R. B. A. van den Brink

To operate or not on elderly patients with aortic stenosis: the decision and its consequences

OBJECTIVE To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients. DESIGN Cohort analysis based on a prospective inclusive registry. SETTING 205 consecutive patients (⩾ 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands. RESULTS The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment. CONCLUSIONS In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.

Influence of transoesophageal echocardiography on therapy and prognosis in young patients with TIA or ischaemic stroke

Objective. To determine the influence of transoesophageal echocardiography (TEE) on therapy and prognosis in patients with cryptogenic transient ischaemic attack (TIA) or ischaemic stroke under the age of 50 years.Methods and results. We evaluated all patients aged 50 and under who were referred to our university hospital for cryptogenic TIA or ischaemic stroke during the period 1 January 1996 to 31 December 2004. All patients underwent both transthoracic echocardiography (TTE) and TEE. Patients with known pre-existent heart disease, such as atrial fibrillation, were excluded. Eighty-three patients with TIA (22) and ischaemic stroke (61) were enrolled. Mean age was 39±8 years (range 18 to 50). In 30% of the patients TEE detected one or more potential cardioembolic source, compared with 10% for TTE (p=0.003). Standard treatment (aspirin 38 mg daily) was changed in 7% of the patients due to the TEE findings. Complete followup was obtained in 93% with an average of 5±3 years. Twelve recurrences occurred; two out of six patients (33%) with therapy change and ten out of 71 (14%) of the patients without therapy change had a recurrent TIA or ischaemic Stroke.Conclusion. In patients with cryptogenic TIA or ischaemic stroke, TEE is superior to TTE in the detection of a potential cardiac source of embolism. However, findings obtained by TEE only influence the already initiated treatment in a small percentage of patients. The recurrence rate both in the group with and without therapy change is high. (Neth Heart J 2009;17:373–7.)

Open access echocardiography: from high budget to low budget referral, but what about quality of patient care and delayed referral to the cardiologist?

Open access echocardiography (OAE) is defined as echocardiography that is requested by, reported to, and acted upon by general practitioners (GPs). Echocardiography provides information about cardiac anatomy (e.g. volumes, geometry, mass) and function (e.g. left ventricular function and wall motion, valvular function, right ventricular function, pulmonary artery pressure, pericardium). In the population referred by the GPs, the pretest likelihood of disease is much lower than in the (prescreened) hospital population. Thus OAE is mainly used as a screening tool to exclude clinically relevant abnormalities. The most common indications for OAE are assessment of asymptomatic murmurs, breathlessness and suspected heart failure. OAE is able to exclude significant valvular heart disease, with the exception of dynamic, exercise-related mitral regurgitation. OAE is also valuable in a breathless patient if left ventricular (LV) dysfunction (ejection fraction <40 %) is found, leading to a management change, e.g. starting an ACE inhibitor and β-blocker. However, a normal systolic LV function in a breathless patient does not exclude a cardiac cause of breathlessness, as this may be caused by diastolic LV dysfunction, ischaemia or paroxysmal heart rhythm problems. In such cases, the echocardiographic examination needs to be interpreted in the context of clinical history and examination, ECG, exercise ECG or other tests. Van Gurp et al. describe their experience with OAE, which was set up independently from the regional hospitals [1]. The aim of the study was to demonstrate that OAE reduces the number of referrals to the cardiologist and found a decrease in intended referrals within a mean follow-up of 4 months (92 % vs. 34 %, p<0.001). However, the aim of the study should have been: reducing the number of referrals, without compromising patient care. This means that one should also investigate subsequent patient management (change in medication), delayed referrals and hospitalisations. Ideally, this should have been investigated in a randomised controlled trial. The indication for echocardiography (and potential referral to the cardiologist) in the present study was suspected valve disease in the majority of cases and, less often, suspected heart failure: 81 (55 %) and 55 (35 %), respectively. However, one would expect a much higher number of heart failure indications, as 54 GP practices participated. Each year approximately 7 patients are expected to develop heart failure for the first time in a Dutch average general practice of 2350 patients. Therefore, the OAE indication of suspected heart failure should have been 7 times higher, i.e. circa 375 patients instead of 55 [2]. This underutilisation of OAE in suspected heart failure is also obvious in other studies [3–5].

Perioperative transesophageal echocardiography in mitral valve surgery

Transesophageal two-dimensional and Doppler echocardiography is a valuable tool for the evaluation of mitral prosthesis dysfunction and the intraoperative assessment of the result of mitral valve repair. It provides unique information on both anatomy and function of the mitral valve in the beating heart. Mechanism and severity of mitral regurgitation can be determined. However, for successful application of transesophageal echocardiography both surgeons and echocardiographers should have a thorough knowledge of possibilities and limitations of the technique and they should “understand each others language”. More studies are needed that evaluate short and long-term results of mitral valve repair in relation to postpump MR severity using the size of the proximal convergence zone and width of the vena contracta of the residual MR rather than jet area.