A hybrid technique for treatment of commissural primary mitral regurgitation.

BACKGROUND: MitraClip is an effective transcatheter therapy for mitral regurgitation (MR). However, MitraClip is challenging in commissural MR and the optimal therapeutic approach is unclear. METHODS: We describe a case series of six consecutive patients with severe commissural primary mitral regurgitation who underwent MitraClip insertion followed by an Amplatzer Vascular Plug (AVP) II occluder between the commissure and the MitraClip. RESULTS: The procedure was successful in all patients. MR was reduced from severe to mild/trivial in 50% and moderate in 50% of cases. On 30-day follow-up, NYHA class had improved from III (6 patients) to I (2 patients), II (2 patients), and III (2 patients). The mean transmitral gradient was 2.5 ± 1.8 mmHg at baseline and 4.8 ± 2.6 mmHg following the procedure. One patient developed hemolysis immediately post procedure. The other five patients remained well during a median follow-up of 20 months (range 5-50 months) with no reported device dislodgement. CONCLUSIONS: Elective treatment of severe commissural MR with a laterally or medially placed MitraClip coupled with an AVP II occluder between the clip and the commissure is feasible and safe. This approach may provide a useful management alternative in selected patients.

Characteristics and outcomes of re-do percutaneous paravalvular leak closure.

BACKGROUND: Percutaneous paravalvular leak (PVL) closure is an alternative treatment option for severely symptomatic, high-surgical risk patients with PVL. Some patients require multiple percutaneous PVL closure procedures. However, the procedural characteristics and success rate of re-do PVL closure have not been well studied. AIMS: The aim of this study is to investigate the indications, procedural characteristics, technical success rate, and 30-day major adverse cardiovascular events (MACE) in patients who underwent re-do PVL closure. METHODS: Consecutive patients who underwent percutaneous paramitral or paraaortic leak closure at Mayo Clinic, Rochester, Minnesota from 2004 through 2015 were studied. Clinical and procedural characteristics of patients who underwent re-do PVL closure were compared to age- and sex-matched patients who underwent their first percutaneous PVL closure. Procedure success and 30-day MACE were compared in both the groups. RESULTS: Among 223 identified percutaneous PVL closures, 16 (7%) were re-do procedures. Patients who underwent re-do PVL closure were predominantly men (87.5%) with a mean age of 68 ± 15 years and an estimated mean Society of Thoracic Surgery (STS) 30-day mortality of 4.6 ± 2.8. Half of the re-do PVL closures were performed on mechanical valves and 62.5% were performed on paramitral defects. Indications for re-do PVL closure were: (1) emergence of new significant paravalvular defects in 50%, (2) incomplete index defect closure in 43.75%, and (3) index procedural complication in 6.25% of the cases. Procedural success was 75% in re-do procedures vs. 85.4% in age- and sex-matched control group (P = 0.45). Thirty-day MACE was 12.5% in the re-do group compared to 4.2% in the age- and-sex matched patients who underwent PVL closure for the first time (P = 0.35). CONCLUSION: Re-do percutaneous PVL closure is feasible with favorable procedural success rate and low 30-day MACE. Development of new paravalvular defects is the most common indication for re-do PVL closure, highlighting the importance of careful longitudinal monitoring and follow-up. © 2017 Wiley Periodicals, Inc.

Sex-related differences in calcific aortic stenosis: correlating clinical and echocardiographic characteristics and computed tomography aortic valve calcium score to excised aortic valve weight.

