Usefulness of three-dimensional transesophageal echocardiographic imaging for evaluating narrowing in the coronary arteries.

Coronary artery (CA) imaging has relied on invasive techniques for diagnosing stenotic lesions. Two-dimensional techniques are limited in obtaining optimal longitudinal views of all segments of the CA because of their spatial orientations. Three-dimensional echocardiography (3DE) may produce any desired cross-sectional views and reconstruct 3-dimensional images from a volumetric data set. Its role in CA imaging has not been fully explored. The aim of this study was to evaluate the potential of 3DE in visualizing CAs and in assessing the severity of stenosis. We performed transesophageal 3DE in 46 patients. Images were collected sequentially with the transducer rotated through 180 degrees. From the 3DE data sets of all 46 patients, cross-sectional views and 3-dimensional images of CAs were reconstructed. For segment-by-segment comparison between CA angiography and 3DE in semiquantitative analysis of coronary stenosis, 5 segments were defined for the proximal CA tree in 20 patients who underwent both procedures. The left main, anterior descending, circumflex, and right CAs were visualized from 3DE in 100%, 100%, 98%, and 72%. The available lengths of these segments from 3DE were 12+/-4 mm (range 4 to 22), 15+/-6 mm (range 6 to 36), 30+/-12 mm (range 13 to 60), and 18+/-9 mm (range 6 to 36), respectively. Comparison between 3DE and CA angiography in semiquantitative estimation of CA stenosis resulted in complete agreement in 83% of the segments (kappa value = 0.7). The sensitivity and specificity of 3DE in detecting significant stenosis (> or =50%) were 84% and 97%. In conclusion, transesophageal 3DE allows imaging of the proximal CA, detection of stenotic lesions, and estimation of the severity of stenosis.

Secundum atrial septal defect is a dynamic three-dimensional entity.

BACKGROUND: The aim of this study was to evaluate the diagnostic relevance of 3-dimensional (3D) echocardiography in the assessment of secundum atrial septum defect (ASD2). METHODS AND RESULTS: Twenty-three patients (age 2 to 58 years) with an ASD2 were studied by transthoracic (n = 9) or transesophageal (n = 14) echocardiography for the acquisition of a 3D data set before undergoing surgical repair. Qualitative (location, shape, and structure) and quantitative (largest and smallest anteroposterior and superoinferior diameters) characteristics were analyzed and compared with surgical findings. Intraobserver and interobserver variability were assessed. The gross anatomy of the ASD2, shown by the 3D images, was confirmed by the surgeon in 21 of 23 patients, but the presence of membranous or fenestrated remnants of the valvula foramina ovalis in the defect was not optimally visualized in 7 patients. Three-dimensional echocardiography revealed changes in diameter and shape of the ASD2 during the cardiac cycle. The measured largest and smallest anteroposterior diameters and their intraobserver and interobserver agreement were 274 +/- 12 mm, r = 0. 95 (P <.001), r = 0.92 (P <.001), and 194 +/- 9 mm, r = 0.96 (P <. 001), r = 0.94 (P <.001), respectively. The measured largest and smallest superoinferior diameter and their intraobserver and interobserver agreement were 304 +/- 26 mm, r = 0.90 (P <.001), r = 0.97 (P <.001), and 204 +/- 10 mm, r = 0.83 (P <.001), r = 0.84 ( P <.001), respectively. The correlation coefficient between 2D and 3D echocardiography for the largest anteroposterior and superoinferior diameter was r = 0.69 (P <.001) and r = 0.68 (P =.05), respectively. The correlation coefficient between the measurements from 3D reconstructions and direct surgical measurements was r = 0.20 (P = not significant) and r = 0.57 (P <.05), whereas between 2D and surgery was r = 0.50 (P <.05) and r = 0.26 (P = not significant). CONCLUSIONS: ASD2 has a complex morphology. Three-dimensional echocardiography provides better qualitative and quantitative information on its dynamic geometry, location, and extension as compared with standard 2D echocardiography and might be useful for device selection during catheter-based closure of ASD2.

