Because mitral valve competence after mitral valve reconstruction is awkward to assess during this procedure, we evaluated in this respect transesophageal color-coded Doppler echocardiography in 23 ...patients undergoing mitral valve reconstruction for severe mitral regurgitation. Transesophageal echocardiographic examinations were performed after induction of anesthesia but before sternotomy (baseline), after mitral valve repair before decannulation, and at sternal closure, all at similar mean aortic pressure and echocardiographic instrument settings. The degree of mitral regurgitation by transesophageal color Doppler flow mapping was visually quantified on a 5-point scale (0 to 4), pending the left atrial extent of the regurgitant jet. This was compared with the degree of mitral regurgitation by left ventricular cineangiography performed within several weeks after operation and also visually quantified on a 5-point scale (0 to 4), with use of the right anterior oblique projection. There was good correlation between the two methods (r = 0.83; p less than 0.001). We conclude that residual mitral regurgitation, as assessed by transesophageal color flow mapping in the operating room, highly correlates with the ultimate mitral regurgitation by cineangiography. Therefore transesophageal echocardiography can be helpful for evaluation of mitral valve competence during mitral valve reconstruction, and hence, in case of repair failure, allow valve replacement in the same surgical session, thus avoiding reoperation.
There is a wide array of recommendations for the management of anticoagulant therapy in patients with mechanical heart valves. The optimal intensity of vitamin K antagonists, management of patients ...during noncardiac surgery and use of anticoagulants during pregnancy are all ongoing matters of debate. In this review, we discuss the various studies on these topics and the different guidelines. Based on these, literature recommendations for daily clinical practice are formulated.
Estimation of the jugular venous pressure Hamer, J P M Hans; Pieper, P G Els; van den Brink, Renée B A
Nederlands tijdschrift voor geneeskunde,
2016, Letnik:
160
Journal Article
Estimation of jugular venous pressure (JVP) is valuable for the differentiation between dyspnoea of cardiac or pulmonary origin, and for determining the cause of oedema. JVP assessments are useful ...for evaluation of treatment of right ventricular failure. The correlation between non-invasive JVP and invasive measurement of the central venous pressure (CVP) is remarkably better than previously reported. Correlation between JVP - determined via the external jugular vein - and CVP is excellent when the outcomes are categorised into low, normal and elevated pressure. Optimal measurement configurations include: extended expiration (without Valsalva manoeuvre), and during ventricular diastole. In the literature, these measurement configurations concerning the respiratory cycle and cardiac cycle have not been applied uniformly. To investigate in detail the correlation between JVP and CVP, the methods need to be standardized, and tests performed simultaneously and correctly.
This prospective study was conducted to ascertain whether echocardiographic evaluation could provide more insight into the genesis of mitral regurgitation (MR) before surgery. All patients underwent ...preoperative transthoracic and transesophageal echocardiography. Nine centers participated in the ESMIR (Echocardiographic Selection of patients for Mitral valve Reconstruction) study and 350 patients were included. Compared with surgical findings, the percentage of functional abnormalities correctly predicted by both echo modalities was highest in patients with increased leaflet mobility (83% for transthoracic and 86% transesophageal echocardiography). In contrast, in normal leaflet mobility, the prediction was better by transthoracic than by transesophageal echocardiography (75% vs 64%). In patients with restricted leaflet mobility, the predictive value of both techniques was similar. The diagnostic yield of anatomic abnormalities of both echo techniques was similar, except for chordal rupture: a sensitivity by transesophageal echocardiography of 79% and by transthoracic echocardiography of 57% (p < 0.001). In general, the sensitivity of each echo technique for detecting anatomic abnormalities was <70%, except for annular dilatation, leaflet thickening, and chordal rupture. At surgery, the prevailing functional condition was increased leaflet mobility (42%). The conclusion is that both echo techniques provide adequate information regarding the functional condition of the mitral valve apparatus, notwithstanding limitations in assessing anatomic details. Transthoracic echocardiography appears to be sufficient for preoperative evaluation of MR.
This study determined the relative value of transthoracic and transesophageal color Doppler flow imaging to systolic flow patterns in the left atrium in different types of mechanical prostheses in ...the mitral valve. Thirty-nine patients were investigated. Based on clinical findings, 36 of 39 patients had normal prosthetic valve function. Seventeen patients were interrogated within a few days after surgery. Systolic regurgitant jets in the left atrium were absent in all patients by both transthoracic pulsed and color Doppler flow imaging. Using transthoracic continuous wave Doppler, however, jets were demonstrated in 8 of 39 patients (21%). Transesophageal color Doppler flow imaging demonstrated systolic regurgitant jets originating from the prosthesis in all patients. Tilting disc valves showed jets during the entire systole (closure and leakage backflow). Each type of prosthesis generated a specific jet pattern. Pathologic regurgitant jets were crescent-shaped, more extensive and turbulent than jets caused by normal closure and leakage backflow. Thus, transthoracic color Doppler flow imaging is not sensitive for detecting regurgitant jets in mechanical prostheses in the mitral valve. All mechanical prostheses show a specific jet pattern, which should be helpful when transesophageal echocardiography is used to identify pathologic backflow.
