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The study aim was to evaluate whether, in patients with severe mitral regurgitation (MR), tricuspid valve remodeling was independent of the degree of functional tricuspid regurgitation (FTR) present. Whether any differences in the analysis remodeling, as assessed by two-dimensional (2D) and three-dimensional (3D) echocardiography, can be demonstrated was also addressed.A total of 188 patients (mean age 63.5 +/- 16.0 years) with severe organic or functional MR with or without associated FTR, and 30 normal controls (mean age 59.2 +/- 15 years) were enrolled in the study. Subsequently, both 2D and 3D transthoracic anatomic and functional parameters of the tricuspid valve were analyzed.Patients and controls differed in all 2D and 3D parameters of tricuspid valve remodeling, except for the 2D end-diastolic annular diameter and circularity indices. The patients were then allocated to either group A (trivial/mild FTR) or group B (moderate/severe FTR). Significant differences were identified between groups A and B compared to controls in all tricuspid valve remodeling indices, except for the diastolic 2D annular diameter and circularity indices. Groups A and B had similar 2D and 3D parameters of tricuspid valve remodeling. The right ventricular end-diastolic diameter (RVEDD) (beta = 0.24, 95% CI: 0.11 to 0.22, p = 0.02) and fractional area change (beta = -0.48, 95% CI: -0.24 to 0.09, p = 0.0001, R2 = 0.22) were independent predictors of the tenting area, whereas the RVEDD was the only independent predictor of the diastolic 3D tricuspid annular area (beta = 0.53, 95% CI: 1.2 to 2.7, p = 0.0001, R2 = 0.28).In patients with severe MR, tricuspid valve remodeling was also demonstrated in those with trivial/mild FTR, but was better characterized by 3D echocardiography. Tricuspid valve remodeling and right ventricular dilation were the main determinants of tricuspid valve regurgitation.

The introduction of three-dimensional echocardiography and its evolution from time-consuming and cumbersome off-line reconstruction to real-time volumetric technique (real-time three-dimensional echocardiography) are one of the most significant advances in ultrasound imaging of the heart of the past decade. This imaging modality currently provides realistic views of cardiac valves capable of demonstrating the anatomy of various heart valve diseases in a unique, noninvasive manner. In addition, real-time three-dimensional echocardiography offers completely new views of the valves and surrounding structures, and allows accurate quantification of severity of valve disease. This article reviews the advantages of real-time three-dimensional echocardiography in assessing heart valves and shows also technological limitations in order to provide the scientific basis for its clinical use.

La gravidanza accentua patologie cardiache. Lo scopo di questo lavoro clinico è presentare le differenti gestioni anestesiologiche per taglio cesareo emergente in 2 pazienti con insufficienza cardiaca. La fisiopatologia dell’insufficienza cardiaca è descritta secondo la causa primaria della malattia e secondo e l’impatto di 2 differenti tecniche anestetiche. Vengono presentati 2 casi verificatisi in un ospedale universitario. Entrambe le pazienti hanno lasciato l’ospedale in buone condizioni generali. Caso 1: paziente incinta con insufficienza aortica grave che ha ricevuto anestesia epidurale. Caso2: paziente incinta con cardiomiopatia peripartum che ha ricevuto anestesia generale. Le terapie mediche e chirurgiche per l’insufficienza aortica e per la cardiomiopatia peripartum sono in evoluzione. Per la gestione appropriata di questi casi si richiede un’adeguata conoscienza del campo anestesiologico. Noi abbiamo modulato le tecniche anestesiologiche sulle caratteristiche specifiche delle nostre 2 pazienti. Gli effetti positivi della simpatectomia sono stati osservati nel periodo post-operatorio per il caso 1; per il caso 2 l’uso di alti dosi di oppiacei ha minimizzato il pericolo di variazioni cardiovascolari, ma in questo caso deve essere possibile un’immediata rianimazione del bambino. Il problema più difficile per l’anestesista è la scelta della tecnica anestesiologica in ostetricia: una scelta ottimale richiede una conoscenza approfondita della fisiopatologia cardiaca. Pregnancy exacerbates heart diseases. The aim of this clinical report is to review the different anesthesiological management of emergent cesarean section in 2 patients with heart failure. The pathophysiology of heart failure is described according to the primary cause of disease, as well as the impact of 2 different anesthetic techniques. Two case reports of a university referral hospital are presented. Both patients left the hospital in good general conditions. Case 1: a pregnant patient with severe aortic regurgitation who received epidural anesthesia. Case 2: a pregnant patient with peripartum cardiomyopathy who was given general anesthesia. Medical and surgical therapies for aortic regurgitation and peripartum dilated cardiomyopathy are evolving. Adequate knowledge of anesthesiology is required to appropriately manage these cases. We tailored the anesthetic technique to the specific characteristics of our 2 patients. The beneficial effects of sympathectomy were observed in the postoperative period of case 1; the use of high doses opiates minimised dangerous cardiovascular changes in case 2, but rapid resuscitation of the baby should be available. Selection of the anesthetic technique in obstetrics is the most challenging issue for the anesthesiologist: extensive knowledge of the pathophysiology of heart disease is required for an optimal choice.

