[Early Postoperative Hemodynamics of Mitral Valvuloplasty Using Colvin-Galloway Future Band].

The Colvin-Galloway( CG) Future annuloplasty band is a new semirigid partial band, which was introduced in 2012 in Japan. A total of 60 consecutive patients who underwent mitral valve repair with the CG Future Band were assessed by echocardiography in terms of residual mitral regurgitation and diastolic mitral function postoperatively. Intraoperative 3-dimensional echocardiography beautifully demonstrated the physiological change of the aortic curtain during the cardiac cycle. 30 mm was used in 18 patients, 32 mm in 17, 28 mm in 15, 34 mm in 5, 36 mm in 2, and 26 mm in 2. There were 2 patients with mild residual mitral regurgitation and 58 patients with less than mild. The mean gradient of diastolic mitral pressure gradient was 2.8±1.3 mmHg. Early results of mitral valve repair with a CG Future Band were acceptable in terms of residual mitral regurgitation and diastolic mitral function after repair.

Surgical treatment for degenerative mitral stenosis associated with aortic valve stenosis: A case report.

We report a 73-year-old female who underwent mitral valve replacement for degenerative mitral stenosis (DMS) and aortic valve replacement for aortic valve stenosis. She was transferred to our hospital because of congestive heart failure. Transthoracic echocardiogram demonstrated severe mitral valve stenosis and aortic valve stenosis. Transesophageal echocardiogram (TEE) revealed severe mitral annular calcification (MAC) and calcification of the anterior mitral leaflet without commissure fusion. The diagnosis of DMS associated with MAC and aortic valve stenosis was made. Since she did not have other significant comorbidities except diabetes mellitus and hypertension, open-heart surgery for double valve replacement was scheduled by our heart team. Complete resection of the calcium bar and annulus reconstruction with an autologous pericardium allowed safe mitral valve replacement with a mechanical valve. Concomitant aortic valve replacement with a mechanical valve was carried out for aortic valve stenosis. Intraoperative TEE demonstrated good left ventricular function without perivalvular leakage in both mitral and aortic prosthetic valves. The postoperative course was uneventful, and the patient was discharged from the hospital. Surgical intervention may be one of the alternative treatments for elderly patients with degenerative mitral stenosis and MAC. Learning objective: Degenerative mitral stenosis (DMS) associated with mitral annular calcification (MAC) is a severe heart valve disease in the elderly population in developed countries. The prognosis of patients with severe DMS is poor, and open-heart surgery for elderly patients with MAC is especially challenging from a surgical point of view. We report a surgical treatment for a patient with DMS and aortic valve stenosis considering the patient's comorbidities and extent of MAC.

Diagnostic accuracy of transthoracic and transesophageal echocardiography for the diagnosis of bicuspid aortic valve: comparison with operative findings.

BACKGROUND: Bicuspid aortic valve (BAV) is associated with an increased risk of aortic valve (AV) dysfunction, aortic dissection, and infective endocarditis. Therefore, its accurate diagnosis is critical. The morphological features of AVs are generally evaluated by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE), however, the difference in the diagnostic capability of these imaging modalities for detecting BAV remains unclear. Here, we compared these 2 methods to determine their accuracy, and to clarify each role in the diagnosis of BAV. METHODS: This blind study evaluated 126 patients (age, 70.3 +/- 7.8 years) who subsequently underwent AV replacement. The number of AV cusps of each patient was estimated by TTE and TEE and compared to the number of AV written in the operative record. Patients with poor echocardiographic images were not excluded. RESULTS: Surgical findings showed 97 tricuspid AVs and 29 BAVs. The sensitivity, specificity, and accuracy for the diagnosis of BAV were 61%, 81%, and 77%, respectively, for TTE and 86%, 90%, and 89%, respectively, for TEE. The accuracy of TEE was significantly higher than that of TTE (p = 0.016). In non-calcified AVs, the accuracy of TTE was similar to that of TEE (96%, each) whereas in calcified AVs, TTE had a lower accuracy than TEE (72% vs 87%, p = 0.011). The feasibility was significantly higher for TEE than for TTE (98% vs 90%, p = 0.003). CONCLUSIONS: TEE provides higher accuracy and feasibility than TTE in the diagnosis of BAV, and it should therefore be indicated when morphological features of AVs cannot be evaluated by TTE.

Novel device that produces carbon dioxide mist for myocardial infarction treatment in rats.

