Medição automática de valva mitral a partir de ecocardiograma utilizando processamento digital de imagens / Automatic measurement of the mitral valve based on echocardiography using digital image processing

Fundamento: A avaliação da área valvar mitral por meio da reconstrução multiplano na ecocardiografia tridimensional é restrita a softwares específicos e à experiência dos ecocardiografistas. Eles precisam selecionar manualmente o frame do vídeo que contenha a área de abertura máxima da valva mitral, dimensão fundamental para a identificação de estenose mitral. Objetivo: Automatizar o processo de determinação da área de abertura máxima da valva mitral, por meio da aplicação de Processamento Digital de Imagens (PDI) em exames de ecocardiograma, desenvolvendo um algoritmo aberto com leitura de vídeo no formato avi. Método: Este estudo piloto observacional transversal foi realizado com vinte e cinco exames diferentes de ecocardiograma, sendo quinze com abertura normal e dez com estenose mitral reumática. Todos os exames foram realizados e disponibilizados por dois especialistas, com autorização do Comitê de Ética em Pesquisa, que utilizaram dois modelos de aparelhos ecocardiográficos: Vivid E95 (GE Healthcare) e Epiq 7 (Philips), com sondas multiplanares transesofágicas. Todos os vídeos em formato avi foram submetidos ao PDI através da técnica de segmentação de imagens. Resultados: As medidas obtidas manualmente por ecocardiografistas experientes e os valores calculados pelo sistema desenvolvido foram comparados utilizando o diagrama de Bland-Altman. Observou-se maior concordância entre valores no intervalo de 0,4 a 2,7 cm². Conclusão: Foi possível determinar automaticamente a área de máxima abertura das valvas mitrais, tanto para os casos advindos da GE quanto da Philips, utilizando apenas um vídeo como dado de entrada. O algoritmo demonstrou economizar tempo nas medições quando comparado com a mensuração habitual. (AU)

Background: The evaluation of mitral valve area through multiplanar reconstruction in 3-dimensional echocardiography is restricted to specific software and to the experience of echocardiographers. They need to manually select the video frame that contains the maximum mitral valve opening area, as this dimension is fundamental to identification of mitral stenosis. Objective: To automate the process of determining the maximum mitral valve opening area, through the application of digital image processing (DIP) in echocardiography tests, developing an open algorithm with video reading in avi format. Method: This cross-sectional observational pilot study was conducted with 25 different echocardiography exams, 15 with normal aperture and 10 with rheumatic mitral stenosis. With the authorization of the Research Ethics Committee, all exams were performed and made available by 2 specialists who used 2 models of echocardiographic devices: Vivid E95 (GE Healthcare) and Epiq 7 (Philips), with multiplanar transesophageal probes. All videos in avi format were submitted to DIP using the image segmentation technique. Results: The measurements obtained manually by experienced echocardiographers and the values calculated by the developed system were compared using a Bland-Altman diagram. There was greater agreement between values in the range from 0.4 to 2.7 cm². Conclusion: It was possible to automatically determine the maximum mitral valve opening area, for cases from both GE and Philips, using only 1 video as input data. The algorithm has been demonstrated to save time on measurements when compared to the usual method. (AU)

Miocardiopatía de y movimiento sistólico anterior de válvula mitral / Myocardiopaty and sistolic anterior movement of mitral valve

Tako tsubo cardiomyopathy associated with left ventricular outflow tract obstruction (LVOT) is a rare cause of persistent perioperative hypotension. One of the causes of this association is the systolic anterior motion (SAM) of the mitral valve. We report a case of a 67-year-old woman who, after undergoing liver segmentectomy because of metastasis, presents post-operative hypotension that is difficult to manage. Upon evaluation with a transthoracic echocardiogram, the diagnostic suspicion of Tako tsubo syndrome associated with LVOT obstruction secondary to SAM was raised. As initial therapy, a volume expander, in association with propanolol and phenylephrine were administred, achieving partial hemodynamic response. Later, she evolved with signs of heart failure and was transferred to the intensive care unit for management. In this unit, non-invasive ventilatory support, diuretic and vasopressor therapy were required, achieving favorable results on the second post-operative day. Echocardiography was essential to make the differential diagnosis against a persistent post-operative hypotension