We assessed whether the presence of latent myocardial dysfunction, evaluated by echocardiographic derived force-frequency relationship (FFR) during exercise, predicts the appearance of stress-induced pulmonary hypertension in minimally symptomatic patients with severe mitral regurgitation (MR). Two groups of patients were identified: group I with normal (less than or equal to40 mm Hg) and group II with abnormal (>40 mm Hg) peak stress systemic pulmonary artery pressure. Group I had normal and upsloping FFR and group II had abnormal flat or biphasic FFR. Therefore, in patients with severe MR and apparently normal left ventricular function, the stress-induced pulmonary hypertension seems to be related to the presence of latent left ventricular dysfunction. (C) 2005 by Excerpta Medica Inc.

Prophylactic valve replacement in asymptomatic patients with severe aortic stenosis is controversial. Most authors consider that patients could be managed without surgery until symptoms develop. The incidence of sudden death in patients without symptoms is low, < 1%/year and valve replacement is complicated by an operative mortality up to 5 and 1-2% of incidence of valve-related major events. Early surgical approach is suggested by several observations. The first one is the unpredictable risk of myocardial fibrosis after long standing left ventricular hypertrophy and pressure overload, with associated systolic and diastolic dysfunction. Left ventricular impairment can persist after valve replacement influencing exercise capacity and survival in selected patients. On the other hand, major improvement in myocardial protection techniques, intraoperative monitoring with transesophageal echocardiography, prosthetic design (stentless, supra-annular), all have reduced in-hospital mortality and morbidity. More precise recommendations can be made according to an improved characterization of the patients from fast to slow evolution, according to age, type of aortic stenosis, degree of calcification, changes in transaortic gradients over time, tolerance to exercise test and response of aortic valve area to dobutamine. In patients with high risk of progression (severely calcified valve, Doppler velocity > 4 m/s, rapidly increasing with time), indirect evidence of myocardial fibrosis (excessive left ventricular hypertrophy, systolic or diastolic dysfunction), and need of myocardial revascularization, an early surgical approach should be considered.

OBJECTIVE:Repair of mitral regurgitation (MR) is more demanding in case of prolapse of the anterior leaflet, posterior leaflet with calcified annulus, or prolapse of both leaflets. We evaluated a repair which consists of anchoring the free edge of the prolapsing leaflet to the corresponding free edge of the facing leaflet: the 'edge-to-edge' (E-to-E) technique. The correction results in a double orifice valve when the prolapse is in the middle portion of the leaflet and in a smaller valve orifice when the prolapse is close to a commissure.METHODS:Out of 432 patients with MR submitted to valve repair between January 1991 and September 1997, 121 (mean age 56 +/- 15.8 years) underwent E-to-E correction. The most prevalent etiology was degenerative disease (82 patients, 68%). The mechanism of MR was anterior leaflet prolapse (61 patients), posterior leaflet prolapse (24 patients), prolapse of both leaflets (28 patients) and other complex mechanisms (8 patients). In 72 patients, a double orifice was created, the paracommissural repair was done in 49 patients.RESULTS:Hospital mortality was 1.6%. Overall survival was 92 +/- 3.1% at 6 years with 95 +/- 4.8% freedom from reoperation. Mortality was unrelated to the type of repair. Mitral stenosis was never observed after the correction. At the follow-up (mean 2.2 +/- 1.5 years), all patients but 15 are class I or II. Symptoms at the follow-up are not related to residual MR.CONCLUSIONS:Midterm results of this alternative repair technique are promising, considering the high prevalence of complex anatomical lesions. The technique is simple, easily reproducible and rapidly feasible also when mitral exposure is suboptimal.

