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Aims: After the introduction of the European Society of Cardiology (ESC) guidelines on prevention, diagnosis, and treatment of infective endocarditis (IE) in 2009, prophylaxis for patients at risk became less strict. We hypothesize that there will be a rise in IE after the introduction of the guideline update., Methods and Results: We performed a nationwide retrospective trend study using segmented regression analysis of the interrupted time series. The patient data were obtained via the national healthcare insurance database, which collects all the diagnoses nationwide. We compared the data before and after the introduction of the 2009 ESC guideline. Between 2005 and 2011, a total of 5213 patients were hospitalized with IE in the Netherlands. During this period, there was a significant increase in IE from 30.2 new cases per 1 000 000 in 2005 to 62.9 cases per 1 000 000 in 2011 (P < 0.001). In 2009, the incidence of IE increased significantly above the projected historical trend (rate ratio: 1.327, 95% CI: 1.205-1.462; P < 0.001). This coincides with the introduction of the 2009 ESC guideline. After the introduction of the ESC guideline, the streptococci-positive cultures increased significantly in the following years 2010-11 from 31.1 to 53.2% (P = 0.0031)., Conclusion: This observational study shows that there has been a steady increase in the IE incidence between 2005 and 2011. After the introduction of the 2009 ESC guidelines, the incidence increased more than expected from previous historical trends. Furthermore, there was a significant increase in streptococci-related IE cases., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Objective: To quantify the impact of a practical, hospital-based nurse-coordinated prevention programme on cardiovascular risk, integrated into the routine clinical care of patients discharged after an acute coronary syndrome, as compared with usual care only., Design: RESPONSE (Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists) was a randomised clinical trial., Setting: Multicentre trial in secondary and tertiary healthcare settings., Participants: 754 patients admitted for acute coronary syndrome., Intervention: A nurse-coordinated prevention programme, consisting of four outpatient nurse clinic visits, focusing on healthy lifestyles, biometric risk factors and medication adherence, in addition to usual care., Main Outcome Measures: The main outcome was 10-year cardiovascular mortality risk as estimated by Systematic Coronary Risk Evaluation at 12 months follow-up. Secondary outcomes included Framingham Coronary Risk Score at 12 months, in addition to changes in individual risk factors. Risk factor control was classified as 'poor' if 0 to 3 factors were on target, 'fair' if 4 to 6 factors were on target, and 'good' if 7 to 9 were on target., Results: The mean Systematic Coronary Risk Evaluation at 12 months was 4.4 per cent (SD 4.5) in the intervention group and 5.4 per cent (SD 6.2) in the control group (p=0.021), representing a 17.4% relative risk reduction. At 12 months, risk factor control classified as 'good' was achieved in 35% of patients in the intervention group compared with 25% in the control group (p=0.003). Attendance to the nurse-coordinated prevention programme was 92%. In the intervention group, 86 rehospitalisations were observed against 132 in the control group (relative risk reduction 34.8%, p=0.023)., Conclusions: The nurse-coordinated hospital-based prevention programme in addition to usual care is a practical, yet effective method for reduction of cardiovascular risk in patients with coronary disease. Our data suggest that the counselling component of the programme may lead to a reduction in hospital readmissions., Trial Registration Trialregisternl Identifier: TC1290.

Objectives: This study sought to assess the feasibility and safety of percutaneous edge-to-edge mitral valve (MV) repair in patients with an unacceptably high operative risk., Background: MV repair for mitral regurgitation (MR) can be accomplished by use of a clip that approximates the free edges of the mitral leaflets., Methods: All patients were declined for surgery because of a high logistic EuroSCORE (>20%) or the presence of other specific surgical risk factors. Transthoracic echocardiography was performed before and 6 months after the procedure. Differences in New York Heart Association (NYHA) functional class, quality of life (QoL) using the Minnesota questionnaire, and 6-min walk test (6-MWT) distances were reported., Results: Fifty-five procedures were performed in 52 patients (69.2% male, age 73.2 ± 10.1 years, logistic EuroSCORE 27.1 ± 17.0%). In 3 patients, partial clip detachment occurred; a second clip was placed successfully. One patient experienced cardiac tamponade. Two patients developed inguinal bleeding, of whom 1 needed surgery. Six patients (11.5%) died during 6-month follow-up (5 patients as a result of progressive heart failure and 1 noncardiac death). The MR grade before repair was ≥3 in 100%; after 6 months, a reduction in MR grade to ≤2 was present in 79% of the patients. Left ventricular (LV) end-diastolic diameter, LV ejection fraction, and systolic pulmonary artery pressure improved significantly. Accompanied improvements in NYHA functional class, QoL index, 6-MWT distances, and log N-terminal pro-B-type natriuretic peptide were observed., Conclusions: In a high-risk population, MR reduction can be achieved by percutaneous edge-to-edge valve repair, resulting in LV remodeling with improvement of functional capacity after 6 months., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: To investigate the relationship between advanced glycation end-products (AGEs) and diastolic function and the response to blood pressure treatment in patients with hypertension and diastolic dysfunction., Methods and Results: Data were analysed from 97 patients (aged 65 +/- 10 years, 36% male) who were randomly assigned to 6 months open-label treatment with either eprosartan on top of other anti-hypertensive drugs (n = 47) or other anti-hypertensive drugs alone (n = 50). Tissue AGE accumulation was measured using a validated skin-autofluorescence (skin-AF) reader (n = 26). Plasma N(epsilon)-(carboxymethyl)lysine (CML), N(epsilon)-(carboxyethyl)lysine (CEL), and pentosidine were measured by LC-MS/MS and HPLC. Diastolic function was assessed using echocardiography. Blood pressure was reduced from 157/91 to 145/84 mmHg (P < 0.001) in the eprosartan group and from 158/91 to 141/83 mmHg (P < 0.001) in the control group. No effect of eprosartan was found on AGE levels. In patients with baseline skin-AF < median, E/A ratio (P = 0.04) and the mean peak early-diastolic filling velocity (E') improved (P = 0.001). In contrast, in patients with skin-AF levels > median, E/A ratio (P = 0.84) and mean E' (P = 0.32) remained unchanged., Conclusion: Although eprosartan did not decrease levels of AGEs, patients with lower skin-AF at baseline showed a larger improvement in diastolic function in response to either anti-hypertensive treatment compared with patients with higher skin-AF.

