The grammatical properties of mass nouns: an aphasia case study

A total of 168 consecutive patients with predominant rheumatic mitral stenosis were evaluated by transthoracic (TTE) and transesophageal echocardiography (TEE). Of the 168 patients, 35 had previous embolic events (group I) and 133 had no emboli (group II). A total of 77 (45.8%) patients had atrial fibrillation. The frequency of atrial fibrillation was higher in group I than group II (68.6% vs 39.8%, p < 0.001). The incidence of left atrial enlargement was greater in group I (p < 0.001). Mitral valve area was found to be smaller in group I compared to group II (p < 0.001). In group I 83.3% and 29.2% of the patients with atrial fibrillation had left atrial spontaneous echo contrast (SEC) and left atrial thrombus, respectively, and 72.7% of the patients with sinus rhythm had left atrial SEC. In group II 79.2% and 20.8% of the patients with atrial fibrillation had left atrial SEC and left atrial thrombus whereas 28.6% and 2.6% of the patients with sinus rhythm had left atrial SEC and left atrial thrombus, respectively. The incidence of left atrial thrombus was significantly different in those patients with compared to those without embolic events (20% vs 9.7%, p < 0.01). In groups I and II, 28 of 35 (80%) and 64 of 133 (48.1%) patients had left atrial SEC (p < 0.01). Patients with left atrial SEC had a greater left atrial size (p < 0.01) and smaller mitral valve area (p < 0.01). Left atrial size was normal in 2 patients with left atrial SEC and SEC was not found in 55 patients with enlarged left atrium. Multiple logistic regression analysis showed that atrial fibrillation, mitral valve area and left atrial enlargement were independent predictors of the SEC (p < 0.001) and left atrial SEC was the principal determinant of thromboembolism. These data suggest that regardless of rhythm and atrial size, left atrial SEC is a principal determinant of thromboembolic risk in mitral stenosis. TEE may be able to detect those patients with mitral stenosis at risk for emboli and guide appropriate therapy.     

Improvement in mitral regurgitation after aortic valve replacement

This study sought to determine whether there is a quantitative improvement in mitral regurgitation (MR) after aortic valve replacement (AVR) for aortic stenosis (AS) and, if so, the mechanisms for this change. MR frequently accompanies AS. The addition of mitral valve replacement to AVR significantly increases the risk of surgery. Although previous studies have suggested a qualitative improvement in MR severity after AVR, semiquantitative analysis of this improvement has not been documented nor have the underlying mechanisms been examined. We evaluated 28 patients who had undergone 2-dimensional echo and color flow Doppler imaging an average of 1.5 +/- 2.5 months before and 2.5 +/- 4.2 months after AVR. Maximum MR area, MR percentage (MR area/left atrial area), mitral annular area, left atrial area, aortic gradient, and parameters of left ventricular geometry were measured to evaluate MR severity and to assess functional mechanisms for improvement in MR. There was a significant decrease in MR area (5.5 +/- 2.8 cm2 vs 2.5 +/- 1.9 cm2, p < or =0.0001) and MR percentage (25 +/- 11% vs 12 +/- 10% after operation, p < or =0.0001) between preoperative and postoperative studies. There was a significant reduction in aortic gradient, mitral annular area, left atrial area, and left ventricular length postoperatively. In univariate analysis, MR improvement was related to the lower preoperative left ventricular fractional area change (p = 0.027) and to the changes in fractional area change (p = 0.001) and left ventricular systolic area (p = 0.001). Thus, improvement in MR after AVR is related to changes in left ventricular function postoperatively. These data suggest that reduction in MR is due not only to decreased intraventricular pressure, but also to changes in ventricular morphology.     

Is atrial fibrillation resulting from rheumatic mitral valve disease a proper indication for the maze procedure?

