Fused aortic valve without an elliptical-shaped systolic orifice in patients with severe aortic stenosis: cardiac computed tomography is useful for differentiation between bicuspid aortic valve with raphe and tricuspid aortic valve with commissural fusion.

OBJECTIVE: The objective is to determine cardiac computed tomography (CCT) features capable of differentiating between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) in severe aortic stenosis (AS) patients with fused cusp and without elliptical-shaped systolic orifices. METHODS: We retrospectively enrolled 53 patients who had severe AS with fused cusps and without an elliptical-shaped systolic orifice on CCT and who had undergone surgery. CCT features were analyzed using: 1) aortic valve findings including cusp size, cusp area, opening shape, midline calcification, fusion length, calcium volume score, and calcium grade; 2) diameters of ascending and descending aorta, and main pulmonary artery; and 3) rheumatic mitral valve findings. The variables were evaluated using univariate and multivariate logistic regression analyses. RESULTS: At surgery, 19 patients had BAV and 34 had TAV. CCT features including uneven cusp size, uneven cusp area, round-shaped systolic orifice, longer cusp fusion, and dilatation of ascending aorta were significantly associated with BAV (P < 0.05). In particular, fusion length (OR, 1.76; P = 0.001), uneven cusp area (OR, 10.46; P = 0.012), and midline calcification (OR, 0.08; P = 0.013) were strongly associated with BAV. CONCLUSION: CCT provides diagnostic clues that helps differentiate between BAV with raphe and TAV with commissural fusion in patients with severe AS. KEY POINTS: • Accurate morphologic assessment of the aortic valve is important for treatment planning. • It is difficult to differentiate BAV from TAV with a fused cusp. • CCT provides diagnostic clues for the differentiation of BAV and TAV.

Mid-term results for a patch valvuloplasty technique to correct posterior leaflet prolapse.

BACKGROUND AND AIM OF THE STUDY: Most valve repair techniques require resection and multiple sutures. In the present study, a novel technique without resection for correction of posterior leaflet prolapse due to chordal elongation or rupture was employed, the aim being to evaluate the outcomes of a non-resecting valve repair technique in patients with posterior leaflet prolapse that caused significant mitral regurgitation (MR). METHODS: Between May 2008 and December 2010, a total of 90 consecutive patients with posterior leaflet prolapse (55 males, 35 females; mean age 51.5 ± 14.6 years) underwent patch valvuloplasty. The procedure involved suturing the free margin of the prolapsed leaflet, invagination of the folded leaflet tissue into the left ventricular side, coverage of the dimpled portion with a round bovine pericardial patch using a continuous suture technique, and reshaping of the posterior annulus using a 53- to 61-mm strip. All patients underwent postoperative echocardiography after a mean follow up of 41.9 ± 10.4 months. RESULTS: No early death occurred, but there was one late death due to a non-cardiac cause. At the last echocardiographic follow up, 81 patients (90%) showed none or trace MR, seven (7.8%) had mild MR, and two (2.2%) moderate MR. The mean mitral valve area was 2.4 ± 0.5 cm2 and the mean pressure gradient 2.8 ± 1.2 mmHg. No patient required reoperation due to recurrent or aggravated MR. CONCLUSION: In patients with posterior leaflet prolapse, the applied patch valvuloplasty technique was useful and reliable, showing excellent clinical and echocardiographic outcomes. Additional long-term evaluations with close follow up should be performed.

Diagnostic performance of dual-energy CT stress myocardial perfusion imaging: direct comparison with cardiovascular MRI.

