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Biomedical subjects

A Sagie

Publications and source records attributed to A Sagie.

At least 55 records · Page 3Linked to original sources
PubMed2000

Correlation between the admission electrocardiogram and regional wall motion abnormalities as detected by echocardiography in anterior acute myocardial infarction.

We correlated ST elevation in various leads on admission and regional dysfunction in 132 patient with first anterior acute myocardial infarction using echocardiography. ST elevation in leads I and a VL and II, III and aVF was not associated with a specific pattern of regional dysfunction. Basal anterior and septal regional dysfunction were seen more often in patients with ST elevation in V1 (49 vs. 25%, p = 0.006; 35 vs. 17%, p = 0.048, respectively). Patients with ST elevation in V2 had more regional dysfunction of the apical inferior region (84 vs. 53%; p = 0.01). ST elevation in V5 and V6 was not associated with more apical or lateral wall motion abnormalities. ST elevation in lead V1 in anterior myocardial infarction is associated with a high incidence of regional dysfunction of the basal anterior, anteroseptal and septal regions.

Aged↗
PubMed2000

Repeated thrombolysis in multiple episodes of obstructive thrombosis in prosthetic heart valves: a report of three cases and review of the literature.

BACKGROUND AND AIM OF THE STUDY: Thrombolysis is an emerging method to open thrombosed prosthetic heart valves. However, its applicability and safety in multiple recurrent thrombotic episodes is unclear. METHODS: Among 16 patients with thrombosed prosthetic valves treated with thrombolysis during a 33-month period, three patients (one mitral and two tricuspid) experienced four episodes each, and these were treated with repeated thrombolytic therapy. Data on patient demographics, clinical presentation, diagnosis, treatment and outcome are presented. RESULTS: Thrombolysis was successful in 10/12 episodes (83%); there was delayed response in one episode (8%), and partial response in one episode (8%). There were no major complications. However, a fifth thrombotic episode occurred in two patients with tricuspid prostheses, mandating re-do surgery. CONCLUSION: Thrombolysis in re-thrombosed prosthetic heart valves is feasible, highly successful and safe, and may therefore be used judiciously in selected patients who could not, or would not, undergo redo surgery. A high recurrence rate in the tricuspid position may implicate earlier surgical intervention, which should be individualized.

Adult↗
PubMed2000

Mid-term clinical and echocardiographic follow up of patients with CarboMedics valves in the tricuspid position.

BACKGROUND AND AIM OF THE STUDY: Debate continues regarding tricuspid valve replacement (TVR) with a mechanical prosthesis. Experience with bileaflet prostheses is limited; hence the study aim was to explore early and mid-term outcome and hemodynamic data in patients with bileaflet CarboMedics prosthetic valves in the tricuspid position. METHODS: The study population included 25 patients (21 females, four males; mean age 50.5 +/- 13.4 years) who underwent TVR with a CarboMedics valve over a six-year period. Routine clinical examinations and details of transthoracic echocardiography (TTE) were reviewed. Additional TTE, transesophageal echocardiography (TEE) and fluoroscopy were performed as indicated. The number of previous cardiac operations was zero, one and two in 36%, 32% and 32% of patients, respectively. Previous tricuspid surgery was performed in eight cases (32%); concurrent mitral valve replacement was performed in 17 (68%). The hospital mortality rate was 24% and late mortality rate 12%. Seventeen early survivors (13 females, four males) were followed up for 46 +/- 28 months (range: 4-96 months). RESULTS: Among early survivors, the mean and peak transvalvular gradients were 4.0 +/- 1.7 and 7.9 +/- 3.3 mmHg, respectively. Commonly observed INR levels were >2.5 in seven patients (41%), and >3.0 in only three (18%). Five patients (29% of mid-term survivors) experienced a total of 13 episodes of obstructive valve thrombosis, mostly with inappropriate anticoagulation. One patient required emergency re-do surgery; the others responded initially to thrombolysis or intensified antithrombotic treatment, but experienced at least two additional relapses. Aside from thrombotic episodes, all patients but two were in NYHA functional class II-III, and all but four required diuretics. CONCLUSION: TVR with bileaflet mechanical valves carries a high perioperative mortality and mid-term morbidity. Among patients with poor or fair anticoagulation, these valves were associated with a high incidence of obstructive valve thrombosis. If poor patient compliance is anticipated, insertion of a bioprosthesis should be encouraged.

