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Query: UMLS:C0014118 (endocarditis)
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Three decades after it was demonstrated that nonejection systolic clicks and late systolic murmurs have a mitral valve origin and that a specific syndrome is associated with the primary degenerative mitral lesion, numerous questions remain unanswered. A principal cause of confusion is the use of the term 'prolapse', which essentially implies a pathological state, in many patients with minimal evidence of a mitral valve anomaly. It should be recognised that no specific feature, whether evaluated by high standard echocardiography or indeed by careful morphological and histological examination, can be defined which distinguishes a normal variant from a pathological valve. There is a gradation from the normal billowing during ventricular systole of mitral leaflet bodies to marked billowing. With advanced billowing or floppy leaflets, failure of leaflet edge apposition supervenes (true prolapse). This is functionally abnormal and allows mitral regurgitation. Prolapse in turn may progress to a flail leaflet and hence gross regurgitation. Relatively rare complications of this degenerative mitral valve anomaly include systemic emboli, infective endocarditis, arrhythmias and, arguably, autonomic nervous system abnormalities. An attempt is made to clarify the management of some symptoms and other aspects of mitral prolapse-including rheumatic anterior leaflet prolapse (without billowing) which remains prevalent in South Africa and Third World countries.
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PMID:Mitral valve billowing and prolapse--an overview. 144 36

Echocardiography plays a major role in the management of patients with mitral valve prolapse (MVP). The technique has greatly enhanced our understanding of the pathophysiology, epidemiology and natural history. There are major and minor echocardiographic diagnostic criteria for prolapse. Major criteria involve the mitral leaflets and include late systolic posterior displacement on M-mode, bulging into the left atrium on 2D long-axis (LAX) view, and thickening and redundancy of the leaflets. Minor criteria include holosystolic posterior prolapse on M-mode, bowing of the mitral leaflets into the left atrium (LA) in the apical 2D views, and late systolic mitral regurgitation on the Doppler echogram. Any of the major criteria should be sufficient to make the diagnosis. One or two minor criteria without a major sign would be questionable. The degree of thickening and redundancy and the presence and quantitation of mitral regurgitation influence prognosis. Echocardiography is also helpful in identifying complications such as endocarditis and ruptured chordae. An echocardiogram may not be necessary for the diagnosis, but it is helpful for prognosis and as a baseline for possible future changes. The frequency of follow-up echocardiograms should be determined by clinical findings. When mitral regurgitation is present, then one should follow LA and left ventricular size and function. Transoesophageal echocardiography may be desirable for better definition of vegetations or flail leaflets and is frequently used to monitor surgical repair.
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PMID:Echocardiography in the management of mitral valve prolapse. 144 37

Mitral Valve Prolapse (MVP) is usually a variant of normal occurring in about 4% of the population. Complications are relatively uncommon, but false associations due to ascertainment bias have had a potential for iatrogenic harm. Adverse outcomes which do occur in a subset of MVP subjects are considered here in relation to the contributions of genes, gender and geometry. There are definite associations between MVP and several dominantly inherited connective tissue abnormalities; it occurs in 85% of adults with Marfan syndrome. All these contribute to a very small proportion of the MVP population. A larger less easily characterised group with dominant inheritance and some features of a connective tissue disorder awaits DNA studies for identification. For most MVP subjects our data define significant family aggregation consistent with polygenic inheritance; the likelihood of a first degree relative having MVP is about two and a half times the population average. There is a higher prevalence in young women than in men-5% versus 3%; this has also been demonstrated for floppy mitral valve (MV) at autopsy. MVP complications of chordal rupture, severe mitral regurgitation and infective endocarditis are, however, two to three times more common in men, are age related and evident after the age of 50 years. Higher blood pressure in men may contribute to this in accordance with a response-to-injury hypothesis to explain progressive valve changes. Leaflet, annulus and left ventricular size differences and septal changes are geometric variants with a potential for increasing tension-related valve injury.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Genes, gender and geometry and the prolapsing mitral valve. 144 38

