Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association.

The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.

The burden of rheumatic heart disease among children in Lagos: how are we fairing?

INTRODUCTION: Rheumatic heart disease still remains a cause of morbidity and mortality in low and middle income countries, despite its eradication in developed societies. The study aimed to document the features of children with rheumatic heart disease using clinical evaluation and echocardiography and compare it with reports from other part of the country. METHODS: A review of a prospectively collected data of patients with rheumatic heart disease who had echocardiography done from April 2007-Dec 2016. Information obtained from patients include age, sex, clinical indication for echocardiography, echocardiographic characterization of the valvular lesions and associated complications. RESULTS: A total of 324,676 patients were seen at the Paediatric unit of LASUTH from 2007 to 2016, out of which 36 had Rheumatic heart disease. This translates to a prevalence of 1.1 per 10,000 patients who presented at the study site during the study period. The prevalence of RHD amongst all the patients with structural heart disease was 2.6%. The mean age of patients was 9.12 ± 2.75 years with a male to female ratio of 1.6: 1. The most common valve affected was mitral valve. Heart failure was the most common mode of presentation found in 91.6%. Other complications were pulmonary hypertension and pericardial effusion. CONCLUSION: Rheumatic heart disease is still prevalent among children in Lagos although the prevalence is reducing. Heartfailure is the commonest mode of presentation and complication in them.

Assessment of myocardial fibrosis by late gadolinium enhancement imaging and biomarkers of collagen metabolism in chronic rheumatic mitral regurgitation.

BACKGROUND: In chronic rheumatic mitral regurgitation (CRMR), involvement of the myocardium in the rheumatic process has been controversial. Therefore, we sought to study the presence of fibrosis using late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) and biomarkers of collagen turnover in CRMR. METHODS: Twenty-two patients with CRMR underwent CMR and echocardiography. Serum concentrations of matrix metalloproteinase- 1 (MMP-1), tissue inhibitor of MMP-1 (TIMP- 1), MMP-1-to-TIMP-1 ratio, procollagen III N-terminal pro-peptide (PIIINP) and procollagen type IC peptide (PIP) were measured. RESULTS: Four patients had fibrosis on LGE-CMR. PICP and PIIINP concentrations were similar to those of the controls, however MMP-1 concentration was increased compared to that of the controls (log MMP-1 3.5 ± 0.7 vs 2.7 ± 0.9, p = 0.02). There was increased MMP-1 activity as the MMP-1-to- TIMP-1 ratio was higher in CRMR patients compared to the controls ( -1.2 ± 0.6 vs -2.1 ± 0.89, p = 0.002). CONCLUSIONS: Myocardial fibrosis was rare in CRMR patients. CRMR is likely a disease characterised by the predominance of collagen degradation rather than increased synthesis and myocardial fibrosis.

Assessment of trans-aortic pressure gradient using a coronary pressure wire in patients with mechanical aortic and mitral valve prostheses.

Accurate evaluation of trans-aortic valvular pressure gradients is challenging in cases where dual mechanical aortic and mitral valve prostheses are present. Non-invasive Doppler echocardiographic imaging has its limitations due to multiple geometric assumptions. Invasive measurement of trans-valvular gradients with cardiac catheterization can provide further information in patients with two mechanical valves, where simultaneous pressure measurements in the left ventricle and ascending aorta must be obtained. Obtaining access to the left ventricle via the mitral valve after a trans-septal puncture is not feasible in the case of a concomitant mechanical mitral valve, whereas left ventricular apical puncture technique is associated with high procedural risks. Retrograde crossing of a bileaflet mechanical aortic prosthesis with standard catheters is associated with the risk of catheter entrapment and acute valvular regurgitation. In these cases, the assessment of trans-valvular gradients using a 0.014˝ diameter coronary pressure wire technique has been described in a few case reports. We present the case of a 76-year-old female with rheumatic valvular heart disease who underwent mechanical aortic and mitral valve replacement in the past. She presented with decompensated heart failure and echocardiographic findings suggestive of elevated pressure gradient across the mechanical aortic valve prosthesis. The use of a high-fidelity 0.014˝ diameter coronary pressure guidewire resulted in the detection of a normal trans-valvular pressure gradient across the mechanical aortic valve. This avoided a high-risk third redo valve surgery in our patient. © 2017 Wiley Periodicals, Inc.

Proximal flow convergence method by three-dimensional color Doppler echocardiography for mitral valve area assessment in rheumatic mitral stenosis.

