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Background We have previously reported an increased risk for non-hematological malignancies in young patients with moderate or severe aortic stenosis (AS) (1). These findings were the result of a post-hoc analysis from a large echocardiography database and needed verification. Purpose To determine, using a different study population, whether young patients with AS are at increased risk for cancer. Methods A large echocardiographic database was used to identify patients (age≥20 years) with moderate or severe AS (study group) and patients without aortic stenosis (comparative group). The new occurrence of non-hematological malignancies was determined after the index date (first echo with moderate or severe AS or first recorded echo in the control group). Results The final study group included 7,013 patients with AS and 98,884 without AS. During a median follow-up of 6.9 years (3.0–11.1) there were 10,705 new cases of non-hematological cancer. The crude incidence rate of cancer was higher in AS compared to non-AS patients (22.3 vs. 13.7 per 1,000 patient-year, crude HR 1.58 (95% CI 1.46–1.71). After adjustment for relevant covariates, there was no difference between groups (HR 0.93, 95% CI 0.86–1.01). Only patients in the lowest age quartile (20–49.7 years), had an increased adjusted risk of cancer (HR 1.91, 95% CI 1.08–3.39). The HR for the risk of cancer in AS was inversely proportional to age (P Conclusion Young patients with moderate or severe AS are at increased risk for cancer. Cancer surveillance should be considered for young patients with AS. Funding Acknowledgement Type of funding sources: None. Figure 1

Background: Persistent symptoms affect a subset of coronavirus disease 2019 (COVID-19) survivors. Some of these may be cardiovascular (CV)-related. Objective: To assess the burden of objective CV morbidity among, and to explore the short-term course experienced by, COVID-19 patients with post-infectious symptomatology suspected as CV. Methods: This was a single-center, retrospective analysis of consecutive adult patients with new-onset symptoms believed to be CV following recovery from COVID-19, who had been assessed at a dedicated ‘Cardio’-COVID clinic between June 2020 and June 2021. All participants were followed for 1 year for symptomatic course and the occurrence of new CV diagnoses and major adverse cardiovascular events (MACE). Results: A total of 96 patients (median age 54 (IQR, 44–64) years, 52 (54%) females) were included in the final analysis. Initial visits occurred within a median of 142 days after the diagnosis of acute COVID. Nearly all (99%) patients experienced a symptomatic acute illness, which was graded as severe in 26 (27%) cases according to the National Institutes of Health (NIH) criteria. Long-COVID symptoms included mainly dyspnea and fatigue. While the initial work-up was mostly normal, 45% of the 11 cardiac magnetic resonance studies performed revealed pathologies. New CV diagnoses were made in nine (9%) patients and mainly included myocarditis that later resolved. An abnormal spirometry was the only variable associated with these. No MACE were recorded. Fifty-two (54%) participants felt that their symptoms improved. No association was found between CV morbidity and symptomatic course. Conclusions: In our experience, long-COVID symptoms of presumed CV origin signified actual CV disease in a minority of patients who, irrespective of the final diagnosis, faced a fair 1-year prognosis.

Objectives: Fever following transcatheter aortic valve implantation (TAVI) is a common phenomenon, attributed mostly to inflammatory response which may impact outcome. Systemic inflammatory response may be triggered by multiple factors, most associated with the TAVI procedure itself. However, there are no data regarding the incidence of fever following TAVI in contemporary era with newer generation devices. Our primary objective was to measure temporal trends in fever incidence and features following TAVI. Methods: We analyzed a retrospective cohort of 802 consecutive patients who underwent TAVI at our institution between November 2008 and February 2018. We identified and characterized all patients who developed fever (>38.0°C from any cause) within the first 72 h following the procedure and analyzed incidence and characteristics stratified into 3 time frames: 2008–2014, 2014–2016, and 2016–2018. Results: Following TAVI, 190 (23.7%) patients developed fever (mean age 82.3 ± 5.2 years, 64.2% female). An infectious etiology was evident in only 32.1% of cases. The frequency decreased gradually and significantly across timeframes (32.8, 23.6, and 14.5%, respectively, p < 0.001). In a multivariate regression analysis, 1st generation CoreValve (HR 1.91; CI 95% 1.2–3.04, p = 0.006) was found to be associated with higher incidence of fever in addition to female gender, vascular complications, transfemoral access, and reduced GFR. Conclusions: Fever incidence post TAVI decreased significantly throughout the last decade. The higher rate of fever in the early years of TAVI was likely associated with first-generation devices, vascular complications, and reduced GFR.

Few data exist regarding the effect of image quality on measurements of two-dimensional longitudinal strain (2DLS). In the 2DLS for Diagnosing Chest Pain in the Emergency Room (2DSPER) multicenter study, 2DLS was not useful for ruling out acute coronary syndromes (ACS) in the emergency department (ED). The aim of this substudy was to determine the effect of 2D image quality on the diagnostic accuracy of 2DLS for ACS. We reviewed apical views used for 2DLS analysis in all 605 patients included in the 2DSPER study. Studies with the best image quality (HighQ, n = 177), were compared to the lower quality group (LowQ, n = 428). Abnormal 2DLS was defined as PSS20% > − 17% (PSS20% being the peak left ventricular systolic strain value identifying the 20% worst strain values). Global longitudinal strain (GLS) and PSS20% were significantly worse in LowQ compared to HighQ patients. LowQ independently predicted abnormal 2DLS (OR 1.9, 95% CI 1.3–2.9, P = 0.003). The sensitivity of PSS20% > − 17% for ACS was 85% for LowQ vs. 73% for HighQ (P = 0.2), specificity 22% vs. 38% (P

Aims Left ventricular (LV) two-dimensional longitudinal strain (2DLS) analysis by echocardiography has been suggested as a useful tool for the detection of acute coronary syndromes (ACS). Our aim was to determine whether 2DLS analysis could assist in triage of patients with chest pain (CP) in the emergency department (ED). Methods and results We prospectively enrolled patients presenting to the ED with CP and suspected ACS but without a diagnostic ECG or elevated troponin. An echocardiogram was performed within 24 h of CP. For each patient, a histogram of LV myocardial peak systolic strain (PSS) was generated and the value identifying the 20% worst strain values (PSS20%) was determined. A predefined value of greater than −17% was considered abnormal. 2DLS analysis was available for 605 patients (mean age 58 ± 9 years, 70% males), of which 74 (12.2%) had ACS. During a 6-month follow-up, MACE occurred in 4 (5.8%) patients with and in 3 (0.6%) without ACS. An abnormal PSS20% was present in 60/74 patients with ACS (sensitivity 81%, negative predictive value 91%), but also in 391/531 patients without ACS (specificity 26%, positive predictive value 13%). Similar results were found for global longitudinal strain (GLS). Receiver-operating characteristic curves showed an area under curve of 0.59 for PSS20% and 0.6 for GLS ( P = 0.3). Independent predictors of abnormal 2DLS were male gender, body mass index, heart rate, and mean tissue Doppler e ′, but not ACS. Conclusion In this large multicentre prospective study, 2DLS was not a useful tool to rule out ACS in the ED. Clinical trial registration . Unique identifier NCT01163019.

