[Show abstract][Hide abstract] ABSTRACT: Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. As the repair techniques for mitral valve disease evolved, so has the need for detailed and accurate imaging of the mitral valve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation. In patients with significant mitral valve disease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. However, a comprehensive TEE in a patient with complex mitral valve disease requires great experience and skill. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitral valve surgery. In the following sections, we review some of the crucial 2D and 3D echo images necessary for evaluation of MR based on the Carpentier classification.
Full-text · Article · Oct 2014 · Cardiovascular Ultrasound
[Show abstract][Hide abstract] ABSTRACT: Ventricular septal myectomy in patients with obstructive hypertrophic cardiomyopathy (HC) has been shown to reduce left ventricular (LV) outflow tract (LVOT) gradient and improve symptoms, although little data exist regarding changes in left atrial (LA) volume and LV diastolic function after myectomy. We investigated changes in LA size and LV diastolic function in patients with HC after septal myectomy from 2004 to 2011. We studied 25 patients (age 49.2 ± 13.1 years, 48% women) followed for a mean of 527 days after surgery who had serial echocardiography at baseline and at most recent follow-up, at least 6 months after myectomy. In addition to myectomy, 3 patients (12%) underwent Maze surgery and 13 (52%) underwent mitral valve surgery, of whom 5 had a mitral valve replacement or mitral annuloplasty. Patients with mitral valve replacement or mitral annuloplasty were excluded from LV diastolic function analysis. LA volume index decreased (from 47.2 ± 17.6 to 35.9 ± 17.0 ml/m(2), p = 0.001) and LV diastolic function improved with an increase in lateral e' velocity (from 7.3 ± 2.9 to 9.8 ± 3.1 cm/sec, p = 0.01) and a decrease in E/e' (from 14.8 ± 6.3 to 11.7 ± 5.5, p = 0.051). Ventricular septal thickness and LVOT gradient decreased, and symptoms of dyspnea and heart failure improved, with reduction in the New York Heart Association functional class III/IV symptoms from 21 (84%) to 1 (4%). In conclusion, relief of LVOT obstruction in HC by septal myectomy results in improved LV diastolic function and reduction in LA volume with improved symptoms.
No preview · Article · Aug 2014 · The American Journal of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Background
The objectives of this study were twofold: to assess the diagnostic utility of three-dimensional (3D) multiplanar reconstruction (MPR) in identifying prolapsing mitral valve (MV) scallops, and (2) to compare two-dimensional (2D) transthoracic echocardiography (TTE) and 3DMPR to (2D) transesophageal echocardiography (TEE) approaches among patients with mitral valve prolapse (MVP).Methods
Fifty-five patients with MVP who underwent MV repair or replacement were retrospectively analyzed using 3 types of echocardiographic studies (2DTEE, 2DTTE, 3DMPR). The operative (OR) findings were considered the gold standard.ResultsWhen 3DMPR was combined with 2DTTE, the agreement with the OR findings was moderately strong for the A2 scallop (P < 0.001) and strong for the A3 scallop (P = 0.001), entire anterior leaflet (P < 0.001), P2 scallop (P < 0.001) and the entire posterior leaflet (P < 0.001). In comparison to the OR findings, 2DTEE demonstrated moderately strong agreement for the A2 scallop (P = 0.010) and the entire anterior leaflet (P < 0.001), and strong agreement for the P2 scallop (P < 0.001) and entire posterior leaflet (P < 0.001).Conclusions
Three-dimensional MPR should be added to the armamentarium of complementary echo techniques in the evaluation of MVP. There is increased benefit in combining 3DMPR with 2DTTE findings as part of the preoperative evaluation of patients with MVP.
No preview · Article · Apr 2014 · Echocardiography
[Show abstract][Hide abstract] ABSTRACT: The mitral valve annulus is a complex structure that is an integral part of the mitral valve apparatus. The annulus plays an active role in mitral valve leaflet coaptation and in left atrial and ventricular function. The annulus is susceptible to disease processes that are distinct from those that affect the mitral valve leaflets. Advanced annular calcification may extend onto the mitral valve leaflets, thereby causing increased diastolic gradients across the mitral valve. This review highlights risk factors for mitral annular calcification, features of calcific mitral stenosis, differentiation from rheumatic mitral valve disease, and the echocardiographic approach to this disorder.