BACKGROUND: There are a few patients without detectable atrial contraction despite restoration of atrial rhythm after the maze procedure for atrial fibrillation (AF) associated with mitral valve disease. METHODS: From January 1995 to March 1997, 29 consecutive patients with AF associated with mitral valve disease underwent our modified maze procedure combined with mitral or other valve operations. The causes of mitral valve disease were rheumatic mitral stenosis (n = 22) and nonrheumatic mitral regurgitation (n = 7). The 17 patients with postoperative atrial rhythm were divided into group I with rheumatic mitral stenosis (n = 10), and group II with mitral regurgitation of nonrheumatic origins (n = 7). RESULTS: Seventeen patients regained atrial rhythm, 2 patients had junctional rhythm, and another 10 remained in AF. Between the group of patients with restoration of atrial rhythm and that of patients remaining in AF, significant differences were found in the percentage with rheumatic disease, history of AF, and maximum f-wave voltage. The postoperative peak velocity of the atrial filling wave to peak velocity of early filling wave ratio for the left atrium measured using Doppler echocardiography was 0.25 in group I, which was significantly lower than that (0.42) in group II. CONCLUSIONS: Reconsideration of the indications for the maze procedure for AF associated with rheumatic mitral stenosis may thus be reasonable, particularly for cases in which replacement using a prosthetic valve is necessary, but we believe that patients with nonrheumatic mitral valve disease, especially those able to undergo reconstructive operations, are the best candidates for the maze procedure.     

Late postoperative outcome of plastic operation versus valve replacement for mitral regurgitation]

Between January 1980 and August 1991, 99 patients underwent operation for mitral valve regurgitation (MR). The ages of the patients ranged from 12 to 67 years, (49.4 +/- 11.9 years), and there were 39 males and 60 females. Pathological cause of regurgitation, which was determined by intraoperative inspection and histological findings of excised leaflets, was rheumatic in 46, degenerative in 38, infective endocarditis in 9, ischemic in 4 and unknown in 2 patients. Cardiac rhythm was atrial fibrillation in 73, normal sinus rhythm in 24 and junctional rhythm in 2 patients. Our principles for valve repair were (1) excision of responsible segment and repair for prolapsed leaflet due to torn chordae, (2) shortening of elongated chordae, (3) annuloplasty, and (4) repair of perforated leaflet. Finally, 19 patients endured plastic operation, and 80 patients underwent prosthetic valve replacement. The rate of plastic procedure was 62.5% (10/16) in degenerative MR with mural chordal lesions, 42.9% (3/7) in rheumatic MR without stenosis, 22.2% (2/9) in infective endocarditis and 100% (2/2) in MR with unknown etiology. Mitral valve repair was failed both in rheumatic MR associated with stenosis (39 patients) and in ischemic MR (4 patients). A ten-year survival rate after operation was 92.2 +/- 3.1% in patients with valve replacement and 83.6 +/- 10.0% with valve repair (N.S.), and a proportion of event-free survival in patients with valve replacement was similar to valve. Late postoperative cardiac catheterization revealed decreased left ventricular volume indices and increased left ventricular end-systolic stress/volume ratio in both groups compared to preoperative values, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left atrial appendage flow velocity and spontaneous echo contrast in patients with rheumatic mitral stenosis: a multiplane transesophageal echocardiographic study