La cardiomiopatía de Tako tsubo asociada a obstrucción del tracto de salida del ventrículo izquierdo (TSVI) es una causa poco frecuente de hipotensión persistente en el perioperatorio. Uno de los motivos de esta asociación es el movimiento anormal sistólico (SAM) de la válvula mitral. A continuación, presentamos el caso de una mujer de 67 años que, tras ser sometida a segmentectomía hepática por metástasis, presenta cuadro de hipotensión postoperatoria de difícil manejo. Al ser evaluada con ecocardiograma transtorácico se plantea la sospecha diagnóstica de síndrome de Tako tsubo asociado a obstrucción del TSVI secundario a SAM. Como terapia inicial se realizó aporte de volumen, en asociación con propanolol y fenilefrina, logrando parcial respuesta hemodinámica. Posteriormente, evolucionó con signos de insuficiencia cardiaca y fue trasladada a unidad de cuidados intensivos para su manejo. En esta unidad requirió apoyo ventilatorio no invasivo, terapia diurética y vasopresora, logrando resultados favorables al segundo día postoperatorio. La ecocardiografía fue fundamental para realizar el diagnóstico diferencial frente a un cuadro de hipotensión postoperatoria persistente.

The factors affecting rhythm control for cryoablation of atrial fibrillation in mitral valve surgery

Abstract Objective: To evaluate the factors impacting on the conversion to sinus rhythm and on the postoperative rhythm findings in the six-month follow-up period of a mitral valve surgery combined with cryoablation Cox-Maze III procedure, in patients with atrial fibrillation. Methods: In this study, we evaluated 80 patients who underwent structural valve disease surgery in combination with cryoablation. Indications for the surgical procedures were determined in the patients according to the presence of rheumatic or non-rheumatic structural disorders in the mitral valve as evaluated by echocardiography. Cox-Maze III procedure and left atrial appendix closure were applied. Results: The results of receiver operating characteristics analysis indicated that the rate of conversion to the sinus rhythm was significantly higher in patients with left atrial diameters ≥ 45.5 mm and with ejection fraction (EF) ≥ 48.5%. However, the statistical differences disappeared in the sixth month. Thromboembolic (TE) events were seen only in three patients in the early period and no more TE events occurred in the six-month follow-up period. Conclusion: The EF and the preoperative left atrial diameter were determined to be the factors impacting on the conversion to sinus rhythm in patients who underwent mitral valve surgery in combination with cryoablation. Mitral valve surgery in combination with ablation for atrial fibrillation does not affect mortality and morbidity in the experienced health centers; however, it remains controversial whether it will provide additional health benefits to the patients compared to those who underwent only mitral valve surgery.

The relationship between mitral annular calcification, metabolic syndrome and thromboembolic risk

Abstract Introduction: Metabolic syndrome (MetS) is defined as an association between diabetes, hypertension, obesity and dyslipidemia and an increased risk of cardiovascular disease. Mitral annular calcification (MAC) is associated with several cardiovascular disorders, including coronary artery disease, atrial fibrillation (AF), heart failure, ischemic stroke and increased mortality. The CHA2DS2-VASc score is used to estimate thromboembolic risk in AF. However, the association among MAC, MetS and thromboembolic risk is unknown and was evaluated in the current study. Methods: The study group consisted of 94 patients with MAC and 86 patients with MetS. Patients were divided into two groups: those with and those without MAC. Results: Patients with MAC had a higher MetS rate (P<0.001). In patients with MAC, the CHA2DS2-VASc scores and the rate of cerebrovascular accident and AF were significantly higher compared to those without MAC (P<0.001, for both parameters). The results of the multivariate regression analysis showed that history of smoking, presence of MetS and high CHA2DS2-VASc scores were associated with the development of MAC. ROC curve analyses showed that CHA2DS2-VASc scores were significant predictors for MAC (C-statistic: 0.78; 95% CI: 0.706-0.855, P<0.001). Correlation analysis indicated that MAC was positively correlated with the presence of MetS and CHA2DS2-VASc score (P=0.001, r=0.264; P<0.001, r=0.490). Conclusion: We have shown that CHA2DS2-VASc score and presence of MetS rates were significantly higher in patients with MAC compared without MAC. Presence of MAC was correlated with CHA2DS2-VASc score, presence of MetS, AF and left atrial diameter and negatively correlated with left ventricular ejection fraction.

