Objectives A substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not. Methods Retrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes. Results Among a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71). Conclusion Although corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients. / Revisión por pares

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Since living conditions have improved and antibiotics have entered routine use, valvular heart disease (VHD) in the developed world is mostly degenerative in origin, rather than rheumatic. Our population is increasing with age, and therefore the burden of VHD is likely to increase. Despite this, the epidemiology & prognostication in VHD remain poorly understood. A better understanding of the prevalence of VHD in our population, and improved methods of predicting outcomes, are essential if we are to be better equipped to meet the challenges of this new “epidemic”. This thesis aims to improve our knowledge of the prevalence of VHD in the elderly, and the potential benefits of cardiac magnetic resonance (CMR) assessment of patients with clinically significant mitral regurgitation. The prevalence of undiagnosed valvular heart disease in those aged 65 and over is examined in Chapters 2 and 3. Chapter 2 outlines a population-based screening study for VHD in primary care in Oxfordshire, which the author played a central role in establishing. The results show that VHD is extremely common in this cohort, and is strongly associated with increasing age. In chapter 4, the level of anxiety provoked by screening for VHD is looked at; this demonstrates that only a small number of patients have significant anxiety levels, but it is more likely in those with a new diagnosis of VHD, and in women. From Chapter 5 onwards, the thesis focuses on the use of CMR in patients with significant mitral regurgitation (MR). In Chapter 5, the clinical value of quantitative assessment of MR using CMR is examined, showing that it was able to predict progression to symptoms or surgery in these patients. In conclusion, this thesis offers insights into the prevalence of VHD in the elderly population, and looks at the anxiety associated with looking for VHD in this group. The potential clinical benefits of CMR in patients with MR are examined, and quantification of MR with this modality would appear to be of prognostic utility.

The echocardiographic assessment of valvular heart diseases is the basic analysis of valvular defects next to clinical investigation and stethoscopy. Severity of mitral regurgitation (MR) is usually estimated by an integrated approach using semi quantitative parameters and is still one of the biggest challenges of echocardiography. Quantitative echocardiographic analysis of MR severity often fails to describe comprehensible hemodynamic conditions. However, comprehensive echocardiography based on standardized image acquisition and proper image quality is required to properly assess hemodynamic parameter comparable to cardiac magnetic resonance tomography. This review focuses on the uncertainty of MR severity assessed by echocardiography in recent trials of interventional MR treatment. In addition, the necessity to provide plausible echocardiographic data for individual decision making is highlighted. In conclusion, plausible functional diagnostics by rational echocardiography is a prerequisite in patients with valvular heart diseases.

Valvular disease affects the heart's valves and can lead to complications if left untreated. In 2017, about 2.7% (U. S) of the population had a valvular disease. The Centers for Disease Control and Prevention (CDC) also estimated that about 2500 Americans die yearly due to valvular disease. Several factors, such as the type of valvular disease, can affect the outcome of this disease. However, the hospital type, insurance status, and location of the patients may determine the quality of care and valvular disease outcome. Teaching hospitals are often in urban regions and house various well-grounded specialists as well as tools and equipment that may be a significant contributory factor to the outcome of Valvular heart disease. This study aims at determining the importance of quality of healthcare access in the outcome of valvular disease. At the bivariate analysis level, it was hypothesized that the type of hospital, location of patients, and age at diagnosis are significantly related to the outcome of valvular disease. At the multivariate level, it was hypothesized that after controlling for every other variable, the predictor variables were significantly related to the outcome of valvular disease. Data analysis was conducted on cross-2012 sectional National Inpatient Survey (NIS) data. The Core, severity, and hospital data were used for this analysis. Descriptive statistics and bivariate and multivariate logistic regressions were conducted to assess the association between the outcome of valvular disease and the type of hospital (teaching or non-teaching), patient location, age at diagnosis, insurance, income, and sex. All analysis was performed using the Statistical Analysis System (SAS). The results of the descriptive study showed about 2.9% of patients had comorbidity from valvular disease. Patients attending teaching hospitals had a 0.3% comorbidity present (P =.001). At the multivariate analysis level, patients at the teaching hospital were less likely to have comorbidity compared to individuals at non-teaching (AOR = 0.735; CI = 0.549, 0.970, P = 0.0303). Patients with public or no insurance were less likely to have a comorbidity of valvular disease as compared to patients with private insurance (AOR =0.596, AOR =0.288; CI = 0.393, 0.904 CI= 0.120, 0.692 P= 0.0149 P= 0.0054 respectively). Also, males were less likely to have valvular heart disease comorbidity as compared to females. All other variables not mentioned were not significant in the multivariate analysis. Accreditation programs can ensure that non-teaching hospitals have the necessary resources, equipment, and personnel to manage the valvular disease. Furthermore, providing incentives, such as financial support or performance-based incentives, can encourage non-teaching hospitals to invest in the necessary resources and personnel to manage valvular heart disease. We also recommend awareness campaigns and screening programs for patients in rural regions.

