Introduction. Transcatheter aortic valve implantation (TAVI) is established as an attractive treatment option for high-risk patients with aortic valve stenosis. One concern is the high risk of prosthetic valve regurgitation. This study aimed to examine for potential preoperative risk factors for postprocedural transcatheter heart valve regurgitation and to quantify the risk, degree, and consequences of postprocedural regurgitation. Materials and methods. 100 consecutive patients who underwent femoral (n = 22) or transapical (n = 78) TAVI were retrospectively reviewed. Echocardiographic valve regurgitation and clinical parameters were analyzed over the first year after TAVI. Results. Seventy-five percent of all patients had prosthetic valve regurgitation. It was, however, only mild or absent in 64% of patients and did not require re-intervention in any of the patients in the series. The severity of the regurgitation appeared unchanged over the one-year follow-up period. Moderate to severe regurgitation was associated with significant yet stable dilatation of the left ventricle over one year and lesser NYHA class improvement three months after TAVI. Asymmetrical native valve calcification increased the risk of paravalvular regurgitation non-significantly. Conclusion. Transcatheter heart valve regurgitation seems to be mild in the majority of cases and unchanged over a 12 months follow-up period. While affecting left ventricular dimensions in moderate or severe cases, we observed no obvious undesirable consequences of the prosthetic valve regurgitation within the first year.

AIMS:In a prospective randomised trial we aimed to compare transapical transcatheter aortic valve implantation (a-TAVI) with surgical aortic valve replacement (SAVR) in operable elderly patients.METHODS AND RESULTS:The study was designed as a randomised controlled trial of a-TAVI (Edwards SAPIEN heart valve system; Edwards Lifesciences, Irvine, CA, USA) vs. SAVR. Operable patients with isolated aortic valve stenosis and an age ≥75 years were included. The primary endpoint was the composite of all-cause mortality, cerebral stroke and/or renal failure requiring haemodialysis at 30 days. After advice from the Data Safety Monitoring Board, the study was prematurely terminated after the inclusion of 70 patients because of an excess of events in the a-TAVI group. The primary endpoint was met in five a-TAVI patients (two deaths, two strokes, and one case of renal failure requiring dialysis) vs. one stroke in the SAVR group (p=0.07). In the a-TAVI group, one patient was converted to SAVR because of an abnormally positioned heart, and four patients were re-operated with open heart surgery because of annulus rupture (n=1), severe paravalvular leakage (n=2), and blockage of the left coronary artery (n=1). In the SAVR group, one patient was converted to TAVI because of a large intra-thoracic goitre.CONCLUSIONS:Given the limitations of a small prematurely terminated study, our results suggest that a-TAVI in its present form may be associated with complications and device success rates in low-risk patients similar or even inferior to those found in high-risk patients with aortic valve stenosis. This will probably change in the near future with improved catheter based devices and better pre-procedural assessment.

Objective. To investigate if earlier reported retrospectively derived criteria for predicting absence of infective endocarditis (IE) on transthoracic echocardiography could be prospectively confirmed or improved with transoesophageal echocardiography (TOE). Design. Prospective analysis of the relationship between predefined clinical IE features and findings on TOE in 708 IE suspected patients. Results. The previously reported criteria were rejected as 1/10 of our confirmed IE patients fulfilled criteria for predicting absence of IE. However, our study generated another model of low probability of IE: This disease was absent in 99.4% of patients with negative blood cultures and absence of vascular phenomena and predisposing cardiac conditions. Such patients accounted for 25% of our population of patients suspected of IE. Conclusions. The utility of earlier reported clinical criteria for predicting absence of IE proved insufficient. Instead the study generated new simpler criteria of low probability of IE. However, these included negative blood cultures, but echocardiography must not be postponed while awaiting the results of blood cultures. Therefore the proposed new criteria only apply to patients with documented negative blood cultures when the suspicion of IE arises, in our study only 10% of the population. Accordingly, the study documented the essential role of early echocardiography in suspected IE.