BACKGROUND: The two-dimensional (2D) proximal isovelocity surface area (PISA) method has important technical limitations for mitral valve orifice area (MVA) assessment in mitral stenosis (MS), mainly the geometric assumptions of PISA shape and the requirement of an angle correction factor. Single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions or the requirement of an angle correction factor. The aim of this study was to validate this method in patients with rheumatic MS. METHODS: Sixty-three consecutive patients with rheumatic MS were included. MVA was assessed using the transthoracic 2D and 3D PISA methods. Planimetry of MVA (2D and 3D) and the pressure half-time method were used as reference methods. RESULTS: The 3D PISA method had better correlations with the reference methods (with 2D planimetry, r = 0.85, P < .001; with 3D planimetry, r = 0.89, P < .001; and with pressure half-time, r = 0.85, P < .001) than the conventional 2D PISA method (with 2D planimetry, r = 0.63, P < .001; with 3D planimetry, r = 0.66, P < .001; and with pressure half-time, r = 0.68, P < .001). In addition, a consistent significant underestimation of MVA using the conventional 2D PISA method was observed. A high percentage (30%) of patients with nonsevere MS by 3D planimetry were misclassified by the 2D PISA method as having severe MS (effective regurgitant orifice area < 1 cm(2)). In contrast, the 3D PISA method had 94% agreement with 3D planimetry. Good intra- and interobserver agreement for 3D PISA measurements were observed, with intraclass correlation coefficients of 0.95 and 0.90, respectively. CONCLUSIONS: MVA assessment using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Three-dimensional echocardiographic assessment before and after percutaneous transvenous mitral commissurotomy in patients with rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Real-time three-dimensional transthoracic echocardiography (RT3DE) is a relatively recent imaging technique that provides excellent image quality of the mitral valve. It has been suggested that this new echocardiographic modality, which allows a precise cross-section of the mitral orifice at the tips of the leaflets with correct plane orientation, may provide a more accurate assessment of rheumatic mitral stenosis (MS) than two-dimensional echocardiography (2DE), before and after percutaneous transvenous mitral commissurotomy (PTMC). METHODS: A total of 50 patients with symptomatic mitral stenosis who underwent PTMC was evaluated prospectively. Patients in all age groups, with evidence of severe MS admitted to the authors' institution, in whom PTMC was feasible were included. RESULTS: A good valve opening was observed in 45 patients (90%). The mitral valve area (MVA) assessed before PTMC with 3DE (3D-MVA) correlated well with that assessed with 2DE (2D-MVA) (0.85 +/- 0.12 cm2 versus 0.86 +/- 0.13 cm2, p < 0.001); the mean difference between methods was small (0.01 +/- 0.11 cm2) and correlation excellent (r = 0.64, p < 0.001). After PTMC, values of 3D-MVA did not differ from, and correlated well with, values of 2D-MVA (1.79 +/- 0.20 cm2 versus 1.74 +/- 0.18 cm2, p = 0.006); the mean difference between methods was small (0.05 +/- 0.02 cm2) and correlation excellent (r = 0.76, p = 0.0001). Before PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.01 +/- 0.11 cm2, lower limit -0.24, upper limit 0.22). After PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.05 +/- 0.13 cm2, lower limit -0.3, upper limit 0.2). Evaluation of the commissural opening after PTMC, using RT3DE, showed that excellent commissural evaluation was possible in all patients. Compared with RT3DE, an underestimation of the degree of commissural fusion using 2DE was observed in 32%, with a weak agreement between methods. CONCLUSION: RT3DE provided accurate measurements of MVA, similar to 2D planimetry. RT3DE also improved the description of valvular anatomy and provided a unique assessment of the extent of commissural splitting.

Quantitative assessment of the left atrial myocardial deformation in patients with chronic mitral regurgitation by strain and strain rate imaging: an observational study.

