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Introduction Appropriate use criteria (AUC) for echocardiography based on clinical scenarios were previously published by an American Task Force. We determined whether members of the Dutch Working Group on Echocardiography (WGE) would rate these scenarios in a similar way. Methods All 32 members of the WGE were invited to judge clinical scenarios independently using a blanked version of the previously published American version of AUC for echocardiography. During a face-to-face meeting, consensus about the final rating was reached by open discussion for each indication. For reasons of simplicity, the scores were reduced from a 9-point scale to a 3-point scale (indicating an appropriate, uncertain or inappropriate echo indication, respectively). Results Nine cardiologist members of the WGE reported their judgment on the echo cases (n = 153). Seventy-one indications were rated as appropriate, 35 were rated as uncertain, and 47 were rated as inappropriate. In 5% of the cases the rating was opposite to that in the original (appropriate compared with inappropriate and vice versa), whereas in 20% judgements differed by 1 level of appropriateness. After the consensus meeting, the appropriateness of 7 (5%) cases was judged differently compared with the original paper. Conclusions Echocardiography was rated appropriate when it is applied for an initial diagnosis, a change in clinical status or a change in patient management. However, in about 5% of the listed clinical scenarios, members of the Dutch WGE rated the AUC for echocardiography differently as compared with their American counterparts. Further research is warranted to analyse this decreased external validity. Electronic supplementary material The online version of this article (doi: 10.1007/s12471-017-0960-9) contains supplementary material, which is available to authorized users.

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.

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. © 2006 Wiley-Liss, Inc.

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, I device embolisation and I device non-fixation, occurred and required urgent surgery. There was I patient with pericardial effusion after the intervention, requiring pericardiocentesis. Three late placement failures occurred: 2 device embolisations and I 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 (I device embolisation, requiring surgery, occurred before follow-up was completed).Two patients with significant shunt, I late device dislocation and I 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.

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.

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.

Myocardial perforation by a guidewire after retrograde crossing of a stenotic aortic valve during cardiac catheterization is rare. We present a patient with calcific aortic stenosis who suffered this potentially life-threatening complication and in whom conservative treatment was successful. Early recognition of this complication is important for the operator performing cardiac catheterizations in patients with calcific aortic stenosis.

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

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.

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.

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 trialregister.nl Identifier TC1290.

Myocardial perfusion imaging in conjunction with dipyridamole low-level exercise stress has proved its value in the evaluation of patients with coronary artery disease (CAD). Simultaneous wall motion analysis by two-dimensional (2D) echocardiography may provide additional information beyond that obtained by myocardial perfusion imaging alone. The purpose of this study was to compare 99mTc-labeled sestamibi single-photon emission computed tomography (SPECT) and 2D echocardiography for the evaluation of CAD according to a dipyridamole low-level bicycle exercise stress protocol.We studied 35 consecutive patients referred for the evaluation of chest pain who had undergone coronary arteriography. 99mTc-labeled sestamibi SPECT and 2D echocardiography agreed in 27 patients (80%) studied for overall detection of CAD. On a segmental basis, agreement was found between SPECT and 2D echocardiography in 124 (73%) of 170 segments (Cohen's kappa = 0.43). The accuracy of the combined assessment of myocardial perfusion and echocardiographic wall motion in detecting CAD was 86%, which was not different from the accuracy of SPECT alone (80%; difference not significant) but significantly higher than for 2D echocardiography alone (71%; p = 0.03). In the detection of individual coronary artery stenoses, SPECT had a significantly higher accuracy for detecting left anterior descending coronary artery lesions than had 2D echocardiography (80% vs 60%; p0.01); combining the two method did not improve the accuracy (80%). The combined assessment slightly improved the accuracy for detecting left circumflex coronary artery stenoses from 71% to 83% (p = 0.05).The combined simultaneous assessment of myocardial perfusion by 99mTc-labeled sestamibi SPECT and wall motion by 2D echocardiography did not significantly improve overall accuracy over that obtained by 99mTc-labeled sestamibi SPECT alone. Therefore 99mTc-labeled sestamibi SPECT with dipyridamole low-level exercise stress appears the preferred imaging modality for the evaluation of patients with CAD.

