients (i) without both significant MR and AR versus (ii) those with either significant MR or significant AR versus (iii) with significant MR and AR, all postprocedure. 381 participants of the Polish Transcatheter Aortic Valve Implantation Registry (166 males (43.6%) and 215 females (56.4%), age 78.8±7.4 years) were analysed. Follow-up was 94.1±96.5 days. Results Inhospital and midterm mortality were 6.6% and 10.2%, respectively. Significant MR and AR were present in 16% and 8.1% patients, including 3.1% patients with both significant MR and AR. Patients with significant versus insignificant AR differed with respect to mortality (log rank p=0.009). This difference was not apparent in a subgroup of patients without significant MR (log rank p=0.80). In a subgroup of patients without significant AR, there were no significant differences in mortality between individuals with versus without significant MR (log rank p=0.44). Significant MR and AR had a significant impact on mortality only when associated with each other (log rank p<0.0001). At multivariate Cox regression modelling concomitant significant MR and AR were independently associated with mortality (OR 3.2, 95% CI 1.54 to 5.71, p=0.002). Conclusions Significant MR or AR postprocedure, when isolated, had no impact on survival. Combined MR and AR had a significant impact on a patient's prognosis. PMID:26908096
Lagoski, Thomas J.; Coutu, Ronald A., Jr.; Starman, LaVern A.
In order to meet the goals of the Department of Defense (DoD) for smaller and more accurate weapons, numerous projects are currently investigating the miniaturization of weapons and munition fuze components. One of these efforts is to characterize the performance of small detonators. The velocity of the flyer, the key component needed to initiate a detonation sequence, can be measured using a photonic Doppler velocimeter (PDV). The purpose of this research was to develop a microelectromechanical system (MEMS) device that would act as an optimal retroreflective surface for the PDV. Two MEMS solutions were explored: one using the PolyMUMPsTM fabrication process and one in-house fabrication design using silicon on insulator (SOI) wafers. The in-house design consisted of an array of corner reflectors created using an SOI wafer. Each corner reflector consisted of three separate mirror plates which were self-assembled by photoresist pad hinges. When heated to a critical temperature (typically 140-160 °C), the photoresist pads melted and the resulting surface tension caused each mirror to rotate into place. The resulting array of corner reflectors was then coated with a thin layer of gold to increase reflectivity. Despite the successful assembly of a PolyMUMPsTM corner reflector, assembling an array of these reflectors was found to be unfeasible. Although the SOI corner reflector design was completed, these devices were not fabricated in time for testing during this research. However, the bidirectional reflectance distribution function (BRDF) and optical cross section (OCS) of commercially available retroreflective tapes were measured. These results can be used as a baseline comparison for future testing of a fabricated SOI corner reflector array.
Brioschi, Maura; Baetta, Roberta; Ghilardi, Stefania; Gianazza, Erica; Guarino, Anna; Parolari, Alessandro; Polvani, Gianluca; Tremoli, Elena; Banfi, Cristina
The mitral valve is a highly complex structure which regulates blood flow from the left atrium to the left ventricle (LV) avoiding a significant forward gradient during diastole or regurgitation during systole. The integrity of the mitral valve is also essential for the maintenance of normal LV size, geometry, and function. Significant advances in the comprehension of the biological, functional, and mechanical behavior of the mitral valve have recently been made. However, current knowledge of protein components in the normal human mitral valve is still limited and complicated by the low cellularity of this tissue and the presence of high abundant proteins from the extracellular matrix. We employed here an integrated proteomic approach to analyse the protein composition of the normal human mitral valve and reported confident identification of 422 proteins, some of which have not been previously described in this tissue. In particular, we described the ability of pre-MS separation technique based on liquid-phase IEF and SDS-PAGE to identify the largest number of proteins. We also demonstrated that some of these proteins, e.g. αB-Crystallin, septin-11, four-and-a-half LIM domains protein 1, and dermatopontin, are synthesised by interstitial cells isolated from human mitral valves. These initial results provide a valuable basis for future studies aimed at analysing in depth the mitral valve protein composition and at investigating potential pathogenetic molecular mechanisms. Data are available via ProteomeXchange with identifier PXD004397.
Boronyak, Steven M; Merryman, W David
Percutaneous approaches to mitral valve repair are an attractive alternative to surgical repair or replacement. Radiofrequency ablation has the potential to approximate surgical leaflet resection by using resistive heating to reduce leaflet size, and cryogenic temperatures on a percutaneous catheter can potentially be used to reversibly adhere to moving mitral valve leaflets for reliable application of radiofrequency energy. We tested a combined cryo-anchoring and radiofrequency ablation catheter using excised porcine mitral valves placed in a left heart flow loop capable of reproducing physiologic pressure and flow waveforms. Transmitral flow and pressure were monitored during the cryo-anchoring procedure and compared to baseline flow conditions, and the extent of radiofrequency energy delivery to the mitral valve was assessed post-treatment. Long term durability of radiofrequency ablation treatment was assessed using statically treated leaflets placed in a stretch bioreactor for four weeks. Transmitral flow and pressure waveforms were largely unaltered during cryo-anchoring. Parameter fitting to mechanical data from leaflets treated with radiofrequency ablation and cryo-anchoring revealed significant mechanical differences from untreated leaflets, demonstrating successful ablation of mitral valves in a hemodynamic environment. Picrosirius red staining showed clear differences in morphology and collagen birefringence between treated and untreated leaflets. The durability study indicated that statically treated leaflets did not significantly change size or mechanics over four weeks. A cryo-anchoring and radiofrequency ablation catheter can adhere to and ablate mitral valve leaflets in a physiologic hemodynamic environment, providing a possible percutaneous alternative to surgical leaflet resection of mitral valve tissue.