OBJECTIVE: The purpose of this study was to assess the diagnostic performance of stress perfusion dual-energy CT (DECT) and its incremental value when used with coronary CT angiography (CTA) for identifying hemodynamically significant coronary artery disease. SUBJECTS AND METHODS: One hundred patients with suspected or known coronary artery disease without chronic myocardial infarction detected with coronary CTA underwent stress perfusion DECT, stress cardiovascular perfusion MRI, and invasive coronary angiography (ICA). Stress perfusion DECT and cardiovascular stress perfusion MR images were used for detecting perfusion defects. Coronary CTA and ICA were evaluated in the detection of ≥50% coronary stenosis. The diagnostic performance of coronary CTA for detecting hemo-dynamically significant stenosis was assessed before and after stress perfusion DECT on a per-vessel basis with ICA and cardiovascular stress perfusion MRI as the reference standard. RESULTS: The performance of stress perfusion DECT compared with cardiovascular stress perfusion MRI on a per-vessel basis in the detection of perfusion defects was sensitivity, 89%; specificity, 74%; positive predictive value, 73%; negative predictive value, 90%. Per segment, these values were sensitivity, 76%; specificity, 80%; positive predictive value, 63%; and negative predictive value, 88%. Compared with ICA and cardiovascular stress perfusion MRI per vessel territory the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA were 95%, 61%, 61%, and 95%. The values for stress perfusion DECT were 92%, 72%, 68%, and 94%. The values for coronary CTA and stress perfusion DECT were 88%, 79%, 73%, and 91%. The ROC AUC increased from 0.78 to 0.84 (p=0.02) with the use of coronary CTA and stress perfusion DECT compared with coronary CTA alone. CONCLUSION: Stress perfusion DECT plays a complementary role in enhancing the accuracy of coronary CTA for identifying hemodynamically significant coronary stenosis.

Relationship between bicuspid aortic valve phenotype, valvular function, and ascending aortic dimensions.

BACKGROUND AND AIM OF THE STUDY: Bicuspid aortic valve (BAV) is known to be associated with aortic valve dysfunction and ascending aorta (AA) dilatation. However, the relationship between BAV morphology and AA dimensions remains unclear. Thus, the study aim was to characterize the aortic valve function and AA dimensions according to the presence of raphe and BAV phenotype. METHODS: A total of 164 patients with BAV who underwent aortic valve surgery between October 2007 and November 2012 was investigated. BAV was classified as either type I (anterior-posterior orientation) or type II (right-left orientation), and subdivided as raphe+ (presence of raphe) and raphe-(no raphe). RESULTS: Type I BAV was present in 103 patients (62.8%), and raphe+ in 100 (61.0%). Patients with raphe+ were typically younger than those with raphe-, and male gender was more predominant (88.0% and 53.1%, respectively, p < 0.05). Aortic regurgitation was more common in patients with type I and raphe+ BAV, and aortic stenosis in patients with type II and raphe- BAV. In patients with raphe+, the diameters of aortic annulus related to the body surface area (BSA) were larger, and the diameters of the tubular portion of AA indexed to BSA were smaller than in patients with raphe- (p < 0.05). CONCLUSION: BAV morphology is helpful for predicting the type of aortic valve dysfunction and the location of AA dilatation.

Detection of left atrial thrombus in patients with mitral stenosis and atrial fibrillation: retrospective comparison of two-phase computed tomography, transoesophageal echocardiography and surgical findings.

OBJECTIVE: This retrospective study aims to assess the accuracy of two-phase computed tomography (CT) and transoesophageal echocardiography (TEE) for the detection of left atrial (LA) thrombus in patients with mitral stenosis (MS) and atrial fibrillation (AF), by using intraoperative findings as the reference standard. METHODS: Preoperative two-phase CT and intraoperative TEE were performed in 106 patients with MS and AF. The ratio (LAA/AAL) of Hounsfield units (HU) in the LA appendage (LAA) to the ascending aorta (AA) was calculated on the late-phase CT image. RESULTS: LA echodense masses on TEE and LA filling defects on two-phase CT were observed in 29 and 39 patients, respectively. Thirty-five LA thrombi were identified at surgery in 27 patients. Compared with the intraoperative findings, per-patient sensitivity, specificity, positive and negative predictive values of two-phase CT were 100 %, 85 %, 69 % and 100 %, and those by using TEE were 93 %, 95 %, 86 % and 97 % in detecting LAA thrombus. After adopting the cut-off value of 0.5 for the LAA/AAL HU ratio, the specificity and positive predictive value of two-phase CT were increased to 96 % and 90 %, respectively. CONCLUSION: Two-phase CT with a cut-off value of LAA/AAL HU ratio of 0.5 provides high performance for the detection of LAA thrombus. KEY POINTS: • Accurate detection of left atrial appendage (LAA) thrombus is extremely important. • However artefacts from flow effects influence both CT and ultrasound findings. • Two-phase ECG-gated CT offers new insight into thrombus detection. • Analysis of aortic/atrial opacification helps differentiate LAA thrombus from artefact at CT.