Background and aim of the study: The edge-to-edge technique is used to restore valvular competence in mitral insufficiency. The efficacy of the method is under debate due to the potential for creating functional mitral stenosis. An exercise echocardiographic study was carried out to investigate valve function and hemodynamics in patients who had undergone double-orifice mitral valve repair. Methods: Thirty patients (mean age 49.1 +/- 12.7 years) with previous double-orifice mitral valve repair underwent exercise echocardiography (10 W/min). An annular prosthesis was present in 28 patients (93%). The mean and maximum mitral valve gradient, planimetric valve area, stroke volume, systolic pulmonary artery pressure, heart rate and systolic blood pressure were measured at baseline and at peak stress. Results: At peak stress, heart rate (77.7 +/- 12.2 versus 118.6 +/- 26.0 beats/min, p < 0.00001), systolic blood pressure (124.1 +/- 10.9 versus 146.6 +/- 22.8 mmHg, p < 0.00001) and stroke volume (78.0 +/- 10.2 versus 97.0 +/- 15.1 ml, p

In this paper we describe 1-year experience with a perspective operative protocol of emergency myocardial revascularization in extensive acute myocardial infarction (AMI). Entry criteria were: age75 years; anterior AMI with ST segment elevation4 leads, infero-postero-lateral or inferior and right ventricular AMI, within 6 hours from symptom onset. After coronary arteriography, an emergency staff, composed by cardiologists and cardiac surgeons, addresses the patients to coronary artery bypass grafting (CABG) or to percutaneous transluminal coronary angioplasty (PTCA). From November 1994 to November 1995, 35 patients were enrolled: 19 (mean age 54.3 +/- 9.7 years) underwent CABG and 16 were treated with PTCA. Myocardial protection was such as to restore energetic substrates and to prevent reperfusion injury: surgical technique consisted of antegrade-retrograde substrate-enriched blood cardioplegic solution delivery, early cardioplegic delivery on the infarcting area via a saphenous graft, retrograde controlled reperfusion before aortic unclamping and then prolonged reperfusion of the infarcted myocardium. In 8 patients (mean age 50.9 +/- 8.6 years), with anterior AMI and stable hemodynamics, a left internal thoracic artery graft was used, performing the prolonged controlled reperfusion retrogradely before aortic unclamping. In hospital death occurred in 1/19 (5.3%) patients because of cerebral hemorrhage. At a mean follow-up of 5.1 +/- 3.7 months 17 patients (94.4%) were in NYHA functional class I-II and 1 patient (5.6%) complained of effort angina, that was well controlled with medical therapy. Left ventricular ejection fraction calculated by echocardiography preoperatively, before discharge and at follow-up was respectively 39.3 +/- 12.7, 43.1 +/- 8.9 and 43.4 +/- 9.0%. In the last 8 consecutive patients thermodilution and transesophageal echocardiography monitoring were performed preoperatively and 12 hours after CABG: in all cases ejection fraction and cardiac index increased after CABG, from 42.2 +/- 13.5 to 48.6 +/- 14.3% (p = 0.01) and from 2.8 +/- 0.5 to 3.4 +/- 0.6 l/min/m2 (p = 0.005), respectively. The preliminary results show the effectiveness of this perspective protocol in the management of critically ill patients with extensive AMI.

Refractory angina pectoris (RAP) represents a clinical condition characterized by frequent episodes of chest pain despite therapy optimization. According to myocardial stunning and myocardial hibernation definitions, RAP should represent the ideal condition for systolic dysfunction development. We aim to investigate the evolution of left ventricular (LV) function in patients with RAP. A retrospective study which encompasses 144 patients with RAP referred to our institution from 1999 to December 2014 was performed. Of them, 88 met the inclusion criteria, and LV function was assessed by echocardiography. All of them had persistent angina episodes on top of optimal medical therapy and evidence of significant inducible myocardial ischemia and no further revascularization options. Nitrates consumption rate, time of angina duration, and the number of angina attacks were evaluated. In the whole population, ejection fraction (EF) was 44% ± 2. EF was significantly lower in patients with previous myocardial infarction (41% ± 1.5 vs 51% ± 1.8, p 5 years (5 years 44% ± 2 [n = 44]; p 0.02). Long-term LV function in patients with RAP is generally preserved. A previous history of myocardial infarction is the only determinant in the development of systolic dysfunction. In conclusion, frequent angina attacks and a long-term history of angina are not apparently associated to worse LV function.

