Obstruction of left ventricular outflow tract by vegetation and periaortic abscess.

Echocardiography is the modality of choice for the noninvasive recognition of vegetations and abscesses that complicate endocarditis. Vegetation size is highly variable, and it has been suggested that large vegetations are related to a more complicated course. The case we present is unusual in that the echocardiographically detected vegetation was very large, highly mobile, and caused severe obstruction of the left ventricular outflow tract, which led to impaction and cardiac arrest.

Left main stenting-as a bridge to surgery-for acute type A aortic dissection and anterior myocardial infarction.

Acute anterior wall myocardial infarction is a rare but often catastrophic presentation of ascending aortic dissection. We report the case of a patient who was successfully treated by direct stenting of the left main coronary artery, allowing for definitive surgical correction.

Videoassisted thrombectomy of mechanical prosthetic heart valves.

BACKGROUND AND AIM OF THE STUDY: Thrombosis of a bileaflet mechanical heart valve is a life-threatening clinical event. Surgical thrombectomy of bileaflet mechanical prostheses remains an appropriate treatment in selected patients. METHODS: Between 1996 and 1998, five patients (three men, two women; average age 56 +/- 1 years; range: 56 to 66 years) with thrombosis of left-sided bileaflet mechanical valves were treated with videoassisted thrombectomy of the prosthesis. Four patients had thrombosis of a bileaflet mitral mechanical valve, and one patient had thrombosis of an aortic valve prosthesis. Preoperatively, patients were in either NYHA functional class IV (n = 4) or class I (n = 1). Surgery was performed through a right anterior thoracotomy or a median sternotomy. A rigid 30 degrees thoracoscope was inserted into the left atrium or aorta to visualize the thrombosed valve. The thrombus was extracted and the prosthesis under-surface examined and cleaned. Leaflet mobility, assessed with transesophageal echocardiography, was normal following surgical thrombectomy. RESULTS: Mean cardiopulmonary bypass time was 102 +/- 30 min; mean aortic cross-clamping time was 47 +/- 25 min. There was no hospital mortality; mean hospital stay was 9 +/- 1 days (range: 6 to 11 days). Anticoagulation with intravenous heparin was resumed 24 h after surgery. Three patients were discharged on coumarin treatment alone; two patients received aspirin plus coumarin. Mean postoperative follow up was 7 +/- 8 months (range: 1 to 21 months). One patient died 21 months after thrombectomy of a mitral prosthesis, with an unconfirmed diagnosis of recurrent mitral valve dysfunction. At 1-15 months after surgery, four patients are in NYHA class I, without evidence of prosthesis dysfunction. CONCLUSION: Videoassisted thrombectomy of a bileaflet mechanical heart valve is a treatment option in patients with acute thrombosis of the prosthesis.

Nitric oxide inhalation in the treatment of primary graft failure following heart transplantation.

BACKGROUND: Primary graft failure from right or left ventricular insufficiency remains a serious cause of early death following heart transplantation. Inhaled nitric oxide (NO) is a potent pulmonary vasodilator that could decrease pulmonary pressure and improve right ventricular function. METHODS: Two cases of early graft failure following orthotopic heart transplantation were treated with NO inhalation. The treatment consisted of inhalation of 20 ppm of NO, introduced 4 to 6 hours following transplantation, in 2 patients supported with high doses of inotropic agents and vasopressors in addition to the intra-aortic balloon pump. RESULTS: In the first and second cases, NO inhalation resulted in a decrease in pulmonary artery pressure, in a decrease in pulmonary vascular resistance and in an increase in cardiac index. In the second patient, systemic oxygenation improved markedly 30 minutes after initiation of NO. In the 2 patients, NO inhalation, mechanical ventilation and the intra-aortic balloon pump were weaned 4 days following transplantation. CONCLUSION: Primary graft failure from donor ischemic damage, reperfusion injury or pulmonary hypertension remains a serious complication. The use of an intra-aortic balloon pump, inotropic agents and of inhaled NO appears to offer the best support for recovery of donor heart function. Primary graft failure from right or left ventricular insufficiency remains a serious cause of early mortality following heart transplantation. Ischemic damage of donor heart, reperfusion injury or pulmonary hypertension are the main causes of early graft failure. Although the cause is multifactorial, treatment of primary organ failure remains difficult with dismal results. The objective of the present study was to review the result of 2 patients with donor right heart failure following heart transplantation treated with inhaled nitric oxide (NO).

