Amplitude-weighted mean velocity: Clinical utilization for quantitation of mitral regurgitation

AbstractObjectives. The purpose of this study was to determine the clinical usefulness of the amplitude-weighted mean velocity method for quantitation of mitral regurgitation.Background. Amplitude-weighted mean velocity is a nonvolumetric method for calculating the mitral regurgitant fraction. Its previous validation at one center mandated an independent assessment of its usefulness and limitations.Methods. In 56 patients with and 16 patients without mitral regugitation, the regurgitant fraction was measured simultaneously by amplitude-weighted mean velocity, quantitative Doppler study and quantitative two-dimensional echocardiography. In 16 patients, multiple gain settings were used to determine the influence of this variable on amplitude-weighted mean velocity.Results. In ptients without regurgitation, amplitude-weighted mean velocity showed more scattering of regurgitant fraction (−18% to 23%) than Doppler (p = 0.016) or two-dimensional echocardiography (p = 0.022). The absolute value of regurgitant fraction was (mean ± SD) 8 ± 6%, 4 ± 2% and 4 ± 3%, respectively (p = NS). With increasing gain, the amplitudeweighted mean velocity mitral and aortic integrals increased, but the calculated regurgitant fraction remained unchanged. In patients with mitral regurgitation, significant correlation was found between amplitude-weighted mean velocity and Doppler study (r = 0.79, p = 0.0001) and between implitude-weighted mean velocity and two-dimensional echocardiography (r = 0.76, p = 0.0001) for calculated regurgitant fraction, but the standard error of the estimate (12%) was large.Conclusions. The amplitude-weighted mean velocitycalculated regurgitant fraction is gain independent, whereas the aortic and mitral integrals are gain dependent. Compared with Doppler and two-dimensional echocardiography, It shows more scattering of values in patients without regurgitation, but the methods correlate significantly in patients with mitral regurgitation. Amplitude-weighted mean velocity can be used as a simple adjunctive tool for comprehensive, noninvasive quantitation of mitral regurgitation

B-type natriuretic peptide clinical activation in aortic stenosis : impact on long-term survival

Objectives : This study was conducted to define the association between serum B-type natriuretic peptide (BNP) activation and survival after the diagnosis of aortic stenosis (AS).Background : In AS, the link between BNP levels and clinical outcome is in dispute. Failure to account for the normal shifting of BNP ranges with aging in men and women, not using hard endpoints (survival), and not enrolling large series of patients have contributed to the uncertainty.Methods : A program of prospective measurement of BNP levels with Doppler echocardiographic AS assessment during the same episode of care was conducted. BNP ratio (measured BNP/maximal normal BNP value specific to age and sex) >1 defined BNP clinical activation.Results : In 1,953 consecutive patients with at least moderate AS (aortic valve area 1.03 ± 0.26 cm2; mean gradient 36 ± 19 mm Hg), median BNP level was 252 pg/ml (interquartile range: 98 to 592 pg/ml); BNP ratio 2.46 (interquartile range 1.03 to 5.66); ejection fraction (EF) 57% ± 15%, and symptoms present in 60% of patients. After adjustment for all survival determinants, BNP clinical activation (BNP ratio >1) independently predicted mortality after diagnosis (p 2 (HR: 0.56; 95% CI: 0.47 to 0.66; p < 0.0001).Conclusions : In this large series of patients with AS, BNP clinical activation was associated with excess long-term mortality incrementally and independently of all baseline characteristics. Higher mortality with higher BNP clinical activation, even in asymptomatic patients, emphasizes the importance of appropriate clinical interpretation of BNP levels in managing patients with AS

Assessment of cardiac remodeling in asymptomatic mitral regurgitation for surgery timing: a comparative study of echocardiography and magnetic resonance imaging