Han, Jiancheng; He, Yihua; Gu, Xiaoyan; Sun, Lin; Zhao, Ying; Liu, Wenxu; Zhang, Ye; Yang, Xu; Li, Yan
Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare but potentially fatal entity. Early diagnosis and surgical treatment are particularly important to decrease risk of mortality. The purpose of this study was to explore the echocardiographic characteristics and outcome of P-MAIVF and to evaluate the potential application of three-dimensional (3D) echocardiography in the evaluation of P-MAIVF. Clinical and echocardiographic characteristics were retrospectively evaluated in 9 patients with P-MAIVF, 5 of them assessed by 3D echocardiography. P-MAIVF was identified on echocardiography and located in the posterior aspect of the aortic root, expanding in systole and collapsing in diastole. Of the 9 cases examined, 8 were associated with endocarditis and 1 was caused by radio frequency catheter ablation of atrial fibrillation. Five cases were associated with bicuspid aortic valve, and rupture of P-MAIVF was identified in 3 patients. The morphology of P-MAIVF was clearly demonstrated on 3D echocardiography in 5 cases. In conclusion, echocardiography provides a useful tool in the diagnosis of P-MAIVF. Color Doppler flow imaging can ease identification of the ostium in cases of ruptured pseudoaneurysms. Three-dimensional echocardiography shows the relationship between P-MAIVF and the adjacent anatomic structures.
Gittins, John; Martin, Kevin
Doppler flow and string phantoms have been used to assess the performance of ultrasound Doppler systems in terms of parameters such as sensitivity, velocity accuracy and sample volume registration. However, because of the nature of their construction, they cannot challenge the accuracy and repeatability of modern digital ultrasound systems or give objective measures of system performance. Electronic Doppler phantoms are able to make use of electronically generated test signals, which may be controlled precisely in terms of frequency, amplitude and timing. The Leicester Electronic Doppler Phantom uses modern digital signal processing methods and field programmable gate array technology to overcome some of the limitations of previously described electronic phantoms. In its present form, it is able to give quantitative graphical assessments of frequency response and range gate characteristics, as well as measures of dynamic range and velocity measurement accuracy. The use of direct acoustic coupling eliminates uncertainties caused by Doppler beam effects, such as intrinsic spectral broadening, but prevents their evaluation.
Zhang, Fan; Kanik, Jingjing; Mansi, Tommaso; Voigt, Ingmar; Sharma, Puneet; Ionasec, Razvan Ioan; Subrahmanyan, Lakshman; Lin, Ben A; Sugeng, Lissa; Yuh, David; Comaniciu, Dorin; Duncan, James
Transesophageal echocardiography (TEE) is routinely used to provide important qualitative and quantitative information regarding mitral regurgitation. Contemporary planning of surgical mitral valve repair, however, still relies heavily upon subjective predictions based on experience and intuition. While patient-specific mitral valve modeling holds promise, its effectiveness is limited by assumptions that must be made about constitutive material properties. In this paper, we propose and develop a semi-automated framework that combines machine learning image analysis with geometrical and biomechanical models to build a patient-specific mitral valve representation that incorporates image-derived material properties. We use our computational framework, along with 3D TEE images of the open and closed mitral valve, to estimate values for chordae rest lengths and leaflet material properties. These parameters are initialized using generic values and optimized to match the visualized deformation of mitral valve geometry between the open and closed states. Optimization is achieved by minimizing the summed Euclidean distances between the estimated and image-derived closed mitral valve geometry. The spatially varying material parameters of the mitral leaflets are estimated using an extended Kalman filter to take advantage of the temporal information available from TEE. This semi-automated and patient-specific modeling framework was tested on 15 TEE image acquisitions from 14 patients. Simulated mitral valve closures yielded average errors (measured by point-to-point Euclidean distances) of 1.86 ± 1.24 mm. The estimated material parameters suggest that the anterior leaflet is stiffer than the posterior leaflet and that these properties vary between individuals, consistent with experimental observations described in the literature.
Rausch, Manuel K; Famaey, Nele; Shultz, Tyler O'Brien; Bothe, Wolfgang; Miller, D Craig; Kuhl, Ellen
Alterations in mitral valve mechanics are classical indicators of valvular heart disease, such as mitral valve prolapse, mitral regurgitation, and mitral stenosis. Computational modeling is a powerful technique to quantify these alterations, to explore mitral valve physiology and pathology, and to classify the impact of novel treatment strategies. The selection of the appropriate constitutive model and the choice of its material parameters are paramount to the success of these models. However, the in vivo parameters values for these models are unknown. Here, we identify the in vivo material parameters for three common hyperelastic models for mitral valve tissue, an isotropic one and two anisotropic ones, using an inverse finite element approach. We demonstrate that the two anisotropic models provide an excellent fit to the in vivo data, with local displacement errors in the sub-millimeter range. In a complementary sensitivity analysis, we show that the identified parameter values are highly sensitive to prestrain, with some parameters varying up to four orders of magnitude. For the coupled anisotropic model, the stiffness varied from 119,021 kPa at 0 % prestrain via 36 kPa at 30 % prestrain to 9 kPa at 60 % prestrain. These results may, at least in part, explain the discrepancy between previously reported ex vivo and in vivo measurements of mitral leaflet stiffness. We believe that our study provides valuable guidelines for modeling mitral valve mechanics, selecting appropriate constitutive models, and choosing physiologically meaningful parameter values. Future studies will be necessary to experimentally and computationally investigate prestrain, to verify its existence, to quantify its magnitude, and to clarify its role in mitral valve mechanics.