BACKGROUND: Left atrial spontaneous echo contrast (LASEC), a putative marker of thrombo-embolic risk, is commonly located in the left atrial appendage (LAA). The aims of this work were to evaluate, using multiplane transesophageal echography, the echocardiographic determinants, specifically LAA outflow Doppler velocity, in the presence of SEC in patients with rheumatic MS. METHODS: Transthoracic and transesophageal echocardiographic tests were performed on 61 patients. The patients were divided into 3 groups based on the presence and type of valvular disease. Patients in group I (n = 28) presented with rheumatic mitral stenosis (MS). Patients in group II (n = 18) presented with valvular heart disease other than MS, and patients in group III (n = 15) had no history of valvular heart disease. The left atrium and appendage were examined for the presence of spontaneous echocontrast and thrombus, using multiplane echo scopy with transducer rotation. Minimal and maximal appendage areas were measured, on a computer-assisted bablet, by tracing a line from the top of the limbus of the left upper pulmonary vein to the appendage endocardial border. The LAA ejection fraction was calculated according to the formula: (maximal area-minimal area)/maximal area. Mitral valvular condition was evaluated with transthoracic and transesophageal echocardiography. Left atrial appendage blood flow velocity profiles were obtained with pulsed-wave Doppler at the orifice of the LAA. RESULTS: LASEC was present in 18 of 28 patients with mitral stenosis (64.3%). Patients with LASEC showed a greater incidence of atrial fibrillation (14/18 vs 12/43, p < 0.005), larger LAD (53.67 +/- 8.74 vs 40.54 +/- 14.85, p < 0.005), smaller LAAEF (38.7 +/- 1.53 vs 69.5 +/- 24.0, p < 0.05), smaller LAAMEV (20.28 +/- 10.07 vs 2.95 +/- 25.11, p < 0.005) and smaller LAAMFV (24.6 +/- 12.23 vs 36.00 +/- 11.01, p < 0.01), when compared with patients without LASEC. For group I, LAAEF, LAAMEV and LAAFV were smaller in patients with SEC than in patients without SEC (p < 0.005, p < 0.05, p < 0.01). However LAD values were similar for patients with and without SEC (53.67 +/- 8.75 vs 54.20 +/- 18.81, p = NS). Both LAAMEV and LAAMFV were related to SEC in patients with atrial fibrillation. However, LAD did not show the same trend. CONCLUSIONS: LASEC is more commonly observed in patients with rheumatic mitral stenosis or atrial fibrillation. Both LAAMEV and LAAMFV are associated with SEC in these patients.     

The frequency of left atrial spontaneous echo contrast and its clinical significance in mitral valve insufficiency

The authors investigated the frequency of left atrial spontaneous echo contrast in mitral valve disease. They also tested whether there was any correlation between the presence of left atrial spontaneous echo contrast and the severity of the mitral valve disease. Echocardiographic investigations were performed using both transthoracal and transesophageal echocardiographic methods employing monoplane transducer. The authors carried out 273 transesophageal investigations over a period of 2 years and found left atrial spontaneous echo contrast in 85 patients, who had mitral valve disease. Of this, in 18 cases thrombi were also detected in the left atrium and/or auricula. The diagnoses of mitral stenosis were made in 24 patients, of whom in 12 cases the stenosis were found to be severe, whilst in 12 cases to be moderate. Furthermore insufficiency of the mitral valve was detected in 35 cases. 20 patients had artificial mitral valve implanted, they received long term anticoagulant treatment. 59 patients had no spontaneous echo contrast. 14 patients had previous embolic events of which 9 were cerebral and in other cases arteries of the kidney, eye and extremities were affected. 71 patients had no history of embolism. The authors concluded that mitral valve disease, particularly mitral stenosis is frequently associated with left atrial spontaneous echo contrast. It has been also observed, that the more severe the mitral valve disease, the greater the probability of left atrial spontaneous echo contrast. In all cases where thrombi were found, left atrial echo contrast were demonstrated and the risk of embolism is high. In these cases anticoagulant therapy is suggested.     

Predicting the occurrence of adverse events after coronary artery bypass surgery

Approximately 15% of patients with mitral valve disease will experience left atrial thrombosis and its consequences. The etiology and diagnosis of left atrial thrombosis are reviewed, stressing the importance of blood stagnation as the most important etiologic factor. Atrial fibrillation, a left atrial diameter greater than 60 mm and absence of significant mitral regurgitation are predictors of left atrial thrombosis in mitral stenosis. Left atrial thrombus can be detected in 50% of patients with all three factors; all influence blood stagnation. Smoke-like echoes in the left atrium, detected by echocardiography, provide a semi-quantitative assessment of left atrial blood stagnation. The incidence of thrombi in patients with well marked smoke-like echoes is 60%, while in those without this echocardiographic finding it is only 9%. Smoke-like echoes provide an early warning system of conditions in the left atrium likely to lead to thrombosis unless the patient is anticoagulated.     

