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This study was performed to evaluate the incidence and genesis of systolic anterior motion (SAM) of the mitral valve apparatus in patients with aortic regurgitation (AR). The study population consisted of 44 patients with non-rheumatic AR, without significant aortic stenosis or mitral regurgitation. The presence and location of SAM in the short-axis view were determined by M-mode echocardiography guided by two-dimensional echocardiography. The extent and direction of the regurgitant jet were decided by pulsed or two-dimensional Doppler echocardiography. SAM was observed in 21 (48%) of the 44 patients, and it was more frequently observed in patients with an etiology of aortic valve prolapse or annuloaortic ectasia than in those of other etiology (10/14 vs 10/30; p less than 0.05). Twenty-eight patients whose regurgitant jet was directed posteriorly and impinged on the mitral valve apparatus had a significantly higher incidence of SAM than did the other 16 patients (18/28 vs 3/16; p less than 0.01). In eight of 10 patients in whom the direction of the regurgitant jet could be precisely observed by two-dimensional Doppler echocardiography. SAM was observed at the place where a regurgitant jet was directed along the anterior mitral valve in the short-axis view. M-mode measurements (LVDd, LVDs, %FS, LVDd-LVDs) of the patients with SAM had greater values than those of patients without SAM.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Genesis of systolic anterior motion (SAM) of the mitral valve in patients with aortic regurgitation]. 281 36

Non-inflammatory calcific disease of the mitral valve apparatus is a common finding in elderly patients. This study describes the incidence, clinical findings and location of mitral calcium deposits detected by 2D-echocardiography in an unselected series of patients referred for echocardiography to a general hospital. In addition, valvular function was assessed by Doppler sonography. In 48 out of 217 consecutive patients, 2D-echocardiography showed mitral calcium deposits. The mean age of this patient group was 72 +/- 11 years. Clinical histories and findings in most patients indicated an association between calcium deposits and increased tension of valve structures by left ventricular pressure overload (i.e., hypertension, aortic stenosis), dilatative cardiomyopathy or valve prolapse. Calcific deposits were located predominantly at the posterior mitral ring, but in 48% of our patients calcification of mitral chordae was also seen. Mitral regurgitation was detected by Doppler sonography in 52% of the patient group, in 25% at least moderate mitral regurgitation could be demonstrated. The presence of valve incompetence was not dependent on the location of calcium deposits. Mitral valve area, as assessed by Doppler, ranged from 2.1 to 6.7 cm2.
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PMID:[Calcinosis of the mitral valve system and its effect on valve function. A Doppler echocardiography study]. 319 74

In emergency surgery, the essential prerequisites for success are speed, promptitude and precision. For this reason diagnosis must be equally prompt and precise and may require not only clinical examination but also a number of instrumental examinations designed to confirm or even to formulate the diagnosis which is usually the case in precordialgias of cardiovascular origin. In such syndromes ultrasound cardiography is particularly advantageous for the following reasons: it is non-invasive, provides immediate results and any number of examinations can be performed on the patient in bed. Since such ultrasound techniques are also reliably accurate, they constitute the method of choice when the patient's condition is critical, when a serial study of a single patient is required and when the results are required immediately, as is the case in emergency heart surgery. Four types of ultrasound cardiography are currently available for the diagnosis of precordialgias of cardiovascular origin: 1) one dimensional M-mode echocardiography; 2) two dimensional real time echocardiography; 3) Doppler ultrasound cardiography; 4) the echo-Doppler system in which Doppler ultrasound cardiography is combined with one or two dimensional echocardiography. Acute precordial pain of cardiovascular origin may be due to the following pathological conditions: 1) ischaemic cardiopathy especially acute myocardial infarction and transitory myocardial ischaemia; 2) acute pericarditis; 3) aortic stenosis; 4) idiopathic hypertrophic subaortic stenosis; 5) mitral prolapse; 6) dissecting aneurysm of the aorta; 7) pulmonary thromboembolism. In all these cases the single and two dimensional image and Doppler ultrasound cardiography provide highly sensitive and specific information that is, in some cases, decisive for diagnosis and in others confirms the diagnosis already formulated. In addition these techniques may provide valuable prognostic data. Ultrasound cardiography is indeed useful in all cardiological emergencies, such as those caused by cardiomegaly, new and developing murmurs, peripheral embolisms, cardiac traumas and arrhythmias. It is therefore suggested that every Emergency and Intensive Care Unit should be able to use the resources offered by ultrasound cardiography in diagnosis.
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PMID:[Emergency ultrasound cardiography in acute precordial pain of cardiovascular origin]. 362 31