Objective: To compare the effects of an angiotensin receptor blocker(ARB)-based regimen versus a non-ARB based regimen on diastolic function and neurohormones in patients with hypertension and diastolic dysfunction., Methods: 97 patients with a systolic blood pressure (SBP) > or =140 mmHg, a left ventricular ejection fraction >0.50, and echocardiographic evidence of diastolic dysfunction were randomly assignment to open-label treatment with eprosartan (with other anti-hypertensives; n = 47) or other anti-hypertensives alone (n = 50). Echocardiography, including tissue Doppler imaging (TDI), and neurohormones were done at baseline and after 6 months., Results: Mean age was 65 (+/-10) years and 64% was female. During 6 months of treatment, SBP decreased from 157 +/- 16 to 145 +/- 18 mmHg in the eprosartan group and from 158 +/- 17 to 141 +/- 18 mmHg in the control group (both p < 0.001; p = ns between groups). Diastolic function was unaffected in both groups and there was no correlation between changes in SBP and changes in mean TDI (r = -0.06; p = 0.58). Aldosterone levels decreased in the eprosartan group, but other neurohormones remained largely unchanged. Change in SBP was however related to the change in NT-proBNP (r = 0.26; p = 0.019)., Conclusion: Lowering blood pressure, either with eprosartan or other anti-hypertensives in hypertensive patients with diastolic dysfunction did not change diastolic function after 6 months of treatment, but was associated with a decrease of NT-proBNP.

Three men, aged 67 years, 80 years and 53 years, respectively, developed signs and symptoms of progressive right-sided heart failure following open heart surgery. They were diagnosed with constrictive pericarditis based on echocardiography, cardiac magnetic resonance and cardiac catheterisation. Following pericardiectomy, two of the patients fully recovered, while one, the 80-year-old man, died during convalescence. When signs and symptoms of progressive right-sided heart failure develop after open heart surgery, a diagnosis of constrictive pericarditis should be considered. Constrictive pericarditis after open heart surgery may be caused by inflammation of the pericardium; an old, fibrotic haemopericardium, which may be diffuse or loculated; pericardial adhesions; or a combination of these entities. Diagnosing constrictive pericarditis is difficult and may take a long time. However, it is important to recognise this disorder early before it has progressed to an advanced stage. Pericardiectomy is the only effective therapy. When performed too late, survival is significantly reduced.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 154-156, . The duplicate article has therefore been withdrawn.

Background: Anticoagulation after coronary stenting is essential to prevent stent thrombosis. Drug-eluting stents, which are the preferred therapy, may be associated with a higher tendency for stent thrombosis., Methods: Patients who underwent coronary stent placement and presented with late stent thrombosis are described., Results: Eight patients with stent thrombosis are presented. Early discontinuation of the antithrombotic medication is associated with the occurrence of these complications., Conclusion: Long-term antithrombotic therapy seems essential to prevent stent thrombosis, especially for patients treated with drug-eluting stents.

A drug-eluting stent was implanted in four patients, a man aged 67 and a woman aged 42 with acute myocardial infarction, a woman aged 41 with unstable angina pectoris and a man aged 41 with stable angina pectoris. All suffered stent thrombosis after discontinuation (in three cases prematurely) of clopidogrel therapy. Reasons for discontinuation included allergic reaction, a dental procedure and refusal of reimbursement by the insurer. In order to restore stent patency they were treated by percutaneous coronary intervention and all patients suffered irreversible myocardial damage. Combination therapy using acetylsalicylic acid and clopidogrel during and after angioplasty for the prevention of long- and short-term complications is necessary. Stent thrombosis after drug-eluting stent implantation usually occurs within 1-4 weeks following discontinuation ofantiplatelet medication. These cases stress the importance of antiplatelet therapy after stent implantation. Physicians, dentists and patients must be aware of the risk of the early discontinuation ofantiplatelet therapy.

The objective of this study was to find differences in outcome and complications using three different types of devices for percutaneous atrial septal defect (ASD) closure in adults. Percutaneous closure of a secundum-type ASD is increasingly performed in adult patients. All adult patients who underwent a percutaneous closure of a secundum-type ASD in our center between November 1996 and November 2004 were included. Failure was defined as dislocation or embolization of the device, which required surgical intervention. Periprocedural and mid-term complications were registered. Sixty-five patients, mean age 45.7+/-18.1 years (18 men, 47 women), underwent a percutaneous closure of an ASD with an ASDOS in 3, an Amplatzer in 36, and a Cardioseal/Starflex closure device in 26 patients. During an overall median follow-up of 1.2 years (range, 0.1-6.7 years), the failure occurred in four patients, all Cardioseal/Starflex (P=0.04). Within the Cardioseal/Starflex subgroup, the ASD and device diameters were significantly higher in those patients in whom the primary endpoint occurred compared to the others, 18.8+/-3.8 vs. 13.0+/-3.8 mm for ASD diameter (P=0.01) and 40 (range, 40-43) vs. 33 mm (range, 20-40) for device diameter (P=0.008). Overall complications were transient arrhythmias in 15.4%, pericardial effusion in 1.5%, and transient ischemic attack in 1.5%. Complete closure 6 months after the procedure occurred in 79.6%, without difference between the devices. Percutaneous ASD closure seems to be a relatively safe and effective procedure. However, using the larger Cardioseal/Starflex devices for closure seems to be related to a higher rate of device dislocation and embolization., (Copyright (c) 2006 Wiley-Liss, Inc.)