In recent years, transcatheter aortic valve replacement (TAVR) has emerged as a revolutionary alternative for surgical aortic valve replacement (SAVR) for the treatment of severe symptomatic aortic stenosis in patients at high risk for surgery. Prosthetic aortic valve endocarditis is a serious complication after SAVR with high morbidity and mortality. Although numerous TAVR procedures have been performed worldwide, infective endocarditis (IE) after TAVR was reported in the literature in few cases only and in 0% to 2.3% of patients enrolled in large TAVR cohorts. Our aim was to review the literature for IE following TAVR and to discuss the diagnostic and management strategies of this rare complication. Ten case reports of IE after TAVR were identified, 8 of which were published as case reports and 2 of which were presented in congresses. Infective endocarditis occurred in a mean time period of 186 days (median, 90 days) after TAVR. Most cases were characterized by fever and elevated inflammatory markers. Infective endocarditis after TAVR shared some common characteristics with IE after SAVR, yet it has some unique features. Echocardiographic findings included leaflet vegetations, severe mitral regurgitation with rupture of the anterior leaflet, and left ventricle outflow tract to left atrium fistula. Bacteriologic findings included several atypical bacteria or fungi. Cases of IE were managed either conservatively by antibiotics and/or using surgery, and the overall prognosis was poor. Infective endocarditis after TAVR deserves prompt diagnosis and treatment. Until further evidence is present, IE after TAVR should be managed according to SAVR guidelines with modifications as needed on a case‐by‐case basis. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Eur J Clin Invest 2012; 42 (4): 402–410 Abstract Background We examined the feasibility of estimating left ventricular ejection fraction (LVEF) by a novel acoustic-based device [vibration response imaging (VRI); Deep Breeze]. Methods One hundred and forty-one subjects (117 patients and 24 healthy volunteers; age 55 ± 15 years, 82% men) were examined by both VRI and echocardiography. LVEF was determined by echocardiography (echo-LVEF) using the biplane Simpson’s method. Low-frequency acoustic signals (10–70 Hz) were recorded by VRI from the left posterior thorax by a matrix of 36 microphones during 8 s of breath holding, and an electrocardiogram was recorded simultaneously. The acoustic signals were processed digitally, and an algorithm designed to estimate LVEF was developed (VRI-LVEF), based on a combination of multiple acoustic (systolic and diastolic acoustic signals, beat-to-beat variability of acoustic signals and propagation of acoustic signals throughout the matrix), electrocardiographic and clinical parameters. Results Mean echo-LVEF was 51 ± 15% (range, 11–76%). Echo-LVEF was reduced (

Cardiotoxicity associated with doxorubicin (DOX) treatment limits the therapeutic efficiency of this drug against cancer. 2-Chloro-N(6)-(3-iodobenzyl)adenosine-5'-N-methyluronamide (Cl-IB-MECA), a selective agonist of A(3) adenosine receptor (A(3)R), reduces DOX toxicity in newborn rat cultured cardiomyocytes. The study's aim was to determine whether the protection demonstrated by Cl-IB-MECA attenuates cardiac depression in vivo. In addition, we wished to examine whether this protective pathway affects the sarcoplasmic reticulum (SR) calcium uptake and release, as well as intramitochondrial Ca(2+) accumulation induced by DOX. Rats were injected every alternate day (6 times) with (1) saline, (2) 2.5mg/kg i.p. DOX, (3) 33 microg/kg i.v. Cl-IB-MECA, (4) DOX+Cl-IB-MECA. Left ventricular functions were assessed by invasive (pressure) and non-invasive (echocardiography) techniques at the end of the injection period and 4 weeks later. Cytosolic and intramitochondrial calcium levels were measured with indo-1 and rhod-2 probes. SR Ca(2+) content was determined by exposing cultured rat cardiomyocytes to caffeine. Echocardiography data demonstrate left ventricular wall thinning (23%), an increase in the end systolic dimension (170%) and decreased fractional shortening (35+/-5% vs. 54+/-5%, p

Tricuspid regurgitation (TR) in patients with mitral valve (MV) disease is associated with poor outcome and predicts poor survival, heart failure, and reduced functional capacity. It is common if left untreated after MV replacement mainly in rheumatic patients, but it is also common in patients with ischemic mitral regurgitation. It is less common, however, in those with degenerative mitral regurgitation. It might appear many years after surgery and might not resolve after correcting the MV lesion. Late TR might be caused by prosthetic valve dysfunction, left heart disease, right ventricular (RV) dysfunction and dilation, persistent pulmonary hypertension, chronic atrial fibrillation, or by organic (mainly rheumatic) tricuspid valve disease. Most commonly, late TR is functional and isolated, secondary to tricuspid annular dilation. Outcome of isolated tricuspid valve surgery is poor, because RV dysfunction has already occurred at that point in many patients. MV surgery or balloon valvotomy should be performed before RV dysfunction, severe TR, or advanced heart failure has occurred. Tricuspid annuloplasty with a ring should be performed at the initial MV surgery, and the tricuspid annulus diameter (≥3.5 cm) is the best criterion for performing the annuloplasty. In this article we will review the current data available for understanding the prognostic implications, mechanism, and management of TR in patients with MV disease.

Obstructive prosthetic valve thrombosis is a serious complication in patients with prosthetic heart valves. It should be suspected in patients with worsening functional class, embolic phenomena, and inadequate anticoagulation. TTE is very informative and the most frequent modality to begin with. TEE is extremely important, with its unique role in excluding high-risk thrombi. Fluoroscopy is currently the best modality for the assessment of leaflet motion, especially for the aortic position, while cardiac CT may be of added value due to its unique post-processing features. Efforts to discriminate thrombosis from pannus should be made, although current methods are frequently inconclusive. The application of 3-dimensional TEE is hoped to improve the diagnostic accuracy further. Once the diagnosis is established, therapy should be offered according to the local expertise, considering the risk of surgery, the risk of thrombolysis (mainly--bleeding and embolism), the patients' functional class, and the likelihood of achieving valve reopening. Guidelines are numerous and puzzling. Thrombus size is probably the most important determinant of complications, and if it is small, thrombolysis is probably advised across all degrees of functional class, as suggested by American College of Chest Physicians.

To evaluate the potential protective affects of Epo on left ventricular (LV) function and remodeling after acute myocardial infarction (MI).Epo was injected into the peritoneum of male Wistar rats (250 g) during 6 weeks post induction of MI. Rats were divided into five groups: MI treated with single high dose (MT1, 5,000 U/kg, n=10), single high dose (5,000 U/kg) and repeated high doses (MTHi, 1,000 U/kg twice a week; n=8), or single high dose (5,000 U/kg) and repeated low doses (MTLo, 750 U/kg once a week, n=10), MI non-treated (MNT, n=10), sham (S, n=5). Echocardiography was performed 3.6+/-1.5 days and 43.7+/-2.3 days post MI. Collagen deposition and infarct size were measured on histological sections using computerized image analysis. Apoptosis was assessed by ApopTag staining.Baseline fractional shortening (FS) was similar between groups. Six weeks after MI the FS of MTLo (26.9%) was significantly higher compared to MNT (17.8%), MT1 (19.5%) and MTH (22.3%) (p=0.01). However, remodeling indices (end diastolic and end systolic areas, LV circumference) did not improve in the Epo groups, and even worsened in the MTHi group. There was significantly less collagen staining in non-infarct areas in MT1 and MTHi groups compared to MNT and MTLo (0.38+/-0.3%, 0.49+/-0.34%, vs 0.89+/-0.41%, 0.95+/-0.33%, respectively, p0.001). The number of ApopTag positive nucleus was significantly higher in the MNT group compared to the MT1, MTHi, MTLo groups (14.4+/-8, 7.6+/-4, 5.8+/-7, 4.8+/-5, respectively, p=0.01 for trend).Repeated low doses of Epo after MI improved LV function, but the role of Epo on remodeling is not clear. It did not reduce left ventricular indices, but reduces fibrosis and apoptosis. High Epo doses reduced LV function and aggravated remodeling.

