<p>Large quantities of data have described left ventricular adaptation to endurance training, but basic concepts on left ventricular performance during exercise remain controversial. In this thesis, we present the results of studies of left ventricular dynamics during exercise in 89 endurance-trained athletes.</p><p>Using radionuclide ventriculography, 35 female and 30 male endurance athletes were studied in supine position. During supine exercise at 70% of the age-expected maximal heart rate, the adjustments in left ventricular volumes were small, suggesting a high preload before exercise. Stroke volume increased by changes in the left ventricular end-diastolic volumes but no changes were observed in the end-systolic volumes. Moreover, no significant differences were noted between male and female athletes.</p><p>Contrast echocardiography was utilized when 24 male endurance athletes were studied during upright exercise. An almost linear increase in stroke volume was seen from upright rest to upright exercise at a heart rate of 160 beats per minute. Stroke volume increased by an almost linear increase in end-diastolic volume and showed an initial small decrease in end-systolic volume. The left ventricular cavity became geometrically more spherical with the largest increase in the left ventricular end-diastolic short-axis cavity diameters in the mid and apical part of the left ventricle. Left ventricular long-axis length obtained from the epicardial apex to the middle of the mitral annulus at end-diastole showed no significant change from rest to exercise. The mitral annulus motion contributed to more than 50% of the stroke volume during exercise with no significant difference between septal and lateral annular motion at peak exercise. Major changes were observed in left ventricular filling indices during upright exercise. The mean transmitral pressure gradient showed a linear increase and increased several times as the mean diastolic time decreased, with large reductions in mean left ventricular filling time. Despite the shortened filling time, the heart was able to increase the filling rate (measured as volume per time) five times. This observation verifies that the heart has large reserves at rest and reveals the increase in capacity during exercise.</p>

Large quantities of data have described left ventricular adaptation to endurance training, but basic concepts on left ventricular performance during exercise remain controversial. In this thesis, we present the results of studies of left ventricular dynamics during exercise in 89 endurance-trained athletes. Using radionuclide ventriculography, 35 female and 30 male endurance athletes were studied in supine position. During supine exercise at 70% of the age-expected maximal heart rate, the adjustments in left ventricular volumes were small, suggesting a high preload before exercise. Stroke volume increased by changes in the left ventricular end-diastolic volumes but no changes were observed in the end-systolic volumes. Moreover, no significant differences were noted between male and female athletes. Contrast echocardiography was utilized when 24 male endurance athletes were studied during upright exercise. An almost linear increase in stroke volume was seen from upright rest to upright exercise at a heart rate of 160 beats per minute. Stroke volume increased by an almost linear increase in end-diastolic volume and showed an initial small decrease in end-systolic volume. The left ventricular cavity became geometrically more spherical with the largest increase in the left ventricular end-diastolic short-axis cavity diameters in the mid and apical part of the left ventricle. Left ventricular long-axis length obtained from the epicardial apex to the middle of the mitral annulus at end-diastole showed no significant change from rest to exercise. The mitral annulus motion contributed to more than 50% of the stroke volume during exercise with no significant difference between septal and lateral annular motion at peak exercise. Major changes were observed in left ventricular filling indices during upright exercise. The mean transmitral pressure gradient showed a linear increase and increased several times as the mean diastolic time decreased, with large reductions in mean left ventricular filling time. Despite the shortened filling time, the heart was able to increase the filling rate (measured as volume per time) five times. This observation verifies that the heart has large reserves at rest and reveals the increase in capacity during exercise.

Background and Objectives: Mitral stenosis with extensive mitral annular calcification (MAC) remains surgically challenging in respect to clinical outcome. Prolonged surgery time with imminent ventricular rupture and systolic anterior motion can be considered as a complex of causal factors. The aim of our alternative hybrid approach was to reduce the risk of annual rupture and paravalvular leaks and to avoid obstruction of the outflow tract. A review of the current literature was also carried out. Materials and Methods: Six female patients (mean age 76 9 years) with severe mitral valve stenosis and severely calcified annulus underwent an open implantation of an Edwards Sapien 3 prosthesis on cardiopulmonary bypass. Our hybrid approach involved resection of the anterior mitral leaflet, placement of anchor sutures and the deployment of a balloon expanded prosthesis under visual control. Concomitant procedures were carried out in three patients. Results: The mean duration of cross-clamping was 95 31 min and cardiopulmonary bypass was 137 60 min. The perioperative TEE showed in three patients an inconspicuous, heart valve-typical gradient on all implanted prostheses and a clinically irrelevant paravalvular leakage occurred in the anterior annulus. In the left ventricular outflow tract, mild to moderately elevated gradients were recorded. No adverse cerebrovascular events and pacemaker implantations were observed. All but one patient survived to discharge. Survival at one year was 83.3%. Conclusions: This “off label” implantation of the Edwards Sapien 3 prosthesis may be considered as a suitable bail-out approach for patients at high-risk for mitral valve surgery or deemed inoperable due to extensive MAC.

Background Caseous mitral annular calcification (CMAC) is a rare liquefactive variant of mitral annular calcification (MAC) and superficially mimics a cardiac vegetation or abscess. CMAC is viewed as a benign condition of MAC, while MAC has clinical implications for patients’ lives. Correctly diagnosing CMAC is essential in order to avoid unnecessary interventions, cardiac surgery or even psychological suffering for the patient. Case presentation We report on 6 patients with suspected intra-cardiac masses of the mitral annulus that were referred to our institution for further clarification. A definitive diagnosis of CMAC was achieved by combining echocardiography (Echo), cardiac magnetic resonance imaging (MRI) and cardiac computed tomography (CT) for these patients. Echo assessed the mass itself and possible interactions with the mitral valve. MRI was useful in differentiating the tissue from other benign or malign neoplasms. CT revealed the typical structure of CMAC with a “soft” liquefied centre and an outer capsule with calcification. Conclusion CMAC is a rare condition, and most clinicians and even radiologists are not familiar with it. CMAC can be mistaken for an intra-cardiac tumour, thombus, vegetation, or abscess. Non-invasive multimodality imaging (i.e. Echo, MRI, and CT) helps to establish a definitive diagnosis of CMAC and avoid unnecessary interventions especially in uncertain cases.