This document discusses flail mitral leaflet, which is a condition where a mitral valve leaflet ruptures causing it to flutter aimlessly in the heart. Some key points:
1. A study of 229 patients with flail leaflet found that long term survival with medical treatment was poorer than expected, with death from cardiac causes being 21% at 5 years and 33% at 10 years.
2. Multivariate analysis showed that age, NYHA functional class, and ejection fraction independently predicted survival.
3. Surgery occurred in 62% of patients after a mean of 23 months, with 5-year survival being 79% and 10-year survival being 66%.
A estenose mitral é quase sempre resultado da febre reumática e causa um estreitamento da válvula mitral, levando a aumento da pressão no átrio esquerdo e nas veias pulmonares. Isso gera sintomas como dispnéia em esforço e pode evoluir para hipertensão pulmonar. O exame físico revela um sopró diastólico mesodiastólico e testes complementares como ecocardiograma e radiografia de tórax fornecem mais detalhes. O tratamento inclui medicamentos e
Anatomy of mitral valve echo evaluationmadhusiva03
The document discusses the anatomy and function of the mitral valve complex. It notes that the mitral valve has a triple function regulating blood flow between the left atrium and ventricle. The mitral valve complex relies on normal morphology and function of the annulus, leaflets, chordae tendineae, papillary muscles, and left ventricle. Echocardiography is useful for evaluating each of these structures and identifying abnormalities that can cause mitral dysfunction. Detailed assessment of the leaflet segments, called scallops, aids in characterizing valvular lesions.
This document provides an overview of the anatomy and assessment of the mitral valve using transesophageal echocardiography (TEE). It describes the components of the mitral valve complex including the annulus, leaflets, chordae tendineae, and papillary muscles. It outlines different TEE views used to evaluate the mitral valve and provides details on quantifying mitral stenosis and regurgitation. Causes of mitral valve dysfunction like rheumatic heart disease and ischemic mitral regurgitation are summarized. Assessment of mitral valve repair is also discussed, including complications like paravalvular leaks and systolic anterior motion.
JetBlue has strengths in effective aircraft operations, positioning in New York, and active marketing with low distribution costs. However, it has weaknesses such as high debt obligations, sluggish profits, and low margins. External opportunities include recovery of the US airline industry and benefits to low-cost carriers in a weak economy, but threats include intense price competition, industry consolidation, terrorism, and increased government regulations.
My cousin helped me buy my first car after graduating and finding a job. We had an intense negotiation with the dealer that lasted all day before finally agreeing on a price the next morning. The experience taught me lessons about not rushing into big purchases, being influenced by others, and choosing negotiating partners wisely.
JetBlue has strengths in effective aircraft operations, strong positioning in the New York metropolitan area, and active marketing with low-cost distribution channels. However, JetBlue also has weaknesses such as high debt and fixed obligations, sluggish profits and margins. External threats include intense competition from low-cost airlines, industry consolidation, terrorism, and increased government regulations. The recovery of the US airline industry works in JetBlue's favor.
Peritonitis in patients undergoing peritoneal dialysis is commonly diagnosed based on symptoms of fever, abdominal pain, and nausea, along with lab findings of increased white blood cells over 100 cells/mm3 with neutrophil predominance. Infections are often gram positive or gram negative bacteria but about 20% have no growth on culture. Fungal infections are rare but Candida is the most common cause. Noninfectious complications include GERD, vomiting, electrolyte abnormalities like hypokalemia, and potentially fatal acute mesenteric ischemia.
A estenose mitral é quase sempre resultado da febre reumática e causa um estreitamento da válvula mitral, levando a aumento da pressão no átrio esquerdo e nas veias pulmonares. Isso gera sintomas como dispnéia em esforço e pode evoluir para hipertensão pulmonar. O exame físico revela um sopró diastólico mesodiastólico e testes complementares como ecocardiograma e radiografia de tórax fornecem mais detalhes. O tratamento inclui medicamentos e
Anatomy of mitral valve echo evaluationmadhusiva03
The document discusses the anatomy and function of the mitral valve complex. It notes that the mitral valve has a triple function regulating blood flow between the left atrium and ventricle. The mitral valve complex relies on normal morphology and function of the annulus, leaflets, chordae tendineae, papillary muscles, and left ventricle. Echocardiography is useful for evaluating each of these structures and identifying abnormalities that can cause mitral dysfunction. Detailed assessment of the leaflet segments, called scallops, aids in characterizing valvular lesions.