Objective: To evaluate the feasibility of mitral valve (MV) reconstruction protocol by real-time 3D echocardiography (RT3DE) in the assessment mitral regurgitant (MR) lesions, and to determine the accuracy of RT3DE compared with transthoracic (TTE) and transesophageal (TEE) echocardiographies using surgical findings as gold standard. Patients and methods: Sixty-three consecutive patients (mean age 61.7 +/- 12.5 years, 35 men and 28 women) with severe organic MR were enrolled. Data were acquired in zoom and in full-volume modes from apical and/or parasternal windows. A volume rendered en-face view of MV and five serial longitudinal cut planes were reconstructed to visualize all segments of both leaflets. Results: The feasibility of RT3D reconstruction was 94%. Compared with surgical diagnosis, the accuracy of RT3D was 91% for aetiology, 92% for mechanisms, 94% for prolapse, 88% for flail and 94% for defect location. Diagnostic accuracy was significant higher for RT3D than TTE for all end points except for flail lesion and similar to TEE but inferior to this for flail lesion. The accuracy, sensitivity and specificity were higher in patients with good-excellent than those with poor image quality regarding aetiology, mechanisms and defect location (all p=0.0001). Conclusions: RT3D imaging of MV is feasible and accurate in defining aetiology, mechanism and defect location in patients with MR and has incremental diagnostic value if TTE is inconclusive and similar diagnostic value of TEE except for flail lesion. RT3D, at least in patients with good acoustic window, may obviate the need for subsequent TEE and/or can be considered a complementary technique to study MV in patients with MR. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

a Anesthesia and Intensive Care Department, San Raffaele University Hospital, Milan, Italy b Invasive Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy c Non-invasive Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy d Arrhythmia Unit, Cardiology Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy e Cardiac Surgery Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy

Background Doppler of mitral and pulmonary vein flows are used to estimate left ventricular (LV) filling pressure. Mitral regurgitation (MR) makes unreliable these parameters by inducing changes of both mitral inflow and pulmonary vein flow. Objectives To evaluate whether Doppler tissue imaging (DTI) diastolic indices obtained at the level of LV lateral mitral annulus can provide accurate estimation of LV filling pressure in patients with MR. Methods Forty-three patients (age 55 +/- 11 years) with severe MR and mean LV ejection fraction (EF) 58 +/- 13 were enrolled, 10 (23%) with LV EF 50%. Doppler signals from the mitral inflow, pulmonary venous flow, and DTI indices of the lateral mitral annulus were obtained. LV end-diastolic pressure (LVEDP) was measured invasively with fluid-filled catheter. Results In the overall population, the majority of standard Doppler and DTI indices correlated with LVEDP, but the multivariate analysis showed that the ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/Em ratio) (beta = .87, P = .0001) was independent predictor of LVEDP (R-2 = 0.74, SE = 4, P = .0001). An E/Em ratio >10 predicted an LVEDP >15 mm Hg (sensitivity 90%, specificity 83%). In both groups with LV EF >50% (beta = .77, P = .005; cumulative R-2 = 0.73, SE = 2.5, P = .0001) and 50% and

Transesophageal echocardiography has been widely used as a diagnostic tool during the past two decades to detect cardiac abnormalities that are not visible or poorly visible with transthoracic echocardiography. At present, transesophageal echocardiography is a cornerstone of modern diagnosis of several cardiac diseases, providing diagnostic, prognostic and therapeutic information. In this review, the present status of transesophageal echocardiography not only as a diagnostic tool, underlining its effects on clinical decision making, but also as a monitoring adjunct for many interventional cardiac procedures is examined.

We evaluate, in 37 consecutive patients (mean age 67 +/- 9 years) with functional mitral regurgitation (FMR), several rest and stress echocardiographic predictors of outcome. Rest end-systolic volume, peak stress end-diastolic volume and effective regurgitant orifice were independent predictors of death at 25 months follow-up. Therefore, rest and stress echocardiographic evaluation of patients with FMR provides strong prognostic information. (c) 2007 Elsevier Ireland Ltd. All rights reserved.