To recognize patients prone to subsequent left ventricular dilation after the acute phase of a myocardial infarction treated with thrombolysis, we studied 233 patients with a first anterior infarction, treated with thrombolysis, with 2-dimensional echocardiography within 12 hours after admission and 3 months later. A wall motion score index (WMSI) and left ventricular volumes were assessed, and enzymatic infarct size was expressed as cumulative alphahydroxybutyrate dehydrogenase determined in the first 72 hours after infarction. patients who died (17 of 233, 7%) after a mean follow-up of 517 days had a significantly higher acute WMSI (2.1 +/- 0.3, mean +/- SD) than those who survived (1.9 +/- 0.4) (p=0.006),With use of this cutoff value of 2 for WMSI, ventricles with an acute WMSI less than or equal to 2 (62%) showed no increase in end-diastolic volume index (EDVI) or end-systolic volume index (ESVI), whereas ventricles with an acute WMSI >2 (38%) showed a significant increase in ESVI (6.1 +/- 12.2 ml/m(2)) and in EDVI (10.3 +/- 16.6 ml/m(2)) in the first 3 months. Using a cutoff value of 1,000 U/L for cumulative alphahydroxybutyrate dehydrogenase, only infarcts with a value of >1,000 U/L (52%) caused a significant increase in EDVI (10.8 +/- 14.3 ml/m(2)) and ESVI (6.5 +/- 10.0 ml/m(2)) in the first 3 months. Thus, acutely assessed WMSI of >2 can readily predict subsequent dilation in patients with a first anterior infarction treated with streptokinase and is a good predictor of mortality. Enzymatic infarct size also is a good predictor of dilation, although not available until 3 days after infarction.

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

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 echocardiography 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.

This study evaluated the efficacy of computer-controlled closed-loop delivery of a new synthetic catecholamine, arbutamine, when given to induce myocardial ischemia detected by electrocardiography and echocardiography with a high (10 beats/min/min) and low (6 beats/min/min) rate of increase in heart rate (heart rate slope) in 70 patients with coronary artery disease. The electrocardiographic sensitivity for the detection of myocardial ischemia was 52% for the low slope and 51% for the high slope. The corresponding figures for echocardiographic sensitivity were 83% and 79% for the low and high slopes, respectively. There were no significant differences in changes from baseline to maximum in pharmacodynamic variables, although the mean times to reach maximum heart rate and systolic blood pressure were 1.4 minutes shorter (p = 0.001) and 3.7 minutes shorter (p < 0.05), respectively, for the high-slope regimen. The duration of the infusion was shorter (p < 0.001) for the high slope. In this study, closed-loop arbutamine administration was effective and safe in the detection of coronary artery disease for both heart rate slope regimens.

A case of a patient with a rupture of the left coronary cusp of the aortic valve caused by blunt chest trauma is presented. Early diagnosis by transesophageal echocardiography led to successful surgical repair.

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.MV repair for mitral regurgitation (MR) can be accomplished by use of a clip that approximates the free edges of the mitral leaflets.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.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.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.

We report a case of a 78-year old man presenting with a pseudo aneurysm of a valve conduit in the ascending aorta 6 weeks after Bentall (Shiley conduit 25) operation because of aortic stenosis and aneurysmatic aorta. Further medical history includes hypertension, left ventricular hypertrophy, diabetes and chronic obstructive pulmonary disease. The patient presented with acute dyspnoea at rest and was unresponsive to furosemide treatment. Clinical investigation revealed blood pressure 96/46, a regular pulse 107 and saturation 90%. There were bilateral basal crackles and peripheral edema. A new systolic murmur 3/6 was heard on the left parasternal side. Electrocardiogram showed a left bundle branch block and serology revealed maximal creatine kinase level of 995 U/L. After admission there was anuria with a creatinine level of 341 μmol/L (normal 62–106). A transthoracic echocardiography showed a large pseudo aneurysm at the origin of the conduit. A massive paravalvular

With the widespread use of transoesophageal echocardiography, atrial septal aneurysm (ASA) is more frequently recognized. Diagnostic criteria, however, remain arbitrary. A meticulous search for interatrial shunting (most often patent foramen ovale (PFO)) and associated cardiac diseases is important. ASA is considered a risk factor for cardioembolism, especially in association with PFO. We describe a patient with a giant multiperforated ASA presenting with refractory paroxysmal atrial fibrillation.