AIMS: Calcific aortic valve stenosis (AS) is purportedly associated with less calcium burden in women than in men. We sought to examine sex-related differences and correlates of surgically excised aortic valve weight (AVW) in pure AS. METHODS AND RESULTS: Clinical and echocardiographic characteristics of 888 consecutive patients who underwent aortic valve replacement for severe AS were correlated to AVW, and in 126 patients, AVW was also correlated to computed tomography aortic valve calcium (AVC) score. Women and men had similar indexed valve area (0.42 ± 0.09 vs. 0.42 ± 0.07 cm (2)/m(2), P = 0.95) and mean systolic gradient (53 ± 15 vs. 52 ± 13 mmHg, P = 0.11), but women had higher New York Heart Association class (2.63 ± 0.70 vs. 2.50 ± 0.70, P = 0.01) and less prevalent coronary artery disease (38 vs. 52%, P < 0.0001). Aortic valve weight was lower in women (1.94 ± 0.88 vs. 3.08 ± 1.32 g, P < 0.0001) even when indexed to body surface area (1.09 ± 0.48 vs. 1.48 ± 0.62 g/m(2), P < 0.0001) or left ventricular outflow tract (LVOT) area (0.54 ± 0.23 vs. 0.71 ± 0.29 g/cm(2), P < 0.0001). Using multivariate analysis, male sex (P < 0.0001), bicuspid valve (P < 0.0001), and larger LVOT area (P < 0.0001) were the major determinants of increased AVW, along with current cigarette smoking (P = 0.007). Diabetes (P = 0.004) and hypertension (P = 0.03) were independently associated with lower AVW. Aortic valve calcium correlated well with AVW (r = 0.81, P < 0.0001) and was lower in women than in men (2520 ± 1199 vs. 3606 ± 1632 arbitrary units, P < 0.0001). CONCLUSIONS: Despite the same degree of AS severity, women have less AVC and lower AVW compared with men, irrespective of valve morphology. Aortic valve calcium is correlated to excised AVW. Hypertension, diabetes, and current cigarette smoking were independently associated with AVW.

The Learning Curve for Transcatheter Mitral Valve Repair With MitraClip.

OBJECTIVES: This study sought to assess the learning curve for TMVR for treatment of primary mitral regurgitation (MR). BACKGROUND: Data are lacking regarding the technical experience required to achieve optimal clinical outcomes with transcatheter mitral valve repair (TMVR) using the edge-to-edge MitraClip technique. METHODS: We examined the sequential experience of the first 75 patients (age 80 ± 9 years; 77% male) who underwent TMVR at our institution. A sequence number of each patient was assigned as a continuous variable and in tertiles for analysis. RESULTS: TMVR with MitraClip was successful in 97% with an average procedural time of 106 ± 39 minutes. The 30-day rate of major adverse cardiovascular events was 7%. With increased case experience, there were decreases in procedural time, fluoroscopy time, length of hospital stay, and major adverse cardiovascular events. Procedural success, residual mitral regurgitation and NYHA functional classification at 30-day follow-up remained unchanged throughout the experience. CONCLUSIONS: The learning curve for TMVR with MitraClip for treatment of primary MR is characterized by a sequential reduction in procedure time, fluoroscopy time, procedural complications, and hospital length of stay at a tertiary academic medical center. Thirty-day procedural results are favorable and similar during the initial learning period.

Acute LVOT Obstruction with a Carbomedics Mechanical Valve Prosthesis.

A 62-year-old female with severe symptomatic rheumatic mitral stenosis was referred for mitral valve replacement. A 27-mm Carbomedics mechanical mitral valve was placed using everting sutures. As the patient was weaned off cardiopulmonary bypass, she became hemodynamically unstable. Intraoperative transesophageal echocardiogram revealed a significant drop in left ventricular function along with severe LVOT obstruction. The Carbomedics prosthesis was replaced by a 27-mm St. Jude mechanical valve using noneverting sutures which relieved the LVOT obstruction. doi: 10.1111/jocs.12749 (J Card Surg 2016;31:376-379).

Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction: clinical characteristics and predictors of survival.