To assess the usefulness and safety of transesophageal echocardiography in critically ill patients, we analysed the transesophageal echocardiography studies in 60 of such cases (age: 58 +/- 11 and 38 males). Every patient underwent a previous transthoracic echocardiogram, that was considered inadequate for diagnostic purposes. Thirty patients (50%), were on mechanical ventilation and 17 patients (28%) showed hypotension and/or shock. Forty patients (66%) were at special care units and in 31 (52%) of them, pulmonary and systemic pressures, and continuous analysis of venous pressure of oxygen were available. Indications for study were: 17 patients with clinical suspicion of aortic dissection (confirmed in 5 cases): 9 patients infective endocarditis (4 cases showed valvular vegetations); 6 patients with mitral prosthesis dysfunction (confirmed in 4 cases); complicated acute myocardial infarction (MI) in 8 patients (2 cases with mitral insufficiency, 3 with left ventricular dysfunction, 1 with right ventricular MI, 1 with left ventricular pseudoaneurysm and other with isolated inferior MI); in 11 patients the study was performed to evaluate the result of cardiac transplantation immediately (< 4 h) and it showed 2 cases of left ventricular dysfunction; 3 patients were studied for severe cardiac dysfunction of unknown etiology (a dilated cardiomyopathy was confirmed in one and ruled out in the other, and one patient showed signs of restrictive situation); there were other causes in the rest. The procedure could be completely performed in all cases. In conclusion in critically ill patients the transesophageal echocardiography has a great usefulness and minimal complications.
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PMID:[Usefulness of transesophageal echocardiography in the critical patient]. 147 Jul 40

A 38-year-old man was admitted with coingestive heart failure due to infective endocarditis. Echocardiography with color Doppler imaging revealed severe aortic regurgitation, mitral valve premature closure and diastolic mitral regurgitation. The flow of the diastolic mitral regurgitation was directed to the posterior wall of the left atrium through just behind the posterior mitral leaflet. The diastolic mitral regurgitation was observed only in the period of late diastole and no mitral regurgitation could be detected in the systolic phase. After successful aortic valve replacement, the diastolic mitral regurgitation disappeared completely.
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PMID:Diastolic mitral regurgitation in intact mitral valve detected by color Doppler echocardiography in a patient with acute aortic regurgitation. 147 33

The applications of transesophageal echocardiography (TEE) now encompass the arena of critical care. We reviewed the indications, findings, and outcome of TEE in the critical care setting in a tertiary care hospital and report our experience. Eighty-three transesophageal echocardiograms were performed in 69 critically ill patients for the following indications: endocarditis (43%), embolic source (13%), hypotension (10%), mitral regurgitation (10%), left ventricular function (6%), aortic dissection (4%), prosthetic valve dissection (4%), and other (10%). Findings were unexpected in 21 of 83 studies and led to a change in management in 17%. On the basis of the results of TEE, 22% of patients had further evaluation by a more invasive technique, and 19% of patients had surgical intervention without further study. No significant complications attributable to TEE were noted. We conclude that TEE is a safe and useful diagnostic technique with fairly broad applications in the critical care setting.
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PMID:The role of transesophageal echocardiography in critical care: UCSF experience. 151 Aug 52

Recommendations for the prophylaxis of infective endocarditis have been published by working groups in several countries. We performed an enquiry amongst 276 dentists in Geneva to evaluate how the Swiss recommendations were applied. Of the 183 dentists who answered, the majority knew that extraction (85%) or scaling (76%) required prophylaxis. They correctly prescribed antibiotics to patients with valve prostheses (84%), to those with rheumatic heart disease (80%), a previous history of endocarditis (73%) or congenital heart disease (49%). Not conforming to the recommendations, many dentists considered that coronary bypass surgery (40%), mitral valve prolapse without mitral regurgitation (30%) or previous myocardial infarction (22%) also required antibiotic prophylaxis. Only 34% of dentists used the recommended 3 g of amoxicillina, the others preferring a lower dose of another antibiotic. About one third started prophylaxis 1 to 3 days too early and less than 20% used the suggested single dose of antibiotics. These results showed that dentists caring for cardiac patients should be better informed of the risks of endocarditis and its prevention. We make a few suggestions to improve antibiotic prophylaxis.
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PMID:[Do dentists enforce correctly the recommendations for prophylaxis of bacterial endocarditis?]. 156 27