We present a case of a traumatic aorto-right ventricular fistula coexistent with aortic insufficiency due to perforation of the left coronary leaflet, which is a lesion rarely described in the literature. We compare our experience with reports from the literature.

Background and Aim: Functional mitral regurgitation (FMR) is defined as mitral regurgitation in the absence of intrinsic valvular abnormalities. We prospectively evaluated the effect of coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR), without additional mitral valve repair, on the degree of moderate or severe FMR., Study Design and Methods: From a cohort of 2829 patients undergoing CABG and/or AVR in the St. Antonius Hospital, 67 patients were identified with moderate or severe FMR by transthoracic and transoesophageal Doppler echocardiography., Results: Two out of the 67 patients (3%) died perioperatively. During follow-up (3-18 months) mitral regurgitation decreased by one grade in 29 patients, by two grades in 28, by three grades in five patients and remained unchanged in one patient (p=0.0001). Of all patients, 85% had grade I mitral regurgitation or less. Grade II mitral regurgitation remained in nine patients with a previous large myocardial infarction and/or annular calcifications. NYHA class improved from 3.1+0.5 to 1.4+0.4 (p=0.0001). Ejection fraction increased from 46 to 55% (p=0.0001). Overall, left atrial and left ventricular end-diastolic dimensions decreased significantly. In contrast, no decrease in dimensions was seen in patients with postoperative grade II mitral regurgitation., Conclusion: FMR may improve significantly following CABG and/or AVR, although a previous large myocardial infarction and/or annular calcifications may affect outcome.

Objective: Registry to report our single-centre experience in closing defects of the atrial septum., Methods: Between 1996 and 2001, transcatheter device closure of significant atrial septal defects was performed in 32 adults (mean age 45.1 years, range from 15 to 76 years), using different device types. Six patients had a patent foramen ovale (PFO) and 26 patients had a secundum atrial septal defect (ASD II). Defects were selected by means of two-dimensional transoesophageal echocardiography (2D TOE). For 12 defects additional three-dimensional transoesophageal echocardiography (3D TOE) was performed., Results: Mean balloon-stretched diameter was 19.3 mm (range from 11 to 24 mm). A device was successfully placed in all PFO patients (100%) without complications at follow-up. Successful immediate device placement occurred in 24 out of 26 ASD patients. Two immediate placement failures, 1 device embolisation and 1 device non-fixation, occurred and required urgent surgery. There was 1 patient with pericardial effusion after the intervention, requiring pericardiocentesis. Three late placement failures occurred: 2 device embolisations and 1 device dislocation. Clinical success after 3 to 6 months follow-up, defined as the absence of shunt or small shunt, was achieved in all 6 PFO patients and in 21 out of 23 ASD patients (1 device embolisation, requiring surgery, occurred before follow-up was completed). Two patients with significant shunt, 1 late device dislocation and 1 late device embolisation, underwent elective surgery. For patient selection, 3D TOE proved useful in the evaluation of large and/or complex defects., Conclusion: Transcatheter device closure of carefully selected atrial septal defects is an alternative to surgery. Although the results are promising, surgical back-up is often needed.

In this report we describe a 75-year-old woman who presented with an acute coronary syndrome and transient catecholamine-induced cardiomyopathy with severe pulmonary oedema necessitating mechanical ventilation. During mechanical ventilation several episodes of hypertension occurred despite severe left ventricular systolic dysfunction. A pheochromocytoma was diagnosed and after successful surgical resection the patient's condition improved. Three months after surgery myocardial scintigraphic examination demonstrated a normal ejection fraction and no signs of adenosine-induced ischaemia.

Objective: To evaluate clinical and echocardiographic outcomes for the semi-flexible Carpentier-Edwards Physio and the rigid Classic mitral annuloplasty ring., Methods: Ninety-six patients were randomized for either a Classic (n = 53) or a Physio (n = 43) ring from October 1995 through July 1997. Mean follow-up was 5.1 years (range .1-6.6). We included standard patient characteristics at baseline and during follow-up. Analyses were adjusted for age and gender, and for factors that differed across groups at baseline. In 2002, echocardiography was performed in 74% of the survivors., Results: We found a 16% difference in mortality: 14% in the Physio group (n = 6) and 30% in the Classic group (n = 16) (adjusted P = .41). Life table analysis shows that the absolute risk of death after 30 months is lower in the Physio group. Intra-operative repair failure occurred in 3 patients (6%) of the Classic group, and in 4 (9%) of the Physio group, resulting in mitral valve replacement. Late failure occurred in 1 patient (2%) in the Classic group, and in 4 (9%) in the Physio group. At follow-up, left ventricular function did not differ across groups (ejection fraction 45% and 48% (adjusted P = .65)). The combined NYHA class III-IV had improved for the Classic group in 42% and for the Physio group in 34%., Conclusion: Although the 16% difference in mortality did not reach statistical significance, it is considered clinically important. No differences in morbidity, valve function, and left ventricular function were found. Further research to explain the difference in mortality is required.

Percutaneous transvenous mitral balloon valvotomy (PTMV) has been proven to be an effective and safe method for treatment of patients with severe mitral valve stenosis. This technique has become an accepted alternative for surgical commissurotomy, not only in young patients with pliable valves, but also in selected older patients with extensive valvular pathology. This review highlights the significance of coexisting atrial fibrillation, patient selection and timing of PTMV in patients with mitral valve stenosis.

