Clinical outcome of isolated tricuspid regurgitation.

Objectives: The aim of this study was to assess the outcome of isolated tricuspid regurgitation (TR) and the added value of quantitative evaluation of its severity.

Background: TR is of uncertain clinical outcome due to confounding comorbidities. Isolated TR (without significant comorbidities, structural valve disease, significant pulmonary artery systolic pressure elevation by Doppler, or overt cardiac cause) is of unknown clinical outcome.

Impact of aortic valve calcification, as measured by MDCT, on survival in patients with aortic stenosis: results of an international registry study.

Background: Aortic valve calcification (AVC) load measures lesion severity in aortic stenosis (AS) and is useful for diagnostic purposes. Whether AVC predicts survival after diagnosis, independent of clinical and Doppler echocardiographic AS characteristics, has not been studied.

Objectives: This study evaluated the impact of AVC load, absolute and relative to aortic annulus size (AVCdensity), on overall mortality in patients with AS under conservative treatment and without regard to treatment.

Left ventricular dysfunction after mitral valve repair--the fallacy of "normal" preoperative myocardial function.

Objective: A proportion of patients experience a decrease in left ventricular (LV) ejection fraction (EF) after mitral valve repair; however, predictors and long-term consequences remain unclear.

Methods: A study of 1705 patients with severe, degenerative mitral valve regurgitation and normal preoperative EF (>60%) undergoing mitral valve repair from 1993 to 2012 was performed. Multivariate logistic regression and Cox proportional hazards models were used to determine the predictors of early postoperative LV dysfunction (EF < 50%) and long-term survival, respectively.

Adult perioperative echocardiography: anatomy, mechanisms and effective communication.

Intra-operative transesophageal echocardiography (TEE) is a mature imaging technique which represents the premier surgical quality control instrument in the contemporary operating room. In adult cardiac surgery, management of valvular heart disease and related structural cardiac abnormalities derive the most benefit from perioperative echocardiography which includes pre-operative transthoracic echocardiography, intra-operative TEE and post-surgical echocardiographic surveillance. This review discusses the theoretical background upon which these imaging techniques are built-on, and offers a practical state-of-the-art guide on their application, emphasizing the importance of anatomic relationships, mechanisms of dysfunction and effective communication with our surgeons.

Early regression of severe left ventricular hypertrophy after transcatheter aortic valve replacement is associated with decreased hospitalizations.

Objectives: This study sought to examine the relationship between left ventricular mass (LVM) regression and clinical outcomes after transcatheter aortic valve replacement (TAVR).

Background: LVM regression after valve replacement for aortic stenosis is assumed to be a favorable effect of LV unloading, but its relationship to improved clinical outcomes is unclear.

Methods: Of 2,115 patients with symptomatic aortic stenosis at high surgical risk receiving TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) randomized trial or continued access registry, 690 had both severe LV hypertrophy (left ventricular mass index [LVMi] ≥ 149 g/m(2) men, ≥ 122 g/m(2) women) at baseline and an LVMi measurement at 30-day post-TAVR follow-up.

Untreated aortic valve stenosis identified at the time of coronary artery bypass grafting: thresholds associated with adverse prognosis.

Objectives: Aortic valve replacement (AVR) for severe aortic valve stenosis (AS) is a Class I indication at the time of coronary artery bypass grafting (CABG). Management of less-than-severe AS in patients undergoing CABG is uncertain however, because the thresholds at which untreated AS impacts long-term outcome are unclear.

Methods: We identified 312 patients who underwent isolated CABG between 1993 and 2006 with mild or moderate AS [aortic valve area (AVA) 1-2 cm(2)], and matched them to patients undergoing CABG alone during the same period with similar characteristics but without AS (AVA >2 cm(2)).

The global burden of aortic stenosis.

Degenerative, calcific valvular aortic stenosis (AS), caused by an active process of atherosclerosis, calcification and ossification, is the most common cause of AS in industrialized nations. The prevalence of calcific AS is age-dependent, and thus is expected to increase due to demographic aging of the global population. It is well recognized that severe AS carries a poor prognosis if left untreated.

Alternative for surgical management of calcific aortic valve stenosis: sutureless valve implants.

Patients who are candidates for surgical valve replacement (AVR) may benefit from diminished length of cardiopulmonary bypass time. Sutureless valve technology for AVR may facilitate the performance of the operation through smaller incisions, and more expeditiously due to the ability to anchor traditional bovine pericardial prostheses without the need for sutures. We report the first successful US implants of the Sorin PERCEVAL valve as part of the FDA IDE trial.

Cardiopulmonary responses to exercise and its utility in patients with aortic stenosis.

Utility of cardiopulmonary exercise test is unknown in patients with aortic stenosis. In this retrospective study, we examined the maximal indexes of cardiopulmonary testing at peak exercise in 155 consecutive patients with aortic valve area of ≤ 1.5 cm(2) who were referred for this test.

An approach to the stepwise management of severe mitral regurgitation with optimal cardiac pacemaker function.

Right ventricular apical pacing may cause or worsen mitral regurgitation (MR). Potential mechanisms for this adverse sequelae include intraventricular dyssynchrony, altered papillary muscle function, pacing-induced cardiomyopathy with left ventricular dilation, and annular dilation. In contrast, biventricular (BiV) pacing may improve MR presumably by opposing the negative effects.

B-type natriuretic peptide clinical activation in aortic stenosis: impact on long-term survival.

Objectives: This study was conducted to define the association between serum B-type natriuretic peptide (BNP) activation and survival after the diagnosis of aortic stenosis (AS).