BACKGROUND: Carbon dioxide (CO(2)) baths have been used to treat a variety of diseases, but developing an artificial bath of highly concentrated CO(2) is difficult. Here, we tried the efficacy of a novel device instead of a CO(2) bath. METHODS AND RESULTS: Using a device equipped with double fluid nozzles, CO(2) gas and H(2)O were compounded and compressed at 4 barometric pressures. As a result, CO(2) gas was dissolved in H(2)O, which contained a few micrometers of CO(2) particles, namely, a CO(2) mist. Wistar rats with myocardial infarction (MI) by ligation of the left coronary artery were percutaneously administered CO(2) mist or CO(2) gas alone or no treatment for 30 min daily. With regard to tissue blood flow during treatment, the group treated with CO(2) mist had significantly increased tissue oxygenated hemoglobin levels and tissue saturation levels, and significantly decreased deoxygenated hemoglobin levels compared with the group treated with CO(2) gas. After 4 weeks treatment, the group treated with CO(2) mist had a significantly improved ejection fraction by echocardiography compared with the untreated group. Interestingly, the group treated with CO(2) mist had significantly increased nitrate concentrations in serum and vascular endothelial growth factor mRNA expression levels in the myocardium compared with the untreated group. CONCLUSIONS: Our new mist production device may be potentially useful for the treatment of heart failure caused by MI.

Detailed observation of arterial healing after stent implantation in swine arteries by using optical coherence tomography.

BACKGROUND: Histopathological examination is not suitable for sequential in vivo analysis of arterial healing after stenting because it can be performed only after the animals are killed. Optical coherence tomography (OCT) provides higher resolution than intravascular ultrasound (IVUS). The aim of this study was to compare arterial healing images after stenting on the basis of the findings of histopathological examination, IVUS, and OCT. METHODS: We examined 12 vessels; 12 bare-metal stents were implanted in 6 miniature swine. Histopathological examination, IVUS, and OCT imaging were performed at 1 and 4 weeks after stenting. For quantitative analysis of IVUS and OCT images, we examined cross-sectional frames at 1-mm intervals. For neointimal coverage analysis, the neointimal coverage score was classified into 1 of the 4 categories. A fully covered strut was scored as 3, a partially covered strut was scored as 1 or 2, and an uncovered strut was scored as 0. RESULTS: In IVUS and OCT analyses, the average neointimal thickness increased between 1 and 4 weeks (p < 0.0001). OCT revealed higher scores at 1 and 4 weeks than IVUS did (at week 1, p < 0.0001; at week 4, p < 0.0001). OCT analysis evaluated the neointimal coverage similarly to histopathological examination. CONCLUSIONS: On assessment of arterial healing after stenting, we found that the results of the histological examination were more similar to those of the OCT analysis than to those of the IVUS. An OCT imaging device can be used to precisely and sequentially analyze the arterial healing process after stenting.

Utility of myocardial fractional flow reserve for prediction of restenosis following sirolimus-eluting stent implantation.

Drug-eluting stents reduce restenosis due to neointimal growth suppression. Considering long-term outcomes, it is both difficult and important to predict drug-eluting stent restenosis. Thus, this study was designed to examine the utility of myocardial fractional flow reserve (FFR) as a predictor of sirolimus-eluting stent (SES) restenosis. Thirty-three patients (35 lesions) were enrolled. Upon completion of SES implantation, FFR was obtained under hyperemia. At 8 months of follow-up, coronary angiography revealed that five lesions had restenosis. Percent diameter stenosis (restenosis 68.7 ± 12.8% vs. non-restenosis 68.7 ± 12.4%, p = 0.78) and lesion length (restenosis 15.8 ± 9.4 mm vs. non-restenosis 14.4 ± 9.2 mm, p = 0.60) were similar. At post-intervention, percent diameter stenosis (restenosis 16.4 ± 6.1% vs. non-restenosis 14.0 ± 7.4%, p = 0.48) and minimum stent area (restenosis 6.01 ± 1.08 mm2 vs. non-restenosis 6.27 ± 1.85 mm2, p = 0.92) were also equivalent. However, proximal edge lumen area was smaller (restenosis 4.24 ± 1.40 mm2 vs. non-restenosis 7.73 ± 2.64 mm2, p = 0.004) and FFR was lower in the restenosis group (restenosis 0.81 ± 0.12 vs. non-restenosis 0.92 ± 0.06, p = 0.029). SES patients with restenosis had a lower FFR post stent deployment, suggesting the decreased FFR may be a useful predictor for SES restenosis.