Partial mitral homograft: a new technique for mitral valve repair

Partial mitral homograft was used in 22 patients with localized lesions contraindicating a conventional valve repair. The etiologies of valve disease were: calcified rheumatic stenosis (n=14) and acute bacterial endocarditis (n=8). One patient died three months after surgery from cancer. Another patient required reoperation for residual stenosis 14 months postoperatively. All other patients had an excellent functional result with 19 patients in sinus rhythm. In this series, partial homograft replacement of the mitral valve significantly extended the possibilities of reconstructive surgery.     

Predictors of systemic embolism in patients with mitral stenosis. A prospective study

BACKGROUND: Most studies of the predictors of systemic embolism in patients with mitral stenosis have been retrospective. OBJECTIVE: To prospectively study factors associated with systemic embolism in mitral stenosis. DESIGN: Prospective cohort study. SETTING: University-affiliated medical institution with 3000 beds. PATIENTS: 534 consecutive patients with a mitral valve area of 2.0 cm2 or less; 132 patients were in sinus rhythm, and 402 were in atrial fibrillation. MEASUREMENTS: Nine clinical and 10 echocardiographic variables were assessed for prediction of systemic embolism over a mean (+/- SD) follow-up of 36.9 +/- 22.5 months. Diagnosis of systemic embolism was based on symptoms and signs (sudden onset of peripheral arterial ischemic or neurologic manifestations without prodromes) and on findings on computed tomography, angiography, and surgery. RESULTS: For patients in sinus rhythm, age (relative risk [RR], 1.12 [95% CI, 1.04 to 1.21]), the presence of a left atrial thrombus (RR, 37.1 [CI, 2.82 to 487.8]), mitral valve area (RR, 16.9 [CI, 1.53 to 187.0]), and the presence of significant aortic regurgitation (RR, 22.4 [CI, 2.72 to 184.8]) were positively associated with embolism. For patients in atrial fibrillation, previous embolism (RR, 3.11 [CI, 1.66 to 5.85]) was positively associated with embolism; percutaneous balloon mitral commissurotomy (RR, 0.37 [CI, 0.18 to 0.79]) was a negative predictor. CONCLUSIONS: It may be prudent to give anticoagulants not only to patients in atrial fibrillation and patients with previous systemic embolism but also to those showing a left atrial thrombus or significant aortic regurgitation on echocardiography. Early percutaneous balloon mitral commissurotomy may also help prevent systemic embolism in patients with mitral stenosis.     

Thirty years experience with heart valve surgery: isolated mitral valve replacement

BACKGROUND: Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic mitral valve replacement during this period. METHODS: Questionnaires and personal contact have been used to generate a combined database of pre-operative and post-operative information and long-term follow-up on 938 patients who underwent isolated prosthetic mitral valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1993. RESULTS: Complete survival follow-up data were obtained for 92% (865) of the patients. The Starr-Edwards valve was used in 95% (891) of the patients, a Bjork-Shiley prosthesis in 2.5% (23) of the patients, and only 24 (2.5%) other valves were inserted. The hospital mortality rate for the 30-year period was 4.7%. The mean age of the patients who underwent surgery was greater in each of the three successive decades. A long-term survival advantage was observed for patients with mitral stenosis, however, survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following mitral valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. CONCLUSION: Mitral valve recipients do not regain a normalized life expectancy, but risk factors that determine long-term survival can be identified pre-operatively to aid appropriate patient selection.     

Prediction of change in mitral valve area after mitral balloon commissurotomy using cine computed tomography

RATIONALE AND OBJECTIVES: Mitral balloon commissurotomy (MBC) can successfully increase the mitral valve area (MVA) in mitral stenosis, but the outcome is variable. In multicenter studies, qualitative echocardiographic scores obtained before MBC are only weakly predictive of the increase in MVA after MBC. METHODS: To evaluate whether the change in MVA after MBC can be predicted by evaluating mitral valve morphology using cine computed tomography (CT), we studied 12 women with mitral stenosis and 11 female control subjects. RESULTS: In the patients with mitral stenosis, MVA increased from 1.13 +/- 0.24 to 1.93 +/- 0.56 cm2 (P < .0001) after MBC. A standard echocardiographic score assessment of mitral valve morphology before MBC was not associated with the change in MVA after MBC in these patients (P > .20). However, the total mitral valve morphology score evaluated by cine computed tomography was strongly associated with the change in MVA after MBC (r = -.87; P < .0005). In addition, the individual morphologic characteristics of mitral valve mobility (P < .0025), leaflet thickness (P < .05), and subvalvular disease (P < .05) were significant predictors of the change in MVA after MBC. CONCLUSION: Cine computed tomography may be useful for predicting immediate increases in MVA in patients after MBC and may be helpful for preoperative assessment of these patients.     