A structural modeling analysis of anxiety and depression in patients undergoing coronary artery bypass graft surgery: a model generating approach.

The present study is a longitudinal study designed to explore structural relationships between anxiety, depression, personality, and background factors (e.g., gender, age, and complicated medical characteristics) in patients undergoing coronary artery bypass graft (CABG) surgery. At two timepoints before and two after CABG, 217 patients completed self-report questionnaires. To explore structural relationships, the structural equation modeling (SEM) method was applied. Using the model-generating approach, a model was developed, providing a good fit. The structural relationships revealed, in particular, the key position of neuroticism, which was related to both pre- and postoperative anxiety and depression. Relationships between anxiety and depression over time, both intra- and interrelationships, were relatively weak. Relationships between anxiety and depression at the same points in time were relatively strong, with preoperative depression leading to preoperative anxiety, and postoperative anxiety leading to postoperative depression. To provide a useful framework for development of intervention strategies, further research is needed to evaluate the plausibility of the final structural model.

Intracranial high-intensity transient signals after homograft or mechanical aortic valve replacement.

OBJECTIVE: Comparison of the occurrence, intensity and rate of high-intensity transient signals (HITS), measured in both middle cerebral arteries by transcranial Doppler ultrasound (TCD) after mechanical or homograft aortic valve implantation. EXPERIMENTAL DESIGN: TCD monitoring was performed by means of a pulsed Doppler ultrasound with two 2 MHz probes, stabilized on the head and directed at the middle cerebral artery. SETTING: Outdoor patients after aortic valve replacement in a university hospital. PATIENTS: The study cohort comprised a random transverse sample of patients and included 20 patients with a mechanical aortic valve and 20 with a homograft aortic valve. Comparisons were made with 20 admitted control patients. INTERVENTIONS: No interventions. MEASURES: No significant number of HITS were expected in the homograft group and a limited number in the mechanical valve group. RESULTS: HITS were detected in more patients after implantation of a mechanical aortic valve prosthesis compared with a homograft aortic valve (16 versus 8, p=0.02). Nevertheless, more patients with a homograft aortic valve showed HITS than the control patients (8 versus 1, p=0.02). The mean number of HITS in the mechanical prosthesis group was higher than in the homograft group (3, range 0-18 versus 13, range 0-70, p<0.05). HITS in patients with mechanical prostheses had a higher amplitude than HITS in patients with homograft aortic valves (p<0.0001). Focal neurological deficit (FND) was diagnosed in 9 patients (mechanical prosthesis 6 versus homograft 3, ns). CONCLUSIONS: HITS commonly occur both in patients with a mechanical aortic valve and in patients with a homograft aortic valve. HITS occur significantly less often, at a lower rate and with a lower intensity in patients with homograft aortic valve compared with patients with a mechanical aortic valve. Future studies should elucidate the nature and prognostic significance of HITS and their relationship with thromboembolic events.

Gradient echo MRI for measurement of the pulmonary autograft diameter after transplantation to the aortic root: validation and comparison with ultrasound.

The purpose of this study was to s the value of MRI for measurement of pulmonary autograft diameters after transplantation to the aortic root in adults. Thirty-eight adults underwent this operation. MRI and transesophageal echocardiography (TEE) were performed in 30 and 27 patients, respectively, after a mean follow-up period of 2.8 years. For internal validation of MRI, measurements at the diastolic short and long axes of the sinus level were used. Pulmonary autograft diameters were measured and compared with MRI and TEE at five different levels: the subannular region (1), annulus (2), sinus (3), sinotubular junction (4), and the distal part of the autograft (5). The correlation coefficient (r2) between long- and short-axis measurements for corresponding sinuses was .97. Diameters obtained with MRI were 1 to 3 mm larger than those obtained with TEE (P < .05), except for the annulus at systole (P > .3). Cine gradient echo MRI is an appropriate technique to evaluate pulmonary autograft diameters during follow-up. Concordance with TEE was good, apart from a systematic difference of approximately 2 mm.

The course of anxiety and depression in patients undergoing coronary artery bypass graft surgery.