OBJECTIVE: We evaluated regional left atrial (LA) myocardial deformations by strain (S) and strain rate (SR) imaging during LA pump, reservoir, and conduit phases in patients with chronic rheumatic mitral regurgitation (MR). METHODS: This cross-sectional observational study included 42 patients with moderate-to-severe MR who had normal left ventricular (LV) function, and 36 healthy control subjects. Conventional echocardiographic data were used to calculate LV and LA dimensions, volumes and functional indices (LA ejection fraction, LA active and passive emptying fraction). Longitudinal S/SR indices of the mid and superior segments of LA walls were measured during the three LA phases. Student t-test, Mann-Whitney U test, Chi-square test and Bland-Altman analysis were used for statistical analysis. RESULTS: LV systolic functions were similar in the patient and control groups. LV diameters, LA diameters and LA volumes were greater in the patient group compared with the control group (p<0.05, p<0.001, and p<0.001). LA ejection fraction and LA active emptying fraction values were lower in the patient group than in the control group (56 ± 7 vs. 63 ± 5%, 33 ± 9 vs. 40 ± 4%, p<0.05 for both). During the three LA phases, longitudinal S/SR values were significantly lower in all the segments in the patient group compared with the control group (p<0.001 for S, p<0.001 and p<0.05 for SR). CONCLUSION: Regional LA longitudinal myocardial deformations are observed to be impaired during all the mechanical phases in patients with moderate-to-severe MR. Volume overload, remodeling and rheumatic effects may be responsible for the LA myocardial dysfunction in these patients.

Assessment of right ventricular function for patients with rheumatic mitral stenosis by 64-slice multi-detector row computed tomography: comparison with magnetic resonance imaging.

BACKGROUND: Right ventricular (RV) dysfunction ensues due to rheumatic mitral stenosis (RMS). The evaluation of RV function is clinically important for the diagnosis, treatment, and follow-up for patients with different degrees of RMS. The purpose of this study was to determine whether the 64-slice multi-detector row computed tomography (64-slice MDCT) can assess the RV function in RMS with high accuracy and reproducibility when compared to MR imaging (MRI). METHODS: Right ventricular end-diastolic and end-systolic volumes (RV-EDV and RV-ESV), stroke volume (RV-SV), ejection fraction (RV-EF), cardiac output (RV-CO), and wall mass (RV-Mass) were measured with dedicated cardiac analysis software on 64-slice MDCT and compared with values measured with MRI in 43 consecutive patients with RMS. Agreement between MRI and 64-MDCT results were compared with Bland and Altman analysis and linear regression analysis. Repeated measurements were performed to determine intraobserver and interobserver variability. RESULTS: No significant differences were revealed in calculated RV function parameters between the two methods. RV-EDV, RV-ESV, RV-SV, RV-EF, RV-CO, and RV-Mass by 64-slice MDCT were similar to those by MRI (P > 0.05). There were good correlations (r = 0.98, 0.97, 0.96, 0.96, 0.95 and 0.77, respectively) and close agreement (bias = -0.2 ml, -1.0 ml, 0.8 ml, 0.5%, 26.1 ml, and 0.5 g, respectively, P > 0.05). The variability in 64-slice MDCT measurements was similar to that in MRI values. CONCLUSION: ECG-gated 64-slice MDCT could assess the RV function in RMS with high accuracy and reproducibility when compared to MRI.

Dynamic assessment of 'valvular reserve capacity' in patients with rheumatic mitral stenosis.

AIMS: Mitral stenosis (MS) may exhibit a dynamic valvular reserve. When resting gradients and systolic pulmonary pressure (sPAP) do not reflect the real severity of the disease, a dynamic evaluation becomes necessary. The aim of the study was to assess the clinical utility of exercise echocardiography in symptomatic patients with apparently subcritical MS. METHODS AND RESULTS: One hundred and thirty consecutive patients were referred for symptomatic MS. Patients with unimpressive resting MVA (>1-1.5 cm(2)) and mean PG (≥5-9 mmHg) underwent exercise echocardiography. Cardiac performance and mitral indices (MVA, peak/mean PG, sPAP) were measured. Exhaustion of valvular reserve capacity under exercise was defined as appearance of symptoms and sPAP > 60 mmHg. Forty-six patients (35%) (age: 53 ± 10 years; 74%, female) with resting MVA (1.2 ± 0.36 cm(2)), mean PG (6.8 ± 2.7 mmHg), and sPAP (38 ± 7 mmHg) inconsistent with symptoms underwent stress echocardiography. Exercise was stopped for dyspnoea (76%) or fatigue (24%). At peak workloads (57.2 ± 21.8 Watts), increased mean PG (17.2 ± 4.8 mmHg, P< 0.001) and sPAP (67.4 ± 11.4 mmHg; P< 0.0001) were observed, without change in MVA (1.25 ± 0.4 cm(2); P= n.s.). At univariate analysis, predictors of adaptation to exercise were age (-0.345; P = 0.024), mean PG (0.339; P= 0.023), and sPAP (0.354; P= 0.024); at multivariate analysis, best predictor was resting mean PG, although correlation was poor (-0.339; P= 0.015). CONCLUSION: In MS with limiting symptoms despite unimpressive findings at rest, valvular capacity exhaustion should be tested on a dynamic background, as no single resting index can predict potential haemodynamic adaptation to exercise. In such context, the contribution of exercise echocardiography remains extremely valuable.