Rostagno, Carlo; Gelsomino, Sandro; Capecchi, Irene; Rossi, Alessandra; Montesi, Gian Franco; Stefàno, Pier Luigi
Late recovery of sinus rhythm is unusual in patients with permanent AF treated by (radiofrequency) RF maze procedure during mitral valve surgery. Identification of clinical and instrumental preoperative factors predictive of early success of RF ablation in patients with permanent AF undergoing mitral valve surgery may improve selection of subjects to obtain long-term results. Hundred and thirty consecutive patients with permanent AF and mitral valve disease underwent modified RF maze procedure during concomitant mitral valve surgery. Rheumatic valve disease (61 pts) and mitral valve prolapse (41 pts) were the more common aetiology of valve abnormalities. Mitral valve replacement was performed in 54 % of patients and mitral valve repair in the remaining 46 %. Four patients died after surgery. At discharge, 87 patients (69 %) were in sinus rhythm (group 1) and 43 patients in AF persisted (group 2). At an average 24-month follow-up, sinus rhythm was present in 67 % of patients, and 33 % were in atrial fibrillation. In this period, late recovery of sinus rhythm was observed only in five patients, while eight discharged in sinus rhythm developed again atrial fibrillation. Among preoperative parameters at univariate analysis female sex, atrial fibrillation >24 months, left atrial diameter >54 mm, left atrial area >24 cm(2), rheumatic valve disease and NYHA class were associated with persistence of AF. At Cox regression multivariate analysis, increased left atrial area (OR 1.07 per unit increase-95 % CI 1.01-1.131) and rheumatic aetiology of valve disease (OR 4.52, 95 % CI 1.65-12.4) were associated with persistence of AF at hospital discharge. Persistence of AF after RF ablation in patients undergoing mitral valve surgery is related to aetiology, e.g. rheumatic valve disease, and to increasing left atrial diameter. Due to low rate of late recovery of sinus rhythm, indication to RF ablation associated with MV surgery should be carefully considered in patients with large
Halldorsdottir, H; Nordström, J; Brattström, O; Sennström, M M; Sartipy, U; Mattsson, E
Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. We present the case of a 29-year-old woman who developed early postpartum mitral valve thrombus after an elective cesarean delivery. The patient had a mechanical mitral valve and was treated with warfarin in the second trimester, which was replaced with high-dose dalteparin during late pregnancy. Elective cesarean delivery was performed under general anesthesia at 37weeks of gestation. The patient was admitted to the intensive care unit for postoperative care and within 30min she developed dyspnea and hypoxia requiring mechanical ventilation. She deteriorated rapidly and developed pulmonary edema, worsening hypoxia and severe acidosis. Urgent extra corporeal membrane oxygenation was initiated. Transesophageal echocardiography revealed a mitral valve thrombus. The patient underwent a successful mitral valve replacement after three days on extra corporeal membrane oxygenation. This case highlights the importance of multidisciplinary care and frequent monitoring of anticoagulation during care of pregnant women with prosthetic heart valves.
Domenichini, Federico; Pedrizzetti, Gianni
The vortex formation process inside the left ventricle is intrinsically connected to the dynamics of the mitral leaflets while they interact with the flow crossing the valve during diastole. The description of the dynamics of a natural mitral valve still represents a challenging issue, especially because its material properties are not measurable in vivo. Medical imaging can provide some indications about the geometry of the valve, but not about its mechanical properties. In this work, we introduce a parametric model of the mitral valve geometry, whose motion is described in the asymptotic limit under the assumption that it moves with the flow, without any additional resistance other than that given by its shape, and without the need to specify its material properties. The mitral valve model is coupled with a simple description of the left ventricle geometry, and their dynamics is solved numerically together with the equations ruling the blood flow. The intra-ventricular flow is analyzed in its relationship with the valvular motion. It is found that the initial valve opening anticipates the peak velocity of the Early filling wave with little influence of the specific geometry; while subsequent closure and re-opening are more dependent on the intraventricular vortex dynamics and thus on the leaflets' geometry itself. The limitations and potential applications of the proposed model are discussed.
Kamal, Muhammad Umar; Riaz, Irbaz Bin; Smith, M Cristy
Summary In intravenous drug abusers, infective endocarditis usually involves right-sided valves, with Staphylococcus aureus being the most common etiologic agent. We present a patient who is an intravenous drug abuser with left-sided (aortic valve) endocarditis caused by Enterococcus faecalis who subsequently developed an anterior mitral valve aneurysm, which is an exceedingly rare complication. A systematic literature search was conducted which identified only five reported cases in the literature of mitral valve aneurysmal rupture in the setting of E. faecalis endocarditis. Real-time 3D-transesophageal echocardiography was critical in making an accurate diagnosis leading to timely intervention. Learning objectives Early recognition of a mitral valve aneurysm (MVA) is important because it may rupture and produce catastrophic mitral regurgitation (MR) in an already seriously ill patient requiring emergency surgery, or it may be overlooked at the time of aortic valve replacement (AVR). Real-time 3D-transesophageal echocardiography (RT-3DTEE) is much more advanced and accurate than transthoracic echocardiography for the diagnosis and management of MVA. PMID:27249815
Chen, Yei-Tsung; Wang, Juan; Wee, Abby S Y; Yong, Quek-Wei; Tay, Edgar Lik-Wui; Woo, Chin Cheng; Sorokin, Vitaly; Richards, Arthur Mark; Ling, Lieng-Hsi
Myxomatous mitral valve prolapse (MMVP) and fibroelastic deficiency (FED) are two common variants of degenerative mitral valve disease (DMVD), which is a leading cause of mitral regurgitation worldwide. While pathohistological studies have revealed differences in extracellular matrix content in MMVP and FED, the molecular mechanisms underlying these two disease entities remain to be elucidated. By using surgically removed valvular specimens from MMVP and FED patients that were categorized on the basis of echocardiographic, clinical and operative findings, a cluster of microRNAs that expressed differentially were identified. The expressions of has-miR-500, -3174, -17, -1193, -646, -1273e, -4298, -203, -505, and -939 showed significant differences between MMVP and FED after applying Bonferroni correction (p < 0.002174). The possible involvement of microRNAs in the pathogenesis of DMVD were further suggested by the presences of in silico predicted target sites on a number of genes reported to be involved in extracellular matrix homeostasis and marker genes for cellular composition of mitral valves, including decorin (DCN), aggrecan (ACAN), fibromodulin (FMOD), α actin 2 (ACTA2), extracellular matrix protein 2 (ECM2), desmin (DES), endothelial cell specific molecule 1 (ESM1), and platelet/ endothelial cell adhesion molecule 1 (PECAM1), as well as inverse correlations of selected microRNA and mRNA expression in MMVP and FED groups. Our results provide evidence that distinct molecular mechanisms underlie MMVP and FED. Moreover, the microRNAs identified may be targets for the future development of diagnostic biomarkers and therapeutics.
Warnes, C; Honey, M; Brooks, N; Davies, J; Gorman, A; Parker, N
Two cases are described in which severe mechanical haemolytic anaemia developed shortly after operation for repair of non-rheumatic mitral regurgitation. One patient had a "floppy" valve and the other cleft mitral leaflets, and both had chordal rupture. In both there was residual regurgitation after repair though in one this was initially only trivial. Clinically manifest haemolysis ceased after replacement of the valve by a frame-mounted xenograft. There are two previously reported cases in which haemolytic anaemia followed an unsuccessful mitral valve repair operation. Subclinical haemolysis or mild haemolytic anaemia may occur with unoperated valve lesions, but hitherto frank haemolytic anaemia has been observed only when turbulent blood flow is associated with the presence of a prosthetic valve or patch of prosthetic fabric. In these four cases, however, polyester or Teflon sutures were the only foreign material, and it is suggested that when these are used for the repair of leaflets, particularly in non-rheumatic mitral valve disease, they may increase the damaging effect of turbulence on circulating red blood cells. PMID:7426198
Sanae, T; Kazama, S; Nie, M; Miyoshi, Y; Machii, M; Ohara, K; Yoshimura, H
A 61-year-old woman was found to have a free-floating ball, thrombus in the left atrium on echocardiographic examination 2 weeks after mitral valve replacement and tricuspid, annuloplasty. The free-floating thrombus was successfully, removed by an open-heart procedure without clinical sequelae. The diagnostic value of routine echocardiography on follow-up of valve surgery is emphasized.