Surgical treatment of atrial fibrillation in patients with rheumatic valve disease

Abstract Objective: To assess heart rhythm and predictive factors associated with sinus rhythm after one year in patients with rheumatic valve disease undergoing concomitant surgical treatment of atrial fibrillation. Operative mortality, survival and occurrence of stroke after one year were also evaluated. Methods: Retrospective longitudinal observational study of 103 patients undergoing rheumatic mitral valve surgery and ablation of atrial fibrillation using uni- or bipolar radiofrequency between January 2013 and December 2014. Age, gender, functional class (NYHA), type of atrial fibrillation, EuroSCORE, duration of atrial fibrillation, stroke, left atrial size, left ventricular ejection fraction, cardiopulmonary bypass time, myocardial ischemia time and type of radiofrequency were investigated. Results: After one year, 66.3% of patients were in sinus rhythm. Sinus rhythm at hospital discharge, lower left atrial size in the preoperative period and bipolar radiofrequency were associated with a greater chance of sinus rhythm after one year. Operative mortality was 7.7%. Survival rate after one year was 92.3% and occurrence of stroke was 1%. Conclusion: Atrial fibrillation ablation surgery with surgical approach of rheumatic mitral valve resulted in 63.1% patients in sinus rhythm after one year. Discharge from hospital in sinus rhythm was a predictor of maintenance of this rhythm. Increased left atrium and use of unipolar radiofrequency were associated with lower chance of sinus rhythm. Operative mortality rate of 7.7% and survival and stroke-free survival contribute to excellent care results for this approach.

Progressão de Valvopatia Esquerda durante o Uso de Dopaminérgicos / Progression of Left Valve Disease during Use of Dopaminergic Drugs

A cabergolina e a bromocriptina são drogas dopaminérgicas derivadas do ergot e utilizadas para tratamento de distúrbios hiperprolactinêmicos idiopáticos ou adenomas hipofisários, cujo mecanismo de ação é decorrente da redução da secreção de prolactina. Alguns relatos na literatura demonstram que a cabergolina pode causar valvopatia após sua administração a longo prazo. Relatamos o caso de um paciente com diagnóstico de macroprolactinoma que fez uso intercalado de cabergolina e bromocriptina e desenvolveu alterações valvares antes inexistentes

Experimental validation of a cardiac simulator for in vitro evaluation of prosthetic heart valves

Abstract Objective: This work describes the experimental validation of a cardiac simulator for three heart rates (60, 80 and 100 beats per minute), under physiological conditions, as a suitable environment for prosthetic heart valves testing in the mitral or aortic position. Methods: In the experiment, an aortic bileaflet mechanical valve and a mitral bioprosthesis were employed in the left ventricular model. A test fluid of 47.6% by volume of glycerin solution in water at 36.5ºC was used as blood analogue fluid. A supervisory control and data acquisition system implemented previously in LabVIEW was applied to induce the ventricular operation and to acquire the ventricular signals. The parameters of the left ventricular model operation were based on in vivo and in vitro data. The waves of ventricular and systemic pressures, aortic flow, stroke volume, among others, were acquired while manual adjustments in the arterial impedance model were also established. Results: The acquired waves showed good results concerning some in vivo data and requirements from the ISO 5840 standard. Conclusion: The experimental validation was performed, allowing, in future studies, characterizing the hydrodynamic performance of prosthetic heart valves.

