The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome.

BACKGROUND: Transthoracic echocardiography (TTE) has been traditionally considered inadequate for the diagnosis of acute type A aortic syndrome (AAAS). In the last decade, high-resolution probes and harmonic imaging have been implemented in new echocardiographic systems. However, studies assessing the diagnostic accuracy of TTE for the identification of AAAS in large populations using modern ultrasound technology are lacking. METHODS: The diagnostic value of harmonic imaging TTE was assessed in 270 consecutive patients with suspected AAAS in whom TTE was the initial diagnostic test. RESULTS: Acute type A aortic syndrome was diagnosed in 67 patients and excluded in 203 patients (disease prevalence 25%). Sixty-two patients had a classic acute type A aortic dissection, and 5, an acute type A intramural hematoma. Image quality achieved was considered optimal in 244 patients (90%). In the whole study population, TTE had sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of AAAS of 87%, 91%, 75%, and 95%, respectively. When evaluating only patients with optimal image quality, these values increased to 97%, 100%, 100%, and 99%, respectively. Forty-seven patients with clear-cut evidence of AAAS were transferred immediately to the operative room, where transesophageal echocardiography confirmed the diagnosis obtained by TTE in all patients. CONCLUSIONS: Transthoracic echocardiography is a useful imaging modality for the diagnosis of classic acute type A aortic dissection. It cannot be used as the sole screening technique for detecting AAAS, but in the light of the predictive values observed, patients with optimal image quality and clear-cut diagnosis of AAAS should proceed to the operative room, whereas in patients with negative or indeterminate studies, other imaging techniques are needed to refine the diagnosis.

Delayed systolic anterior motion after mitral valve repair.

A rare case of systolic anterior motion (SAM) after mitral valve repair is described. A temporary postoperative left ventricular (LV) dysfunction protected against this complication during the early postoperative period. Only on day 9 postoperatively did the left ventricle recover and SAM develop, with significant obstruction of the LV outflow tract. Subsequently, mitral valve replacement was required. This case demonstrates the importance of the LV geometrical relationships that predispose to this complication.

[Mortality risk estimation in cardiac surgery]. / Previsione del rischio operatorio in cardiochirurgia.

BACKGROUND: The aim of this study was to compare the ability of three risk models to predict operative mortality after cardiac surgery. METHODS: Risk factors of 3111 patients (73% male, mean age 65.2 +/- 10.7 years) were derived from our institutional database at the Cardiac Surgery Department of the G.M. Lancisi Hospital, Ancona, Italy. The predicted mortality was derived from the Society of Thoracic Surgeons risk score (STS), the EuroSCORE (ES) and the Northern New England Cardiovascular Disease Study Group score (NE). RESULTS: The observed mortality in the myocardial revascularization population (1995 patients) was 2.2% (43 patients). The mean predicted mortality by STS, ES and NE was 1.9, 4.2 and 1.9%, respectively. The predictive ability of the models was measured by means of the ROC curve. Curves were respectively of 0.82, 0.77 and 0.78. CONCLUSIONS: All tested models proved e good accuracy level but ES showed a constant overestimation of mortality at all risk levels.

Functional systolic anterior motion of the mitral valve due to accessory chordae.

Accessory mitral valve tissue is an uncommon finding, usually associated with other congenital cardiac malformations and diagnosed during childhood. We present the case of a 70-year-old patient referred to our hospital for aortic valve and ascending aorta replacement. At preoperative examination, no evidence of mitral valve structural abnormalities was detected. Anaesthesia induction was complicated by sudden haemodynamic impairment. Intraoperative transoesophageal echocardiography showed two anomalous mitral chordae. The presence of abnormal mitral tissue also allowed to assess the mechanism of unexpected haemodynamic worsening: anomalous chordae caused anterior displacement of the anterior mitral leaflet, resulting in left ventricular outflow tract obstruction and mitral regurgitation. Medical therapy was instituted and the planned surgical approach was modified according to the new anatomy observed at echocardiographic examination. A valve-sparing technique was successfully applied. This case provides a good example of the diagnostic usefulness of routine intraoperative transoesophageal echocardiography, especially when facing unexpected findings. It also shows how transoesophageal echocardiography may help guide medical and surgical treatment.

Atrial myxoma: a 25-year single-institutional follow-up study.

OBJECTIVE: A single-institutional study on atrial myxoma. Patient data and data obtained from the survivors during follow-up were reviewed. METHODS: We studied 109 patients (61.5% female) who underwent surgical excision of atrial myxoma between January 1980 and December 2005. Mean age at the time of surgery was 60 +/- 14 years (range 1-83 years). Overall survival and atrial myxoma recurrence were determined by Kaplan-Meier analysis. Linearized rates of recurrence at follow-up are reported. RESULTS: One hundred and two (93.6%) of the 109 tumours were found in the left atrium. Comparative mean age distribution revealed a significant difference between patients operated on between 1980 and 1992 and patients operated on between 1993 and 2005 (55 +/- 15 and 63 +/- 13 years, respectively; P < 0.05). All patients survived the operation. Three patients were lost to follow-up. The 15-year and 25-year survival rates were 91 +/- 4% and 72 +/- 12%, respectively. Survival of patients after myxoma removal did not significantly differ from the expected survival of the general population. Recurrent myxomas developed in two patients (mean age 50 +/- 7 years) with a 25-year freedom from reoperation of 96 +/- 3% and a linearized rate of 0.17 +/- 0.12%/year. CONCLUSIONS: Myxomas tend to be observed in a more elderly and higher-risk population, often at an early stage. The extended follow-up of patients with intracardiac myxomas shows that surgical excision of such tumours is curative with low mortality and good long-term outcome.

Delayed traumatic aortic cusp detachment mimicking aortic dissection.

We report a case of delayed detachment of the right coronary cusp, occurring 12 days after a motorcycle crash. Echocardiographic findings mimicked a type I De Bakey aortic dissection. A brief discussion of cause, evolution, diagnosis, and treatment is included.