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Role of Echocardiography and Phonocardiography in Diagnosis of Mitral Paraprostheticregurgitation With

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Role of Echocardiography and Phonocardiography in Diagnosis of Mitral Paraprostheticregurgitation With Br Heart J: first published as 10.1136/hrt.35.12.1217 on 1 December 1973. Downloaded from British Heart Journal, I973, 35, I2I7-I225. Role of echocardiography and phonocardiography in diagnosis of mitral paraprosthetic regurgitation with Starr-Edwards prostheses H. C. Miller', D. G. Gibson, and J. D. Stephens From the Cardiac Department, Brompton Hospital, Fulham Road, London Twenty-three patients who were symptomatic after mitral valve replacement, and in whom mitral parapros- thetic regurgitation was a possible cause of deterioration, were investigated by cardiac catheterization, phono- cardiography, and echocardiography. Severe paraprosthetic regurgitation was present in ii patients and slight regurgitation in 2 patients. Two patients had aortic regurgitation which was responsible for their symptoms and the remaining 9 patients had either poor left ventricular function, an obstructed mitral prosthesis, or an obstructed tricuspid prosthesis. The various groups could not be identified on clinical, radiological, or electro- cardiographic features, but severe paraprosthetic regurgitation was associated with a reduced A2-OC interval on phonocardiography and normal septal movement with a large stroke volume on echocardiography. In view of the difficulties in clinical diagnosis, the value ofphonocardiography and echocardiography has been empha- sized, particularly in illpatients in whom, on the basis of these investigations, cardiac catheterization may be copyright. avoided. The results of mitral valve replacement continue to were investigated on account of deteriorating exercise improve (Barclay et al., I972; Morrow et al., I967; tolerance or the development of clinical evidence of Najafi et al., I969; Starr, I971). In a small pro- heart failure, with mitral paraprosthetic regurgitation portion of patients, however, the outcome may be as an important diagnostic possibility. They were di- and this is due to vided into 4 groups on the basis of the final diagnosis http://heart.bmj.com/ disappointing though usually made after cardiac catheterization (23 patients) or re- irreversible left ventricular disease, the possibility operation. Pertinent clinical details are given in Table i. of malfunction of the prosthesis or of additional un- Group i consisted of 9 patients in whom there was no corrected valve disease must always be considered evidence of paraprosthetic leak demonstrable by left (Peterson et al., I967; Rockoff et al., I966). Un- ventriculography. Symptoms were eventually ascribed fortunately, clinical diagnosis in this situation is to an obstructed mitral prosthesis in i, to an obstructed unreliable, so that a number of attempts have been tricuspid prosthesis in a second, and to left ventricular made to use non-invasive techniques in order to disease in the remainder, one of whom had in addition a improve diagnostic accuracy (Willerson et al., I972; small fistula between the left ventricle and coronary sinus. on September 27, 2021 by guest. Protected Wise, Webb-Peploe, and Oakley, 197I). We have Group 2 consisted of 2 patients in whom symptoms were ascribed to left ventricular disease, but who had, in studied a group of patients who deteriorated after addition, small leaks associated with the prosthesis. mitral valve replacement with a Starr-Edwards Operation was not advised in either and they continue on prosthesis, correlating the clinical, phono-, and medical treatment. echocardiographic features with the results of in- Group 3 consisted of ii patients with severe mitral vestigation by cardiac catheterization and angio- paraprosthetic leak, which was felt to be the cause of graphy in order to define their role in the diagnosis symptoms and who were therefore referred for operation. of mitral paraprosthetic leak. Group 4 contained 2 patients in whom symptoms were due primarily to aortic regurgitation, not corrected at Subjects the time of the first operation. Both were considerably Twenty-four patients were studied. All had mitral valve improved after aortic valve replacement. replacement with a Starr-Edwards prosthesis, and all Received 25 June 1973. Cardiac catheterization and angiography "Present address: Department of Medicine, Duke University This was performed using standard techniques. Left Medical Center, Durham, North Carolina, U.S.A. ventriculography was performed in the right anterior Br Heart J: first published as 10.1136/hrt.35.12.1217 on 1 December 1973. Downloaded from I2I8 Miller, Gibson, and Stephens TABLE I Clinical features Case Age Onset of Previous operation Factors Tricuspid Systolic Haemolysis Remarks No. and deteriora- on mitral valve predisposing to regurgn