BACKGROUND AND PURPOSE: (As are found in 2.3% of adults; the mean age at detection is 52 years. Prevalence is <0.5% in young adults. Early studies suggest that 10%-50% of patients with aortic coarctation have (As. Screening recommendations are variable. We sought to examine the prevalence of (As through screening with MRA.MATERIALS AND METHODS: Consecutive patients older than 16 years of age with coarctation undergoing brain MRA between May 1999 and October 2007 were included. MRA was performed by using a 1.5T scanner with a 3D time-of-flight protocol; simultaneous MR imaging was performed of the heart and aorta. Cerebral MRAs were double-reported by a neuroradiologist. Statistics are described as mean +/- SD and median range. Continuous variables were compared by using Student t tests and Mann-Whitney U tests (categoric variables, by using the Fisher exact test).RESULTS: One hundred seventeen MRAs were double-reported. The median age was 29 +/- 11 years (range, 16-59 years). IAs were found in 12 patients (10.3%). The mean diameter of (As was 3.9 mm (range, 2.0-8.0 mm). Patients with aneurysms were older (median, 37 years; range, 16-50 years) than those without (median, 23 years; range, 16-59 years; Z = -2.01, P = .04). Hypertension was more common in those with (As (IA 83% versus no IA 43%, P = .01). There was no association between ascending aortopathy, bicuspid aortic valves, and (As.CONCLUSIONS: Patients with coarctation have a higher prevalence of IAs, occurring at an earlier age than in population studies. Whether routine screening is appropriate for this group of patients is unclear. Hypertension is likely to be an important pathophysiologic factor.

Cardiac failure is a common medical presentation in Uganda. This study primarily focuses on the aetiology of heart failure in 65 adult patients and assesses the utility of echocardiography in a resource-limited setting. Our findings suggest that endomyocardial fibrosis is much less prevalent than previously described in other regions of Uganda and highlights the need for more basic descriptive studies on common presenting illnesses in rural Africa.

The 'left volume ventricular reduction' operation was originally proposed by Dr Batista to reduce the diameter of the dilated left ventricle by excising a sizable amount of the ventricular free wall. Batista explains that the mechanism of cardiac improvement totally depends on La Place's law, therefore left ventricular wall tension is decreased by reducing the diameter leading to an increase in ejection fraction. Questions, however, still remain on diastolic function, preoperative judgement of left ventricular wall characteristics and late re-dilatation of the left ventricle. The operation was originally performed using normothermic cardiopulmonary bypass on the beating heart. Additional techniques with cardioplegic arrest, concomitant mitral valve repair, and closure of the left ventricle for improvement of hemostasis are shown.

BACKGROUND:Midterm clinical and morphologic results of the septal-reshaping exclusion of anteroseptal dyskinetic or akinetic areas were evaluated.METHODS:From January to June 2003, 44 patients with myocardial infarction following left anterior descending coronary artery (LAD) occlusion underwent septal reshaping. The mean (+/- SD) New York Heart Association (NYHA) class of the patients at admission was 2.7 +/- 0.9. Angina was referred in 21 cases. The incision was started at the apex and directed parallel to the LAD toward the base of the heart. The septum was rebuilt with 1 or 2 U-stitches passed from the inside to join the anterior wall to the septum by starting as high as possible where the scar began and continuing in an oblique direction toward the new apex. An oval polyethylene terephthalate fiber (Dacron) patch was then sutured from the septum (at the end of the direct suture through the border with the inferior septum) to the anterior wall (between the healthy wall and the scarred wall) and up to the new apex.RESULTS:The 30-day mortality rate was 2.2% (1 patient, due to the failure of a previously implanted defibrillator). Three patients experienced acute renal failure. No patient had restrictive syndrome. After a mean follow-up period of 8.5 +/- 4.9 months (range, 4-22 months), the mean NYHA class improved from 2.7 +/- 0.9 to 1.6 +/- 0.5 (P < .001). The 18- month survival rate and the probability of being alive in NYHA class I or II were 93.2% +/- 2.0% and 90.9% +/- 4.3%, respectively. Echocardiographic results showed reductions in the left ventricle volume with a normalization of the stroke volume. The diastolic longitudinal length remained unchanged, and the diastolic sphericity index was reduced but not significantly.CONCLUSIONS:At 1 year after surgery, the good clinical and morphologic results demonstrate the safety and effectiveness of septal reshaping for anteroseptal scars.