Bicuspid aortic valve: spectrum of imaging findings at cardiac MDCT and cardiovascular MRI.

OBJECTIVE: Cardiac MDCT and cardiovascular MRI have become widely used for the evaluation of cardiovascular disease, including aortic valve disease. The purpose of this article is to present the cardiac MDCT and cardiovascular MRI findings of bicuspid aortic valve, its various complications, and other congenital cardiovascular malformations. CONCLUSION: Radiologists should be aware of the clinical significance and the varied appearance of bicuspid aortic valve at cardiac MDCT and cardiovascular MRI.

Diagnostic performance of combined noninvasive anatomic and functional assessment with dual-source CT and adenosine-induced stress dual-energy CT for detection of significant coronary stenosis.

OBJECTIVE: The purpose of our study was to prospectively evaluate the incremental diagnostic value of combined dual-source coronary CT angiography (CTA) and CT myocardial perfusion imaging (MPI) for the detection of significant coronary stenoses. SUBJECTS AND METHODS: Forty-five patients with known coronary artery disease detected by dual-source coronary CTA were investigated by adenosine-induced stress dual-source CTA and conventional coronary angiography. Analysis was performed in three steps: classification of coronary stenosis severity using dual-source coronary CTA, identification of myocardial perfusion defects using rest and stress CT MPI, and reclassification of coronary stenosis severity according to combined dual-source coronary CTA and CT MPI. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of dual-source coronary CTA before and after CT MPI were calculated on a per-vessel basis compared with conventional coronary angiography as the standard of reference. RESULTS: Dual-source coronary CTA revealed 87 significantly stenotic vessels in 45 patients. Conventional coronary angiography revealed significant stenoses in 73 vessels in 42 patients. CT MPI showed myocardial perfusion defects in 81 vessel territories in 43 patients. After the CT MPI analysis, dual-source coronary CTA identified significant stenoses in 77 coronary vessels in 42 patients. Sensitivity, specificity, PPV, and NPV of the dual-source coronary CTA on a per-vessel basis before CT MPI were 91.8%, 67.7%, 73.6%, and 87.5%, respectively, and after CT MPI were 93.2%, 85.5%, 88.3%, and 91.4%, respectively. The area under the receiver operating characteristic curve increased significantly from 0.798 to 0.893 (p = 0.004). CONCLUSION: Combined dual-source coronary CTA and CT MPI provides incremental diagnostic value compared with dual-source coronary CTA alone for the detection of significant coronary stenoses.

Assessment of global left ventricular function with dual-source computed tomography in patients with valvular heart disease.

BACKGROUND: Left ventricular (LV) function is a vital parameter for prognosis, therapy guidance, and follow-up of cardiovascular disease. Dual-source computed tomography (DSCT) provides an accurate analysis of global LV function. PURPOSE: To assess the performance of DSCT in the determination of global LV functional parameters in comparison with cardiovascular magnetic resonance (CMR) and two-dimensional transthoracic echocardiography (2D-TTE) in patients with valvular heart disease (VHD). MATERIAL AND METHODS: A total of 111 patients (58 men, mean age 49.9 years) with known VHD and who underwent DSCT, 2D-TTE, and CMR a period of 2 weeks before undergoing valve surgery were included in this study. LV end-systolic volume (ESV), end-diastolic volume (EDV), stroke volume (SV), and ejection fraction (EF) were calculated by DSCT using the threshold-based technique, by 2D-TTE using a modified Simpson's method, and by CMR using Simpson's method. Agreement for parameters of LV global function was determined with the Pearson's correlation coefficient (r) and Bland-Altman analysis. All the DSCT and CMR data-sets were assessed independently by two readers. RESULTS: Fifty of the total 111 patients had aortic VHD, 29 patients had mitral VHD, and 32 patients had mixed aortic and mitral VHD. An excellent inter-observer agreement was seen for the assessment of global LV function using DSCT (r = 0.910-0.983) and CMR (r = 0.854-0.965). An excellent or good correlation (r = 0.93, 0.95, 0.87, and 0.71, respectively, P < 0.001) was noted between the DSCT and 2D-TTE values for EDV, ESV, SV, and EF. EDV (33.7 mL, P < 0.001), ESV (12.1 mL, P < 0.001), SV (21.2 mL, P < 0.001), and EF (1.6%, P = 0.019) were significantly overestimated by DSCT when compared with 2D-TTE. An excellent correlation (r = 0.96, 0.97, 0.91, and 0.94, respectively, P < 0.001) between DSCT and CMR was seen in the evaluation of EDV, ESV, SV, and EF. EDV (15.9 mL, P < 0.001), ESV (7.3 mL, P < 0.001), and SV (8.5 mL, P < 0.001) were significantly underestimated, but EF (1.1%, P = 0.002) was significantly overestimated by DSCT when compared with CMR. CONCLUSION: Our study showed that DSCT measurements of global LV function using the threshold-based technique were highly reproducible and compared more favorably with CMR measurements using Simpson's method than those of 2D-TTE using the modified Simpson's method. DSCT enables accurate quantification of global LV function in patients with VHD.