This document provides an overview of the anatomy and assessment of the mitral valve using transesophageal echocardiography (TEE). It describes the components of the mitral valve complex including the annulus, leaflets, chordae tendineae, and papillary muscles. It outlines different TEE views used to evaluate the mitral valve and provides details on quantifying mitral stenosis and regurgitation. Causes of mitral valve dysfunction like rheumatic heart disease and ischemic mitral regurgitation are summarized. Assessment of mitral valve repair is also discussed, including complications like paravalvular leaks and systolic anterior motion.
JetBlue has strengths in effective aircraft operations, positioning in New York, and active marketing with low distribution costs. However, it has weaknesses such as high debt obligations, sluggish profits, and low margins. External opportunities include recovery of the US airline industry and benefits to low-cost carriers in a weak economy, but threats include intense price competition, industry consolidation, terrorism, and increased government regulations.
My cousin helped me buy my first car after graduating and finding a job. We had an intense negotiation with the dealer that lasted all day before finally agreeing on a price the next morning. The experience taught me lessons about not rushing into big purchases, being influenced by others, and choosing negotiating partners wisely.
JetBlue has strengths in effective aircraft operations, strong positioning in the New York metropolitan area, and active marketing with low-cost distribution channels. However, JetBlue also has weaknesses such as high debt and fixed obligations, sluggish profits and margins. External threats include intense competition from low-cost airlines, industry consolidation, terrorism, and increased government regulations. The recovery of the US airline industry works in JetBlue's favor.
Peritonitis in patients undergoing peritoneal dialysis is commonly diagnosed based on symptoms of fever, abdominal pain, and nausea, along with lab findings of increased white blood cells over 100 cells/mm3 with neutrophil predominance. Infections are often gram positive or gram negative bacteria but about 20% have no growth on culture. Fungal infections are rare but Candida is the most common cause. Noninfectious complications include GERD, vomiting, electrolyte abnormalities like hypokalemia, and potentially fatal acute mesenteric ischemia.
The document discusses strategies for foreign market entry, including overcoming liability of foreignness, understanding factors that influence internationalization, and a comprehensive model for foreign market entries. It addresses questions of where, when, and how to enter foreign markets, analyzing location-specific advantages, timing of market entry, and options for entry modes. Key tradeoffs between equity and non-equity entry modes like exports, licensing, and foreign direct investment are also summarized.
This document discusses syncope, which is a transient loss of consciousness due to temporary reduced blood flow to the brain. It notes that syncope accounts for around 1% of emergency department visits and is a common cause of hospitalization for those over 65. Establishing the exact cause is difficult as the patient has usually recovered by the time they are examined. The document then discusses various causes of syncope and nonsyncopal attacks that can be mistaken for syncope. It provides breakdowns of common causes by age group and discusses the natural history and risk stratification of syncope of unknown cause in the emergency department.
Myocardial Viability - the STICH Trial NEJM May 2011callroom
This study examined whether testing for myocardial viability can identify patients with coronary artery disease and left ventricular dysfunction who benefit most from coronary artery bypass grafting (CABG) compared to medical therapy alone. Of over 1200 patients enrolled in the main trial, 601 who underwent viability testing by single-photon emission computed tomography (SPECT) or dobutamine echocardiography were included in this substudy. Patients who had viability testing were more likely to have certain risk factors and worse heart function. The study aimed to determine if viability testing could identify which patients would have improved survival rates with CABG versus medical therapy.
This document discusses flail mitral leaflet, which is a cause of mitral regurgitation requiring surgical correction. It occurs when the chordae tendineae connecting the mitral leaflet to the papillary muscles rupture. This causes the mitral leaflet to flail or balloon into the left atrium during systole. If left untreated, it can lead to complications like congestive heart failure, atrial fibrillation, thromboembolism and death. Surgical repair or replacement of the mitral valve is usually required to treat significant flail mitral leaflet.
