Epicardial echocardiography

The technique described in this thesis will be referred to as "epicardial echocardiography". The addition "intraoperative" is unnecessary, since "epicardial" presumes operative access to the heart. If the transducer is applied to the aorta or other great vessels after a median sternotomy, it would be more correctly to refer to the technique as "epivascular echography". However, for simplicity, this term will only be used if the transducer is applied to the descending thoracic and abdominal aorta after lateral thoracotomy or thoraco-abdominal incisions. The technique where the transducer is introduced into the esophagus during the operation will be referred to as "intraoperative esophageal echocardiography".4 The traditional approach of echocardiography, by placing the transducer upon the chest, will be referred to as "precordial" or "transthoracic echocardiography"

Initial results of combined anterior mitral leaflet extension and myectomy in patients with obstructive hypertrophic cardiomyopathy

Objectives. The purpose of this study was to describe the clinical and functional results of combined anterior mitral leaflet extension and myectomy in patients with hypertrophic obstructive cardiomyopathy. Background. Septal myectomy is the most commonly performed surgical procedure in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction. Because of the role of the mitral valve in creating the outflow tract gradient, mitral valve replacement or plication is performed in selected cases in combination with myectomy, often with better hemodynamic results than those of myectomy alone. Mitral valve leaflet extension, in which a glutaraldehyde-preserved autologous pericardial patch is used to enlarge the mitral valve along its horizontal axis, is a novel surgical approach in patients with hypertrophic obstructive cardiomyopathy. Methods. Eight patients with hypertrophic obstructive cardiomyopathy were treated with mitral leaflet extension and myectomy. Preoperative and postoperative data (New York Heart Association functional class, number of drugs prescribed, width of the interventricular septum, severity of mitral valve regurgitation, severity of systolic anterior motion of the mitral valve and outflow tract gradient) were compared with those of 12 patients undergoing myectomy alone. Results. Preoperative evaluation demonstrated that mitral regurgitation and systolic anterior motion of the mitral valve were more severe in the group undergoing mitral valve extension (p < 0.001 and p < 0.05, respectively). There were no deaths associated with either surgical procedure. Two patients, both treated by myectomy alone, died during the follow-up period. Postoperatively, patients treated with mitral valve extension had less mitral regurgitation (p < 0.005), less residual systolic anterior motion (p < 0.01), greater improvement in functional class (p = 0.05) and greater reduction in the number of drugs (p < 0.005) and in septal thickness (p < 0.05). Conclusions. Mitral leaflet extension in combination with myectomy is a promising new surgical approach that may provide superior results to those of myectomy alone. Further studies are needed to determine the clinical value of this procedure

Human tissue valves in aortic position: determinants of reoperation and valve regurgitation

BACKGROUND: Human tissue valves for aortic valve replacement have a limited durability that is influenced by interrelated determinants. Hierarchical linear modeling was used to analyze the relation between these determinants of durability and valve regurgitation measured by serial echocardiography. METHODS AND RESULTS: In adult patients, 218 cryopreserved aortic allografts were implanted with the subcoronary (85) or the root replacement technique (133), and 81 patients had root replacement with a pulmonary autograft. Mean follow-up was 4.2 years (SD 2.7; range, 0 to 10.5). Patient age, operator experience with subcoronary implantation, and allograft diameter were independent predictors for reoperation. With repeated color Doppler echocardiography, the severity of aortic regurgitation was assessed by the jet length method and the jet diameter ratio. Multilevel hierarchical linear modeling was used to estimate initial aortic regurgitation (intercept), its change over time (slope), and the effect of 11 potential determinants of durability on aortic regurgitation. With the jet length method, the intercept was 0.94 grade and the slope was 0.11 grade per year. With the jet diameter ratio, the intercept was 0.34 and the annual increase was 0.01. Subcoronary implanted valves had more initial aortic regurgitation, but progression of aortic valve regurgitation did not differ from root replacement. At midterm follow-up, recipient age <40 years was the only independent predictor of aortic regurgitation. CONCLUSIONS: Subcoronary implantation has a learning curve, resulting in more initial aortic regurgitation and early reoperation compared with root replacement. In both techniques, progression of aortic regurgitation over time is small but accelerated in young adults

Prognosis after aortic valve replacement with a bioprosthesis: predictions based on meta-analysis and microsimulation

BACKGROUND: Bioprostheses are widely used as an aortic valve substitute, but knowledge about prognosis is still incomplete. The purpose of this study was to provide insight into the age-related life expectancy and actual risks of reoperation and valve-related events of patients after aortic valve replacement with a porcine bioprosthesis. METHODS AND RESULTS: We conducted a meta-analysis of 9 selected reports on stented porcine bioprostheses, including 5837 patients with a total follow-up of 31 874 patient-years. The annual rates of valve thrombosis, thromboembolism, hemorrhage, and nonstructural dysfunction were 0.03%, 0.87%, 0.38%, and 0.38%, respectively. The annual rate of endocarditis was estimated at 0.68% for >6 months of implantat

140 Impact of TAVI with the Edwards-SAPIEN endoprosthesis on mitral regurgitation: results of a serial echocardiography assessment

PurposeThe impact of transcatheter aortic valve implantation (TAVI) on mitral regurgitation (MR) is controversial. Two recent publications have reported improvement in MR grades following implantation of the Edwards-SAPIEN endoprosthesis. These findings were not replicated with the Core-Valve. The time course of improvement in MR grades with the Edwards-SAPIEN valve has not been described on an individual patient basis and the potential mechanisms of benefit are unclear. The aim of this study was to assess the acute and intermediate changes in MR severity after TAVI with the Edwards-SAPIEN endoprosthesis.MethodsEchocardiography was performed in 22 consecutive patients before and after treatment, and at 1 month follow-up. MR was assessed by color flow mapping and was graded as none, mild, moderate, or severe. MR was defined as organic or functional.ResultsThe aortic valve area increased from pretreatment 0.72cm2 to post-treatment 1.87cm2 and postdischarge 1.81cm2 (P<0.0001). Before intervention MR was present in 73% of the patients. It was mild, moderate, or severe in 36% (n=8), 32% (n=7), and 4% (n=1) respectively. MR was defined as organic in 6 patients (27%) and functional in 10 patients (45%). Compared to baseline, MR grades improved by 1 month (p for trend=0.01). This benefit was secondary to a reduction in regurgitation grades in 50% of patients with an MR at baseline (n=6), while no worsening was observed in the other patients with an MR (n=6) and no occurrence of MR was observed in patients without MR (n=6). A trend for a greater improvement in MR grade was observed in patients with functional MR (n=7, − 1.00) compared to those with an organic MR (n=5, − 0.294; p=0.10).ConclusionIn consecutive patients with a successful implantation of an Edwards-SAPIEN valve a significant improvement in MR was observed. This benefit was secondary to an improvement in 50% of patients with an MR and no worsening in the others