No preview · Article · May 2013 · Cardiology clinics
[Show abstract][Hide abstract] ABSTRACT: This study compares 2-dimensional, transthoracic echocardiography with cardiac magnetic resonance imaging in the preoperative identification of bicuspid aortic valve before aortic valve surgery.
Of 1203 patients who underwent an aortic valve operation, 218 had both preoperative transthoracic echocardiography and cardiac magnetic resonance imaging. Patients in the study group were aged 56 years and had an ejection fraction of 56%, 76% were male, and 29% had associated coronary artery disease. The results of transthoracic echocardiography and cardiac magnetic resonance imaging were classified as bicuspid aortic valve, trileaflet aortic valve, or nondiagnostic. Of the 218 patients, 123 (56%) had bicuspid aortic valve as determined at the time of surgery and 116 (53%) had an ascending aortic aneurysm.
Of the 123 patients with bicuspid aortic valve confirmed at surgery, by transthoracic echocardiography 76 (62%) were identified preoperatively with bicuspid aortic valve, 12 (10%) were misidentified with trileaflet aortic valve, and 35 (28%) were nondiagnostic for valve morphology. In the same patients with bicuspid aortic valve, by cardiac magnetic resonance imaging 115 (93%) were identified with bicuspid aortic valve, 5 (4%) were misidentified with trileaflet aortic valve, and 3 (2%) were nondiagnostic. The difference between transthoracic echocardiography and cardiac magnetic resonance imaging to determine the presence of bicuspid aortic valve was statistically significant (P<.001). In the entire cohort of patients, transthoracic echocardiography was diagnostic for valve morphology in 155 patients (71%) compared with cardiac magnetic resonance imaging, which was diagnostic in 212 patients (97%) (P<.001).
Cardiac magnetic resonance imaging is more diagnostic than transthoracic echocardiography in determining the presence of bicuspid aortic valve. A significant factor is the rate of nondiagnostic transthoracic echocardiography for aortic valve morphology. Cardiac magnetic resonance imaging can be performed as a complementary test when transthoracic echocardiography is nondiagnostic for aortic valve morphology.
No preview · Article · Dec 2011 · The Journal of thoracic and cardiovascular surgery
[Show abstract][Hide abstract] ABSTRACT: Patients with obstructive hypertrophic cardiomyopathy who undergo septal myectomy are at risk for developing postoperative atrial fibrillation. Amiodarone is effective in treating this arrhythmia but is associated with multiple adverse effects, often with delayed onset. A novel case is described of a patient who developed type 2 amiodarone-induced hyperthyroidism that presented as recurrence of outflow obstruction after septal myectomy. The patient's symptoms and echocardiographic findings of outflow obstruction resolved substantially with the treatment of the amiodarone-induced hyperthyroidism. Amiodarone-induced hyperthyroidism of delayed onset can be a subtle diagnosis, requiring a high index of suspicion. In conclusion, recognition of this diagnosis in patients with recurrence of outflow obstruction by symptoms and cardiac imaging after septal myectomy may avoid unnecessary repeat surgical intervention.
No preview · Article · Dec 2010 · The American journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: The evaluation of valvular and nonvalvular structures is of central importance in the diagnosis, management, and treatment of infective endocarditis (IE). The incidence of IE has remained constant due to changing substrate, with notably higher prevalence observed in the elderly. Mortality and morbidity continue to remain high, despite advances in medical and surgical treatment. This article reviews the technical and practical aspects of the use of echocardiography to evaluate patients with suspected IE.
