Large Tissue Debris Causing Cerebral Embolism After Transcatheter Aortic Valve Replacement.

Cerebral vascular embolism is one of the complications of transcatheter aortic valve replacement (TAVR). Thrombolytic therapy is not expected to be effective when embolic material consists of a large tissue fragment. Instead, mechanical aspiration may be more effective therapy for acute cerebral infarction after TAVR. Here, we describe the case of an 87-year-old woman with aortic valve stenosis and heart failure who underwent TAVR using a self-expandable valve. Acute cerebral infarction with left middle cerebral artery occlusion caused by a large tissue fragment developed after the procedure.

Utility of Routine Transthoracic Echocardiographic Parameters to Predict Functional Recovery after Catheter Ablation Therapy in Patients with Atrial Fibrillation and Left Ventricular Systolic Dysfunction.

Arrhythmia-induced cardiomyopathy (AIC) occurring in patients with atrial fibrillation (AF) is a reversible form of cardiomyopathy characterized by LV systolic dysfunction. However, it is difficult to predict the reversibility before rhythm control therapy. We performed this study to develop a parameter for the identification of AIC in routine transthoracic echocardiography (TTE) in patients with presumptive AIC due to AF.We retrospectively studied 72 patients treated with catheter ablation therapy for persistent AF, and LV ejection fraction (LVEF) ≤ 45%. The patients were divided into 2 groups by follow-up TTE performed within 12 ± 6 months postoperatively. Patients with ≥ 15% improvement in LVEF or ≥ 10% improvement and ≥ 50% in LVEF were classified as the AIC group, and the others were classified as the non-AIC group.A total of 57 (79%) patients were classified as the AIC group. In the stepwise multivariate logistic regression model, LV end-diastolic dimension (LVDd) and e' (septal) were independent predictors of AIC. The sensitivities of LVDd ≤ 53 mm and e' (septal) ≥ 6.3 cm/second were 60% and 75%, respectively. Their specificities were 80% and 67%, respectively. The presence of either LVDd ≤ 53 mm or e' (septal) ≥ 6.3 cm/second had a higher sensitivity (90%); their co-occurrence had a higher specificity (93%) in predicting AIC.The functional recovery in patients with AIC can occur in LV systolic dysfunction without remodeling and impairment of relaxation. The combination of LVDd and e' (septal) is useful in predicting AIC due to AF with routine TTE.

The Impact of Aorto-Mitral Angle on New-Onset Atrial Arrhythmia after Mitral Valve Repair in Patients with Mitral Regurgitation.

In this study, we hypothesized that post-operative aorto-mitral angle might be associated to the occurrence of post-operative atrial arrhythmia (AA), including atrial fibrillation and atrial tachycardia, after mitral valve repair in patients with mitral regurgitation (MR). Thus, this present study aims to determine the effects of post-operative aorto-mitral angle on new-onset AA after mitral valve repair with mitral annuloplasty for the treatment of MR.In total, 172 patients without any history of AA underwent mitral valve repair with mitral annuloplasty in our institution between 2008 and 2017. Patient information, including medical records and echocardiographic data, were retrospectively studied.As per our findings, AA occurred in 15 (8.7%) patients during the follow-up period (median, 35.7 months; range, 0.5-132 months). The patients with AA were noted to have a longer cardiopulmonary bypass time and a smaller aorto-mitral angle at post-operative TTE than the others (119 ± 6° versus 125 ± 10°, P = 0.003). No significant difference was noted in the degree of post-operative residual MR or functional MS between the groups. In a multivariate Cox proportional hazards analysis, the longer cardiopulmonary bypass time and the smaller post-operative aorto-mitral angle were independent predictors of the occurrence of AA during the follow-up period (odds ratio per 10 minutes 1.11; 95% CI 1.02-1.22, P = 0.019: odds ratio 0.91; 95% CI 0.85-0.98, P = 0.012).A small aorto-mitral angle at post-operative TTE was determined to be a predictor of new-onset AA after a mitral valve repair for treating MR.

Etiology of Atrial Functional Mitral Regurgitation: Insights from Transthoracic Echocardiography in 159 Consecutive Patients with Atrial Fibrillation and Preserved Left Ventricular Ejection Fraction.