Myocardial perfusion imaging using adenosine-induced stress dual-energy computed tomography of the heart: comparison with cardiac magnetic resonance imaging and conventional coronary angiography.

OBJECTIVE: To evaluate the feasibility and diagnostic accuracy of adenosine-stress dual-energy computed tomography (DECT) for detecting haemodynamically significant stenosis causing reversible myocardial perfusion defect (PD) compared with stress perfusion magnetic resonance imaging (SP-MRI) and conventional coronary angiography (CCA). METHODS: Fifty patients with known coronary artery disease (CAD) detected by dual-source CT (DSCT) were investigated by contrast-enhanced, stress DECT with high- and low-energy x-ray spectra settings during adenosine infusion. A colour-coded iodine map was used for evaluation of myocardial PDs compared with rest DSCT perfusion images. Reversible myocardial PDs according to the stress DECT/rest DSCT were compared with SP-MRI on a segmental basis and CCA on a vascular territorial basis. RESULTS: A total of 697 myocardial segments and 123 vascular territories of 41 patients were analysed. Three hundred one segments and 72 vascular territories in 38 patients showed reversible PDs on stress DECT. Stress DECT had 89% sensitivity, 78% specificity and 82% accuracy for detecting segments with reversible PDs seen on SP-MRI (n=28). Compared with CCA (n=41), stress DECT had 89% sensitivity, 76% specificity and 83% accuracy for the detection of vascular territories with reversible myocardial PDs that had haemodynamically relevant CAD. CONCLUSION: Adenosine stress DECT can identify stress-induced myocardial PD in patients with CAD.

Heart transplantation in pediatric patients: twelve-year experience of the Asan Medical Center.

Heart transplantation is a standard treatment for end-stage heart disease. Pediatric heart transplantation, however, is not frequently performed due to the shortage of pediatric heart donors. This is the first report of pediatric heart transplantation in Korea. Our retrospective study included 37 patients younger than 18 yr of age who underwent heart transplantation at Asan Medical Center between August 1997 and April 2009. Preoperative diagnosis was either cardiomyopathy (n = 29, 78.3%) or congenital heart disease (n = 8, 22.7%). Mean follow up period was 56.9 ± 44.6 months. There were no early death, but 7 late deaths (7/37, 18.9%) due to rejection after 11, 15, 41 months (n = 3), infection after 5, 8, 10 months (n = 3), suspicious ventricular arrhythmia after 50 months (n = 1). There was no significant risk factor for survival. There were 25 rejections (25/37, 67.6%); less than grade II occurred in 17 patients (17/25, 68%) and more than grade II occurred in 8 patients (8/25, 32%). Actuarial 1, 5, and 10 yr survival was 88.6%, 76.8%, and 76.8%. Our midterm survival of pediatric heart transplantation showed excellent results. We hope this result could be an encouraging message to do more pediatric heart transplantation in Korean society.

Anthropometric estimation of femoral venous cannula length for cardiovascular surgery.