Aims The prognostic role of tricuspid regurgitation (TR) associated with organic left-sided valvular heart disease is well known. However, no data are available regarding the prognostic value of functional TR (FTR) in patients with functional mitral regurgitation (FMR) and left ventricular (LV) dysfunction. The purpose of this study was to evaluate the prognostic role of FTR for occurrence of heart failure (HF) and mortality in patients with FMR. Methods and results We enrolled 373 consecutive patients (mean age 68 ±11 years) with LV dysfunction and at least mild FMR and with or without FTR, both quantitated by echocardiography. The median follow-up was 32 months (range 1–120 months); 132 (35.4%) and 97 patients developed HF or died, respectively. The incidence of HF at 3 and 6 years was 36 ±2% and 55 ±4%, respectively. Moderate to severe FTR [hazard ratio (HR) 1.4, 95% confidence interval (CI) 1.1–2.1, P = 0.01) was an independent determinant of HF. The incidence of HF was 41 ±5, 46 ±7, 57 ±7, and 65 ±8% for patients without, and with mild, moderate, and severe FTR respectively (P = 0.03). At 3 and 6 years the survival free of all-cause mortality was 77.5 ±2% and 60 ±3%, respectively. Moderate to severe FTR (HR 1.6, 95% CI 1.2–2.1, P = 0.01) was an independent determinant of overall mortality. At 6 years, survival free of all-cause mortality was 69 ±2.5, 67 ±2.1, 51 ±2.5, and 40 ±4.8% for patients without, and with mild, moderate, and severe FTR, respectively (P = 0.004). Conclusions Moderate or more FTR is independently associated with worse survival and a high incidence of HF episodes in patients with FMR.

Aims To assess long-term prognosis in patients with functional mitral regurgitation (FMR) and left ventricular (LV) dysfunction, receiving current standard pharmacological therapy. Methods and results We prospectively enrolled 404 consecutive patients (mean age 70.2 ± 10 years) with ischaemic (76.5%) and non-ischaemic (23.5%) LV dysfunction (ejection fraction 34.4 ± 10.8%) and at least mild MR. Results are reported at 4 years' follow-up. Survival free of all-cause mortality was 53% and cardiac death was 74%. Survival free of all-cause mortality was 50% (95% CI 35–72) for patients with moderate MR, 49% (95% CI 27–65) for severe MR, and 64% (95% CI 47–78) for mild MR (P = 0.03). Survival free of cardiac death was 57% (95% CI 38–74) for patients with moderate MR, 55% (95% CI 30–77) for severe MR, and 94% (95% CI 59–98) for mild MR (P = 0.003). Moderate-to-severe MR [relative risk (RR) 2.7, 95% CI 1.2–6.1, P = 0.003] was an independent predictor of cardiac death but not of all-cause mortality. Survival free of heart failure (HF) was 32%. Survival free of HF was 20% (95% CI 17–35) for patients with moderate MR, 18% (95% CI 15–32) for severe MR, and 62% (95% CI 45–72) for mild MR (P = 0.0001). Moderate-to-severe MR (RR 3.2, 95% CI 1.9–5.2, P = 0.0001) was an independent predictor of HF. Conclusion The mortality and morbidity of patients with LV dysfunction and FMR remain high despite current standard pharmacological therapy. Moderate-to-severe MR is an independent predictor of cardiac death and HF.

Chronic ischemic mitral regurgitation (IMR) is a common complication of myocardial infarction and severely affects cardiovascular mortality and morbidity. Multiple pathophysiologic mechanisms, such as left ventricular (LV) remodeling and dysfunction, annular dilation/dysfunction, and mechanical dyssynchrony, are involved in generating IMR, each of them having different weight. However, the prerequisite to initially creating regurgitation is the presence of local or global LV remodeling that alters the geometrical relationship between the ventricle and valve apparatus. In the wide spectrum of patients with chronic IMR, the assessment of some echocardiographic parameters, such as tethering pattern, leaflet motion, origin and direction of the regurgitant jets, allows one to identify different specific subgroups of patients subjected to different therapeutic approaches. The aim of medical and/or surgical therapy is to ameliorate heart failure symptoms, and improve LV remodeling and function and the intermediate/long-term outcome. The targets of surgical MV repair involve annulus, leaflets, chordae and ventricles. The restricted annuloplasty is the most commonly adopted surgical procedure that improves heart failure symptoms but not survival when compared to medical therapy and is also subject to a high incidence of late failure (approximately 30%). There are some preoperative echocardiographic predictors of failure that include valve (degree of valve remodeling, jet characteristics), ventricular (degree of remodeling, diastolic dysfunction) and surgical factors.