No preview · Article · May 2010 · Current Cardiology Reports
[Show abstract][Hide abstract] ABSTRACT: Valvular heart disease (VHD) encompasses a number of common cardiovascular conditions that account for 10% to 20% of all cardiac surgical procedures in the United States. A better understanding of the natural history coupled with the major advances in diagnostic imaging, interventional cardiology, and surgical approaches have resulted in accurate diagnosis and appropriate selection of patients for therapeutic interventions. A thorough understanding of the various valvular disorders is important to aid in the management of patients with VHD. Appropriate work-up for patients with VHD includes a thorough history for evaluation of causes and symptoms, accurate assessment of the severity of the valvular abnormality by examination, appropriate diagnostic testing, and accurate quantification of the severity of valve dysfunction and therapeutic interventions, if necessary. It is also important to understand the role of the therapeutic interventions vs the natural history of the disease in the assessment of outcomes. Prophylaxis for infective endocarditis is no longer recommended unless the patient has a history of endocarditis or a prosthetic valve.
Full-text · Article · May 2010 · Mayo Clinic Proceedings
[Show abstract][Hide abstract] ABSTRACT: Takotsubo cardiomyopathy mimics acute myocardial infarction but is a separate clinical entity characterized by distinct wall motion abnormalities in the absence of obstructive coronary lesions. The prevalence of this condition is relatively uncommon yet has gained increasing recognition in recent years. It has rarely been associated with the use of dobutamine infusion during cardiac stress testing. We present in detail two cases of dobutamine-induced Takotsubo cardiomyopathy from our case series, one from 2002 and the other from 2008. While both cases display the typical features of Takotsubo cardiomyopathy, the former was initially diagnosed as dobutamine-induced vasospasm. These cases may provide insight into the pathophysiological mechanism of the condition and suggest that the increasing recognition of Takotsubo cardiomyopathy results from increasing familiarity of the condition.
[Show abstract][Hide abstract] ABSTRACT: Transcatheter aortic valve implantation may become a potential treatment for high-risk patients with aortic stenosis (AS). We analyzed our contemporary series of isolated aortic valve replacement (AVR) for AS to determine implications for patients referred for AVR.
From April 2004 through December 2008, 190 patients (mean age, 68 years; 68% men) underwent isolated AVR for AS. Mean ejection fraction was 0.58. Sixty-one percent underwent minimally invasive AVR and 18% were reoperations. Twenty-one percent were aged 80 years or older, and 34% were in New York Heart Association functional class III-IV. Estimated operative mortality was 3.6%.
Thirty-day mortality was 0%. One in-hospital death (0.5%) occurred from complications of an esophageal perforation. Reoperation for bleeding occurred in 4.7%. Acute renal failure developed in 2.1%. Actuarial survival was 97% at 1 year and 94% at 3 years. Hospital length of stay was 7.0 days for patients aged 80 and older vs 5.0 days (p < 0.001), and they were less likely to be discharged to home (50% vs 83%, p < 0.001).
Contemporary results show that AVR for AS can be performed with low operative mortality and morbidity, although patients aged 80 years and older are at increased risk of prolonged recovery. Transcatheter aortic valve implantation may be an alternative for high-risk patients, but AVR is still appropriate for low-risk patients. The low risk of AVR supports the argument that asymptomatic patients who have a high likelihood of progression of AS may be considered for earlier surgical referral.
No preview · Article · Mar 2010 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Stress echocardiography was introduced in the early 1980s and has matured into a robust, versatile, widely available, reliable,
and cost-effective technique utilized for noninvasive imaging of the heart. In combination with a variety of stressors, stress
echocardiography provides a means for the detection of ischemia by assessment of regional wall motion abnormalities. In addition
to its utility in detection and accurate risk stratification of patients with suspected and established coronary artery disease,
it has a role in assessment of severity of valvular heart disease by providing valuable physiological hemodynamic data and
also has a proven role in the assessment of myocardial viability in patients with dyssynergic segments as well as with left
[Show abstract][Hide abstract] ABSTRACT: Prompt diagnosis and treatment are important in the management of valvular heart disease. The American College of Cardiology
and American Heart Association task force has been instrumental in providing comprehensive practice guidelines to help clinicians
manage valve diseases. Nonivasive techniques for surveillance of left ventricular function, quantification of valvular dysfunction,
and continued improvements in surgical techniques have contributed to improved survival and decreased morbidity in patients
with chronic valvular heart disease. The management of valvular diseases in women is similar to that in men, but there are
certain special considerations, as outlined in this review.
No preview · Article · May 2008 · Current Cardiovascular Risk Reports