BACKGROUND: Left atrial (LA) dilatation in patients with atrial fibrillation (AF) can induce functional mitral regurgitation (MR) despite a preserved left ventricular ejection fraction (LVEF). The purpose of this study was to investigate the etiology of this functional MR. METHODS: We retrospectively examined clinical and echocardiographic data from 5,202 consecutive cases that underwent transthoracic echocardiography. AF appeared in 544 patients, and we selected 159 with AF and LVEF ≥50% after excluding patients with other underlying heart diseases. RESULTS: Significant (moderate or greater) degrees of functional MR were seen in 13 (8.2%) patients and were more frequently seen in patients with an AF duration of >10 years than in others (27 vs. 4%, p = 0.0057). Multiple regression analysis revealed that both the LA dimension index and the left ventricular (LV) systolic dimension index were independent determinants of the MR grading. Among the mitral morphologic parameters, the mitral annular (MA) dimension index and the hamstringing phenomenon of the posterior mitral leaflet were independent determinants of MR grading. Significant MR was not seen in patients without LA dilatations, but it occurred in 14% of patients with LA dilatation alone and in 55% with both LA and LV dilatations; the MA dimension index increased in this order. CONCLUSIONS: The grading of functional MR occurring in patients with AF and preserved LVEF depends on both the LA dimension and the LV systolic dimension. The MR grading also depends on both the MA dilatation and the hamstringing phenomenon of the posterior mitral leaflet.

Utility of the combination of simple electrocardiographic parameters for identifying mid-septal pacing.

INTRODUCTION: The electrocardiograms (ECG) criteria to anchor the lead to the right ventricular septum have not been established. This study aimed to identify ECG criteria of pacing at the right ventricular mid septum (RVMS) and investigate whether the paced QRS duration (pQRSd) from the RVMS was narrow. METHODS AND RESULTS: In 42 patients, ECG pacing at the basal anterior wall (BA), mid-anterior wall (MA), apex (AP), and mid septum (MS) was recorded. The pacing sites were validated by using right ventriculography and computed tomography. We estimated the ECG parameters and compared them among the four pacing sites. The combination of simple four paced-ECG parameters could reliably confirm the pacing at the RVMS. The area under the receiver-operating characteristics curve for the number of positive findings among the following: (a) positive QRS in lead aVL, (b) QRS notching in lead I, (c) precordial leads transition at less than V5, and (d) presence of isoelectric QRS in the inferior leads was 0.95 (95% confidence interval, 0.91-0.98) and the number of positive findings (≥3) had a sensitivity of 83.3% and a specificity of 93.7% for discriminating MS from the other sites. The pQRSd with three or more positive findings was significantly narrower than that with less than three positive findings (≥3: 137.4 ± 9.2 ms, <3: 151.8 ± 13.1 ms, P ≤ .05). CONCLUSION: The combination of ECG parameters can help identify right ventricular mid-septal pacing. The use of these parameters may enable the implantation of the pacing lead in the RVMS accurately and obtain a narrower QRS duration.

Efficacy of the current of injury in envisaging the dislodgement of leads implanted in the right atrial septum or the right ventricular septum.

BACKGROUND: The implantation of leads in the right atrial septum (RAS) or the right ventricular septum (RVS) is technically challenging, and dislodgement occurs occasionally. This study aims to determine a predictor for the dislodgement of leads implanted in the RAS or RVS. METHODS: This retrospective cohort study enrolled 137 consecutive patients who underwent the cardiac implantable electronic devices implantation, using active fixation leads in the RAS and RVS. We compared the pacing threshold, R- or P-wave amplitude, slew rate, and presence of the current of injury (COI) between dislodged and nondislodged leads. RESULTS: We performed lead fixation for 74 and 125 times in the RAS and RVS, respectively. Atrial lead dislodgement occurred five times (6.8%) intraoperatively and five times (6.8%) postoperatively, whereas ventricular lead dislodgement occurred eight times (6.4%) intraoperatively and three times (2.4%) postoperatively. Although there were no lead parameters that showed a significant difference common to RAS lead and RVS lead, the presence of the COI was significantly different between nondislodged and dislodged leads in both the RAS and RVS (atrial leads: 57.8% vs 0%, P < 0.001; ventricular leads: 67.5% vs 9.1%, P < 0.001). The positive predictive value of COI presence for predicting no lead dislodgement was 100% and 98.7% in the RAS and RVS, respectively. CONCLUSION: Lead dislodgement is more likely when the COI is absent; documentation of COI should be pursued during lead implantation in challenging sites as the RAS and RVS.