Three female patients, a 22-year-old Moroccan woman, a 25-year-old Turkish woman and a 35-year-old Iraqi woman, became increasingly dyspnoeic during their pregnancy; this was a symptom of congestive heart failure due to mitral valve stenosis. Since all patients were refractory to medical treatment, they underwent invasive therapy by percutaneous transvenous mitral balloon valvotomy (PTMV). In two patients this therapy was successful, but in one patient a closed mitral valvotomy was needed. All three women delivered healthy infants, two immediately following the PTMV; at follow-up 2-4 years later, the women and infants were all doing well. The prevalence of mitral valve stenosis in the western world is increasing because of changing immigration patterns. When pregnant patients start complaining about dyspnoea, especially if they are immigrants, one should be aware of the possibility of mitral valve stenosis. PTMV is a safe and successful treatment for these patients and is preferred above surgical therapy because of its low morbidity and mortality for both mother and foetus. PTMV must be performed in a thoracic surgery centre by an experienced team and the X-ray exposure should be minimised.

Background: Management guidelines for heart failure recommend ACE-I and beta-blockers. The perception of difficult up-titration might have added to the slow uptake of beta-blockers despite their mortality and morbidity benefits., Aims: CARMEN offered a possibility to study safety and tolerability of enalapril against carvedilol and their combination., Methods: Five hundred and seventy-two patients were blindly up-titrated on carvedilol (target 25 mg bid) and/or enalapril (target 10 mg bid), and continued for 18 months. In the combination arm, carvedilol was up-titrated before enalapril., Results: There was no group related difference in adverse events during up-titration. Withdrawal rates were 31, 30 and 30%, and serious adverse events 28, 29 and 34% in the combination, carvedilol and enalapril arms. Mortality was similar in all groups (all-cause N=14, 14 and 14; cardiovascular N=9, 13 and 14). All-cause and cardiovascular hospitalizations occurred in 26, 27 and 32%, and in 12, 16 and 22% in the combination, carvedilol and enalapril arms, respectively., Conclusion: The safety profile was similar in all treatment arms. In contrast to common perception, there was no difference in tolerability between the ACE-I and carvedilol. This result is even more remarkable as the high prestudy use of ACE-I (65%) might have introduced a bias by selecting ACE-I tolerant patients, who were only switched from their former ACE-I to enalapril.

Aims: Heart failure (HF) treatment guidelines of the ESC recommend ACE-inhibitors (ACE-I) as first-line treatment and beta-blockers added if patients remain symptomatic. CARMEN explored the need for combined treatment for remodelling and order of introduction by comparing the ACE-I enalapril against carvedilol and their combination., Methods: In a parallel-group, 3-arm study of 18 months duration, 572 mild heart failure patients were randomly assigned to carvedilol (N = 191), enalapril (N = 190) or their combination (N = 191). In the latter, carvedilol was up-titrated before enalapril. Left ventricular (LV) remodelling was assessed by transthoracic echocardiography (biplane, modified Simpson) at baseline and after 6, 12 and 18 months of maintenance therapy. Primary comparisons considered the change in LV end-systolic volume index (LVESVI) from baseline to month 18 between the combination and enalapril, and between carvedilol and enalapril., Results: In the first primary comparison, LVESVI was reduced by 5.4 ml/m2 (p = 0.0015) in favour of combination therapy compared to enalapril. The second primary comparison tended to favour carvedilol to enalapril (NS). In the within treatment arm analyses, carvedilol significantly reduced LVESVI by 2.8 ml/m2 (p = 0.018) compared to baseline, whereas enalapril did not. LVESVI decreased by 6.3 ml/m2 (p = 0.0001) with combination therapy. All three arms showed similar safety profiles and withdrawal rates., Conclusion: CARMEN is the first study to demonstrate that early combination of ACE-I and carvedilol reverses LV remodelling in patients with mild to moderate HF and LV systolic dysfunction. The results of the CARMEN study support a therapeutic strategy in which the institution of beta-blockade should not be delayed.

Background: Conventional Doppler echocardiography offers an indirect assessment of left ventricular (LV) diastolic function, hampered by preload dependency. Tissue Doppler imaging (TDI) is a tool to study diastolic function in a more direct and less preload-dependent manner., Methods: The Medline database has been searched for literature on TDI for the analysis of diastolic function. A secondary search reviewed the relevant references related to TDI or diastolic function in general., Results: TDI measures myocardial velocities with a high temporal and velocity resolution but lacks spatial information. In particular, the velocity of early diastolic wall motion (E(m)) and its timing are promising indices of local myocardial relaxation. E(m) at the mitral annulus offers fair estimates of ventricular relaxation, relatively independent of preload and systolic function. Combined with early transmitral flow velocity (E), detection of pseudo-normalized filling patterns and estimation of filling pressures are enhanced by E/E(m)., Conclusion: TDI has an emerging role in the study and assessment of diastolic function. However, TDI-derived information needs to be integrated with other echocardiographic data because single diagnostic accuracy remains unsatisfactory.