Echocardiography↗
PubMed2000

Fluoroscopy of prosthetic heart valves: does it have a place in the echocardiography era?

Fluoroscopy is the best method for delineation of the radio-opaque elements of prosthetic heart valves. It is the modality of choice for the validation and quantification of leaflet motion abnormalities, and for the identification of structural valve dysfunction. Normal values are shown. Echocardiography and fluoroscopy may be seen as complementary diagnostic techniques and, when used appropriately, may help to evaluate prosthetic valve function, integrity and associated complications.

Echocardiography↗
PubMed2000

Association between mitral annulus calcification and peripheral arterial atherosclerotic disease.

The authors previously demonstrated a significant association between the presence of mitral annulus calcification (MAC) and aortic atheroma, carotid atherosclerotic disease, and coronary artery disease. The present study was designed to determine whether an association exists between MAC and peripheral arterial atherosclerotic disease. Of the 805 patients in whom the diagnosis of MAC was made by transthoracic echocardiography between 1995 and 1997, 77 patients (40 men and 37 women; mean age, 73.1 +/- 11.4 years; range, 44-90 years) underwent peripheral arterial testing for various indications, and comprised the study group. They were compared with 58 age-matched and sex-matched patients without MAC (30 men and 28 women; mean age, 73.2 +/- 11.8 years; range, 31-93 years) who underwent peripheral arterial testing during the same period for the same indications (control group). MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet detected by transthoracic echocardiography. An ankle/brachial systolic pressure index (ABI) was calculated by dividing the higher dorsalis pedis or posterior tibial Doppler-derived pressures by the higher of the 2 upper extremity systolic pressures. ABI was graded as follows: normal > or = 1, abnormal < 1, mild 0.71 to 0.99, moderate 0.41 to 0.7, and severe < or = 0.4. No differences were found between the groups in indications for referral for peripheral arterial testing and in risk factors for atherosclerosis except for hypertension, which was found to be significantly more prevalent in the study group (66% vs 41%, p = 0.004). The study group included 151 limbs, and the control group included 113 limbs. The mean ABI was significantly lower for all limbs in the MAC group (0.56 +/- 0.27 vs 0.87 +/- 0.24, p = 0.0001), abnormal ABI < 1 (94% vs 68%, p = 0.001), moderate peripheral arterial disease (44% vs 25%, p = 0.001), and a severe disease (27% vs 1%, p = 0.001). Of the 77 patients with MAC, 73 (95%) had a disease (right and/or left limbs) compared with 40 of 58 (69%) in the control group (p = 0.001). Bilateral disease (Doppler index < 1 for both right and left limbs), and severe bilateral disease (Doppler index < or = 0.4 for both right and left limb) were also found to be significantly more prevalent in the MAC group (87% vs 60%, p = 0.001; and 12% vs 0%, p = 0.007, respectively). There is a significant association between the presence of MAC and peripheral arterial disease. This information strengthens our hypothesis that MAC may be an important marker for generalized vascular atherosclerotic disease.

Adult↗
PubMed2000

Iatrogenic left ventricular-right atrial fistula following mitral valve replacement and tricuspid annuloplasty: diagnosis by transthoracic and transesophageal echocardiography.

Acquired left ventricle-to-right atrium communications are a known complication of valvular heart surgery. Previous reports have described the clinical features and diagnosis using cardiac catheterization. We report two cases of acquired left ventricle-to-right atrium fistula following mitral valve replacement. Particular emphasis is placed on the diagnosis using transthoracic and transesophageal echocardiography, obviating the need for cardiac catheterization before repair.

Aged↗
PubMed1999

Thrombosis of bileaflet tricuspid valve prosthesis: clinical spectrum and the role of nonsurgical treatment.