The usefulness of right ventriculography to aid anchoring a pacing lead to the right ventricular septum.

Aims: Although right ventricular septal pacing is thought to be more effective in minimizing pacing-induced left ventricular dysfunction, the accurate way to anchor the lead to the right ventricular septum (RVS) has not been established. Our aim was to clarify the usefulness of right ventriculography (RVG) to aid accurate anchoring of the lead to the RVS. Methods and results: Eighty-four patients who underwent pacemaker implantation were enrolled. We anchored the lead to the RVS by using an RVG image obtained at a 30° right anterior oblique view as a reference. We confirmed the actual lead position by performing computed tomography after the procedure and examined the characteristics of the paced QRS complex. Of the 81 patients, except 3 patients whose leads were anchored to the apex due to high pacing thresholds in the RVS, the leads were successfully anchored to the RVS in the 79 (98%) patients, and the number of leads placed in the high-, mid-, and low-RVS was 3 (4%), 58 (73%), and 18 (23%), respectively. The paced QRS duration in these 79 patients was 140 ± 13 ms. The paced QRS duration from mid-RVS was considerably narrower than that from high- or low-RVS (137 ± 12 ms vs. 146 ± 12 ms; P = 0.012). Conclusion: Right ventriculography was very useful in aiding accurate anchoring of the lead to the RVS. Further, pacing from mid-RVS may be more effective in minimizing the QRS duration than pacing from other RVS sites.

Prevalence and Prognostic Significance of Functional Mitral and Tricuspid Regurgitation Despite Preserved Left Ventricular Ejection Fraction in Atrial Fibrillation Patients.

BACKGROUND: We investigated the prevalence and prognostic significance of functional mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with atrial fibrillation (AF) and preserved left ventricular ejection fraction (LVEF).Methods and Results:We retrospectively studied the cases of 11,021 consecutive patients who had undergone transthoracic echocardiography. AF appeared in 1,194 patients, and we selected 298 with AF and LVEF ≥50% but without other underlying heart diseases. Moderate or greater (significant) degree of functional MR and of TR was seen in 24 (8.1%) and in 44 (15%) patients, respectively (P=0.0045). In contrast, significant MR and TR were more frequently seen in patients with AF duration >10 years (28% vs. 25%, respectively). During the follow-up period of 24±17 months, 35 patients (12%) met the composite endpoint defined as cardiac death, admission due to heart failure, or mitral and/or tricuspid valve surgery. On Cox proportional hazard ratio analysis, both MR and TR grading predicted the endpoint, independently of other echocardiographic parameters. On Kaplan-Meyer analysis, presence of both significant functional MR and TR was associated with poor prognosis, with an event-free rate of only 21% at the mean follow-up period of 24 months. CONCLUSIONS: Significant functional MR and TR are seen in a substantial proportion of patients with longstanding AF, despite preserved LVEF. This MR/TR combination predicts poor outcome for AF patients, who may have to be treated more intensively.

Administration of tolvaptan with reduction of loop diuretics ameliorates congestion with improving renal dysfunction in patients with congestive heart failure and renal dysfunction.

In patients with congestive heart failure and renal dysfunction, high dose of diuretics are necessary to improve congestion, which may progress to renal dysfunction. We examined the efficacy of tolvaptan with reduction of loop diuretics to improve renal function in patients with congestive heart failure and renal dysfunction. We conducted a multicenter, prospective, randomized study in 44 patients with congestive heart failure and renal dysfunction (serum creatinine concentration ≥1.1 mg/dl) treated with conventional diuretics. Patients were randomly divided into two groups: tolvaptan (15 mg) with a fixed dose of diuretics or with reducing to a half-dose of diuretics for 7-14 consecutive days. We examined the change of urine volume, body weight, serum creatinine and electrolyte concentrations in each group. Both groups demonstrated significant urine volume increase (724 ± 176 ml/day in the fixed-dose group and 736 ± 114 ml/day in the half-dose group) and body weight reduction (1.6 ± 1.5 kg and 1.6 ± 1.9 kg, respectively) from baseline, with no differences between the two groups. Serum creatinine concentration was significantly increased in the fixed-dose group (from 1.60 ± 0.47 to 1.74 ± 0.66 mg/dl, p = 0.03) and decreased in the half-dose group (from 1.98 ± 0.91 to 1.91 ± 0.97 mg/dl, p = 0.10). So the mean changes in serum creatinine concentration from baseline significantly differed between the two groups (0.14 ± 0.08 mg/dl in the fixed-dose group and -0.07 ± 0.19 mg/dl in the half-dose group, p = 0.006). The administration of tolvaptan with reduction of loop diuretics was clinically effective to ameliorate congestion with improving renal function in patients with congestive heart failure and renal dysfunction.