Twenty-five patients (14 males and 11 females aged 11 to 45 years) with rhythm disorders and valvular defects were operated on. Supraventricular paroxysmal tachycardia was the most common of rhythm disorders occurring in 15 cases, with Ebstein's anomaly in 11, mitral valve incompetence in 2, combined mitral defects in 1 and aortic stenosis in 1 of those. Atrial fibrillation was recorded in 7 patients, with Ebstein's anomaly in 2, mitral stenosis in 2, mitral incompetence in 2 and mitral prolapse in 1 of those. Nodal tachycardia was found in 1 patients with Ebstein's anomaly and in 1 patient with mitral valve incompetence. Left-ventricular tachycardia was diagnosed in a female patient with mitral prolapse. The operations were simultaneous and comprised two steps; they were performed under extracorporeal circulation and drug- and cold-induced cardioplegia, with the elimination (surgical interruption) of accessory conduction pathways or removal of arrhythmogenic areas as the first step, and reconstructive surgery on heart valves as the second step.
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PMID:[Surgical treatment of rhythm disorders with simultaneous correction of heart valve defects]. 371 46

Valve replacement was performed during a 7-year period in 27 patients with acute or subacute infective endocarditis. Twenty-three patients had single valve affection--16 aortic and 7 mitral--and 4 patients had affection of both the aortic and mitral valves. Eight of the patients with aortic valve lesion had congenital aortic valve stenosis and 2 of the mitral patients had mitral prolapse. Two patients were operated upon only on the echocardiographic finding of valvular vegetations. The rest of the patients were operated because of cardiac insufficiency, intractable infection or peripheral embolization. Five patients died and 22 patients (82%) were discharged. One of these patients died in the follow-up period. The remaining 21 patients all belong to class I or II (NYHA) postoperatively. There were no cases of reinfection. Emphasis is placed on the use of echocardiography in detecting valvular vegetations, and the need to take the proper surgical action as a result of this finding, even in asymptomatic patients.
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PMID:Surgical treatment of bacterial endocarditis. 618 93

Anatomic and functional features of the normal and abnormal mitral valve are reviewed. Of 1,010 personally studied necropsy patients with severe (functional class III or IV, New York Heart Association) cardiac dysfunction from primary valvular heart disease, 434 (43%) had mitral stenosis (MS) with or without mitral regurgitation (MR): unassociated with aortic valve stenosis or regurgitation or with tricuspid valve stenosis in 189 (44%) patients, and associated with aortic stenosis in 152 (35%), with pure (no element of stenosis) aortic regurgitation in 65 (15%) patients, and with tricuspid valve stenosis with or without aortic valve stenosis in 28 (6%) patients. The origin of MS was rheumatic in all 434 patients. Of the 1,010 necropsy patients, 165 (16%) had pure MR (papillary muscle dysfunction excluded): unassociated with aortic valve stenosis or regurgitation or with tricuspid valve stenosis in 97 (59%) patients, and associated with pure aortic regurgitation in 45 (27%) and with aortic valve stenosis in 23 (14%) patients. When associated with dysfunction of the aortic valve, pure MR was usually rheumatic in origin, but when unassociated with aortic valve dysfunction it was usually nonrheumatic in origin. Review of operatively excised mitral valves in patients with pure MR unassociated with aortic valve dysfunction disclosed mitral valve prolapse (most likely an inherent congenital defect) as the most common cause of MR. Excluding the patients with MR from coronary heart disease (papillary muscle dysfunction), mitral prolapse was the cause of MR in 60 (88%) of the other 68 patients, and a rheumatic origin was responsible in only 3 of the 68 patients, all 68 of whom were greater than 30 years of age. Mitral anular calcification in persons aged greater than 65 years is usually associated with calcific deposits in the aortic valve cusps and in the coronary arteries. Because calcium in each of these 3 sites is common in older individuals residing in the Western World, it is most reasonable to view mitral anular calcification in older individuals as a manifestation of atherosclerosis. Mitral anular calcium appears to be extremely uncommon in persons with total serum cholesterol levels less than 150 mg/dl. Mitral anular calcium may produce mild MR and, if the deposits are heavy enough, MS.
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PMID:Morphologic features of the normal and abnormal mitral valve. 633 91