Combined warfarin and antiplatelet therapy after St. Jude Medical valve replacement for mitral valve disease

OBJECTIVES: The clinical effect of combined warfarin and antiplatelet therapy on the incidence of stroke and postoperative complications after mitral (plus aortic) valve replacement was studied and compared with that observed with warfarin therapy alone. BACKGROUND: It has been reported that combined warfarin and antiplatelet therapy may be effective but may be associated with an increased hemorrhagic risk. Therefore, definite benefits of the treatment in patients with an implanted prosthetic valve have not been clearly documented. METHODS: Between January 1980 and December 1992, 195 patients with a St. Jude Medical valve at the mitral (plus aortic) position were assigned to receive treatment with either warfarin alone (125 patients) or warfarin plus antiplatelet agents (70 patients), such as dipyridamole (150 or 300 mg daily, 14 patients) or ticlopidine (200 or 400 mg daily, 56 patients). A minimal dose of aspirin (10 to 40 mg) was added (29 patients) if the maximal platelet aggregation rate by collagen was not reduced. The target thrombotest level was 10% to 20%. RESULTS: The two treatment groups were similar with regard to gender and age distribution. The number of patients with atrial fibrillation, left atrial thrombus, history of previous stroke, simultaneous aortic valve operation and previously performed valve procedures were comparable in the two groups. Actuarial survival rate at 10 years was 98.3 +/- 1.7% (mean +/- SD) in the warfarin plus antiplatelet group and 90.3 +/- 3.2% in the warfarin group (p < 0.05 at 1 and 9 to 12 years). The actuarial stroke-free rate at 10 years was 95.3 +/- 3.4% and 84.3 +/- 3.8%, respectively (p < 0.05 by the generalized Wilcoxon test). The actuarial complication-free rate at 10 years was 89.4 +/- 4.3% and 67.9 +/- 4.8%, respectively (p < 0.05 by the generalized Wilcoxon test). No hemorrhagic complications were seen in the warfarin plus antiplatelet group. CONCLUSIONS: The results strongly indicate the effectiveness and safety of combined warfarin plus antiplatelet treatment after St. Jude Medical valve replacement for mitral (plus aortic) valve disease.     

Mitral valve replacement under beating heart in 137 cases

To avoid damage of myocardial ischemia, myocardial hypoxia and reperfusion injury, we designed mitral valve replacement in beating heart under extracorporeal circulation with low dose temperature of 31 degrees C to 35 degrees C in 137 cases of rheumatic heart disease, congenital heart disease mitral stenosis and mitral insufficiency, or concurrent aortic insufficiency. The patients were rept in unblocking aorta, unfilling cardiac arrest perfusion, idle pulse and dradycardia of 40-50 times/min, nose temperature of 32 +/- 1 degrees C. Patients with concurrent aortic insufficiency should first undergo replacement of aorta under cold cardiac arrest and then replacement mitral valve under beating heart to reduce the time of cold heart ischemia. Plastic surgery for tricuspid valve was done under beating heart. Good postoperative prognosis was nated: an average arterial pressure of 9.5-10.5 kPa (70 to 80 mmHg), dose of dopamine was obviously reduced. No low cardiac output syndrome, acute renal failure and severe arrythmia were observed in 137 cases, except 4 deaths due to infection and blood coagulation (2.9%). A left cardiac chamber no-level air removal device and aorta perfusioner leading flow device were designed for exsufflation of left pneumatocardia.     

