Acute rejection after heart transplantation: noninvasive echocardiographic evaluation.

OBJECTIVES: The purpose of this study was to assess the reliability of echocardiography in the noninvasive diagnosis of acute rejection in heart transplant recipients. BACKGROUND: Although echocardiographic results seem to correlate well with allograft rejection, published data are limited and contradictory. METHODS: In 130 transplant recipients, 1,400 serial echocardiograms were recorded within 24 h of endomyocardial biopsy. Increased wall thickness, myocardial echogenicity, pericardial effusion, shorter pressure half-time, isovolumetric relaxation time and a decrease in left ventricular ejection fraction were considered markers of rejection. RESULTS: The distribution of echocardiographic markers revealed highly significant differences between bioptically graded moderate, mild and no rejection and between untreated and treated rejection episodes (both chi-square test, p < 0.0001). Specificity was 98.6% for two markers, but sensitivity was good (80%) for only moderate rejection because of the large number of false negatives in untreated patients with mild rejection. In untreated patients, there was a highly significant difference in the number of echocardiographic criteria between a benign and nonbenign outcome (chi-square test, p < 0.0001). In treated patients, the significant difference in the variation in echocardiographic criteria between favorable and unfavorable responses after 1 week was more pronounced after 2 weeks (t test, p < 0.01 vs. < 0.001). Diastolic indexes and pericardial effusion at 2 weeks seemed to be predictive of therapeutic response. CONCLUSIONS: Poor sensitivity to mild rejection indicates that serial echocardiography cannot supplant endomyocardial biopsy in the early diagnosis of acute rejection, but it seems to be a reliable noninvasive means of identifying acute rejection requiring intensified immunosuppressive therapy and of evaluating outcome.

Which variable of stenosis severity best describes the significance of an isolated left anterior descending coronary artery lesion? Correlation between quantitative coronary angiography, intracoronary Doppler measurements and high dose dipyridamole echocardiography.

OBJECTIVES: This study sought to investigate the angiographic or intracoronary Doppler variables of stenosis severity that best correlate with the results of dipyridamole echocardiography. BACKGROUND: Quantitative coronary angiography and intracoronary Doppler flow velocity assessments are the commonly used techniques for the objective identification of significant coronary artery stenosis. METHODS: Thirty patients with an isolated lesion of the left anterior descending coronary artery (LAD) were studied by means of on-line quantitative coronary arteriography, intracoronary Doppler flow velocity measurements and dipyridamole echocardiography 6 months after percutaneous transluminal coronary angioplasty. The quantitative arteriographic analyses were performed on-line; post-stenotic Doppler flow velocities were measured at baseline and after adenosine infusion. Angiographic and Doppler measurements were compared with the corresponding dipyridamole echocardiographic data and analyzed by discriminant analysis. RESULTS: The dipyridamole echocardiographic response was positive in 11 patients (37%). The best cutoff values for predicting an abnormal echocardiographic response were 1) stenotic flow reserve of 2.8 (p = 0.0001); 2) 59% diameter stenosis (p = 0.0001); 3) minimal lumen diameter of 1.35 mm (p = 0.001); 4) coronary flow reserve of 2.0 (p = 0.0002); and 5) maximal peak velocity of 60 cm/s during hyperemia (p = 0.04). Multivariate analysis identified stenotic flow reserve as the only independent predictor of ischemia during dipyridamole echocardiography. CONCLUSIONS: Stenotic flow reserve is the variable that best describes the functional significance of an isolated LAD lesion, and a value of 2.8 is the best predictor of a positive dipyridamole echocardiographic response. Furthermore, angiographic variables of stenosis severity relate to echocardiographic test results better than intracoronary Doppler variables.

Significance of pericardial effusion after heart transplantation.

