Multidisciplinary decision-making in mitral valve disease: the mitral valve heart team.

BACKGROUND: Although decision-making using the heart-team approach is apparently intuitive and has a class I recommendation in most recent guidelines, supportive data is still lacking. The current study aims to demonstrate the individualised clinical pathway for mitral valve disease patients and to evaluate the outcome of all patients referred to the dedicated mitral valve heart team. METHODS: All patients who were evaluated for mitral valve pathology with or without concomitant cardiac disease between 1 January 2016 and 31 December 2016 were prospectively followed and included. Patients were evaluated, and a treatment strategy was determined by the dedicated mitral valve heart team. RESULTS: One hundred and fifty-eight patients were included; 67 patients were treated surgically (isolated and concomitant surgery), 20 by transcatheter interventions and 71 conservatively. Surgically treated patients had a higher 30-day mortality rate (4.4%), which decreased when specified to a dedicated surgeon (1.7%) and in primary, elective cases (0%). This was also observed for major adverse events within 30 days. Residual mitral regurgitation >grade 2 was more frequent in the catheter-based intervention group (23.5%) compared to the surgical group (4.8%). CONCLUSION: In conclusion, the implementation of a multidisciplinary heart team for mitral valve disease is a valuable approach for the selection of patients for different treatment modalities. Our research group will focus on a future comparative study using historical cohorts to prove the potential superiority of the dedicated multidisciplinary heart-team approach.

Idiopathic atrial fibrillation patients rapidly outgrow their low thromboembolic risk: a 10-year follow-up study.

BACKGROUND: Healthy atrial fibrillation (AF) patients will eventually outgrow their low thromboembolic risk. The purpose of this study is to compare the development of cardiovascular disease in healthy AF patients as compared to healthy sinus rhythm patients and to assess appropriate anticoagulation treatment. METHODS: Forty-one idiopathic paroxysmal AF patients (56 ± 10 years, 66% male) were compared with 45 healthy sinus rhythm patients. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography. RESULTS: Baseline characteristics and echocardiographic parameters were the same in both groups. During 10.7 ± 1.6 years, cardiovascular disease and all-cause death developed significantly more often in AF patients as compared to controls (63% vs 31%, log rank p < 0.001). Even after the initial 5 years of follow-up, survival curves show divergent patterns (log rank p = 0.006). Mean duration to reach a CHA2DS2-VASc score > 1 among AF patients was 5.1 ± 3.0 years. Five of 24 (21%) patients with CHA2DS2-VASc > 1 did not receive oral anticoagulation therapy at follow-up. Mean duration of over- or undertreatment with oral anticoagulation in patients with CHA2DS2-VASc > 1 was 5 ± 3.0 years. CONCLUSION: The majority of recently diagnosed healthy AF patients develop cardiovascular diseases with a consequent change in thromboembolic risk profile within a short time frame. A comprehensive follow-up of this patient category is necessary to avoid over- and undertreatment with anticoagulants.

The occurrence of cardiovascular disease during 5-year follow-up in patients with idiopathic atrial fibrillation.

AIMS: Idiopathic atrial fibrillation (AF) may be an expression of as yet undetected underlying heart disease. We found it useful for clinical practice to study the long-term development of cardiovascular disease (CVD) in patients diagnosed with idiopathic AF. METHODS AND RESULTS: Forty-one consecutive idiopathic AF patients (56 ± 10 years, 66% male) were compared with 45 healthy control patients in permanent sinus rhythm. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography. Baseline characteristics and echocardiographic parameters were equal in AF cases and controls. During a mean follow-up of 66 ± 11 months, CVD occurred significantly more often in idiopathic AF patients compared with controls (49 vs. 20%, P= 0.006). Patients with idiopathic AF were significantly younger at the time of their first CV event compared with controls (59 ± 9 vs. 64 ± 5 years, P= 0.027), and had more severe disease. Multivariable Cox regression analysis revealed that age, a history of AF, and echocardiographic left ventricular wall width were significant predictors of CVD development. CONCLUSION: Patients originally diagnosed with idiopathic AF develop CVD more often, at younger age, and with a more severe disease profile compared with healthy sinus rhythm control patients. The detection and treatment of CVD in an early stage could improve the prognosis of these patients. At present it seems prudent to regularly check idiopathic AF patients for the insidious development of CVD.

A challenging lead endocarditis.