Risk of reoperative valve replacement for failed mitral and aortic bioprostheses

BACKGROUND: One factor influencing the choice of mechanical versus bioprosthetic valves is reoperation for bioprosthetic valve failure. To define its operative risk, we reviewed our results with valve reoperation for bioprosthetic valve failure. METHODS: Records of 400 consecutive patients having reoperative mitral, aortic, or mitral and aortic bioprosthetic valve replacement from January 1985 to March 1997 were reviewed. RESULTS: Reoperations were for failed bioprosthetic mitral valves in 219 patients, failed aortic valves in 153 patients, and failed aortic and mitral valves in 28 patients. Including 26 operations (6%) for acute endocarditis, 153 operations (38%) were nonelective. One hundred nine patients (27%) had other valves repaired or replaced, and 72 (18%) had coronary bypass grafting. The incidence of death in the mitral, aortic, and double-valve groups was respectively, 15 (6.8%), 12 (7.8%), and 4 (14.3%); and the incidence of prolonged postoperative hospital stay (>14 days) was, respectively, 57 (26.0%), 41 (26.8%), and 8 (28.6%). Only 7 of 147 patients (4.8%) having elective, isolated, first-time valve reoperation died. Multivariable predictors (p < 0.05) of hospital death were age greater than 65 years, male sex, renal insufficiency, and nonelective operation; and predictors of prolonged stay were acute endocarditis, renal insufficiency, any concurrent cardiac operation, and elevated pulmonary artery systolic pressure. CONCLUSIONS: Reoperative bioprosthetic valve replacement can be performed with acceptable mortality and hospital stay. The best results are achieved with elective valve replacement, without concurrent cardiac procedures.     

Early result comparison following mitral valve replacement with partial or entire subvalvular structure preservation

21 patients after mitral valve replacement with partial subvalvular structure preservation and 20 patients with entire subvalvular structure preservation were compared with 26 patients after mitral valve replacement with entire subvalvular structure excision. We found that patients after mitral valve replacement with partial or entire subvalvular structure preservation had a more uneventful postoperative course with less inotropic therapy and more decreased left atrial dimension when compared to those with conventional mitral valve replacement. But the patients after mitral valve replacement with entire mitral structure preservation had more decreased left ventricular dimension and short hospital stay when compared to those of the other two groups. The authors suggest that mitral subvalvular structure should be preserved, and we especially recommend the procedure of intravalvular implantation of mitral prosthesis with entire mitral subvalvular structure preservation.     

Echocardiography after mitral valve replacement and criteria of paraprosthetic regurgitation

19 patients with Bj?rk-Shiley mitral tilting disc valve prostheses were studied by echocardiography before the valve replacement operation and postoperatively every three months up to one year. In 14 patients with normal prosthetic function the left atrial diameter decreased markedly after operation (p less than 0.001), but echocardiographic dimensional indices of left ventricular performance remained unchanged. Paradoxical or markedly hypokinetic motion of the interventricular septum was observed within 3 months of operation in 46% of the patients, but in only 28% in studies performed 9 - 12 months after the replacement. The ampliture of the disc was on average 11 +/- 2 mm. In 5 patients with paraprosthetic regurgitation the left atrial diameter increased with the development of regurgitation and decreased again after successful reoperation. In these patients the left ventricular end diastolic and stroke volumes were great (p less than o.01) than in patients with normal prostheses. The septal motion was in the normal direction in all these 5 patients and the septal amplitudes were greater (p less than 0.01) than in the patients with normal prostheses. The amplitudes of the disc were normal, but abnormal anterior movement of the disc at the beginning of the diastole was observed. These data demonstrate that echocardiography is useful in the diagnosis of paraprosthetic mitral valve regurgitation.     