A semilongitudinal study was designed to follow-up the course of anxiety and depression in patients undergoing coronary artery bypass graft (CABG) surgery. The focus was on possible effects of gender and age on variations in both mean level and interindividual differences over time. At two timepoints before and two after surgery, 217 patients completed self-report questionnaires. Multivariate testing revealed an overall decrease in mean levels of anxiety and depression in the postoperative period but different trends for men and women. Compared with men, women reported more anxiety and depression, both pre- and postoperatively, but showed a relatively stronger decrease in the early postoperative period. Regarding variations in interindividual differences over time, multivariate testing revealed different trends of depression for men and women. Women appeared to be most homogeneous in the early days after surgery, whereas interindividual differences for men showed a stable trend.

Aortic allograft implantation techniques: pathomorphology and regurgitant jet patterns by Doppler echocardiographic studies.

BACKGROUND: The diagnosis of allograft-specific pathology by echocardiography has important consequences for patient counseling and research. This study describes the pathomorphologic findings and color Doppler jet patterns in a consecutive series of patients after allograft placement with either the subcoronary implantation or root replacement technique. METHODS: From 1987 to July 1996, the subcoronary allograft implantation technique and root replacement technique were used in 82 patients and 70 patients, respectively. These patients comprised the study group. RESULTS: The incidence of paravalvular leaks and eccentric regurgitant jets was higher with subcoronary implantation (41%) than with root replacement (11%). Patients with a subcoronary implanted allograft had a higher incidence of eccentric jets. CONCLUSIONS: These findings support the concept of preservation of valve geometry after root replacement, as allograft-specific pathomorphologic abnormalities and eccentric jets are more common after subcoronary implantation of allografts. Learning effects, however, cannot be excluded as the cause of these abnormalities.

Cosgrove-Edwards mitral ring dynamics measured with transesophageal three-dimensional echocardiography.

BACKGROUND: Flexible rings have been introduced for improved mitral valve annuloplasty. These rings allow systolic-diastolic variation of both the shape and the area of the valve orifice, mimicking the normal dynamics of the mitral valve ring. In humans, information on the functional behavior of the Cosgrove-Edwards ring during the cardiac cycle is limited at present. METHODS: We used transesophageal three-dimensional echocardiography to analyze mitral valve rings in 19 consecutive patients who underwent annuloplasty because of severe (grade III to IV) mitral regurgitation. Fifteen patients received a Cosgrove-Edwards ring and 4 received a Carpentier ring. The acquisition for three-dimensional reconstruction was performed using the transesophageal rotational technique, immediately after operation. Horizontal cross-sections through the mitral valve ring were selected from the data sets for measurement of the dimensions and surface area of the mitral valve orifice at end-systole and end-diastole. Measurements of the flexible Cosgrove-Edwards ring and the rigid Carpentier ring were compared. RESULTS: Adequate images for measurements were obtained in 17 of 19 patients. The end-systolic orifice area of the Cosgrove-Edwards ring was 4.21 +/- 1.50 cm2 (mean +/- standard deviation) and the end-diastolic area was 4.81 +/- 1.56 cm2 (p < 0.0001). No significant change in the orifice area of the Carpentier ring was observed. CONCLUSIONS: Three-dimensional transesophageal echocardiography allows the functional assessment in vivo of mitral valve annuloplasty rings. The Cosgrove-Edwards ring maintains its flexibility early after implantation and demonstrates significant systolic-diastolic changes in the orifice area during the cardiac cycle.

A comparison of adult pulmonary autograft diameter measurements with echocardiography and magnetic resonance imaging.