This study examined the association between cardiorespiratory fitness, adiposity, and mortality in older adults. It found that higher fitness levels were associated with lower mortality rates regardless of body composition. Specifically, even obese individuals had lower mortality if they were fit compared to unfit normal-weight or lean individuals. The study also found a J-shaped relationship between BMI and mortality both before and after adjusting for fitness levels.
An 80 year old female with a history of hypertension, hyperlipidemia, diabetes, and prior stroke presented with 2 weeks of continuous chest pain and was found to have a left bundle branch block. Cardiac enzymes were negative. She was transferred to the hospital for further management and evaluation.
This document describes a case of an 80 year old female patient with a history of hypertension, hyperlipidemia, diabetes, and prior stroke who presented with 2 weeks of continuous chest pain. She was found to have left bundle branch block of unknown duration on EKG. Cardiac enzymes were negative. The patient was transferred for further cardiac management.
The document discusses several cases presenting with abnormal liver function tests (LFTs). Case 1 shows a mild isolated transaminitis. Case 2 involves severe hepatocellular injury and mild cholestasis in an alcoholic patient. Case 3 examines LFT patterns in an alcoholic cirrhotic with possible alcoholic hepatitis.
This document summarizes methods for predicting the functional effects of amino acid substitutions, including SIFT (Sorts Intolerant From Tolerant), which uses sequence conservation to predict whether an amino acid substitution will affect protein function. SIFT has similar prediction accuracy to tools using protein structure. Case studies on disease genes like MSHR, PPARα, and MTHFR show SIFT can distinguish pathogenic from benign variants and detect variants under balancing selection. Focusing genetic association studies on predicted functional variants in genes and conserved non-coding regions improves the direct approach to finding disease loci.
This document summarizes a 56-year-old African American man who presented to the hospital after an abnormal stress test. He has a history of hypertension and was previously diagnosed with left ventricular hypertrophy. A recent stress test found ventricular tachycardia and imaging showed an apical aneurysm and small inferior wall ischemia. He is currently taking medications for hypertension and has a family history of coronary artery disease.
Clostridium difficile infection rates in the US increased from 30-40 per 100,000 in the mid-1990s to 84 per 100,000 in 2005, and in Britain C. diff became the primary cause of an increasing number of deaths from 499 in 1999 to 3393 in 2006. While metronidazole and vancomycin have been the standard treatments since the 1970s, failure rates for metronidazole increased significantly to 18.2% since 2000. Metronidazole is recommended as the first line treatment for mild cases, but vancomycin should be used for more severe infections. The ultimate goal in treating recurrent C. diff infections is to discontinue all antibiotics
The document provides an overview and introduction to the key features and functionality of the Android 2.3 mobile operating system. It describes how to perform basic tasks like starting up Android for the first time, getting familiar with the home screen and user interface, managing notifications, using applications and more. The guide is organized by topic, with each section providing details on a different aspect of the Android system like calls, contacts, browsing the web, and changing system settings.
- A 53-year-old female with a history of breast cancer was admitted for an elective ureteral stent placement due to tumor compression of her left ureter.
- Shortly after the uncomplicated procedure, the patient became hypotensive, hypoxic, and unresponsive. Imaging showed bowel ischemia with pneumatosis and hemoperitoneum.
- Despite pressor support and broad-spectrum antibiotics, the patient's condition deteriorated and she eventually passed away.
The document discusses the use of an intra-aortic balloon pump (IABP), including appropriate timing of inflation in the cardiac cycle, risks of premature or late deflation, and guidelines for weaning a patient from the device. It notes that the IABP has applications in cardiac failure, refractory angina, cardiogenic shock, and as a bridge to transplantation. Risks include limb ischemia, thrombosis, emboli, bleeding, and aortic complications. Weaning should occur over 24-48 hours with decreasing inotropic support and pump ratios monitored closely.
A 45-year-old Pakistani man presented with chest pain and was found to have a ventricular septal defect. He required an intra-aortic balloon pump and intubation due to worsening pulmonary edema. On the fifth day of hospitalization, the patient underwent surgical repair of the ventricular septal defect. Post-operatively, the patient developed complications including confusion, renal and hepatic failure, and left-sided weakness.