Predictors of silent brain infarction on magnetic resonance imaging in patients with nonvalvular atrial fibrillation: A transesophageal echocardiographic study.

BACKGROUND: Silent brain infarction (SBI) is often found in patients with atrial fibrillation (AF) and may be related to cognitive decline. We investigated the predictors of SBI on brain magnetic resonance imaging (MRI) using transesophageal echocardiography (TEE) in patients with nonvalvular AF. METHODS: The study population consisted of 103 neurologically asymptomatic patients with nonvalvular AF who underwent TEE before transcatheter AF ablation (76 men; mean age 63 ± 10 years). Left atrial (LA) abnormalities such as LA thrombus, spontaneous echo contrast, or abnormal LA appendage emptying velocity (<20 cm/s) and complex plaques in the aortic arch defined as large plaques ≥4 mm thickness, ulcerated plaques, or mobile plaques were evaluated by TEE. All patients were screened for SBI by brain MRI. RESULTS: Of 103 patients, 31 (30%) showed SBI on brain MRI. Most lesions were multiple (61%) and small (<15 mm) in diameter (84%). Patients with SBI had a higher prevalence of LA abnormalities (45% vs 14%; P < .001) and complex arch plaques (45% vs 7%; P < .001) compared with those without SBI. In a multivariate logistic regression analysis including age and CHADS2 score ≥2, LA abnormalities (odds ratio 4.13; 95% CI 1.34-12.72; P = .014) and complex arch plaques (odds ratio 4.82; 95% CI 1.23-18.92; P = .024) were independent predictors of SBI. CONCLUSIONS: Left atrial abnormalities and complex arch plaques detected by TEE were closely associated with the presence of SBI on brain MRI, suggesting that microembolization of small thrombi derived from the fibrillating LA or advanced aortic atherosclerotic lesions may be important causes of SBI in patients with nonvalvular AF.

Body-part specificity for learning of multiple prior distributions in human coincidence timing.

During timing tasks, the brain learns the statistical distribution of target intervals and integrates this prior knowledge with sensory inputs to optimise task performance. Daily events can have different temporal statistics (e.g., fastball/slowball in baseball batting), making it important to learn and retain multiple priors. However, the rules governing this process are not yet understood. Here, we demonstrate that the learning of multiple prior distributions in a coincidence timing task is characterised by body-part specificity. In our experiments, two prior distributions (short and long intervals) were imposed on participants. When using only one body part for timing responses, regardless of the priors, participants learned a single prior by generalising over the two distributions. However, when the two priors were assigned to different body parts, participants concurrently learned the two independent priors. Moreover, body-part specific prior acquisition was faster when the priors were assigned to anatomically distant body parts (e.g., hand/foot) than when they were assigned to close body parts (e.g., index/middle fingers). This suggests that the body-part specific learning of priors is organised according to somatotopy.

Enhanced expression of neopterin in valve tissue of bicuspid aortic stenosis.

Background: Aortic valve stenosis (AS) occurs in bicuspid aortic valve (BAV) patients at a relatively young age compared to tricuspid aortic valve (TAV) patients. However, the underlying cause of this phenomenon remains unknown. Neopterin, which is a by-product of the guanosine triphosphate (GTP) pathway, enhances the oxidative potential of reactive oxygen species. To clarify the role of neopterin in the aortic valve, we immunohistochemically studied the presence of neopterin in aortic valve specimens from patients with AS harboring either TAV or BAV. Methods: Frozen aortic valve samples were surgically obtained from 68 patients with severe AS with TAV (n=34) and BAV (n=34). Normal aortic valves were obtained from cadavers who died of non-cardiovascular causes as controls (n=9). Samples were immunohistochemically stained with antibodies against smooth muscle cells, macrophages, T lymphocytes, neopterin, and 4-hydroxy-2-nonenal (4-HNE). Results: Quantitative analysis showed that the percentage of macrophages, 4-HNE- and neopterin-positive macrophage score, and the number of T lymphocytes were significantly higher in BAV patients than in TAV patients (macrophages, P=0.013; T lymphocytes, P=0.011; neopterin, P<0.001; 4-HNE, P=0.008). Double immunostaining for neopterin and macrophages demonstrated that most neopterin-positive cells were macrophages in BAV patients. Conclusions: Neopterin accumulation in macrophages may increase oxidative stress and contribute to the early onset of AS in BAV.