The clinical value of the apex beat as a marker of left atrial enlargement.

BACKGROUND: The palpation of the apex beat, one of the most fundamental physical examinations, provides a clue to left ventricular (LV) dilatation and hypertrophy; however, its relation to left atrial (LA) volume has rarely been investigated. METHODS: The clinical value of the apex beat, especially in relation to LA volume was studied in 138 consecutive patients. Patients were examined in the supine position for a palpable apex beat. When an apex beat was felt, the apex beat distance, defined as the distance from the mid-clavicular line to the lateral border of the apex beat, was measured. The LA and LV geometry were assessed using echocardiography. RESULTS: Of the 138 patients, an apex beat was palpable in 52 (38%) patients and the apex distance of these 52 patients ranged from -2 to 8 cm. The parameters of LV dilatation or hypertrophy were significant according to univariate but not to multivariate analysis. Only LA volume index was significant both for the palpability of the apex beat (p=0.0042) and the apex distance (p=0.0017) by multivariate analysis. The best cut-off point for the apex distance was -1 cm for LA enlargement (sensitivity 61%, specificity 92%, p<0.0001). CONCLUSIONS: The LA volume is the most significant factor for the palpability and leftward deviation of the apex beat. Palpation of the apex beat is a crucial diagnostic tool for the detection of not only LV dilatation or hypertrophy but also of LA enlargement.

Mitral valve repair for infective endocarditis: Kobe experience.

OBJECTIVES: We retrospectively analyzed our experience of mitral valve repair for native mitral valve endocarditis in a single institution. METHODS: From January 1991 to October 2011, 171 consecutive patients underwent surgery for infective endocarditis. Of these, 147 (86%) had mitral valve repair. At the time of surgery, 98 patients had healed (group A) and 49 had active infective endocarditis (group B). Repair procedures included resection of all infected tissue and thick restricted post-infection tissue, leaflet and annulus reconstruction with treated autologous pericardium, chordal reconstruction with polytetrafluoroethylene sutures, and ring annuloplasty if necessary. Fifty-two (35%) patients required concomitant procedures. The study endpoints were overall survival, freedom from reoperation, and freedom from valve-related events. The median follow-up was 78 months. RESULTS: There was one hospital death (hospital mortality 0.7%). Survival at 10 years was 88.5% ± 3.5% with no significant difference between the two groups (p = 0.052). Early reoperation was required in 4 patients in group B due to persistent infection or procedure failure. Freedom from reoperation at 5 years was 99% ± 1.0% in group A and 89.6 ± 4.0% in group B (p = 0.024). Event-free survival at 10 years was 79.3% ± 4.8% (group A: 83.4% ± 5.9%, group B: 72.6% ± 6.9%, p = 0.010). CONCLUSIONS: Mitral valve repair was highly successful using autologous pericardium, chordal reconstruction, and ring annuloplasty if required. Long-term results were acceptable in terms survival, freedom from reoperation, and event-free survival. Mitral valve repair is recommended for mitral infective endocarditis in most patients.

Cardiac and autonomic nerve function after reduced-intensity stem cell transplantation for hematologic malignancy in patients with pre-transplant cardiac dysfunction.

Recent reports have shown that cardiomyopathy caused by hemochromatosis in severe aplastic anemia is reversible after reduced-intensity allogeneic stem-cell transplantation (RIST). We comprehensively evaluated cardiac and autonomic nerve function to determine whether cardiac dysfunction due to causes other than hemochromatosis is attenuated after RIST. In five patients with cardiac dysfunction before transplant, we analyzed the changes in cardiac and autonomic nerve function after transplant, using electrocardiography (ECG), echocardiography, radionuclide angiography (RNA), serum markers, and heart rate variability (HRV), before and up to 100 days after transplant. There was no significant improvement in cardiac function in any patient and no significant alteration in ECG, echocardiogram, RNA, or serum markers. However, on time-domain analysis of HRV, the SD of normal-to-normal RR intervals (SDNN) and the coefficient of variation of the RR interval (CVRR) decreased significantly 30 and 60 days after transplant (P = 0.04 and 0.01, respectively). Similarly, on frequency-domain analysis of HRV, low and high frequency power (LF and HF) significantly and temporarily decreased (P = 0.003 and 0.03, respectively). Notably, in one patient who had acute heart failure after transplantation, the values of SDNN, CVRR, r-MSSD, LF, and HF at 30 and 60 days after transplantation were the lowest of all the patients. In conclusion, this study suggests that (a) RIST is well-tolerated in patients with cardiac dysfunction, but we cannot expect improvement in cardiac dysfunction due to causes other than hemochromatosis; and (b) monitoring HRV may be useful in predicting cardiac events after RIST.