The document discusses strategies for foreign market entry, including overcoming liability of foreignness, understanding factors that influence internationalization, and a comprehensive model for foreign market entries. It addresses questions of where, when, and how to enter foreign markets, analyzing location-specific advantages, timing of market entry, and options for entry modes. Key tradeoffs between equity and non-equity entry modes like exports, licensing, and foreign direct investment are also summarized.
This document discusses syncope, which is a transient loss of consciousness due to temporary reduced blood flow to the brain. It notes that syncope accounts for around 1% of emergency department visits and is a common cause of hospitalization for those over 65. Establishing the exact cause is difficult as the patient has usually recovered by the time they are examined. The document then discusses various causes of syncope and nonsyncopal attacks that can be mistaken for syncope. It provides breakdowns of common causes by age group and discusses the natural history and risk stratification of syncope of unknown cause in the emergency department.
Myocardial Viability - the STICH Trial NEJM May 2011callroom
This study examined whether testing for myocardial viability can identify patients with coronary artery disease and left ventricular dysfunction who benefit most from coronary artery bypass grafting (CABG) compared to medical therapy alone. Of over 1200 patients enrolled in the main trial, 601 who underwent viability testing by single-photon emission computed tomography (SPECT) or dobutamine echocardiography were included in this substudy. Patients who had viability testing were more likely to have certain risk factors and worse heart function. The study aimed to determine if viability testing could identify which patients would have improved survival rates with CABG versus medical therapy.
This document discusses flail mitral leaflet, which is a cause of mitral regurgitation requiring surgical correction. It occurs when the chordae tendineae connecting the mitral leaflet to the papillary muscles rupture. This causes the mitral leaflet to flail or balloon into the left atrium during systole. If left untreated, it can lead to complications like congestive heart failure, atrial fibrillation, thromboembolism and death. Surgical repair or replacement of the mitral valve is usually required to treat significant flail mitral leaflet.
This study examined the association between cardiorespiratory fitness, adiposity, and mortality in older adults. It found that higher fitness levels were associated with lower mortality rates regardless of body composition. Specifically, even obese individuals had lower mortality if they were fit compared to unfit normal-weight or lean individuals. The study also found a J-shaped relationship between BMI and mortality both before and after adjusting for fitness levels.
An 80 year old female with a history of hypertension, hyperlipidemia, diabetes, and prior stroke presented with 2 weeks of continuous chest pain and was found to have a left bundle branch block. Cardiac enzymes were negative. She was transferred to the hospital for further management and evaluation.
This document describes a case of an 80 year old female patient with a history of hypertension, hyperlipidemia, diabetes, and prior stroke who presented with 2 weeks of continuous chest pain. She was found to have left bundle branch block of unknown duration on EKG. Cardiac enzymes were negative. The patient was transferred for further cardiac management.
The document discusses several cases presenting with abnormal liver function tests (LFTs). Case 1 shows a mild isolated transaminitis. Case 2 involves severe hepatocellular injury and mild cholestasis in an alcoholic patient. Case 3 examines LFT patterns in an alcoholic cirrhotic with possible alcoholic hepatitis.
This document summarizes methods for predicting the functional effects of amino acid substitutions, including SIFT (Sorts Intolerant From Tolerant), which uses sequence conservation to predict whether an amino acid substitution will affect protein function. SIFT has similar prediction accuracy to tools using protein structure. Case studies on disease genes like MSHR, PPARα, and MTHFR show SIFT can distinguish pathogenic from benign variants and detect variants under balancing selection. Focusing genetic association studies on predicted functional variants in genes and conserved non-coding regions improves the direct approach to finding disease loci.
This document summarizes a 56-year-old African American man who presented to the hospital after an abnormal stress test. He has a history of hypertension and was previously diagnosed with left ventricular hypertrophy. A recent stress test found ventricular tachycardia and imaging showed an apical aneurysm and small inferior wall ischemia. He is currently taking medications for hypertension and has a family history of coronary artery disease.