The aim of this study was to evaluate the clinical significance of pericardial effusion after heart transplantation and to assess its correlation with acute rejection. One hundred fifty transplanted patients were followed up for the first year: serial echocardiographic studies were performed on the same day as were the endomyocardial biopsies; hemodynamic studies and coronary angiographies were performed 1 year after transplant. Ten days after surgery, pericardial effusion was absent in 77 patients, small in 52, moderate in 14, and large in 7, and was significantly related to severe postoperative bleeding (p < 0.001). Patients were classified according to the presence and the course of pericardial effusion in group A (absence or disappearance of previous pericardial effusion within 1 month, 107 patients) and in group B (onset, persistence, or increase in pericardial effusion, 43 patients). One hundred nineteen patients experienced > or = 1 acute rejection episode. The evolution of pericardial effusion was different (p < 0.0001) according to the number of acute rejection episodes and biopsy specimens showing acute rejection, histologic grading and time of the first episode, and histologic grading of the most severe acute rejection episode. Furthermore, there was a significant correlation with the cumulative duration of acute rejection episodes (p < 0.005) and the presence of previous cardiac surgical history (p < 0.007), but no correlation with cardiac transplant vasculopathy or with a positive weight mismatch. This study suggests that pericardial effusion in transplant recipients is associated with a higher incidence and more severe histologic grading of acute rejection episodes; its presence indicates the need for stricter monitoring of acute rejection.

Aorto-atrial fistula through the septum in recurrent aortic dissection.

A case of aortic dissection (De Bakey type I) with a fistula to the right atrium through the interatrial septum, diagnosed by transthoracic and transesophageal echocardiography is reported. The patient presented with cardiac failure and a continuous murmur in the right second and third intercostal spaces. The patient underwent successful operative repair.

The clinical value of blunting of cyclic gray level variation for the detection of acute cardiac rejection: a two-dimensional, Doppler, and videodensitometric ultrasound study.

Aims of this study were to assess (1) whether videodensitometric analysis of myocardial gray-level variation can distinguish normal from rejecting transplanted hearts in a clinical setting and (2) whether this sign, used in combination with the other conventional two-dimensional and Doppler echocardiographic findings, might improve the accuracy of ultrasound techniques. Thirty heart transplant recipients (23 men; mean age 40 years; range 20 to 54 years) were studied in 87 different situations by endomyocardial biopsy and echocardiographic evaluation. Of the 87 situations, 37 ("rejectors") showed histologic evidence of rejection of mild (n = 17) or moderate (n = 10) severity and 50 ("nonrejectors") did not show rejection processes. Cyclic variation was decreased significantly in rejectors compared with nonrejectors in both the septum (15% +/- 10% versus 25% +/- 11%; p < 0.0001) and the posterior wall (19% +/- 10% versus 25% +/- 12%; p < 0.01). When a cutoff of 20% or greater of cyclic variation in the septal wall was taken as a positivity criterion, it yielded a 70% sensitivity and 70% specificity for identifying rejection. Sensitivity of conventional two-dimensional and Doppler echocardiographic signs was 51% and increased to 89%, increased by the videodensitometric criteria (p < 0.001). Specificity was 92% and decreased to 62% with videodensitometric criteria (p < 0.001). Overall diagnostic accuracy was 75% for conventional two-dimensional echocardiographic Doppler criteria alone and remained unchanged by the addition of videodensitometric criteria. In conclusion, blunting of cyclic gray-level variation induced by rejection is detectable with videodensitometric analysis. The clinical impact of this sign appears to be limited, because the resulting increase in sensitivity is counter-balanced by a reduced specificity compared with the currently available conventional ultrasound techniques.

Color Doppler echocardiographic assessment of atrial septal defect size: correlation with surgical measurements.