Objectives. The use of transcatheter aortic valve implantation (TAVI) for high-risk patients was introduced in the early 2000s for treatment of aortic valve stenosis patients with too high surgical risk. During the last years, there has been a dramatic increase in TAVI procedures. TAVI programs are implemented in numerous cardiac centers. This paper describes a single center experience with its first 100 TAVI procedures. Methods. This study included the first 100 patients who were scheduled for either transfemoral (F-TAVI) or transapical (A-TAVI) aortic valve implantation at Aarhus University Hospital, Skejby, using the Edwards SAPIEN™ valve. The indication for TAVI was unacceptable high predicted risk associated with conventional surgery. Patients with adequate diameter of iliac arteries were scheduled for F-TAVI, otherwise A-TAVI was preferred. Results. The patients were treated between February 2006 and June 2010. Of these were 44% males and 56% females with a mean (S.D.) age of 81 (7.0). Thirty-days mortality rate was 8%, and decreased from 12% among the first 50 patients to 4% for the last 50 patients. Successful implantation was achieved in 92% patients. Major non-fatal complications were seen in 5% of 76 A-TAVI and in 0% of 24 F-TAVI patients. Mean (S.D.) EuroSCORE in the F-TAVI and A-TAVI groups was 15.9 (9.4) and 21.5 (14), respectively (p = 0.06). Post-procedural leakage of cardiac biomarkers was significantly higher in the A-TAVI group as compared to in the F-TAVI group. Mean (S.D.) NYHA class improved from 2.9 (0.6) to 1.8 (0.7) p < 0.001, with no significant difference between A-TAVI and F-TAVI patients. Conclusion. In surgically non-amenable patients, TAVI can be performed with acceptable mortality and morbidity and results in marked functional improvement. A decrease in 30-day mortality over time indicated a learning curve when implementing this treatment.

The case is reported of a young adult with Wolff-Parkinson-White (WPW) syndrome who, three years after a complicated radiofrequency (RF) catheter ablation procedure, developed dyspnea on exertion. Echocardiography revealed severe mitral valve regurgitation caused by a perforation of the posterior leaflet. Echocardiographic follow up is recommended after a complicated course of left-sided catheter ablation.

AIMS:To investigate whether biventricular (BIV) pacing preserves left ventricular ejection fraction (LVEF) and reduces LV dyssynchrony when compared with standard dual-chamber right ventricular (RV) pacing in consecutive patients with high-grade atrioventricular block during 3 years of pacing.METHODS AND RESULTS:Fifty patients were randomized to RV pacing or BIV pacing. LVEF was measured using three-dimensional echocardiography. Tissue Doppler imaging was used to quantify LV dyssynchrony in terms of the standard deviation of the time-to-peak velocity (Ts-SD). LVEF differed significantly between the two groups during 3 years of pacing (ANOVA: P=0.003). LVEF in the RV group decreased from 59±5% at baseline to 53±11% (P=0.01), while LVEF remained unchanged in the BIV group (57±7% at baseline vs. 58±10% (P=0.40). After 3 years of follow-up, we observed no difference in LV dyssynchrony, LV remodelling or measurements of clinical heart failure (N-terminal pro-brain natriuretic peptide, walking test, and New York Heart Association functional class) between the two groups. However, in the RV group, but not in the BIV group, dyssynchrony increased significantly (P=0.005) during follow-up. Furthermore, adverse LV remodelling was observed in the RV group with increased systolic volume and thinning of the LV septum.CONCLUSION:BIV pacing preserves LVEF and minimizes LV dyssynchrony during long-term follow-up. Adverse remodelling observed during 3 years of RV pacing was prevented by BIV pacing. However, the adverse impact of RV pacing on LV function was not reflected in measures of clinical heart failure.CLINICAL TRIAL REGISTRATION:www.clinicaltrials.gov (identification number: NCT00228241).

A 69-year-old man presented with symptoms of right heart failure due to stenosis of a tricuspid valve bioprosthesis. Echocardiography revealed right atrial dilatation and an estimated tricuspid valve area of 0.4 cm2. Because of advanced poor general condition and comorbidities, he was found unfit for conventional reoperation. Instead, transcatheter transatrial stent-valve implantation through a right thoracotomy was scheduled. The procedure resulted in a markedly improved clinical condition and an increased valve area measured to 2.5 cm2. In conclusion, transcatheter transatrial stent-valve implantation in stenotic valves is technically feasible and may lead to substantial improvement of the clinical condition.