BACKGROUND: Among patients with severe aortic stenosis (AS) and preserved ejection fraction, those with low gradient (LG) and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. METHODS AND RESULTS: We examined 1704 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and preserved ejection fraction (≥50%) using 2-dimensional and Doppler echocardiography. Patients were stratified by stroke volume index (<35 mL/m(2) [low flow, LF] versus ≥35 mL/m(2) [normal flow, NF]) and aortic gradient (<40 mm Hg [LG] versus ≥40 mm Hg [high gradient, HG]) into 4 groups: NF/HG, NF/LG, LF/HG, and LF/LG. NF/LG (n=352, 21%), was associated with favorable survival with medical management (2-year estimate, 82% versus 67% in NF/HG; P<0.0001). LF/LG severe AS (n=53, 3%) was characterized by lower ejection fraction, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2-year estimate, 60% versus 82% in NF/HG; P<0.001). In multivariable analysis, the LF/LG pattern was the strongest predictor of mortality (hazard ratio, 3.26; 95% confidence interval, 1.71-6.22; P<0.001 versus NF/LG). Aortic valve replacement was associated with a 69% mortality reduction (hazard ratio, 0.31; 95% confidence interval, 0.25-0.39; P<0.0001) in LF/LG and NF/HG, with no survival benefit associated with aortic valve replacement in NF/LG and LF/HG. CONCLUSIONS: NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management, and the impact of aortic valve replacement on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity.

Incremental value of 3-D transesophageal echocardiographic imaging of the mitral valve.

Transesophageal echocardiography provides excellent visualization of the posteriorly located mitral valve. Over the last decade, 3-dimensional transesophageal echocardiography (3D TEE) has emerged as an exciting imaging modality, particularly of the mitral valve. The current generation matrix array technology allows the operator to perform 2D and 3D imaging with a single transducer. 3D TEE affords the unique ability to view the mitral valve and its surrounding structures "en face" in real time (RT), and provide contextual anatomical guidance during surgical and transcatheter interventions. Additionally, offline quantification has made significant contributions to our mechanistic understanding of the normal and diseased mitral valve, and alterations induced by therapeutic intervention such as surgical repair. This review will address recent advances in the incremental role of 3D TEE in mitral valve imaging.

3D echocardiography in cardiac surgery.

Herein, we present a patient who underwent successful repair of failed mitral valve repair in whom intraoperative 3D transesophageal echocardiography provided accurate assessment of the mechanism of mitral regurgitation. In addition, we review the potential advantages and limitations of 3D echocardiography and its role in cardiac surgery.

Risk for Increased Mean Diastolic Gradient after Transcatheter Edge-to-Edge Mitral Valve Repair: A Quantitative Three-Dimensional Transesophageal Echocardiographic Analysis.

BACKGROUND: Iatrogenic mitral stenosis is a known limitation of transcatheter edge-to-edge mitral valve repair (TMVr), but determinants of increased postprocedural mean diastolic gradient (MG) are not well defined. The aim of this study was to determine correlates of increased post-TMVr MG or aborted clip implantation due to increased MG. METHODS: Procedural three-dimensional transesophageal echocardiographic (TEE) data sets of 112 patients who underwent TMVr were retrospectively analyzed. Three-dimensional TEE mitral valve area (MVA) planimetry and mitral annular calcification (MAC) were quantified using multiplanar reconstruction. When MAC extension into the mitral leaflets was present, MAC with leaflet calcification (MAC-LC) length was recorded as the maximum distance from the mitral annulus to the most distal leaflet calcification. Increased MG after TMVr, measured on intraprocedural TEE imaging, was defined as ≥5 mm Hg or aborted clip implantation due to increased MG. RESULTS: Baseline MVA was 5.9 ± 1.7 cm2, baseline MG was 2.1 ± 1.2 mm Hg, and MAC-LC length was 4.0 ± 4.5 mm. Thirty-two patients (29%) had increased post-TMVr MG. Risk for increased post-TMVr MG was 86%, 28%, and 14% in patients with baseline MVA < 4.0, 4.0 to 6.0, and >6.0 cm2, respectively (P < .001). In patients with baseline MVA 4.0 to 6.0 cm2, concurrent baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm was associated with higher risk for increased post-TMVr MG (53% vs 12%, P = .002). In patients with baseline MVA < 4.0 and >6.0 cm2, the risk for increased post-TMVr MG was similar in the presence or absence of baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm (P > .05 for both). CONCLUSIONS: Patients with baseline three-dimensional TEE MVA < 4.0 cm2 are at high risk for increased post-TMVr MG. Additionally, patients with borderline MVA (4.0-6.0 cm2) and concurrent MAC-LC length ≥ 6 mm or baseline MG ≥ 4 mm Hg are at moderate risk for increased MG after TMVr.