Transesophageal echocardiographic evaluation of perioperative coronary sinus trauma.

Retrograde cardioplegia is relatively safe, with a rate of coronary sinus rupture of 0.6%. With the advent of perioperative transesophageal echocardiography, it is now possible to detect and evaluate the extent of damage consequent to the use of retrograde cardioplegia and better formulate an intraoperative course of action. The evolution of these lesions can also be monitored by transesophageal echocardiography during the postoperative period.

Remnants of the right valve of the sinus venosus presenting as a right atrial mass on transthoracic echocardiography.

Three patients were referred for suspicion of intracardiac tumour on transthoracic echocardiography. In all patients, the mass appeared as a nonobstructive oval structure measuring approximately 12 x 4 mm, located near the posterior third of the interatrial septum in the right atrium in the apical four-chamber view. The characteristics of the mass were not those of a Eustachian valve or a Chiari network. Multiplane transesophageal echocardiography performed in each of these patients did not reveal a tumour but rather a fibrous band in the right atrium, extending from the inferior to the superior vena cava. These findings are consistent with remnants of the right valve of the sinus venosus. Inclusion of a persistent right valve of the sinus venosus in the differential diagnosis of a right atrial mass can alleviate concern and spare an unnecessary transesophageal examination when the typical transthoracic echocardiographic characteristics are identified.

Simultaneous determination of aortic valve area by the Gorlin formula and by transesophageal echocardiography under different transvalvular flow conditions. Evidence that anatomic aortic valve area does not change with variations in flow in aortic stenosis.

OBJECTIVES: The purpose of this study was to determine the impact of changes in flow on aortic valve area (AVA) as measured by the Gorlin formula and transesophageal echocardiographic (TEE) planimetry. BACKGROUND: The meaning of flow-related changes in AVA calculations using the Gorlin formula in patients with aortic stenosis remains controversial. It has been suggested that flow dependence of the calculated area could be due to a true widening of the orifice as flow increases or to a disproportionate flow dependence of the formula itself. Alternatively, anatomic AVA can be measured by direct planimetry of the valve orifice with TEE. METHODS: Simultaneous measurement of the planimetered and Gorlin valve area was performed intraoperatively under different hemodynamic conditions in 11 patients. Left ventricular and ascending aortic pressures were measured simultaneously after transventricular and aortic punctures. Changes in flow were induced by dobutamine infusion. Using multiplane TEE, AVA was planimetered at the level of the leaflet tips in the short-axis view. RESULTS: Overall, cardiac output, stroke volume and transvalvular volume flow rate ranged from 2.5 to 7.3 liters/min, from 43 to 86 ml and from 102 to 306 ml/min, respectively. During dobutamine infusion, cardiac-output increased by 42% and mean aortic valve gradient by 54%. When minimal flow was compared with maximal flow, the Gorlin area varied from (mean +/- SD) 0.44 +/- 0.12 to 0.60 +/- 0.14 cm2 (p < 0.005). The mean change in Gorlin area under different flow rates was 36 +/- 32%. Despite these changes, there was no significant change in the planimetered area when minimal flow was compared with maximal flow. The mean difference in planimetered area under different flow rates was 0.002 +/- 0.01 cm2 (p = 0.86). CONCLUSIONS: By simultaneous determination of Gorlin formula and TEE planimetry valve areas, we showed that acute changes in transvalvular volume flow substantially altered valve area calculated by the Gorlin formula but did not result in significant alterations of the anatomic valve area in aortic stenosis. These results suggest that the flow-related variation in the Gorlin AVA is due to a disproportionate flow dependence of the formula itself and not a true change in valve area.

Transthoracic echocardiographic assessment of periprosthetic mitral regurgitation using intravenous injection of sonicated albumin.