In patients with atrial septal defect (ASD), color flow Doppler echocardiography provides visualization of the transseptal jet, the maximal dimension of which can be assumed to correspond to the maximal dimension of the true orifice. To test whether color flow Doppler echocardiography can provide an alternative method for measurement of ASD size, we studied 63 consecutive patients with echocardiographic evidence of ASD. In 48 patients the maximal dimension of the jet was measured in the parasternal, apical, or subcostal four-chamber view or in the parasternal short-axis view. In the remaining 15 patients transesophageal echocardiography was performed because of transthoracic views were inadequate. The transesophageal studies also measured, from two-dimensional images, the maximal transverse discontinuity in the atrial septum. All patients underwent surgical repair, during which the surgeon directly measured the maximal dimension of ASD. Linear regression equations were performed to compare transthoracic and transesophageal dimensions to those measured at operation. Correlation coefficients were as follows for transthoracic versus surgical measurements: r = 0.745, standard error = 4.35, p less than 0.001. Transesophageal measurements derived from both two-dimensional images and echocardiographic jet width showed similar excellent correlation with surgical measurements (n = 0.91, standard error = 4.33, p less than 0.001; and r = 0.919, standard error = 4.42, p less than 0.001, respectively). We conclude that ASD size derived from color flow Doppler echocardiography shows a good correlation with the anatomic maximal dimension observed at operation. Both transesophageal color flow Doppler echocardiography of jet width and direct surgical measurement of the defect provide an accurate estimation of ASD size.

Left ventricular performance in chronic mitral regurgitation: temporal response to valve repair and prognostic value of early postoperative echocardiographic parameters.

BACKGROUND: The temporal response of the left ventricle due to the relief of volume loading after mitral valve repair, and the prognostic value of early changes in left ventricular size and function, are not fully documented. The purpose of this study was to analyze the evolution of left ventricular performance after surgery, and to evaluate how early postoperative echocardiographic parameters compare with late ventricular function. METHODS: We studied 58 patients with chronic degenerative mitral regurgitation using echocardiography, before, and 9 +/- 3 days and 38 +/- 6 months after mitral valve repair. RESULTS: Between the preoperative and early postoperative study, left ventricular end-diastolic and left atrial size, and ejection fraction decreased, whereas left ventricular end-systolic dimension did not change. Between the early and late postoperative study left ventricular end-systolic size decreased significantly, there was a further decrease in left ventricular end-diastolic dimension and a significant increase in ejection fraction; left atrial size did not change. Multivariate analysis showed that preoperative and early postoperative ejection fraction, and the early postoperative reduction in diastolic dimension were the best predictors of late left ventricular function. CONCLUSIONS: In patients with chronic degenerative mitral regurgitation, the greatest reduction in end-diastolic dimension occurs within 2 weeks of the reversal of volume overload; a significant reduction in end-systolic dimension with an increase in ejection fraction occurs later. In our experience, early postoperative echocardiographic measurements of left ventricular size and function can provide important prognostic information.

[Doppler echocardiography after heart transplantation]. / L'esame ecocardiografico Doppler dopo trapianto cardiaco.

Acute rejection, graft atherosclerosis and infections are the major causes of morbility and mortality after heart transplantation. Therefore clinical follow-up after heart transplantation is usually focused on the early diagnosis and treatment of these complications. The early recognition of acute rejection episodes in cardiac allograft recipients remains a major challenge during follow-up after heart transplantation. The standard method used to identify rejection is endomyocardial biopsy, but this technique shows some important inherent limitations. Even if noninvasive methods are generally considered inaccurate in the early diagnosis of acute rejection, echocardiography is routinely used in the surveillance of heart transplant recipients to monitor allograft function. Furthermore it may be used to screen significant acute rejection episodes, because it can identify several morphologic and functional changes that are related to acute rejection: increase in left ventricular myocardial thickness, changes in ultrasonic texture, pericardial effusion, systolic and diastolic dysfunction. In this setting it is very useful to perform serial echocardiographic examinations, because the changes of echocardiographic and Doppler parameters in comparison with previous examination in each individual patient can be accurate in detecting acute rejection and evaluating the response after immunosuppressive treatment. The development of coronary artery disease (CAD) is the major factor limiting long-term survival. Serial coronary artery angiography remains the only effective diagnostic tool for detecting CAD, while noninvasive tests commonly used in atherosclerotic heart disease are considered inaccurate, due to their low sensitivity. However several studies reported a high accuracy of dobutamine stress echocardiography in the diagnostic and prognostic assessment of CAD. Furthermore, rest wall motion abnormalities and left ventricular systolic dysfunction can identify patients with significant CAD and worse prognosis. In conclusion, echocardiography cannot supplant invasive methods for monitoring acute rejection and CAD, but it is a useful tool for surveillance after heart transplantation.