Background: In AS, the link between BNP levels and clinical outcome is in dispute. Failure to account for the normal shifting of BNP ranges with aging in men and women, not using hard endpoints (survival), and not enrolling large series of patients have contributed to the uncertainty.

Quantitative Doppler-echocardiographic imaging and clinical outcomes with left ventricular systolic dysfunction: independent effect of pulmonary hypertension.

Background: Doppler-echocardiography provides quantitative imaging of systolic and diastolic left ventricular (LV) function, functional mitral regurgitation (FMR), and pulmonary hypertension (PH) in patients with LV systolic dysfunction. Whether PH is linked to survival independently of LV features and FMR in symptomatic and asymptomatic patients is unknown.

Methods And Results: Patients with LV ejection fraction ≤40% and quantitative Doppler-echocardiography assessment of FMR and PH were studied.

Functional mitral regurgitation in patients with aortic stenosis: prevalence, clinical correlates and pathophysiological determinants: a quantitative prospective study.

Aims: In patients with aortic stenosis (AS) functional mitral regurgitation (FMR) is frequent and is attributed to left ventricular (LV) remodelling and to aortic gradient. However, the association of these variables with mitral effective regurgitant orifice (ERO) is still unknown.

Methods And Results: We prospectively enrolled patients with aortic valve thickness and aortic velocities >2.

Long-term mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets: a multicenter analysis.

Background: Ejection fraction (EF) as a marker of left ventricular (LV) dysfunction and the appropriate thresholds for diagnosing severe or mild/moderate LV dysfunction in mitral regurgitation are doubted and poorly followed in clinical practice. We aimed at assessing the role of EF in a large registry of organic mitral regurgitation to objectively establish thresholds for various degrees of LV dysfunction and to analyze whether mitral surgery remains beneficial in those subsets of patients.

Methods And Results: We investigated the relation between EF and mortality in 1875 patients with mitral regurgitation due to flail leaflets in sinus rhythm (65±13 years; median EF, 66% [60%-71%]) enrolled in the Mitral Regurgitation International Database (MIDA) registry.

Improving affordability through innovation in the surgical treatment of mitral valve disease.

Objective: To determine whether technically innovative cardiac surgical platforms (ie, robotics) deployed in conjunction with surgical process improvement (systems innovation) influence total hospital costs to address the concern that expanding adoption might increase health care expenses.

Patients And Methods: We studied 185 propensity-matched patient pairs (370 patients) undergoing isolated conventional open vs robotic mitral valve repair with identical repair techniques and care teams between July 1, 2007, and January 31, 2011. Two time periods were considered, before the implementation of system innovations (pre-July 2009) and after implementation.

The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study.

Objectives: With concomitant Doppler echocardiography and multidetector computed tomography (MDCT) measuring aortic valve calcification (AVC) load, this study aimed at defining: 1) independent physiologic/structural determinants of aortic valve area (AVA)/mean gradient (MG) relationship; 2) AVC thresholds best associated with severe aortic stenosis (AS); and 3) whether, in AS with discordant MG, severe calcified aortic valve disease is generally detected.

Background: Aortic stenosis with discordant markers of severity, AVA in severe range but low MG, is a conundrum, unresolved by outcome studies.

Methods: Patients (n = 646) with normal left ventricular ejection fraction AS underwent Doppler echocardiography and AVC measurement by MDCT.

Type A aortic dissection in patients with bicuspid aortic valves: clinical and pathological comparison with tricuspid aortic valves.

Objective: Bicuspid aortic valve (BAV) is associated with a higher risk of type A aortic dissection (AD) compared with tricuspid aortic valve (TAV). We sought to study differences between patients with BAV and TAV with AD.

Design And Setting: Observational descriptive analysis of clinical, imaging and pathological characteristics of all patients with confirmed BAV and AD from 1980-2010, compared with a consecutive TAV group with AD.

Three-dimensional color Doppler echocardiographic quantification of tricuspid regurgitation orifice area: comparison with conventional two-dimensional measures.

Background: Three-dimensional (3D) color Doppler echocardiography (CDE) provides directly measured vena contracta area (VCA). However, a large comprehensive 3D color Doppler echocardiographic study with sufficiently severe tricuspid regurgitation (TR) to verify its value in determining TR severity in comparison with conventional quantitative and semiquantitative two-dimensional (2D) parameters has not been previously conducted. The aim of this study was to examine the utility and feasibility of directly measured VCA by 3D transthoracic CDE, its correlation with 2D echocardiographic measurements of TR, and its ability to determine severe TR.

Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets.

Importance: The optimal management of severe mitral valve regurgitation in patients without class I triggers (heart failure symptoms or left ventricular dysfunction) remains controversial in part due to the poorly defined long-term consequences of current management strategies. In the absence of clinical trial data, analysis of large multicenter registries is critical.

Objective: To ascertain the comparative effectiveness of initial medical management (nonsurgical observation) vs early mitral valve surgery following the diagnosis of mitral regurgitation due to flail leaflets.

Psycho-emotional manifestations of valvular heart diseases: prospective assessment in mitral regurgitation.

Objective: To define the prevalence and consequences of post-traumatic stress disorder (PTSD) as an emotional response to cardiac diseases in patients with mitral regurgitation.

Methods: We prospectively enrolled 186 patients with moderate or severe organic mitral regurgitation, presenting class I (absent) or II (minimal) dyspnea, who were compared with 80 controls of similar age (38 with completely normal cardiac function; 42 with mild mitral-valve prolapse; all with no, or at most mild, mitral regurgitation). Mitral-regurgitation severity and consequences were comprehensively measured, simultaneously with PTSD, anxiety, and depression.