Clostridium difficile infection rates in the US increased from 30-40 per 100,000 in the mid-1990s to 84 per 100,000 in 2005, and in Britain C. diff became the primary cause of an increasing number of deaths from 499 in 1999 to 3393 in 2006. While metronidazole and vancomycin have been the standard treatments since the 1970s, failure rates for metronidazole increased significantly to 18.2% since 2000. Metronidazole is recommended as the first line treatment for mild cases, but vancomycin should be used for more severe infections. The ultimate goal in treating recurrent C. diff infections is to discontinue all antibiotics
The document provides an overview and introduction to the key features and functionality of the Android 2.3 mobile operating system. It describes how to perform basic tasks like starting up Android for the first time, getting familiar with the home screen and user interface, managing notifications, using applications and more. The guide is organized by topic, with each section providing details on a different aspect of the Android system like calls, contacts, browsing the web, and changing system settings.
- A 53-year-old female with a history of breast cancer was admitted for an elective ureteral stent placement due to tumor compression of her left ureter.
- Shortly after the uncomplicated procedure, the patient became hypotensive, hypoxic, and unresponsive. Imaging showed bowel ischemia with pneumatosis and hemoperitoneum.
- Despite pressor support and broad-spectrum antibiotics, the patient's condition deteriorated and she eventually passed away.
The document discusses the use of an intra-aortic balloon pump (IABP), including appropriate timing of inflation in the cardiac cycle, risks of premature or late deflation, and guidelines for weaning a patient from the device. It notes that the IABP has applications in cardiac failure, refractory angina, cardiogenic shock, and as a bridge to transplantation. Risks include limb ischemia, thrombosis, emboli, bleeding, and aortic complications. Weaning should occur over 24-48 hours with decreasing inotropic support and pump ratios monitored closely.
A 45-year-old Pakistani man presented with chest pain and was found to have a ventricular septal defect. He required an intra-aortic balloon pump and intubation due to worsening pulmonary edema. On the fifth day of hospitalization, the patient underwent surgical repair of the ventricular septal defect. Post-operatively, the patient developed complications including confusion, renal and hepatic failure, and left-sided weakness.
2. Mitral Valve Prolapse - General Considerations The n e w e ng l a n d j o u r na l of m e dic i n e
•
A
Epidemiology Aortic valve
• Likely occurs in around 2 to 5 percent of the Left coronary
population artery Right fibrous
trigone
• Terminology
Left fibrous
Bundle of
His
• Normally the mitral valve billows slightly into
trigone
the LA - if this is exaggerated it is called a AC Anterior leaflet PC
billowing mitral valve
Circumflex
•
artery
Floppy valve is an extreme form of billowing Posterior leaflet
Coronary
Annulus
•
sinus
Flail leaflet occurs with a ruptured chordae
B C
•
Annulus
MVP is characterized by myxomatous degeneration Leaflet
• In younger patient’s it manifests as excess
leaflet tissue with diffuse, generalized thickening AC PC
Secondary
cord
A3
of the valve -> Barlow’s Syndrome A1 Primary
cord
A2 P3
•
P1
In older patients, the prolapsing mitral valve P2
tends to have thickening to an isolated area -> Papillary
muscle
fibroelastic dysplasia
• Increasing severity of MR imposes volume load on Figure 1. The Mitral Valve.
the LV resulting ventricular dilation, hypertrophy, The mitral valve has anterior and posterior leaflets, which are separated by the anterior commissure (AC) and the
and heart failure
Braunwald et al. p1565-7
posterior commissure (PC) (Panel A). The leaflets are inserted on the circumference of the mitral annulus, which is
in continuity with the aortic annulus and the left and right fibrous trigones. The circumflex coronary artery, coronary
Foster, E NEJM 2010
sinus, aortic valve, and bundle of His are all close to the mitral valve. Panel B shows the mitral-valve leaflets, each of
which usually consists of three discrete segments or scallops. These are designated A1, A2, and A3 for the anterior
leaflet and P1, P2, and P3 for the posterior leaflet. The valve leaflets each receive chordae tendineae from the anter-
3. The Ruptured Chordae
• In Western countries, flail mitral leaflet is The n e w e ng l a n d j o u r na l of m e dic i n e
the most common cause of mitral
regurgitation requiring surgical correction
• Abnormalities of the chordae are
important causes of MR
• May be congenitally abnormal
• Causes of rupture
• Spontaneous (primary)
• Infective endocarditis
• Trauma
• Osteogenesis imperfecta
• Relapsing polychondritis
• Acute LV dilation
• No identifiable case is apparent
other than increased mechanical
Figure 2. Echocardiographic Evidence of Rupture of the Elongated Chordae.