Pacemaker/implantable cardioverter-defibrillator (ICD) lead endocarditis remains a challenging diagnosis in cardiology. Several parameters can be involved in the clinical path leading to the definite diagnosis. Clinical appearance and physical findings, together with transoesophageal echocardiography and serum levels of inflammatory parameters, are necessary in the workup towards the diagnosis. It is highly unlikely that ICD-lead vegetation is accompanied by positive blood cultures solely. We describe a case of ICD-infected endocarditis with positive blood cultures for Staphylococcus epidermidis without any physical findings or raised inflammatory parameters in serum plasma levels. In this case, three-dimensional echocardiography demonstrated an added value to two-dimensional echocardiography.

Bilobar apical pseudoaneurysm after left ventricular venting in a Marfan's patient.

A Marfan patient presented with a bilobar apical pseudoaneurysm after repeated surgery. These abnormalities were demonstrated by three-dimensional-echo, Doppler, and CT-reconstruction. The pseudoaneurysm was related to an apical venting procedure. In this case, a conservative approach was chosen, although in general, pseudoaneurysms form an indication for operative correction, because of the risk of rupture and acute tamponade.

Effect of upper arm brachial basilic and prosthetic forearm arteriovenous fistula on left ventricular hypertrophy.

BACKGROUND: Creation of an arteriovenous fistula (AVF) may increase left ventricular hypertrophy in the hemodialysis population. Aim of this study was to compare the effects of a brachial-basilic (BB) AVF and the prosthetic brachial-antecubital forearm loop access (PTFE) on cardiac performance. METHODS: Patients were randomized to receive BB-AVF or prosthetic brachial-antecubital forearm loop access. Before and three months after AVF creation patients underwent an echocardiographic examination. Mann-Whitney U-test was used to compare relative increase between the measured cardiac parameters for the two groups. RESULTS: Twenty-seven patients participated in the study. The relative increase in left ventricular parameters was not significantly different between the two groups. Only left ventricular end-diastolic diameter tended to be of significance. Mean blood flow through the brachial artery was 1680+/-156 and 1450+/-221 mL/min three months after surgery for the PTFE and the BB-AVF group, respectively. CONCLUSION: After three months of follow-up, changes in cardiac structure were comparable between patients with BB and PTFE AVFs. Also access flow was comparable at this time. In general, the effects of creation of a fistula on LV structure were limited. Longer follow up time may be needed to explore the long term effects of different vascular accesses on cardiac function.

Long-term follow-up (12 to 35 weeks) after dynamic cardiomyoplasty.

OBJECTIVES: To obtain information on the long-term effects of dynamic cardiomyoplasty on hemodynamics and muscle histology, this surgical method was evaluated in goats. BACKGROUND: Dynamic cardiomyoplasty has been introduced as a new method to treat patients with severe cardiac failure. METHODS: In 24 goats, the left latissimus dorsi muscle was wrapped around the heart. The muscle was then subjected to progressive electrical stimulation. In 16 goats, invasive transesophageal Doppler echocardiographic measurements and histologic evaluation of the latissimus dorsi muscle were performed at > or = 12 weeks after the wrapping. RESULTS: Only two goats showed an increase in aortic and left and right ventricular pressures concomitant with increased aortic flow during latissimus dorsi muscle stimulation both before and after induction of cardiac failure using imipramine. This was accompanied by a preserved latissimus dorsi muscle structure and nearly complete transformation to type I muscle fibers. The remaining 14 goats showed extensive lipomatosis in the latissimus dorsi muscle, with severe intimal hyperplasia and proliferation of smooth muscle cells in the walls of the thoracodorsal artery and its branches. An increase in endoneural and endomysial connective tissue was observed, with some goats showing destroyed nerve branches near the electrodes. These findings differed from those observed after long-term electrical stimulation of goat latissimus dorsi muscle in situ. CONCLUSIONS: Dynamic cardiomyoplasty is of use in the treatment of severe heart failure if the histologic structure of the wrapped latissimus dorsi muscle remains intact. Long-term results in goats suggest that the current approach used in dynamic cardiomyoplasty may lead to deterioration of the wrapped muscle.

Reversibility of tachycardia-induced cardiomyopathy after cure of incessant supraventricular tachycardia.