<p>Abstract</p> <p>Background</p> <p>Early surgery is recommended for asymptomatic severe mitral regurgitation (MR), because of increased postoperative left ventricular (LV) dysfunction in patients with late surgery. On the other hand, recent reports emphasized a "watchful waiting" process for the determination of the proper time of mitral valve surgery. In our study, we compared magnetic resonance imaging (MRI) and transthoracic echocardiography to evaluate the LV and left atrial (LA) remodeling; for better definitions of patients that may benefit from early valve surgery.</p> <p>Methods</p> <p>Twenty-one patients with moderate to severe asymptomatic MR were evaluated by echocardiography and MRI. LA and LV ejection fractions (EFs) were calculated by echocardiography and MRI. Pulmonary veins (PVs) were measured from vein orifices in diastole and systole from the tangential of an imaginary circle that completed LA wall. Right upper PV indices were calculated with the formula; (Right upper PV diastolic diameter- Right upper PV systolic diameter)/Right upper PV diastolic diameter.</p> <p>Results</p> <p>In 9 patients there were mismatches between echocardiography and MRI measurements of LV EF. LV EFs were calculated ≥60% by echocardiography, meanwhile < 60% by MRI in these 9 patients. Severity of MR evaluated by effective regurgitant orifice area (EROA) didn't differ with preserved and depressed EFs by MRI (p > 0.05). However, both right upper PV indices (0.16 ± 0.06 vs. 0.24 ± 0.08, p: 0.024) and LA EFs (0.19 ± 0.09 vs. 0.33 ± 0.14, p: 0.025) were significantly decreased in patients with depressed EFs when compared to patients with normal EFs.</p> <p>Conclusions</p> <p>MRI might be preferred when small changes in functional parameters like LV EF, LA EF, and PV index are of clinical importance to disease management like asymptomatic MR patients that we follow up for appropriate surgery timing.</p

Acute severe mitral regurgitation: consideration of papillary muscle architecture

We present a case of an individual who presented with acute severe mitral regurgitation in the setting of an inferior ST elevation myocardial infarction. Both transthoracic and transesophageal echocardiography demonstrated a posteriorly directed eccentric jet of severe mitral regurgitation with flail anterior mitral valve leaflet attached presumably to the anterior papillary muscle. Intraoperative findings demonstrated rupture of the postero-medial papillary muscle attached via chords to the anterior mitral valve leaflet. This case serves to remind us that both the anterior and posterior leaflets of the mitral valve are attached to both papillary muscle heads. The direction and eccentricity of the mitral regurgitant jet on echocardiography helps to locate the leaflet involved, but not necessarily the coexisting papillary muscle pathology

Functional anatomy of mitral regurgitation Accuracy and outcome implications of transesophageal echocardiography

AbstractOBJECTIVESThis study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography.BACKGROUNDIn patients with mitral regurgitation (MR), valve repair is a major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown.METHODSIn 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined.RESULTSCompared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease.CONCLUSIONSTransesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR

Sex differences and survival in adults with bicuspid aortic valves : verification in 3 contemporary echocardiographic cohorts

Background-—Sex-related differences in morbidity and survival in bicuspid aortic valve (BAV) adults are fundamentally unknown. Contemporary studies portend excellent survival for BAV patients identified at early echocardiographic-clinical stages. Whether BAV adults incur a survival disadvantage throughout subsequent echocardiographic-clinical stages remains undetermined. Methods and Results-—Analysis was done of 3 different cohorts of consecutive patients with echocardiographic diagnosis of BAV identified retrospectively: (1) a community cohort of 416 patients with first BAV diagnosis (age 35 21 years, follow-up 16 7 years), (2) a tertiary clinical referral cohort of 2824 BAV adults (age 51 16 years, follow-up 9 6 years), and (3) a surgical referral cohort of 2242 BAV adults referred for aortic valve replacement (AVR) (age 62 14 years, follow-up 6 5 years). For the community cohort, 20-year risks of aortic regurgitation (AR), AVR, and infective endocarditis were higher in men (all P=0.04); for a total BAV-related morbidity risk of 52 4% vs 35 6% in women (P=0.01). The cohort’s 25-year survival was identical to that in the general population (P=0.98). AR independently predicted mortality in women (P=0.001). Baseline AR was more common in men (P=0.02) in the tertiary cohort, with 20-year survival lower than that in the general population (P<0.0001); age-adjusted relative death risk was 1.16 (95% confidence interval [CI] 1.05-1.29) for men versus 1.67 (95% CI 1.38-2.03) for women (P=0.001). AR independently predicted mortality in women (P=0.01). Baseline AR and infective endocarditis were higher in men (both =0.001) for the surgical referral cohort, with 15-year survival lower than that in the general population (P<0.0001); age-adjusted relative death risk was 1.34 (95% CI 1.22-1.47) for men versus 1.63 (95% CI 1.40-1.89) for women (P=0.026). AR and NYHA class independently predicted mortality in women (both P=0.04). Conclusions-—Within evolving echocardiographic-clinical stages, the long-term survival of adults with BAV is not benign, as both men and women incur excess mortality. Although BAV-related morbidity is higher in men in the community, and AR and infective endocarditis are more prevalent in men, women exhibit a significantly higher relative risk of death in tertiary and surgical referral cohorts, which is independently associated with A