Does left atrial size predict mortality in asymptomatic patients with severe aortic stenosis?

BACKGROUND: We assessed the hypothesis that diastolic function represented by left atrial size determines the rate of development of symptoms and the risk of all-cause mortality in asymptomatic patients with severe aortic stenosis (AS). METHODS: From a database of 622 asymptomatic patients with isolated severe AS (velocity by Doppler >or= 4 m/sec) followed for 5.4 +/- 4 years, we reviewed the echocardiograms and evaluated Doppler echocardiographic indices of diastolic function. Prediction of symptom development and mortality by left atrial diameter with and without adjusting for clinical and echocardiographic parameters was performed using Cox proportional-hazards regression analysis. RESULTS: The age was 71 +/- 11 years and 317 (62%) patients were males. The aortic valve mean gradient was 46 +/- 11 mmHg, and the Doppler-derived aortic valve area was 0.9 +/- 0.2 cm(2). During follow-up, symptoms developed in 233 (45%), valve surgery was performed in 290 (57%) and 138 (27%) died. Left atrial enlargement was significantly correlated with symptom development (P < 0.05) but the association diminished after adjusting for aortic valve area and peak velocity (P = 0.2). However, atrial diameter predicted death independent of age and gender (P = 0.007), comorbid conditions (P = 0.03), and AS severity and Doppler parameters of diastolic function (P = 0.002). CONCLUSION: Diastolic function, represented as left atrial diameter, is related to mortality in asymptomatic patients with severe AS.

Adult Intraoperative Echocardiography: A Comprehensive Review of Current Practice.

Intraoperative transesophageal echocardiography is a mature imaging modality and critical component of contemporary heart surgery, in which it plays a key role in surgical planning, determination of cardiac chamber filling and function early after cardiopulmonary bypass, and timely assessment of surgical interventions. Intraoperative transesophageal echocardiography affords the unique opportunity to correct suboptimal surgical results before leaving the operating room. Herein, the authors provide a comprehensive review of their institution's experience with intraoperative transesophageal echocardiography, emphasizing a practical assessment of commonly encountered noncongenital surgical heart lesions in adults, anticipation of potential surgical complications, and imaging approaches to facilitate timely surgical correction of unsatisfactory results.

Quantitative Three-Dimensional Echocardiographic Correlates of Optimal Mitral Regurgitation Reduction during Transcatheter Mitral Valve Repair.

BACKGROUND: Patient selection for transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging because of heterogenous mitral valve pathology and highly variable anatomy. The aim of this study was to investigate whether quantitative three-dimensional (3D) transesophageal echocardiographic modeling parameters are associated with optimal mitral regurgitation (MR) reduction in patients undergoing TMVR. METHODS: Fifty-nine patients underwent 3D transesophageal echocardiography during TMVR. Volumetric data sets were retrospectively analyzed using mitral valve quantitative 3D modeling software (Mitral Valve Navigator). Optimal MR reduction was defined as less than moderate residual MR. Logistic regression was used to correlate 3D transesophageal echocardiographic quantitative data to procedural success. RESULTS: Thirty-five patients had primary MR, 24 had mixed or secondary MR, and all patients had grade ≥ 3/4 MR before the procedure. Optimal MR reduction was achieved in 40 of 59 patients (68%). Univariate correlates of optimal MR reduction in patients with primary MR were lower mitral leaflet tenting volume (P = .049) and lower tenting height (P = .025); tenting height < 3 mm and tenting volume < 0.7 mL were associated with increased likelihood of optimal MR reduction (92% vs 48% [P = .01] and 81% vs 47% [P = .03], respectively). In mixed or secondary MR, annular height ≥ 5.5 mm was associated with increased likelihood of optimal MR reduction (94% vs 38%; P = .03). During follow-up, redo TMVR or surgical mitral valve replacement occurred exclusively in patients with suboptimal anatomy defined by 3D transesophageal echocardiography (10% vs 0%, P = .045). CONCLUSIONS: Quantitative 3D echocardiographic data are associated with favorable response to TMVR and could help optimize patient selection.

