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Over the past decade, our concept of the pathogenesis of calcific aortic valve disease has undergone a major transformation. We now recognise that calcific valve disease is the end stage [...]

Aortic valve disease is increasingly common. Aortic stenosis and insufficiency are reviewed in this article. The epidemiology, pathophysiology, clinical presentation and evaluation of each disorder is discussed. Additionally, the management, including medical therapy and the timing of surgery, is reviewed. History, exam, and echocardiographic features of each disorder are described, as is appropriate decision making based on those findings. Selected literature is discussed. There is a specific focus on providing a stepwise approach to the evaluation and management of patients with aortic stenosis or aortic insufficiency.

Objective: This study investigated the sensitivity of 3-dimensional (3D) midwall ejection fraction (EF) (3DEF"m"w) to the presence of left ventricular (LV) hypertrophy (LVH) in comparison with conventional echocardiographic indices for systolic function. Background: EF and fractional shortening (FS) do not reflect the prognosis of patients with LVH. Midwall mechanics better represent the true function in LVH. However, midwall FS (FS"m"w) interrogates a limited region of LV. We developed a method for determining 3DEF"m"w. Methods: This study compared 3DEF"m"w with 2-dimensional (endocardial EF [EF"e"n"d"o], endocardial FS, FS"m"w, and systolic tissue velocity) and 3D (3D EF"e"n"d"o and mitral annular motion [MAM]) echocardiographic indices in 28 patients with essential hypertension and LV mass index by M-mode greater than 125 g/m^2 versus 21 healthy individuals. Results: Systolic function assessed by EF"e"n"d"o, endocardial FS, 3D EF"e"n"d"o, and systolic tissue velocity did not differ between the two groups, but MAM (11.6 vs 14.0 mm), FS"m"w (14.7 vs 18.2%), and 3DEF"m"w (36.6 vs 44.1%) were significantly decreased in LVH compared with normal. Only 3 parameters correlated significantly with both the M-mode and 3D measurements of LV mass index: FS"m"w (r = -0.74 [M-mode]; r = -0.48 [3D]), 3DEF"m"w (r = -0.63 [M-mode]; r = -0.68 [3D]), and MAM (r = -0.43 [M-mode]; r = -0.36 [3D]). Midwall indices FS"m"w (F = 40.4) and 3DEF"m"w (F = 26.5) better discriminated LVH and normal groups than MAM or endocardial indices. Conclusions: The 3DEF"m"w method discriminates the systolic function of LVH and normal groups, and correlates with the degree of hypertrophy. By avoiding the limitations of FS"m"w or MAM, 3DEF"m"w provides a more comprehensive metric of systolic function in patients with LVH. .

Valvular aortic stenosis, defined as obstruction to left ventricular (LV) outflow, is most commonly caused by calcific degeneration of a trileaflet or congenitally bicuspid valve. It is present in 1-2% of adults over the age of 65 years. Rheumatic aortic stenosis is common in developing countries but less common in Europe and the USA and invariably associated with mitral disease. Almost 30,000 aortic valve replacements were performed in the UK in 1986-1995; 3.7% were in patients aged over 80 years. Mild, irregular valve thickening without obstruction to ventricular outflow (so-called aortic sclerosis) is present in about 25% of elderly individuals.

Ten phantoms were scanned with a multiplane transesophageal echocardiographic probe in a water bath to assess a new method for three-dimensional modeling of the mitral annulus. The annulus was reconstructed from manually outlined borders with Fourier series in each of the three spatial coordinates. Comparisons with direct measurements by least-squares linear regression gave coefficients of determination of 0.99 for annular height, area, and circumference. Expressed as a percentage of their true values, the mean +/- SD of the errors were -0.1% +/- 3.0% for annular height, -2.8% +/- 3.1% for area, and -0.2% +/- 1.7% for circumference. The mean residual error length for phantoms was 0.64 mm compared with 1.21 mm in nine patients studied during general anesthesia. This method gives accurate and precise measurements of the mitral annulus in vitro and should be valuable for studying its morphology and dynamics in vivo.

The objective of this study was to develop and validate a three-dimensional technique of left ventricular shape analysis. Geometric phantoms and left ventricles of excised calf hearts, normal human subjects, and one subject each with aortic stenosis and dilated cardiomyopathy were reconstructed from three-dimensional echocardiograms. The fit between the reconstructions and true surfaces of the geometric phantoms and excised ventricles was determined. To evaluate in vivo left ventricular shape, a center axis was constructed from the centroid of the mitral annulus to the furthest endocardial point. Regional shape was evaluated as the relative distances of 16 separate myocardial segments from the center axis compared with a population-derived mean value. Global shape was evaluated as the average standard deviation from the normal value over the 16 segments. The system precisely reproduced the shapes of the phantoms and excised left ventricles (root-mean-square error between true and reconstructed surface 1.0 0.2 mm and 1.2 0.8 mm, respectively). The in vivo shape analysis differentiated the pathological from normal left ventricles. (J Am Soc Echocardiogr 1998;11:761-9.)

Three-dimensional echocardiography has demonstrated superiority over two-dimensional techniques in the determination of left ventricular mass and volumes. We describe a technique based on a magnetic tracking system which provides rapid three-dimensional image acquisition from multiple acoustic windows. Interactive three-dimensional border tracing and reconstruction with a piecewise smooth subdivision model accurately reproduced phantom volume (calculated volume = 1.00 true volume - 0.6 ml, r = 1.000, standard error of the estimate = 1.3 ml), in vitro heart volume (calculated volume = 1.02 true volume - 1.3 ml, r = 1.000, standard error of the estimate = 0.4 ml), in vitro heart mass (calculated mass = 0.98 true mass + 1.4 gm, r = 0.998, standard error of the estimate = 2.5 gm), and in vivo stroke volume (calculated stroke volume = 1.18 Doppler stroke volume - 17.9 ml, r = 0.990, standard error of the estimate = 2.8 ml). The three-dimensional in vivo data sets, which include views from three acoustic windows, were acquired in less than 90 seconds. We conclude that this method of three-dimensional echocardiographic data acquisition and analysis overcomes limitations inherent in currently available systems. (J Am Soc Echocardiogr 1997;10:830-9.)

Am Heart J 1998;136: 940-2.

This case report describes the appearance of a new homogenous mass seen in the leftatrium on intraoperative transesophageal echocardiography after mitral valve repair. This ''mass'' was the inverted left atrial appendage. Echocardiographers need to recognize normal variants, such as an inverted left atrial appendage, to avoid misdiagnosis.