Prosthesis-Patient Mismatch after Mitral Valve Replacement: Comparison of Different Methods of Effective Orifice Area Calculation

PURPOSE: The incidence of prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) has been reported to vary. The purpose of the current study was to investigate incidence of PPM according to the different methods of calculating effective orifice area (EOA), including the continuity equation (CE), pressure half time (PHT) method and use of reference EOA, and to compare these with various echocardiographic variables. MATERIALS AND METHODS: We retrospectively reviewed 166 individuals who received isolated MVR due to rheumatic mitral stenosis and had postoperative echocardiography performed between 12 and 60 months after MVR. EOA was determined by CE (EOA(CE)) and PHT using Doppler echocardiography. Reference EOA was determined from the literature or values offered by the manufacturer. Indexed EOA was used to define PPM as present if < or =1.2 cm2/m2. RESULTS: Prevalence of PPM was different depending on the methods used to calculate EOA, ranging from 7% in PHT method to 49% in referred EOA method to 62% in CE methods. The intraclass correlation coefficient was low between the methods. PPM was associated with raised trans-prosthetic pressure, only when calculated by CE (p=0.021). Indexed EOA(CE) was the only predictor of postoperative systolic pulmonary artery (PA) pressure, even after adjusting for age, preoperative systolic PA pressure and postoperative left atrial volume index (p<0.001). CONCLUSION: Prevalence of mitral PPM varied according to the methods used to calculate EOA in patients with mitral stenosis after MVR. Among the various methods used to define PPM, EOA(CE) was the only predictor of postoperative hemodynamic parameters.

Relationship of Mitral Annular Plane Systolic Excursion (MAPSE) to Left Ventricular Thrombus Formation.

Background: Dilated cardiomyopathy is associated by radial and longitudinal contractile cardiac dysfunction. Left ventricular (LV) thrombus is a frequent finding in patients with dilated cardiomyopathy. The main purpose of our study was to evaluate the role of mitral annular plane systolic excursion (MAPSE) in LV thrombus formation in patients with dilated cardiomyopathy by assessing their correlation. Our additional objective was to compare the relationship of average MAPSE to relations of other LV features [LV size, LV ejection fraction (EF), wall motion score index (WMSI), sphericity index-width to length ratio (w/l) of the LV] and LV thrombus development. Material and Methods: This was a prospective cross-sectional study conducted from October 2009 until January 2012 in 100 sinus rhythm patients with dilated cardiomyopathy without anticoagulation therapy. We excluded patients with: swallowing problems, acute myocardial infarction, atrial fibrillation/flutter, severe systolic dysfunction, severe arterial hypertension, valvular disease, and/or mechanical valves. Results: Mean patient age was 58.1±12.7 years and 69% were men. Mean LV EF was 39.1±6.4%, while mean value of average MAPSE was 9.3±2.2mm. LV thrombus was detected in 14% of patients and its presence correlated well with: average MAPSE (r=-0.22, p=0.01), MAPSE of sepatal wall (r=-0.23, p=0.01), MAPSE of lateral wall (r=-0.2, p=0.02), MAPSE of inferior wall (r=-0.22, p=0.01), LV EF (r=-0.21, p=0.02), LV end diastolic diameter (r=0.24, p=0.008), LV end systolic diameter (r=0.31, p=0.0008), WMSI (r=0.22, p=0.01) and w/l (r=0.19, p=0.03). Conclusions: Longitudinal LV dysfunction is associated with LV thrombus formation, as average MAPSE demonstrates a negative correlation with LV thrombus, and its role is similar to LV size, LV EF, sphericity index and WMSI.