strain Panel A, in the parasternal long-axis view, shows severe displacement of the posterior leaflet (arrow). Panel B,
•
a Doppler color-flow echocardiogram, shows severe mitral regurgitation. Panel C shows the M mode of the mitral
Chordae in the posterior leaflet valve with color flow superimposed, indicating holosystolic mitral regurgitation (arrow). Panel D, a transesophageal
echocardiogram, shows a flail posterior mitral leaflet (ML, arrow). LA denotes left atrium, and LV left ventricle.
rupture more frequently than the Foster, E NEJM 2010
anterior leaflet Baxley, Wi Circulation 1973
veloped countries who have native-valve endo- the onset of atrial fibrillation may have an abrupt
11
4. Death from cardiac cause 31 21 4 33 7 4.3 25 9 32 11 0.10
Outcome in patients with flail leaflet
Congestive heart failure 55 30 4 63 8 8.2 53 10 82 14 0.015
Chronic atrial fibrillation† 13 8 3 30 12 2.2 30 16 29 17 0.13
CLINICAL OUTCOME OF MITRAL REGURGITATION DUE TO FL AIL LEAFLET
Thromboembolism 13 12 3 12 3 1.9 10 3 19 9 0.36
Hemorrhage 3 1 1 3 2 0.4 2 2 8 8 0.62
Endocarditis 10 5 2 8 3 1.5 9 4 0 0.45
• Study Design Mitral-valve surgery
Mitral-valve surgery or death
143
188
57
69
3 82 4
90 2.
20.0
26.3
71 7 93 6 0.001
3 TABLE 3 OUTCOME AT 80AND 10 YEARS WITH MEDICAL TREATMENT OF MITRAL
5 5 96 4 0.001
• 229 patients with flail leaflet diagnosed btw Janin1980 and Dec
Outcome subgroups of
patients
REGURGITATION DUE TO FLAIL LEAFLET.*
1989 at Mayo Clinic had clinical follow-upDeath obtained
data 10-YEAR RATE ACCORDING
through 1994-5 NYHA class III or IV
NYHA class I or II‡
86 EVENT —
18 4
9
33 9
34.0
4.1
OVERALL POPULATION TO NYHA CLASS
LINEAR-
•
Ejection fraction 60% 24 4 39 8 5.3
Exclusion criteria - papillary muscle rupture, previous valve
IZED
Ejection fraction 60%§ 47 11 60 12 11.3 NO. OF 5-YEAR 10-YEAR YEARLY P
Congestive heart failure I II
surgery, associated aortic or congenital heart disease Left atrial diameter 18 5 59 12 5.4
EVENTS RATE RATE RATE CLASS CLASS VALUE
30 mm/m2 ‡ percent
• Results Left atrial diameter
30 mm/m2
47 9 75 10
Death from any cause
Death from cardiac cause
14.5
45
31
28 4
21 4
43 7
33 7
6.3
4.3
32
25
9
9
34
32
11
11
0.26
0.10
• Baseline Characteristics *Plus–minus values are means SE. NYHACongestive heart failure
denotes New York Heart Association. 30 4 63 8
55
Chronicat risk fibrillation† atrial fibrillation,8and all 30 12
†The 175 patients presenting in sinus rhythm were atrial for chronic 13 3 229
8.2
2.2
53
30
10
16
82
29
14
17
0.015
0.13
• 82 % of patients had a history of murmur or cardiac Thromboembolism
patients were at risk for all the other end points.
‡P 0.001 as compared with the higher category.Hemorrhage
13
3
12 3
1 1
12 3
3 2
1.9
0.4
10
2
3
2
19
8
9
8
0.36
0.62
symptoms > 3 months Endocarditis 10 5 2 8 3 1.5 9 4 0 0.45
§P 0.034 as compared with the higher category.