Comparaison de deux méthodes de sélection classique avec l'haplodiploïdisation pour la résistance à la mouche de Hesse chez le blé tendre (Triticum aestivum)

L'efficacité des méthodes classiques et alternatives d'amélioration génétique repose sur l'évolution de la variabilité génétique des populations ségrégatives sous sélection. L'objectif de cette étude est de comparer l'évolution de la fréquence des gènes de résistance à la mouche de Hesse (Mayetiola destructor) sous deux méthodes classiques de sélection en comparaison avec la méthode de l'haplodiploïdisation. Les distributions et les proportions observées du caractère "résistance à la mouche de Hesse" ont été évaluées pour des lignées produites par la méthode de filiation unipare (FUP), la méthode " bulk " et l'haplodiploïdisation (DH) de quatre populations hybrides de blé tendre (Triticum aestivum). Ces populations sont issues des croisements entre des parents résistants à la mouche de Hesse marocaine et des parents sensibles mais adaptés aux conditions marocaines. Les résultats ont montré un effet marqué de la méthode d'amélioration génétique. En effet, malgré leur avancement à la génération F6, les lignées produites par les méthodes FUP et " bulk " présentent toujours un taux non négligeable d'hétérozygotie pour ce caractère alors que la méthode DH a abouti à une homozygotie parfaite. Les proportions de résistance observées chez les lignées FUP et haploïdes doublées sont approximativement les mêmes que celles théoriquement attendues. Cependant, la méthode " bulk " a permis une sélection naturelle au champ qui a favorisé le caractère résistant de manière significativeThe relative usefulness of conventional and alternative breeding methods relies on the evolution of genetic variability in segregating populations undergoing selection. The objective of this study was to compare the frequencies of genetic resistance to Hessian fly (Mayetiola destructor) in populations generated by two conventional breeding methods in comparison with lines advanced through doubled haploid method. Distribution and proportions of Hessian fly resistance were evaluated in four populations of bread wheat lines advanced through 'Single Seed Descent' (SSD), 'Bulk', and doubled-haploid (DH) methods. These populations were all derived from crosses involving resistant parents and susceptible lines adapted to Moroccan conditions. The results of this study have shown a clear effect of the breeding method. The Bulk and SSD (F6) derived lines have shown a substantial residual heterozygocity while DH method has produced completely homozygous material. The observed proportions of resistance did not deviate from expected in the populations of lines derived through SSD and DH methods while evidence of natural selection for resistance was significant in the lines derived through the Bulk method

Surgery for Valvular Heart Disease: A Population-Based Study in a Brazilian Urban Center

BACKGROUND: In middle income countries, the burden of rheumatic heart disease (RHD) remains high, but the prevalence of other heart valve diseases may rise as the population life expectancy increases. Here, we compared population-based data on surgical procedures to assess the relative importance of causes of heart valve disease in Salvador, Brazil. METHODOLOGY/PRINCIPAL FINDINGS: Medical charts of patients who underwent surgery for valvular heart disease from January 2002-December 2005 were reviewed. Incidence of surgery for valvular heart disease was calculated. Logistic regression was used to identify factors associated with in-hospital death following surgery. The most common etiologies for valvular dysfunction in 491 valvular heart surgery patients were RHD (60.3%), degenerative valve disease (15.3%), and endocarditis (4.5%). Mean annual incidence for surgeries due to any valvular heart diseases, RHD, and degenerative valvular disease were 5.02, 3.03, and 0.77 per 100,000 population, respectively. Incidence of surgery due to RHD was highest in young adults; procedures were predominantly paid by the public health sector. In contrast, the incidence of surgery due to degenerative valvular disease was highest among those older than 60 years of age; procedures were mostly paid by the private sector. The overall in-hospital case-fatality ratio was 11.9%. Independent factors associated with death included increase in age (odds ratio: 1.04 per year of age; 95% confidence interval: 1.02-1.06), endocarditis (6.35; 1.92-21.04), multiple valve operative procedures (4.35; 2.12-8.95), and prior heart valve surgery (2.49; 1.05-5.87). CONCLUSIONS/SIGNIFICANCE: RHD remains the main cause for valvular heart surgery in Salvador, which primarily affects young adults without private health insurance. In contrast, surgery due to degenerative valvular disease primarily impacts the elderly with private health insurance. Strategies to reduce the burden of valvular heart disease will need to address the disparate factors that contribute to RHD as well as degenerative valve disease