Mitral regurgitation is a common disease in patients with cardiomyopathies, constituting poor prognosis when present. In patients with an increased risk for surgery, a minimally-invasive, percutaneous procedure currently exists, in the form of an edge-to-edge repair technique using the MitraClip device. This approach allows for great flexibility in specific situations, such as in the addition of another clip when necessary, either during the procedure or after a follow-up period. The following case study depicts the course of therapy for a patient with ischemic cardiomyopathy and severe bi-ventricular failure. The patient was implanted with a MitraClip device five months before the current event, and now presents with clinical deterioration, and a renewed mitral valve insufficiency.

To investigate the in-hospital and long-term outcomes of patients at extreme age with severe symptomatic aortic stenosis (AS) who underwent transcatheter aortic valve implantation (TAVI).A total of 276 consecutive patients with a mean age of 82.2 ± 5.0 years with severe symptomatic AS underwent TAVI at our institute. We evaluated periprocedural, in-hospital, and long-term outcomes in all patients aged ≥87 years (the highest 20th percentile of age distribution) and compared them with the less elderly patients.The extremely aged group included 58 patients (21%) ≥87 years (mean age, 89.0 ± 1.9 years; 67.2% women). Baseline EuroSCOREs and STS scores were 19.6 ± 11.2% and 9.4 ± 5.0%, respectively. Nineteen patients (34.5%) were considered frail. Following TAVI, all patients regained New York Heart Association class 1-2 functional capacity. The main periprocedural and in-hospital complications were minor vascular complications, bleeding requiring blood transfusions, and the need for permanent pacemaker. None of the patients suffered from clinical stroke. In comparison to the less elderly patients, there were no significant differences in the rates of periprocedural, in-hospital complications or long-term survival (log rank, 0.87).Meticulously selected patients at extreme age benefit from TAVI with a reasonable overall risk, which does not impact the overall survival or functional status.

Intermediate- or low-risk patients with severe aortic stenosis were excluded from earlier transcatheter aortic valve implantation (TAVI) clinical trials; however, they are already being treated by TAVI despite a lack of data regarding the safety and efficacy in these patients. We aimed to assess the safety and efficacy of TAVI in patients at intermediate or low risk. Patients undergoing TAVI during 2008 to 2014 were included into a shared database (n = 1,327). Procedural outcomes were adjudicated according to Valve Academic Research Consortium 2 definitions. Patients were stratified according to their Society of Thoracic Surgeons (STS) score into 3 groups: high (STS ≥8, n = 223, 17%), intermediate (STS 4 to 8; n = 496, 38%), or low risk (STS

Most patients with Primary Pulmonary Hypertension (PPH) have severe exertional limitation which ultimately leads to right heart failure and death. The purpose of the study was to assess the correlation between right ventricular (RV) systolic and diastolic noninvasive variables and exercise tolerance, as well as the predictors of adverse outcome in treated patients.We prospectively studied 29 patients, 17 with PPH and 12 with PPH due to collagen disease. RV parameters were assessed by echocardiography and Radionuclide ventriculography. Pulmonary function and clinical profile were assessed by 6 min walk test and NYHA class. The patients were followed-up during 2 years for cardiac death and cardiac deterioration.Mean age was 51 +/- 15 years, 22 (78%) women. NYHA class1 in 2 pts, class 2 in 17, class 3 in 8 and class 4 in 2 pts. Pulmonary function (DLCO) was low in 25 (86%) pts, mean 22 +/- 48%. Six minutes walk distance was 358 +/- 132 m, RVEF was 34 +/- 11% (range 16-51%). Among RV variables, RVEF, RA area and TR were independently correlated to 6 min walk. Within follow up of 2 years, there were 10 patients with adverse outcome (4 deaths and 6 deteriorated to NYHA class 3 and 4). Among all clinical and noninvasive variables, RVEF only was correlated to adverse outcome.The noninvasive tests of RVEF, RA size and TR were closely correlated to exercise tolerance. However, among the various clinical, functional and RV variables, RVEF was the only variable correlated with adverse outcome in pts with PPH.

One thousand fifty-one consecutive patients who had acute myocardial infarction were classified into 3 risk groups by 4 echocardiographic risk assessments: left ventricular ejection fraction, left ventricular filling pattern, estimated systolic pulmonary artery pressure, and mitral regurgitation, with 30-day mortality rates of 13.7%, 3.8%, and 1%, respectively (p0.001). Independent echocardiographic and clinical predictors of 30-day mortality included age (10 years, hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.91 to 1.89), female gender (HR 2.12, 95% CI 0.94 to 4.74), Killip's classor =II on admission (HR 3.09, 95% CI 1.38 to 7.11), group 2 (moderate) risk (HR 2.89, 95% CI 1.07 to 8.56), and group 1 (high) risk (HR 8.16, 95% CI 2.95 to 25.23).

We compared clinical, microbiological, and prognostic characteristics of infective endocarditis in patients with and without diabetes mellitus. In 1987--1996, 213 patients with definite or possible infective endocarditis were included, of which 39 (18%) had diabetes mellitus. Diabetic patients were older than non-diabetic (median age of 71 vs 65 y, respectively; p =0.04), had more aortic valve and less mitral valve involvement (71% vs 27%, and 21% vs 62%; p = 0.004). There was no significant difference in the frequency of Staphylococcus aureus involvement between the 2 groups (21% in diabetic vs 20% in non-diabetic group; p = ns). On multivariate analysis diabetes mellitus was not found to be an independent factor for mortality. Unlike other infections diabetes mellitus does not significantly affect clinical and microbiological features, and outcome of infective endocarditis.

Background Isolated stenosis of the left main coronary artery is usually treated by coronary bypass surgery. However, this approach restores a less physiologic perfusion of the myocardium that leads to occlusion of the left main coronary artery, and restores only a retrograde perfusion of a rather extensive myocardial area. Coronary ostial plasty has been described as an alternative surgical technique in isolated ostial left main coronary artery stenosis without calcification. We review our experience with 15 patients. Methods After placing the patient on cardiopulmonary bypass and aortic cross clamping, the main pulmonary trunk was retracted laterally. The left main coronary artery was approached anteriorly through a curved aortotomy. Reconstruction was performed using fresh pericardial patch or saphenous vein that was tailored as a patch. Results There were no early mortality or perioperative myocardial infarctions. During mean follow-up of 55 ± 39 months, no patients had any cardiac events or required repeated coronary intervention. All patients underwent follow-up transesophageal echocardiography, which demonstrated a wide open left main coronary artery (range 3 to 8 mm), normal flow pattern by pulsed-wave Doppler, and no aneurysmal dilatation or calcification of the onlay patch. Coronary angiography and intravascular ultrasound were performed in 2 patients because of nonspecific chest discomfort. In both cases, the left main coronary artery was found to be wide open, and there were no signs of patch calcification. Conclusions Surgical reconstruction of the left main coronary artery is safe and effective for the treatment of selected cases of isolated left main stenosis. The use of autologous pericardium appears to be as safe as saphenous vein patch. Neither method was associated with postoperative aneurysmal dilatation or calcification.