Small diameter aortic valve bioprostheses are associated with resting ventriculo-aortic pressure gradients of 10 to 35 mmHg. In order to avoid this factor favouring degradation of left ventricular function and early deterioration of the bioprosthesis, we enlarged the aortic ring when the diameter was less than 23 mm in patients considered unsuitable for long-term anticoagulation. The surgical technique involved incising the annulus from the postero-lateral commissure to the anterior mitral leaflet and implanting a Dacron patch lined with pericardium. Nine patients aged from 10 to 70 years (average 22 years) underwent aortic valve replacement with a Carpentier-Edwards bioprosthesis associated with enlargement of the aortic ring, between June 1979 and December 1981. The mean follow-up period is now 18 months (range 9 to 39 months). One patient has been lost to follow-up. Before surgery, 6 patients were in Stage III and 3 patients in Stage IV of the NYHA classification. There were 4 patients with pure aortic regurgitation with valve prolapse, 1 patient with aortic regurgitation due to endocarditis, and 4 patients with mixed aortic valve disease. The underlying disease was rheumatic in 6 cases, congenital in 2 cases and infective endocarditis in 1 case. The mean diameter of the aortic ring before enlargement was 19 mm. After the procedure, it increased to 23,8 mm, so enabling the implantation of no 23 and no 25 bioprostheses. Three patients had associated mitral regurgitation, 3 patients had mixed mitral valve disease, 1 patient had a membranous VSD with infundibular stenosis, and 1 patient had subvalvular aortic stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Aortic valve replacement by bioprosthesis with enlargement of the aortic ring]. 642 18

The many changes in classification of cardiovascular disease during the twentieth century reflect changing etiology of diseases, clinical comprehension and technological advances. In particular, the etiology of valvular heart disease has changed dramatically in the last five decades. The significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of valvular disease are responsible for the metamorphosis in the etiology of valvular disorders. Valvular heart disease can be classified as follows: 1) Heritable-congenital causes of valvular heart disease e.g., floppy mitral valve with mitral valve prolapse, bicuspid aortic valve, and the Marfan syndrome; 2) Inflammatory-immunologic causes such as rheumatic fever, acquired immune deficiency syndrome, endocardial proliferative disorders, and antiphospolipid syndrome; 3) Myocardial dysfunction-ischemic cardiomyopathy, dilated or hypertrophic cardiomyopathy-resulting in valvular heart disease; 4) Diseases and disorders of other organs as causes of valvular heart disease, e.g., chronic renal failure and carcinoid heart disease; 5) Valvular heart disease related to aging: calcific aortic stenosis and mitral annular calcification; 6) Valvular disease following interventions such as valvuloplasty, valve reconstructive surgery and valve replacement; and 7) Valvular disease related to drugs and physical agents, such as chronic ergotamine use, radiation therapy and trauma. In clinical practice the most common causes of mitral regurgitation are floppy mitral valve with mitral valve prolapse, ischemic heart disease, dilated cardiomyopathy and mitral annular calcification, while the most common cause of mitral stenosis is rheumatic fever. The most common causes of isolated aortic regurgitation are bicuspid aortic valve and floppy aortic valve, while the most common causes of isolated aortic stenosis are related to the bicuspid aortic valve and the development of calcific senile aortic stenosis. The most common causes of tricuspid regurgitation are dilated cardiomyopathy, ischemic cardiomyopathy, floppy tricuspid valve with tricuspid valve prolapse and infectious endocarditis. Combined mitral and tricuspid regurgitation occur with heritable connective tissue disorders, dilated or ischemic cardiomyopathy, while the most common cause of mitral stenosis plus aortic regurgitation is rheumatic fever. Statistics obtained from cardiac surgery and necropsy may underestimate the true incidence of certain valvular diseases by selection bias. This is particularly so with valvular disease associated with significant ventricular dysfunction, or in the elderly who may not be surgical candidates, or in cases where the valvular disease is not severe enough to require surgical intervention. Recent advances in hemodynamic and imaging technology allow clinicians to define valvular structure and function and to accurately classify valvular heart disease in clinical practice.
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PMID:Valvular heart disease: the influence of changing etiology on nosology. 800 Jun 16