Comparison of anticoagulant and anti-inflammatory responses using enoxaparin versus unfractionated heparin for transesophageal echocardiography-guided cardioversion of atrial fibrillation.

The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) II study compared enoxaparin with unfractionated heparin (UFH) as bridging therapy in patients with atrial fibrillation >2 days in duration who underwent transesophageal echocardiography-guided cardioversion. In the present study, the anticoagulant and anti-inflammatory effects of enoxaparin and UFH were compared at prespecified time points. In a randomized substudy of 155 patients from 17 clinical sites, the anticoagulant activity of enoxaparin (n = 76) was compared with that of UFH (n = 79). Blood samples were drawn at enrollment, on day 2, and on day 4 in the 2 groups. Blood samples were evaluated for anticoagulant activity by measuring the activated partial thromboplastin time, anti-Xa, anti-IIa, and tissue factor pathway inhibitor levels. In addition, levels of coagulation activation (by thrombin antithrombin complex) and inflammation (by highly sensitive C-reactive protein) were measured. The results of this substudy showed that the anti-Xa levels in the 2 groups increased on day 2. Similar increases in anti-Xa were observed on day 4. The anti-Xa levels and tissue factor pathway inhibitor levels were higher in the enoxaparin group compared with the UFH group on days 2 and 4. However, as expected, the anti-IIa levels in the UFH group were higher. In addition, markers of coagulation activation and inflammation were increased in patients with atrial fibrillation. Treatment with enoxaparin significantly decreased thrombin antithrombin complex levels compared with treatment with UFH. Highly sensitive C-reactive protein levels were also decreased after treatment in the 2 groups. In conclusion, the ACUTE II study showed that the use of enoxaparin for bridging therapy in patients with atrial fibrillation who underwent transesophageal echocardiography-guided cardioversion resulted in a more predictable and stronger anticoagulant response than that observed with UFH. Markers of inflammation were also decreased in the 2 groups.

Mitral Valve Anatomic Predictors of Hemodynamic Success With Transcatheter Mitral Valve Repair.

BACKGROUND: Mitral regurgitation is a heterogeneous disease. Determining which patients derive optimal outcomes from transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging. We sought to determine whether baseline mitral valve anatomic characteristics are predictive of left atrial pressure (LAP) changes during TMVR with MitraClip. METHODS AND RESULTS: Consecutive patients with severe mitral regurgitation undergoing TMVR (n=112) underwent continuous intraprocedural LAP monitoring and retrospective echocardiographic analysis for specific mitral anatomic characteristics. Procedural success (optimal LAP reduction) was defined as ≥40% reduction in left atrial V-wave pressure compared with baseline. Echocardiographic predictors of optimal LAP reduction and increased postprocedure mean diastolic gradient were evaluated. Mean age was 79±14 years, and 36 patients (32%) were women. Primary, mixed, and secondary mitral regurgitation were present in 78 patients (70%), 22 patients (20%), and 12 patients (10%), respectively. Baseline mean LAP and V-wave were 22±6 and 38±13 mm Hg; after TMVR, these decreased to 19±5 and 27±10 mm Hg, respectively (P<0.0001 for both). Independent predictors of optimal LAP reduction were the presence of a flail scallop, mitral regurgitation localized to a single scallop, and high-quality 3-dimensional echocardiographic imaging. Independent predictors of elevated postprocedure mean diastolic gradient were elevated preprocedure mean diastolic gradient, mitral annular calcification, and implantation of multiple clips. CONCLUSIONS: Mitral valve pathoanatomic features, including a flail leaflet and single jet, are predictive of optimal LAP reduction with TMVR. High-quality 3-dimensional imaging may help select patients with the highest likelihood of optimal hemodynamic results with TMVR. These data expand current knowledge about patient selection for TMVR and deserve further study in larger cohorts.