A 38-year-old female was admitted to our hospital because she was suffered from severe dyspnea on effort. She had a history of nasal bleeding, endocarditis, fever, proteinuria, and alopecia at the age of 16, and was diagnosed as SLE. She was suffered from recurrent cerebral infarctions at the age of 35 and 38, and then mitral regurgitation was pointed out. Preoperative examination revealed non-active phase of SLE and UCG showed massive mitral regurgitation. Operative findings showed thrombosed verrucca circumferentially on the mitral valve. Mitral valve replacement (B-S #27) was done with using a felt strip in order to reinforce the mitral annular tissues. Histological findings of the verrucca showed Libman-Sacks endocarditis. Postoperative course was uneventful. Surgical treatment for Libman-Sacks endocarditis is extremely rare.
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PMID:[A case of mitral valve replacement for Libman-Sacks endocarditis]. 156 50

This report is concerned with results of surgical treatment for Marfan's syndrome combined with annulo-aortic ectasia (AAE) and mitral regurgitation (MR). Of the 23 patients with Marfan's syndrome who received Bentall's procedure during 14 year period, seven (30%) of these patients had both AAE and MR. The MR grade of seven patients by cardiac Doppler or left ventriculographic studies were grade 1 in 2, 2 in 1, 3 in 1, and 4 in 3. Atrial fibrillation was present in 4 patients. New York Heart Association Functional Class on admission in these 7 patients were II in 1, III in 4, and IV in 2. The mitral valve was replaced with mechanical valve in 4 patients by left atrial approach whose MR grade were over 3. In the 4 patients the mitral annuli were extremely dilated, both valve leaflets were massively redundant, and all chordae were elongated and turned chordae and vegetation were detected due to infective endocarditis. Only Bentall's procedure was performed in 3 patients whose MR were minimal. There were no early death, but two late deaths. One of them died of cardiac failure 2.3 years after Bentall's procedure because grade 2 MR was increased. Another one died from ventricular arrhythmia 1.6 years after MVR and Bentall's procedure. The remaining 5 patients are doing well for 3 months to 11.5 years after operation. For Marfan's syndrome combined with AAE and MR, early operation is recommended before left ventricular impairment. Mitral valve repair was not performed, both to save time and because anticoagulant therapy was need for aortic valve replacement. Concomitant MVR was to be done for moderate to severe MR.
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PMID:[Surgical treatment of Marfan's syndrome with annulo aortic ectasia and mitral regurgitation]. 158 63

The usefulness of transesophageal echocardiography (TEE) in cardiovascular clinical practice is assessed. Seven hundred transesophageal studies were performed between November 1989 and October 1991. One hundred and seventeen studies carried out during the follow-up of treated non-acute pathologies were excluded. The study could not be made in 6 patients. The most frequent indications of TEE were aortic pathology study, 120 (21%), infective endocarditis, 72 (13%), origin of systemic embolisms, 66 (11%), and mitral pre-valvuloplasty and intensive care, 64 (11%). The incidence of pathologic findings on TEE not diagnosed by conventional echocardiography was 32% (182/577). The incidence of pathologic findings with therapeutic implications was 15% (85/577). Indications showing a greater incidence of pathologic findings with therapeutic implications were: 1) thoracic aorta pathology, 42 (35%); 2) mitral prostheses disfunction, 8 (19%), and 3) mitral pre-valvuloplasty, 10 (16%). Infective endocarditis, intensive care studies and congenital cardiopathies had an incidence of 12%. TEE findings in the study of intracardiac masses, the origin of peripheral embolisms and mitral insufficiency had little influence (less than 5%) on the management of the patient.
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PMID:[The performance of transesophageal echocardiography in clinical cardiovascular practice]. 160 33


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