BACKGROUND: Thrombosis of a mechanical tricuspid valve prosthesis is a potentially hazardous event. This study aimed to explore the incidence and the clinical presentation of tricuspid valve thrombosis occurring in bileaflet valves and to evaluate the diagnostic and the therapeutic approach. METHODS AND RESULTS: Tricuspid valve thrombosis was sought in 22 late survivors with the CarboMedics valve in a follow-up period of 36.0 +/- 20.8 months. Limited leaflet motion and/or a visible thrombus were considered diagnostic of valve thrombosis. Eight episodes of tricuspid valve thrombosis were diagnosed among 5 patients (12.1 episodes per 100 patient-years). Anticoagulation was inadequate in 3 patients and fair in 2. Florid right heart failure occurred in 3 episodes. Common physical findings included increased jugular venous pulse (5 patients), diastolic tricuspid murmur (4 patients), and peripheral edema (4 patients). The diagnosis was suspected in all clinically and by transthoracic echocardiography and confirmed by fluoroscopy and/or transesophageal echocardiography. In 4 patients, both leaflets were involved. No thrombi were visualized. Three patients received thrombolytic therapy in 4 episodes (complete success in 3, partial success in 1) without hemorrhagic or embolic complications. One patient responded to aggressive anticoagulant therapy. One patient required an emergent repeat surgery. In 1 patient, valve thrombosis recurred thrice. CONCLUSIONS: In patients with fair or poor anticoagulation, a bileaflet valve in the tricuspid position is associated with a high incidence of valve thrombosis. Hinge entrapment requires only a small amount of thrombotic material. Valve thrombosis may be asymptomatic. Involvement of both leaflets is usually required to produce symptoms. A nonsurgical approach (thrombolysis or intensified anticoagulation) is usually successful. Patients should be instructed about heralding signs of valve thrombosis.

Adult↗
PubMed1999

The natural history of aortic valve disease after mitral valve surgery.

OBJECTIVES: The present study evaluates the long-term course of aortic valve disease and the need for aortic valve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery. BACKGROUND: Little is known about the natural history of aortic valve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition there is no firm policy regarding the appropriate treatment of mild aortic valve disease while replacing the mitral valve. METHODS: One-hundred thirty-one patients (44 male, 87 female; mean age 61+/-13 yr, range 35 to 89) were followed after mitral valve surgery for a mean period of 13+/-7 years. All patients had rheumatic heart disease. Aortic valve function was assessed preoperatively by cardiac catheterization and during follow-up by transthoracic echocardiography. RESULTS: At the time of mitral valve surgery, 59 patients (45%) had mild aortic valve disease: 7 (5%) aortic stenosis (AS), 58 (44%) aortic regurgitation (AR). At the end of follow-up, 96 patients (73%) had aortic valve disease: 33 AS (mild or moderate except in two cases) and 90 AR (mild or moderate except in one case). Among patients without aortic valve disease at the time of the mitral valve surgery, only three patients developed significant aortic valve disease after 25 years of follow-up procedures. Disease progression was noted in three of the seven patients with AS (2 to severe) and in six of the fifty eight with AR (1 to severe). Fifty two (90%) with mild AR remained stable after a mean follow-up period of 16 years. In only three patients (2%) the aortic valve disease progressed significantly after 9, 17 and 22 years. In only six patients of the entire cohort (5%), aortic valve replacement was needed after a mean period of 21 years (range 15 to 33). In four of them the primary indication for the second surgery was dysfunction of the prosthetic mitral valve. CONCLUSIONS: Our findings indicate that, among patients with rheumatic heart disease, a considerable number of patients have mild aortic valve disease at the time of mitral valve surgery. Yet most do not progress to severe disease, and aortic valve replacement is rarely needed after a long follow-up period. Thus, prophylactic valve replacement is not indicated in these cases.

Adolescent↗
PubMed1999

Infective endocarditis in renal transplant recipients.