Echocardiographic assessment of the effects of mitral valve repair on mitral valve geometry in rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: While mitral valve replacement is generally considered as the standard surgical treatment for rheumatic mitral stenosis (MS), mitral valve repair may be an alternative therapeutic option. Several techniques have been used to overcome the anatomic difficulties involved in the repair of a rheumatic mitral valve. In the present study, quantitative echocardiography was used to investigate the effects of mitral valve repair and the influence of surgical procedures on mitral valve geometry in patients with rheumatic MS. METHODS: Mitral valve repair was successfully performed in seven patients with MS, by the same surgeon. Ring annuloplasty and slicing of the anterior mitral leaflet (AML) were performed in all patients. Concomitant surgical techniques included commissurotomy, decalcification, chordal resection, and division of the papillary muscles. The preoperative and postoperative echocardiographic findings in these patients were compared. RESULTS: The thickness of both the AML and posterior mitral leaflet (PML) (p = 0.01 for both), the opening angles of the AML (p = 0.02) and PML (p = 0.01), and the closing angle of the PML, the extent of calcification in the AML, and the pressure half-time (PHT) (p = 0.03 for all three parameters) were all significantly improved after mitral valve repair. CONCLUSION: In the present study, the transmitral peak velocity and mean pressure gradient were not significantly changed after mitral valve repair, whereas the PHT showed a marked improvement. Hence, the PHT may represent a suitable marker for evaluating the efficacy of mitral valve repair for MS.

[Comparative assessment of inotropic reaction of isolated myocardium of patients with ischemic and rheumatic heart disease after short-term periods of rest at the background of amiodarone].

We studied inotropic reaction of isolated myocardium of patients with heart failure induced by ischemic and rheumatic cardiac involvement after periods of rest at the background of amiodarone. The studies were carried out on muscular trabeculi separated from right atrial auricle during surgery. It was shown that inotropic reaction of insufficient myocardium could be of 2 types. In type I inotropic reaction first contraction after period of rest either exceeded basal contractions or remained at their level. Type 2 was characterized by significant lowering of amplitude of contractions relative to regular ones. Exposure of the myocardium to amiodarone (1 micro/L) led to significant potentiation of trabeculi contraction after periods of rest of muscles with type I reaction and did not affect response of muscles with type II reaction. These results allow to conclude that the state of calcium transporting systems of sarcoplasmic reticulum (SR) is different in ischemic and rheumatic heart failure and that realization of therapeutic effect of amiodarone depends on functional state of SR.

Serial radionuclide angiographic assessment of left ventricular ejection fraction and regional wall motion after mitral valve replacement in patients with rheumatic disease.

BACKGROUND: This study was designed to prospectively investigate the effects of total or partial chordal-sparing and chordal-nonsparing mitral valve replacement (MVR) procedures on regional and global ventricular function in a rheumatic population using sequential multiple-gated acquisition scan. METHODS: One hundred five consecutive patients undergoing different techniques of chordal preservation procedures during MVR are included in this prospective study. Fifteen patients had complete excision of the chordopapillary apparatus (group 1), 34 had total chordal preservation (group 2), and 56 had preservation of the posterior chordopapillary apparatus (group 3). Radionuclide-derived left ventricular ejection fraction (LVEF) and regional wall motion (RWM) studies on 99 survivors were performed preoperatively, at discharge, at 1 year, and at 2 years. RESULTS: At discharge, there was a decline in LVEF in all the 3 groups. Statistically significant improvement in ejection fraction occurred in the chordal preservation groups (2 and 3) (P < .05) as compared with the nonchordal group immediately and late postoperatively. Only the total chordal group (2) demonstrated complete recovery of LVEF by 2 years postoperatively. Significant and persistent RWM abnormalities were noted in both the nonchordal and posterior chordal groups. CONCLUSIONS: We conclude that complete retention of the chordopapillary apparatus during MVR provides superior results compared with nonchordal and partial chordal preservation in terms of preservation of LVEF and reduced incidence of abnormal postoperative RWM.

Assessment of cardiac function and rheumatic heart disease in children with adenotonsillar hypertrophy.