Meschini, Valentina; de Tullio, Marco Donato; Querzoli, Giorgio; Verzicco, Roberto
In this paper Direct Numerical Simulations (DNS), implemented using a fully fluid-structure interaction model for the left ventricle, the mitral valve and the flowing blood, and laboratory experiments are performed in order to cross validate the results. Moreover a parameter affecting the flow dynamics is the presence of a mitral valve. We model two cases, one with a natural mitral valve and another with a prosthetic mechanical one. Our aim is to understand their different effects on the flow inside the left ventricle in order to better investigate the process of valve replacement. We simulate two situations, one of a healthy left ventricle and another of a failing one. While in the first case the flow reaches the apex of the left ventricle and washout the stagnant fluid with both mechanical and natural valve, in the second case the disturbance generated by the mechanical leaflets destabilizes the mitral jet, thus further decreasing its capability to penetrate the ventricular region and originating heart attack or cardiac pathologies in general.
Akboga, Mehmet Kadri; Akyel, Ahmet; Sahinarslan, Asife; Cengel, Atiye
Radiotherapy is extensively used in the treatment of Hodgkin's disease. One of its untoward effects is on heart. Coronary arteries and heart valves can be adversely affected from radiotherapy. However, co-existence of both conditions is very rare. In this report, we present a patient with Hodgkin's disease who developed both coronary artery stenosis and severe mitral valve regurgitation after radiotherapy.
Chen, Yei-Tsung; Wang, Juan; Wee, Abby S. Y.; Yong, Quek-Wei; Tay, Edgar Lik-Wui; Woo, Chin Cheng; Sorokin, Vitaly; Richards, Arthur Mark; Ling, Lieng-Hsi
Myxomatous mitral valve prolapse (MMVP) and fibroelastic deficiency (FED) are two common variants of degenerative mitral valve disease (DMVD), which is a leading cause of mitral regurgitation worldwide. While pathohistological studies have revealed differences in extracellular matrix content in MMVP and FED, the molecular mechanisms underlying these two disease entities remain to be elucidated. By using surgically removed valvular specimens from MMVP and FED patients that were categorized on the basis of echocardiographic, clinical and operative findings, a cluster of microRNAs that expressed differentially were identified. The expressions of has-miR-500, -3174, -17, -1193, -646, -1273e, -4298, -203, -505, and -939 showed significant differences between MMVP and FED after applying Bonferroni correction (p < 0.002174). The possible involvement of microRNAs in the pathogenesis of DMVD were further suggested by the presences of in silico predicted target sites on a number of genes reported to be involved in extracellular matrix homeostasis and marker genes for cellular composition of mitral valves, including decorin (DCN), aggrecan (ACAN), fibromodulin (FMOD), α actin 2 (ACTA2), extracellular matrix protein 2 (ECM2), desmin (DES), endothelial cell specific molecule 1 (ESM1), and platelet/ endothelial cell adhesion molecule 1 (PECAM1), as well as inverse correlations of selected microRNA and mRNA expression in MMVP and FED groups. Our results provide evidence that distinct molecular mechanisms underlie MMVP and FED. Moreover, the microRNAs identified may be targets for the future development of diagnostic biomarkers and therapeutics. PMID:27213335
Vasquez, Julio C; DeLaRosa, Jacob; Montesinos, Efrain; Rojas, Luis; Peralta, Julio; Leon, Juan J
Hydatid cyst can simultaneously affect the liver and lung. Some patients might have additional comorbidities that can make management more challenging. Here, we present a 10-year-old boy with hepatopulmonary hydatid cysts and severe mitral regurgitation, who was successfully managed with a staged surgical approach treating the lung first, followed by the liver and finally, the heart.
Castilla, Elena; Gato, Manuel; Ruiz, José Ramón
Pseudoaneurysm of the left ventricle (LV) is a rare cardiac disease that occurs after myocardial infarction or cardiac surgery. Because patients frequently present with nonspecific symptoms, a high index of suspicion is needed to make the diagnosis. This report describes an unusual case demonstrating a large LV pseudoaneurysm after mitral valve replacement performed 30 years earlier.
Stevenson, J G; Kawabori, I; Morgan, B C; Dillard, D H; Merendino, K A; Guntheroth, W G
Eight youngsters (five female, three male, ages 10 to 19 years, mean 15 years) with isolated severe rheumatic mitral regurgitation have been subjected to mitral annuloplasty because of limiting symptoms and prominent ECG and X-ray changes. They have been followed for up to 11 years (mean 3.7 years), and 7 have had excellent results. An early (1961) patient had a small annulus and was not a favorable candidate; he had only transient improvement. Seven are greatly improved, have decreased cardiac size (often dramatic), and have improved ECG's. One has undergone successful pregnancy, and none has been limited in activities. The extent and duration of improvement, lack of mortality, and resumption of normal activities by these youngsters indicate surgical success. The essence of childhood and youth is activity and the future life span hopefully long; hence, annuloplasty would appear to be the procedure of choice for severe rheumatic mitral regurgitation in the pediatric age group, avoiding the usual need for anticoagulation and uncertain long-term results associated with mitral valve replacement.
Bande, Dinesh; Abbara, Suhny; Kalva, Sanjeeva P.
We report a case of a 62-year-old man who presented with right groin pain who subsequently was found to have a renal infarct secondary to calcific embolus from mitral annular calcification on CT and angiography. We briefly review the literature and discuss the importance of this entity in clinical practice.