murmur sex tion after mitral para- operation prosthetic regurgitation Group I I 65F 8 mth Nil Ruptured chordae Present Soft apical Nil LV failure 2 44F I5 ,, Closed mitral None - None + Obstructed mitral valvotomy (2) prosthesis 3 5iF 9 ,, Nil Floppy valve Present Soft apical NR LV failure 4 siF 3 ,, Nil None Present Soft apical Nil LV failure 5 4iF 71 yr Nil None - None Nil Also tricuspid valve replace- ment, partially obstructed 6 54F IS mth Nil None Present Soft apical NR LV failure + left sternal edge 7 6oF I I , Closed mitral Calcification + Present Soft left NR LV failure valvotomy sternal edge 8 46M 44yr Closed mitral Calcification+ + Present Soft left NR LV failure valvotomy (2) sternal edge 9 58F 2 mth Closed mitral Calcification + + Present Soft apical NR LV failure: also valvotomy LV to coronary sinus fistula Group 2 I0 56F 39 mth Closed mitral None Present Soft apical Nil Slight mitral valvotomy (3) + left sternal paraprosthetic edge, aortic regurgn + copyright. systolic LV failure murmur II 64M 5 yr Nil Calcification+ + Present Soft apical Nil Slight mitral paraprosthetic regurgn + LV failure GrouP 3 I2 56F 20 mth Closed mitral Calcification + Present Soft apical + + + Mitral parapros- http://heart.bmj.com/ valvotomy; left sternal thetic regurgita- homograft edge; aortic tion, also mitral valve systolic aortic valve replacement murmur replacement I3 40F 6 is Homograft Calcification + Present Soft left + Mitral para- mitral valve sternal edge prosthetic replacement regurgitation I4 58F 3 ,, Closed mitral Calccification+ + Present Soft apical + Mitral para- valvotomy; prosthetic homograft regurgitation, on September 27, 2021 by guest. Protected mitral valve also aortic valve replacement replacement I5 47F I 33 Homograft mitral Nil Present Soft apical+ Nil Mitral para- valve replace- left sternal prosthetic ment edge regurgitation i6 48M 5I , Mitral para- Calccification+ + Present Soft apical+ + + Mitral para- prosthetic left sternal prosthetic regurgitation edge regurgitation (reattd) 17 59F 13,i, Closed mitral Calccification + Intermittent Nil Mitral para- valvotomy; apical prosthetic homograft regurgitation mitral valve on angiogram; replacement not seen at re-op.; further mitral valve replacement; patient well Br Heart J: first published as 10.1136/hrt.35.12.1217 on 1 December 1973. Downloaded from Role of echocardiography and phonocardiography in diagnosis of mitral paraprosthetic regurgitation 1219 Case Age Onset of Previous operation Factors Tricuspid Systolic Haemolysis Remarks No. and deteriora- on mitral valve predisposing to regurgn murmur sex tion after mitral para- operation prosthetic regurgitation i8 56M 2 wk Mitral valve Ruptured chordae Present Soft apical+ NR Mitral para- repair; homo- left sternal prosthetic graft mitral edge regurgitation valve replacement I9 35F 8 mth Closed mitral Calcification+ Present Left sternal + + Mitral para- valvotomy; edge in- prosthetic homograft creasing regurgitation + mitral valve inspiration intravalvar replacement leak 20 47F 2 ,, Nil Calcification+ Present Soft left Nil Mitral para- sternal edge prosthetic regurgitation 2I 36F 29 ,, Nil Nil Present Soft left NR Mitral para- sternal edge prosthetic + apex regurgitation 22 49M 5 wk Nil Floppy valve - None NR Sinus rhythm, aortic valve replacement; not catheter- ized; mitral paraprosthetic regurgitation copyright. Group 4 23 34M i6 mth Nil Calcification+ + Present None Nil Aortic regurgitation + LV failure; sinus rhythm; ventricular fibrillation at catheterization http://heart.bmj.com/ 24 57F 4 yr Nil Calcification+ Present Aortic systolic NR Aortic murmur regurgitation NR not recorded. + = mild/moderate. + + = severe. oblique position, and particular care was taken to ensure electrocardiogram using an Ekoline 20 ultrasonoscope. that the catheter did not interfere with the function ofthe The position of the transducer was adjusted until a on September 27, 2021 by guest. Protected prosthesis. In two cases, of whom one had a parapros- satisfactory record was obtained showing the inter- thetic leak, the left atrium was entered from the left ventricular septum and the endocardial surface of the ventricle. Mitral regurgitation was classified as mild, posterior wall of the left ventricle. In all cases, the two moderate, or severe, puffs of 'smoke-ring' incompetence echoes from the ball of the prosthesis, and those from being considered a normal finding (Rockoff et al., I966). the valve ring and the apex of the cage were identified Left ventricular function was considered to be impaired first and the position of the septal echo was confirmed to if ejection fraction was reduced, if the left ventricular be anterior to these (Fig. I). In several patients, further end-diastolic pressure was greater than I2 mmHg with identification of the septal echo was obtained by record- respect to the mid-thorax, or if dyskinetic areas were ing a tricuspid
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