Mechanical prostheses induce artifacts that decrease the accuracy of conventional transthoracic echocardiographic imaging for the detection and quantitation of periprosthetic mitral regurgitation. In 15 patients undergoing transthoracic echocardiography, injection of sonicated albumin significantly enhanced the assessment of periprosthetic mitral regurgitation with an accuracy similar to that of transesophageal echocardiography.

[Clinical results of peroperative transesophageal echography in peri-valvular leaks of heart prosthesis]. / Résultats cliniques de réparation d'insuffisance périprothétique avec l'aide de l'échographie transoesophagienne per-opératoire.

Perivalvular leaks following prosthetic valve replacement are associated with significant morbidity. Management has classically consisted of valve replacement or blind surgical repair. Our study examines the results of intraoperative transesophageal echo-guided repair of perivalvular leaks (ITEGR). Between November 24, 1987 and January 1st, 1996, 23 patients (10 men, 13 women) at the Montreal Heart Institute underwent ITEGR. Ninety percent were NYHA class III-IV preoperatively. Seventy to 85% had significant cardiac insufficiency preoperatively. Eighty-six percent of the leaks were in the mitral valve location, 90% of which were mechanic prosthesis. Eighty-nine percent of patients had hemolysis with an average LDH of 720. Mean bypass time was 125 minutes with a mean clamp time of 77 minutes. Most patients were undergoing a third operation at the time of repair. Operative mortality was 8%, all due to biventricular failure. A mean follow-up of 67 months showed a late death of 10%. Of the 19 survivors, 77% were NYHA class I-II. Overall mortality was 20%. In our institution valve re-replacement in similar circumstances was associated with an operative and long-term mortality of 7% and 26% respectively. We conclude that intraoperative transesophageal echo-guided repair is an excellent management alternative in patients with perivalvular leaks with decreased late and overall mortality.

Angiosarcomas of the interatrial septum mimicking atrial myxomas.

Angiosarcoma of the heart is a rare tumor. This tumor is most frequently located in the right atrium and pericardium. Localization of a tumor in the interatrial septum usually suggests atrial myxoma. We report two cases of angiosarcoma originating from the interatrial septum, one extending into the right atrium and the other into the left atrium, mimicking atrial myxomas. Transesophageal echocardiography allowed the diagnosis and comprehensive assessment of compromised structures.

Mitral valve rupture following percutaneous mitral commissurotomy: existence of predictive factors.

The purpose of this study was to describe the mechanism and determine predictive factors of mitral valve rupture requiring valve replacement following percutaneous mitral commissurotomy. Of the 350 consecutive patients treated by balloon mitral commissurotomy, the procedure was not completed in 16, and 11 developed acute severe mitral regurgitation requiring valve replacement: seven cases of anterior leaflet rupture, three cases of posterior leaflet rupture and one case of anterior chordal surface. These 27 group I patients were compared to the remaining 323 (group II) in whom the procedure was completed. The 11 excised valves were evaluated by an experienced pathologist. Eight of the 11 patients had an echocardiographic score < 8 (mean score 6.5 +/- 1), no valvular calcification at X-ray and double balloon percutaneous mitral commissurotomy. Microscopy in six patients showed focal fibrous thickening at the site of the rupture but no calcification. One patient developed severe mitral regurgitation due to chordal rupture with an Inoue balloon. The two remaining patients had an echo score of ten and valve calcification on X-ray. Microscopy revealed severe homogeneous chronic rheumatic mitral disease. In one of these two patients, leaflet rupture was related to an 'oversized balloon' (2 x 19 mm + 15 mm). Statistical analysis showed only echo score differences between the two groups (6.9 +/- 1.4 in group I vs 8.2 +/- 1.6 in group II, P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[Is the quantification of mitral valve involvement by transesophageal echography useful before percutaneous mitral commissurotomy?]. / La quantification de l'atteinte valvulaire mitrale par échographie transoesophagienne est-elle utile avant commissurotomie mitrale percutanée?