•
Mitral-valve surgery 143 57 3 82 4 20.0 71 7 93 6 0.001
77% of patients did not have an identifiable cause Mitral-valve surgery or death 188 69 3 90 3 26.3 80 5 96 4 0.001
Outcome in subgroups of
• 82% had posterior leaflet involvement Death
patients
•
NYHA class III or IV 86 9 — 34.0
87% of patient had grade 3 or 4 MR
In the multivariate analysis (Table 3), the base-line NYHA class I 100 or II‡ 18 4 33 9 4.1
variables that were independently predictive of sur- Ejection fraction 60%§
Ejection fraction 60% 24 4 39 8 5.3
• Overall Outcomes vival were age, NYHA class, and ejection fraction. Congestive heart failure80 47 11 60 12 11.3 Expected
Survival (%)
Figures 2 and 3 show the Kaplan–Meier survival Left atrial diameter 18 5 59 12 5.4
30 mm/m260
• Long term survival with medical treatment was shorder
curves according to NYHA class and ejection frac- Left atrial diameter
tion, respectively. 30 mm/m240
‡
47 9 75 10 14.5 Observed
than expected survival
The incidence of congestive heart failure was *Plus–minus values are means SE. NYHA denotes New York Heart Association.
•
20
The rate of death 30 4 cardiac causes was 21+4 percent at 10 †The 175 patients presenting in sinus rhythm were at risk for chronic P 0.016
from percent at 5 years and 63 8 percent atrial fibrillation, and all 229
years (Fig. 4). 10 years
at 5 years and 33+7 percent at Multivariate predictors of the devel- patients were at risk for all the other end points.
0
opment of congestive heart failure were age, ejection ‡P 0.001 as compared with the higher3 4 5 6 7 8 9 10
0 1 2 category.
• Multivariate analysis showed that age, NYHA class, and for body-
fraction, and left atrial diameter adjusted
surface area (Table 3). Of the 55 patients with a first
§P 0.034 as compared with the higher category.
Years after Diagnosis
EF were independent predictors of survival the diagnosis of mitral
episode of heart failure after NO. AT RISK 229 133 115 103 84 70 52 34 21 12 7
• Surgery regurgitation, 27 (49 percent) underwent surgery.
Most of the remaining patients had symptomatic
Figure 1. Long-Term Survival with Medical Treatment, as Com-
pared with Expected Survival, in 229 Patients with Mitral Re-
In the multivariate analysis (Table 3),to Flail Leaflet.
gurgitation Due the base-line 100
• Occurred in 62% of patients with a medicalof 23+32 butthat were independently predictive of sur-
improvement with mean treatment,
variables
these pa-
tients nevertheless had a higher mortality rate than 80
months vival were age, NYHA class, and ejection fraction.
urvival (%)
those without an episode of heart failure (adjusted
Figures 2 and 3 show the Kaplan–Meier survival 60
• hazard ratio, 16.53; 95 percent confidence interval, NYHA class and ejection frac-
5 yr survival was 79% and31.36; P 0.001). 66% that according to
8.72 to
10 yr survival was curves Ling, LH NEJM 1996
was not different than expected survival were tion, respectively. at
Of the 175 patients who in The incidence of congestive heart failure was
sinus rhythm
40
5. AF Per AF present 2.40 0.97–5.95 0.059
*There were 347 patients in the model.
The risk of sudden death
AF atrial fibrillation; CI confidence interval; EF ejection fraction; NYHA New York Heart Association.
II and 7.8% in class III or IV (p 0.0001) (Fig. 2). fibrillation at diagnosis (p 0.0004) (Fig. 4). Among the 25
However, of the 25 patients with SUD, 10 were in func- patients with SUD, 16 (64%) were in sinus rhythm at
• Study Designclass I at was in class wereAmong the 5 were in class baseline and 13patients who until SUD. SUD (20%) pre-
tional
III and only 1
diagnosis, 9
IV.
in class II,
19 patients in
class I or II at baseline, 10 (five in each class) had worsening
Overall, five
remained so
experienced
•
sented no evidence at any time during their follow-up of
Pts first diagnosedSUD. These patients did not undergo atrial fibrillation,anddysfunction or severe symptoms,not undergo
of symptoms before with flail mitral leaflet btw Jan 1980 LV Dec 1994 who did until
surgical correction within one rapidly withof diagnosis
surgery because the symptoms improved
monthof treat- SUD.
ment and were not considered disabling. The rate SUD
Associated treatment—SUD. No significant differences
•
was higher in functional class II than in class I (p 0.01).