Comparison of superior septal approach with left atriotomy in mitral valve surgery / Comparação da abordagem septal superior com atriotomia esquerda em cirurgia valvar mitral

Objective: In this study, we aimed to compare clinical outcomes of superior transseptal approach with the conventional left atriotomy in patients undergoing mitral valve surgery. Methods: Between January 2010 and November 2012, a total of 91 consecutive adult patients (39 males, 52 females; mean age: 54.0±15.4 years; range, 16 to 82 years) who underwent mitral valve surgery in the Division of Cardiovascular Surgery at Koşuyolu Training Hospital were included. The patients were randomized to either superior transseptal approach (n=47) or conventional left atriotomy (n=44). Demographic characteristics of the patients, comorbidities, additional interventions, intraoperational data, pre- and postoperative electrophysiological study findings, and postoperative complications were recorded. Results: Of all patients, 86.7% (n=79) were in New York Heart Association Class III, while 12 were in New York Heart Association Class IV. All patients underwent annuloplasty (42.9%) or valve replacement surgery (57.1%). There was no significant difference in pre- and postoperative electrocardiogram findings between the groups. Change from baseline in the cardiac rhythm was statistically significant in superior transseptal approach group alone (P<0.001). There was no statistically significant difference in mortality rate between the groups. Permanent pacemaker implantation was performed in 10.6% of the patients in superior transseptal approach group and 4.5% in the conventional left atriotomy group. No statistically significant difference in bleeding, total length of hospital and intensive care unit stay, the presence of low cardiac output syndrome was observed between the groups. Conclusion: Our study results suggest that superior transseptal approach does not lead to serious or fatal adverse effects on sinus node function or atrial vulnerability, compared to conventional approach. .

Objetivo: O objetivo deste estudo é comparar os resultados clínicos da abordagem septal superior com a atriotomia esquerda convencional em pacientes submetidos à cirurgia valvar mitral. Métodos: Entre janeiro de 2010 e novembro de 2012, foi incluído um total de 91 pacientes adultos consecutivos (intervalo de 16 a 82 anos, média 54,0±15,4 anos; 39 homens, 52 mulheres) submetidos à cirurgia valvar mitral no Serviço de Cirurgia Cardiovascular no Hospital Training Koşuyolu. Os pacientes foram randomizados para abordagem septal superior (n=47) ou atriotomia esquerda convencional (n=44). Foram registradas características demográficas dos pacientes, comorbidades, intervenções adicionais, dados intraoperatórios, achados do estudo eletrofisiológico pré e pós-operatório e complicações pós-operatórias. Resultados: Do total de pacientes, 86,7% (n=79) estavam na Classe III e 12 na Classe IV da New York Heart Association. Todos os pacientes foram submetidos à anuloplastia (42,9%) ou cirurgia de troca valvar (57,1%). Não houve diferença significativa nos resultados do eletrocardiograma pré e pós-operatórios entre os grupos. Mudança da linha de base no ritmo cardíaco foi estatisticamente significativa apenas no grupo abordagem septal superior (P<0,001). Não houve diferença estatisticamente significativa na taxa de mortalidade entre os grupos. Marca-passo definitivo foi implantado em 10,6% dos pacientes no grupo abordagem septal superior e em 4,5% dos pacientes no grupo atriotomia esquerda convencional. Não houve diferença estatisticamente significativa no sangramento, tempo total de internação e de permanência na UTI, tendo sido observada síndrome de baixo débito cardíaco entre os grupos. Conclusão: Nossos resultados sugerem que a ...

