Search

Copyright of Der Internist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Herz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Herz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

History: A 64-year old male marathon runner noted during training an asymptomatic sudden increase in heart rate as recorded on his heart rate monitor. But this was not verifiable on subsequent Holter-ECG monitoring. However, treadmill exercise testing revealed unexpected signs of ischemia, which required further diagnostic tests., Investigations: Cardiac computed tomography (CT) demonstrated advanced coronary atherosclerosis, with suspected morphologically significant stenosis after contrast injection. Because of the absence of angina, a myocardial perfusion scintigraphy was done which gave no evidence of ischemia, and there was no late enhancement on magnetic resonance imaging. In view of these findings invasive coronary angiography was not performed., Treatment and Course: The patient received aggressive risk modifying therapy. He is still running regularly event-free after nine months., Conclusion: This case shows that the use of modern non-invasive cardiovascular imaging can have an impact in preventive clinical decision making., (Georg Thieme Verlag KG Stuttgart, New York.)

Even today, in times of modern antibiotic therapy, infective endocarditis is a disease with a high mortality which is difficult to diagnose and to treat. The changing clinical face of this disease in the last decades results from a changing predisposition of the patients, an increasing age, and is accompanied with shift from streptococci toward staphylococci as the main causative microorganisms. Evidence from randomized trials is limited due to a low incidence of the disease. Thus, application of the guidelines for diagnosis and treatment on a patient has always to respect the individual history, and the individual clinical course. The authors describe and comment the case of a patient with endocarditis of the native aortic valve due to S. epidermidis from diagnosis to discharge from the hospital following the current German guidelines for diagnosis and treatment of infective endocarditis.

Besides diagnosis of the mechanism of mitral regurgitation accurate evaluation of the severity is of critical importance for the assessment of prognosis and planning of therapy. Current recommendations are differentiating two levels of evaluation of severity, (1) a rapid, basic evaluation, and (2) an extended, quantitative evaluation. In the present article the following modified practically applicable system for evaluation and scoring of severity of mitral regurgitation is proposed: step 1: color Doppler jet size: < 4 cm(2) or < 20% of left atrium (LA; = 1 scoring point), 4-8 cm2 or 20-40% of LA (2 points), > 8 cm(2) or > 40% of LA (3 points); step 2: central jet (1 point), eccentric/wall jet (2 points); step 3: LA width: 4 cm (2 points); step 4: proximal jet width: < 0,3 cm (1 point), 0,3-0,7 cm (3 points), > 0,7 cm (5 points). Grades of severity are scored as follows: grade I = 4-5 points, I-II = 6 points, II = 7-8 points, II-III = 9 points, III = 10-12 points. Quantitative Doppler method and PISA (proximal isovelocity surface area) method can be used for calculation of regurgitant volume and effective regurgitant orifice area (EROA), but recommendations for routine application are limited due to indirect measurements and inaccurate hemodynamic assumptions. Special techniques like real-time 3-D echocardiography, quantitative spectral Doppler analysis or stress echocardiographic assessment of severity are still under scientific evaluation. Due to the growing possibilities of early reconstruction of the mitral valve and catheter-based interventional annulus reconstructions, more accurate methods for direct quantification of regurgitant flow will be demanded in the future.

Mitral valve prolapse shows a wide spectrum from a benign anatomic variant to a progressive disease with severe cardiovascular morbidity and mortality. Echocardiography is the most important tool for diagnosis and risk stratification. Predictors for high risk are significant thickening of mitral leaflet of > 5 mm ("classic" prolapse), moderate to severe mitral regurgitation and reduced left ventricular function. These patients have an increased risk of infective endocarditis, cerebral ischemia and sudden cardiac death. Because of the risk for the development of severe mitral regurgitation requiring surgery short follow-up intervals are necessary. In mitral prolapse syndrome cardiac clinical signs (palpitation, rhythm disorders, syncope, etc.) are associated with a prolapse that can be treated symptomatically with drugs after exclusion of other causes and significant mitral regurgitation requiring surgery.

Echocardiography is an important tool for diagnosis and risk assessment in patients with infective endocarditis. In addition to the identification of typical vegetations, echocardiography is crucial for the evaluation of valvar regurgitations, and the early diagnosis of complications. Transesophageal echocardiography is, in nearly every aspect, except with concern to right-sided endocarditis, superior to the transthoracic approach. Thus, transesophageal echocardiography represents, in patients with substantial clinical suspicion for an active infection of endocardial structures, the currently most sensitive diagnostic tool.

Background: Beyond conventional echocardiographic Doppler methods allowing only semiquantitative estimation of the severity of valvular regurgitation, new approaches are attempting to quantify regurgitant flow as a measure of left ventricular volume overload. Different concepts are leading to significant differences in accuracy and feasibility in clinical routine between the methods. We are reviewing the existing methods with their advantages and limitations as well as the underlying hemodynamic concepts., Echocardiographic Methods for Estimation of Severity: Semiquantitative methods are jet area/jet length method, proximal jet width as well as the pressure half-time method. Determination of regurgitant flow is permitted by means of the continuity method, PISA ("Proximal Isovelocity Surface Area") method, ACOM ("Automated Cardiac Output Measurement") technique, and the PVI ("Power-Velocity Integral") method. Grading of severity is usually based on a scale from 1 to 3 or 1 to 4 where semiquantitative methods are limited by a significant overlap of the individual degrees and therefore only provide rough estimates of severity. Compared to this, quantitative methods allow quantitative determination of regurgitant flow, regurgitant volume, regurgitant fraction, and effective regurgitant orifice area based on different Doppler flow measurements, that are again affected by specific limitations: (1) the continuity method is considerably limited because it is measuring the flow through two different valves; (2) the PISA method is dependent on the geometry of the proximal flow convergence zone and requires highly skilled observers; (3) the ACOM method is also dependent on the geometry of the proximal flow convergence zone und ideally requires three-dimensional color Doppler datasets; (4) the PVI method provides direct measurement of regurgitant flow from a pulsed Doppler signal of sufficient high quality, however, this method is not widely available, yet. For the decision which method to apply the following should be taken into account: (1) interpretation of semiquantitative findings depends on the extent by which the methods' estimation of flow deviates from a measurement of flow; (2) accuracy of the quantitative methods depends on the underlying hemodynamic concept and the simplifying assumptions., Conclusion: Current echocardiography provides a broad spectrum of semiquantitative und quantitative Doppler methods for the estimation of regurgitant flow. Since semiquantitative methods only allow rough estimates of severity, quantitative measurement of regurgitant volume/fraction or effective regurgitant orifice area should be attempted in any case with uncertainty whether regurgitation is mild, moderate, or severe.