BACKGROUND: Femoral vein cannulation is an alternative method for central cannulation. However, no clinical guidelines have been established for optimal insertion length of femoral venous cannula. The purpose of the present study was to evaluate the correlation between the insertion length of femoral venous cannula (L), and the sum of the length from femoral artery (FA) puncture site to umbilicus (P-U) and the length from umbilicus to lower border of the sternum (U-S) as an anthropometric estimation for adult patients undergoing cardiovascular surgery using femoral vein cannulation. We also attempted to determine the insertion length of femoral venous cannula by the patient's height and weight. METHODS: P-U and U-S were measured after anesthesia induction. L was measured after femoral venous cannula tip was positioned at the junction of inferior vena cava and right atrium using transesophageal echocardiography. The relationship between the sum of P-U and U-S (P-U-S), and L was analyzed by Pearson's correlation analysis. Bland-Altman analysis was used to compare the agreement between P-U-S and L. Multiple linear regression analysis was performed to identify the height and weight factors capable of predicting L. RESULTS: One-hundred study patients were enrolled. P-U-S was highly correlated with L (r = 0.95). The bias and precision were -2.60 ± 8.57 mm. L was predicted from height and weight: L (mm) = 0.82 × height (cm) + 1.18 × weight (kg) + 188.46. CONCLUSIONS: P-U-S can be used as a reliable anthropometric estimation of L during adult cardiovascular surgery using femoral vein cannulation.

Long-term outcomes after mitral ring annuloplasty for degenerative mitral regurgitation: Duran ring versus Carpentier-Edwards ring.

BACKGROUND AND AIM OF THE STUDY: The preferred choice of annuloplasty ring in mitral surgery has not yet been determined. The study aim was to compare the effects of using two ring types, the Duran and the Carpentier-Edwards, for degenerative mitral valve repair. METHODS: The follow up data were reviewed from 294 patients who underwent mitral valvuloplasty for degenerative mitral regurgitation (MR) with either a Carpentier-Edwards ring (n = 153) or a Duran ring (n = 141), between 1994 and 2004. The long-term clinical and echocardiographic outcomes were compared. RESULTS: There were no inter-group preoperative demographic differences. The preoperative left ventricular (LV) ejection fraction (EF) and MR grade were similar in both groups, but the left atrial (LA) size, LV mass and LV dimension were significantly greater in the CE group. Rates of overall survival, reoperation-free survival and MR (> or = 3)-free survival were similar in the two groups (five-year MR-free survival 75.1 +/- 4.6% for CE and 82.4 +/- 4.5% for Duran; p = 0.83). The CE group showed an overall superior five-year mitral stenosis (MS)-free survival. Significantly more Duran patients had a mean transmitral pressure gradient (MPG) of > or = 10 mmHg (five-year MS (MPG > or = 10 mmHg)-free survival rate: 91.2 +/- 2.8% in for CE and 65.1 +/- 10.7% for Duran group; p = 0.011). The LV EF did not change over time in either group. In contrast, the LV mass and LV dimension decreased significantly after surgery in both groups, but no significant inter-group difference was seen for either index. CONCLUSION: Although the Duran and Carpentier-Edwards rings showed comparable long-term outcomes in terms of LV function, MR recurrence, survival and reoperation, a greater tendency towards MS development was observed with the Duran ring, this being most likely due to late pannus formation.

Novel technique of aortic valvuloplasty.

