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Effect of left atrial plication for the giant left atrium on left ventricular function.

Left atrial plication (LAP) following Kawazoe's method was performed on eight patients with mitral valve stenosis associated with a giant left atrium. To investigate the effect of LAP particularly on left ventricular function, the preoperative and postoperative left ventricular function in these patients were compared. The data were also compared to that of the non-left atrial plication (non-LAP) group with left atrial dimension of 60 mm or over. In the LAP group, there were significant differences between preoperative and postoperative data in the following parameters; New York Heart Association (NYHA) class, cardiothoracic ratio, mean pulmonary arterial pressure (PAP), left ventricular end-diastolic pressure (LVEDP), left atrial dimension, stroke volume index, ejection fraction and cardiac index. On the contrary, in the non-LAP group, there were significant differences between preoperative and post-operative data in the following two factors; NYHA class and PAP. The size of the left atrium in the non-LAP group remained unchanged over the course of long-term follow-up. Despite severe clinical symptoms and severely reduced cardiac function of the patients in the LAP group, cardiac function in all patients improved satisfactorily. This suggests that left atrial plication has a considerably beneficial effect on left ventricular function, and therefore, may be recommended for patients with a giant left atrium.

Adult↗

Bronchial hyperreactivity in patients with moderate pulmonary circulation overload.

The clinical course of congestive heart failure (CHF) and mitral valve stenosis (MVS) is accompanied by episodes of dyspnea, wheezing, and cough, symptoms also observed in patients with bronchial hyperreactivity. However, it is still controversial whether bronchial hyperreactivity is demonstrable in patients with chronic overload of the pulmonary circulation. In order to examine the effects of CHF on the respiratory function, we performed pulmonary function tests, titrated bronchial acetylcholine provocations, and left and right heart catheterization in 21 patients with impaired left ventricular function (mean ejection fraction, 37 percent, NYHA class 3), 5 patients with MVS, and 17 control patients with coronary artery disease (mean ejection fraction, 63 percent). Bronchial hyperresponsiveness was defined as an obstructive response to increased doses of inhaled acetylcholine. A 20 percent fall in forced expiratory volume in the first second (FEV1), a 100 percent increase in total airway resistance (Rtot), and a 60 percent reduction of pulmonary conductance (SGtot) were considered positive. Patients with impaired left ventricular function showed significantly higher airway resistance, and lower airway conductance at the maximal tolerated acetylcholine dose compared with control patients. Patients with MVS had a significant lower airway conductance. The induced bronchial obstruction was completely reversible upon inhalation of a beta 2-mimetic. We conclude that chronic overload of the pulmonary circulation is accompanied by bronchial hyperreactivity that may augment the symptoms of dyspnea in patients with CHF and MVS.

Acetylcholine↗

Treatment of pulmonary hypertension in patients undergoing cardiac surgery with cardiopulmonary bypass: a randomized, prospective, double-blind study.

OBJECTIVE: Pulmonary hypertension can already be present in patients undergoing cardiac surgery or can be exacerbated by cardiopulmonary bypass. Postoperative treatment is still a challenge for physicians. The aim of this study was to evaluate the effects of inhaled prostacyclin (iPGI2) and nitric oxide (iNO) compared with those of intravenous vasodilators. METHODS: This prospective, randomized, double-blind study included 58 patients affected by severe mitral valve stenosis and pulmonary hypertension with high pulmonary vascular resistance (> 250 dynes x s x cm(-5)) and a mean pulmonary artery pressure > 25 mmHg. All patients were monitored by central venous, radial arterial and Swan-Ganz catheters. Data were recorded at six different time points, before induction of anaesthesia, during and after surgery. Prostacyclin and nitric oxide were administered by inhalation 5 min before weaning from cardiopulmonary bypass and continued in the intensive care unit. Right ventricular function was evaluated by transoesophageal echocardiography. RESULTS: Hospital mortality was 3.4%. After drug administration, the mean pulmonary artery pressure and pulmonary vascular resistance were significantly decreased in the iNO and iPGI2 groups with respect to the baseline values (P < 0.05) and such a decrease was maintained throughout the study; this was not observed in the control group. In the iNO and iPGI2 groups we demonstrated a significant increase in cardiac indices and right ventricular ejection fraction after drug administration with respect to baseline. Furthermore, patients in the inhaled drug groups were weaned easily from cardiopulmonary bypass (P = 0.04) and had a shorter intubation time (P = 0.03) and intensive care unit stay (P = 0.02) than the control group. CONCLUSIONS: Our data suggest that both iNO and iPGI2 are effective in the treatment of pulmonary hypertension. iPGI2 has a number of advantages over iNO, including its easy administration and lower cost. Intravenous vasodilator treatment, on the other hand, is effective in terms of mortality but has a higher morbidity rate.

Administration, Inhalation↗

Mitral valve area by colour flow imaging.

Colour Doppler assessment of mitral valve area was carried out in 78 patients with mitral stenosis. The mitral valve area was calculated using the equation pi/4 (a x b), where a = color jet width at the mitral valve in the apical long axis view and b = width of the color jet in a 90 degree rotated view from the apex. The valve area obtained from the color jet was compared with the valve area obtained from the pressure half time. It was found that there was a good correlation between these two measurements (r = 0.82; p < 0.001) while 2D echo derived mitral valve area correlated at an r value of 0.80 (p < 0.001). It is concluded that the new method can be used as an adjunct to currently available methods to assess the severity of mitral stenosis.

Adolescent↗

Clinical applications of echocardiographic studies of the mitral valve. A review.

We have reviewed the clinical usefulness of echocardiographic studies of the mitral valve in mitral stenosis, atrial myxoma, mitral valve prolapse, rupture of chordae tendinae and idiopathic hypertrophic subaortic stenosis. Emphasis has been placed on the recognition of different patterns of mitral valve motion and where necessary, to avoid misinterpretations, appropriates recording techniques.

Aortic Valve Insufficiency↗

Noninvasive determination of the mitral valve area in stenosis: a computational model and correlation with autopsy and open heart measurements.

An analytical formulation has been developed which allows the computation of mitral valve area (A) from the potentially noninvasive paramaeters of hear rate (R), cardiac output (CO) and diastolic filling period (DFP) by the equation A = 21 CO/R x DFP2. The computed areas correlate with autopsy and open heart measurements (r = 0.91) for resting state conditions of moderate to severe mitral stenosis. These results suggest that noninvaasive methods can have an application in mitral valve determinations.

Cardiac Output↗