[Long-term effects of sublingual isosorbide dinitrate (author's transl)]. / Effetti e durata di azione del dinitrato di isosorbitolo per via sublinguale

The effect of 10 mg of sublingual isosorbide dinitrate were studied using exercise test in 10 patients with stable angina pectoris. First the reproducibility of angina threshold of each patient was controlled. then the effects after 30, 90, 150 minutes of the administration of the drug and a placebo, administered in random sequence, were studied. No significant changes of the parameters examined were observed after the placebo. Significant increase of duration of exercise and total amount of work performed before angina were observed after the drugs. Also, the appearance of electrocardiographic alterations was retarded, and disappearance of pain after exercise interruption was quicker. These changes were maximal in the tests made 30 minutes after administration of the drug, declining therafter; nevertheless, statistically significant differences from placebo were also observed in tests after 90 and 150 minutes.

[Orally administered nitroderivates: efficacy and duration of the effects of isosorbide dinitrate (author's transl)]. / Nitroderivati per via orale. Efficacia e durata di azione del dinitrato di isosorbitolo

The effects of 20 mg of orally administered isosorbide dinitrate on 10 patients with stable angina pectoris were studied by means of exercise tests. First, the reproducibility of the angina threshold of each patient was controlled; then the effects after 60, 150 and 210 minutes after administration of the drug and of a placebo, given in a random sequence, were studied. No significant changes of the parameters examined were observed after the placebo. A significant increase of duration of exercise and total amount of work performed before appearance of angina were observed after the drug. These changes were maximal in tests made 60 minutes after administration of the drug, declining thereafter; nevertheless, statistically significant differences from placebo were also observed in tests performed after 150 and 210 minutes. The appearance of ischemic ST changes was retarded by the administration of the drug. Disappearance of pain after interruption of exercise was significantly quicker when compared with the observations made after placebo.

[Abnormal electrocardiographic changes induced by hypocalcemia secondary to extracorporeal circulation]. / Abnormi alterazioni elettrocardiografiche indotte da ipocalcemia secondaria a circolazione extracorporea.

We report hereby the case of a 20-year-old woman, whose electrocardiogram showed unusual repolarization abnormalities 36 hours after open heart surgery. They were due to pure hypocalcemia (7,1 mg/100 ml) secondary to extracorporeal circulation, were sudden in onset, transient, variable within a few minutes, and immediately suppressed by intravenous calcium chloride. Some of the changes were similar to those already reported in literature (lengthening of QT and ST segments, changes in T wave voltage but not duration) whereas other were quite unusual i.e. the extreme variability and transientness of these changes, the marked ST level alterations and the presence of wide and diphasic U waves. Intravenous administration of 2 g of calcium chloride was followed by immediate and complete normalization of the electrocardiographic tracing.

[Pre- and post-operative echocardiographic evaluations of mitral stenosis]. / Valutazioni ecocardiografiche pre- e post-operatorie della stenosi mitralica.

