Accuracy and cost- and time-effectiveness of digital clip versus videotape interpretation of echocardiograms in patients with valvular disease

Background. Although digital and videotaped images are known to be comparable for the evaluation of left ventricular function, their relative accuracy for assessment of more complex anatomy is unclear. We sought to compare reading time, storage costs, and concordance of video and digital interpretations across multiple observers and sites. Methods. One hundred one patients with valvular (90 mitral, 48 aortic, 80 tricuspid) disease were selected prospectively, and studies were stored according to video and standardized digital protocols. The same reviewer interpreted video and digital images independently and at different times with the use of a standard report form to evaluate 40 items (eg, severity of stenosis or regurgitation, leaflet thickening, and calcification) as normal or mildly, moderately, or severely abnormal Concordance between modalities was expressed at kappa Major discordance (difference of >1 level of severity) was ascribed to the modality that gave the lesser severity. CD-ROM was used to store digital data (20:1 lossy compression), and super-VHS video-tape was used to store video data The reading time and storage costs for each modality were compared Results. Measured parameters were highly concordant (ejection fraction was 52% +/- 13% by both). Major discordance was rare, and lesser values were reported with digital rather than video interpretation in the categories of aortic and mitral valve thicken ing (1% to 2%) and severity of mitral regurgitation (2%). Digital reading time was 6.8 +/- 2.4 minutes, 38% shorter than with video (11.0 +/- 3.0, range 8 to 22 minutes, P < .001). Compressed digital studies had an average size of 60 <plus/minus> 14 megabytes (range 26 to 96 megabytes). Storage cost for video was A$0.62 per patient (18 studies per tape, total cost A$11.20), compared with A$0.31 per patient for digital storage (8 studies per CD-ROM, total cost A$2.50). Conclusion. Digital and video interpretation were highly concordant; in the few cases of major discordance, the digital scores were lower, perhaps reflecting undersampling. Use of additional views and longer clips may be indicated to minimize discordance with video in patients with complex problems. Digital interpretation offers a significant reduction in reading times and the cost of archiving.

Clinical efficacy of pimobendan versus benazepril for the treatment of acquired atrioventricular valvular disease in dogs

Seventy-six dogs with clinical acquired atrioventricular valvular disease were evaluated to determine the efficacy of pimobendan (n=41) versus benazepril hydrochloride (n=35) in a randomized, positive-controlled, multicenter study. The study was divided into 56-day and long-term evaluation periods. In a subgroup of dogs with concurrent furosemide treatment (pimobendan [n=31], benazepril [n=25]), the Heart Insufficiency Score improved in favor of pimobendan (P=0.0011), equating to a superior overall efficacy rating (P<0.0001) at day 56. Long-term median survival (i.e., death or treatment failure) for dogs receiving pimobendan was 415 days versus 128 days for dogs not on pimobendan (P=0.0022).

Importance of the right ventricle in valvular heart disease.

The importance of the right ventricle as a determinant of clinical symptoms, exercise capacity, peri-operative survival and postoperative outcome has been underestimated for a long time. Right ventricular ejection fraction has been used as a measure of right ventricular function but has been found to be dependent on loading conditions, ventricular interaction as well as on myocardial structure. Altered left ventricular function in patients with valvular disease influences right ventricular performance mainly by changes in afterload but also by ventricular interaction. Right ventricular function and regional wall motion can be determined with right ventricular angiography, radionuclide ventriculography, two-dimensional echocardiography or magnetic resonance imaging. However, the complex structure of the right ventricle and its pronounced translational movements render quantification difficult. True regional wall motion analysis is, however, possible with myocardial tagging based on magnetic resonance techniques. With this technique a baso-apical shear motion of the right ventricle was observed which was enhanced in patients with aortic stenosis.