ObjectivesThe aim of this study was to evaluate the significance of increased left atrial (LA) volume determined within the first 48 h of admission as a long-term predictor of outcome in patients with acute myocardial infarction (MI).BackgroundThe LA volume reflects left ventricular (LV) diastolic properties. Whereas other LV Doppler diastolic characteristics are influenced by acute changes in LV function, LA volume is stable and reflects diastolic properties before MI.MethodsClinical and echocardiographic parameters were prospectively collected in 395 consecutive patients with acute MI. Patients with LA volume index (LAVI) >32 ml/m2(normal + 2 standard deviations) were compared with those with LAVI ≤32 ml/m2. Independent clinical and echocardiographic prognostic risk factors for five years' mortality were determined by the Cox proportional hazard model.ResultsLeft atrial volume index >32 ml/m2was found in 63 patients (19%) who had a higher incidence of congestive heart failure on admission (24% vs. 12%, p < 0.01), a higher incidence of mitral regurgitation, increased LV dimensions, and reduced LV ejection fraction when compared with patients with LAVI ≤32 ml/m2. Their five-year mortality rate was 34.5% versus 14.2% (p < 0.001). Significant independent risk predictors of five years' mortality were age (10 years) (odds ratio [OR] 1.45; 95% confidence interval [CI]1.14 to 1.86), Killip class ≥2 on admission (OR 2.30; 95% CI 1.29 to 4.09), LAVI >32 ml/m2(OR 2.22; 95% CI 1.25 to 3.96), diabetes (OR 1.94; 95% CI 1.15 to 3.28), and LV restrictive filling pattern (OR 1.89; 95% CI 1.09 to 3.31).ConclusionsIn patients with acute MI, increased LA volume, determined within the first 48 h of admission, is an independent predictor of five-year mortality with incremental prognostic information to clinical and echocardiographic data.

Patients with rheumatic mitral valve disease (n = 48) underwent treadmill stress echocardiography and were classified as those with mitral stenosis (n = 24) or those with mitral regurgitation with mild mitral stenosis (n = 24). Despite marked differences in mitral valve area (1.1 +/- 0.3 vs 2.1 +/- 0.6 cm(2), respectively; p

Postpericardiotomy syndrome (PPS) is a troublesome complication of cardiac surgery, occurring in 10-45% of cases. Accepted modalities of treatment include nonsteroidal anti-inflammatory drugs, corticosteroids, and pericardiectomy in severe cases. The optimal method for prevention of PPS has not been established. Recent trial data have shown that colchicine is efficient in the secondary prevention of recurrent episodes of pericarditis. The aim of the present study was to evaluate the possible benefit of colchicine for the primary prevention of PPS in patients after cardiac surgery. To the best of our knowledge, this is the first study addressing this issue.A prospective, randomized, double-blind design was used. The initial study group included 163 patients who underwent cardiac surgery in two centers in Israel between October 1997 and September 1998. On the 3rd postoperative day, the patients were randomly assigned to receive colchicine (1.5 mg/day) or placebo for 1 month. All were evaluated monthly for the first 3 postoperative months for development of PPS.52 of the 163 patients were excluded because of postoperative complications, noncompliance, or gastrointestinal side effects of treatment. Of the 111 patients who completed the study, 47 (42.3%) received colchicine and 64 (57.7%) placebo. There was no statistically significant difference between the groups in clinical or surgical characteristics. PPS was diagnosed in 19 patients (17.1%), 5/47 cases (10.6%) in the colchicine group and 14/64 (21.9%) in the placebo group. The difference showed a trend toward statistical significance (p0.135).Colchicine may be efficacious for the prevention of PPS in patients after cardiac surgery. Further evaluations in larger clinical trials are warranted.

Tricuspid valve replacement (TVR) is considered a high-risk operation. The study aim was to analyze the authors' eight-year experience with TVR and to characterize the specific risk factors for this operation.Between January 2005 and August 2012, a total of 67 patients (46 females, 21 males; mean age 58 +/- 14 years; range: 25-86 years) underwent TVR at the authors' center. Re-do operations were performed in 48 patients (72%), including 37 patients (55%) who had at least two previous surgeries. Isolated TVR was performed in 28 patients (42%). The follow up (mean 28 months) included echocardiography and survival analysis.The overall operative mortality was 17.9% (n = 12, all female). In the latter half of the study period, mortality declined to 11.4% (p = NS). Major postoperative morbidity included prolonged mechanical ventilation (28.4%), low cardiac output (29.8%), and acute renal failure requiring hemodialysis (10.4%). Univariate analysis revealed that female gender (p = 0.007), NYHA class (p = 0.038), serum bilirubin level (p = 0.02) and number of previous cardiac surgeries (p = 0.05) were associated with increased operative mortality. Multivariable analysis demonstrated that reoperation (OR 6.06, p = 0.036) was an independent risk factor for operative mortality or complications. Echocardiography at follow up showed that 92.6% of all patients had tricuspid regurgitation grade2. The overall five-year survival rates for males and females were 82% and 53%, respectively (p = 0.03), but five-year survival for operative survivors was similar in males and females (82% versus 73%, p = 0.5). Cox regression analysis showed that age (OR 1.07, p = 0.028) and reoperation (OR 6.1, p = 0.038) were independent risk factors for late mortality.TVR remains a high-risk operation, particularly for advanced age and previously operated patients; however, the long-term survival is satisfactory. Typically, women undergo TVR at an older age with a higher mortality rate than men. However, the long-term mortality rate of patients who survived surgery was not associated with gender.

To determine the impact of early surgical intervention on long-term survival in patients with infective endocarditis (IE), charts of all patients who had IE from January 1987 through December 1996 were reviewed. A total of 252 patients with definite or possible IE were included. Forty-four patients (17.5%) had early surgery on median hospital day 2 (range, 0‐30 days), and 208 patients (82.5%) received medical treatment alone. On multivariate analysis, several variables, including early surgical intervention, improved long-term survival rates (hazard ratio, 1.5; ), mainly in patients with Staphylococcus aureus etiology ( ). When patients P p .03 P p .04 with prosthetic devices were excluded, the median duration of survival for patients who had early surgery was 1150 months, compared with 61.5 months for patients in the medical group ( ). Early surgical P p .1 intervention compared with medical therapy alone is associated with increased short- and long-term survival rates in patients with IE, primarily when IE is caused by S. aureus. In the era before antibiotics, infective endocarditis (IE) was always fatal. More than 50 years after the introduction of antibiotic therapy, and more than 30 years after the first successful valve replacement, the reported early mortality rate of IE remains considerable (14%‐ 31%), and late mortality rates after 5-year follow-up range from 25% to 60% [1‐4]. Only a few large series on the long-term outcome of patients with IE have been reported, and even fewer have studied the impact of early surgery on long-term outcome [1, 5‐16]. The purposes of the present study were to determine long-term survival rates after an episode of IE, to delineate risk factors for mortality, and to focus on the impact of surgery performed during the active phase of IE on the long-term survival rate.

Idebenone, a synthetic analogue of coenzyme Q10, has been shown to improve cardiac function in patients with Friedreich ataxia and a deficiency of respiratory chain complexes I-III. We describe a woman with severe combined right and left heart failure due to a mitochondrial cardiomyopathy. The patient underwent an endomyocardial biopsy as part of an evaluation for cardiac transplantation. It showed severely decreased respiratory complex activities dependent on CoQ, pointing to CoQ depletion. Following idebenone treatment there was a dramatic improvement in her clinical status with resolution of the heart failure.

Mitral regurgitation (MR) complicating acute myocardial infarction (AMI) is associated with increased mortality. The prognostic significance of only mild MR detected by echocardiography in patients with AMI is unknown. This study assessed the long-term risk associated with mild MR detected by color Doppler echocardiography within the first 48 hours of admission in 417 consecutive patients with AMI. No MR was detected in 271 patients (65%), mild MR was seen in 121 patients (29%), and moderate or severe MR was noted in 25 patients (6%). One-year mortality rates were 4.8%, 12.4%, and 24%, respectively (p0.001). Multivariate analysis revealed that mild MR was independently associated with increased 1-year mortality (p0.05) after adjustment for age, gender, previous myocardial infarction, diabetes mellitus, systemic hypertension, Killip gradeor =2 on admission, and left ventricular ejection fractionor =40%. The hazard ratio for 1-year mortality was 2.31 (95% confidence interval 1.03 to 5.20) for mild MR and 2.85 (95% confidence interval 0.95 to 8.51) for moderate or severe MR. Thus, mild MR detected by color Doppler echocardiography within the first 2 days of admission in patients with AMI is a significant independent risk predictor for 1-year all-cause mortality.