Klaffvitier är några av de vanligaste hjärtsjukdomarna och studier visar att fysisk aktivitet är en viktig del av den kliniska diagnostiken speciellt för individer med symtomfri problematik. Fysisk aktivitet leder hos en del individer till typiska symtom för klaffvitium och ger således möjlighet till förbättrad gradering av klaffvitier jämfört med i vila. Syftet med studien är att ekokardiografiskt studera eventuell förändring av trikuspidalisklaffunktion i vila och efter lättare fysisk ansträngning, samt undersöka hypotesen om trikuspidalisinsufficiens samt tryckgradienten över trikuspidalisklaffen förändras i samband med denna typ av diagnostik. Sexton deltagare inkluderas vid anamnes på andfåddhet eller ansträngningsutlösta hjärtbesvär samt även fynd av trikuspidalisinsufficiens i samband med ordinarie undersökningstillfälle. Även de med känd trikuspidalis-insufficiens sedan tidigare inkluderades. Efter ordinarie ekokardiografisk undersökning som individerna var remitterade till fick inkluderade deltagare utföra ett cykeltest på ergometercykel under sex minuter med en lättare belastning. Ultraljudsbilder på hjärtat samlades in direkt efter avslutad ansträngning. Två variabler, tryckgradient före respektive efter ansträngning över trikuspidalisklaffen, analyserades enligt dess differens och därefter analyserades differenserna i förhållande till nollhypotesen. Medianvärden av variablerna jämfördes i Wilcoxons teckenrangtest och med Spearmans rangkorrelation studerades förhållandet mellan stigande hjärtfrekvens samt tryckgradient vid fysisk ansträngning. Studien visade att tryckgradienten hos trikuspidalis-insufficiensen förändrades vid utförande av lättare fysisk ansträngning hos individer med ansträngningsutlösta hjärtbesvär samt att denna form av undersökning i anslutning till ordinarie undersökningstillfälle kan vara av värde bland individer med anamnes på ansträngningsutlösta hjärtbesvär. / Valvular heart disease are one of the most common heart diseases and previous studies have shown that exercise is an important part of the clinical diagnostics, especially in asymphtomatic individuals. In some cases, exercise lead to typical symptoms of valvular heart disease and improved grading compared to rest. The aim of the present study was to analyze tricuspid valvular function in rest compared to exercise and examine whether or not tricuspid regurgitation and pressure gradient over the tricuspid valve will alter after exercise. Sixteen participants was included with anamnesis of dyspnea or cardiac symptoms related to exercise as well as findings of tricuspid regurgitation during the echocardio-graphic examination. Individuals with known tricuspid regurgitation were also included. After the transthoracic echocardiographic examination, included individuals performed a bicycle test for six minutes with light workload. Additional ultrasound images of the heart was collected immediately after finished bicycle test. Two variables, pressure gradient over the tricuspid valve before and after right exercise, were analyzed according to its difference and then the differences were analyzed relative to the zero hypothesis. Median values of the variables were compared in Wilcoxon's signed-rank test and Spearman's rank correlation analyzed the relationship between increasing heart rate and pressure gradient under the influence of exercise. This study has shown that the pressure gradient of the tricuspid regurgitation changes in the performance of light exercise in individuals with history of dyspnea or cardiac symptoms related to exercise. It also showed the value of an exercise test in adherence to the echocardiographic examination in this group of individuals.