Impact of the disease: acceptability, ceiling and floor effects and reliability of an instrument on heart failure

This study evaluated the acceptability, ceiling/floor effects, and the reliability of the instrument for measuring the Impact of the Disease on the Daily Life of Patients with Valvular Disease (IDCV) when applied to 135 patients with heart failure (HF). Acceptability was evaluated by the percentage of unanswered items and by the proportion of patients who responded to all items; the ceiling/floor effects by the percentage of patients who scored in the top of 10% best and worst results of the scale, respectively. Reliability was estimated by internal consistency (Cronbach's alpha coefficient) and stability of the measure (intraclass correlation coefficient - ICC). All patients responded to all items. Ceiling/floor effects evidenced were of moderate magnitude. The Cronbach's alpha was satisfactory for the majority of the domains and ICC> 0.90 in all the domains. The IDCV proved to be an easy to understand questionnaire, with evidence of reliability in patients with HF.

Oral triiodothyronine for the prevention of thyroid hormone reduction in adult valvular cardiac surgery

Treatment of non-thyroidal illness by intravenous triiodothyronine (T3) after cardiac surgery causes a disproportional elevation of hormone levels. The administration of oral T3, which has never been studied in this context, could cause physiological hormone levels. The aim of this study was to test oral T3 for the prevention of T3 reduction during the postoperative period of valvular cardiac surgery in adults. Eighteen patients who underwent cardiac surgery for valvular disease with invasive hemodynamic monitoring were randomly assigned to 2 groups: the T group received oral T3 (N = 8), 25 µg three times/day, initiated 24 h before surgery and maintained for 48 h and the NT group (N = 10) received placebo. Serum T3, thyroxine and thyrotropin were determined at baseline, 1 h before surgery, within 30 min of cardiopulmonary bypass and 6, 12, 24, and 48 h after removal of the aortic cross-clamp. Baseline T3 was similar in both groups (T: 119 ± 13; NT: 131 ± 9 ng/dL). Serum T3 increased during the first 24 h in the T group compared to the NT group (232 ± 18 vs 151 ± 13 ng/dL; P < 0.001). In the NT group, T3 was reduced by 24% (P = 0.007) 6 h after removal of the aortic cross-clamp, confirming the non-thyroidal illness syndrome. There were no differences in clinical or hemodynamic parameters between groups. Administration of oral T3 prevented its serum reduction after valvular cardiac surgery in adults, with normal serum levels for 48 h without disproportional elevations.

Análisis de supervivencia en pacientes con prótesis valvular biológica, Fundación Cardioinfantil-Instituto de Cardiología, Colombia, 2005-2013

Introducción: A partir de la década de los cincuenta el manejo de la enfermedad valvular presenta cambios significativos cuando se incorporan los reemplazos valvulares tanto mecánicos como biológicos dentro de las opciones de tratamiento quirúrgico (1). Las válvulas biológicas se desarrollaron como una alternativa que buscaba evitar los problemas relacionados con la anticoagulación y con la idea de utilizar un tejido que se comportara hemodinámicamente como el nativo. Este estudio está enfocado en establecer la sobrevida global y la libertad de reoperación de la válvula de los pacientes sometidos a reemplazo valvular aórtico y mitral biológicos en la Fundación Cardioinfantil - IC a 1, 3, 5 y 10 años. Materiales y métodos: Estudio de cohorte retrospectiva de supervivencia de pacientes sometidos a reemplazo valvular aórtico y/o mitral biológico intervenidos en la Fundación Cardioinfantil entre 2005 y 2013. Resultados: Se obtuvieron 919 pacientes incluidos en el análisis general y 876 (95,3%) pacientes con seguimiento efectivo para el análisis de sobrevida. La edad promedio fue 64años. La sobrevida a 1, 3, 5 y 10 años fue 95%,90%,85% y 69% respectivamente. El seguimiento efectivo para el desenlace reoperación fue del 55% y se encontró una libertad de reoperación del 99%, 96%, 93% y 81% a los 1, 3, 5 y 10 años. No hubo diferencias significativas entre la localización de la válvula ni en el tipo de válvula aortica empleada. Conclusiones: La sobrevida de los pacientes que son llevados a reemplazo valvular biológico en este estudio es comparable a grandes cohortes internacionales. La sobrevida de los pacientes llevados a reemplazo valvular con prótesis biológicas en posición mitral y aortica fue similar a 1, 3, 5 y 10 años.

