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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.

Objective: To assess regional mechanical dyssynchrony as a determinant of the degree of functional mitral regurgitation (FMR). Setting: Tertiary cardiology clinic. Patients: 74 consecutive patients with left ventricular (LV) dysfunction (ejection fraction Methods: Effective regurgitant orifice (ERO) area, indices of mitral deformation (systolic valvular tenting, mitral annular contraction) and of global LV function and remodelling (ejection fraction, end systolic volume, sphericity index) and local remodelling (papillary-fibrosa distance, regional wall motion score index), and tissue Doppler-derived dyssynchrony index (DI) (regional DI, defined as the standard deviation of time to peak myocardial systolic contraction of eight LV segments supporting the papillary muscles attachment) were measured. Results: All the assessed variables correlated significantly with ERO. By multivariate analysis, systolic valvular tenting was the strongest independent predictor of ERO (R 2 = 0.77, p = 0.0001), with a minor influence of papillary-fibrosa distance (R 2 = 0.77, p = 0.01) and regional DI (R 2 = 0.77, p = 0.03). Local LV remodelling (regional wall motion score index: R 2 = 0.58, p = 0.001; papillary-fibrosa distance: R 2 = 0.58, p = 0.002) and global remodelling indices (sphericity index: R 2 = 0.58, p = 0.003) were the main determinants of systolic valvular tenting, whereas regional DI did not enter into the model. Regional DI was an independent predictor of ERO (R 2 = 0.56, p = 0.005) in patients with non-ischaemic LV dysfunction but not in patients with ischaemic LV dysfunction when these groups were analysed separately. Conclusions: The degree of FMR is associated mainly with mitral deformation indices. The regional dyssynchrony also has an independent association with ERO but with a minor influence; however, it is not a determinant of FMR in patients with ischaemic LV dysfunction.

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 This observational study was designed to evaluate the prevalence of coronary microvascular dysfunction (CMD) in asymptomatic patients affected by systemic sclerosis (SSc), stratifying the results according to the limited (lcSSc) and the diffuse (dcSSc) forms of the disease. METHODS AND RESULTS We enrolled 19 consecutive asymptomatic patients with dcSSc (n=7) or lcSSc (n=12). In all subjects, coronary flow reserve (CFR) was assessed by measuring diastolic coronary flow velocities in the left anterior descending artery by pulsed wave Doppler at baseline and after dipyridamole infusion (0.84 mg·kg(-1)·6 min(-1)). Wall motion score index was evaluated at baseline and during stress. We enrolled 20 healthy subjects as controls. Mean CFR was 1.96±0.62 in patients and 2.69±0.47 in controls (P

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

Although the mechanism of ischemic mitral regurgitation (MR) is understood, the echocardiographic picture of ischemic MR is not homogeneous. Ninety-two consecutive patients with chronic ischemic MR due to restricted motion were divided into two groups according to tethering pattern: the asymmetric group with predominant posterior tethering of both leaflets (54 patients) and the symmetric one with predominant apical tethering of both leaflets (38 patients). The mitral deformation indexes, LV global (volume, function and sphericity) and local (papillary muscle displacements and regional wall motion score index) remodeling were evaluated. All indexes of global LV remodeling were significantly higher in the symmetric than asymmetric group (all p

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.

The aim of this study is to evaluate the role of contrast transesophageal echocardiography (cTEE) in the diagnostic characterization of acute aortic syndromes (AAS) [aortic dissection, intramural hematoma, penetrating ulcer]. We enrolled 66 non-consecutive patients with clinical suspicion of AAS. Standard transesophageal echocardiography and cTEE were performed prior to gated-CT angiography, which has been assumed as refer- ence standard. cTEE was obtained with a single bolus of contrast agent injection. The definitive diagnosis of AAS was made in 48 patients by gated-CT angiography: 22 aortic dissections, 15 intramural hematomas and 11 pene- trating aortic ulcers. Standard TEE and cTEE correctly diagnosed AAS in 87 and 100 % (P = 0.03) cases respectively. Standard TEE correctly diagnosed aortic dissection in 20/22 (91 %) and cTEE in 22/22 (100 %) (P = 0.5) cases. cTEE was superior than standard TEE in the visualization of false lumen entry tear (22/22 vs. 16/22, P = 0.03). Standard TEE correctly diagnosed intramural hematoma in 11/15 and cTEE 15/15 (P = 0.12) cases. Microtears were identified in 3 patients by cTEE an in 1 patient by standard TEE (P = 0.4). The presence of focal contrast enhancement was identified in 4 and 0 patients by cTEE and standard TEE respectively (P = 0.06). Both standard and cTEE correctly diagnosed penetrating aortic ulcer in 11/11 (100 %) (P = 1.0) cases. cTEE provides additional value over standard TEE in the diagnosis and in the anatomic and functional characterization of AAS.

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.