Doppler echocardiographic evaluation of the prosthetic valve function is usually performed at rest, although this situation is not representative for patients' daily activities. Therefore, a ...symptom-limited Master 2-step test was performed in 61 asymptomatic patients with normal left ventricular function. No adequate Doppler signals were obtained in 5 of 61 patients (8%) within 60 second after termination of exercise. In patients with aortic valve prostheses (n = 24), heart rate increased from 74 +/- 10 to 105 +/- 18 beats/min, the maximal instantaneous gradient from 44 (range 22 to 90) to 68 (range 28 to 165) mm Hg (r = 0.89) and the mean gradient from 24 (range 12 to 50) to 39 (range 18 to 100) mm Hg (r = 0.90). In 6 of 11 patients with a maximal flow velocity ratio between the left ventricular outflow tract and the aortic valve prosthesis less than or equal to 0.25, the mean gradient increased to a value greater than or equal to 50 mm Hg after exercise, whereas in patients with a ratio of greater than or equal to 0.25, this never occurred. In patients with mitral valve prostheses (n = 39), heart rate increased from 80 +/- 12 to 116 +/- 14 beats/min and mean gradient from 6 (range 3 to 10) to 14 (range 6 to 25) mm Hg (r = 0.59). The correlation of the mean diastolic pressure gradient after exercise with pressure half-time was 0.66. Systolic pulmonary artery pressure at rest and after exercise could be determined in 22 of 39 patients (56%) and increased from 34 (range 20 to 70) to 57 (range 35 to 110) mm Hg. It is concluded that the response to exercise can, to a large extent, be inferred from Doppler parameters at rest, particularly in patients with aortic valve prostheses. The clinical implication of the high gradients found in some asymptomatic patients in the present study should be elucidated by follow-up studies.
Mitral regurgitation is the second most frequent valvular heart disease. Echocardiography is the principal examination to determine severity, mechanism and hemodynamic consequences of mitral ...regurgitation and consequently contributes to the assessment and accurate timing of the best treatment strategy. To clarify clinical decision making in severe mitral regurgitation, this review will discuss the diagnostic work-up and treatment options according to the most recent guidelines. Mitral valve surgery, preferably repair, is indicated in symptomatic patients with severe, organic mitral regurgitation. Chronic, functional mitral regurgitation is often medically treated (including cardiac resynchronization therapy if indicated), however surgery (preferably annuloplasty) can be recommended. Percutaneous MitraClip-implantation may be considered as an alternative option in symptomatic patients with severe mitral regurgitation who are considered inoperable. At present, there is no consensus on the optimal care in asymptomatic patients with severe, organic mitral regurgitation and preserved left ventricular function. A prospective trial is highly needed to elucidate this best treatment strategy.
If patients being treated with anticoagulants need to undergo an operation then physicians need to consider whether to suspend the use of this medication or to allow its use to be continued. ...Suspending the use of anticoagulants increases the risk of thrombosis, whereas continued use may cause bleeding complications. No evidence-based scientific research has been carried out regarding best practice for the perioperative use of anticoagulants.Antithrombotic drugs are vitamin K antagonists and platelet aggregation inhibitors. For daily practice, appropriate bridging strategies can be used for perioperative anticoagulant policy for various risk groups, such as patients with venous thromboembolism, atrial fibrillations, mechanical heart valves and coronary heart diseases (including coronary stents) and patients who have experienced a cerebrovascular accident. In the vast majority of cases the treating physician must carefully consider each individual case in order to realise the best policy.
A total of 8-10 million persons are infected worldwide with Trypanosoma cruzi, the causative parasite of Chagas disease, most of whom are inhabitants of Latin America. Due to the increased migration ...of peoples, Chagas disease has been on the uprise outside Latin America, including in Europe. The course of Chagas, also called American trypanosomiasis, runs in 2 phases: an acute phase lasting approximately 2 months, and a chronic phase in which symptoms may appear years after infection. Without treatment, the patient will remain infected for life. The acute phase is usually asymptomatic; in the chronic phase of American trypanosomiasis, severe gastro-intestinal and cardiac abnormalities may develop, finally with fatal course. In the Netherlands, the number of immigrants who would serologically test positive for American trypanosomiasis is estimated to be between 726 and 2929. Healthcare providers in the Netherlands may encounter patients who have Chagas disease more and more frequently. The screening of pregnant women and blood donors at risk for American trypanosomiasis should be considered.
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