Quantitative myocardial contrast echocardiography during pharmacological stress for diagnosis of coronary artery disease: a systematic review and meta-analysis of diagnostic accuracy studies.

AIMS: We conducted a meta-analysis to evaluate the accuracy of quantitative stress myocardial contrast echocardiography (MCE) in coronary artery disease (CAD). METHODS AND RESULTS: Database search was performed through January 2008. We included studies evaluating accuracy of quantitative stress MCE for detection of CAD compared with coronary angiography or single-photon emission computed tomography (SPECT) and measuring reserve parameters of A, beta, and Abeta. Data from studies were verified and supplemented by the authors of each study. Using random effects meta-analysis, we estimated weighted mean difference (WMD), likelihood ratios (LRs), diagnostic odds ratios (DORs), and summary area under curve (AUC), all with 95% confidence interval (CI). Of 1443 studies, 13 including 627 patients (age range, 38-75 years) and comparing MCE with angiography (n = 10), SPECT (n = 1), or both (n = 2) were eligible. WMD (95% CI) were significantly less in CAD group than no-CAD group: 0.12 (0.06-0.18) (P < 0.001), 1.38 (1.28-1.52) (P < 0.001), and 1.47 (1.18-1.76) (P < 0.001) for A, beta, and Abeta reserves, respectively. Pooled LRs for positive test were 1.33 (1.13-1.57), 3.76 (2.43-5.80), and 3.64 (2.87-4.78) and LRs for negative test were 0.68 (0.55-0.83), 0.30 (0.24-0.38), and 0.27 (0.22-0.34) for A, beta, and Abeta reserves, respectively. Pooled DORs were 2.09 (1.42-3.07), 15.11 (7.90-28.91), and 14.73 (9.61-22.57) and AUCs were 0.637 (0.594-0.677), 0.851 (0.828-0.872), and 0.859 (0.842-0.750) for A, beta, and Abeta reserves, respectively. CONCLUSION: Evidence supports the use of quantitative MCE as a non-invasive test for detection of CAD. Standardizing MCE quantification analysis and adherence to reporting standards for diagnostic tests could enhance the quality of evidence in this field.

Multiple cardiac thrombi and thromboembolism in a heparin-induced thrombocytopenia antibody-positive patient with heart failure.

A 49-year-old Japanese man presented with orthopnea and edema in both legs. He was diagnosed with congestive heart failure with triple-vessel coronary artery disease. Low antithrombin and left ventricular systolic dysfunction were possible causes of his hypercoagulable state. Echocardiography revealed thrombi in the left ventricle and left trium, poor left ventricular contractility, and a normal mitral valve. Electrocardiogram revealed normal sinus rhythm. We found small infarctions of the brain and spleen in the computed tomography. The heparin treatment of cardiac thrombi is useless because the patient had heparin-induced thrombocytopenia antibody. We removed thrombi in the left ventricle and left atrium by thrombectomy and performed coronary artery bypass graft. Warfarin was administered for anticoagulation. He recovered completely and is now doing well. Our experience indicates that poor cardiac function can together cause multiple cardiac thrombi and subsequent thromboembolism without mitral stenosis or atrial fibrillation.

Mitral valve repair for traumatic mitral regurgitation.

Mitral valve injury after blunt chest trauma is a rare clinical condition. We describe a case of mitral valve repair for severe mitral regurgitation due to blunt chest trauma 5 years previously. A 22-year-old man was referred to our hospital for surgical correction of severe mitral regurgitation. Echocardiography demonstrated a partial tear of the anterolateral papillary muscle which lacerated to the apex. The entire anterolateral part of the mitral valve including the anterior commissure and posterior leaflets had prolapsed. Reimplantation of the papillary muscle to the posterior left ventricular wall and ring annuloplasty were successfully performed without residual regurgitation.

Effect of azithromycin therapy on coronary circulation in patients with coronary artery disease.

This study examined the effect of azithromycin therapy on the coronary microcirculation using measurement of coronary flow velocity reserve (CFVR) by transthoracic Doppler echocardiography in 35 patients with coronary artery disease. CFVR increased significantly after azithromycin therapy (3.0 +/- 0.7 vs 3.5 +/- 0.7, p <0.001). The changes in CFVR were negatively correlated with changes in high-sensitivity C-reactive protein levels in patients receiving azithromycin.