Seven of 17 patients with incessant supraventricular tachycardia caused by an accessory pathway with a long retrograde conduction time were seen with symptoms or echocardiographic signs of a tachycardia-induced cardiomyopathy. Three patients were in New York Heart Association functional class II with dyspnea and four were in class III. Eight patients (six with tachycardia-induced cardiomyopathy) underwent surgery because of failure of medical treatment (including one patient in functional class I) and one underwent direct current catheter ablation of the atrioventricular (AV) node. In six patients echocardiograms recorded before and after the procedure were available. Before surgery or direct current ablation the mean left ventricular ejection fraction was 36.3 +/- 8.7%, the left ventricular end-diastolic diameter 55.7 +/- 7.6 mm and the left ventricular end-systolic diameter 44.3 +/- 7.8 mm. A mean of 21.6 +/- 6.8 months after the procedure the mean left ventricular ejection fraction increased to 58.6 +/- 8.0%, the left ventricular end-diastolic diameter decreased to 49.0 +/- 3.6 mm and the left ventricular end-systolic diameter decreased to 32.2 +/- 2.7 mm; all six patients were in functional class I. These results confirm that control of incessant tachycardia leads to a regression of symptoms and signs of cardiomyopathy and progressive normalization of the dimensions of the heart. Because of these findings, surgery should be considered early in patients with an accessory AV pathway and incessant tachycardia. The presence of a tachycardia-induced cardiomyopathy should therefore be an indication for surgery rather than a contraindication.

Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction.

OBJECTIVES: The study assessed the value of the electrocardiogram (ECG) as predictor of the left anterior descending coronary artery (LAD) occlusion site in relation to the first septal perforator (S1) and/or the first diagonal branch (D1) in patients with acute anterior myocardial infarction (AMI). BACKGROUND: In anterior AMI, determination of the exact site of LAD occlusion is important because the more proximal the occlusion the less favorable the prognosis. METHODS: One hundred patients with a first anterior AMI were included. The ECG showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site as determined by coronary angiography. RESULTS: ST-elevation in lead aVR (ST elevation(aVR)), complete right bundle branch block, ST-depression in lead V5 (ST depression(V5)) and ST elevation(V1) > 2.5 mm strongly predicted LAD occlusion proximal to S1, whereas abnormal Q-waves in V4-6 were associated with occlusion distal to S1 (p = 0.000, p = 0.004, p = 0.009, p = 0.011 and p = 0.031 to 0.005, respectively). Abnormal Q-wave in lead aVL was associated with occlusion proximal to D1, whereas ST depression(aVL) was suggestive of occlusion distal to D1 (p = 0.002 and p = 0.022, respectively). For both the S1 and D1, inferior ST depression > or = 1.0 mm strongly predicted proximal LAD occlusion, whereas absence of inferior ST depression predicted distal occlusion (p < or = 0.002 and p < or = 0.020, respectively). CONCLUSIONS: In anterior AMI, the ECG is useful to predict the LAD occlusion site in relation to its major side branches.

Abdominal aortic aneurysm screening during transthoracic echocardiography in an unselected population.

OBJECTIVE: We sought to investigate the echocardiographic prevalence of abdominal aortic aneurysm (AAA) in an unselected group of patients referred for regular transthoracic echocardiography (TTE). METHODS: Prospectively, during a 3-month period, a limited ultrasound examination of the infrarenal aorta was performed. AAA was defined as a diameter of 30 mm or more. RESULTS: The abdominal aorta could be visualized in 742 patients. The prevalence of AAA was 4.6%. AAA prevalence increased with age, especially in men. In 34 patients AAA was unknown and aortic diameters exceeded 50 mm in 4 patients. Two underwent elective but urgent operation. Patients with AAA were older and had an increased ascending aorta diameter, larger left ventricular dimensions, higher left ventricular mass index, and lower ejection fraction. CONCLUSION: AAA is prevalent in patients referred for regular TTE. Routine rapid screening of the abdominal aorta during TTE is beneficial and should, therefore, be part of a standard TTE examination for patients older then 50 years.

Measurement of anterior-posterior diameter of inferior vena cava by ultrasonography: a new non-invasive method to assess acute changes in vascular filling state.