INTRODUCTION:Tricuspid valve regurgitation (TVR) is often secondary to left-sided or congenital heart disease (CHD). Surgical correction of TVR is indicated when the primary abnormalities require operation.MATERIAL AND METHODS:Retrospective analysis of all 50 patients (mean age: 65 years (range: 24-83), 27 males, 23 females) operated with tricuspid valve annuloplasty (TVA) in our hospital from 2000 to 2007. TVA took place concomitantly with operation for left heart disease (n = 39, 78%) or CHD (n = 11, 22%).RESULTS:Preoperatively, TVR was severe in 40, moderate in six and mild in four cases. Thirty-four had annulus dilation > 2 cm/m(2) body surface area. Half of the patients were in New York Heart Association (NYHA) class III or IV. Postoperatively, TVR was severe in two cases, moderate in one, mild in 25 and absent in 18, and 95% of patients followed up were in NYHA I or II. There were five (10%) early and two (4%) late deaths. Temporary arrhythmias requiring medical treatment occurred in 35 cases, but eight required permanent pacemaker. No tricuspid valve reoperations were performed.CONCLUSIONS:The combination of correction of primary heart abnormalities and TVA is associated with high perioperative mortality. In survivors, postoperative clinical improvement is common, in all probability this is mainly due to the correction of the primary disease. TVA reduces TVR, but its precise contribution to clinical improvement and prognosis remains unknown.

AIMS To examine left ventricular (LV) longitudinal systolic myocardial function in patients with hypertrophic obstructive cardiomyopathy (HOCM) before and after transcoronary ablation of septal hypertrophy (TASH). METHODS AND RESULTS Twenty-three of 39 consecutive patients with HOCM had serial two-dimensional (2D) echocardiograms available for speckle tracking analyses before and up to 36 months after TASH. Before TASH, overall LV myocardial longitudinal systolic 2D strain was decreased despite normal LV ejection fraction (EF). A significant reduction of LV mass and left ventricular outflow tract (LVOT) gradients occurred during long-term follow-up after TASH, but this was not accompanied by improvement of average LV longitudinal systolic strain. However, in the basal LV segments remote to the site of alcohol injection longitudinal systolic strain increased [baseline: -13.1 ± 5.4%; 1 month: -16.0 ± 5.5% (NS); 12 months: -16.5 ± 4.9% (P < 0.05 vs. baseline); 36 months: -17.4 ± 4.2% (P < 0.01 vs. baseline)]. In contrast, the alcohol-treated basal segments of the septum and adjacent myocardium showed unchanged strain over time. CONCLUSION Average LV longitudinal myocardial systolic function is depressed in HOCM despite normal LV EF. TASH-induced reduction of the LVOT obstruction does not improve average LV longitudinal systolic 2D strain. This is in contrast to global improvement of longitudinal systolic function after valve replacement in aortic valve stenosis. The discrepancy may be caused by the fact that HOCM is a primary myocardial disease.

BACKGROUND:diagnostic delay contributes to high morbidity and mortality in infective endocarditis. A readily available diagnostic marker of infective endocarditis is desirable. S-procalcitonin has been proposed as a candidate, but data on its yield are conflicting. We tested its diagnostic value in a large population of patients seen in a tertiary center.METHODS:this prospective study included 759 consecutive patients referred for echocardiographic examination on clinical suspicion of infective endocarditis. Transthoracic echocardiography was followed by immediate transesophageal examination, and a blood sample was obtained for procalcitonin analysis. Infective endocarditis was diagnosed by an interdisciplinary team and confirmed according to the Duke criteria. The team was unaware of the results of procalcitonin analyses.RESULTS:infective endocarditis was present in 147 patients (19%). Procalcitonin was higher in these patients than in those in whom infective endocarditis was rejected (median, 0.21 ng/mL vs. 0.13 ng/mL; P <.0005). Multivariate analysis identified significant independent determinants of high procalcitonin: blood culture with endocarditis-typical microorganisms (odds ratio [OR], 2.81), temperature ≥ 38°C (OR, 2.61), symptoms ≤ 5 days (OR, 2.39), immunocompromised status (OR, 1.74), and male gender (OR, 1.61). Tests at various procalcitonin thresholds yielded an acceptable sensitivity of 95% at 0.04 ng/mL, but specificity was only 14%. Only 12% had procalcitonin below this threshold, which might justify postponement of further examinations for infective endocarditis.CONCLUSIONS:procalcitonin was significantly higher in patients with infective endocarditis than in patients without infective endocarditis and bacteremia with endocarditis-typical organisms was the strongest independent determinant of high procalcitonin. The clinical importance of this is questionable, because a suitable procalcitonin threshold for diagnosing or excluding infective endocarditis was not established.