The objective of this study was to validate the additional value of 3-dimensional (3D) transesophageal echocardiography (TEE) for patients with mitral valve stenosis undergoing percutaneous mitral balloon valvotomy (PTMV). Therefore, in a series of 21 patients with severe mitral valve stenosis selected for PTMV, 3D TEE was performed before and after PTMV. The mitral valve area was assessed by planimetry pre- and post-PTMV; the mitral valve volume was assessed and attention was paid to the amount of fusion of the commissures. These results were compared with findings by 2-dimensional transthoracic echocardiography using pressure half-time method for assessment of mitral valve area, and were analyzed for the prediction of successful outcome. Pre-PTMV the mitral valve area assessed by 3D TEE was 1.0 +/- 0.3 cm(2) vs 1.2 +/- 0.4 cm(2) assessed by 2-dimensional transthoracic echocardiography (P =.03) and post-PTMV it was 1.8 +/- 0.5 cm(2) vs 1.9 +/- 0.6 cm(2) (not significant), respectively. The mitral valve volume could be assessed by 3D TEE (mean 2.4 +/- 2.5 cm(3)) and was inversely correlated to a successful PTMV procedure (P <.001). The 3D TEE method enabled a better description of the mitral valvular anatomy, especially post-PTMV. We conclude that 3D TEE will have additional value over 2-dimensional echocardiography in this group of patients, for selection of patients pre-PTMV, and for analyzing pathology of the mitral valve afterward.

This case report describes a patient with severe calcific aortic stenosis who was initially considered inoperable because of a very poor left ventricular function and severe pulmonary hypertension. After balloon aortic valvuloplasty, the clinical and haemodynamic status of the patient improved to such an extent that subsequent aortic valve replacement was considered possible and eventually proved to be successful. Balloon aortic valvuloplasty has value as a potential bridge to aortic valve replacement when the risks for surgery are considered to be too high.

Background: Unmodified maze III operations show long-term eradication of atrial fibrillation (AF) in more than 85% of patients with or without structural heart disease. The effect of this procedure on atrial volumes is not known., Methods: Two patient populations were studied: (1) patients undergoing unmodified maze III operations combined with surgical structural heart disease, mostly mitral valve operations (group A; n = 32); and (2) patients with only AF selected for unmodified maze III operations (group B; n = 32). In groups A and B, transthoracic Doppler echocardiographic studies were prospectively made preoperatively, and at 3 and 12 months postoperatively. Left and right atrial dimensions and volumes and atrial contractions were determined and compared with base line patient characteristics and 12 months arrhythmia outcomes., Results: One year postoperatively all patients were alive. In groups A and B, 92% were free of AF and other atrial arrhythmias. A significant reduction of left atrial volume at 1 year postoperatively was apparent in group A, whereas the left atrial volume did not change significantly in group B. The reduction observed in group A was not related to postoperative age, type or duration of AF, or late atrial arrhythmia outcome. In both groups the right atrial volume remained unchanged at 12 months postoperatively., Conclusions: The unmodified maze III operation does not affect atrial volume in patients without structural heart disease. In patients with structural heart disease, the mitral valve operation contributes to the reduction of left atrial volume and dimension by improving the hemodynamic condition.

Aims: Little information is available about short-term and none about long-term follow-up of cardiac rhythm after percutaneous mitral balloon valvotomy (PTMV)., Methods and Results: We studied the long-term course of the supraventricular rhythm in 137 consecutive patients with severe mitral stenosis, who underwent PTMV. The rhythm before PTMV was sinus rhythm (SR) in 55% and chronic AF in 45% of patients. The mean follow-up time was 3.7+/-2.5 years (n=126). In patients with SR before PTMV, SR persisted in 91% of patients at the end of follow-up. In patients with chronic AF before PTMV, 84% of these patients were still in chronic AF at the end of follow-up, spontaneous conversion to SR did not occur. In 12 of 14 patients (85%), selected for cardioversion, SR was achieved, by DC cardioversion (n=11) or by drugs alone (n=1). After 2 years this outcome persisted, but after 4 years only 38% remained in SR., Conclusion: Pre-procedural SR will persist following PTMV. However in patients with chronic AF PTMV is not associated with reversion to SR, suggesting that measures should be undertaken to restore sinus rhythm., (Copyright 2003 The European Society of Cardiology.)

Objective: To evaluate the initial experience with pulmonary thromboendarterectomy for cor pulmonale due to chronic pulmonary embolism., Method: In the period 1 April 1996 to 31 October 2001, 18 patients with right ventricular failure due to chronic thromboembolic pulmonary hypertension were operated on. Their mean age was 54 (SD: 14) years. Preoperatively, all of the patients were in functional New York Heart Association (NYHA) class III or IV. Pulmonary angiography revealed pulmonary hypertension with an increased pulmonary vascular resistance, as well as typical angiographic signs of unresolved chronic emboli. Pulmonary thromboendarterectomy was performed via median sternotomy, using extracorporeal circulation and intermittent deep hypothermic circulatory arrest. The patients were monitored via the outpatients' department., Results: From a technical viewpoint, the procedure was performed successfully in all of the patients. Initially the pulmonary thromboendarterectomy was performed unilaterally (n = 7), which did not decrease pulmonary artery pressure significantly. The following 11 patients were treated bilaterally; in them thromboendarterectomy required an average of circulatory arrest totalling 64 (SD: 30) min with 161 (SD: 35) min of myocardial ischemia. After bilateral pulmonary thromboendarterectomy, the pulmonary artery pressure decreased from 45 (SD: 13) to 28 (SD: 9) mmHg (p = 0.001). Reperfusion pulmonary oedema, requiring prolonged ventilation, occurred in 3 patients. There was no operative or later mortality. At a mean follow-up of 28 (SD: 19) months, all but one of the patients were in functional NYHA class I or II. Echocardiography revealed reduced right ventricular dimensions and pulmonary artery pressures. One patient, with mainly distally located obstructions, exhibited no substantial improvement., Conclusion: The initial experience with pulmonary thromboendarterectomy for patients with cor pulmonale due to chronic pulmonary emboli demonstrated satisfactory mid-term follow-up data.