Technical and Clinical Outcomes After Transcatheter Edge-to-Edge Repair of Mitral Regurgitation in Male and Female Patients: Is Equality Achieved?

Currently, no clear impact of sex on short- and long-term survival following transcatheter edge-to-edge mitral valve repair (TEER) is evident, although no data are available on postprocedural life expectancy. Our aim was to assess sex-specific differences in outcomes of patients with mitral regurgitation (MR) treated by TEER. Short-term and 5-year outcomes in men and women undergoing TEER between 2011 and 2018 who were included in the large, multicenter, real-world MitraSwiss registry were analyzed. Outcomes were compared stratified by sex and according to MR cause (primary versus secondary). The impact of TEER on postprocedural life expectancy was estimated by relative survival analysis. Among 1142 patients aged 60 to 89 years, 39.8% were women. They were older, with fewer cardiovascular risk factors and lower functional capacity compared with men. Thirty-day mortality was higher in men than in women (3.3% versus 1.1%; odds ratio, 3.16 [95% CI, 1.16-10.7]; P=0.020). Five-year survival was comparable in both sexes (adjusted hazard ratio for 5-year mortality in men, 1.14 [95% CI, 0.90-1.44], P=0.275). Both men and women with either primary or secondary MR showed similar clinical efficacy over time. TEER provided high relative survival estimates among all groups, and fully restored predicted life expectancy in women with primary MR (5-year relative survival estimate, 97.4% [95% CI, 85.5-107.0]). TEER is not associated with increased short-term mortality in women, whereas 5-year outcomes are comparable between sexes. Moreover, TEER completely restored normal life expectancy in women with primary MR. A residual excess mortality persists in secondary MR, independently of sex

Left atrial size is a potent predictor of mortality in mitral regurgitation due to flail leaflets results from a large international multicenter study

Background-Left atrium (LA) enlargement is common in organic mitral regurgitation (MR) and is an emerging prognostic indicator. However, outcome implications of LA enlargement have not been analyzed in the context of routine clinical practice and in a multicenter study. Methods and Results-The Mitral Regurgitation International DAtabase (MIDA) registry enrolls patients with organic MR due to flail leaflets, diagnosed in routine clinical practice, in 5 US and European centers. We investigated the relation between LA diameter and mortality under medical treatment and after mitral surgery in 788 patients in sinus rhythm (64±12 years; median LA, 48 [43 to 52] mm). LA diameter was independently associated with survival after diagnosis (hazard ratio, 1.08 [1.04 to 1.12] per 1 mm increment). Compared with patients with LA<55 mm, those with LA â¥55 mm had lower 8-year overall survival (P<0.001). LA â¥55 mm independently predicted overall mortality (hazard ratio, 3.67 [1.95 to 6.88]) and cardiac mortality (hazard ratio, 3.74 [1.72 to 8.13]) under medical treatment. The association of LA â¥55 mm and mortality was consistent in subgroups. Similar excess mortality associated with LA â¥55 mm was observed in asymptomatic and symptomatic patients (P for interaction, 0.77). In patients who underwent mitral surgery, LA â¥55 mm had no impact on postoperative outcome (P<0.20). Mitral surgery was associated with greater survival benefit in patients with LA â¥55 mm compared with LA <55 mm (P for interaction, 0.008). Conclusions-In MR caused by flail leaflets, LA diameter â¥55 mm is associated with increased mortality under medical treatment, independent of the presence of symptoms or left ventricular dysfunction. © 2011 American Heart Association, Inc