Our aim was to evaluate whether adenotonsillar hypertrophy (ATH) is associated with rheumatic heart disease (RHD) in children. Fifty-three patients with ATH and 50 healthy children as a control group were enrolled in the study. Medical history and clinical findings were investigated, and echocardiographies were done by researchers who were unaware of the diagnosis. The two groups were compared. Valvular findings suggesting RHD were encountered in four patients (7.5%) in the ATH group and in two children (4%) in the control group. This difference was not statistically significant (p = 0.098); however, we found physiological mitral regurgitation to be significantly more frequent in the ATH group than in the control group (p = 0.023). ATH did not increase the risk of valvulitis related to RHD regardless of adenoid size and frequency of the infection. To preclude the misdiagnosis of mitral regurgitation that results from RHD, diagnostic criteria for pathological mitral regurgitation should be carefully applied.

[Pneumocalorimetric assessment of functional state of the cardiorespiratory system in polyclinical practice].

Physical efficiency (PhE), maximal calorific capacity (MCC) and Pneumocalorimetric index which conditions the function of the respiratory apparatus can be described by the following equation: PhE = 59.9 . MCC + 33. An error of PhE calculated with the above mentioned technique doesn't exceed 12,5%. The use of pneumocalorimetric enables to assess the functional state of the cardiorespiratory system by determining PhE, labour-intensiveness of the method is 5.1 minutes per a test.

Clinical applicability for the assessment of the valvular mitral stenosis severity with Doppler echocardiography and the proximal isovelocity surface area (PISA) method.

Evaluation of the severity of valvular mitral stenosis and measurements of the effective rheumatic mitral valve area by noninvasive echocardiography has been well accepted. The area is measured by the two-dimensional planimetry (PLM) method and the Doppler pressure half-time (PHT) method. Recently, the proximal isovelocity surface area (PISA) by color Doppler technique has been used as a quantitative measurement for valvular heart disease. However, this method needs more validation. The aim of this study was therefore to investigate the clinical applicability of the PISA method in the measurements of effective mitral valve area in patients with rheumatic valvular heart disease. Forty-seven patients aged from 23 to 71 years, with a mean age of 53 +/- 13 (25 male and 22 female, 15 with sinus rhythm, mean heart rate of 83 +/- 14 beats per minute, with rheumatic valvular mitral stenosis without hemodynamically significant mitral regurgitation) were included in the study. Effective mitral valve area (MVA) derived by the PISA method was calculated as follows: 2 x Pi x (proximal aliasing color zone radius)2x aliasing velocity/peak velocity across mitral orifice. Effective mitral valve areas measured by three different methods (PLM, PHT, and PISA) were compared and correlated with those calculated by the "gold standard" invasive Gorlin's formula. The MVA derived from PHT, PLM, PISA and Gorlin's formula were 1.00 +/- 0.31cm2, 0.99 +/- 0.30 cm2, 0.95 +/- 0.30 cm2 and 0.91 +/- 0.29 cm2, respectively. The correlation coefficients (r value) between PHT, PLM, PISA, and Gorlin's formula, respectively, were 0.66 (P = 0.032, SEE = 0.64), 0.67 (P = 0.25, SEE = 0.72) and 0.80 (P = 0.002, SEE = 0.53). In conclusion, the PISA method is useful clinically in the measurement of effective mitral valve area in patients with rheumatic mitral valve stenosis. The technique is relatively simple, highly feasible and accurate when compared with the PHT, PLM, and Gorlin's formula. Therefore, this method could be a promising supplement to methods already in use.

The subvalvular apparatus in rheumatic mitral stenosis: methods of assessment and therapeutic implications.

The assessment of the structure and function of the subvalvular apparatus (SVA) in patients with rheumatic mitral stenosis (MS) is complex, yet is of major importance prior to therapeutic decision making. Currently available methods of assessment are neither sufficiently accurate nor feasible. We review anatomic and functional aspects of the SVA and define SVA involvement in rheumatic MS. The role of various noninvasive and invasive methods for evaluating the integrity and function of SVA in rheumatic MS, as well as clinical implications and pitfalls in assessment of SVA are also discussed.

Iodine-123 metaiodobenzylguanidine scintigraphic assessment of the transplanted human heart: evidence for late reinnervation.