Risk factors of pacing-induced cardiomyopathy-Insights from lead position.

There was no significant difference in the incidence of pacing-induced cardiomyopathy between right ventricular apex pacing group and OpenCurlyQuote;true CloseCurlyQuote; mid-right ventricular septum pacing group. The preoperative left ventricular end-systolic diameter and paced QRS duration were independent predictors of PICM.

Absence of left ventricular concentric hypertrophy: a prerequisite for zero coronary calcium score.

The identification and intervention of factors associated with a coronary artery calcification (CAC) score of zero, suggesting the absence of significant coronary artery disease (CAD) with high probability, would be meaningful in the clinical setting. Thus far, the relationship between CAC and left ventricular (LV) hypertrophy has not been documented. We identified factors associated with a CAC score of zero and evaluated the relationship between this score and LV concentric hypertrophy in 309 consecutive patients with suspected CAD who were clinically indicated to undergo multislice computed tomography angiography for coronary artery evaluation. The quantitative CAC score was calculated according to Agatston's method. The total coronary calcium score (TCS) was defined as the sum of the scores for each lesion. Four absolute TCS categories were considered: zero, mild (0-100), moderate (100-400), and severe (>400). LV hypertrophy was classified into concentric (LV mass index >104 g/m(2) in women or >116 g/m(2) in men; LV end-diastolic volume index ≤109.2 mL/m(2)) and eccentric (LV end-diastolic volume index >109.2 mL/m(2)) patterns. In the zero-TCS group, the frequency of LV concentric hypertrophy was extremely low (zero 6%, mild 17%, moderate 26%, severe 19%). Multivariate analysis revealed that age, hypercholesterolemia, diabetes mellitus, LV concentric hypertrophy, and LV mass index, but not hypertension, were the independent factors associated with a CAC score of zero. The present study demonstrated that the absence of LV concentric hypertrophy was a prerequisite for a CAC score of zero. That is, the presence of LV concentric hypertrophy, which indicated more severe underlying hypertension, long duration, or poor control of blood pressure, implicates the presence of CAC.

Assessing the true severity of low-gradient aortic stenosis using resting echocardiography.

BACKGROUND: Dobutamine stress echocardiography (DSE) is required to determine whether low-gradient aortic stenosis (AS) with a small aortic valve area (AVA) is truly severe. The purpose of the present study was to evaluate the usefulness of ejection dynamics parameters at resting echocardiography for predicting the result of DSE performed in patients with low-gradient AS. METHODS: The results of resting echocardiography and DSE performed on 51 AS patients with low mean-gradient (<40 mmHg) and small indexed AVA (<0.60 cm2/m2) were retrospectively reviewed. Acceleration time (AT) and the ratio of AT to ejection time (ET) were measured on the recorded images. True-severe AS was defined as that with indexed projected AVA < 0.60 cm2/m2. RESULTS: Twenty-six (51%) patients had true-severe AS, while 22 (43%) patients had preserved left ventricular ejection fraction (≥50%). Baseline indexed AVA and AT/ET were independently associated with indexed projected AVA at DSE. AT/ET was the only independent determinant of valve compliance. Indexed AVA ≤ 0.493 cm2/m2 and AT/ET > 0.334 at baseline had sensitivities of 69% and 65% and specificities of 84% and 84%, respectively, for predicting true-severe AS. The presence of either indexed AVA ≤ 0.493 cm2/m2 or AT/ET > 0.334 had a higher sensitivity (88%), and their co-occurrence had a higher specificity (100%). CONCLUSIONS: Indexed projected AVA at DSE was predicted by AT/ET, which represented valve compliance, along with indexed AVA. The true severity of low-gradient AS can be screened using a combination of resting indexed AVA and AT/ET without performing DSE.