Because of the increasing number of renal transplantations performed and the rarity of reported cases of infective endocarditis in these patients, we studied the clinical characteristics of this infection in this population. We report on two cases from our experience and review reported cases of infective endocarditis in renal transplant recipients retrieved from the MEDLINE system. In addition, we reviewed a large series of infective endocarditis looking for patients with renal transplants. In addition to our 2 cases, 12 previously reported cases were found. The mean time from transplantation to diagnosis of infective endocarditis was 3.5 years (range 2 months to 15 years). Causative organisms included fungi, Staphylococcus aureus (3 cases each), Corynebacterium sp. (2 cases), Streptococcus viridans, VRE, Brucella sp., Clostridium sp., Nocardia sp. and Erysipelothrix sp. (one case each). Skin manifestations of endocarditis and/or splenomegaly were not reported in these patients. Septic emboli and mycotic aneurysms were relatively common. The overall mortality rate was 50% (7 of 14 patients died). Infective endocarditis seems to be rare in renal transplant recipients. The few reported cases are characterized by unusual causative micro-organisms and atypical clinical presentation. Further studies are needed to delineate the magnitude and scope of this association.

Adult↗
PubMed1999

Tricuspid regurgitation late after mitral valve replacement: clinical and echocardiographic evaluation.

BACKGROUND AND AIM OF THE STUDY: Significant tricuspid regurgitation (TR) can contribute to increased morbidity and mortality in patients after mitral valve replacement (MVR), both in the immediate and late postoperative period. The aim of this study was to evaluate the prevalence and the clinical importance of TR late after MVR, as assessed both clinically and echocardiographically. METHODS: The study group comprised 65 patients (39 women, 26 men; mean age 61+/-12 years) with rheumatic heart disease who had undergone MVR without tricuspid valve surgery between one and 30 years (mean 11.3+/-8 years) before their last clinical examination. All patients underwent a complete color-Doppler echocardiographic examination. The predominant presurgical mitral lesion was stenosis in 44 patients and regurgitation in 21. The severity of the tricuspid valve disease was assessed echocardiographically using color-Doppler flow images and flow direction in the inferior vena cava or hepatic veins, and by clinical evaluation. RESULTS: Echocardiography revealed significant late TR in 44 patients (67%), which was moderate in 16 and severe in 28, and evident on physical examination in 24 cases (37%). Age (relative risk (RR) = 1.1; C.I. 1-1.1) and female sex (RR = 1.8; C.I. = 1.0-3.2) were identified as statistically significant predictors for late clinical TR development, but only age was found as a statistically significant predictor for echocardiographic TR development. An elevated RR for organic TR and predominant mitral regurgitation was found. In contrast, pre- and postoperative pulmonary artery pressure, predominant mitral lesion, prosthetic valve gradient and regurgitation were similar in patients with and without late TR. CONCLUSIONS: Significant TR diagnosed by echocardiography late after MVR is common, and clinically evident in more than one-third of patients. Therefore, a lower threshold for tricuspid valve repair should be considered when mitral valve surgery is carried out.

Aged↗
PubMed1999

Outcome and risk factors in octogenarians undergoing open-heart surgery.

BACKGROUND AND AIM OF THE STUDY: Increasing numbers of elderly (aged > 80 years) patients are being referred for cardiac surgery, and results for coronary artery bypass grafting (CABG) are generally better than for combined CABG and valve replacement. METHODS: During the past 55 months, 77 octogenarians underwent cardiac intervention in our institution. Forty-five patients (mean age 82.5 years) underwent CABG alone; surgery was elective in 33% of patients and 2.7 +/- 1.0 grafts per patient were performed. Thirty-two patients (mean age 82.4 years) underwent combined CABG and valve surgery (28 aortic, four mitral); 2.1 +/- 0.8 grafts per patient were performed and 65% of cases were emergencies. RESULTS: In patients undergoing CABG alone, the operative mortality rate was 2% and rose to 4% (n = 2) at the end of follow up. Mean NYHA functional class improved significantly from 3.5 +/- 0.5 to 1.4 +/- 0.3 after surgery (p < 0.05) and most patients reported marked improvement in their quality of life. In CABG + valve surgery patients, the operative mortality rate was 6% (n = 2) and reached 18% by the end of follow up. In these patients the complication rate was 24% and mean hospitalization stay 11.0 +/- 2.9 days, while mean NYHA functional class improved from 3.4 +/- 0.6 to 1.2 +/- 0.5. Data analysis revealed that mitral regurgitation combined with coronary artery disease (p < 0.03) and prolonged cross-clamping time (p < 0.01) were the most important independent factors for mortality. CONCLUSION: This study confirms that, in selected elderly patients, combined CABG and cardiac surgery can achieve good postoperative results.