Un lien entre certaines dysfonctions du système sérotoninergique et la survenue de valvulopathies a été suggéré par les lésions valvulaires observées au cours de l’utilisation chronique de certains agonistes des récepteurs 5-HT2 (dérivés de l’ergot de seigle, fenfluramine) et les atteintes tumorales carcinoïdes (qui entrainent une augmentation des taux de 5-HT circulante). Les lésions dégénératives associent une fibrose, une sténose et/ou une régurgitation des valves pouvant conduire à de nombreuses complications cardiovasculaires. À l’heure actuelle, il n’existe aucune thérapeutique pouvant freiner ou faire régresser les lésions. Nos travaux démontrent à partir de modèles animaux et cellulaires, l’implication effective des récepteurs 5-HT2B et 5-HT2A dans l’initiation des lésions. L’analyse histologique des valves à partir de nos modèles animaux a révélé la contribution des cellules endothéliales au cours des stades précoces. Ces cellules sont des progéniteurs endothéliaux (CD34+) recrutés à partir de la moelle au sein de la valve sous la stimulation des récepteurs 5-HT2 et par un mécanisme intracellulaire impliquant la eNOS. Des travaux ultérieurs permettront de mieux caractériser les différents types cellulaires et les biomarqueurs d’initiation du processus afin de déterminer de nouvelles pistes thérapeutiques. / Several studies have reported a strong correlation between the development of cardiac valve injury and some dysfunctions of the serotonergic system. Valve lesions are observed during the chronic use of some 5-HT2 receptors agonists (ergot derivates or fenfluramine derivatives) or are secondary to metastatic carcinoid tumours (with increased circulating 5-HT amount). These lesions show fibrosis, with thickened leaflets, valves stenosis and/or regurgitation followed by several cardiovascular complications. There is no medical treatment to stop or alter the natural course of the lesions. Surgical replacement by prosthesis is the only effective therapy. Our study based on animal and cellular pharmacological models, demonstrates the serotonergic system contribution through 5-HT2B and 5-HT2A receptors in the pathogenesis of valve degeneration. Histological analysis of the lesions reveals the contribution of endothelial cells to the initiation process. These cells are probably endothelial progenitors (CD34+) recruited inside the valve implying a NO-dependent mechanism. Further studies will characterize the specific cells to find biomarkers of valve remodelling initiation and at term, will identify best therapeutic targets around the serotonergic system.