We correlated ST elevation in various leads on admission and regional dysfunction in 132 patient with first anterior acute myocardial infarction using echocardiography. ST elevation in leads I and a VL and II, III and aVF was not associated with a specific pattern of regional dysfunction. Basal anterior and septal regional dysfunction were seen more often in patients with ST elevation in V1 (49 vs. 25%, p = 0.006; 35 vs. 17%, p = 0.048, respectively). Patients with ST elevation in V2 had more regional dysfunction of the apical inferior region (84 vs. 53%; p = 0.01). ST elevation in V5 and V6 was not associated with more apical or lateral wall motion abnormalities. ST elevation in lead V1 in anterior myocardial infarction is associated with a high incidence of regional dysfunction of the basal anterior, anteroseptal and septal regions.

Because of the increasing number of renal transplantations performed and the rarity of reported cases of infective endocarditis in these patients, we studied the clinical characteristics of this infection in this population. We report on two cases from our experience and review reported cases of infective endocarditis in renal transplant recipients retrieved from the MEDLINE system. In addition, we reviewed a large series of infective endocarditis looking for patients with renal transplants. In addition to our 2 cases, 12 previously reported cases were found. The mean time from transplantation to diagnosis of infective endocarditis was 3.5 years (range 2 months to 15 years). Causative organisms included fungi, Staphylococcus aureus (3 cases each), Corynebacterium sp. (2 cases), Streptococcus viridans, VRE, Brucella sp., Clostridium sp., Nocardia sp. and Erysipelothrix sp. (one case each). Skin manifestations of endocarditis and/or splenomegaly were not reported in these patients. Septic emboli and mycotic aneurysms were relatively common. The overall mortality rate was 50% (7 of 14 patients died). Infective endocarditis seems to be rare in renal transplant recipients. The few reported cases are characterized by unusual causative micro-organisms and atypical clinical presentation. Further studies are needed to delineate the magnitude and scope of this association.

Background Thrombosis of a mechanical tricuspid valve prosthesis is a potentially hazardous event. This study aimed to explore the incidence and the clinical presentation of tricuspid valve thrombosis occurring in bileaflet valves and to evaluate the diagnostic and the therapeutic approach. Methods and Results Tricuspid valve thrombosis was sought in 22 late survivors with the CarboMedics valve in a follow-up period of 36.0 ± 20.8 months. Limited leaflet motion and/or a visible thrombus were considered diagnostic of valve thrombosis. Eight episodes of tricuspid valve thrombosis were diagnosed among 5 patients (12.1 episodes per 100 patient-years). Anticoagulation was inadequate in 3 patients and fair in 2. Florid right heart failure occurred in 3 episodes. Common physical findings included increased jugular venous pulse (5 patients), diastolic tricuspid murmur (4 patients), and peripheral edema (4 patients). The diagnosis was suspected in all clinically and by transthoracic echocardiography and confirmed by fluoroscopy and/or transesophageal echocardiography. In 4 patients, both leaflets were involved. No thrombi were visualized. Three patients received thrombolytic therapy in 4 episodes (complete success in 3, partial success in 1) without hemorrhagic or embolic complications. One patient responded to aggressive anticoagulant therapy. One patient required an emergent repeat surgery. In 1 patient, valve thrombosis recurred thrice. Conclusions In patients with fair or poor anticoagulation, a bileaflet valve in the tricuspid position is associated with a high incidence of valve thrombosis. Hinge entrapment requires only a small amount of thrombotic material. Valve thrombosis may be asymptomatic. Involvement of both leaflets is usually required to produce symptoms. A nonsurgical approach (thrombolysis or intensified anticoagulation) is usually successful. Patients should be instructed about heralding signs of valve thrombosis. (Am Heart J 1999;137:721-5.)

This study tests the hypothesis that mitral annular calcium (MAC) detected by transthoracic echocardlography (TTE) is a marker for high prevalence and severity of coronary artery disease (CAD) in patients undergoing coronary angiography. Pathological studies have suggested that there is an association between MAC and calcific deposits in coronary arteries; however, there are no clinical data to support this association. One hundred sixty-five patients with MAC (101 women and 64 men; mean age 71 ± 8 years) who underwent cardiac catheterization with coronary angiography for various reasons were compared with 147 age-matched controls without MAC who underwent coronary angiography for the same indications during the same period. MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet detected by TTE. Obstructive CAD was defined as either ≥50% reduction of the internal diameter of the left main coronary artery or ≥70% reduction of the internal diameter of the left anterior descending, right coronary, or left circumflex artery distribution. Compared with controls, the MAC group had a significantly higher prevalence of CAD (89% vs 75%, p = 0.001) and higher rates of 3-vessel disease (45% vs 24%, p = 0.001) and left main CAD (13% vs 5%, p = 0.009). Nonsignificant CAD was more common in the control group (25% vs 11%, p = 0.001). Multivariate analysis identified MAC (p = 0.0002), indications for cardiac angiography (p = 0.02), sex (p = 0.03), and diabetes mellitus (p = 0.03) as independent predictors for the presence and severity of obstructive CAD. MAC detected by TTE may be a marker for high prevalence and severity of CAD in patients undergoing coronary angiography.

Background —In hypertrophic cardiomyopathy, a spectrum of mitral leaflet abnormalities has been related to the mechanism of mitral systolic anterior motion (SAM), which causes both subaortic obstruction and mitral regurgitation. In the individual patient, SAM and regurgitation vary in parallel; clinically, however, great interindividual differences in mitral regurgitation can occur for comparable degrees of SAM. We hypothesized that these differences relate to variations in posterior leaflet length and mobility, restricting its ability to follow the anterior leaflet (participate in SAM) and coapt effectively. Methods and Results —Different mitral geometries produced surgically in porcine valves were studied in vitro. Comparable degrees of SAM resulted in more severe mitral regurgitation for geometries characterized by limited posterior leaflet excursion. Mitral geometry was also analyzed in 23 patients with hypertrophic cardiomyopathy by intraoperative transesophageal echocardiography. All had typical anterior leaflet SAM with significant outflow tract gradients but considerably more variable mitral regurgitation; therefore, regurgitation did not correlate with obstruction. In contrast, mitral regurgitation correlated inversely with the length over which the leaflets coapted ( r =−0.89), the most severe regurgitation occurring with a visible gap. Regurgitation increased with increasing mismatch of anterior to posterior leaflet length ( r =0.77) and decreasing posterior leaflet mobility ( r =−0.79). Conclusions —SAM produces greater mitral regurgitation if the posterior leaflet is limited in its ability to move anteriorly, participate in SAM, and coapt effectively. This can explain interindividual differences in regurgitation for comparable degrees of SAM. Thus, the spectrum of leaflet length and mobility that affects subaortic obstruction also influences mitral regurgitation in patients with SAM.