Ultrasound lung comet images (ULC) are useful for the noninvasive assessment of extravascular lung water (EVLW). We investigated the modification of EVLW, its relation to indices of left ventricular systolic and diastolic function, and noninvasively determined pulmonary capillary wedge pressure (PCWP) (PCWP = 1.24 ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus [E/Em] + 1.9) at rest and its variation during exercise echocardiography. A total of 72 patients (mean age 66.4 ± 8.4 years) with mean ejection fraction of 41.2 ± 14.4% underwent symptoms-limited exercise echocardiography. The sum of the ULC yielded a score of EVLW. The ULC increased significantly from baseline to postexercise (5.9 ± 14.9 vs 11 ± 20.7, P = .0001). Positive linear correlations were found between baseline ULC score and baseline ejection fraction ( r = −0.37, P = .002), systolic pulmonary artery pressure ( r = 0.69, P = .0001), E/Em ( r = 0.70, P = .0001), and estimated PCWP ( r = 0.69, P = .0001). The variation between postexercise and baseline ULC score correlated significantly with the variation between peak stress and rest PCWP ( r = 0.62, P = .0001), systolic pulmonary artery pressure ( r = 0.44, P = .0001), wall-motion score index ( r = 0.30, P = .01), and peak stress E/Em ( r = 0.71, P = .0001), whereas no significant correlations were found between variations of ULC score and ejection fraction. This study shows that ULC represents a simple way to assess the presence of excess EVLW. Increased EVLW is associated with estimated PCWP and indices of left ventricular systolic and diastolic dysfunction. The additional exercise-induced increase of PCWP, the worsening of left ventricular diastolic function, and extensive wall-motion abnormalities correlate with variations of EVLW.

Aortic aneurysms (AAs) can develop in all parts of the aorta and a lot of them remain undetected unless incidentally discovered or until a lifethreatening complication occurs [1,2]. Thoracic aorta is usually studied with computed tomographic imaging (CT),magnetic resonance imaging and echocardiography [1,2]. Transthoracic echocardiography (TE) is commonly performed prior to abdominal AA (AAA) repair to evaluate the cardiac structure and function. In a recent paper, a highprevalence of thoracicAA(ATA) inpatientswithAAAassessedbyCThas been reported [3]. In our study we retrospectively enrolled 1942 patients in order to evaluate the prevalence of the ascending thoracic aortic and aortic arch dilatation/aneurysm in patients with AAA that underwent transthoracic echocardiography (TE) prior to surgery. The exclusion criteriawere: the presence of bicuspid aortic valve, previous aortic valve and/or ascending aortic surgery, genetic syndromes (Marfan syndrome, Ehlers–Danlos syndrome and others), and inflammatory and traumatic diseases. Thus, 1305 patients were considered eligible for the study. The aortic root and the proximal ascending aorta segments were visualized in the left and rightparasternal long-axis views. Inparasternal view the Valsalva sinuses and the proximal portion of the ascending aorta were measured. In the parasternal short axis bicuspid aortic valve was rule out. The aortic arch was evaluated by suprasternal view between the innominate and left carotid artery. Standardmeasurements were made by the leading edge-to-leading edge diameter in enddiastole taking care to obtain a true perpendicular dimension and appropriate gain settings [4]. Views used for measurements were those that showed the largest diameter of the aortic segment and in particular the maximum diameter measured perpendicular to the long axis of the vessel in that view. All the measurements were achieved in twodimensional mode. We used the absolute values as normal standard references of aortic sizes as follows: 1. Valsalva sinuses: 37 mm inmen and 33 inwomen; 2. Proximal ascending aorta: 34 mm inmen and 31 mm inwomen; and 3. Aortic arch: 32 mm in men and 29 mm in women. Sex-specific criteria wereused todefineanascendingaortic aneurysm:womenN42 mmand men N47 mm, and aortic arch aneurysm: women N32 mm and men N37 mm [5–7]. The study complies with the principles and guidelines of the Declaration of Helsinki. The clinical characteristics of the study population and the median diameters of the aorta are reported in Tables 1 and 2. 50% of the population had increased diameters of the Valsalva sinuses and proximal portion of ascending aorta, and 25% had the diameter of the aortic arch greater than normal range. Valsalva sinuses were increased in 25% of men and 75% of women. 50% of men and 75% of women had increased diameter of the proximal ascending aorta. The aortic arch diameter was above the normal range in 25% ofmen and 50% ofwomen. On the basis of sex-specific criteria for aneurysm4% of the patients had an ascending aortic aneurysm and 6.5% an aortic arch aneurysm. Furthermore, 2% men had an ascending aortic aneurysm compared with 25.8% of the women (p b 0.0001), and 6.6% men had an aortic arch aneurysm compared with 10.5% of the women (p b 0.4). Thus, we demonstrate a high prevalence of dilatation/aneurysm of the ascending aorta and the aortic arch in patients with AAA evaluated by TE during pre-operative risk stratification. Our study supports the common idea that ATA is commonly misdiagnosed because of its lack of symptoms. Itani et al. estimated the prevalence of asymptomatic ATA between 0.16 and 0.34% [8]. Larrson et al. evaluated the prevalence of ATA in AAA with CT scan, and they reported the presence of thoracic aorta dilatation in more than 25% of 422 patients [3]. Other retrospective studies had already assessed a higher incidence of thoracic aorta repair in patients that had previously undergone to abdominal aortic repair, although in their reports patients with connective disease were included as well. Alegret et al. stated that