Doppler-derived preoperative mitral regurgitation volume predicts postoperative left ventricular dysfunction after mitral valve repair.

BACKGROUND: Unexpected postoperative left ventricular (LV) dysfunction after valve repair for mitral regurgitation (MR) occurs in some patients with normal preoperative LV function. Identification of factors that predispose to such LV dysfunction would enhance our understanding of the indications and outcomes of surgery. METHODS: We retrospectively analyzed pre- and postoperative (median fourth day) echocardiograms of 174 patients undergoing valve repair for pure and isolated MR. Preoperative MR volume was quantified by the quantitative Doppler and/or proximal isovelocity surface area method. RESULTS: There was an incremental predictive value of MR quantification over the current recommendations (global chi(2) from 48.14 to 81.57, P < .001; Hosmer-Lemeshow test, P = .98), for postoperative LV dysfunction, defined as ejection fraction <50%. The independent predictors were MR volume and LV end-systolic dimension (P < .001 and P = .01, respectively). Sixty-nine patients underwent surgery before development of the current surgical criteria, namely, symptoms, atrial fibrillation, preoperative LV dysfunction, or pulmonary hypertension. Of these, MR volume was the only independent significant predictor (P < .001) of unexpected postoperative LV dysfunction that developed in 14 patients (20%). Unexpected LV dysfunction could be predicted with sensitivity of 86% (95% CI 67%-100%) and specificity of 89% (95% CI 81%-97%), using the optimal cutoff of 80 mL for MR volume. CONCLUSIONS: Doppler-derived preoperative MR volume is a powerful predictor of unexpected postoperative LV dysfunction. Prompt mitral valve repair may be beneficial for patients with high likelihood of successful repair and MR volume >/=80 mL.

Left atrial function assessed by real-time 3-dimensional echocardiography is related to right ventricular systolic pressure in chronic mitral regurgitation.

BACKGROUND: Left atrial (LA) volume is a prognostic index in chronic mitral regurgitation (MR). However, little is known about LA function in this setting. We hypothesized that LA dysfunction is related to pulmonary hypertension in chronic MR. METHODS: Seventy-one patients with organic chronic MR who underwent real-time 3-dimensional transthoracic echocardiography (RT3DE) were studied. Left atrial volumes and peak passive and active LA emptying rates were obtained. Total LA emptying fraction was calculated as follows: [(maximum - minimum LA volume)/maximum LA volume] x 100. Similarly, active and passive LA emptying fractions were calculated. From transmitral flow, the peak early (E) and late (A) diastolic filling velocities and E/A ratio were obtained. The early (E') and late (A') diastolic myocardial velocities were obtained by tissue Doppler interrogation of mitral annulus. RESULTS: Effective regurgitant orifice area (EROA) was 0.57 +/- 0.29 cm(2). Right ventricular systolic pressure (RVSP) was measured in 57 patients and averaged 37 +/- 13 mm Hg. Patients with MR and high RVSP displayed higher minimum LA volume, E/A ratio, E/E' ratio, EROA, and MR volume, and lower A' velocity, peak active LA emptying rate, active LA emptying fraction, and total LA emptying fraction than patients with MR and normal RVSP. Multiple regression analysis revealed that EROA (r = 0.51, P = .01) active LA emptying fraction (r = -0.53, P = .02), E/E' ratio (r = 0.50; P = .04), and the lateral A' velocity (r = -0.46; P = .003) were independently correlated with RVSP. CONCLUSIONS: Left atrial function determined by RT3DE had significant correlation with RVSP in chronic MR, irrespective of MR severity. Thus, pulmonary hypertension in chronic MR may depend not only on MR severity but also on LA function.

Geometry of the proximal isovelocity surface area in mitral regurgitation by 3-dimensional color Doppler echocardiography: difference between functional mitral regurgitation and prolapse regurgitation.