OBJECTIVE: The present study was aimed to assess the results of newly developed aortic valve repair technique. METHODS: Between 1997 and 2004, 69 aortic valvuloplasties were performed with a new technique addressing the three main components of the aortic root; leaflets (L), sinotubular junction (STJ), and aortic annulus (A). For leaflet correction, additional leaflets were implanted and for STJ and annular reduction, an internal synthetic ring and strip along the fibrous annulus were implanted, respectively. The patients were divided into two groups: 30 patients with isolated aortic regurgitation (group IAR) were treated by correction of STJ+L (n=21) and STJ+A+L (n=9), and 39 aortic regurgitation patients with annuloaortic ectasia or ascending aortic aneurysm (group AAR) were treated with STJ correction only (n=16), STJ+A (n=6), STJ+L (n=9), and STJ+A+L (n=8). RESULTS: The mean age was 43.4 and 49.5 years for groups IAR and AAR, respectively. There was neither operative nor follow-up death in either group. Suture breakage caused one reoperation in group IAR. Mean follow-up was 13.8 and 20.3 months in groups IAR and AAR, respectively. The preoperative aortic regurgitation grade was 3.67 in group IAR and 2.67 in group AAR. The last follow-up aortic regurgitation grade was 1.1 in group IAR and 1.05 in group AAR. No patient, except for the reoperated patient had AR greater than grade 2. The postoperative pressure gradient was 19.3 mmHg in group IAR and 8. 4mmHg in group AAR. CONCLUSIONS: The results showed this technique to be safe and effective. Thus far broad application of this repair technique has been demonstrated to be highly feasible.

Usefulness of the initial noninvasive imaging study to predict the adverse outcomes in the medical treatment of acute type A aortic intramural hematoma.

BACKGROUND: There have been contradictory reports about the outcomes of medically treated patients with type A aortic intramural hematoma (AIH), and it is not certain if the initial noninvasive imaging studies can provide any useful predictors for the adverse outcomes. METHODS AND RESULTS: Imaging studies and clinical outcomes of 25 consecutive patients with type A AIH who initially received medical treatment were analyzed retrospectively. Adverse outcomes (death, surgery, and development of dissection) occurred in 9 patients (group A), whereas the other 16 patients showed an uneventful course (group B). The hematoma thickness (14+/-4 versus 8+/-4 mm, P<0.005) and hematoma area (988+/-316 versus 555+/-352 mm2, P<0.01) in the imaging study performed or=11 mm predicted the adverse outcomes with sensitivity 89% and specificity 69%. No one with hemodynamically stable initial condition and the hematoma thickness <11 mm experienced the adverse outcomes. CONCLUSIONS: Noninvasive imaging study provides important prognostic information in the medical treatment of acute type A AIH, and initial hematoma thickness seems to be the best index for predicting adverse clinical outcome.

Midterm results of mitral valve repair with lifting annuloplasty strip for acute phase infective endocarditis.

BACKGROUND: Mitral valve repair is favored over replacement due to superior outcomes. However, extensive infective endocarditis (IE) often has been considered unreconstructable. We retrospectively analyzed the mid-term outcomes of an individualized repair approach using a lifting annuloplasty strip. METHODS: Between December 2007 and March 2014, 27 consecutive patients with acute single mitral valve IE (age 43 ± 16 years, 11 men) underwent lifting mitral annuloplasty (LMA) with a strip (Mitracon® strip, 28 mm in 4, 32 mm in 10, and 34 mm in 13). Blood culture was positive in 70 % (Streptococcus 10, Staphylococcus 4, HACEK 3, Enterococcus 1, Gram negative bacilli 1). One case (4 %) had a previously repaired mitral valve-the repair was redone. Via right thoracotomy (74 %) or median sternotomy (26 %), repair was performed by removal of vegetation and resection of infected tissue, the defect typically then being repaired using a bovine pericardial patch (81 %). Artificial chordae were formed in 5 patients. Nine (33 %) of them had posterior leaflet augmentation (PLA) to get sufficient coaptation height. Clinical and echocardiographic follow-up were performed. RESULTS: Compared with preoperative ones, postoperative echocardiograms revealed decreases of left ventricular (LV) end-diastolic dimensions (57.2 ± 6.3 versus, 45.4 ± 6.2, or 44.8 ± 4.1 mm, all p < 0.01). The LV ejection fraction decreased immediately, but recovered (64.4 ± 9.6 % vs. 54.5 ± 9.8 %, or 65.2 ± 6.1 %, p = 0.002, p = 1.000, respectively). The latest follow-up echocardiograms (median 28 months) universally showed no or minimal regurgitation, with a preserved mitral valve opening area (2.27 ± 0.48 cm(2)). During the clinical follow-up (median, 54 months), one (3.7 %) death was observed (in-hospital, due to biliary sepsis and pneumonia). There was no reoperation or major cardiovascular event. The 5 year survival rate was 96.3 %. CONCLUSIONS: The repair technique of LMA and/or PLA in patients with IE achieved good structural and functional outcomes as well as an excellent 5 year survival rate. An individualized repair approach should be recommended in patients with acute phase IE.

Lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair: midterm outcomes.

BACKGROUND: We evaluated the midterm outcomes of lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair. METHODS: Between October 2007 and December 2012, 341 consecutive patients with significant mitral regurgitation underwent lifting posterior mitral annuloplasty using a specially designed fabric annuloplasty strip that lifts the middle portion of the posterior annulus. Associated procedures for mitral valve repairs, such as patch valvuloplasty for posterior leaflet prolapse (n=80), new chord placement for anterior leaflet prolapse (n=33), commissurotomy (n=29), and posterior leaflet extension (n=23), were performed in 141 patients (41.3%). RESULTS: Thirty-day mortality was 0.9%. Nine late deaths (2.6%) occurred. Mean overall survival at 5 years was 96.0%±1.1%. During the mean follow-up period of 38±17 months, six patients (1.8%) underwent valve-related reoperation (5-year freedom from valve-related reoperation, 98.1%±0.8%). At 5 years, mean freedom from recurrence of mitral regurgitation grade 3+ to 4+ (moderate to severe) was 95.1%±1.6%. The mean valve pressure gradient (PG) was 3.2±1.5 mmHg across all strip sizes at the time of follow-up. CONCLUSIONS: Lifting posterior mitral annuloplasty using an innovative annuloplasty strip in mitral valve repair has a low rate of recurrent regurgitation or valve-related reoperation with rare relevant complications.

Quantification of stenotic mitral valve area and diagnostic accuracy of mitral stenosis by dual-source computed tomography in patients with atrial fibrillation: comparison with cardiovascular magnetic resonance and transthoracic echocardiography.

This study aimed to evaluate the utility of dual-source computed tomography (DSCT) for quantification of the mitral valve area (MVA) in patients with atrial fibrillation (AF) and mitral stenosis (MS) and to compare the results of DSCT with those of cardiovascular magnetic resonance (CMR) and transthoracic echocardiography (TTE). One hundred-two patients with AF and MS who had undergone electrocardiography-gated DSCT, TTE and CMR prior to operation were retrospectively enrolled. The MVA was planimetrically determined by DSCT, CMR, and TTE, as well as by Doppler TTE using the pressure half-time method (TTE-PHT). Agreement, relationship between measurements, and the highest accuracy were evaluated using Bland-Altman, Pearson correlation, and receiver operating characteristic analyses. The MVA on DSCT (mean, 1.27 ± 0.27 cm(2)) was significantly larger than that on CMR (1.15 ± 0.28 cm(2), P < 0.05), TTE-planimetry and TTE-PHT (1.16 ± 0.28 and 1.07 ± 0.30 cm(2), respectively; P < 0.05). TTE-planimetry had better correlation with planimetry on DSCT and CMR (r = 0.65 and 0.67, respectively; P < 0.05) than TTE-PHT (r = 0.51 and 0.55, respectively; P < 0.05). Using an MVA of 1.0 cm(2) on TTE-planimetry and TTE-PHT as the reference, the optimal thresholds for detecting severe MS on DSCT was 1.19 cm(2). The planimetry of the MVA measured by DSCT may be a reliable, alternative method for the quantification of MS in patients with AF.

Surgical outcome of the maze procedure for atrial fibrillation in mitral valve disease: rheumatic versus degenerative.