Although aortic root dilation has etiologic and prognostic significance in patients with chronic aortic regurgitation (AR), no information is available regarding changes over time in aortic root size in patients with the entire spectrum of AR severity or how such changes relate to progression of the AR or to left ventricular (LV) overload. To analyze this, a total of 127 patients with chronic AR who had more than 6 months of follow-up by two-dimensional and Doppler echocardiography were included in the study (69 men and 58 women; mean age 59.3 +/- 21.2 years [range 14 to 94 years]; 67 cases of mild, 45 moderate, 15 severe, and 21 bicuspid aortic valve disease). The aortic anulus, sinuses of Valsalva, supraaortic ridge, and ascending aorta were measured in the parasternal long-axis view, LV volumes were calculated (biplane Simpson's approach), and the severity of AR was quantified based on proximal jet size and graded according to an algorithm that takes into account major color Doppler criteria. At entry to the study, significant differences between patients with mild, moderate, and severe AR were noted only in supraaortic ridge size (1.46 +/- 0.29 cm/m2 vs 1.63 +/- 0.33 cm/m2 [p0.006]; vs 1.67 +/- 0.43 cm/m2 [p0.03]). A significant increase in aortic root size at all levels was observed during the follow-up period in all three groups of severity of AR. The rate of change of the supraaortic ridge, the upper support structure of the anulus and cusps, was faster in patients with more severe degrees of AR (p = 0.013); this was not the case at the other aortic levels. No differences were observed in aortic root size or rate of progression between patients with bicuspid or tricuspid aortic valves. Patients were considered "progressive" if they lay on the steepest positive segment of the curve representing the rank order in the rate of aortic root progression. Compared with "nonprogressive" patients, patients who were progressive in supraaortic ridge size (rate0.12 cm/yr; n = 23) had a faster rate of progression in the degree of regurgitation as assessed by the regurgitant jet area/LV outflow tract area ratio measured in the parasternal short-axis view (0.48 +/- 0.45 vs 0.24 +/- 0.5/yr; p0.03) and a foster rate of progression of LV end-diastolic volume (30 +/- 22.8 vs 14.4 +/- 15.6 ml/yr; p0.0002) and LV mass (70.8 +/- 74.4 vs 16.8 +/- 19.2 gm/yr; p0.0004). In conclusion, there is progressive dilation of the aortic root at all levels, even in patients with mild AR. More rapid progression in aortic root size is associated with more rapid progression of the underlying aortic insufficiency, as well as more rapid increases in LV volume and mass.

Objectives. This study assessed prospectively the correlation between the conal branch of the right coronary artery and the pattern of ST segment elevation in leads V1and V3R during anterior wall acute myocardial infarction (AMI).Background. The traditional electrocardiographic (ECG) definition of anteroseptal AMI—ST segment elevation in leads V1to V3—has recently been challenged. The significance of ST segment elevation in lead V1during anterior wall AMI is unclear.Methods. The admission 12-lead ECG with additional lead V3R and the coronary angiograms performed within 10 days of hospital admission were evaluated in 28 consecutive patients (mean age ± SD 62 ± 9 years) admitted to the coronary care unit with anterior wall AMI. Patients were classified into two groups according to the magnitude of ST segment elevation in lead V1: group A (elevation ≥1.5 mm, n = 12) and group B (elevation

Objectives: This study sought to explore the frequency and prognostic implications of infectious and noninfectious fever following transcatheter aortic valve implantation (TAVI). Methods: We performed a retrospective cohort study including 194 consecutive patients who underwent TAVI at our institution. We identified and characterized all patients who developed fever within the first 72 h following the procedure. We determined the etiology of the fevers (infectious vs. noninfectious) and assessed their impact on in-hospital complications and 1-year mortality. Results: Following TAVI, 65 (33.5%) patients had fever (mean age 83.7 ± 3.8 years, 70.2% female). An infectious etiology was evident in only 17 of the 65 patients (26.1%) with fever, mainly due to pneumonia (52.9%) and a urinary tract infection (41.2%). No significant difference was observed in baseline characteristics, the mean fever temperature/duration, or signs of inflammatory response between infectious and noninfectious fevers. The mean hospital duration was longer (7 ± 4.8 days vs. 4.7 ± 2.4 days, p = 0.01) among patients with an infectious fever; however, fever had no impact on the 1-year mortality rate (5.9 and 4.5%, respectively, p = 0.71). Conclusions: Our study demonstrates that, although fever was a common phenomenon after TAVI, it represented an infectious complication only in a minority of cases. Nevertheless, fever, infectious or not, had no impact on the 1-year mortality rate following TAVI.

Objective: Transcatheter aortic valve implantation (TAVI) is occasionally associated with stroke and silent cerebral ischemia, which may affect cognitive and functional performance. The aim of this study was to evaluate the changes in cognitive performance and functional status following TAVI. Methods: We performed a comprehensive prospective functional, cognitive and quality of life (QOL) evaluation in consecutive patients who underwent TAVI using the CoreValve device (Medtronic Inc.). The evaluation was performed at baseline and 1 month after the procedure and included the 36-item Short-Form Health Survey for QOL assessment, Mini-Mental State Examination (MMSE), quantitative clock drawing test (Rouleau), color trails test, Cognistat evaluation, Barthel Index and Duke Activity Status Index. Results: A total of 36 patients completed the full pre- and post-TAVI evaluation. Mean age was 82.2 ± 4.2 years (52.8% men); 94.5% of patients had low functional class (New York Heart Association III/IV), and 13.9% had prior stroke. After the procedure, all patients had improved functional status and valve hemodynamics. At 1 month, there was a significant improvement in the MMSE and Cognistat evaluations (from 25.9 ± 3.3 to 27.6 ± 2.4, p < 0.001, and from 5 ± 1 to 5.7 ± 0.7, p = 0.001, respectively). Conclusions: Our preliminary results of a comprehensive assessment of patients undergoing TAVI indicate favorable results for both functional performance and cognitive function early after the procedure.

Replacement of the aortic valve for moderate aortic regurgitation (AR) as an adjunct to another cardiac surgery, primarily for coronary artery bypass grafting (CABG) or mitral valve replacement or repair, remains the subject of much debate. The study aim was to monitor the progression rate of moderate AR by means of echocardiography, and to reveal the need for future surgical intervention.A total of 262 consecutive patients (162 males, 100 females; mean age 65 +/- 15 years; range: 21-93 years) with moderate AR and no more than mild aortic stenosis, were followed for a mean of 42 +/- 31 months. AR resulted from disease of the aortic leaflets in 145 patients (55%) and was secondary to dilatation of the aortic root in 70 patients (27%). The cause of AR could not be determined in 47 patients (18%).Progression to severe AR occurred in 18 patients (6.9%), an average progression rate of 1.9% per year. Patients in whom the main pathology was aortic dilatation had a significantly higher rate of progression to severe AR (9/70; 3.7%/year) compared to those with leaflet pathology (7/145; 1.4%/year, p0.03). Only three patients were referred for aortic valve replacement during follow up (yearly rate 0.3%); all of these patients had aortic dilatation as the cause of AR. In total, 26 patients (9.9%) died during the follow up, representing an annual all-cause mortality rate of 2.8%.In the face of a slow progression and a low event rate, there is no support for 'prophylactic' valve replacement in patients with moderate AR who have been referred for CABG or mitral valve surgery.