Os objetivos deste estudo foram correlacionar o tipo de lesão valvar mitral com eventos maternos e neonatais. É um estudo retrospectivo, observacional, realizado na Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina de São Paulo. Foram coletados dados de 117 gestações em 111 mulheres com valvopatia mitral e 117 recém-nascidos resultantes destas gestações. No grupo estudado, foram observados 71 casos de gestantes portadoras de insuficiência mitral e 46 casos de gestantes portadoras de estenose mitral e seus 117 recém-natos. O tipo de lesão valvar, a estenose mitral, esteve significantemente relacionado piores classes funcionais (com predominância de CF III/IV), a maior necessidade de uso de medicamentos cardiovasculares, à maior freqüência de internação para compensação do quadro cardíaco, a maiores índices de parto cesárea, a menor média ponderal ao nascimento e a maior incidência de RNs pequenos para idade gestacional. Entretanto, a lesão valvar predominante não influiu com relevância estatística quanto à presença de complicações obstétricas, presença de co-morbidades clínicas, a complicações fetais, índice de Apgar < 7, e necessidade de UTI neonatal. A presença de valvopatia mitral na gravidez, principalmente a estenose mitral, acompanha-se de riscos maternos e perinatais / PURPOSE: To evaluate the maternal (clinical e obstetrical) and perinatal events related to the predominant valvar lesion in pregnant women with mitral valve disease. This is a Observational and retrospective study of 117 pregnancies in 111 patients with mitral disease, followed in a single tertiary center from January 2004 until August 2008. Clinical and obstetrical data were reviewed and analyzed according to the main type of valvar lesion (stenosis or insufficiency). The statistical analysis of the results was performed by chi-square test, Fishers exact test, and Mann-Whitney test. Among the 117 pregnancies (and neonates), there were 71 cases of predominant mitral regurgitation (MR group) and 46 with predominant mitral stenosis. The MS group presented more severe heart failure symptoms (functional class III and IV) during pregnancy, received more cardiovascular drugs and needed more hospital admissions due to cardiac reasons . Concerning perinatal events, MS presented higher rates of cesarean sections, smaller birthweight and higher incidence of SGA (small for gestational age, babies. Nevertheless, the predominant valvar lesion was not significantly related to other clinical co-morbidities, obstetrical or perinatal complications. Mitral valve disease in pregnancy is related to clinical and perinatal events, especially in patients with predominant mitral stenosis

Os objetivos deste estudo foram correlacionar o tipo de lesão valvar mitral com eventos maternos e neonatais. É um estudo retrospectivo, observacional, realizado na Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina de São Paulo. Foram coletados dados de 117 gestações em 111 mulheres com valvopatia mitral e 117 recém-nascidos resultantes destas gestações. No grupo estudado, foram observados 71 casos de gestantes portadoras de insuficiência mitral e 46 casos de gestantes portadoras de estenose mitral e seus 117 recém-natos. O tipo de lesão valvar, a estenose mitral, esteve significantemente relacionado piores classes funcionais (com predominância de CF III/IV), a maior necessidade de uso de medicamentos cardiovasculares, à maior freqüência de internação para compensação do quadro cardíaco, a maiores índices de parto cesárea, a menor média ponderal ao nascimento e a maior incidência de RNs pequenos para idade gestacional. Entretanto, a lesão valvar predominante não influiu com relevância estatística quanto à presença de complicações obstétricas, presença de co-morbidades clínicas, a complicações fetais, índice de Apgar < 7, e necessidade de UTI neonatal. A presença de valvopatia mitral na gravidez, principalmente a estenose mitral, acompanha-se de riscos maternos e perinatais / PURPOSE: To evaluate the maternal (clinical e obstetrical) and perinatal events related to the predominant valvar lesion in pregnant women with mitral valve disease. This is a Observational and retrospective study of 117 pregnancies in 111 patients with mitral disease, followed in a single tertiary center from January 2004 until August 2008. Clinical and obstetrical data were reviewed and analyzed according to the main type of valvar lesion (stenosis or insufficiency). The statistical analysis of the results was performed by chi-square test, Fishers exact test, and Mann-Whitney test. Among the 117 pregnancies (and neonates), there were 71 cases of predominant mitral regurgitation (MR group) and 46 with predominant mitral stenosis. The MS group presented more severe heart failure symptoms (functional class III and IV) during pregnancy, received more cardiovascular drugs and needed more hospital admissions due to cardiac reasons . Concerning perinatal events, MS presented higher rates of cesarean sections, smaller birthweight and higher incidence of SGA (small for gestational age, babies. Nevertheless, the predominant valvar lesion was not significantly related to other clinical co-morbidities, obstetrical or perinatal complications. Mitral valve disease in pregnancy is related to clinical and perinatal events, especially in patients with predominant mitral stenosis