Choi, Ahnryul; McPherson, David D; Kim, Hyunggun
Mitral valve prolapse (MVP) refers to an excessive billowing of the mitral valve (MV) leaflets across the mitral annular plane into the left atrium during the systolic portion of the cardiac cycle. The underlying mechanisms for the development of MVP and mitral regurgitation in association with MV tissue remodeling are still unclear. We performed computational MV simulations to investigate the pathophysiologic developmental mechanisms of MVP. A parametric MV geometry model was utilized for this study. Posterior leaflet enlargement and posterior chordal elongation models were created by adjusting the geometry of the posterior leaflet and chordae, respectively. Dynamic finite element simulations of MV function were performed over the complete cardiac cycle. Computational simulations demonstrated that enlarging posterior leaflet area increased large stress concentration in the posterior leaflets and chordae, and posterior chordal elongation decreased leaflet coaptation. When MVP was accompanied by both posterior leaflet enlargement and chordal elongation simultaneously, the posterior leaflet was exposed to extremely large prolapse with a substantial lack of leaflet coaptation. These data indicate that MVP development is closely related to tissue alterations of the leaflets and chordae. This biomechanical evaluation strategy can help us better understand the pathophysiologic developmental mechanisms of MVP.
Perrault, Louis P.; Moskowitz, Alan J.; Kron, Irving L.; Acker, Michael A.; Miller, Marissa A.; Horvath, Keith A.; Thourani, Vinod H.; Argenziano, Michael; D'Alessandro, David A.; Blackstone, Eugene H.; Moy, Claudia S.; Mathew, Joseph P.; Hung, Judy; Gardner, Timothy J.; Parides, Michael K.
Background Ischemic mitral regurgitation (MR), a complication of myocardial infarction and coronary artery disease more generally, is associated with a high mortality rate and estimated to affect 2.8 million Americans. With 1-year mortality rates as high as 40%, recent practice guidelines of professional societies recommend repair or replacement, but there remains a lack of conclusive evidence supporting either intervention. The choice between therapeutic options is characterized by the trade-off between reduced operative morbidity and mortality with repair versus a better long-term correction of mitral insufficiency with replacement. The long-term benefits of repair versus replacement remain unknown, which has led to significant variation in surgical practice. Methods and Results This paper describes the design of a prospective randomized clinical trial to evaluate the safety and effectiveness of mitral valve repair and replacement in patients with severe ischemic mitral regurgitation. This trial is being conducted as part of the Cardiothoracic (CT) Surgical Trials Network. This paper addresses challenges in selecting a feasible primary endpoint, characterizing the target population (including the degree of MR), and analytical challenges in this high mortality disease. Conclusions The paper concludes by discussing the importance of information on functional status, survival, neurocognition, quality of life and cardiac physiology in therapeutic decision-making. PMID:22054660
Malev, Eduard; Zemtsovsky, Eduard; Pshepiy, Asiyet; Timofeev, Eugeny; Reeva, Svetlana; Prokudina, Maria
OBJECTIVE: To evaluate left ventricular function in young adults with mitral valve prolapse (MVP) without significant mitral regurgitation using two-dimensional strain imaging. METHODS AND RESULTS: A total of 58 asymptomatic young subjects (mean [± SD] age 19.7±1.6 years; 72% male) with MVP were compared with 60 sex- and age-matched healthy subjects. MVP was diagnosed by billowing one or both mitral leaflets >2 mm above the mitral annulus in the long-axis parasternal view. Longitudinal, radial and circumferential strain and strain rate were determined using speckle tracking with a grey-scale frame rate of 50 fps to 85 fps. There were no significant differences in the global systolic left ventricular function of the subjects with MVP compared with the control group. In the MVP group, most of the global myocardial systolic deformation indexes were not reduced. Only the global circumferential strain showed a decrease in the prolapse subjects. Regional, longitudinal, circumferential and radial strain and strain rate were decreased only in septal segments. A decrease in the rotation of the same septal segments at the basal level was also observed. CONCLUSION: Regional septal myocardial deformation indexes decrease in subjects with MVP. These changes may be the first sign indicating the deterioration of left ventricular systolic function as well as the existence of primary cardiomyopathy in asymptomatic young subjects with MVP. PMID:23592928
Erkan, Gulbanu; Erkan, Aycan Fahri; Cemri, Mustafa; Karaahmetoglu, Selma; Cesur, Mustafa; Cengel, Atiye
Background. Subclinical hypothyroidism (SH) predominantly affects women. The necessity of treatment in SH is controversial. Objective. We aimed to investigate the response of diastolic dysfunction to thyroid hormone replacement therapy (THRT) in women. Methods and Results. Twenty-two female subjects with SH and 20 euthyroid female controls were enrolled. Baseline and follow-up biochemical, hormonal, and echocardiographic evaluations were performed. Repeat echocardiograms were performed three months after the achievement of a euthyroid status with THRT. Mean baseline myocardial performance index (MPI) was 0.27 ± 0.08 in the SH group, and 0.22 ± 0.06 in the control group (P = 0.03). MPI did not change significantly after THRT. Pulsed-wave Doppler findings were not different among the groups. However, tissue Doppler-derived mitral annular E' velocities were significantly lower in the SH group. A moderate but significant improvement was observed in E' velocities after THRT (13.2 ± 3.87 versus 14.53 ± 2.75, P = 0.04). We also observed left ventricular concentric remodeling in SH patients which was reversible with THRT. Conclusions. Tissue Doppler echocardiography may be a useful tool for monitoring the response of diastolic dysfunction to thyroid hormone replacement therapy in patients with SH. Our findings suggest that THRT may reverse diastolic dysfunction in women with SH.
Erkan, Gulbanu; Erkan, Aycan Fahri; Cemri, Mustafa; Karaahmetoglu, Selma; Cesur, Mustafa; Cengel, Atiye
Background. Subclinical hypothyroidism (SH) predominantly affects women. The necessity of treatment in SH is controversial. Objective. We aimed to investigate the response of diastolic dysfunction to thyroid hormone replacement therapy (THRT) in women. Methods and Results. Twenty-two female subjects with SH and 20 euthyroid female controls were enrolled. Baseline and follow-up biochemical, hormonal, and echocardiographic evaluations were performed. Repeat echocardiograms were performed three months after the achievement of a euthyroid status with THRT. Mean baseline myocardial performance index (MPI) was 0.27 ± 0.08 in the SH group, and 0.22 ± 0.06 in the control group (P = 0.03). MPI did not change significantly after THRT. Pulsed-wave Doppler findings were not different among the groups. However, tissue Doppler-derived mitral annular E' velocities were significantly lower in the SH group. A moderate but significant improvement was observed in E' velocities after THRT (13.2 ± 3.87 versus 14.53 ± 2.75, P = 0.04). We also observed left ventricular concentric remodeling in SH patients which was reversible with THRT. Conclusions. Tissue Doppler echocardiography may be a useful tool for monitoring the response of diastolic dysfunction to thyroid hormone replacement therapy in patients with SH. Our findings suggest that THRT may reverse diastolic dysfunction in women with SH. PMID:21860776
Frazin, Leon J.; Vonesh, Michael J.; Chandran, Krishnan B.; Khasho, Fouad; Lanza, George M.; Talano, James V.; McPherson, David D.