Objectives.The purpose of this study was to determine, in a large referral population, the rate of echocardiographic change in mitral valve area (MVA) without interim intervention, to determine which factors influence progression of narrowing and to examine associated changes in the right side of the heart.Background.Little information is currently available on the echocardiographic progression of mitral stenosis, particularly on progressive changes in the right side of the heart and the ability of a previously proposed algorithm to predict progression.Methods.We studied 103 patients (mean age 61 years; 74% female) with serial two-dimensional and Doppler echocardiography. The average interval between entry and most recent follow-up study was 3.3 ± 2 years (range 1 to 11).Results.During the follow-up period, MVA decreased at a mean rate of 0.09 cm2/year. In 28 patients there was no decrease, in 40 there was only relatively little change (

Objectives.Using two-dimensional echocardiography, we sought to identify features that are associated with severe mitral regurgitation after percutaneous mitral valvulotomy and combine them into a predictive score.Background.Severe mitral regurgitation after percutaneous mitral valvulotomy is a major complication carrying an adverse prognosis that, to date, has not been predictable in advance.Methods.In a consecutive series of 566 patients who underwent percutaneous mitral valvulotomy, 37 (6.5%) developed severe mitral regurgitation (assessed by angiography) after the procedure, 31 of whom had an echocardiogram available before percutaneous mitral valvulotomy. These 31 patients were matched by age, gender, mitral valve area and degree of mitral regurgitation before valvulotomy with 31 randomly selected patients who did not develop severe mitral regurgitation after percutaneous mitral valvulotomy. An echocardiographic score was developed on the basis of the pathologic studies of valves of patients who developed severe regurgitation after percutaneous mitral valvulotomy (leaflet rupture of relatively thin portions of nonhomogeneously thickened leaflets in the presence of commissural and subvalvular calcification) and evaluated uneven distribution of thickness in the anterior and posterior mitral leaflets, degree of commissural disease and subvalvular disease involvement, with each component graded from 0 to 4 (total, 0 to 16). Intraobserver and interobserver variability for score assessment were 6% and 7%, respectively.Results.The total mitral regurgitation echocardiographic score was significantly greater in the severe mitral regurgitation group (11.7 ± 1.9 [mean ±SD] vs. 8.0 ± 1.2, p < 0.001). In addition, the component grades for the anterior leaflet (3.2 ± 0.7 vs. 2.3 ± 0.6, p < 0.001), commissures (2.6 ± 0.7 vs. 1.6 ± 0.6, p < 0.001) and subvalvular apparatus (3.2 ± 0.6 vs. 2.3 ± 0.7, p < 0.001) were also higher in the mitral regurgitation group. With a total score ≥10 as a cutoff point for predicting severe mitral regurgitation after percutaneous mitral valvulotomy, a sensitivity of 90 ± 5% and a specificity of 97 ± 3% were obtained. Stepwise logistic regression analysis identified the mitral regurgitation echocardiographic score as the only independent predictor for developing severe mitral regurgitation after percutaneous mitral valvulotomy (p < 0.0001).Conclusions.This new mitral regurgitation echocardiographic score can predict the development of severe mitral regurgitation after percutaneous mitral valvulotomy and can be useful in the selection of patients for this technique.

Patient gender can affect not only the clinical manifestations of coronary artery disease (CAD) but also the clinician's interpretation of the symptoms and results of exercise stress tests for management decisions. This may be true also for aortic stenosis (AS), given its many shared features with CAD and similar symptom-based management. The study aim was to evaluate the effect of gender on the assessment of severe asymptomatic AS by exercise stress echocardiography (ESE).A total of 160 patients (89 males, 71 females) with severe asymptomatic AS and good left ventricular function underwent ESE for assessment of their clinical status. Of these patients, 133 (83%) were followed up after echocardiography for a mean of 644 +/- 467 days. The findings and outcome were compared between males and females.No gender-related differences were identified for mean age, baseline and peak exercise heart rates and blood pressures, aortic valve area, and prevalence of CAD. Female patients had a lower exercise capacity (shorter exercise time, lower exercise load), but there were no significant between-group differences in the exercise-related parameters defining AS. In total, 38 women (24%) and 45 men (28%) were treated by aortic valve replacement (p = 0.2) within a similar time range from echocardiography (p = 0.6).Asymptomatic women with severe AS have similar rates of abnormal ESE as men, despite limitations in exercise capacity among women compared to men.

A total of 318 consecutive patients with mitral stenosis underwent percutaneous mitral valvotomy at our institution from 1987 to 1993. Of those, 98 patients had color Doppler echocardiographic studies performed before, 24 hours after, and late after the intervention. On the basis of color Doppler echocardiographic grading of tricuspid regurgitation, 32 patients (32%; mean age 57 +/- 15 years) had significant (moderate or severe) tricuspid regurgitation before the intervention and were the subject of this study. The follow-up study was performed 18.4 +/- 13 months after the procedure. Successful percutaneous mitral valvotomy (> or = 1.5 cm2 valve area or > or = 50% increase after valvotomy) with no restenosis at follow-up was achieved in 20 patients. Tricuspid regurgitation decreased by one grade (from severe to moderate) in only four subjects in this group and in none of the 12 patients who did not meet the criteria for successful percutaneous mitral valvotomy or who had restenosis. Thus tricuspid regurgitation did not improve in 88% of all patients studied. On average, no significant change was observed in the ratio of maximal tricuspid regurgitant jet area to right atrial area 24 hours after percutaneous mitral valvotomy and at late follow-up (37% vs .33% vs 34%, respectively) or in any of the right heart dimensions, even in patients who underwent successful percutaneous mitral valvotomy. Right ventricular systolic pressure also did not change significantly on average in those patients (46 +/- 15 versus 42 +/- 14 versus 48 +/- 18 mm Hg, respectively). However, right ventricular dimensions did not decrease and tricuspid regurgitation did not resolve even in a subgroup of patients in whom right ventricular systolic pressure fell by more than 10 mm Hg (up to 41 mm Hg).

Objectives, This study examined the association between the presence of tricuspid regurgitation and immediate and late adverse outcomes in patients undergoing balloon mitral valvuloplasty. Background. Significant tricuspid regurgitation has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery for mitral stenosis. Methods. We studied 318 consecutive patients (mean [± SD] age 54 ± 15 years) who underwent ballon mitral valvuloplasty and had color Doppler ecnocardiographic studies before the procedure. Patients were classified into three groups: 221 with no or mild (69%), 60 with moderate (19%) and 37 with severe (12%) tricuspid regurgitation. Clinical follow-up ranged from 6 to 62 months. Results. Before mitral valvuloplasty, increasing degrees of tricuspid regurgitation were associated with a smaller initial mitral valve area (p < 0.05), higher echocardiographic score (p < 0.05), lower cardiac output (p < 0.01) and higher pulmonary vascular resistance (p < 0.01). Although the initial success rate did not differ significantly between groups, patients with a higher degree of tricuspid regurgitation had less optimal results, as reflected by a smaller absolute increase in mitral valve area (1.02 vs. 0.9 vs. 0.7 cm2, p < 0.01). The estimated 4-year event-free survival rate (freedom from death, mitral valve surgery, repeat valvuloplasty and heart failure) was lower for the group with severe tricuspid regurgitation (68% vs. 58% vs. 35%, p < 0.0001). At 4 years, 94% of patients with mild tricuspid regurgitation were alive compared with 90% and 69%, respectively, of patients with moderate or severe tricuspid regurgitation (p < 0.0001). Cox proportional analysis identified tricuspid regurgitation as an independent predictor of late outcome (p < 0.001). Conclusions. Patients with mitral stenosis and severe tricuspid regurgitation undergoing mitral valvuloplasty have advanced mitral valve and pulmonary vascular disease, suboptimal immediate results and poor late outcome.