Comparative study of bicuspid vs. tricuspid aortic valve stenosis.

Aims: To examine differences and similarities in bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) stenosis occurring during the same age and whether any differences impact outcomes following aortic valve replacement (AVR). Methods and results: An age-matched cohort of 198 BAV stenosis and 198 TAV stenosis patients was identified from 888 consecutive patients undergoing AVR for severe AS. Mean age 68 ± 6 years; 68% male. Patients with BAV were less likely to have multiple comorbidities, as measured by the Charlson Comorbidity Index (CCI) >2 (3 vs. 10%, P = 0.007). Indexed aortic valve area (0.44 ± 0.09 vs. 0.42 ± 0.08 cm2/m2, P = 0.17) and left ventricular ejection fraction (LVEF) were similar (62 ± 11 vs. 61 ± 12%, P = 0.12), but E/e' ≥15 (46 vs. 66%, P = 0.0002) was less common in BAV stenosis. A tissue aortic valve prosthesis was more commonly utilized in both groups (81 vs. 78%, P = 0.54). Overall indexed effective orifice area was larger in BAV compared with TAV (1.08 ± 0.33 vs. 0.96 ± 0.25 cm2/m2, P = 0.0008). Five-year survival following AVR was lower in TAV compared with BAV stenosis (61 vs. 79%, P = 0.02). Independent predictors of survival following AVR were LVEF < 50% [hazard ratio (HR): 4.8, P = 0.0005], CCI > 2 (HR: 3.1, P = 0.015), effective orifice area index ≤0.85 cm2/m2 (HR: 2.5, P = 0.004), and bioprosthesis (HR: 3.7, P = 0.02). Conclusion: In an age-matched cohort, TAV compared with BAV stenosis is associated with greater prevalence of cardiovascular risk factors and cardiac impairment and worse survival after AVR.

Impact of prosthesis-patient mismatch on long-term survival in patients with small St Jude Medical mechanical prostheses in the aortic position.

BACKGROUND: The impact of aortic prosthesis-patient mismatch (P-PtM) on long-term survival is unclear. METHODS AND RESULTS: Between 1985 and 2000, 388 patients at Mayo Clinic in Rochester, Minn, underwent aortic valve replacement (AVR) with 19- or 21-mm St Jude Medical prostheses and had transthoracic echocardiography within 1 year after AVR. Mean age of patients was 62+/-13 years; 69% were female. Prosthesis effective orifice area (EOA) was derived from the continuity equation. P-PtM was classified as severe (indexed EOA < or =0.60 cm2/m2), moderate (0.60 cm2/m20.85 cm2/m2). P-PtM was severe in 66 patients (17%), moderate in 168 (43%), and not hemodynamically significant in 154 (40%). Patients with severe P-PtM had a significantly larger body surface area (P<0.0001), higher mean gradient (P<0.0001), lower preoperative (P<0.0001) and postoperative (P<0.0001) ejection fractions, and lower stroke volume (P<0.0001) and more often received a 19-mm prosthesis (P=0.0008) than patients with moderate or no hemodynamically significant mismatch. For patients with severe mismatch, 5-year survival rates (72+/-6%) and 8-year survival rates (41+/-8%) were significantly less than for patients with moderate mismatch (80+/-3% and 65+/-5%; P=0.026) or no hemodynamically significant mismatch (85+/-3% and 74+/-5%; P=0.002). On multivariate analysis after adjustment for other predictors of outcome, severe mismatch was associated with higher mortality (hazard ratio 2.18; 95% confidence interval 1.24 to 3.85; P=0.007) and higher incidence of congestive heart failure (hazard ratio 3.1; 95% confidence interval 1.3 to 7.4; P=0.009) than no hemodynamically significant mismatch. CONCLUSIONS: Severe P-PtM is an independent predictor of higher long-term mortality and congestive heart failure in patients with small St Jude Medical aortic valve prostheses. For patients undergoing AVR who are at risk of severe mismatch, every effort should be made to use a larger prosthesis or to consider a prosthesis with a larger EOA.