The aims of this study were to determine the value of quantifying mitral valve disease by transoesophageal echocardiography before percutaneous mitral commissurotomy (PMC) and to analyse the incidence of embolic complications during PMC since the introduction of transoesophageal echocardiography. From March 1987 to December 1991, 317 patients with pure or dominant mitral stenosis were selected by Doppler echocardiography to undergo PMC at the Montreal Institute of Cardiology. The clinical features of the first 138 patients (Group I) were the same as those of the last 179 patients (Group 2) who also underwent routine transoesophageal echocardiography the day before the procedure. A thrombus in the left atrial appendage was observed in 8 patients in Group 2 (4.4%). No embolic complications have occurred since the protocol was changed to include routine transoesophageal echocardiography, whereas 4 embolic episodes, 3 of which were fatal, occurred in patients in group 1. The indication of PMC was turned down because of angiographically severe mitral regurgitation which was underestimated by transthoracic echocardiography in 2 patients in Group 1 (1.4%) and in 3 patients in group 2 (1.6%). The mobility, thickness and degree of calcification of the valves were attributed a score from 0-4 at transthoracic and transoesophageal echocardiography. No difference was observed in the scores of mobility (2.3 +/- 0.5 versus 2.3 +/- 0.05, NS) or valve thickness (2.1 +/- 0.4 versus 2.1 +/- 0.4, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon mitral commissurotomy for mitral restenosis after surgical commissurotomy.

Balloon mitral commissurotomy (BMC) was performed in 113 patients. Of these patients, 27 (24%) (25 women and 2 men, aged 49 +/- 13 years) had recurrent mitral stenosis 13 +/- 6 years (range 5 to 29) after surgical commissurotomy. Eleven patients (41%) were considered at high risk for surgery. BMC resulted in an increase in mitral valve area from 1.1 +/- 0.3 to 1.9 +/- 0.7 cm2 (p < 0.0001), and a decrease in mean mitral gradient from 16 +/- 7 to 6 +/- 3 mm Hg (p < 0.0001). An optimal result of BMC (increase in valve area > or = 25% with a post-BMC valve area > or = 1.5 cm2) was obtained in 18 patients (67%). The results did not differ from those observed in the 86 patients of our entire series without prior surgical commissurotomy. Patients with an optimal result of BMC had a more recent surgical commissurotomy and lesser morphologic alterations of the mitral valve than did those with a nonoptimal result. Patients with echocardiographic scores < 10 had an 80% success rate of BMC; however, this rate decreased to 29% for those with scores > or = 10. One patient (4%) died from a cerebrovascular accident. Clinical follow-up at 1 year showed persistent clinical improvement in 89% of patients with an optimal result of BMC; 72% were in New York Heart Association class I and 17% in class II.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon mitral commissurotomy in patients aged > or = 70 years.

Of 280 patients treated by balloon mitral commissurotomy (BMC) between 1987 and 1991, 28 (10%) were > or = 70 years old. Two patients with associated significant aortic stenosis were excluded from the study. Older patients more often were in New York Heart Association class III or IV (84 vs 67%; p < 0.007) and atrial fibrillation (61 vs 36%; p < 0.0001), and had a higher echocardiographic score (9.3 +/- 2 vs 8 +/- 1.6; p < 0.0004) and a lower baseline cardiac index (2.1 +/- 0.6 vs 2.4 +/- 0.6 liters/min/m2; p < 0.03) than younger ones. Baseline mean pulmonary pressure (37 +/- 11 vs 34 +/- 12 mm Hg), transmitral gradient (14 +/- 4 vs 14 +/- 5 mm Hg) and valve area (1.0 +/- 0.4 vs 1.1 +/- 0.3 cm2) were not different between older and younger patients (p = NS). Acute complications during the procedure (including cardiac perforation, embolism, severe mitral regurgitation and surgical atrial shunt), and 30-day mortality after BMC were more frequent in older than younger patients (27 vs 9% [p < 0.01], and 12 vs 0.8% [p < 0.005], respectively). A complete success, defined as a mitral valve area increase > 25% and postmitral valve area > 1.5 cm2 was obtained in 16 of the 22 older patients (72%) with the completed procedure (compared with 81% of younger ones; p = 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term (9 to 33 months) echocardiographic follow-up after successful percutaneous mitral commissurotomy.