The purpose of this study was to investigate a Doppler guided catheterization system as an adjunctive or alternative methodology to overcome the disadvantages of left heart catheterization and angiography. These disadvantages include the biological effects of radiation and the toxic and volume effects of iodine contrast. Doppler retrograde guidance uses a 20 MHz circular pulsed Doppler crystal incorporated into the tip of a triple lumen multipurpose catheter and is advanced retrogradely using the directional flow information provided by the Doppler waveform. The velocity detection limits are either 1 m/second or 4 m/second depending upon the instrumentation. In a physiologic flow model of the human aortic arch, multiple data points revealed a positive wave form when flow was traveling toward the catheter tip indicating proper alignment for retrograde advancement. There was a negative wave form when flow was traveling away from the catheter tip if the catheter was in a branch or bent upon itself indicating improper catheter tip position for retrograde advancement. In a series of six dogs, the catheter was able to be accurately advanced from the femoral artery to the left ventricular chamber under Doppler signal guidance without the use of x-ray. The potential applications of a Doppler guided retrograde catheterization system include decreasing time requirements and allowing safer catheter guidance in patients with atherosclerotic vascular disease and suspected aortic dissection. The Doppler system may allow left ventricular pressure monitoring in the intensive care unit without the need for x-ray and it may allow left sided contrast echocardiography. With pulse velocity detection limits of 4 m/second, this system may allow catheter direction and passage into the aortic root and left ventricle in patients with aortic stenosis. A modification of the Doppler catheter may include transponder technology which would allow precise catheter tip localization once the
Eckert, Chad E; Zubiate, Brett; Vergnat, Mathieu; Gorman, Joseph H; Gorman, Robert C; Sacks, Michael S
Though mitral valve (MV) repair surgical procedures have increased in the United States [Gammie, J. S., et al. Ann. Thorac. Surg. 87(5):1431-1437, 2009; Nowicki, E. R., et al. Am. Heart J. 145(6):1058-1062, 2003], studies suggest that altering MV stress states may have an effect on tissue homeostasis, which could impact the long-term outcome [Accola, K. D., et al. Ann. Thorac. Surg. 79(4):1276-1283, 2005; Fasol, R., et al. Ann. Thorac. Surg. 77(6):1985-1988, 2004; Flameng, W., P. Herijgers, and K. Bogaerts. Circulation 107(12):1609-1613, 2003; Gillinov, A. M., et al. Ann. Thorac. Surg. 69(3):717-721, 2000]. Improved computational modeling that incorporates structural and geometrical data as well as cellular components has the potential to predict such changes; however, the absence of important boundary condition information limits current efforts. In this study, novel high definition in vivo annular kinematic data collected from surgically implanted sonocrystals in sheep was fit to a contiguous 3D spline based on quintic-order hermite shape functions with C(2) continuity. From the interpolated displacements, the annular axial strain and strain rate, bending, and twist along the entire annulus were calculated over the cardiac cycle. Axial strain was shown to be regionally and temporally variant with minimum and maximum values of -10 and 4%, respectively, observed. Similarly, regionally and temporally variant strain rate values, up to 100%/s contraction and 120%/s elongation, were observed. Both annular bend and twist data showed little deviation from unity with limited regional variations, indicating that most of the energy for deformation was associated with annular axial strain. The regionally and temporally variant strain/strain rate behavior of the annulus are related to the varied fibrous-muscle structure and contractile behavior of the annulus and surrounding ventricular structures, although specific details are still unavailable. With the high resolution
Miyazaki, Aya; Sakaguchi, Heima; Uchiyama, Takamichi; Kurita, Takashi; Ohuchi, Hideo; Yamada, Osamu
The atrioventricular (AV) conduction system in AV discordance remains unclear, especially in cases with complex cardiac anomaly. We report a case of accessory pathway reciprocating tachycardia in atrioventricular discordance (AVD) and mitral atresia with twin AV nodes. In this case, the anterior AV node was located along the atretic mitral valve. The anterior AV node was involved in tachycardia and the posterior AV node acted as a bystander during tachycardia. The anterior AV node in AVD can be located along the atretic mitral valve, and one of twin AV nodes might act as a bystander during AV reciprocating tachycardia.
Liang, Michael; Kelly, Damian; Puri, Aniket; Devlin, Gerard
A 28 year-old lady with severe rheumatic mitral stenosis presented with non-ST-elevation myocardial infarction secondary to angiographically confirmed right coronary artery embolus with a likely source of mitral valve stenosis origin. This patient was successfully treated medically with dual anti-platelet and 72 hours of intravenous heparin, glycoprotein IIb/IIIa inhibitor and eptifibitide (Integrilin) with a repeated coronary angiogram showing complete resolution of embolus. The management of embolic myocardial infarction is discussed along with the risks of embolism in patients with mitral stenosis who remain in sinus rhythm.
Daum, F. E.
The single-pulse Doppler estimation accuracy of an unweighted linear FM waveform is analyzed in detail. Simple formulas are derived that predict that one-sigma Doppler estimation error for realistic radar applications. The effects of multiple target interference and nonlinearlities in the radar measurements are considered. In addition, a practical method to estimate Doppler frequency is presented. This technique uses the phase data after pulse compression, and it limits the effect of multiple target interference. In contrast, the available literature is based on the Cramer-Rao bound for Doppler accuracy, which ignores the effects of nonlinearities, multiple target interference and the question of practical implementation. A simple formula is derived that predicts the region of validity for the Cramer-Rao bound. This formula provides a criterion for minimum signal-to-noise ratio in terms of time-bandwidth product. Finally, an important concept that is demonstrated in this paper is that: the bulk of the Doppler information in a linear FM pulse is encoded in the range sidelobes after pulse compression.