Heart rate variability and arrhythmias evaluated with Holter in dogs with degenerative mitral valve disease / Variabilidade da frequência cardíaca e arritmias detectadas pelo exame Holter em cães com degeneração valvar mitral

Cardiac diseases promote alterations in the autonomic control of the heart, leading to an increase in heart rate and, as a result, a decrease in heart rate variability (HRV).The aim of this study was to evaluate if the development of heart failure secondary to degenerative mitral valve disease (DMVD) concurs with changes in autonomic modulation of heart rhythm which are assessed by long electrocardiography examination (Holter). Dogs were evaluated by clinical examination and echocardiography in order to be categorized into the following groups: Control (healthy; n=6), DMVD (disease without heart failure; n=8), and DMVD heart failure (disease with heart failure; n=13). Arrhythmias and frequency domain HRV were determined by Holter. Diseased animals, when compared to healthy, had significantly lower total power, which indicates overall HRV. DMVD heart failure dogs also showed other disturbances such as high incidence of supraventricular arrhythmias, high heart rate, little amount of pauses (2.0s long between consecutive heartbeats), longer time in tachycardia, shorter time in bradycardia, low high frequency (parasympathetic control), and high low frequency (sympathetic and parasympathetic control) when compared to control (p<0.05). In DMVD dogs, Holter-derived variables changed with the development of heart failure...

As cardiopatias cursam com alterações do controle autonômico do coração, resultando em taquicardia e consequente diminuição na variabilidade da frequência cardíaca (VFC). O objetivo deste estudo foi avaliar se o desenvolvimento de insuficiência cardíaca secundária à degeneração valvar mitral (DVM) leva a alterações no controle autonômico do coração, as quais podem ser determinadas pela eletrocardiografia contínua (Holter). Cães foram distribuídos em grupos experimentais após avaliação clínica e ecocardiográfica da seguinte maneira: controle (saudáveis; n=6), DVM sem insuficiência cardíaca (n=8) e DVM com insuficiência cardíaca (n=13). Arritmias e VFC foram determinadas pelo Holter. Animais portadores de DVM, quando comparados ao controle, apresentaram diminuição significativa da potência total, a qual é representativa de toda a VFC. Somente cães doentes e com insuficiência cardíaca apresentaram incidência elevada de arritmias supraventriculares, frequência cardíaca aumentada, pequena quantidade de pausas superiores a 2,0s entre batimentos consecutivos, permanência por mais tempo em taquicardia do que em bradicardia, diminuído índice de alta frequência (indicativo de controle parassimpático) e elevado índice de baixa frequência (indicativo de controle simpático e parassimpático), quando comparados ao controle (p<0,05). Assim, conclui-se que, em cães portadores de DVM, as variáveis obtidas com o Holter apresentam-se alteradas devido ao desenvolvimento de insuficiência cardíaca...

Avaliação não invasiva das pressões de enchimento e remodelação do ventrículo esquerdo após infarto do miocárdio / Non invasive assessment of left ventricular filling pressure and remodeling after acute myocardial infarction

FUNDAMENTO: A dilatação do ventrículo esquerdo (VE) após infarto agudo do miocárdio (IAM) é um importante determinante do prognóstico. A razão entre a velocidade diastólica E do fluxo mitral e a velocidade diastólica e' do anel mitral (relação E/e') é o melhor índice não invasivo para detectar elevação aguda da pressão de enchimento do VE. A hipótese deste estudo é que a E/e' possa predizer remodelação do VE após IAM tratado. OBJETIVO: Avaliar se a E/e' prediz remodelação ventricular após IAM, em comparação aos dados clínicos, laboratoriais e ecocardiográficos tradicionais. MÉTODO: Ecocardiogramas foram realizados em pacientes consecutivos com primeiro IAM, após angioplastia transluminal coronariana (ATC) seguida de recanalização efetiva, 48 horas e 60 dias após o evento. A E/e' foi calculada pela média de quatro sítios do anel mitral. Remodelação do VE foi definida como aumento ≥ 15% do volume sistólico final ao método de Simpson. Análises estatísticas incluíram teste t de Student, curvas receptor-operador (ROC) e regressão logística multivariada, com p significante < 0,05. RESULTADOS: Estudados 55 pacientes, com idade 58 ± 11 anos, 43 homens, observou-se E/e' maior (13 ± 4 versus 8,5 ± 2; p < 0,001) no grupo com remodelação (n = 13) em relação ao grupo sem remodelação (n = 42). A curva ROC indicou E/e' como preditor de remodelação (área sob a curva = 0,81, p = 0,001). Análises de regressão contendo variáveis clínicas, laboratoriais e Doppler-ecocardiográficas confirmaram E/e' como preditor independente da remodelação (odds ratio 1,42; p = 0,01). CONCLUSÃO: A relação E/e' é um preditor útil de remodelação do VE após IAM, indicando pacientes com maior risco cardiovascular.