UNLABELLED: In 38 consecutive patients the pulmonary autograft was used in aortic root replacement. Investigations were performed with transthoracic echocardiography, transoesophageal echocardiography and magnetic resonance imaging in 31, 27 and 27 patients respectively. The mean age at operation was 28.7 years (range 19.0-52.0) and the follow-up period was 2.8 years (range 0.8-6.7). The pulmonary autograft diameter was measured at the subannular region (1), at the annulus at the hinge points of the valve leaflets (2), at the sinus (3), at the sino-tubular junction (4) and at the distal part of the autograft (5). With transoesophageal echocardiography the mean systolic measurements at levels 1 to 5 were 32, 31, 42, 35 and 34 mm, respectively. The corresponding diastolic measurements were smaller: 25, 28, 42, 35 and 34 mm respectively. There was no significant difference between transthoracic echocardiography and transoesophageal echocardiography measurements of the proximal autograft (levels 1-3). Diameters obtained with magnetic resonance imaging were 1 to 3 mm larger than those obtained with transthoracic echocardiography and transoesophageal echocardiography (P < 0.05), except the annulus at systole (P > 0.3). CONCLUSIONS: The mean pulmonary autograft diameters measured using transthoracic echocardiography, transoesophageal echocardiography and magnetic resonance imaging were larger than native aortic and pulmonary diameters of a normal population in the same age group. Diameters of the distal 2 levels could not be imaged reliably with transthoracic echocardiography. Magnetic resonance imaging diameter measurements were, in general, larger than with echocardiography.

Prediction of quality of life after coronary artery bypass graft surgery: a review and evaluation of multiple, recent studies.

OBJECTIVE: To review studies predicting psychosocial outcome after coronary artery bypass graft surgery (CABG). METHODS: Seventeen prospective studies, appearing in the MEDLINE and PsycLIT data bases between 1986 and 1996, were reviewed regarding objectives, methodological issues, results, and clinical relevance. RESULTS: All studies reported that psychological factors bad predictive value. In particular, preoperative anxiety and depression predicted postoperative psychological maladjustment; social support, preoperative feelings of control, denial, and optimism contributed to psychological adjustment. CONCLUSIONS: Many specific psychological outcomes seem to be best predicted by preoperative assessment of functions in that specific area, especially in the case of anxiety and depression. Furthermore, personality factors including denial, optimism, control, and the need for support appear to be predictors of psychological outcome. Appropriate identification of predictive factors might improve the development of individually tailored interventions for patients at risk of postoperative psychological problems.

Does the pulmonary autograft in the aortic position in adults increase in diameter? An echocardiographic study.

OBJECTIVE: The objective of this study was to discern the fate of the pulmonary autograft diameter over time in adults and its relation to aortic regurgitation in the setting of aortic root replacement. METHODS: From January 1989 to May 1995, 36 consecutive adult patients underwent aortic root replacement with a pulmonary autograft for aortic valve disease. The mean age of 20 male and 16 female patients was 29.1 years (range 19.3 to 52.1 years). The mean follow-up was 2.3 years (range 0.3 to 6.0 years). Two patients died in the hospital. One other patient had a second operation for stenosis at the distal suture line of the allograft in the pulmonary position. Pulmonary autograft anulus and sinus diameters were measured with epicardial echocardiography before (only anulus) and after cardiopulmonary bypass, with transthoracic echocardiography at hospital discharge, and with transesophageal echocardiography during follow-up. RESULTS: The mean autograft anulus diameter did not increase immediately after cardiopulmonary bypass (mean diameter 26.2 mm before and 26.4 mm after cardiopulmonary bypass). The mean autograft sinus diameter after cardiopulmonary bypass was 36.5 mm. The mean autograft anulus diameter increased to 31.5 mm at follow-up, an increase of 5.1 mm (19%). The mean autograft sinus diameter increased to 43.9 mm at follow-up, an increase of 7.4 mm (20%). Fifty-nine percent of the anulus diameter increase and 40% of the sinus diameter increase was already reached at hospital discharge (7 to 10 days after the operation); the other part of the increase occurred during follow-up. Diameter increase was associated with neither the length of follow-up (follow-up less than 1 year compared with a longer follow-up) or severity of aortic regurgitation. CONCLUSION: Pulmonary autograft anulus and sinus diameters increase the first year after aortic root replacement with a pulmonary autograft. This occurs rapidly within 10 days after the operation, with a further increase during follow-up, without causing significant aortic regurgitation at medium-term follow-up.