Objectives. The aim of this study was to investigate the association between the pattern of incomplete tricuspid valve closure and the presence of tricuspid regurgitation and to identify factors that determine the severity of regurgitation associated with this pattern. Background. The incomplete tricuspid valve closure pttern (defined as apical displacement of the leaflets) has been described by two-dimensional echocardiography. However, whether this pattern is universally associated with tricuspid regurgitation and the determinants of severity of regurgitation in its presence have not been studied by Doppler color flow mapping. Methods. We identified 109 consecutive patients (mean age 62 ± 17 years) with incomplete tricuspid valve closure who were studied by Doppler color flow mapping. We measured the linear apical displacement of the coaptation point from the tricuspid annulus and the area of displacement between the leaflets and annulus. Right atrial, ventricular and annular dimensions were measured and compared with those in a group of normal subjects. Results. Tricuspid regurgitation was present in all ptients with the incomplete closure pattern; it was mild in 14%, moderate in 19% and severe in 67%. Apical displacement was significantly greater (p < 0.02) in those with severe regurgitation than in those with mild regurgitation or in normal subjects. Tricuspid annulus dilation was the only independent predictor of severity of regurgitation. The right ventricle was not significantly dilated in 32% of patients, and right ventricular systolic pressure was not correlated with the severity of regurgitation and was

The prevalence of aortic stenosis increases with advancing age. Once symptoms occur the prognosis in patients with severe aortic stenosis is poor. The current and recommended treatment of choice for these patients is surgical aortic valve replacement. However, many patients, mainly the very elderly and those with major comorbidities, are considered to be at high surgical risk and are therefore denied treatment. Recently, a transcatheter alternative to surgical AVR has emerged.To describe the first year experience and 30 day outcome of transcatheter aortic self-expandable CoreValve implantation in Israel.Transcatheter aortic valve implantation using the CoreValve system has been performed in Israel since September 2008. In the following year 55 patients underwent CoreValve TAVI in four Israeli centers.Patients' mean age was 81.7 +/- 7.1 years; there were 35 females and 20 males. The mean valve area by echocardiogram was 0.63 +/- 0.16 cm2. The calculated mean logistic Euroscore was 19.3 +/- 8%. Following TAVI, mean transvalvular gradient decreased from baseline levels of 51 +/- 13 to 9 +/- 3 mmHg. The rate of procedural success was 98%. One patient died on the first day post-procedure (1.8%) and all-cause 30 day mortality was 5.5% (3 of 55 patients). One patient had a significant post-procedural aortic regurgitation ofgrade 2. Symptomatic improvement was evident in most patients, with reduction in functional capacity grade from 3.2 +/- 0.6 at baseline to 1.4 +/- 0.7. The most common post-procedural complication was complete heart block, which necessitated permanent pacemaker implantation in 37% of patients.The Israeli first year experience of transcatheter aortic valve implantation using the CoreValve self-expandable system demonstrates an effective and safe procedure for the treatment of severe aortic stenosis in patients at high surgical risk.

Patients with isolated systolic hypertension are at increased risk for cardiovascular disorders. We attempted to determine whether those with borderline isolated systolic hypertension (defined as a systolic blood pressure of 140 to 159 mm Hg and a diastolic blood pressure below 90 mm Hg) have a greater risk of progression to definite (more severe) hypertension and of major morbid or fatal events than people with normal blood pressure (140/90 mm Hg).A total of 2767 of the original participants in the Framingham Heart Study were monitored with biennial examinations for up to 34 years for the development of definite hypertension (defined as a systolic blood pressure ofor = 160 mm Hg, a diastolic blood pressure ofor = 90 mm Hg, or the initiation of antihypertensive therapy) and for major cardiovascular events.Borderline isolated systolic hypertension was the most common type of untreated hypertension among adults over the age of 60. After 20 years of follow-up, 80 percent of those with borderline isolated systolic hypertension had progression to definite hypertension, as compared with 45 percent of the normotensive participants (P0.001). After adjustment for age, sex, and risk factors for cardiovascular disease, participants with borderline isolated systolic hypertension had an excess long-term risk of cardiovascular disease (hazard ratio, 1.47; 95 percent confidence interval, 1.24 to 1.74) and death from cardiovascular disease (hazard ratio, 1.57; 95 percent confidence interval, 1.24 to 2.00), as compared with normotensive participants. In an analysis of pooled data from biennial examinations to study short-term sequelae, subjects with borderline isolated systolic hypertension had an increased risk of progression to definite hypertension (odds ratio, 3.84; 95 percent confidence interval, 3.35 to 4.41) and of cardiovascular disease (odds ratio, 1.39; 95 percent confidence interval, 1.06 to 1.82).In both the short term and the long term, subjects with borderline isolated systolic hypertension are at increased risk of progression to definite hypertension and the development of cardiovascular disease.

Congestive heart failure increases in prevalence with age. A large number of elderly subjects with heart failure have either normal or slightly reduced left ventricular (LV) systolic function; their symptoms are due to diastolic LV dysfunction. Reference values for Doppler indexes of LV diastolic filling in a large sample of the very elderly (>70) have not been reported previously. The objective of this study was to generate reference values for Doppler indexes of LV filling in a population of apparently healthy elderly men and women. A total of 1201 surviving original subjects of the Framingham Heart Study were evaluated by Doppler echocardiography. A subset of 114 rigorously selected healthy subjects (26 men and 88 women) aged 70 to 87 years (mean 76) constituted the study group. Measurements of seven commonly used Doppler indexes were obtained. Mean and 2.5, 5, 10, 25, 50, 75, 90, 95, and 97.5 percentile values for Doppler diastolic indexes were generated. Stepwise regression analyses were performed to determine the relation of diastolic LV filling to age group (70 to 74 years, 75 to 79 years, and 80 years and over), sex, and other clinical variables. Reference values for the various Doppler parameters were generated on the basis of this healthy elderly cohort. There was evidence for a slight progressive decline in indexes of LV inflow with age. In 87% of this elderly population the ratio of peak early to late velocities of LV diastolic inflow was less than 1.0. Although there were trends toward augmentation of atrial contribution to ventricular filling with advancing age, only peak velocity of late filling (56 vs 62 cm, P = 0.005) changed significantly with age. The present study extends our knowledge of Doppler LV filling patterns in the elderly and documents a minor degree of further impairment in indexes of LV filling with advancing age. The availability of reference Doppler values may prove useful for the identification of LV diastolic dysfunction, which is an important cause of congestive heart failure in the elderly.

Abnormalities in left ventricular (LV) structure and function have been shown in patients with diastolic hypertension and recently in subjects with isolated systolic hypertension. The purpose of this study was to determine whether abnormalities of cardiac structure or function are present in elderly subjects with borderline isolated systolic hypertension (defined as systolic blood pressure [BP] between 140 and 159 mm Hg, and diastolic BP90 mm Hg). Ninety-one subjects (mean age 77 years) from the original Framingham Heart Study with untreated borderline isolated systolic hypertension, who were free of cardiovascular disease, were compared with 139 normotensive (BP140/90 mm Hg) subjects (mean age 76 years). Measurements included M-mode values for LV structure, and 6 Doppler indexes of LV diastolic filling. Subjects with borderline isolated systolic hypertension and the control group differed in mean systolic (147 vs 125 mm Hg) and diastolic (76 vs 70 mm Hg) BP. Borderline systolic hypertension was the most frequent form of untreated hypertension in this elderly group. The sum of LV wall thicknesses (septum+posterior wall) was significantly higher in borderline hypertensive subjects than in normotensive ones (20.5 vs 19.7 mm; p = 0.002). No difference was detected in LV internal dimension or systolic function. After adjustment for age and other clinical variables, comparisons between the groups revealed significant differences in indexes of Doppler diastolic filling. Peak velocity of early filling, and the ratio of early to late peak velocities were lower in the hypertensive group (40 vs 44 cm/s [p = 0.03] and 0.69 vs 0.76 [p = 0.01], respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Four patients with no known predisposing conditions developed tricuspid valve endocarditis. All patients had community-acquired infection with a rapidly progressive course that was complicated by right heart failure and respiratory insufficiency. Pulmonary involvement was prominent in all cases. The infectious process was due to Staphylococcus aureus in three patients and to Streptococcus intermedius in one patient. Three patients underwent early surgical intervention; the outcome was favourable in all cases. It is clear that tricuspid valve endocarditis can occur in the absence of known predisposing factors, and when Staphylococcus aureus is involved, the course of the disease may be acute and rapidly progressive.