Background and aim of the study: The study aim was to monitor infective endocarditis (IE) before and after the condition was brought into focus in hospitals in the Aarhus region of Denmark.Methods: A total of 172 patients with IE, all of whom had been referred to the regional tertiary center during 2000-2001 or during 2005-2006, was included prospectively into the study.Results: Between 2000-1 (n = 51) and 2005-6 (n = 121), a very large (137%) increase occurred in the number of IE patients referred (p <0.01). Yet, over this period, the delay from onset of symptoms to admission remained at one month, with a further prolongation of one week (p <0.05) in 40% of patients who had received pre-hospital antibiotic treatment. A previous healthcare procedure was recorded in 37% of cases, with an ascending trend from 2000-1 to 2005-6. The increase in six-month mortality was high, from 16% to 26%, but was not statistically significant. Independent predictors were prosthetic valve IE (p = 0.02), advanced age (p = 0.03) and co-morbidity (p = 0.05); all three of these features increased over the five-year study interval.Conclusion: Although increased regional hospital attention to IE seemed to facilitate admission to the authors' center, this did not improve survival, apparently because of an unchanged admission delay and increasing age, comorbidity, and prosthetic valve IE. Delayed admission and health care-induced IE were susceptible to modification. Future measures should, therefore, be particularly focused on high-risk patients, on educating the general practitioners, and on improving access to primary healthcare facilities for blood culture and echocardiography.

INTRODUCTION:Surgical ventricular reconstruction is an option for treatment of heart failure elicited by left ventricular aneurism. The aim of this study was to report the results of such treatment in our tertiary centre.MATERIAL AND METHODS:From January 2002 through October 2007 surgical ventricular restoration was performed in 26 patients (23 males) with a median age of 64 years (47-74 years). Twenty-one of the patients were in New York Heart Association (NYHA) class III-IV. The median preoperative left ventricular ejection fraction was 27% (13-38%). We collected both pre- and postoperative data retrospectively.RESULTS:Eighty-five percent of the patients received additional operative procedures, in most cases coronary artery bypass grafting. Ninety-six percent survived the follow-up period which had a median duration of 392 days (1-1777). At follow-up left ventricular ejection fraction had increased to 35% (18-53%) (p < 0.05) and 20 patients were in NYHA class I-II (p < 0.05).CONCLUSION:Surgical left ventricular reconstruction is a feasible option for treatment of heart failure in patients with post myocardial infarction aneurisms. In selected patients this treatment carries a low mortality and results in improved left ventricular function and functional capacity.

Background. The presence of mild to moderate ischemic mitral regurgitation (IMR) marks a significantly reduced long-term survival and increased hospitalizations due to heart-failure. However, it is common practice in many institutions to refrain from repairing the mitral valve in these patients. There are no available conclusive data to support this practice, and thus there is a need for an adequately powered randomized trial. Study design. The Moderate Mitral Regurgitation In Patients Undergoing CABG (MoMIC) trial is the first international multi-center, large-scale study to clarify whether moderate IMR in CABG patients should be corrected. A total of 550 CABG patients with moderate IMR are to be randomized to treatment of either CABG alone or CABG plus mitral valve correction. The primary end point is a composite end point of mortality and rehospitalization for heart failure at five years. The inclusion and randomization of patients started in February 2008. Implication. If correction of moderate IMR in CABG patients proves to be the superior strategy, most patients should be treated accordingly.