OBJECTIVE: The aim was to determine whether measurement of the anterior-posterior diameter of the inferior vena cava (IVC) by ultrasonography, before and during deep inspiration, allows indirect information on baseline blood volume and changes in vascular filling state to be obtained in healthy subjects. METHODS: Blood volume was measured in 12 volunteers by a standard radioactive isotope method. The IVC dimensions were measured by ultrasound in various positions. In addition, in 10 male subjects the effect on the IVC dimensions of volume loading was evaluated by rapid infusion of plasma expander. During and immediately following volume loading, the IVC dimensions and blood volume were remeasured. RESULTS: Neither the baseline IVC diameters nor any combination of these variables correlated with the concomitant blood volume. Volume loading increased the anterior-posterior IVC dimensions linearly, the largest increase being observed with the maximum IVC diameter and the subject in supine position. CONCLUSIONS: It follows that ultrasonic IVC indices cannot be used as accurate indirect estimate of baseline blood volume, but provide reliable information on acute changes of the subjects' vascular filling state.

Imipramine induced heart failure in the dog: a model to study the effect of cardiac assist devices.

OBJECTIVE: The value of intravenous imipramine in creating a reversible model of short term heart failure was evaluated in anaesthetised dogs. METHODS: Acute effects of imipramine were studied in 11 dogs using invasive haemodynamic pressure measurements and two dimensional echo evaluation. RESULTS: After a 30 min imipramine infusion (7.5 mg.kg-1.h-1), positive left ventricular dP/dtmax decreased from 1368(SEM 108) to 909(119) mm Hg.s-1 (p < 0.05), left ventricular end diastolic pressure increased from 8(1) to 12(2) mm Hg (p < 0.05), while left ventricular pressure decreased from 106(4) to 87(6) mm Hg (p < 0.05). Cessation of imipramine administration resulted within 60 min in partial restoration of cardiac function. This deterioration and subsequent recovery was also demonstrated with echocardiographic measurements, which showed a decrease in ejection fraction from 54(3)% to 28(2)% (p < 0.05). During administration of imipramine neither significant electrophysiological changes nor supraventricular/ventricular arrhythmias were seen. Repeated infusions of imipramine in three anaesthetised dogs with a two week interval showed the reproducibility of the haemodynamic effects and the recovery of ventricular function. Since the model was developed to evaluate the use of cardiomyoplasty in heart failure, the effect of imipramine was also evaluated on latissimus dorsi muscle contraction. Administration of imipramine did not affect skeletal muscle force development at the dosage used to create heart failure. CONCLUSIONS: This model can be used to produce short term reversible heart failure in anaesthetised animals to test the efficacy of supportive interventions like dynamic cardiomyoplasty, intra-aortic balloon pumping, and mechanical cardiac assist devices.

Value of the 12-lead electrocardiogram at hospital admission in the diagnosis of pulmonary embolism.

In 49 consecutive patients (27 men and 22 women, age range 44 to 86 years) presenting with acute symptoms and with subsequently proven pulmonary embolism, and without previous lung disease, the 12-lead electrocardiograms obtained at hospital admission were reviewed in a blinded fashion to identify electrocardiographic features suggestive of right ventricular overload. Pulmonary embolism was considered probable in 37 patients (76%), from the presence of > or = 3 of the following abnormalities: (1) incomplete or complete right bundle branch block (n = 33); which was associated with ST-segment elevation (n = 17) and positive T wave (n = 3) in lead V1; (2) S waves in leads I and aVL of > 1.5 mm (n = 36); (3) a shift in the transition zone in the precordial leads to V5 (n = 25); (4) Q waves in leads III and aVF, but not in lead II (n = 24); (5) right-axis deviation, with a frontal QRS axis of > 90 degrees (n = 16), or an indeterminate axis (n = 15); (6) a low-voltage QRS complex of < 5 mm in the limb leads (n = 10); and (7) T-wave inversion in leads III and aVF (n = 16) or leads V1 to V4 (n = 13), which occurred more often in patients with symptoms for > 7 days. In the 12 patients with normal electrocardiograms at admission, serial electrocardiograms revealed diagnostic features of embolism in an additional 3 patients. Two-dimensional Doppler echocardiography at admission revealed tricuspid valve regurgitation and an increased right ventricular end-diastolic diameter in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk of aortic dissection after aortic valve replacement.