Doença periodontal em portadoras de valvopatia durante a gravidez: estudo clínico e microbiológico

FUNDAMENTO: A doença periodontal representa risco à gestante portadora de valvopatia reumática, seja para contrair endocardite infecciosa, seja por propiciar complicações obstétricas. OBJETIVO: Estudar a frequência da doença periodontal em portadoras de valvopatia reumática durante a gravidez. MÉTODOS: Foram estudadas 140 gestantes, comparáveis quanto a idade e o nível socioeconômico, divididas em: 70 portadoras de doença valvar reumática e 70 mulheres saudáveis. Todas se submeteram a: 1) avaliação clínica odontológica que incluiu a análise dos seguintes parâmetros: 1.1) profundidade à sondagem, 1.2) distância da linha esmalte-cemento à margem gengival, 1.3) nível clínico de inserção, 1.4) índice de sangramento, 1.5) índice de placa bacteriana, e, 1.6) comprometimento de furca; e, 2) exame microbiológico nas amostras de saliva e do cone que considerou o controle positivo para as cepas das bactérias Porphyromonas gingivalis, Tannerella forsithia e Aggregobacter actinomycetemcomitans. RESULTADOS: A lesão valvar mitral foi prevalente (65 casos = 92,8%) dentre as gestantes cardiopatas. A comparação entre os grupos mostrou não haver diferenças entre idade e a paridade, e embora tenham sido verificadas diferenças entre as medidas da distância da linha esmalte-cemento à margem gengival (p = 0,01) e o índice de placa (p=0,04), a frequência da doença periodontal identificada em 20 (14,3%) gestantes, não foi diferente entre os grupos (p = 0,147). O exame microbiológico mostrou uma proporção maior da bactéria P. gingivalis na saliva de gestantes saudáveis (p = 0,004). CONCLUSÃO: O estudo clínico e microbiológico periodontal durante a gravidez demonstrou igual frequência da doença periodontal em portadoras de valvopatia reumática quando comparada às mulheres saudáveis.

Carcinoid syndrome - Case report

Carcinoid tumors are rare neoplasms with, an estimated incidence of I to 2 cases per 100, 000 inhabitants. The malignant carcinoid syndrome, characterized by flushing, diarrhea, abdominal pain and, less frequently, pellagra, bronchospasm and valvular disease, occurs in less than 10% of patients. Nevertheless, in advanced stages of the disease, the incidence is about 40 to 50%. Retrospective studies and descriptive case series have shown that cutaneous involvement is relatively common but has rarely been reported. We present a case of carcinoid syndrome diagnosed with basis on skin findings on clinical examination.

Cirurgia Cardíaca em Doentes de Muito Alto Risco

Purpose: To assess the results obtained in very high-risk patients, which are those patients with an EUROSCORE greater than 13 points. Material and methods: From September 2001 to September 2003, thirty-three very high-risk patients were operated on in our department, which represents 1.6% of all the surgical activity during that period of time, being 17 male and 16 female, with an average of 69 years old (maximum 86 and minimum 32). Diagnosis includes: post infarction CIV 5, coronary insufficiency 11, aortic dissection 3, mitral prosthesis 3, valvular disease 9, aortic prosthesis disfunction 2. Fifteen patients underwent an emergency procedure, 12 were urgent and the remaining 6 were electively operated on. Results: Overall post-operative mortality was 12 patients (36%), being 6 emergent, 5 urgent and 1 elective patient. Patients who survived the operation had longer intensive care and hospital admission periods, which will be analyzed in detail. Conclusion: Surgery can be justified in very high risk patients. Despite the high perioperative mortality and longer periods of hospital stay, they will be otherwise condamned to death, if surgery would not be performed.