BACKGROUND: Left ventricular (LV) dilation after acute myocardial infarction (AMI) is an important determinant of prognosis. The ratio of early mitral inflow velocity (E) and peak early diastolic annular velocity (e') provides the best single index for noninvasive detection of acute elevation of LV filling pressure. OBJECTIVE: To assess whether E/e' ratio predicts LV remodeling after properly treated AMI compared with traditional clinical, laboratory and echocardiographic data. METHODS: Comprehensive echocardiograms were performed in a series of consecutive patients with first AMI successfully treated with primary percutaneous transluminal angioplasty (PTCA), both 48 hours after intervention and 60 days later. Mean E/e' was determined from four sites of the mitral annulus. LV remodeling was defined as more than 15% increase in end-systolic volume estimated by Simpson method. Statistical analysis included Student's t test, receiver-operator curves (ROC) and multivariate logistic regression (all significant with p < 0.05). RESULTS: Fifty-five patients were included, with mean age 58 ± 11 years, 43 men. The group of patients who underwent LV remodeling (n = 13) had higher baseline E/e' than those without (13 ± 4 versus 8.5 ± 2, p < 0.001). The ROC curve showed E/e' > 15 as a predictor of remodeling (AUC = 0.81, p = 0.001). In addition, regression analysis (comprising clinical, laboratory and echocardiographic variables along with AMI site) confirmed the independent value of E/e' in the prediction of LV remodeling (odds ratio 1.42, p = 0.01). CONCLUSION: The E/e' ratio is a useful predictor of LV remodeling after AMI, indicating patients with increased cardiovascular risk.

Correção da ruptura de cordas tendíneas na insuficiência mitral degenerativa pelo emprego de cordas padronizadas de pericárdio bovino / Surgical repair of chordae tendineae rupture after degenerative valvular regurgitation using standardized bovine pericardium

OBJETIVO: Avaliar, clinicamente e pelo ecodopplercardiograma, o funcionamento da valva mitral em 22 pacientes submetidos à correção do refluxo valvar com substituição das cordas tendíneas nativas por cordas padronizadas de pericárdio bovino. MÉTODOS: Os pacientes apresentavam insuficiência mitral degenerativa. Quatorze (63,6%) pacientes eram do gênero masculino e a idade variou de 19 a 76 anos (média 56,8±13,8 anos). As cordas de pericárdio bovino foram tratadas com glutaraldeído, com reforço de suas extremidades transversais formando um trapézio. RESULTADOS: Um (4,5%) paciente faleceu no pós-operatório imediato em síndrome de baixo débito cardíaco e três (13,6%) no pós-operatório tardio. Uma (4,5%) paciente foi reoperada. As curvas atuariais de sobrevivência livre de óbitos por causa cardiovascular e livres de reoperações para os pacientes que deixaram o hospital (21) demonstraram taxas de 82,0±9,8% e 83,9±10,4%, aos 70 meses de pós-operatório, respectivamente. Dezessete (77,3%) pacientes estão vivos com a própria valva. Dos 17 pacientes vivos com a própria valva 16 (94,1%) estão em classe funcional I. O ecodoppler pós-operatório (média de 41 meses; 4 a 70 meses) demonstrou ausência de regurgitação mitral em 11 (64,7%) pacientes e regurgitação discreta em cinco (29,4%). CONCLUSÃO: A técnica de implante de cordas padronizadas de pericárdio bovino para substituição de cordas tendíneas da valva mitral em pacientes com insuficiência mitral degenerativa demonstrou resultados bastante satisfatórios.

