William A. M. Esteves

Impact of Net Atrioventricular Compliance on Clinical Outcome in Mitral Stenosis

Background—Net atrioventricular compliance (Cn) has been reported to be an important determinant of pulmonary hypertension in mitral stenosis (MS). We hypothesized that it may be useful in assessing prognosis because Cn reflects hemodynamic consequences of MS. To date, limited data with an assumed Cn cutoff have indicated the need for larger prospective studies. This prospective study was designed to determine the impact of Cn on clinical outcome and its contribution to pulmonary pressure in MS. In addition, we aimed to identify a cutoff value of Cn for outcome prediction in this setting. Methods and Results—A total of 128 patients with rheumatic MS without other significant valve disease were prospectively enrolled. Comprehensive echocardiography was performed and Doppler-derived Cn estimated using a previously validated equation. The end point was either mitral valve intervention or death. Cn was an important predictor of pulmonary pressure, regardless of classic measures of MS severity. During a median follow-up of 22 months, the end point was reached in 45 patients (35%). Baseline Cn predicted outcome, adding prognostic information beyond that provided by mitral valve area and functional status. Cn ⩽4 mL/mm Hg best predicted unfavorable outcome in derivation and validation sets. A subgroup analysis including only initially asymptomatic patients with moderate to severe MS without initial indication for intervention (40.6% of total) demonstrated that baseline Cn predicted subsequent adverse outcome even after adjustment for classic measures of hemodynamic MS severity (hazard ratio, 0.33; 95% confidence interval, 0.14–0.79; P=0.013). Conclusions—Cn contributes to pulmonary hypertension beyond stenosis severity itself. In a wide spectrum of MS severity, Cn is a powerful predictor of adverse outcome, adding prognostic value to clinical data and mitral valve area. Importantly, baseline Cn predicts a progressive course with subsequent need for intervention in initially asymptomatic patients. Cn assessment therefore has potential value for clinical risk stratification and monitoring in MS patients.

Dobutamine-stress echocardiography in asymptomatic patients with aortic regurgitation

BACKGROUND Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHODS Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS Mean age was 37.8+/-16.8 years and 16 patients (66%) were male. EF increased from a mean baseline value of 62.3+/-7.9% to 71.5+/-10.5% at a dobutamine dose of 20 microg/kg/min (p<0.001). The patients were followed-up for 36.6+/-20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.FUNDAMENTO: La reserva contractil disminuida puede ya estar presente en pacientes portadores de regurgitacion aortica, asintomaticos con fraccion de eyeccion (FE) normal, indicando la necesidad de evaluaciones frecuentes y cuidadosas de la funcion ventricular izquierda para detectar disfuncion sistolica incipiente. OBJETIVO: Analizar se incrementos en la FE en dosis bajas de dobutamina pueden predecir cirugia y/o muerte en pacientes con regurgitacion aortica. METODOS: Eco de estres con dobutamina se realizo en 24 pacientes portadores de regurgitacion aortica para verificar se incrementos de la FE en dosis bajas de dobutamina serian capaces de predecir la necesidad de cirugia y/o muerte en ese grupo de pacientes. RESULTADOS: La edad promedio fue de 37,8±16,8, y 16 (66%) eran varones. La FE aumento de un valor basal promedio de 62,3±7,9% para 71,5±10,5%, en la dosis de 20 µg/kg/min de dobutamina (p < 0,001). Los pacientes se siguieron por 36,6±20,1 meses: dos pacientes murieron (uno de muerte cardiovascular) y cinco se sometieron a cirugia cardiaca. La FE basal se correlaciono con cirugia y muerte en el seguimiento de pacientes. CONCLUSION: La fe basal se correlaciono con cirugia o muerte en el seguimiento de pacientes jovenes con regurgitacion aortica. Sin embargo, el incremento porcentual en la FE con dosis baja de dobutamina no fue capaz de predecir eventos en esos pacientes.