Cirurgia de Reparação Mitral em Crianças com Valvulopatia Adquirida

BACKGROUND: Valve surgery in children is aimed at restoring correct hemodynamics with few reoperations and limited resort to prostheses, which would imply early deterioration or definitive hypocoagulation. OBJECTIVES: Report a series of paediatric pts with acquired mitral valve disease, mostly due to rheumatic disease, in whom it was possible, for the great majority, to repair the damaged valve. DEMOGRAPHICS: Fifty children with predominant mitral valve disease, 47 rheumatic (94%) and 3 after endocarditis were consequently operated by the same surgical team over the last five years. Ages were 12.5+/-3.1 yrs and weights 33.2+/-8.4 Kg, 30 pts presented with predominant mitral regurgitation and 20 pts had significant stenosis. In 8 pts there also moderate to severe aortic regurgitation and in 2 pts severe tricuspid regurgitation was present. Patients were not operated during the acute phase of the disease. Five pts were reoperations and from those, all but one received mechanical prosthesis. RESULTS: In all operations the intention was to repair the mitral valve. In 46 pts complex mitral valvuloplasties were performed extended comissurotomies, shortening of chordae, chordal replacement with PTFE, and reconstruction of valve leaflefts by direct patching or pericardial extension of the retracted posterior leaflet (78.2% cases), plus reshaping of the annulus by using a fixed prosthetic CE ring (sizes 26 to 32) in every case. Ring sizes correlated poorly with body weights, but correlation was close and positive for the use of pericardial advancement of the posterior leaflet (p<0.01). There was no operative mortality, but one pt died early from sepsis and there was no late mortality. Maximum follow up extends now to 50 months (median 28 months) and functional evaluation, at latest follow up, as assessed by Doppler Echocardiography, showed residual mitral regurgitation, mild-moderate in 4 pts and LA-LV gradients mild in 5 and moderate in 2 pts. NYHA functional class, at present follow-up is class I for 43 pts (88%) and class II in the remaining 6 pts. Along the follow-up period 2 pts had to be reoperated for early repair failures and other three for late failures, presently freedom for reoperation is 91.8% at 5 years. CONCLUSIONS: Mitral valve repair in children with rheumatic lesions can be achieved for the great majority of cases by using different techniques. Pericardial extension of the retracted posterior leaflet allowed the use of a bigger size prosthetic ring. Intermediate functional results are good with fair functional classes and few reoperations but follow-up is short and does not allow us to draw conclusions about the long-term results of the repair in these rheumatic patients.

Percutaneous Treatment of Mitral Valve Regurgitation: Initial Experience with the MitraClip Device

INTRODUCTION: Mitral regurgitation (MR) is the most common valvular disease and has recently become the target of a number of percutaneous approaches. The MitraClip is virtually the only device for which there is considerable experience, with more than 20,000 procedures performed worldwide. OBJECTIVE: To describe our initial experience of the percutaneous treatment of MR with the MitraClip device. METHODS: We describe the first six MitraClip cases performed in this institution (mean age 58.5 ± 13.1 years), with functional MR grade 4+ and New York Heart Association (NYHA) heart failure class III or IV (n=3), with a mean follow-up of 290 ± 145 days. RESULTS: Procedural success (MR ≤ 2+) was 100%. Total procedure time was 115.8 ± 23.7 min, with no in-hospital adverse events and discharge between the fourth and eighth day, and consistent improvement in the six-minute walk test (329.8 ± 98.42 vs. 385.33 ± 106.95 m) and in NYHA class (three patients improved by two NYHA classes). During follow-up there were two deaths, in two of the four patients who had been initially considered for heart transplantation. CONCLUSION: In patients with functional MR the MitraClip procedure is safe, with both a high implantation and immediate in-hospital success rate. A longer follow-up suggests that the clinical benefit decreases or disappears completely in patients with more advanced heart disease, namely those denied transplantation or on the heart transplant waiting list.