BACKGROUND: The results of the maze procedure are known to be less satisfactory in rheumatic mitral disease than in nonrheumatic mitral valve disease. The aim of this study was to determine whether the etiology of mitral valve disease affected surgical outcome. METHODS: From July 1997 to January 2001, 129 consecutive patients with chronic atrial fibrillation associated with mitral valve disease had mitral valve operations with the maze procedure. The underlying mitral pathology was rheumatic in 86 patients (group R) and degenerative in 43 (group D). Echocardiograms and electrocardiograms were performed immediately and then repeated 3 months and 6 months postoperatively. RESULTS: The mean age, duration of atrial fibrillation, and preoperative left atrial size were similar between the groups. There was no operative mortality and no significant difference in cardiopulmonary bypass and aortic cross-clamp times. The sinus conversion rate at 7 days postoperatively was 86% in both groups, and at 6 months it was 95.3% in group R and 97.7% in group D (p > 0.05). The transmitral A wave detection rates in groups R and D at 7 days and 6 months postoperatively were, respectively, 63.1% versus 67.4% and 90.4% versus 91.9% (p > 0.05). The transmitral A wave velocity (cm/second) at the same times (7 days and 6 months postoperatively) was 41.9 +/- 41.6 versus 45.5 +/- 37.7 and 67.8 +/- 38.2 versus 69.8 +/- 35.8 in groups R and D, respectively (p > 0.05). CONCLUSIONS: The maze procedure is equally effective in treating chronic atrial fibrillation in patients with either rheumatic or nonrheumatic mitral valve disease in terms of sinus conversion rate and left atrial transport function.

Echocardiographic and clinical characteristics of aortic regurgitation because of systemic vasculitis.

BACKGROUND: Although systemic vasculitis has been described as one cause of aortic regurgitation (AR), clinical features of this disease entity have not been fully characterized. METHODS: The clinical data of 153 consecutive patients (103 male), who underwent open-heart operation to correct predominant AR from January 1990 to December 2000 were retrospectively analyzed. RESULTS: A total of 16 patients (10%) were found to have AR associated with systemic vasculitis; there were 9 patients with Takayasu's arteritis (TA) and 7 with Behçet's disease (BD). All patients with TA, but only 3 with BD, were female (P <.05). Echocardiography showed redundant motion of the elongated aortic cusp with the frequent periaortic echo-free space in BD, and characteristic motion limitation of thickened cusp with dilated and thickened aorta in TA. All patients with TA, but only 1 patient with BD, were given a diagnosis before operation (P <.05); the others underwent emergency operation to control acute AR of unknown etiology, and were given a correct diagnosis after detection of paravalvular leakage. In TA, paravalvular leakage developed in 1 patient (11%) and another died suddenly with chest pain. In BD, paravalvular leakage developed in 6 patients (86%) who needed repeated operation, and 2 died even after the third operation. The 2-year survival without clinical events (paravalvular leakage, repeated operation, or death) was 76 +/- 15% in TA and 14 +/- 13% in BD (P <.05). CONCLUSIONS: TA and BD are 2 important causes of AR, and show different clinical features. A high rate of paravalvular leakage, especially in BD, warrants cautious systemic evaluations for the cause of AR, and characteristic echocardiographic findings seem to be helpful in the differential diagnosis.

Excellent results for atrial fibrillation surgery in the presence of giant left atrium and mitral valve disease.

OBJECTIVE: The incidence of sinus conversion in the enlarged left atrium after atrial fibrillation surgery is reported to be low. The purpose of the current study was to investigate the effects of atrial fibrillation surgery on mitral valve disease associated with a giant left atrium (GLA). METHOD: From July of 1997 to February of 2002, 188 patients received mitral valve and atrial fibrillation surgery. The patients were placed in either GLA group (n = 94), or NGLA group (n = 94), based on LA size. The presence and onset of sinus rhythm and the incidence and velocity of transmitral A waves were monitored during the early postoperative period and throughout the follow up period of 42 months. RESULTS: The onset of postoperative sinus rhythm was slightly earlier in the NGLA group than in the GLA group at 1.3+/-0.4 days versus 3.1+/-1.2 days, respectively, (P = 0.008). The sinus conversion rates in the GLA and the NGLA groups were 91.5 and 97.9% in the early postoperative period, and 94.7 and 95.7% at 6 months after surgery, respectively. A wave appearance rates in the early postoperative period in the GLA and the NGLA groups were 62.2 and 71.7%, and continued to improve over time to 94 and 95% by 36 months, respectively. Peak A wave velocities in the early postoperative period in GLA and NGLA groups were 67.4+/-34.0 and 61.1+/-29.5 cm/s without significant change during the follow up. CONCLUSION: The results suggest that atrial fibrillation surgery is effective at inducing sinus rhythm and restoring left atrial contractile function after concomitant mitral valve surgery regardless of LA size.