Impact of percutaneous mitral valvuloplasty on left ventricular function in patients with mitral stenosis assessed by 3D echocardiography

BACKGROUND The status of intrinsic left ventricular (LV) contractility in patients with isolated rheumatic mitral stenosis (MS) has been debated. The acute changes in loading conditions after percutaneous mitral valvuloplasty (PMV) may affect LV performance. We aimed to examine the acute effects of PMV on LV function and identify factors associated with LV ejection fraction (LVEF) changes, and determinants of long-term events following the procedure. METHODS One hundred and forty-two patients who underwent PMV for symptomatic rheumatic MS (valve area of 0.99±0.3cm2) were prospectively enrolled. LV volumes and LVEF were measured by three-dimensional (3D) echocardiography. Long-term outcome was a composite endpoint of death, mitral valve (MV) replacement, repeat PMV, new onset of atrial fibrillation, and stroke. RESULTS The mean age was 42.3±12.1years, and 125 patients were women (88%). After PMV, LVEF increased significantly (51.4 vs 56.5%, p<0.001), primary due to a significant increase in LV end-diastolic volume (65.8mL vs 67.9mL, p=0.002), and resultant increase in the stroke volume (33.9mL vs 39.6mL, p<0.001). Changes in cardiac index and systolic pulmonary artery pressure were associated with LVEF changes after PMV. During a mean follow-up period of 30.8months, 28 adverse clinical events were observed. Postprocedural mitral regurgitation, MV area, and mean gradient were independent predictors of composite endpoints. CONCLUSIONS In patients with rheumatic MS, PMV resulted in a significant improvement in LV end-diastolic volume, stroke volume and consequently increased in LVEF. Changes in cardiac index and systolic pulmonary artery pressure were associated with LVEF changes after PMV. The predictors of long-term adverse events following PMV were post-procedural variables, including mitral regurgitation, valve area, and mean gradient.

RIGHT VENTRICULAR FUNCTION AFTER PERCUTANEOUS MITRAL VALVULOPLASTY IN MITRAL STENOSIS: DETERMINANTS FACTORS AND IMPACT ON LONG-TERM OUTCOME

Right-sided heart failure is an important cause of morbidity in rheumatic mitral stenosis (MS), and attributed mainly to pulmonary hypertension. Percutaneous mitral valvuloplasty (PMV) effectively reduces pulmonary artery pressure (PAP) but its influence on RV function is unclear. This study

Ecocardiograma sob estresse com dobutamina em pacientes assintomáticos com regurgitação aórtica

BACKGROUND Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHODS Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS Mean age was 37.8+/-16.8 years and 16 patients (66%) were male. EF increased from a mean baseline value of 62.3+/-7.9% to 71.5+/-10.5% at a dobutamine dose of 20 microg/kg/min (p<0.001). The patients were followed-up for 36.6+/-20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.FUNDAMENTO: La reserva contractil disminuida puede ya estar presente en pacientes portadores de regurgitacion aortica, asintomaticos con fraccion de eyeccion (FE) normal, indicando la necesidad de evaluaciones frecuentes y cuidadosas de la funcion ventricular izquierda para detectar disfuncion sistolica incipiente. OBJETIVO: Analizar se incrementos en la FE en dosis bajas de dobutamina pueden predecir cirugia y/o muerte en pacientes con regurgitacion aortica. METODOS: Eco de estres con dobutamina se realizo en 24 pacientes portadores de regurgitacion aortica para verificar se incrementos de la FE en dosis bajas de dobutamina serian capaces de predecir la necesidad de cirugia y/o muerte en ese grupo de pacientes. RESULTADOS: La edad promedio fue de 37,8±16,8, y 16 (66%) eran varones. La FE aumento de un valor basal promedio de 62,3±7,9% para 71,5±10,5%, en la dosis de 20 µg/kg/min de dobutamina (p < 0,001). Los pacientes se siguieron por 36,6±20,1 meses: dos pacientes murieron (uno de muerte cardiovascular) y cinco se sometieron a cirugia cardiaca. La FE basal se correlaciono con cirugia y muerte en el seguimiento de pacientes. CONCLUSION: La fe basal se correlaciono con cirugia o muerte en el seguimiento de pacientes jovenes con regurgitacion aortica. Sin embargo, el incremento porcentual en la FE con dosis baja de dobutamina no fue capaz de predecir eventos en esos pacientes.