Unlabelled: OBJECTIVES; The goal of this study was to assess the safety and efficacy of femoral artery pseudoaneurysm (FAP) closure by collagen injection. BACKGROUND; The FAP is an infrequent but troublesome complication after percutaneous transfemoral catheter procedures. If ultrasound-guided compression repair (UGCR) fails, vascular surgery is indicated. We have developed a less invasive method to close FAPs percutaneously by injecting collagen and, thus, inducing clotting within the aneurysm., Methods: Via a 9F needle or 11F sheath, a biodegradable adhesive bovine collagen is injected percutaneously into the FAP, guided by angiography from the contralateral site., Results: From 1993 to 2000, compression and UGCR had failed to obliterate 110 FAPs. These patients have been treated by collagen injection. Mean age of the patients was 65.6 +/- 10.2 years (range: 32 to 85 years), and 50% were women. Immediate closure of the FAP was achieved in 107/110 patients (97.3%) without any complication or adverse effect. In one patient the collagen could not be applied due to unfavorable anatomy. One patient needed a second session of collagen injection. In one patient too much collagen was inserted, which resulted in external compression of the artery, and surgical intervention was required. The overall success rate was 108/110 (98%, 95% confidence interval: 93.5% to 99.8%). Among the patients with successful procedures, there were no recurrences during six months follow-up., Conclusions: The percutaneous treatment of iatrogenic FAP, by injection with collagen, is an effective and safe strategy. This method provides an excellent therapeutic alternative to the traditional surgical management.

Background: Recently, percutaneous transluminal septal myocardial ablation (PTSMA) has been introduced as treatment for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM)., Methods: We describe our first experience in 24 patients who were treated in our institution during the year 2000., Results: The procedure was initially successful in all but one patient. In that patient the septal branch that was perfusing the proximal septum could not be found. The procedure was complicated in three patients. One patient died suddenly on the second day after the procedure. Two additional patients needed a permanent pacemaker for persisting total heart block. In the other 22 patients the procedure was successful with an acute decrease of the mean outflow tract gradient from 89±43 mmHg to 21±19 mmHg. In those 19 patients who had a follow-up of at least three months (mean follow-up 172±87 days), the mean NYHA class decreased from 2.7±0.7 before PTSMA to 0.6±0.9 at the last follow-up. The echocardiographic gradient decreased from 92±39 mmHg before the procedure to 26±23 mmHg at the last follow-up., Conclusions: Our preliminary results demonstrate that PTSMA is an effective treatment for symptomatic patients with HOCM.

Background and Aim of the Study: The predictive value of chronic atrial fibrillation (AF) before percutaneous mitral balloon valvotomy (PMBV) is still under discussion. The effect of the duration of chronic AF on short- or long-term results is not known. Therefore, we analyzed the predictive value of pre-procedural chronic AF and the duration of this rhythm disturbance for short- and long-term outcome after PMBV in patients with mitral valve stenosis., Methods: A total of 140 PMBV procedures was performed in 137 patients with severe mitral stenosis. Sixty-three patients (45%) were in chronic AF; in 40 patients (63%) the AF was of more than one year duration. A successful procedure is defined as PMBV achieved without acute mitral valve replacement, and a mitral valve area after PMBV of > or =1.5 cm2., Results: Patients in chronic AF were significantly older, had a larger left atrial diameter and higher NYHA functional class, compared with patients in sinus rhythm (SR). The success rates of PMBV were 80.5% and 77.6% in patients with SR and AF, respectively (p = NS). Mean follow up was 4.2+/-2.6 years (n = 127). At four years' follow up the event-free survival was 86.5% in patients with SR, and 78.5% in those with chronic AF at baseline (p = 0.031). Multivariate analysis of the entire study population showed the presence of chronic AF to be the only pre-procedural independent predictor for severe mitral regurgitation after PMBV (p = 0.030), as well for an event (p = 0.039) and restenosis (p = 0.034) during follow up. The risk for an event or restenosis during follow up increased seven-fold when chronic AF at baseline was present for more than one year (p = 0.010)., Conclusion: Pre-procedural chronic AF is an independent predictor for unfavorable outcome at short- and long-term follow up after PMBV. A longer duration of AF further increases the risk of an event or restenosis.

Upon examination, a 40-year-old man was found to have fever, weight loss, and malaise. A blood culture was positive for Streptococcus mutans. Under the suspicion of endocarditis, he was treated with penicillin. Echocardiography revealed a large tumor in the left atrium. After 6 weeks of penicillin treatment, he was transferred to our hospital for excision of the tumor. Pathology revealed a myxoma with fibrin deposits, bacterial colonization, and massive infiltration with neutrophils.

A 56-year-old woman without structural heart disease had an ECG typical of Brugada syndrome. Syncope occurred due to monomorphic VT with left bundle branch block (LBBB) morphology. At electrophysiological study, VT with the same morphology was inducible.