Zhai, S. L.; Zhao, X. P.; Liu, S.; Shen, F. L.; Li, L. L.; Luo, C. R.
The Doppler effect refers to the change in frequency of a wave source as a consequence of the relative motion between the source and an observer. Veselago theoretically predicted that materials with negative refractions can induce inverse Doppler effects. With the development of metamaterials, inverse Doppler effects have been extensively investigated. However, the ideal material parameters prescribed by these metamaterial design approaches are complex and also challenging to obtain experimentally. Here, we demonstrated a method of designing and experimentally characterising arbitrary broadband acoustic metamaterials. These omni-directional, double-negative, acoustic metamaterials are constructed with ‘flute-like’ acoustic meta-cluster sets with seven double meta-molecules; these metamaterials also overcome the limitations of broadband negative bulk modulus and mass density to provide a region of negative refraction and inverse Doppler effects. It was also shown that inverse Doppler effects can be detected in a flute, which has been popular for thousands of years in Asia and Europe. PMID:27578317
We discuss spacecraft Doppler tracking in which Doppler data recorded on the ground are linearly combined with Doppler measurements made on board a spacecraft. By using the four-link radio system first proposed by Vessot and Levine, we derive a new method for removing from the combined data the frequency fluctuations due to the Earth troposphere, ionosphere, and mechanical vibrations of the antenna on the ground. Our method provides also for reducing by several orders of magnitude, at selected Fourier components, the frequency fluctuations due to other noise sources, such as the clock on board the spacecraft or the antenna and buffeting of the probe by non-gravitational forces. In this respect spacecraft Doppler tracking can be regarded as a xylophone detector. Estimates of the sensitivities achievable by this xylophone are presented for two tests of Einstein's theory of relativity: searches for gravitational waves and measurements of the gravitational red shift. This experimental technique could be extended to other tests of the theory of relativity, and to radio science experiments that rely on high-precision Doppler measurements.
Fleischer, Arthur C; Andreotti, Rochelle F
This review aims to provide the reader with an overview of the present and future clinical applications in color Doppler sonography for the evaluation of vascularity and blood flow within the uterus (both gravid and nongravid), ovaries, fetus and placenta. The clinical use of color Doppler sonography has been demonstrated within many organ systems. Color Doppler sonography has become an integral part of cardiovascular imaging. Significant improvements have recently occurred, improving the visualization and evaluation of intra-organ vascularity, resulting from enhancements in delineation of tissue detail through electronic compounding and harmonics, as well as enhancements in signal processing of frequency- and/or amplitude-based color Doppler sonography. Spatial representation of vascularity can be improved by utilizing 3D and 4D (live 3D) processing. Greater sensitivity of color Doppler sonography to macro- and microvascular flow has provided improved anatomic and physiologic assessment throughout pregnancy and for pelvic organs. The potential use of contrast enhancement is also mentioned as a means to further differentiate benign from malignant ovarian lesions. The rapid development of these new sonographic techniques will continue to enlarge the scope of clinical applications in a variety of obstetric and gynecologic disorders.
Khoshniat, Mahdieh; Thorne, Meghan L.; Poepping, Tamie L.; Holdsworth, David W.; Steinman, David A.
Doppler ultrasound (DUS) is widely used to diagnose and plan treatments for vascular diseases, but the relationship between complex blood flow dynamics and the observed DUS signal is not completely understood. In this paper, we demonstrate that Doppler ultrasound can be realistically simulated in a real-time manner via the coupling of a known, previously computed velocity field with a simple model of the ultrasound physics. In the present case a 3D computational fluid dynamics (CFD) model of physiologically pulsatile flow a stenosed carotid bifurcation was interrogated using a sample volume of known geometry and power distribution. Velocity vectors at points within the sample volume were interpolated using a fast geometric search algorithm and, using the specified US probe characteristics and orientation, converted into Doppler shifts for subsequent display as a Doppler spectrogram or color DUS image. The important effect of the intrinsic spectral broadening was simulated by convolving the velocity at each point within the sample volume by a triangle function whose width was proportional to velocity. A spherical sample volume with a Gaussian power distribution was found to be adequate for producing realistic Doppler spectrogram in regions of uniform, jet, and recirculation flow. Fewer than 1000 points seeded uniformly within a radius comprising more than 99% of the total power were required, allowing spectra to be generated from high resolution CFD data at 100Hz frame rates on an inexpensive desktop workstation.
Crossfield, I.; Biller, B.; Schlieder, J.; Deacon, N.; Bonnefoy, M.; Homeier, D.; Allard, F.; Buenzli, E.; Henning, T.; Brandner, W.; Goldman, Bertr; Kopytova, T.
Doppler Imaging produces 2D global maps. When applied to cool planets or more massive brown dwarfs, it can map atmospheric features and track global weather patterns. The first substellar map, of the 2pc-distant brown dwarf Luhman 16B (Crossfeld et al. 2014), revealed patchy regions of thin & thick clouds. Here, I investigate the feasibility of future Doppler Imaging of additional objects. Searching the literature, I find that all 3 of P, v sin i, and variability are published for 22 brown dwarfs. At least one datum exists for 333 targets. The sample is very incomplete below ~L5; we need more surveys to find the best targets for Doppler Imaging! I estimate limiting magnitudes for Doppler Imaging with various hi-resolution near-infrared spectrographs. Only a handful of objects - at the M/L and L/T transitions - can be mapped with current tools. Large telescopes such as TMT and GMT will allow Doppler Imaging of many dozens of brown dwarfs and the brightest exoplanets. More targets beyond type L5 likely remain to be found. Future observations will let us probe the global atmospheric dynamics of many diverse objects.
Hudson, H. S.; Woods, T. N.; Chamberlin, P. C.; Didkovsky, L.; Del Zanna, G.