Prognostic factors of the results of cardiopulmonary resuscitation in a cardiology hospital

OBJECTIVE: To analyze the early and late results of cardiopulmonary resuscitation in a cardiology hospital and to try to detect prognostic determinants of both short- and long-term survival. METHODS: A series of 557 patients who suffered cardiorespiratory arrest (CRA) at the Dante Pazzanese Cardiology Institute over a period of 5 years was analyzed to examine factors predicting successful resuscitation and long-term survival. RESULTS: Ressuscitation maneuvers were tried in 536 patients; 281 patients (52.4%) died immediately, and 164 patients (30.6%) survived for than 24 hours. The 87 patients who survived for more than 1 month after CRA were compared with nonsurvivors. Coronary disease, cardiomyopathy, and valvular disease had a better prognosis. Primary arrhythmia occurred in 73.5% of the >1-month survivor group and heart failure occurred in 12.6% of this group. In those patients in whom the initial mechanism of CRA was ventricular fibrillation, 33.3% survived for more than 1 month, but of those with ventricular asystole only 4.3% survived. None of the 10 patients with electromechanical dissociation survived. There was worse prognosis in patients included in the extreme age groups (zero to 10 years and 70 years or more). The best results occurred when the cardiac arrest took place in the catheterization laboratories. The worst results occurred in the intensive care unit and the hemodialysis room. CONCLUSION: The results in our series may serve as a helpful guide to physicians with the difficult task of deciding when not to resuscitate or when to stop resuscitation efforts.

Clinical review: practical recommendations on the management of perioperative heart failure in cardiac surgery.

Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery.

IRM cardiaque dans le suivi des cardiopathies congénitales à l'âge adulte [Cardiac MRI in the follow-up of adult congenital cardiomyopathy patients].

Magnetic resonance imaging is a rapidly developing modality in cardiology. It offers an excellent image definition and a large field of view, allowing a more accurate morphological assessment of cardiac malformations. Due to its unique versatility and its ability to provide myocardial tissue characterization, cardiac magnetic resonance (CMR) is now recognized as a central imaging modality for a wide range of congenital heart diseases, including assessment of post-surgical cardiac anatomy, quantification of valvular disease and detection of myocardial ischemia. CMR provides useful diagnostic information without any radiation exposure, and improves the global management of patients with congenital heart disease.

Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: Results from the global valve-in-valve registry.

BACKGROUND Transcatheter aortic valve-in-valve implantation is an emerging therapeutic alternative for patients with a failed surgical bioprosthesis and may obviate the need for reoperation. We evaluated the clinical results of this technique using a large, worldwide registry. METHODS AND RESULTS The Global Valve-in-Valve Registry included 202 patients with degenerated bioprosthetic valves (aged 77.7±10.4 years; 52.5% men) from 38 cardiac centers. Bioprosthesis mode of failure was stenosis (n=85; 42%), regurgitation (n=68; 34%), or combined stenosis and regurgitation (n=49; 24%). Implanted devices included CoreValve (n=124) and Edwards SAPIEN (n=78). Procedural success was achieved in 93.1% of cases. Adverse procedural outcomes included initial device malposition in 15.3% of cases and ostial coronary obstruction in 3.5%. After the procedure, valve maximum/mean gradients were 28.4±14.1/15.9±8.6 mm Hg, and 95% of patients had ≤+1 degree of aortic regurgitation. At 30-day follow-up, all-cause mortality was 8.4%, and 84.1% of patients were at New York Heart Association functional class I/II. One-year follow-up was obtained in 87 patients, with 85.8% survival of treated patients. CONCLUSIONS The valve-in-valve procedure is clinically effective in the vast majority of patients with degenerated bioprosthetic valves. Safety and efficacy concerns include device malposition, ostial coronary obstruction, and high gradients after the procedure.