Patients with coarctation of the aorta can be treated either with surgery or with balloon angioplasty. So far, the last method has proved to be successful in children, but results of this treatment in (young) adults are virtually unknown. The aim of this study was to evaluate the immediate and mid-term follow-up results of balloon angioplasty of native coarctation in (mainly young) adults. Coarctation of the aorta was diagnosed by means of ultrasound or angiography, and defined as a stenosis with a pressure gradient greater than 20 mm Hg. The balloon angioplasty-procedure was carried out under complete anesthesia, and was considered to be successful, if the pressure gradient was reduced to less than 20 mm Hg. Nineteen consecutive adults (12 males, 7 females; aged 14-67 years, median 29) with native coarctation were treated from 1995-99. Mean pressure gradient decreased from 49.3+/- 20.8 to 4.8+/-8.2 mm Hg (P<0.0001). One patient showed a suboptimal result with a residual pressure gradient of 28 mm Hg. In one other patient a stent was placed on request of the referring physician. Follow-up was 100% complete and ranged from 3-47 months (mean 20.2+/- 12.9). At 1-year follow-up mean systolic blood pressure was reduced from 159.4+/-19.5 to 132.5+/-17.6 mm Hg (n = 18; P<0.0001), and mean ankle-arm pressure index improved from 0.73+/-0.09 to 0.96+/-0.05 (n = 18; P<0.0001). Anti-hypertensive medication could either be reduced or stopped in 7 patients (53.8%). With ultrasound or angiography or MRI, no patients had signs of aneurysm formation or worsening restenosis during follow-up. In adult patients with uncomplicated native coarctation of the aorta, balloon angioplasty (without stenting) would seem to be an excellent and safe alternative for surgery. In our hospital it has completely replaced surgical correction in such patients.

Background: Intracoronary ultrasound (ICUS) imaging is potentially suitable to identify lesions at high risk of restenosis after percutaneous transluminal coronary angioplasty (PTCA), but it has not been studied systematically., Methods and Results: We recruited 200 patients in whom ICUS studies were performed after successful PTCA and related their ICUS parameters to 6-month follow-up quantitative coronary angiography. This was performed in 164 patients (82%), yielding 170 lesions for analysis. The overall incidence of a > or = 50% diameter stenosis at follow-up (categorical restenosis) was 29.4%. Quantitative ICUS parameters were weakly but significantly related to follow-up minimal luminal diameter on quantitative coronary angiography (lumen area: R2 = .36, P = .0001; vessel area: R2 = .29, P = .0002; plaque area: R2 = -.18, P = .021; percent obstruction: R2 = -.15, P = .05), but categorical restenosis was not significantly related to these parameters (P = .63, .77, .38, and .08, respectively). There were no significant predictors of restenosis in ICUS parameters of plaque morphology: eccentric versus concentric (P = 1.0), plaque type (hard, soft, or calcific, P = .98), or the number of calcified quadrants (P = .41). There were no significant predictors of restenosis in two predefined types of vessel-wall disruptions: (1) rupture: presence (P = .79), depth (partial versus complete, P = .85), or extent in quadrants (P = .6), and (2) dissection: presence (P = .31), depth (P = .82), or extent (P = .38)., Conclusions: Qualitative ICUS parameters after PTCA did not predict restenosis. A larger lumen and vessel area and a smaller plaque area by ICUS were associated with a larger angiographic minimal lumen diameter at follow-up, but these parameters were not significantly related to categorical restenosis.

A head-to-head comparison between 99mTc-sestamibi SPECT and planar myocardial imaging using dipyridamole low-level exercise stress was performed for the assessment of coronary artery disease (CAD) and for the impact on patient management in 78 patients (pts) who underwent coronary arteriography. Overall sensitivity and specificity for detection of CAD were 82% and 82% for SPECT, and 78% and 73% for planar imaging, respectively (both NS). Compared to planar imaging the sensitivity of SPECT imaging was significantly higher for detecting left anterior descending (p = 0.02) and left circumflex (p = 0.03) coronary artery disease. In predicting distally located stenoses, SPECT was significantly superior to planar imaging for the left circumflex artery (p = 0.025). Concordance analysis of perfusion status showed agreement in 308 of 390 (79%) of coronary flow regions both with respect to the presence or absence of perfusion and to the reversibility or irreversibility of defects (kappa = 0.60, SE 0.04). Stress-induced perfusion defects were significantly more detected by SPECT than by planar imaging (p < 0.001). Based on SPECT findings 31 pts were proposed for revascularization compared to 30 pts based on planar imaging (NS). Overall there was agreement in 65 (83%) pts regarding treatment strategy. We conclude that in a head-to-head comparison SPECT provided improved diagnostic value compared with planar imaging. However, with respect to patient treatment, the superiority of SPECT was not always translated into improved patient management.

The purpose of this prospective multicenter study of 350 consecutive patients who were accepted for mitral valve surgery because of severe regurgitation, was to assess the value of preoperative transthoracic and transesophageal echocardiography in predicting the surgical strategy in severe mitral regurgitation: repair or replacement. The cardiologist predicted the surgical strategy on the basis of the echocardiographic examination, according to predefined guidelines for repair and replacement. The predicted strategy and motivation thereof were compared with the surgical findings and procedure that was performed. Agreement on the basis of transthoracic echocardiography was reached in 86% of the repair patients and on the basis of transesophageal echocardiography in 89%. Agreement on the basis of transthoracic echocardiography was reached in 74% of the replacement patients and on the basis of transesophageal echocardiography in 75%. This study underlines the potential role of echocardiography in predicting the surgical procedure to be applied, provided that both surgeon and cardiologist use the same nomenclature and that the guidelines for replacement/repair are adhered to. Both transthoracic and transesophageal echocardiography appear to be equally accurate in predicting the optimal surgical procedure in this respect.

This prospective study was conducted to ascertain whether echocardiographic evaluation could provide more insight into the genesis of mitral regurgitation (MR) before surgery. All patients underwent preoperative transthoracic and transesophageal echocardiography. Nine centers participated in the ESMIR (Echocardiographic Selection of patients for MItral valve Reconstruction) study and 350 patients were included. Compared with surgical findings, the percentage of functional abnormalities correctly predicted by both echo modalities was highest in patients with increased leaflet mobility (83% for transthoracic and 86% transesophageal echocardiography). In contrast, in normal leaflet mobility, the prediction was better by transthoracic than by transesophageal echocardiography (75% vs 64%). In patients with restricted leaflet mobility, the predictive value of both techniques was similar. The diagnostic yield of anatomic abnormalities of both echo techniques was similar, except for chordal rupture; a sensitivity by transesophageal echocardiography of 79% and by transthoracic echocardiography of 57% (p < 0.001). In general, the sensitivity of each echo technique for detecting anatomic abnormalities was <70%, except for annular dilatation, leaflet thickening, and chordal rupture. At surgery, the prevailing functional condition was increased leaflet mobility (42%). The conclusion is that both echo techniques provide adequate information regarding the functional condition of the mitral valve apparatus, not withstanding limitations in assessing anatomic details. Transthoracic echocardiography appears to be sufficient for preoperative evaluation of MR.