46 patients, affected by pure mitral stenosis, underwent echocardiographic study before and after mitral commissurotomy. The following echocardiographic parametres were considered: 1) closing velocity of anterior mitral leaflet (E-F slope); 2) amplitude of the mitral valve motion; 3) intensity and number of echoes coming from the mitral leaflet; 4) posterior leaflet motion; 5) left atrial diameter index; 6) right ventricolar diameter index; 7) left atrial and aorta diameter ratio. Moreover mitral diameter, mitral fibrosis or calcification, and possible mitral incontinence were evaluated intraoperatively before and after commissurotomy. The pre-operative echocardiographic examination of the mitral stenosis showed the following specific aspects: 1) reduced E-F slope, significantly correlated with the severity of the stenosis; 2) abnormally moving posterior mitral leaflet; 3) enlargement of the left atrium, directly correlated with the degree of the mitral stenosis. Correspondence was noted between the echocardiographic and the intraoperative evaluation of the anathomical pattern of mitral valve. Postoperatively the echocardiograms showed: 1) improved E-F slope, directly correlated with the surgical dilatation of the valve; 2) persistent abnormal movement of the posterior mitral leaflet; 3) disappeared correlation between the surgical diameter of mitral valve and the left atrial index. The ECHO proved to be a good diagnostic method for both a qualitative and a semiquantitative evaluation of mitral stenosis. The ECHO is also quite usefull in evaluating modifications induced by commissurotomy.

[The significance of ventricular arrhythmias during muscular work: correlations with coronary heart disease (author's transl)]. / Significato delle aritmie ventricolari da lavoro: correlazioni con la coronaropatia

The incidence of ventricular arrhythmias during muscular work in 400 patients hospitalized for clear or suspected coronary artery disease who underwent coronaroangiography and exercise test was studied. The correlations between the arrhythmias and some hemodynamic parameters and the coronaroangiogrphy patterns and left ventricle cineangiography were investigated. None of the factors that were supposed to be significant in the mechanism of the ventricular arrhythmias, such as high left ventricular end dyastolic pressure, modified myocardial contractility, previous myocardial infarct, or higher lesions of coronary arteries, gave significant correlations. In the present study, the ventricular arrhythmias during muscular work do not seem to be of diagnostic significance.

Comparative effects of nifedipine, verapamil, isosorbide dinitrate and propranolol on exercise-induced angina pectoris.

According to the experimental model of a 5 X 5 Latin square, 5 treatments were studied single blind in 5 patients, affected by stable-effort angina, by means of exercise tests. In the period of maximal supposed effect the following treatments were investigated: placebo (P), 1 tablet, orally; isosorbide dinitrate (ISDN), 5 mg, sublingually; propranolol (Pr), 40 mg, orally; nifedipine (N), 10 mg, orally; verapamil (V), 160 mg, orally. Placebo, compared with its own control tests, did not change any of the examined parameters. Comparison of the 'active' treatments with P showed the following results. All the treatments increased the duration of work before ECG positivity appearances. An increase in duration of work and total work performed before angina was seen after administration of ISIDN, N and V; the improvement observed after treatment with Pr was not significant. Comparison of treatments showed that work performance before angina was the same after administration of ISDN, N and V; these treatments were more effective than that with 40 mg Pr. Duration of work before ECG positivity was significantly longer after ISDN and N than after Pr. The changes in heart rate, maximal arterial pressure, ejection time index and triple product confirmed the activity of the administered doses. According to the observed effects on exercise tolerance, in comparison with P the same level of work was performed with the same triple product after Pr, and with lower triple products after ISDN, N and V.

[Echocardiographic diagnosis of infectious endocarditis on patent ductus arteriosus with involvement of the pulmonary artery and the pulmonary and aortic semilunar valves. Description of a case]. / Diagnosi ecocardiografica di endocardite infettiva su dotto arterioso pervio con interessamento dell'arteria polmonare, delle semilunari polmonari ed aortiche. Descrizione di un caso.

Infective endocarditis is one of the most rare complications of patent ductus arteriosus (PDA). Usually vegetations are localised at the level of the patent ductus and can involve the left branch and the trunk of the pulmonary artery. We report the case of a young woman with PDA, who was admitted to the hospital in severe congestive heart failure due to infective endocarditis. A 2D echocardiographic examination revealed vegetations into the ductus with extension to the pulmonary artery, pulmonary valve and aortic valve. The results of the echocardiographic study enabled us to evaluate the extension of the lesions, to avoid heart catheterization and to decide the most suitable surgical approach for repairing all the damage in one surgical operation.