Late results after successful percutaneous mitral commissurotomy were assessed by prospective clinical and echocardiographic follow-up. Fifty-seven patients were followed for a mean of 19 +/- 6 months (range 9 to 33) after the procedure. Mitral valve area (measured by Doppler half-time method) increased from 1.0 +/- 0.2 to 2.2 +/- 0.5 cm2 immediately after commissurotomy, and then decreased to 1.9 +/- 0.5 cm2 at follow-up (p less than 0.05), whereas gradient did not change after its immediate postcommissurotomy reduction. Echocardiographic restenosis (mitral valve area less than or equal to 1.5 cm2 with greater than 50% reduction of initial gain) was seen in 12 of 57 patients (21%). Atrial shunting, detected by transthoracic color Doppler in 61% of patients immediately after the procedure (color flow jet through atrial septum), persisted in 30% at follow-up. Restenosis by univariate analysis correlated with age, smaller valve area after the procedure, and higher echocardiographic score. Multivariate analysis identified leaflet mobility and calcifications as the components of a score that was predictive for restenosis. Magnitude of shunt (pulmonary-to-systemic flow ratio greater than 1.5), use of a Bifoil balloon (2 balloons on 1 shaft), and smaller valve area after the procedure were predictors by multivariate analysis of the persistence of atrial shunting. Clinical improvement persisted at long-term follow-up (mean New York Heart Association class 1.6 +/- 0.6 vs 2.6 +/- 0.6 before commissurotomy). Improvement of greater than or equal to 1 functional class was seen in 75% of patients (80% of those without and 58% of those with restenosis); patients with a shunt did not differ from the entire group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Immediate and mid-term results of percutaneous pulmonary valvotomy in adults. Apropos of 10 cases]. / Résultats immédiats et à moyen terme de la valvulotomie pulmonaire percutanée chez l'adulte. A propos de 10 cas.

Percutaneous pulmonary valvulotomy (PPV) is the treatment of choice for isolated congenital pulmonary stenosis of infancy. However, experience with this technique in the adult is much more limited. From November 1983 to November 1990, PPV was performed in 10 adults in our Institute. The mean age was 40 +/- 19 years (range 21 to 71 years). Before PPV, 4 patients were in functional Class II and 6 in functional Class III of the NYHA classification. All procedures were successful with no complications. The right ventricular systolic pressure decreased from 98 +/- 35 to 57 +/- 30 mmHg (p less than 0.01) and the mean pulmonary gradient decreased from 57 +/- 30 to 23 +/- 15 mmHg (p less than 0.01). The cardiac output was unchanged: 5.3 +/- 2.8 and 5.9 +/- 2.6 l/mn (not significant). Pulmonary valve area increased from 0.59 +/- 0.3 to 1.15 +/- 0.5 cm2 (p less than 0.01). The post-dilatation infundibular gradient was less than 10 mmHg in all patients. After an mean follow-up period of 29 +/- 26 months all but one patient (Class II) were in functional Class I. Exercise capacity was 6.9 +/- 2 Mets. Doppler echocardiography indicated a stable mean pulmonary gradient of 16.5 +/- 6.8 mmHg after PPV and 15.0 +/- 7.0 mmHg during follow-up. Pulmonary regurgitation was less than Grade I in all cases. In conclusion, PPV is an effective treatment for adult pulmonary stenosis and carries a low risk. The mid term results are excellent.

[Comparative, clinical and echocardiographic study of the Bex and De Vega annuloplasties]. / Evaluation comparative, clinique et échocardiographique, des annuloplasties de Bex et de De Vega.