Echocardiography has the ability to noninvasively explore hemodynamic variables during pharmacologic or exercise stress test in patients with heart failure. In this review, we detail some important potential applications of stress echocardiography in patients with heart failure. In patients with coronary artery disease and chronic LV dysfunction, dobutamine stress echocardiography is able to distinguish between viable and fibrotic tissue to make adequate clinical decisions. Exercise testing, in combination with echocardiographic monitoring, is a method of obtaining accurate information in the assessment of functional capacity and prognosis. Functional mitral regurgitation is a common finding in patients with dilated and ischaemic cardiomyopathy and stress echocardiography in the form of exercise or pharmacologic protocols can be useful to evaluate the behaviour of mitral regurgitation. It is clinical useful to search the presence of contractile reserve in non ischemic dilated cardiomyopathy such as to screen or monitor the presence of latent myocardial dysfunction in patients who had exposure to cardiotoxic agents. Moreover, in patients with suspected diastolic heart failure and normal systolic function, exercise echocardiography could be able to demonstrate the existence of such dysfunction and determine that it is sufficient to limit exercise tolerance. Finally, in the aortic stenosis dobutamine echocardiography can distinguish severe from non-severe stenosis in patients with low transvalvular gradients and depressed left ventricular function.

Residual mitral regurgitation (MR) after repair is a risk factor for late reoperation. The use of intraoperative transesophageal echocardiography (IOTEE) decreases the incidence of immediate repair failure. This study identifies the mechanisms of immediate failure by IOTEE in the quadrangular resection technique, a well-standardized mitral valve repair procedure to guide further repair procedures. Two hundred five consecutive patients underwent quadrangular resection due to prolapse or flail posterior leaflet. Twenty-four patients (11%) had immediate failure. Immediate reinstitution of cardiopulmonary bypass ("second pump run") was needed in 21 patients (10%) for further repair. The identified mechanisms of failure were residual cleft provoking interscallop malcoaptation into the posterior leaflet in 8 patients, residual prolapse of the anterior or posterior leaflets in 1 and 4 patients' respectively, residual annular dilation in 3, left ventricular outflow obstruction in 2, suture dehiscence in 2, and other mechanisms in,another 2 patients. In 20 patients (95%), IOTEE guided further repair with resolution of the residual MR, whereas I patient underwent valve replacement due to pharmacologically untreatable left ventricular outflow obstruction. In conclusion, even if this type of valve repair technique is well standardized, the incidence of immediate failure is not negligible. IOTEE identified the mechanisms of the immediate failure and guided further repair procedures, thus reducing the incidence of valve replacement (0.5%) without increasing perioperative mortality and morbility. (C) 2003 by Excerpta Medica, Inc.

Multiplane transesophageal echocardiography is a useful tool to study mitral regurgitation. We evaluated the diagnostic accuracy of multiplane transesophageal echocardiography performed according to the guidelines of the American Society of Echocardiography. We used 4 midesophageal and 2 transgastric views in 313 patients with degenerative lesions, endocarditic lesions, or both to identify regurgitant defects, comparing transesophageal echocardiography results with surgical findings. The overall diagnostic accuracy using individual scallops was 97.2% (P < .00001) with a sensitivity of 96.6% and a specificity of 97.6%. Considering the single sections of the mitral valve, an accuracy of 98%, 97.1%, and 98%, was found, respectively, for the lateral, middle, and medial third of the anterior leaflet. For the posterior leaflet, the accuracy was 98% for the lateral scallop, 98.4% for the middle, and 96.1% for the medial. This strategy provides good accuracy in diagnosing both simple and challenging mitral-valve lesions and its widespread use should be recommended.