A 78 year old woman presented to hospital with chest pain and anterior T wave changes. She was started on clexane, intravenous (iv) nitrate, and iv tirofiban, and transferred for inpatient cardiac catheterisation. The proximal left anterior descending (LAD) coronary artery showed a subtotal lesion, however the right coronary artery (RCA) could not be cannulated by an experienced operator. The aortogram showed flow into …

OBJECTIVES:The aim of this study was to quantify and compare effective doses from conventional angiography and multislice computed tomography (MSCT) coronary angiography using a 16-slice scanner.BACKGROUND:Multislice computed tomography is now a viable modality for cardiac imaging. However, for any diagnostic use of ionizing radiation, the risk to the patient must be considered and justified.METHODS:Multislice computed tomography angiography and conventional angiography were used to assess 180 patients with suspected coronary artery disease. Estimates of effective dose were derived from exposure data recorded for each patient examination. For each modality, a comparable calculation technique was used, based on Monte Carlo modeling of the standard Cristy phantom.RESULTS:In a subset of 91 directly comparable patients the mean effective dose for MSCT coronary angiography was 14.7 mSv (SD 2.2) and that for conventional angiography was 5.6 mSv (SD 3.6). A significant difference in effective dose was seen between the two protocols.CONCLUSIONS:The mean effective dose for MSCT coronary angiography was significantly higher than that for conventional angiography. As MSCT cardiac scanners become increasingly available, operators must be aware of the radiation dose and the factors that affect it.

Objective: Doppler echocardiographic evaluation of prosthetic heart valve function is usually performed at rest although this situation is not representative of patients' daily activities. Following aortic valve replacement. patients most likely to remain symptomatic are those with a small aortic root and dobutamine or exercise echocardiography has been proposed to elicit the presence of abnormal haemodynamics or persistently elevated transvalvular gradients in these patients. This study was carried out to compare dobutamine echocardiography with a symptom limited treadmill exercise echocardiography, in patients following aortic value replacement with a small size ( 19 mm) St. Jude Mechanical valve prosthesis. Methods: The studs, population consisted of ten unselected patients following aortic valve replacement. Dobutamine was infused intravenously starting at 5 mug/kg/min and increasing by 5 mug/kg/min at 15 min interval up to 20 mug/kg/min. Heart rate. blood pressure. cardiac output (170). peak and mean gradients as well as effective orifice area (EOA) were measured. These parameters were also measured following a symptom limited treadmill exercise. Results: Dobutamine stress increased heart rate (HR) and CO by 50 and 74%. respectively (both P < 0.0002), and mean transvalvular gradient from 22 +/- 4.1 mmHg at rest to 40.0 +/- 10 mmHg at maximum stress(P < 0.001). With exercise, HR and CO increased by 48 and 70 %. respectively while mean transvalvular gradient increased from 22 +/- 3.1 mmHg at rest to 38.0 +/- 6.4 mmHg (P < 0.0001). The maximum increase in HR. CO and mean transvalvular gradient with dobutamine and exercise were similar however, There was no significant change in the EOA with either dobutamine or exercise. Conclusion: The result suggests that both treadmill exercise and dobutamine stress echocardiography are equally effective for the hemodynamic evaluation of small aortic valve prosthesis. (C) 2002 Elsevier Science B.V. All rights reserved.

A 56-YEAR-OLD MAN was referred with a 2-week history of Staphylococcus aureus septicemia and bacterial endocarditis on the aortic valve. After 2 weeks of therapy with intravenous antibiotics, he was afebrile with a normal white blood cell count. Because of the appearance of vegetations and moderate-to-severe aortic regurgitation on transthoracic echocardiography, and in the presence of deteriorating renal and hemodynamic function, an aortic valve replacement was performed using a mechanical bileaflet prosthesis. Intraoperatively, inspection of the valve showed no active infection and no vegetations. The noncoronary leaflet of the aortic valve had been eroded, however, and had become detached from the valve annulus. Postoperatively the patient made a good recovery, was extubated on day 1, and was transferred to the regular ward. On the 5th postoperative day, the patient developed refractory pulmonary edema with deteriorating renal function. Transthoracic echocardiography showed no evidence of aortic regurgitation or valve failure. A pulmonary artery catheter was inserted, and pulmonary artery occlusion pressure was 20 cm H2O. A transesophageal echocardiogram was obtained (Figs 1 and 2). Fig. 2The same image as in Fig 1 with color-flow Doppler superimposed. View Large Image Figure Viewer Download Hi-res image What is the diagnosis?

We report 2 cases of localized pericardial tamponade occurring soon after cardiac surgery, in which the diagnosis could not be made with transthoracic echocardiography. Computed tomography and transesophageal echocardiography, respectively, were necessary, and this underlies the importance of alternative imaging modalities when this condition is suspected. A high index of suspicion is crucial for reaching the correct diagnosis.