Reproducibility of color Doppler flow quantification of aortic regurgitation.

The preferred method for quantification of aortic regurgitation severity with color Doppler echocardiography is the assessment of the ratio of jet diameter to left ventricular outflow tract diameter and jet area to left ventricular outflow tract area. However, the reproducibility of these measurements is not known and may limit its clinical application. This study was performed to identify sources of variability and reproducibility of the echocardiographic data. We examined 62 color Doppler echocardiographic examinations of patients showing isolated aortic regurgitation after human tissue valve implantation. The mean differences with standard deviations between paired measurements were calculated. The interobserver, intraobserver, and interframe variability showed a close agreement for the jet diameter and left ventricular outflow tract diameter measurements. The agreement for jet area and left ventricular outflow tract area measurements showed a small bias, but a large variance. The reproducibility of jet-left ventricular outflow tract diameter is better than the jet-left ventricular outflow tract area measurement and is more accurate to assess the severity of aortic regurgitation from color Doppler images.

Initial results of combined anterior mitral leaflet extension and myectomy in patients with obstructive hypertrophic cardiomyopathy.

OBJECTIVES: The purpose of this study was to describe the clinical and functional results of combined anterior mitral leaflet extension and myectomy in patients with hypertrophic obstructive cardiomyopathy. BACKGROUND: Septal myectomy is the most commonly performed surgical procedure in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction. Because of the role of the mitral valve in creating the outflow tract gradient, mitral valve replacement or plication is performed in selected cases in combination with myectomy, often with better hemodynamic results than those of myectomy alone. Mitral valve leaflet extension, in which a glutaraldehyde-preserved autologous pericardial patch is used to enlarge the mitral valve along its horizontal axis, is a novel surgical approach in patients with hypertrophic obstructive cardiomyopathy. METHODS: Eight patients with hypertrophic obstructive cardiomyopathy were treated with mitral leaflet extension and myectomy. Preoperative and postoperative data (New York Heart Association functional class, number of drugs prescribed, width of the interventricular septum, severity of mitral valve regurgitation severity of systolic anterior motion of the mitral valve and outflow tract gradient) were compared with those of 12 patients undergoing myectomy alone. RESULTS: Preoperative evaluation demonstrated that mitral regurgitation and systolic anterior motion of the mitral valve were more severe in the group undergoing mitral valve extension (p < 0.001 and p < 0.05, respectively). There were no deaths associated with either surgical procedure. Two patients, both treated by myectomy alone, died during the follow-up period. Postoperatively, patients treated with mitral valve extension had less mitral regurgitation (p < 0.005), less residual systolic anterior motion (p < 0.001), greater improvement in functional class (p = 0.05) and greater reduction in the number of drugs (p < 0.005) and in septal thickness (p < 0.05). CONCLUSIONS: Mitral leaflet extension in combination with myectomy is a promising new surgical approach that may provide superior results to those of myectomy alone. Further studies are needed to determine the clinical value of this procedure.

Subcoronary implantation or aortic root replacement for human tissue valves: sufficient data to prefer either technique?

The aortic root replacement technique with aortic allograft or pulmonary autograft might be superior to the subcoronary allograft implantation technique with regard to aortic regurgitation. We explored the influence of the learning process on the incidence of reoperation and the severity of postoperative aortic regurgitation as assessed by color Doppler echocardiography. The subcoronary implantation technique was used in 81 patients, and root replacement was done in 63 patients. The first 30 patients of each group were considered as the surgeons' learning curve. Reoperations were more common in the subcoronary implantation group. After exclusion of early reoperations, the median regurgitation score based on echocardiographic examination was 0.22 in the first 30 patients from the subcoronary implantation group and 0.14 in the root replacement group. The subsequent patients from these groups had regurgitation scores of 0.20 and 0.17, respectively. Statistical analysis of these data showed no significant difference. This interim report suggests that the learning curve for the surgical procedure and the grouping of echocardiographic data influence the interpretation of follow-up studies. The superiority of either technique with regard to aortic regurgitation has yet to be proved.