Little information is available regarding the incidence of aortic dissection after previous aortic valve replacement (AVR), and factors associated with its development. Therefore, a meta-analysis of the literature was performed, and a patient population was studied retrospectively. Data from published studies showed that 87% of 31 patients were men (mean age 60 years), and 68% were known to have systemic hypertension. A dilated ascending aorta was observed at the time of AVR in 88% of patients. AVR was performed because of pure aortic regurgitation in 55% of patients, and combined aortic stenosis and regurgitation in 23%. More than 50% of patients did not survive dissection. The present series consisted of 7 patients. Four patients were known to the department before dissection occurred, and the other 3 were referred by other hospitals. Eighteen of 330 patients with previous AVR whose data were stored in an echocardiographic data base had an ascending aortic diameter > 50 mm. Of these 18 patients, aortic dissection occurred in 4. Three of the remaining 14 patients underwent elective ascending aortic replacement. Characteristics including sex, age, severity of dilatation, presence of progression in diameter, left ventricular function and time interval after AVR were not helpful in determining a cumulative risk for developing dissection. Because dissection occurred in 4 of 18 patients (22%) with an ascending aorta diameter > 50 mm, it is suggested to consider replacement of the ascending aorta during AVR when a value of 50 mm is exceeded.

Value of systolic pulmonary venous flow reversal and color Doppler jet measurements assessed with transesophageal echocardiography in recognizing severe pure mitral regurgitation.

We evaluated the value of color and pulsed Doppler transesophageal echocardiographic parameters and of V waves in estimating the severity of mitral regurgitation (MR) in 62 consecutive patients (38 men and 24 women, aged 39 to 80 years) with angiographically proven chronic pure MR (15 grade I/II, 47 grade III/IV). Twenty patients were examined before cardiac surgery under general anesthesia. Sensitivity, specificity, and positive and negative predictive values of systolic pulmonary venous flow reversal for the presence of grade III/IV MR were 87%, 93%, 98%, and 64%, respectively, these were for jet areas > or = 8.0 cm2--66%, 100%, 100%, and 48%, for jet lengths > or = 50 mm--70%, 87%, 94%, and 48%, for enlarged V waves--86%, 38%, 83%, and 43%, and for either flow reversal or a jet area > or = 8.0 cm2--96%, 93%, 98%, and 88%. We conclude that a combination of measurements improved the negative predictive value considerably, which is of importance in a population with a high pretest probability of severe MR. Enlarged V waves are not reliable in predicting severe MR. The optimal cutoff value for jet area and jet length was lower in anesthesized patients than in conscious patients; in anesthesized patients, sensitivity, specificity, and positive and negative predictive values of jet area > or = 5.0 CM2 for grade III/IV MR were 67%, 100%, 100%, and 50%, respectively; these were 87%, 100%, 100%, and 71% for flow reversal. Because the results of mitral repair are often evaluated with transesophageal echocardiography during surgery, our findings have clinical implications for evaluation of severe MR in anesthesized patients: pulmonary venous flow direction is the first-choice measure; jet area can be used when a low cutoff point is chosen.

Effect of dialysate calcium concentrations on intradialytic blood pressure course in cardiac-compromised patients.

To prevent hypercalcemia in the treatment of secondary hyperparathyroidism, low calcium (L-Ca) dialysate is advocated. However, changes in ionized calcium (i-Ca) levels have a pivotal role in myocardial contraction and could influence blood pressure stability during dialysis. Recently, our group found in patients with normal cardiac function a significant decrease in blood pressure (decrease in systolic blood pressure [DSBP]: -13 mm Hg and decrease in mean arterial pressure [DMAP]: -7 mm Hg) during dialysis with L-Ca dialysate compared with high calcium (H-Ca) dialysate, and this was mainly related to a decreased left ventricular contractility with use of L-Ca dialysate. On the basis of these data, it could be expected that changes in i-Ca levels during dialysis are of more clinical importance in cardiac-compromised patients (CCpts), New York Heart Association classifications III and IV. In this study, the effects of L-Ca dialysate (1.25 mmol/L) and H-Ca dialysate (1.75 mmol/L) on arterial blood pressure parameters (systolic [SBP], diastolic [DBP], and mean arterial blood pressure [MAP]), heart rate, stroke distance (SDist), and minute distance (MDist) during 3 hours of a standardized ultrafiltration/hemodialysis (UF+HD) in nine CCpts was investigated. i-Ca levels increased significantly with H-Ca dialysate UF+HD, whereas there was no change with L-Ca dialysate. SBP, DBP, and MAP decreased statistically and clinically significantly during UF+HD with L-Ca dialysate and were significantly lower with the use of L-Ca dialysate compared with H-Ca dialysate. SDist and MDist decreased significantly with L-Ca dialysate, whereas there were no changes in SDist and MDist with H-Ca dialysate. The predialysis and postdialysis index of systemic vascular resistance (SVRI) was similar between L-Ca dialysate and H-Ca dialysate use. Between the two groups, there were no significant differences in changes in SVRI. From this study, we can conclude that changes in i-Ca levels are a very important determinant of the blood pressure response during UF+HD in CCpts, and this response is mediated by changes in myocardial contractility.