Aged↗
PubMed1998

Mitral annular calcium detected by transthoracic echocardiography is a marker for high prevalence and severity of coronary artery disease in patients undergoing coronary angiography.

This study tests the hypothesis that mitral annular calcium (MAC) detected by transthoracic echocardiography (TTE) is a marker for high prevalence and severity of coronary artery disease (CAD) in patients undergoing coronary angiography. Pathological studies have suggested that there is an association between MAC and calcific deposits in coronary arteries; however, there are no clinical data to support this association. One hundred sixty-five patients with MAC (101 women and 64 men; mean age 71 +/- 8 years) who underwent cardiac catheterization with coronary angiography for various reasons were compared with 147 age-matched controls without MAC who underwent coronary angiography for the same indications during the same period. MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet detected by TTE. Obstructive CAD was defined as either > or = 50% reduction of the internal diameter of the left main coronary artery or > or = 70% reduction of the internal diameter of the left anterior descending, right coronary, or left circumflex artery distribution. Compared with controls, the MAC group had a significantly higher prevalence of CAD (89% vs 75%, p = 0.001) and higher rates of 3-vessel disease (45% vs 24%, p = 0.001) and left main CAD (13% vs 5%, p = 0.009). Nonsignificant CAD was more common in the control group (25% vs 11%, p = 0.001). Multivariate analysis identified MAC (p = 0.0002), indications for cardiac angiography (p = 0.02), sex (p = 0.03), and diabetes mellitus (p = 0.03) as independent predictors for the presence and severity of obstructive CAD. MAC detected by TTE may be a marker for high prevalence and severity of CAD in patients undergoing coronary angiography.

Adult↗
PubMed1998

Mechanism of mitral regurgitation in hypertrophic cardiomyopathy: mismatch of posterior to anterior leaflet length and mobility.

BACKGROUND: In hypertrophic cardiomyopathy, a spectrum of mitral leaflet abnormalities has been related to the mechanism of mitral systolic anterior motion (SAM), which causes both subaortic obstruction and mitral regurgitation. In the individual patient, SAM and regurgitation vary in parallel; clinically, however, great interindividual differences in mitral regurgitation can occur for comparable degrees of SAM. We hypothesized that these differences relate to variations in posterior leaflet length and mobility, restricting its ability to follow the anterior leaflet (participate in SAM) and coapt effectively. METHODS AND RESULTS: Different mitral geometries produced surgically in porcine valves were studied in vitro. Comparable degrees of SAM resulted in more severe mitral regurgitation for geometries characterized by limited posterior leaflet excursion. Mitral geometry was also analyzed in 23 patients with hypertrophic cardiomyopathy by intraoperative transesophageal echocardiography. All had typical anterior leaflet SAM with significant outflow tract gradients but considerably more variable mitral regurgitation; therefore, regurgitation did not correlate with obstruction. In contrast, mitral regurgitation correlated inversely with the length over which the leaflets coapted (r= -0.89), the most severe regurgitation occurring with a visible gap. Regurgitation increased with increasing mismatch of anterior to posterior leaflet length (r=0.77) and decreasing posterior leaflet mobility (r= -0.79). CONCLUSIONS: SAM produces greater mitral regurgitation if the posterior leaflet is limited in its ability to move anteriorly, participate in SAM, and coapt effectively. This can explain interindividual differences in regurgitation for comparable degrees of SAM. Thus, the spectrum of leaflet length and mobility that affects subaortic obstruction also influences mitral regurgitation in patients with SAM.

Adult↗