To evaluate clinical and echocardiographic outcomes for the semi-flexible Carpentier-Edwards Physio and the rigid Classic mitral annuloplasty ring.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.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%.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.

Registry to report our single-centre experience in closing defects of the atrial septum.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.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.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.

Eighteen months after mitral (33-mm St. Jude Medical) and aortic (25-mm Carbomedics Tophat) valve replacement because of rheumatic valve disease, a 54-year-old man was admitted with acute pulmonary edema. He had been in excellent condition until the sudden onset of epigastric pain and shortness of breath 2 hours before admission. Other than warfarin (International Normalized Ratio 2.7, 9 days before admission), he was not using any medication. Physical examination …

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.

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.

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 45-year-old male patient, with a history of ischemic cardiomyopathy, peripheral arterial disease, and renal dysfunction, was admitted for percutaneous mitral valve repair. Cardiac magnetic resonance imaging showed an ejection fraction of 18% without viability. Severe mitral regurgitation (MR)

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 ≥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: R 2 =.36, P =.0001; vessel area: R 2 =.29, P =.0002; plaque area: R 2 =−.18, P =.021; percent obstruction: R 2 =−.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.

Objective: To determine the value of biplane transesophageal echocardiography in the assessment of severity of mitral regurgitation compared with left ventricular angiography.Design: Prospective study of consecutive patients.Setting: Two university hospitals, one community hospital.Participants: Thirty seven patients with angiographically proven mitral regurgitation.Intervention: Transthoracic and biplane transesophageal echocardiography. In 19 patients, transesophageal echocardiography was performed during general anesthesia.Measurements and Main Results: The largest mitral regurgitation jet area and longest jet as obtained with Doppler color-flow mapping from transthoracic and biplane transesophageal echocardiography and pulsed-Doppler pulmonary venous flow characteristics. Sensitivity and 100-minus-specificity were plotted to constitute receiver operating characteristics (ROC) curves. Areas under ROC curve for transverse, longitudinal, and biplane jet area were 0.77, 0.75, and 0.81, and for jet length, 0.82, 0.84, and 0.88, respectively; this was for biplane jet area in conscious patients; 0.99 compared with 0.72 in anesthetized patients (p Conclusions: Biplane measurements identified severe mitral regurgitation slightly more reliably than the transverse or longitudinal measurements alone. In conscious patients, jet area was an excellent test for estimating severity of mitral regurgitation. In anesthetized patients, a combination of biplane jet area and length and of systolic pulmonary venous flow reversal accurately predicted angiographic severity of mitral regurgitation. In anesthetized patients, the optimal cut-off value for jet area to distinguish between moderate and severe mitral regurgitation was lower than in conscious patients. In the total population, regardless of hemodynamic and technical variations, a combination of biplane jet area and length and of systolic pulmonary venous flow reversal accurately predicted the severity of mitral regurgitation. Copyright (C) 1996 by W.B. Saunders Company