Interference of mitral valve stenosis with left ventricular diastole and left atrial appendage flow

Atrial fibrillation (AF) has been reported as an independent risk factor of systemic thromboembolism. Almost half of the left atrial thrombi are located in the left atrial appendage (LAA). LAA function, reflected by LAA flow, thus has an influence on the potential of distal embolic complications. To identify factors other than atrial contraction that influence LAA flow during AF, transthoracic and transesophageal echocardiographic studies were performed on 130 patients. Seventy patients with nonrheumatic AF were divided into two groups with higher peak LAA outflow velocity (group 1) and lower peak LAA outflow velocity (group 2) at the ventricular systolic phase. Sixty patients with rheumatic AF were classified as group 3. Group 1 had a higher peak LAA outflow velocity than group 2 at both the ventricular systolic and diastolic phases. Group 2 had a higher peak LAA outflow at the ventricular diastolic phase than group 3 (18.9 +/- 8.0 vs. 11.8 +/- 7.5 cm/s, p < 0.001), whereas there was no significant difference in the peak LAA outflow at the ventricular systolic phase between the two groups (9.6 +/- 4.0 vs. 10.8 +/- 6.8 cm/s, p = NS). Group 3 was subdivided according to mitral valve area. Patients with severe mitral stenosis (mitral valve area < 1 cm2) had a significantly lower diastolic augmentation of LAA outflow velocity (difference of LAA outflow velocity between ventricle systole and diastole) than patients with mild to moderate stenosis (0.5 +/- 3.2 vs. 2.6 +/- 4.9 cm/s, p < 0.05). In conclusion, patients with rheumatic AF, especially those with severe mitral stenosis, have a lower diastolic augmentation of LAA outflow velocity. The lower diastolic augmentation of the LAA outflow velocity at the ventricular diastolic phase might result from interference with the suction effect of the left ventricular diastole by the stenotic mitral valve.     

Adjustable tricuspid valve annuloplasty assisted by intraoperative transesophageal color Doppler echocardiography

Intraoperative transesophageal echocardiography (TEE) can play a major role in active guidance of cardiac surgery. This study describes a new application of TEE for assisting tricuspid suture annuloplasty. Twenty-five patients (aged 52 +/- 11 years) who underwent mitral valve replacement and tricuspid valve annuloplasty were studied intraoperatively by TEE. After cardiopulmonary bypass, the suture annuloplasty was adjusted on the beating heart until palpable regurgitation was eliminated. Further adjustment of the suture was performed under echocardiographic guidance until color Doppler flow imaging showed the most adequate correction of tricuspid regurgitation (TR). A significant decrease in the semiquantitative grade of TR, of regurgitant jet area and of the ratio jet area/right atrial area was obtained when the suture was adjusted under echocardiographic guidance. The peak inflow velocity and the gradient across the tricuspid valve did not show significant changes throughout the procedures. The results showed that the tricuspid suture annuloplasty guided by TEE enables a substantial reduction in residual TR without creating valve stenosis.     

Anesthesia case of the month. Analgesia for fractures until surgery can take place

OBJECTIVE: To emphasize a potentially lethal condition that is virtually impossible to diagnose preoperatively. DESIGN: Case report with review of the literature. SETTING: University Hospital. PARTICIPANT: The patient requiring urgent surgery for heart failure related to severe aortic stenosis and mild mitral stenosis with poor ventricular function. The patient was elderly and suffered from atrial fibrillation. INTERVENTIONS: Preoperative transesophageal echocardiography followed by mitral valve repair and aortic valve replacement. MEASUREMENTS: Clinical outcome and pathological results. RESULTS: Although preoperative TEE demonstrated no left atrial appendage abnormality. After cardiac manipulation prior to the institution of cardiopulmonary bypass a large left atrial mural thrombus was mobilized from the atrial wall and was free floating in the left atrium. CONCLUSIONS: For high risk patients TEE should be applied intraoperatively to avoid undiagnosed left atrial clot dislodgement.     

A case of left atrial free-floating ball thrombus

A rare case of left atrial free floating ball thrombus with mitral stenosis is reported. A 66-year-old woman was admitted for epigastralgia and acute heart failure without atrial fibrillation and previous embolization. The patient was treated successfully with removal of ball thrombus and mitral valve replacement. Intraoperative transesophageal echocardiography was effective for monitoring of mobile left atrial thrombus.