Cut-off value of coronary flow velocity reserve by transthoracic Doppler echocardiography for diagnosis of significant left anterior descending artery stenosis in patients with coronary risk factors.

The purpose of this study was to evaluate the adequate cut-off value of coronary flow velocity reserve (CFVR) with transthoracic Doppler echocardiography for diagnoses of significant left anterior descending (LAD) artery stenosis in a large study population with various coronary risk factors. CFVR, which has been used for evaluation of significant coronary artery stenosis, can be reduced despite angiographically normal coronary arteries in patients with various coronary risk factors. However, the adequate cut-off value of CFVR for diagnosing significant LAD stenosis has not been fully established in patients with coronary risk factors. We examined 138 consecutive patients who underwent coronary angiography. Clinical histories of coronary risk factors were determined from interviews or medical records. CFVR assessment in the LAD artery by transthoracic Doppler echocardiography was performed in all patients. Of the 138 patients, 30 had significant stenosis, and the remainder had no stenotic lesions in the LAD artery. Receiver-operating characteristic curves for detection of significant LAD stenosis showed that a cut-off value of <2.0 was extremely precise. A cut-off value <2.0 of CFVR had a sensitivity of 90%, a specificity of 93%, a positive predictive value of 77%, and a negative predictive value of 97% for the presence of significant LAD stenosis. A cut-off value <2.0 of CFVR by transthoracic Doppler echocardiography was adequate for the diagnosis of significant LAD stenosis in a population that included patients with coronary risk factors.

Pitfalls of echocardiographic measurement in tissue harmonic imaging: in vitro and in vivo study.

BACKGROUND: Tissue harmonic imaging (THI) is a useful method for endocardial border detection by transthoracic echocardiography, especially in technically difficult patients, even though accuracy of this method in the echocardiographic measurement is unclear. The purpose of this study is to evaluate the accuracy of echocardiographic measurement by THI in vivo and in vitro. METHODS: In vitro, we measured wall thickness, dimension, and volume of the excised hearts by THI. In 11 patients, we assessed the comparative accuracy of THI and fundamental imaging (FI) in determination of left ventricular (LV) wall thickness, dimension, volume, and ejection fraction. RESULTS: In vitro, thickness measurements by THI overestimated true length, and both volume and dimension measurements by THI underestimated true values. In vivo, LV ejection fraction measurements obtained by THI exhibited excellent correlation and agreement with those obtained by FI. However, LV wall thickness determined by THI was significantly larger than that determined by FI, and the dimensions and volume of LV measured by THI were significantly smaller than those measured by FI. CONCLUSION: Although THI is an excellent imaging technique for determination of LV ejection fraction, echocardiographic measurement by THI underestimates LV dimensions and volume, and overestimates LV wall thickness.

Simple detection of occluded coronary artery using retrograde flow in septal branch and left anterior descending coronary artery by transthoracic Doppler echocardiography at rest.

BACKGROUND: We hypothesized that coronary flow assessment by transthoracic Doppler echocardiography (TTDE) for both intramyocardial collateral channel and epicardial channels would be useful for identifying occluded left anterior descending coronary artery (LAD). METHODS: We assessed flow direction in the LAD and the septal branch (SEP) by TTDE in 302 consecutive patients who were suggested to have ischemic heart disease. We defined antegrade LAD flow as a direction from the base to the apex of the left ventricle in the anterior groove area, and antegrade SEP flow as a direction from anterior to inferior in the anterior interventricular septum. By contrast, we defined retrograde LAD and SEP flow as an inverse direction. We performed angiography on all patients. RESULTS: Retrograde flow was detected in 22 (LAD, 16 patients; SEP, 6 patients) of 23 patients with occluded LAD, and antegrade flow was detected in all patients without occluded LAD. The sensitivity and specificity for identification of occluded LAD by TTDE were 96% and 100%, respectively. CONCLUSIONS: Assessment of flow direction in both LAD and SEP by TTDE is a useful method in identification of occluded LAD.

Rapid and accurate noninvasive assessment of global left ventricular systolic function using biplane advanced automated contour tracking method.