Ecocardiografía bajo estrés con dobutamina en pacientes asintomáticos con regurgitación aórtica

BACKGROUND Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHODS Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS Mean age was 37.8+/-16.8 years and 16 patients (66%) were male. EF increased from a mean baseline value of 62.3+/-7.9% to 71.5+/-10.5% at a dobutamine dose of 20 microg/kg/min (p<0.001). The patients were followed-up for 36.6+/-20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.FUNDAMENTO: La reserva contractil disminuida puede ya estar presente en pacientes portadores de regurgitacion aortica, asintomaticos con fraccion de eyeccion (FE) normal, indicando la necesidad de evaluaciones frecuentes y cuidadosas de la funcion ventricular izquierda para detectar disfuncion sistolica incipiente. OBJETIVO: Analizar se incrementos en la FE en dosis bajas de dobutamina pueden predecir cirugia y/o muerte en pacientes con regurgitacion aortica. METODOS: Eco de estres con dobutamina se realizo en 24 pacientes portadores de regurgitacion aortica para verificar se incrementos de la FE en dosis bajas de dobutamina serian capaces de predecir la necesidad de cirugia y/o muerte en ese grupo de pacientes. RESULTADOS: La edad promedio fue de 37,8±16,8, y 16 (66%) eran varones. La FE aumento de un valor basal promedio de 62,3±7,9% para 71,5±10,5%, en la dosis de 20 µg/kg/min de dobutamina (p < 0,001). Los pacientes se siguieron por 36,6±20,1 meses: dos pacientes murieron (uno de muerte cardiovascular) y cinco se sometieron a cirugia cardiaca. La FE basal se correlaciono con cirugia y muerte en el seguimiento de pacientes. CONCLUSION: La fe basal se correlaciono con cirugia o muerte en el seguimiento de pacientes jovenes con regurgitacion aortica. Sin embargo, el incremento porcentual en la FE con dosis baja de dobutamina no fue capaz de predecir eventos en esos pacientes.

Diagnóstico pela ecocardiografia transesofágica e evolução de 35 pacientes portadores de flail mitral valve

PURPOSE: To describe transesophageal echocardiographic findings in patients presenting with flail mitral valve and to obtain their clinical follow-up. METHODS: From January/93 to March/97, 1675 patients were submitted to transesophageal echocardiogram at our institution; 35 of them were diagnosed as having flail mitral valve and their clinical follow-up was obtained. RESULTS: Thirty-five patients with the diagnosis of flail mitral valve were studied. Mean age was 65±15 years (12-87) and 27 (77%) were male. The posterior leaflet was involved in 25 (71%) patients. Ruptured chordae tendineae was present in all but one patient in whom flail mitral valve was due to a very elongated and redundant chordae. The etiology was prolapse and/or mixomatous degeneration in 16 patients, degenerative in 10, ischemic in 5, rheumatic in 4 and endocarditis in 3. Mitral regurgitation was severe in 25 (71%) patients and moderate in 10 (29%). The mean follow-up was 375±395 days (1 to 1380). Nineteen patients were followed clinically and 16 were submitted to surgery (transesophageal echocardiogram findings were confirmed in all 16). Overall mortality was high (34%). Among the survivors, 17 are in NYHA class I and 6 in class II. CONCLUSION: The diagnosis of flail mitral valve by transesophageal echocardiography is accurate, allowing for the definition of its mechanism and etiology, as well as the evaluation of hemodynamic compromise. The observed high mortality at the time of diagnosis may be related to the severity of the disease causing the flail mitral valve. Although non-operated survivors are doing well, the observed low functional class in these patients may be related to the short period of follow-up.