Validity of conjoint analysis to study clinical decision making in elderly patients with aortic stenosis.

OBJECTIVE: Written case simulations are increasingly being used to investigate clinical decision making. Our study was designed to determine the validity of written case simulations within a conjoint analysis approach. STUDY DESIGN AND SETTING: We developed a series of 32 written case simulations that differed with respect to nine clinical characteristics. These case simulations represented elderly patients with aortic stenosis. The clinical characteristics varied according to a fractional factorial design. We analyzed retrospectively all consecutive patients of 70 years of age or older with an aortic stenosis in three university hospitals. RESULTS: 34 cardiologists from three Dutch hospitals gave their treatment advice to each of these case simulations on a six-point scale (ranging from 'certainly no' to 'certainly yes' to surgical treatment). We compared the influence that the clinical characteristics had on the responses to these case simulations with their influence on the actual treatment decision for 147 actual patients in the same three hospitals. We found a strong agreement. This agreement was only slightly affected by the cut-off value used to dichotomize the treatment advice into a recommendation in favor of or against surgical treatment. CONCLUSION: Written case simulations reflect well how clinicians are influenced by specific clinical characteristics of their patients.

Maternal volume homeostasis in early pregnancy in relation to fetal growth restriction.

OBJECTIVE: To test the hypothesis that volume adaptation in pregnancies complicated by fetal growth restriction (FGR) is already abnormal very early in pregnancy. METHODS: In six pregnancies later complicated by FGR, volume homeostasis in the first 8 weeks was compared to that in ten normal pregnancies. Creatinine clearance, volume-dependent hormones, hemodilution-related variables, and ultrasonic cardiovascular dimensions were measured weekly between weeks 5 and 10, in the second and third trimesters, and postpartum. Differences between the two groups were analyzed by nonparametric tests. RESULTS: Very early in pregnancy, pregnancies complicated by FGR differed from normal pregnancies in the following ways: smaller left atrial diameter, smaller collapsible part of the inferior vena cava, lower serum sodium concentration, and smaller fall in serum creatinine and urea. CONCLUSION: Fetal growth restriction is preceded by defective volume adaptation very early in pregnancy. It appears that the maternal compensation mechanisms are unable to resolve the transient state of vascular underfill seen in this period in normal gestation.

New techniques to determine fluid status in hemodialyzed patients.

In this paper, several newly developed techniques for the estimation of the fluid status in hemodialysis patients were reviewed. Whereas echography of the inferior caval vein and the measurement of ANP and cGMP levels merely provide information about the intravascular volume, conductivity measurements are able to detect changes in the extracellular and intracellular compartments without being able to differentiate between the intravascular and interstitial fluid spaces. Echography of the inferior caval vein as a tool to assess over- and underhydration has been successfully validated against objective standards as right atrial pressure, total blood volume and the change in hemodynamic parameters during dialysis. Conductivity measurements were significantly related to vena cava measurements before and after dialysis. Whereas ANP levels were significantly related to the vena cava diameter before dialysis, in another group of patients, only a significant relation between the vena cava diameter and cGMP was observed in patients with normal left atrial hemodynamics, whereas they were not in patients with a dilated left atrium. Furthermore, in normovolemic patients with mitral insufficiency, ANP levels after dialysis remained increased compared to patients without mitral insufficiency, suggesting that, in addition to volume expansion, also altered left atrial hemodynamics influence the release of cGMP and ANP. Conductivity measurements and ANP before and after dialysis were not related, whereas only cGMP after dialysis was significantly related to conductivity measurements. ANP and cGMP were not related to the change in hemodynamic parameters during dialysis, questioning their reliability in the assessment of underhydration.

To operate or not on elderly patients with aortic stenosis: the decision and its consequences.

OBJECTIVE: To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients. DESIGN: Cohort analysis based on a prospective inclusive registry. SETTING: 205 consecutive patients (>/= 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands. RESULTS: The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment. CONCLUSIONS: In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.