OBJECTIVES: This study attempted to determine whether cardiac sympathetic reinnervation occurs late after orthotopic heart transplantation. BACKGROUND: Metaiodobenzylguanidine (MIBG) is taken up by myocardial sympathetic nerves. Iodine-123 (I-123) MIBG cardiac uptake reflects intact myocardial sympathetic innervation of the heart. Cardiac transplant recipients do not demonstrate I-123 MIBG cardiac uptake when studied < 6 months from transplantation. However, physiologic and biochemical studies suggest that sympathetic reinnervation of the heart can occur > 1 year after transplantation. METHODS: We performed serial cardiac I-123 MIBG imaging in 23 cardiac transplant recipients early (< or = 1 year) and late (> 1 year) after operation. In 16 subjects transmyocardial norepinephrine release was measured late after transplantation. RESULTS: No subject had visible I-123 MIBG uptake on imaging < 1 year after transplantation. However, 11 (48%) of 23 subjects developed visible cardiac I-123 MIBG uptake 1 to 2 years after transplantation. Only 3 (25%) of 12 subjects with a pretransplantation diagnosis of idiopathic cardiomyopathy demonstrated I-123 MIBG uptake compared with 8 (73%) of 11 with a pretransplantation diagnosis of ischemic or rheumatic heart disease (p = 0.04). All 10 subjects with a net myocardial release of norepinephrine had cardiac I-123 MIBG uptake; all 6 subjects without a net release of norepinephrine had no cardiac I-123 MIBG uptake. CONCLUSIONS: Sympathetic reinnervation of the transplanted human heart can occur > 1 year after operation, as assessed by I-123 MIBG imaging and the transmyocardial release of norepinephrine. Reinnervation is less likely to occur in patients with a pretransplantation diagnosis of idiopathic cardiomyopathy than in those with other etiologies of congestive heart failure.

Comparative results of percutaneous balloon mitral valvuloplasty using the Trefoil/Bifoil and Inoue balloon techniques.

This study compared the results in 150 consecutive patients with rheumatic mitral stenosis who underwent percutaneous balloon mitral valvuloplasty by means of a Trefoil/Bifoil balloon catheter (n = 100, Group 1) or the Inoue balloon catheter (n = 50, Group 2). There was significant improvement in mitral valve area after valvuloplasty in both groups: in Group 1 mitral valve area improved from 0.92 +/- 0.22 to 2.14 +/- 0.64 cm2 (P < 0.001) and in Group 2 from 1.0 +/- 0.26 to 2.06 +/- 0.59 cm2 (P < 0.001). There was no significant difference in the mitral valve area, mean diastolic gradient or mean left atrial pressure between Group 1 and Group 2 patients after valvuloplasty. There was a higher complication rate in Group 1 patients but this was largely related to our early learning experience with the procedure. The Trefoil/Bifoil catheter technique is more complex and involved a longer screening time: Group 1 (39 +/- 15 min) vs. Group 2 (22 +/- 10 min); P < 0.001. The cost of the Inoue balloon technique, however, was almost twice that of the Trefoil/Bifoil technique. This may have important implications for developing countries with limited health care budgets and a high prevalence of rheumatic heart disease.

[The clinico-functional assessment and work capacity of patients undergoing repeated operations on the mitral valve]. / Kliniko-funktsional'naia otsenka i trudosposobnost' bol'nykh pri povtornykh operatsiiakh na mitral'nom klapane.

A complex of examinations (ECG, echocardiographic and X-ray evaluations of heart volumes and cavities, treadmill-test) was performed in 82 patients before and after reoperations on the mitral valve. The type of recorrection was found to be associated with the degree of positive dynamics of the results. The data obtained contradicted to hyperdiagnoses of primary medical-labor examination commission establishing the II group of invalidism in 86 +/- 4% (M +/- m) of the examined patients. As a result of an analysis of all the data obtained the number of such patients was reduced up to 34 +/- 5%. A new approach to solving the problem of medical-labor examination was shown to be necessary for patients reoperated for mitral disease of the heart.

[The assessment of left ventricular diastolic function in patients with aortic defects]. / Otsenka diastolicheskoi funktsii levogo zheludochka u bol'nykh s aortal'nymi porokami.

Thirty patients with aortic heart disease and 10 healthy persons were examined for diastolic function of the left ventricle using two-dimensional Doppler echocardiography. The decline of the rate and volume of early diastolic filling, the rise of the filling during the atrial systole were revealed in 60% of the patients with aortal disease. The decrease of the ejection fraction of the left ventricle was noted in 23.3% of the patients. All the patients with aortic disease were distributed into 2 groups depending on the presence (group II) or lack (group I) of mitral regurgitation. Addition of mitral regurgitation in patients with aortic disease masked the deranged filling of the left ventricle and interfered with the diagnosis of diastolic dysfunction. A reverse moderately pronounced relationship (r = -0.56) has been discovered between the myocardial mass and impairment of the diastolic filling.