OBJECTIVE: To evaluate clinically and by Doppler Echocardiography 22 patients submitted to mitral valve repair after valvular regurgitation using standardized bovine pericardium chordae. METHODS: The patients had degenerative mitral regurgitation. Fourteen (63.6%) patients were male and the age ranged from 19 to 76 years (mean 56.8 ± 13.8 years). The strings of bovine pericardium treated with glutaraldehyde were reinforced in its transverse ends forming a trapezoid. RESULTS: One patient (4.5%) died in the immediate postoperative period with in low cardiac output syndrome and three (13.6%) in the late postoperative period. One patient (4.5%) was reoperated. The actuarial curves for survival free of death from cardiovascular causes and free from reoperation for patients who left the hospital (21), showed rates of 82.0 ± 9.8% and 83.9 ± 10.4% at 70 months postoperatively, respectively. Seventeen patients (77.3%) are alive with native valves. Of the 17 patients alive with native valves 16 (94.1%) were in functional class I. The Doppler Echocardiography postoperatively (mean 41 months, 4-70 months), showed no mitral regurgitation in 11 (64.7%) patients and mild regurgitation in five (29.4%). CONCLUSION: The technique of standard cords of bovine pericardium implantation to replace chordae tendineae of the mitral valve in patients with degenerative mitral regurgitation showed satisfactory results.

Echocardiographic quantification of mitral valvular response to myocardial revascularization.

Aims and Objectives: Mild and/or moderate ischemic mitral regurgitation (IMR) may resolve after isolated coronary artery bypass grafting (CABG). It has been shown that the loss of saddle shape of the mitral valve is associated with IMR and is determined by an increase in the nonplanarity angle (NPA). The aim of this prospective, observational study was to test the hypothesis that NPA might decrease immediately after CABG alone in patients with mild to moderate IMR. Materials and Methods: This prospective, observational study was conducted in an academic, tertiary care hospital. Twenty patients underwent 2D and 3D transoesophageal echocardiography (TEE) and mitral valve assessment before and immediately after the CABG. NPA, circularity index, and other geometric variables were obtained. They were compared using paired t test. The SPSS (Version 15.0, Chicago, IL, USA) was used for statistical analysis. P <0.05 was considered significant. Results: The NPA was similar in the pre- and post-bypass periods (148° ± 15°, 148° ± 19°, P = 0.88). Circularity index (0.93 ± 0.13, 0.97 ± 0.11, P = 0.41) also was similar. Conclusions: There was no change in the mitral valve NPA with revascularization alone in patients with mild or moderate IMR. Mitral valve does not change its planarity (NPA) with revascularization alone in patients with IMR.

Válvula aórtica bicúspide y dilatación de la raíz de la aorta o de la aorta ascendente / Dilatation of the aortic root and the ascending aorta in patients with bicuspid aortic valve disease

La dilatación de la aorta ascendente es un acompañante muy frecuente de la valvulopatía aórtica bicúspide, y a su vez la cardiopatía congénita más frecuente. Entre las teorías acerca de su origen, la más establecida es la que la liga al efecto de metaloproteinasas sobre la pared arterial. En este editorial se hace referencia a la publicación simultánea en este número del artículo de Dayan et al., que describen la evolución de la dilatación aórtica post reemplazo valvular.

Aortic root and ascending aorta dilatacion is a common consequence of bicsupid aortic valve disease, in turn the most frequent form of congenital heart disease. Among the different theories proposed to explain this finding, the action of metallo proteinases upon the aortic wall seems to be well established. In this Editorial, the concurrent work by Dayan et al published in this issue, dealing with aortic root dilatation post aortic valve replacement in patients with bicuspid aortic valve is analyzed.