Multiplane transoesophageal echocardiography and morphology of regurgitant mitral valves in surgical repair.

BACKGROUND: An essential step in the surgical management of patients with mitral regurgitation, is a thorough understanding of the pathophysiological mechanism. This information can be obtained by multiplane transoesophageal echocardiography which displays all the components of the incompetent valve. METHODS AND RESULTS: Forty-nine patients were scanned intra-operatively by multiplane transoesophageal echocardiography, and findings compared with those at visual inspection during surgery. The pre-operative diagnosis was prolapse of the anterior mitral leaflet in nine patients (sensitivity 100%, specificity 95%), prolapse of the posterior leaflet in 17 patients (sensitivity 100%, specificity 94%) and prolapse of both leaflets in eight patients (sensitivity 87%, specificity 100%). In 11 patients annular dilatation with no abnormalities in mitral leaflet closure or motion was diagnosed (sensitivity 73%, specificity 100%). Two patients had a false-positive diagnosis of prolapse of the anterior leaflet, two others on the posterior leaflet. A prolapse of both leaflets was overlooked in one patient. Multiplane transoesophageal echocardiography scanned the mitral valve, disclosing the extent of pathology along the closure line of leaflets in 88% of patients with mitral valve prolapse. The antero-posterior diameter of the mitral annulus was measured: a diameter over 35 mm indicated annular dilatation. Using this criterion, sensitivity was 89% and specificity 100%. CONCLUSIONS: Multiplane transoesophageal echocardiography enabled components of the mitral valve to be examined systematically, and provided important information on the pathophysiological mechanism of mitral regurgitation before surgical repair. The method also allowed the surgical outcome to be assessed, offering the possibility of optimal repair.

Aortic root replacement with a pulmonary autograft.

A series of 42 consecutive patients with exclusively aortic root replacement using the pulmonary autograft is presented. The mean age at operation was 19.3 years (range 0.3-41.4). Two patients died in hospital (4.8%; 70% CL: 0.0-8.2). This mortality was not related to the autograft procedure. The mean follow-up time was 30 months (range 3-70; SD: 20). Late mortality consisted of two patients; in one of these severe autograft failure occurred due to chronic juvenile rheumatoid arthritis. The estimated survival rate at 4 years was 88.8% (70% CL: 83.3-94.5). Morbidity involved three patients. One had a total heart block after operation, requiring pacemaker implantation and two patients were reoperated: one for severe autograft failure due to recurrent acute rheumatic fever and the other for severe stenosis at the distal anastomosis of the pulmonary allograft. Thromboembolic complications and endocarditis were not registered. Reoperations for technical or degenerative reasons were not necessary. The estimated event-free survival rate at 4 years was 78.7% (70% CL: 71.0-86.4). Serial echocardiography (n = 28) showed a significant increase of the autograft annulus diameter of 2.9 mm (SD: 2.7). Thirty-five of the 37 patients with an autograft in situ were in NYHA class I, and 2 in class II. At last follow-up precordial color Doppler echocardiography showed moderate aortic regurgitation in one patient and no, trivial or mild aortic regurgitation in 36 patients. Stenosis of the autograft was not observed. These medium-term results are promising with respect to mortality, morbidity and functional results.(ABSTRACT TRUNCATED AT 250 WORDS)

[An echocardiographic analysis of the insufficient mitral valve: its intraoperative functional anatomy in relation to valvular reconstruction]. / Analisi ecocardiografica della valvola mitrale insufficiente: anatomia funzionale intraoperatoria in relazione alla ricostruzione valvolare.