Background: Echographic examination of the lung surface may reveal multiple "comet-tail images" originating from water-thickened interlobular septa. These images could be useful for noninvasive assessment of interstitial pulmonary edema. Study objective: The purpose of this stud), was to assess the diagnostic accuracy of lung comet-tail images compared with chest radiography, wedge pressure, and extravascular lung water (EVLW) quantified by the indicator dilution method (PiCCO System, version 4.1; Pulsion Medical Systems; Munich, Germany). Methods and patients: We enrolled 20 patients (mean age, 62.6 &PLUSMN; 11.5 years [&PLUSMN; SD]). Patients were studied before, immediately after, and 24 h following cardiac surgery with chest ultrasound, chest radiography, pulmonary artery catheterization, and the PiCCO system. Performing echo scanning (right and left hemithorax, from second to fourth intercostal space, from parasternal to midaxillary line), an individual patient comet score was obtained by summing the number of comets in each scanned space. Results: A total of 60 comparisons were obtained. Significant positive linear correlations were found between comet score and EVLW determined by the PiCCO System (r = 0.42, p = 0.001), between comet score and wedge pressure (r = 0.48, p = 0.01), and between comet score and radiologic lung water score (r = 0.60, p = 0.0001). Conclusions: The presence and the number of comet-tail images provide reliable information on interstitial pulmonary edema. Therefore, ultrasonography represent an attractive, easy-to-use, bedside diagnostic tool for assessing cardiac function and pulmonary congestion.

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.

Objective: To assess whether tissue Doppler myocardial imaging (TDI) indices can predict postoperative left ventricular function in patients with mitral regurgitation (MR) after surgical correction. Methods: 84 patients ( mean (SD) age 54.3 (10.8) years) with asymptomatic severe MR, an end systolic diameter, 45 mm, and an ejection fraction (EF). 60% were subdivided in two groups: 43 patients with a postoperative EF reduction, 10% ( group 1) and 41 patients with a postoperative EF reduction greater than or equal to 10% ( group 2). TDI systolic indices of the lateral annulus were analysed preoperatively to assess myocardial systolic wave (Sm) velocity, myocardial precontraction time (PCTm), myocardial contraction time (CTm), and the PCTm: CTm ratio. Results: Postoperative EF decreased significantly ( from 67 ( 5)% to 60 (5.5)%, p = 0.0001). Group 2 had a higher PCTm, CTm, and PCTm: CTm ratio and a lower Sm velocity than group 1 ( PCTm 100.4 ( 19) ms v 82 (21.8) ms, p = 0.004; CTm 222 (3.1) ms v 215 (2.3) ms, p = 0.01; PCTm: CTm 0.45 (0.08) v 0.38 (0.09), p = 0.001; Sm velocity 10.4 (1.1) cm/s v 13 (1.3) cm/s, p = 0.0001). Multivariate regression analysis showed that the combination of PCTm: CTm ratio greater than or equal to 40 ms and Sm velocity less than or equal to10.5 cm/s was the main independent predictor of postoperative EF reduction greater than or equal to 10% ( sensitivity 78%, specificity 95%). Conclusions: TDI systolic indices can predict postoperative left ventricular function in patients with asymptomatic MR undergoing surgical correction. RI Schinkel, Arend/A-8673-2010 Objective: To assess whether tissue Doppler myocardial imaging (TDI) indices can predict postoperative left ventricular function in patients with mitral regurgitation (MR) after surgical correction. Methods: 84 patients ( mean (SD) age 54.3 (10.8) years) with asymptomatic severe MR, an end systolic diameter, 45 mm, and an ejection fraction (EF). 60% were subdivided in two groups: 43 patients with a postoperative EF reduction, 10% ( group 1) and 41 patients with a postoperative EF reduction greater than or equal to 10% ( group 2). TDI systolic indices of the lateral annulus were analysed preoperatively to assess myocardial systolic wave (Sm) velocity, myocardial precontraction time (PCTm), myocardial contraction time (CTm), and the PCTm: CTm ratio. Results: Postoperative EF decreased significantly ( from 67 ( 5)% to 60 (5.5)%, p = 0.0001). Group 2 had a higher PCTm, CTm, and PCTm: CTm ratio and a lower Sm velocity than group 1 ( PCTm 100.4 ( 19) ms v 82 (21.8) ms, p = 0.004; CTm 222 (3.1) ms v 215 (2.3) ms, p = 0.01; PCTm: CTm 0.45 (0.08) v 0.38 (0.09), p = 0.001; Sm velocity 10.4 (1.1) cm/s v 13 (1.3) cm/s, p = 0.0001). Multivariate regression analysis showed that the combination of PCTm: CTm ratio greater than or equal to 40 ms and Sm velocity less than or equal to10.5 cm/s was the main independent predictor of postoperative EF reduction greater than or equal to 10% ( sensitivity 78%, specificity 95%). Conclusions: TDI systolic indices can predict postoperative left ventricular function in patients with asymptomatic MR undergoing surgical correction.

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)