A retrospective study of 27 cases compared the long term clinical and echocardiographic results of tricuspid valve annuloplasty by the Bex (15 patients) and the De Vega (12 patients) techniques. All patients were in NYHA Classes III or IV before surgery. There was associated mitral valve disease in 24 cases and mixed mitral and aortic valve disease in 3 patients requiring valve replacement. The follow-up period ranged from 3 to 106 months (average 48 +/- 4 months). All patients underwent clinical and color Doppler echocardiographic evaluation. There was symptomatic improvement after surgery as all patients recovered to NYHA Classes I or II. An echocardiographic classification was adopted to assess residual tricuspid regurgitation. The leak was judged to be significant when the surface area of the jet was greater than 5 cm2. Two thirds of patients (17/27) had no significant residual tricuspid regurgitation with the Bex or de Vega techniques of tricuspid annuloplasty according to this criterion. However, significant residual tricuspid regurgitation was observed in 37% of patients (10/27) even though they were all clinically improved. A comparison of the echocardiographic parameters including the severity of residual tricuspid regurgitation, the left and right atrial dimensions, the right ventricular dimensions and tricuspid valve pressure gradients did not show any significant long term difference between the Bex and the De Vega tricuspid annuloplasties.

[Percutaneous mitral valvuloplasty. An analysis of the immediate results]. / Valvuloplastia mitral percutánea. Análisis de los resultados inmediatos.

Percutaneous mitral valvuloplasty (PMV) was performed by the anterograde transseptal approach in 113 patients with symptomatic mitral stenosis. Mean age was 53 +/- 14 years and 89% were female. PMV resulted in a marked decrease in mitral gradient from 16 +/- 5 to 6 +/- 3 mmHg (p less than 0.0001) and a significant increase in mitral valve area from 1.09 +/- 0.36 to 2.12 +/- 0.83 cm2 (p less than 0.0001). An optimal hemodynamic result (gain in valve area greater than or equal to 25% and post-PMV valve area greater than or equal to 1.5 cm2) was obtained in 82 patients (73%). Multivariate statistical analysis selected as independent predictors of an optimal result: normal cardiac index (p = 0.0001), NYHA functional class less than 3 (p = 0.002), smaller left atrial diameter (p = 0.005), and echocardiographic score less than or equal to 8 (p = 0.01). The lowest frequency of optimal results was observed in patients with echocardiographic scores greater than or equal to 11 (20%). Three patients died (2.6%). All deaths occurred among the first 34 patients and none in the last 79 (p less than 0.05). Morbidity was also influenced by a learning curve effect. Mitral regurgitation developed or increased in severity in 38% of patients. This increase was mild (1 degree) in 85% of cases. Although the incidence of atrial shunting was high (76% by indicator dilution curve and 33% by oximetry), their magnitude was usually small (mean Qp/Qs 1.23 +/- 0.23) and lacked clinical significance. In conclusion, PMV provides excellent immediate hemodynamic results with low mortality and morbidity risks, specially once experience has been gained with this technique. Patients with echocardiographic scores less than or equal to 8 and smaller left atrial diameters, usually younger and less symptomatic, are the best candidates for PMV.

Percutaneous mitral valvuloplasty in surgical high risk patients.

Among 126 consecutive patients undergoing percutaneous mitral valvuloplasty, 34 were judged to be at high risk for surgery on the basis of age greater than 70 years (n = 13), New York Heart Association functional class IV (n = 11), ejection fraction less than or equal to 35% (n = 3), severe pulmonary hypertension (n = 7), need for associated coronary bypass (n = 4) or additional valve surgery (n = 20) or severe pulmonary disease (n = 3). Baseline features of the high risk group were substantially worse than those of the other patients: age (65 +/- 11 versus 49 +/- 12 years; p = 0.0001) and echocardiographic score (9.4 +/- 1.8 versus 8.2 +/- 1.5; p = 0.005) were higher, whereas cardiac output (2.9 +/- 0.9 versus 4.1 +/- 1.2 liters/min; p = 0.0001) and mitral valve area (0.9 +/- 0.4 versus 1.1 +/- 0.3 mm2; p = 0.002) were lower. Three high risk patients experienced technical failures and three others had major complications. Among the remaining 28 patients, 18 (65%) had a complete hemodynamic success, 4 (14%) an incomplete success and 6 (21%) hemodynamic failure. Stepwise logistic regression analysis retained echocardiographic score as the only factor independently predictive of success. The percent increase in mitral valve area also correlated with echocardiographic score (r = 0.51, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)