[The effort test in the diagnosis of typical stable effort angina (author's transl)]. / Contributo della prova da sforzo alla diagnostica dell'angina da sforzo stabile tipica.

Among 173 patients with typical effort angina (159 men and 14 women) which underwent exercise test and coronary angiography, significant stenosis (greater than or equal to 70%) of one or more of important coronary branches were present in 93,1% of the cases (96,3% among the males and 57% among the females). In the same group the exercise test sensitivity was 88,8%; when 3 coronary branches were involved the sensitivity rises to 94,3%. The 96,6% of patients with positive exercise test had coronary lesions too (true positives). We did not find any correspondence between the site of transient subendocardial ischemia occurred during the exercise test and coronary branch involved, when the stenosis was limited only one important coronary branch. Finally the researche of correlation between the entity of coronary disease (number of coronary vessels involved, entity of left ventricular contractility impairment) and behavior of patient during exercise test, evaluated with different parameters measured at the moment of stopping of exercise (heart rate and threshold work load, rate-pressure product, maximal downsloping of ST segment, different positivity criteria for exercise test) allowed us to show a good correlation only between the extent of coronary involvement and rate-pressure product or maximal downsloping of ST segment.

[Effects of the association of Ca-antagonists with nitroderivatives or betablocking drugs in effort angina pectoris (author's transl)]. / Associazione dei farmaci calcio-inibenti con nitroderivato e beta-bloccante nell'angina pectoris da sforzo.

The effects of the association of calcium antagonists (CAI) with a nitroderivate and a betablocker were studied by means of exercise tests in 8 patients with stable effort angina pectoris. According the statistical model of a latin square 4 x 4, the first 4 patients were tested with the following treatments: placebo, oral; nifedipine (N) 10 mg, oral; N + isosorbide dinitrate (ISDN) 10 mg oral; N + propranolol (Pr) 40 mg, oral. In the second square verapamil 80 mg oral represented the CAI treatment. Compared to placebo, all the treatments produced a significant increase of exercise duration and total work performed before angina. In both the squares the improvement observed after CAI + ISDN was significantly higher than after administration of CAI alone. In both the squares the association of CAI + Pr determined a little, non significant improvement of exercise duration in respect to CAI alone. EKG positivity was delayed by Pr more than angina appearance: hpwever, also this effect was not significant when compared with administration of CAI alone. By the analysis of the changes of heart rate, maximal arterial pressure, ejection time and triple product at the same level of work, a relevant inhibition of myocardial contractility with the adopted doses of CAI can be excluded; the effect of these drugs seems to be due mainly to a decrease of arterial pressure, and, when associated to ISDN, to decreases of arterial pressure and ejection time.

[Effectiveness of nifedipine on exercise tolerance in patients with angina pectoris. Comparison with a nitroderivative and a beta-blocking agent]. / Efficacia della nifedipina sulla tolleranza allo sforzo di pazienti anginosi. Confronto con nitroderivato e betabloccante.

The effect of nifedipine on effort angina was investigated by means of exercise tests with bycicle ergometer and compared, in the same patients, with the effects of a nitroderivative and a betablocking agent. Five patients with stable effort angina entered the study, after an hemodynamic and contrasto-graphic control. According to the protocol of a latin square 5 X 5, all the patients received in a random sequence the following treatments: placebo, 1 c. orally; isosorbide dinitrate, 5 mg sublingually; propranolol, 40 mg orally; nifedipine, 10 mg sublingually; nifedipine, 10 mg orally. No significant change of any of the considered parameters was observed after the placebo. Isosorbide dinitrate and nifedipine produced significant increases of the duration of work before appearance of pain and EKG positivity, and of total work performed before anginal pain. Only the duration of work before EKG positivity was improved by propranolol. The comparisons between treatments showed no significant difference of the effects of the administered doses of isosorbide dinitrate and nifedipine. The improvements observed after propranolol were significantly lower than that observed after isosorbide dinitrate and oral nifedipine. On the basis of the observed changes of cardiac rate, maximal arterial pressure, ejection time index and triple product, the authors evaluate the possible mechanism of action of nifedipine.