Transcatheter transapical or transfemoral aortic valve replacement has emerged as an alternative therapy of severe, symptomatic valvular aortic stenosis in surgically nonamenable patients. We report a transapical treatment of a severely stenosed 21-mm aortic Mitroflow valve bioprosthesis (Sorin Group, Vancouver, British Columbia, Canada) in an 82-year-old woman using a 23-mm Edwards SAPIEN Transcatheter Heart Valve (Edwards Lifesciences, Irvine, CA).

Background and aim of the study: Ergot-derived dopamine agonists (DAs) are used in the treatment of Parkinson's disease, but may be associated with valvular heart disease and pulmonary hypertension. The study aim was to examine changes in cardiovascular abnormalities after the discontinuation or continuation of anti-parkinson treatment. Methods: Parkinson patients treated with either ergot-derived (n = 32) or non-ergot-derived (n = 8) DAs who had been diagnosed with valvular abnormalities or pulmonary hypertension, were included in this one-year follow up study. After an initial echocardiography, five patients continued ergot-derived DA treatment, while the remaining 35 either changed (n = 27) or continued (n = 8) non-ergot-derived DA treatment. The patients were followed up after a mean of 14 months (range: 12-18 months). Changes in the severity of valve disease and pulmonary hypertension were evaluated by an analysis of digitally stored echocardiograms. The recordings were performed blinded to medical treatment, while the analyses were blinded to both the medical treatment and the timing of image acquisition. Results: Follow up revealed the risk of worsening cardiovascular abnormalities to be 60% in patients who continued ergot-derived DA treatment, compared to 14% in those who changed to, or continued with, non-ergot-derived DA medication (p <0.05). Overall, patients who changed from ergot-derived to non-ergot-derived DAs did not exhibit any significant worsening or improvement of their valve abnormality, although the pulmonary artery pressure (PAP) fell from 26 +/- 12 mmHg to 22 +/- 8 mmHg at follow up (p <0.005). Conclusion: At one year after discontinuation of ergot-derived DAs, a mild but statistically significant reduction in PAP was detected. Overall, valvular regurgitation remained without definite worsening or improvement in these patients. Among patients who continued ergot-derived DAs despite a cardiovascular abnormality, the follow-up indicated an increased risk of worsening.

INTRODUCTION We have experienced a growing demand from patients for minimally invasive cardiac surgery. MATERIAL AND METHODS From March 2006 through November 2007 we performed endoscopic mitral valve surgery in 30 patients (20 mitral valve repairs, eight mitral valve replacements and two extirpations of mitral valve fibroelstoma). Seven patients had concomitant surgery, including cryomaze to eliminate atrial fibrillation and/or closure of an atrial septal defect (ASD). Median preoperative functional class was New York Heart Association (NYHA) II and all patients had severe mitral valve regurgitation. The mean age was 58.0 +/-3 years and 27% of the patients were females. RESULTS The procedure was performed successfully in all patients with no conversion to sternotomy, while postoperative morbidity was very limited and no mortality was seen. Early echocardiographic follow-up showed fully competent mitral valve repairs. CONCLUSION Endoscopic mitral valve surgery is an attractive alternative to conventional sternotomy with an attractive cosmetic result. This can be obtained without compromising quality or safety. This paper confirms that endoscopic mitral valve surgery is feasible and it provides the least invasive operative approach. The technique is currently our primary surgical approach for mitral valve disease.

Left atrial myxomas are extremely difficult to diagnose since their variable manifestations mimic a host of clinical entities more commonly seen, e.g. mitral stenosis, endocarditis, rheumatic fever, cardiomyopathy or mesenchymosis. At the same time, early diagnosis followed by prompt surgical removal are mandatory to prevent mutilating or lethal complications of the tumor. Six cases of left atrial myxoma were diagnosed in our hospital during 2 1/2 years. We present the case histories, diagnostic procedures and surgical findings, consolidating the unique role of echocardiography in detecting left atrial myxomas. We propose the use of echocardiography as a screening examination for atrial myxomas in the following settings: suspected mitral obstructive disease, suspected endocarditis with negative blood cultures, peripheral embolism or thrombosis in young patients, unexplained cardiac failure and mesenchymosis with uncharacteristic presentation.