To assess the predictive value of Residual Mitral Regurgitation (RMR) after valve repair for severe MR, we performed transesophageal color (TEE) Doppler flow imaging intraoperatively, after 3 months and 1 year at similar loading conditions in a prospective study of 178 patients (pts). Intraoperative grading of RMR on a 4 point scale in 159 pts showed no RMR in 77 pts, grade I in 45, grade II in 29 and grade III in 8 pts.Univariate analysis of preoperative and surgical characteristics showed that a history of chronic lung disease (Relative Risk (RR) 1.88*), increased leaflet mobility (RR 1.50*) and normal leaflet mobility (RR 1.51*) at TEE, coronary artery disease (RR 1.38), and a Duran annular ring (RR 1.97*) were associated with an increased risk of intraoperative RMR.In the 8 pts with grade III RMR, immediate valve replacement (VR) was advised and performed in all but one pt, who underwent VR 2 months later.After 3 months, increase of RMR (of at least one grade) was present in 63%, reduction in 8% and no change in 29% of the pts. Compared to three months, no increase or decrease of RMR was seen at 1 year.During the one year follow-up VR was performed in another 7 pts; all but one pt (no RMR) with intraoperative RMR grade I-II. Intraoperative RMR grade I-II was associated with a higher risk of VR (RR 6.51*) and thromboembolic events (RR 6.51*) in relation to absence of RMR, during this one year follow-up.Conclusions(1) RMR increases in most pts within 3 months postoperatively and is stable thereafter. (2) Intraoperative RMR is associated with a substantial reoperation rate and risk of thromboembolic events. 131 RMR S grade II does not exclude a redo during one year follow-up.*= P < 0.05.

To determine the risk of an unsuccessful mitral valve repair followed by replacement we prospectively studied 180 patients (pts) who underwent mitral valve surgery because of severe regurgitation using univariate analysis of preoperative clinical, echocardiographic and surgical characteristics. Clinical and echocardiographic risk factors for unsuccessful repair were: female gender (relative risk (RR) 2.56*), concomitant mitral stenosis (RR 4.63*), restricted leaflet mobility (RR 2.48*), normal left ventricular enddiastolic diameter (RR 3.42*) and prediction of a replacement by echo (RR 4.74*). Surgical risk factors were: restricted leaflet mobility (RR 4.0*), concomitant mitral stenosis (RR 4.83*) and aneurysm of the left ventricle (RR 3.17*). In 12 pts the result of the repair procedure was deemed unsatisfactory after visual inspection and in 9 pts the replacement procedure was carried out on the basis of intraoperative echo assessment of residual regurgitation. One year mortality of these 21 patients was 24% and the RR of death was 2.15* compared to primary replacement pts. (*p l 0.005). Conclusions 1. Risk factors for an unsuccessful repair can readily be identified by preoperative echocardiography and determination of gender. 2. Unsuccessful mitral valve repair followed by valve replacement during the same surgical procedure is related to a substantial one-year mortality.

OBJECTIVE--To investigate the long-term results of the corridor operation in the treatment of symptomatic atrial fibrillation refractory to drug treatment. BACKGROUND--The corridor operation is designed to isolate from the left and right atrium a conduit of atrial tissue connecting the sinus node area with the atrioventricular node region in order to preserve physiological ventricular drive. The excluded atria can fibrillate without affecting the ventricular rhythm. This surgical method offers an alternative treatment when atrial fibrillation becomes refractory to drug treatment. PATIENTS--From 1987 to 1993, 36 patients with drug refractory symptomatic paroxysmal atrial fibrillation underwent surgery. The in hospital rhythm was followed thereafter by continuous rhythm monitoring and with epicardial electrograms. After discharge Holter recording and stress testing were regularly carried out to evaluate the sinus node function and to detect arrhythmias; whereas Doppler echocardiography was used to measure atrial contraction and size. MAIN OUTCOME MEASURES--Maintained absence of atrial fibrillation without drug treatment after operation; preservation of normal chronotropic response in the sinus node. RESULTS--The corridor procedure was successful in 31 (86%) of the 36 patients. After a mean (SD) follow up of 41 (16) months 25 (69%) of the 36 patients were free of arrhythmias without taking drugs (mean (SE) actuarial freedom at four years 72 (9)%)). Paroxysmal atrial fibrillation recurred in three patients; paroxysmal atrial flutter (two patients) and atrial tachycardia (one patient) developed in the corridor in three others. Among the 31 patients in whom the operation was successful sinus node function at rest and during exercise remained undisturbed in 26 and 25 patients respectively (mean (SE) actuarial freedom of sinus node dysfunction at four years (81(7)%)). Pacemakers were needed in five (16%) of the 31 patients for insufficient sinus node rhythm at rest only. Doppler echocardiography showed maintenance of right atrial contribution to right ventricle filling in 26 of the 31 patients after operation in contrast to the left atrium, which never showed such contribution. His bundle ablation was performed and a pacemaker implanted in the five patients in whom the corridor operation was unsuccessful. CONCLUSION--These results substantiate the idea of this surgical procedure. Modification of the technique is, however, needed to achieve a reliable isolation between left atrium and corridor, which would make this experimental surgery widely applicable in the treatment of drug refractory atrial fibrillation.