Mitral valve repair in patients with mitral regurgitation requires a precise evaluation of the mechanism of valvular pathology before surgery. Transesophageal echocardiography has become the principal method for imaging valvular pathology, especially with the latest introduction of multiplanar transesophageal technology. Traditionally, echocardiographic analysis of regurgitant mitral valves has concentrated on the description of abnormalities of leaflet motion such as prolapse, while surgical correction aims at restoring the coaptation of the edges of the leaflets. To reconcile these different approaches, the echocardiographic features the findings on direct inspection, and the types of repair performed were analyzed in 37 incompetent mitral valves. The zone of coaptation of the mitral valve was studied in a series of left ventricular long-axis views obtained with a transesophageal multiplanar echo-transducer from the anterolateral via the central, to the posteromedial segment. Four patterns of leaflet closure were found: normal apart from a dilated annulus (24%), normal apposition but absent coaptation (8%); asymmetrical apposition but intact coaptation (16%); and abnormal apposition and absent coaptation (52%). In addition leaflet motion was described (prolapse, retraction, normal), and the anteroposterior dimension of the mitral annulus was measured. There was a direct relationship between these echocardiographic findings and the types of reconstructive techniques used. The echocardiographic analysis offers a logical approach to the preoperative diagnosis of regurgitant mitral valves, with the possibility to predict the feasibility and the type of mitral repair.

Ultrasonic dynamic three-dimensional visualization of the heart with a multiplane transesophageal imaging transducer.

Dynamic three-dimensional echocardiography enables objective analysis of structures and pathologic conditions of complex geometry. In addition, it may provide more accurate quantitative analysis of cardiac function. This study presents the first results obtained with multiplane transesophageal diagnostic imaging system that is connected to a dedicated software configuration allowing three-dimensional tissue reconstruction and its dynamic display at 25 frames/sec. In addition, it permits "computer slicing" through the beating heart along arbitrary orientations and the display of synthetic cross sections along these orientations with excellent resolution and grey values (dynamic anyplane echocardiography). The advantage of a multiplane transesophageal imaging transducer is that the acquisition of cross sections for three-dimensional reconstruction becomes an integral part of a routine diagnostic transesophageal study and only requires an additional 7 to 10 minutes of examination time. This approach will help to develop three-dimensional echocardiography and synthetic anyplane echocardiography into a practical clinical tool offering diagnostic information similar to magnetic resonance imaging.

[Aortic valve replacement using aortic donor valves of human origin]. / Aortaklepvervanging met menselijke aortale donorkleppen.

OBJECTIVE: To evaluate the experiences of aortic valve replacement with cryopreserved aortic allografts in the subcoronary position. DESIGN: Descriptive clinical study. SETTING: Thorax Centre of Rotterdam University Hospital. METHOD: In the period July 1988-March 1993, 68 patients (45 men and 23 women) with a mean age of 45 years underwent 69 operations. One woman was operated twice. Main criteria for aortic valve replacement by an allograft were age and endocarditis. The pathology leading to aortic valve dysfunction had been: endocarditis (38%), congenital lesions (32%), rheumatic lesions (19%), senile degeneration (7%), paravalvular leakage (3%) and an active autoimmune disease (1%). RESULTS: Hospital mortality was 4%. The mean follow-up was 22 months, with a cumulative follow-up of 126 patient years. One patient died of lung cancer during this period. Six patients needed a second operation (9%); 4 of these were among the first 15 patients operated on. One of these reoperations was necessary to treat a recurrent endocarditis. Only one other late valve-related event took place: a transient ischaemic attack 2 years postoperatively. Ninety-one per cent of the patients with an allograft in situ were in NYHA class I at their last outpatient clinic visit. The other patients were in class II. Pre-cordial color Doppler echocardiography showed no or mild aortic regurgitation in 95% of these patients. The remaining 3 patients had moderate aortic regurgitation. CONCLUSION: Aortic valve replacement with an allograft was performed with low hospital mortality. The expected advantages are greatest in young patients and patients with endocarditis; these patients, therefore, should have priority in allograft allocation.

Repair of commissural prolapse by extended leaflet sliding.

Three patients had chronic mitral regurgitation due to commissural chorda rupture with commissural prolapse. Two of them had myxomatous valve disease and 1 had fibroelastic deficiency. Characteristic intraoperative epicardial and transesophageal echocardiographic findings are demonstrated. A technique is proposed that involves creating a new commissure and avoiding annular plication by extended sliding plasty and rotating the posterior mitral leaflet.