BACKGROUND: The geometry of the proximal isovelocity surface area (PISA) of functional mitral regurgitation (MR), which is conventionally assumed to be a hemisphere, remains to be clarified. We investigated the 3-dimensional (3D) geometry of PISA of functional MR as opposed to that of MR due to mitral valve prolapse (MVP) by real-time 3D echocardiography with color Doppler capability. METHODS: Twenty-seven patients with functional MR and 27 patients with MVP were examined. The horizontal PISA length in the commissure-commissure plane and each PISA radius in 3 anteroposterior planes (medial, central, and lateral) were measured by real-time 3D echocardiography with 3D software. The effective regurgitant orifice (ERO) area was calculated with the maximum PISA radius and compared to that by 2D quantitative Doppler method. RESULTS: En-face 3D color Doppler images showed an elongated and slightly curved PISA geometry along the leaflet coaptation in functional MR, whereas the geometry was rounder in MVP. The PISA horizontal length in functional MR was longer than that in MVP (2.3 +/- 0.4 vs 1.2 +/- 0.2 cm, P < .001). The PISA method with the maximum radius underestimated the ERO area by 2D quantitative Doppler method (by 24%) in functional MR, but not in MVP. CONCLUSIONS: The geometry of PISA in functional MR was elongated, distinctly different from the more focal pathology of MVP, leading to underestimation of the ERO area by PISA method.

Preoperative and postoperative mitral valve prolapse and regurgitation in adult patients with secundum atrial septal defects.

BACKGROUND: Little attention is given to development of mitral regurgitation (MR) in adults with atrial septal defect (ASD). The aim of the study was to determine the associated factors of MR in ASD adults before surgical repair and the fate of moderate to severe MR after surgery. METHODS: We examined 71 consecutive patients with secundum ASD (47 +/- 16 years) who underwent surgical repair. Clinical and echocardiographic variables including size of left and right heart systems and severity of MR and tricuspid regurgitation (TR) were investigated before and early after surgery. RESULTS: Before ASD closure, 14 patients (20%) had moderate to severe MR and 25 patients (35%) showed mitral valve (MV) prolapse. The ASD patients with moderate to severe MR showed worse cardiovascular symptoms, increased occurrence of atrial fibrillation and MV prolapse, and greater left ventricular (LV) end-diastolic volume, left atrial area, and TR severity than those with none to mild MR (all P < 0.05). Among preoperative variables, TR severity, left atrial area, LV end-diastolic volume, and MV prolapse were associated with preoperative MR severity in all the patients (all P < 0.03). Isolated ASD closure (n=46) decreased MV prolapse (P=0.008). Preoperative moderate to severe MR decreased after ASD closure with and without MV surgery (n=9 and 5, respectively; both P < 0.05). CONCLUSIONS: Preoperative MR severity was associated with TR severity, dilated left heart chambers, and MV prolapse. MR decreased after ASD closure with and even without MV surgery.

Three-dimensional geometry of the tricuspid annulus in healthy subjects and in patients with functional tricuspid regurgitation: a real-time, 3-dimensional echocardiographic study.

BACKGROUND: Most rings currently used for tricuspid valve annuloplasty are formed in a single plane, whereas the actual tricuspid annulus (TA) may have a nonplanar or 3-dimensional (3D) structure. The purpose of this study was therefore to investigate the 3D geometry of the TA in healthy subjects and in patients with functional tricuspid regurgitation (TR). METHODS AND RESULTS: This study consisted of 15 healthy subjects and 16 patients with functional TR who had real-time 3D echocardiography. With our customized software, 8 points along the TA were determined with the rotated plane around the axis at 45 degrees intervals. The TA was traced during a cardiac cycle. The distance between diagonals connecting 2 points was measured. The height was defined as the distance from the plane determined by least-squares regression analysis at all 8 points. Both the maximum (7.5+/-2.1 versus 5.6+/-1.0 cm2/m2) and minimum (5.7+/-1.3 versus 3.9+/-0.8 cm2/m2) TA areas in patients with TR were larger than those in healthy subjects (both P<0.01). Healthy subjects had a nonplanar-shaped TA with homogeneous contraction. The posteroseptal portion was the lowest toward the apex from the right atrium, and the anteroseptal portion was the highest. In patients with functional TR, the TA was dilated in the septal to lateral direction, resulting in a more circular shape than in healthy subjects. A similar 3D pattern was observed in patients with TR, but it was more planar than that in healthy subjects. CONCLUSIONS: Real-time 3D echocardiography showed a complicated 3D structure of the TA, which appeared to be different from the "saddle-shaped" mitral annulus, suggesting an annuloplasty for TR different from that for mitral regurgitation.