Objectives: This study sought to determine the efficacy and safety of arbutamine echocardiography in inducing myocardial ischemia and detecting coronary artery disease., Background: Exercise and pharmacologic stress echocardiography are clinically accepted techniques for detecting coronary artery disease. Arbutamine is a new synthetic beta-adrenoceptor agonist developed specifically as a stress agent. Arbutamine is delivered by a new computerized drug delivery device that adjusts the rate of drug infusion according to the patient's heart rate response during stress testing., Methods: The sensitivity of arbutamine echocardiography was determined in 143 patients who had coronary artery disease documented by coronary angiography. A subset of these patients (n = 114) also underwent exercise echocardiography. The specificity, or normalcy, of arbutamine echocardiography was determined in 54 patients considered to have a low likelihood of coronary artery disease., Results: Among those patients who had both stress test results, the incidence of inducing myocardial ischemia (new or worsening wall motion abnormalities) was 79% (95% confidence interval [CI] 69% to 86%, n = 98) for arbutamine and 77% (95% CI 67% to 85%, n = 98) for exercise echocardiography. The sensitivity of detecting coronary artery disease (ischemia or rest wall motion abnormality) was 87% (95% CI 79% to 93%, n = 101) for arbutamine and 83% (95% CI 74% to 90%, n = 101) for exercise echocardiography. The specificity (normalcy) of arbutamine echocardiogrpahy was 96% (95% CI 87% to 100%, n = 52). Arbutamine was well tolerated, and there were no serious adverse events., Conclusions: Arbutamine echocardiography is an effective and safe pharmacologic stress test technique for diagnosing or excluding the presence of coronary artery disease. The ability of arbutamine stress to induce myocardial ischemia, detectable by echocardiography, was comparable to that for exercise.

As regional wall motion abnormality (RWA) is the first sign of ischaemia, transoesophageal echocardiography was evaluated as a monitoring device in 51 patients undergoing abdominal aortic surgery. Wall motion of the entire left ventricular wall (nine segments) was semiquantitatively evaluated 15 min before and after aortic cross-clamping and 3 h after declamping. In addition, limb lead II of the electrocardiogram was simultaneously recorded. At baseline, RWA was present in 16 patients (31%). New or worsened RWA 15 min after aortic cross-clamping was seen in 17 patients, of whom 11 had persistent RWA, i.e. it was still present 3 h after declamping. This was associated in seven patients with enzymatically documented myocardial infarction. Only one infarct patient demonstrated ST segment changes of more than 1 mm. Thus, a single electrocardiographic surface lead is insensitive for perioperative myocardial ischaemia detection. Furthermore, new and/or worsened RWA after aortic cross-clamping, which persists until 3 h after declamping, is, to a considerable degree, associated with perioperative infarction.

Because mitral valve competence after mitral valve reconstruction is awkward to assess during this procedure, we evaluated in this respect transesophageal color-coded Doppler echocardiography in 23 patients undergoing mitral valve reconstruction for severe mitral regurgitation. Transesophageal echocardiographic examinations were performed after induction of anesthesia but before sternotomy (baseline), after mitral valve repair before decannulation, and at sternal closure, all at similar mean aortic pressure and echocardiographic instrument settings. The degree of mitral regurgitation by transesophageal color Doppler flow mapping was visually quantified on a 5-point scale (0 to 4), pending the left atrial extent of the regurgitant jet. This was compared with the degree of mitral regurgitation by left ventricular cineangiography performed within several weeks after operation and also visually quantified on a 5-point scale (0 to 4), with use of the right anterior oblique projection. There was good correlation between the two methods (r = 0.83; p less than 0.001). We conclude that residual mitral regurgitation, as assessed by transesophageal color flow mapping in the operating room, highly correlates with the ultimate mitral regurgitation by cineangiography. Therefore transesophageal echocardiography can be helpful for evaluation of mitral valve competence during mitral valve reconstruction, and hence, in case of repair failure, allow valve replacement in the same surgical session, thus avoiding reoperation.

To ascertain the value of transesophageal echocardiography during percutaneous balloon mitral valvuloplasty, the present study was undertaken in 26 anesthesized patients (21 women and 5 men; mean age, 47 years) with symptomatic rheumatic mitral valve stenosis. In all but one patient the balloon dilation of the mitral valve was successful and Doppler-derived valve area increased (0.9 +/- 0.3 to 1.9 +/- 0.4 cm2). Transesophageal echocardiography provides continuous monitoring, as well as guidance of the procedure. Crossing the arterial septum, as well as delivery of the sheath through the mitral valve orifice and correct positioning of the balloon, was highly facilitated and reduced x-ray exposure time. The degree of mitral regurgitation and the presence of interatrial shunting at the end of the procedure could be readily assessed, making cineangiography not necessary. Complications of the procedure, such as pericardial effusion, could be detected before hemodynamic deterioration had occurred (one patient). The advantages of transesophageal echocardiography for routine monitoring of percutaneous mitral valvuloplasty, however, should be weighted against the added risk and expense of this support.