The limitations of echocardiography in the overall diagnosis of the morphological lesions associated with infective endocarditis: comparison of echocardiographic and surgical findings.

Echocardiography is commonly accepted as the method of choice for the non-invasive diagnosis of vegetations and other lesions associated with infective endocarditis. To assess the accuracy of echocardiography in the overall diagnosis of the morphological cardiac lesions we retrospectively analyzed and compared the preoperative echocardiographic data with the surgical findings of 120 consecutive cases operated for infective endocarditis. Transthoracic echocardiography (TTE) was used in 60 cases (51 with native and 9 with prosthetic valves), both TTE and transesophageal echocardiography (TEE) in 50 (26 with native and 24 with prosthetic valves) and only TEE in 10 patients who underwent emergency surgery. The echocardiographic diagnosis was correct in all the cases, but incomplete in 26 (16 with native and 10 with prosthetic valves). Most of the incomplete diagnoses occurred regarding vegetations, perforations of the valvular leaflets and perivalvular abscesses. There were no differences between aortic or mitral valves (14/66 vs 11/60; p = ns), native or prosthetic (16/79 vs 10/37; p = ns), TTE or TEE (13/60 vs 13/60; p = ns); however, TEE was performed in more complex cases and in severely ill patients. In six of the incomplete diagnoses, echocardiography preceded surgery by one week or more, and in six the mistakes were not confirmed by the reviewer. In conclusion, our study suggests that an echocardiographic diagnosis of endocarditis may be correct but sometimes incomplete. In patients without prosthetic valves who have a technically-adequate transthoracic echocardiogram, transesophageal echocardiography is not indispensable but should be chosen from time to time. However, the patients with endocarditis and no contraindication to the transesophageal procedure should undergo both transesophageal and transthoracic echocardiography before surgery in order to obtain as much and the most definite information possible. An echocardiographic study should be repeated just before any surgical procedures in patients with active endocarditis. Finally, it needs to be emphasized that the training and clinical judgement of the operator performing the study are important elements determining the results of echocardiographic study.

Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair.

METHODS: A prospective analysis was performed on 50 patients (pts) with rheumatic mitral disease and associate secondary tricuspid insufficiency who underwent mitral valve replacement from January 1995 to December 1998. Surgical indication to tricuspid annuloplasty was considered in patients with echocardiographic tricuspid annulus diameter > 21 mm/m2, regardless semiquantitative evaluation of tricuspid insufficiency. De Vega annuloplasty was performed in 33 out of 50 patients. RESULTS: Hospital mortality was 2.0% (CL 0.3-3.6). The follow up of the discharged patients ranged from 3 to 48 months (mean 25 +/- 15.9). Three late deaths occurred (6.1% CL 2.8-9.2). Forty-two patients out of the 46 followed up (91.3% CL 84.9-93.8) were in I or II NYHA class. In eight patients (16.3% of discharged patients) the obtained result has been considered as 'negative late results': persisting moderate (three cases) or moderate-severe (five cases) TrI, together with congestive heart failure requiring a furosemide intake of > 25 mg/day. No patients had severe TrI at follow up. The statistics analysis demonstrated the 'preoperative fraction shortening of the tricuspid annulus' (P = 0.038) as factor predictive of late negative result. The incidence of late negative result was 57.1% among patients with fractional shortening lower than 25% and 0% among those patients with fractional shortening greater than 25% (P = 0.0001). CONCLUSIONS: The choice to treat the tricuspid insufficiency according to indexed tricuspid annulus dimension (> 21 mm/m2) has been effective in terms of clinical efficacy and of late functional result. Fractional shortening of the tricuspid annulus, expression of right ventricular cardiomyopathy in patients with poorest prognosis, affects the postoperative evolution of tricuspid insufficiency.