Background. Small-sized mechanical aortic prostheses are commonly associated with generation of high transvalvular gradients, particularly in patients with large body surface area, and can result in patient-prosthesis mismatch. This study evaluates the hemodynamic performance of 21-mm Sorin Bicarbon bileaflet mechanical prostheses using dobutamine stress echocardiography.Methods. Fourteen patients (7 women; mean age, 63 +/- 8 years) who had undergone aortic valve replacement with a 21-mm Sorin Bicarbon bileaflet mechanical prosthesis 32.4 +/- 5.1 months previously were studied. After a resting Doppler echocardiogram, a dobutamine infusion was started at a rate of 5 mug (.) kg(-1 .) min(-1) and increased to 30 mug (.) kg(-1 .) min(-1) at 15-minute intervals. Pulsed-and continuous-wave Doppler echocardiographic studies were performed at rest and at the end of each increment of dobutamine. Both peak and mean velocity and pressure gradient across the prostheses were measured, and effective orifice area, discharge coefficient, and performance index were calculated.Results. Dobutamine stress increased heart rate and cardiac output by 83% and 81%, respectively (both p < 0.0001), and mean transvalvular gradient increased from 15.6 +/- 5.5 mm Hg at rest to 35.4 +/- 11.9 mm Hg at maximum stress (p < 0.0001). Although the indexed effective orifice area was significantly lower in patients with a larger body surface area, this was not associated with any significant pressure gradient. The performance index of this valve was unchanged throughout the study. Regression analyses demonstrated that the mean transvalvular gradient at maximum stress was independent of all variables except resting gradient (p = 0.05). Body surface area had no association with the changes in cardiac output, transvalvular gradient at maximum stress, and effective orifice area.Conclusions. These data show that the 21-mm Sorin Bicarbon bileaflet mechanical prosthesis offers an excellent hemodynamic performance with full utilization of its available orifice when implanted in the aortic position. The lack of significant transvalvular gradient in patients with a larger body surface area suggests that patient-prosthesis mismatch is highly unlikely when this prosthesis is used. (C) 2001 by The Society of Thoracic Surgeons.

Background. Concern has been raised about residual significant gradients when small aortic prostheses are used, particularly in patients with large body surface areas. We studied the performance of six types of small aortic prostheses using dobutamine stress echocardiography.Methods. Sixty-three patients (mean age, 67 +/- 7 years) who had undergone aortic valve replacement 17 +/- 6 months previously were studied. Two bileaflet mechanical prostheses (St. Jude Medical and CarboMedics: sizes, 19 mm and 21 mm) and two biological prostheses (Medtronic Intact and St. Jude BioImplant: size, 21 mm) were evaluated. A graded infusion of dobutamine was given and Doppler studies of valve performance were carried out.Results. All prostheses except one biological valve had acceptable hemodynamic performance under stress. Using regression modeling, gradient at rest was the only variable found to predict gradient under stress (p < 0.001). Moreover, the most important predictor of gradient at rest was valve design, which accounted for 72% of the variance (p < 0.001). This relationship was independent of valve size (19 mm or 21 mm) or material tie, mechanical or biological). Body surface area accounted for 4% of the variance in gradient only.Conclusions. The main predictor of transprosthetic gradient is the inherent characteristics of each particular prosthesis, with relatively insignificant contribution from variations in body surface area. Patient-prosthesis mismatch is not a problem of clinical significance when certain modern valve prostheses are used. (C) 1999 by The Society of Thoracic Surgeons.

This study examines the hemodynamic performance of small size St. Jude BioImplant aortic prostheses using dobutamine echocardiography. Eleven patients (3 women, mean age 75 years) who had undergone aortic valve replacement with a size 21-mm St. Jude BioImplant aortic prostheses at 10.8 +/- 5.1 months (SD) previously were studied. Dobutamine infusion was started at a rate of 5 microg/kg/min and increased to 10 microg/kg/min, and subsequently to 20 microg/kg/min at 15-minute intervals. Pulsed and continuous-wave Doppler studies were performed at rest and at the end of each stage. Effective orifice area, mean gradient, and the performance index across each prosthesis were calculated and cardiac output was determined by Doppler measurement of flow in the left ventricular outflow tract. Stress dobutamine increased heart rate and cardiac output by 51% and 56%, respectively (both p <0.0001), and the mean transvalvular gradient increased from 30.1 +/- 7.5 mm Hg at rest to 49.3 +/- 11.5 mm Hg at maximum stress (p <0.0005). The performance index increased progressively from 0.29 +/- 0.05 at rest to 0.40 +/- 0.10 at maximum stress (p <0.0005). Regression modeling analyses demonstrated that the maximum stress gradient was independent of all variables except the resting gradient (p = 0.03). Body surface area had no effect on the changes in cardiac output, effective orifice area, or transprosthetic gradient at maximum stress. Thus, these data demonstrate that the size 21-mm St. Jude BioImplant prosthesis exhibits suboptimal hemodynamic performance with transvalvular gradients consistent with mild to moderate aortic stenosis, both at rest and under stress conditions.