Aortic valve replacement in the child and young adult is often delayed, and multiple operations or invasive procedures are performed to avoid valve replacements. Prosthetic valves, bioprosthetic valves, or allograft valves have been associated with significant complications or early failure and have been a disappointing solution for the patient requiring aortic valve replacement. The pulmonary autograft replacement (PAR) of the aortic valve in children has been shown to be safe and effective with a low incidence of late valve dysfunction. The absence of thromboembolism, the avoidance of anticoagulants, and its viability with the potential for growth and repair strongly support its use for the potential parent, patients of age 35 or less. The experience with 112 patients, 32 females and 80 males, ages 1.5 to 35 years (average 16.1) are reviewed. Twenty-four had aortic insufficiency, 34 had aortic stenosis, and 54 had both aortic stenosis and insufficiency. Actuarial survival was 95.4% +/- 2.0% at 7 years and freedom from reoperation or significant aortic insufficiency of the autograft valve was 92.7% +/- 3.7%. Freedom from all valve related complications of the autograft valve and the homograft replacement of the pulmonary valve was 90.0% +/- 4.0%. Reoperation for the autograft valve was related to limited experience in one, leaflet prolapse and adherence to a VSD patch in one, associated lupus erythematosus in one, and annular and sinotubular dilatation in one. Reoperation of the homograft valve in two patients was secondary to early homograft stenosis, probably due to rejection.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Pulmonary autograft replacement of the aortic valve in the potential parent. 818 67

To date, the relation between mitral stenosis (MS) and other associated cardiac valvular lesions has been reported by angiography and surgical pathologic study in patients with more advanced disease but has not been studied systematically by two-dimensional echocardiography and Doppler color flow mapping in a large referral population with a broader spectrum of severity. In addition, prior reports have suggested that up to 40% of patients with MS have mitral valve prolapse (MVP); however, because of recent developments in two-dimensional echocardiographic imaging and the definition of MVP, this association must now be reconsidered. The purpose of this study was to explore the association of other valvular lesions with MS and their relation to its severity and in particular to test whether MS is in fact associated with MVP with the frequency reported previously. We reviewed the studies of 205 consecutive patients (aged 61 +/- 14 years; range 26 to 87 years) with MS who were studied from 1992 to 1994 by two-dimensional echocardiography and Doppler color flow mapping to assess valvular stenosis, regurgitation, and MVP in patients with a range of severity of MS (28% mild, 34% moderate, and 38% severe MS based on mitral valve area). MS was associated with at least mild mitral regurgitation in 78% of patients (160/205), and pure MS was correspondingly uncommon (22%). There was an inverse relationship between the severity of MS and the degree of mitral regurgitation (p < 0.001). MS was frequently associated (54% of patients) with significant lesions of other valves, including aortic stenosis (17%), at least moderate aortic regurgitation (8%) and tricuspid regurgitation (38%), and tricuspid stenosis (4%). Tricuspid stenosis was associated with more severe MS (p < 0.01), and tricuspid regurgitation was more common in patients with mixed MS and regurgitation than in those with pure stenosis (60% versus 26% for at least moderate tricuspid regurgitation; p < 0.001). Mitral valve prolapse was present in only one patient (0.5%). Superior systolic bulging of the midportion of the anterior mitral leaflet toward the left atrium (but not superior to the annular hinge points) was seen in 22 patients (11%). Patients with such superior bulging had significantly lower mitral valve scores but a similar degree of mitral regurgitation compared with those without bulging. The majority of patients with MS (78%) have associated mitral regurgitation and significant lesions of the other cardiac valves (54%). The frequency of true MVP associated with chronic MS is much lower than reported previously. This may provide insight into the underlying pathophysiologic process, tending to shorten the chordae tendineae and leaflets to produce stenosis rather than elongate them to produce prolapse.
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PMID:Echocardiographic assessment of mitral stenosis and its associated valvular lesions in 205 patients and lack of association with mitral valve prolapse. 908 69


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