The Extreme-ultraviolet Variability Experiment (EVE) obtains continuous EUV spectra of the Sun viewed as a star. Its primary objective is the characterization of solar spectral irradiance, but its sensitivity and stability make it extremely interesting for observations of variability on time scales down to the limit imposed by its basic 10 s sample interval. In this paper we characterize the Doppler sensitivity of the EVE data. We find that the 30.4 nm line of He II has a random Doppler error below 0.001 nm (1 pm, better than 10 km/s as a redshift), with ample stability to detect the orbital motion of its satellite, the Solar Dynamics Observatory (SDO). Solar flares also displace the spectrum, both because of Doppler shifts and because of EVE's optical layout, which (as with a slitless spectrograph) confuses position and wavelength. As a flare develops, the centroid of the line displays variations that reflect Doppler shifts and therefore flare dynamics. For the impulsive phase of the flare SOL2010-06-12, we find the line centroid to have a redshift of 16.8 +/- 5.9 km/s relative to that of the flare gradual phase (statistical errors only). We find also that high-temperature lines, such as Fe XXIV 19.2 nm, have well-determined Doppler components for major flares, with decreasing apparent blueshifts as expected from chromospheric evaporation flows.
Simon, Marvin K.; Divsalar, Dariush
An open-loop technique is presented for estimating and correcting Doppler frequency shift in an M-ary differential phase-shift-keyed (MDPSK) receiver. The novelty of the scheme is based on the observation that whereas the change in phase of the received signal over a full symbol contains the sum of the data (phase) and the Doppler-induced phase shift, the same change in phase over half a symbol (within a given symbol interval) contains only the Doppler-induced phase shift. Thus, by proper processing, the latter can be estimated and removed from the former. Analytical and simulation results are given for the variance of the above estimator, and the error probability performance of the MDPSK receiver is evaluated in the presence of the Doppler correction. Next, the practical considerations associated with the application of this technique on bandlimited Nyquist channels are discussed and incorporated into the final design. It is shown that the receiver can, in the absence of timing jitter, be designed to allow combined Doppler correction and data detection with no penalty due to intersymbol interference (ISI). The effects of ISI due to timing jitter are assessed by computer simulation.
Voigt, Ingmar; Ionasec, Razvan Ioan; Georgescu, Bogdan; Houle, Helene; Huber, Martin; Hornegger, Joachim; Comaniciu, Dorin
Disorders of the mitral valve are second most frequent, cumulating 14 percent of total number of deaths caused by Valvular Heart Disease each year in the United States and require elaborate clinical management. Visual and quantitative evaluation of the valve is an important step in the clinical workflow according to experts as knowledge about mitral morphology and dynamics is crucial for interventional planning. Traditionally this involves examination and metric analysis of 2D images comprising potential errors being intrinsic to the method. Recent commercial solutions are limited to specific anatomic components, pathologies and a single phase of cardiac 4D acquisitions only. This paper introduces a novel approach for morphological and functional quantification of the mitral valve based on a 4D model estimated from ultrasound data. A physiological model of the mitral valve, covering the complete anatomy and eventual shape variations, is generated utilizing parametric spline surfaces constrained by topological and geometrical prior knowledge. The 4D model's parameters are estimated for each patient using the latest discriminative learning and incremental searching techniques. Precise evaluation of the anatomy using model-based dynamic measurements and advanced visualization are enabled through the proposed approach in a reliable, repeatable and reproducible manner. The efficiency and accuracy of the method is demonstrated through experiments and an initial validation based on clinical research results. To the best of our knowledge this is the first time such a patient specific 4D mitral valve model is proposed, covering all of the relevant anatomies and enabling to model the common pathologies at once.
Stevanella, Marco; Krishnamurthy, Gaurav; Votta, Emiliano; Swanson, Julia C; Redaelli, Alberto; Ingels, Neil B
The anterior mitral leaflet (AML) is a thin membrane that withstands high left ventricular (LV) pressure pulses 100,000 times per day. The presence of contractile cells determines AML in vivo stiffness and complex geometry. Until recently, mitral valve finite element (FE) models have neglected both of these aspects. In this study we assess their effect on AML strains and stresses, hypothesizing that these will differ significantly from those reported in literature. Radiopaque markers were sewn on the LV, the mitral annulus, and AML in sheep hearts, and their four-dimensional coordinates obtained with biplane video fluoroscopy. Employing in vivo data from three representative hearts, AML FE models were created from the marker coordinates at the end of isovolumic relaxation assumed as the unloaded reference state. AML function was simulated backward through systole, applying the measured trans-mitral pressure on AML LV surface and marker displacements on AML boundaries. Simulated AML displacements and curvatures were consistent with in vivo measurements, confirming model accuracy. AML circumferential strains were mostly tensile (1-3%), despite being compressive (-1%) near the commissures. Radial strains were compressive in the belly (-1 to -0.2%), and tensile (2-8%) near the free edge. These results differ significantly from those of previous FE models. They reflect the synergy of high tissue stiffness, which limits tensile circumferential strains, and initial compound curvature, which forces LV pressure to compress AML radially. The obtained AML shape may play a role not only in preventing mitral regurgitation, but also in optimizing LV outflow fluid dynamics.
Owais, Khurram; Montealegre-Gallegos, Mario; Jeganathan, Jelliffe; Matyal, Robina; Khabbaz, Kamal R.; Mahmood, Feroze
Objectives: Contrary to the rest of the mitral annulus, inter-trigonal distance is known to be relatively less dynamic during the cardiac cycle. Therefore, intertrigonal distance is considered a suitable benchmark for annuloplasty ring sizing during mitral valve (MV) surgery. The entire mitral annulus dilates and flattens in patients with ischemic mitral regurgitation (IMR). It is assumed that the fibrous trigone of the heart and the intertrigonal distance does not dilate. In this study, we sought to demonstrate the changes in mitral annular geometry in patients with IMR and specifically analyze the changes in intertrigonal distance during the cardiac cycle. Methods: Intraoperative three-dimensional transesophageal echocardiographic data obtained from 26 patients with normal MVs undergoing nonvalvular cardiac surgery and 36 patients with IMR undergoing valve repair were dynamically analyzed using Philips Qlab® software. Results: Overall, regurgitant valves were larger in area and less dynamic than normal valves. Both normal and regurgitant groups displayed a significant change in annular area (AA) during the cardiac cycle (P < 0.01 and P < 0.05, respectively). Anteroposterior and anterolateral-posteromedial diameters and inter-trigonal distance increased through systole (P < 0.05 for all) in accordance with the AAs in both groups. However, inter-trigonal distance showed the least percentage change across the cardiac cycle and its reduced dynamism was validated in both cohorts (P > 0.05). Conclusions: Annular dimensions in regurgitant valves are dynamic and can be measured feasibly and accurately using echocardiography. The echocardiographically identified inter-trigonal distance does not change significantly during the cardiac cycle. PMID:26750668