BACKGROUND: The advanced automated contour tracking (AACT) method has been newly developed for automated detection of the left ventricular endocardial boundary. Left ventricular ejection fraction (LVEF) may be estimated by applying the AACT method to 2 orthogonal planes of patients even when regional wall-motion abnormalities exist. The purpose of this study was to examine the reliability of the biplane AACT method in the measurement of LVEF in patients with suggested ischemic heart disease with use of quantitative gated single photon emission computed tomography (QGS) as a reference standard. METHODS: The study population consisted of 47 consecutive patients with suggested ischemic heart disease. All patients underwent 2-dimensional echocardiography and QGS. Biplane LVEF from apical 4- and 2-chamber views was measured offline by the AACT method using disk summation method. The accuracy of the AACT method for LVEF measurement was determined in comparison with QGS. RESULTS: In 41 (29 with and 12 without regional wall-motion abnormalities) of 47 patients (87%), automated tracing of the endocardial border was adequately achieved with the AACT method. LVEF measured by the AACT method correlated well with that measured by QGS (y = 0.97x +2.4, r = 0.91). The mean difference between AACT and QGS was 0.6 +/- 5.5% (mean +/- SD). The mean time required for analysis of 1 set of images during 1 cardiac cycle by the AACT method was much shorter than that required by manual tracing method (7 +/- 1 vs 37 +/- 4 seconds, P <.0001). CONCLUSION: The biplane AACT method provides accurate and quick measurement of LVEF in patients even with regional wall-motion abnormalities.

Noninvasive assessment of myocardial ischemia in the left ventricular inferior regions by coronary flow reserve measurement using transthoracic Doppler echocardiography.

OBJECTIVE: The purpose of this study was to evaluate the potential of noninvasive measurement of coronary flow reserve (CFR) by transthoracic Doppler echocardiography (TTDE) for the assessment of myocardial ischemia in the left ventricular (LV) inferior regions. BACKGROUND: Although coronary flow assessment by TTDE has been determined for the assessment of perfusion abnormality in the LV anterior regions, the usefulness of this method has not been well investigated in the LV inferior regions. METHODS: We studied 50 patients (43 men; mean age 60 +/- 9 years) with suggested coronary artery disease. CFR in the posterodescending coronary artery (PDA) was calculated as a ratio of hyperemic to basal peak (peak CFR) and mean (mean CFR) flow velocities in the PDA, which were measured by TTDE. CFR values were compared with the results of exercise 201-thallium single photon emission computed tomography. RESULTS: CFR was successfully measured in 43 of 50 patients (86%). Mean and peak CFR < 2 were shown in 10 of 12 patients with abnormal perfusion in the LV inferior regions, whereas CFR > or = 2 were shown in 30 of 31 patients with normal perfusion. Thus, CFR < 2 in the PDA by TTDE had a sensitivity of 83% and a specificity of 97% for the assessment of perfusion abnormality in the LV inferior regions by 201-thallium single photon emission computed tomography. CONCLUSIONS: CFR in the PDA measured by TTDE provides data equivalent to those obtained by 201-thallium single photon emission computed tomography for myocardial ischemia in the LV inferior regions.

A novel and simple method using pocket-sized echocardiography to screen for aortic stenosis.

BACKGROUND: Pocket-sized echocardiography may serve as an initial tool to screen for aortic stenosis (AS). The purpose of this study was to evaluate the usefulness of a novel and simple method using pocket-sized echocardiography to screen for AS. METHODS: Subjects (n= 130) with systolic ejection murmur or known AS were studied. After physical examination, each aortic cusp's opening was visually scored using pocket-sized echocardiography as follows: 0= not restricted, 1= restricted, or 2= severely restricted. The sum of the scores was defined as the visual AS score. On the basis of high-end echocardiography, an aortic valve area index <0.60 cm(2)/m(2) and an aortic valve area index of 0.60 to 0.85 cm(2)/m(2) were considered to indicate severe and moderate AS, respectively. RESULTS: For diagnosing severe AS (n= 27), a visual AS score ≥ 4 had sensitivity of 85% and specificity of 89%. For diagnosing moderate to severe AS (n= 57), a visual AS score ≥ 3 had sensitivity of 84% and specificity of 90%. The areas under the receiver operating characteristic curves for diagnosing severe and moderate to severe AS with a visual AS score (0.946 and 0.936, respectively) were slightly larger than those for a skilled physical examination (0.917 and 0.898, respectively) (P= NS for both) but were significantly larger than for an aortic valve calcification score also obtained using pocket-sized echocardiography (areas under the curve, 0.816 [P= .0015] and 0.827 [P= .0001], respectively). CONCLUSIONS: A novel and simple method using pocket-sized echocardiography is useful for rapid grading of AS in subjects with systolic ejection murmur.