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.

Atrial fibrillation without structural heart disease[1] or pre-excitation syndrome[2] is an arrhythmia which does not markedly affect life expectancy but may strongly alter exercise capacity and quality of life. This arrhythmia is highly prevalent among cardiac arrhythmias, particularly in older people, and becomes frequently manifest without demonstrable cause (’lone atrial fibrillation’). In circumstances of drug refractoriness of disabling atrial fibrillation today two alternative electrophysiologic interventions are available: His-bundle ablation followed by chronic cardiac pacing[3,4], or the surgical exclusion of the anatomical substrate of atrial fibrillation[5,6,7].6

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.

To the Editor: Acute thrombotic obstruction of an aortic bioprosthetic valve is an uncommon yet life-threatening condition1–3. A 72-year-old man came to our hospital because of four days of chest pain and dyspnea. Seven months earlier, he had undergone an aortic-valve replacement with a 27-mm Medtronic Intact porcine bioprosthesis. The results of cardiac auscultation were compatible with a diagnosis of aortic stenosis. The patient had mild thrombocytopenia (139,000 platelets per cubic millimeter) and an increased lactate dehydrogenase level (571 U per liter). Echocardiography revealed reduced motion of the prosthetic-valve leaflets and an obstructing mass between the struts ( . . .

To determine the clinical significance of transient remote asynergy after the first acute myocardial infarction (AMI), 2-dimensional echocardiography was performed at rest and directly after dynamic exercise in 49 consecutive patients within 3 weeks of AMI. In 43 patients (88%), technically adequate 2-dimensional echocardiographic examinations were obtained. Asynergy was found in all patients at rest. Immediately after exercise, new areas of asynergy, not adjacent to the infarcted area (i.e., transient remote asynergy), were present in 18 patients. Of these patients, 17 had multivessel coronary artery disease (CAD), compared with 5 of 25 patients without transient remote asynergy. Sensitivity of transient remote asynergy for detecting multivessel CAD was 77% and specificity was 95%. Left ventricular ejection fraction at rest and after exercise was measured in 39 patients (90%) and could only identify patients with 3-vessel CAD. New ischemic events, defined as reinfarction or recurrent angina pectoris, within a mean of 12 weeks (range 8 to 16) after discharge, occurred in 16 patients. Transient remote asynergy was present in 12 of these patients (75%). It is concluded that exercise-induced transient remote asynergy early after AMI can identify patients with multivessel CAD and a subgroup of patients prone to early new ischemic events. Left ventricular ejection fraction, however, is not only more laborious but also of lesser value in identifying patients with multivessel CAD.

Since post-acute myocardial infarction (AMI) Q waves may disappear independent of reinfarction or development of left bundle branch block, the relation between the presence of Q waves and segmental asynergy was assessed in 58 patients with initial Q waves after first AMI. Two-dimensional (2-D) echocardiograms and electrocardiograms were recorded 1 year later. By electrocardiography, 28 had anterior and 25 inferior AMI. At 1 year Q waves had disappeared in 12 of 53 patients (23%): 5 with anterior and 7 with inferior AMI. Segmental asynergy, however, was present in 9 of these 12 patients, although dyskinesia was absent. Presence of Q waves at 1 year (41 patients) was always associated with segmental asynergy. Wall motion score, based on degree of segmental asynergy, was higher in the 41 patients with Q waves compared with patients in whom Q waves disappeared (7.8 +/- 4.4 vs 2.7 +/- 1.9, p less than 0.001). In patients with anterior AMI the number of Q waves at 1 year and the grade of asynergy were correlated. Segmental dyskinesia was rare in patients with inferior AMI (1 of 25) but was common in those with anterior AMI (18 of 28), and was consistently present in patients with more than 2 anterior Q waves.