3D transesophageal echocardiography: A new imaging tool for assessment of mitral regurgitation and for guiding percutaneous edge-to-edge mitral valve repair.

Real time three dimensional transesophageal echocardiography (3D TEE) is probably the most powerful and convincing imaging method for understanding the complicated multiform morphology and for evaluating geometry, dynamics and function of degenerative and functional mitral valve (MV) regurgitation. Moreover, color Doppler 3D TEE has been valuable to identify the location of the regurgitant orifice and the severity of the mitral regurgitation. 3D TEE has been shown to be of enormous value in helping surgeons to perform MV repair. In addition, due to its ability to show a "panoramic" view of the "theater" where the procedure takes place, it has become an indispensable companion of 2D TEE during percutaneous edge-to-edge repair. A novel hybrid imaging modality where echocardiography is merged with fluoroscopy, may in the future further improve guidance of this and other complex percutaneous transcatheter interventions.

Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up.

BACKGROUND: This study assessed the long-term outcome of a large, asymptomatic population with hemodynamically significant aortic stenosis (AS). METHODS AND RESULTS: We identified 622 patients with isolated, asymptomatic AS and peak systolic velocity > or =4 m/s by Doppler echocardiography who did not undergo surgery at the initial evaluation and obtained follow-up (5.4+/-4.0 years) in all. Mean age (+/-SD) was 72+/-11 years; there were 384 (62%) men. The probability of remaining free of cardiac symptoms while unoperated was 82%, 67%, and 33% at 1, 2, and 5 years, respectively. Aortic valve area and left ventricular hypertrophy predicted symptom development. During follow-up, 352 (57%) patients were referred for aortic valve surgery and 265 (43%) patients died, including cardiac death in 117 (19%). The 1-, 2-, and 5-year probabilities of remaining free of surgery or cardiac death were 80%, 63%, and 25%, respectively. Multivariate predictors of all-cause mortality were age (hazard ratio [HR], 1.05; P<0.0001), chronic renal failure (HR, 2.41; P=0.004), inactivity (HR, 2.00; P=0.001), and aortic valve velocity (HR, 1.46; P=0.03). Sudden death without preceding symptoms occurred in 11 (4.1%) of 270 unoperated patients. Patients with peak velocity > or =4.5 m/s had a higher likelihood of developing symptoms (relative risk, 1.34) or having surgery or cardiac death (relative risk, 1.48). CONCLUSIONS: Most patients with asymptomatic, hemodynamically significant AS will develop symptoms within 5 years. Sudden death occurs in approximately 1%/y. Age, chronic renal failure, inactivity, and aortic valve velocity are independently predictive of all-cause mortality.

The effect of patient sex on recurrence of atrial fibrillation following successful direct current cardioversion.

BACKGROUND: The effect of patient sex on recurrence of atrial fibrillation after a successful direct current cardioversion is unknown. METHODS: This prospective study included 773 patients (486 [63%] men and 287 [37%] women) undergoing successful direct current cardioversion of atrial fibrillation between May 2000 and July 2003. Patient characteristics at presentation were recorded. The primary end point was the time between cardioversion and the first documented recurrence of arrhythmia. RESULTS: At presentation, women were older and had a higher prevalence of hypertension and valvular disease compared with men. In addition, women had worse mechanical left atrial appendage function. Arrhythmia recurrence was more prevalent in women (50.0% at 1 year compared with 43.4% in men, and 75.8% at 2 years compared with 67.0% in men; P = .03). On the basis of multivariate analysis, patient sex was a significant predictor of arrhythmia recurrence. There was no significant difference in overall mortality between men and women. CONCLUSIONS: Women were more likely than men to have recurrence of atrial fibrillation after successful direct current cardioversion. Patient sex should be taken into account with other clinical factors when making the decision about cardioversion for atrial fibrillation.