Exclusion criteria - papillary muscle rupture, previous valve surgery, associated during or
However, this difference was confined to patients with were detected comparing the medical treatment aortic
follow-up of group I versus group II or III with respect to
congenital heart disease and EF (p 60%0.002).consid- angiotensin-converting enzyme inhibitors, calcium channel
either atrial fibrillation or EF 60%
only patients in sinus rhythm were
When
blockers, beta-blockers, digoxin, hydralazine, class I antiar-
• ered, yearly rates of SUD in patients in functional class II
Results and I were not different (0.5% and 0.9%, respectively; p
0.60; average 0.8%). The linearized rate of SUD in patients
rhythmic agents, diuretics or nitrates (all p 0.10). How-
ever, when compared with survivors, group I patients were
• Duringfunctional class I or II, in sinus rhythm, with EF 60% more+often months, 27% 0.001), calcium died and 7% of
in a mean medical follow-up of 48 months
and with no history of CAD was also 0.8% per year.
41 taking digoxinp (68%of patient channel
diuretics (80% vs. 28%;
vs. 43%; p 0.008),
patient suffered fromrates of SUDdeath with a blockers (28% vs. 11%; p 0.001) and nitrates (16% vs. 5%;
The yearly linearized sudden in patients
baseline EF 50% were 12.7%, 0.9% for an EF 50% to 59% p 0.03) and were less often taking beta-blockers (4% vs.
• By multivariate 60% (p 0.0001) (Fig. 3).predictors of sudden death were functional class, EF,
and 1.5% for an EF analysis baseline Among 17%; p 0.09).
development SUD,2EF at diagnosis was infibrillation In patients who underwent the operation, SUD occurred
the 25 patients with
(68%), 50% to 59% in
of CHF, and atrial 60% in 17 postoperatively in seven, leading to a total number of 32
(8%) and 50% 6 (24%).
•
Echocardiography, repeated in five patients within six SUDs in the cohort. In a multivariate proportional hazards
Occurs SUD, showed a decrease of EF under 60% in year and accounts for one-fourthof SUD, deaths under
months of in a linearized rate of 1.8% per analysis that included the significant predictors of all
conservativepatient.EF was confirmed in functional surgery performed at any time (time-dependent variable)
and 50% in one
management
only one patient, whereas
Of the 19 patients
60% in three
independently and favorably influenced the incidence of
• class I or II who had SUD, 15 had an EF 60% (eight in
class I and seven in class risk
The yearly linearized rates of SUD in patients in sinus
unexpected death (adjusted hazard ratio 0.29 [95% CI 0.11
In the absence ofII). factors there remains a 0.8% riskThis effect persistedsudden entire
to 0.72], p 0.007). per year of when the death
cohort (n 468) was analyzed (p 0.0001) and when the
• Surgery was associated with a reduction in the rate of sudden death (p 0.007)
rhythm was 1.3%, whereas it was 4.9% in patients with atrial
Grigioni et al.
JACC 1999
Figure 2. Relation between New York Heart Association Figure 3. Relation between left ventricular ejection fraction
6. Surgery and Flail Leaflet
Early Surgery in Patients with Mitral Regurgitation
Due to Flail Leaflet, Circulation 1997
• Study Design
• 221 patients (mean age 65+13 years, 71%
males) with flail leaflets diagnosed from
1980-9 at Mayo Clinic
• Patients divided in 2 grps
• Grp 1 63 patients who had early
surgery
• Grp II 158 patients initially treated
conservatively (80 of which were
operated on later
Outcomes in Mitral Regurgitation Due
to Flail Leaflets, JACC 2008
• Study Design
• 394 patients enrolled from 4 European centers
(mean age 64 + 11 years, 67% men)
• Study enrolled patients between 1988 and
2004 with a median follow up of 3.9 years
• Eligibility criteria
• Presence of echo diagnosed flail leaflet
• Exclusion of ischemic MR (incliding pap
Outcome in all 394
Outcomes in 102
muscle rupture, AV disease, congenital asymptomatic patients
disease or mitral stenosis patients
with EF>60%