Objectives: Mitral-valve repair in Barlow’s disease is challenging; conventional techniques are difficult to perform, and there is a high risk of a postoperative suboptimal result. Double-orifice repair has been applied in a standardized approach to treat patients with severe mitral regurgitation and bileaflet prolapse due to Barlow’s disease. Methods: Since 1993, 82 patients with severe mitral regurgitation due to Barlow’s disease underwent correction applying the edge-to-edge concept. They were submitted to double-orifice repair in a standardized fashion, suturing the middle portions of both leaflets. Results: There were no hospital deaths. The repair was unsatisfactory in one patient who underwent valve replacement soon after the repair. The mean postoperative valve area was 3.7 ^ 0.79 cm 2 against a mean preoperative value of 9.2 ^ 2.1 cm 2 . No or mild regurgitation was found in all but three patients who showed moderate residual regurgitation. There were no late deaths. Freedom from reoperation was 86 ^ 14% at 5 years. At the latest follow-up, all patient but one were New York Heart Association (NYHA) functional class I, and echo-Doppler assessment of valve reconstruction showed stable valve function in all patients. Conclusions: The double-orifice repair can be used as a standardized approach to treat valve regurgitation due to Barlow disease with low risk and good early and mid-term results. q 2000 Elsevier Science B.V. All rights reserved.

The effects of epsilon-aminocaproic acid (EACA) and tranexamic acid (TA) on bleeding and allogeneic transfusions, and the cost of pharmacological and transfusional treatment were compared to aprotinin (AP).We randomized 210 patients subjected to elective cardiac surgery. Of these, 68 patients received EACA (a bolus of 5 g, an infusion of 2 g/h, and 2.5 g in the priming), 72 patients received TA (a bolus of 1 g, an infusion of 400 mg/h, and 500 mg in the priming), and 70 patients received AP (a bolus of 280 mg, an infusion of 70 mg/h, and 280 mg in the priming). Postoperative blood loss and homologous transfusions were collected and the cost of pharmacological treatment and homologous transfusions were calculated.Bleeding but not allogeneic transfusions was significantly higher in the EACA group (467+/-234 versus TA, 311+/-231 versus AP, 283+/-233; p0.001). Costs of pharmacological and transfusional treatment were significantly lower in the TA group ($58.10+/-$105.10) versus the EACA group ($100.70+/-$158.60) versus the AP group ($432.60+/-$118.70) (p0.0001).Compared to AP, TA has the same effects on bleeding and transfusions, but with a significant reduction of costs. Patients treated with EACA showed a significantly higher postoperative bleeding with an increased trend of transfusion requirement.

Objective: Since excessive fibrinolysis during cardiac surgery is frequently associated with abnormal perioperative bleeding, many authors have advocated prophylactic use of antifibrinolytic drugs to prevent hemorrhagic disorders. We compared the effects of tranexamic acid (a synthetic antifibrinolytic drug) with aprotinin (a natural derivative product with antifibrinolytic properties) on perioperative bleeding and the need for allogeneic transfusions. Methods: In a single-center prospective randomized unblinded trial, 1040 consecutive patients undergoing primary, elective cardiac operations with cardiopulmonary bypass received either high-dose aprotinin or tranexamic acid. The aprotinin group (518 patients) received 280 mg in 20 minutes before the skin incision, 280 mg in the priming solution of the extracorporeal circuit, and a continuous infusion of 70 mg/h throughout the operation. The tranexamic acid group (522 patients) received 1 g in 20 minutes before the skin incision, 500 mg in the priming solution of the extracorporeal circuit, and a continuous infusion of 400 mg/h during the operation. Postoperative bleeding, perioperative transfusions, and hematologic variables were evaluated at fixed times. Postoperative thrombotic complications, intubation time, intensive care unit stay, and hospital stay were recorded. Results: Postoperative bleeding was similar in the 2 groups: aprotinin 250 mL (150-400 mL) versus tranexamic acid 300 mL (200-450 mL) (median and 25th-75th quartiles), median difference of 50 mL (95% confidence intervals, 0-50 mL). The number of transfusions and the outcome did not differ. Conclusions: Tranexamic acid and aprotinin show similar clinical effects on bleeding and allogeneic transfusion in patients undergoing primary elective heart operations. Since tranexamic acid is about 100 times cheaper than aprotinin, its use is preferable in this type of patient. (J Thorac Cardiovasc Surg 2000;120:520-7)