Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to patients with severe chronic aortic regurgitation of predominant rheumatic etiology.

Coronary flow and resistance reserve in patients with chronic aortic regurgitation, angina pectoris and normal coronary arteries

Dr Olsen's book avowedly fill the gap between the v books on cardiac patholol necessarily relatively short standard textbooks. He suc aims admirably. A promii is the very clear way in whic are laid out with heading headings which make the bo anyone wanting a rapid ai survey of the subject. Eacl chapters has between 30 a chosen references and the although perhaps in plac murky, excellently complem The author's hopes that it value to candidates for I examinations should be justified. It will also be e preparing lectures on specia and it is the sort of book th teachers secretly hope their not discover. Factually one can cri However, as so often ha specialist textbooks, when summary of a general dise, the system in question it le to be desired. For example, ti amyloidosis manages to get a mentioning the words 'ligh even 'immunoglobulins', on may well be a relief to no orientated morbid anatomist tially misleading to students. 195 superb All professional surgical pathologists vering most keep up to date their personal set of the l aspects of Armed Forces Institute of Pathology histological Atlas of Tumour Pathology, though the trations, the work is largely unknown to surgeons, the attention more's the pity. Though the Editor nd for that denies the intention of 'a second edition icquired and of the first Atlas', in fact this volume will Ll centre and supersede the combined fascicles 20 and engaged in 21 of the old series, and we shall miss the approach and style of Stout and E. WACHTEL Lattes. Fresh information abounds. There is a welcome amplification in the section on conditions associated with By EG. J malignant epithelial tumours of the td. S22.50.) oesophagus, but a confusing account of tal Medical carcinosarcoma and pseudosarcoma. We

https://jcp.bmj.com/content/jclinpath/27/2/171.1.full.pdf

The Pathology of the Heart.

Aims The aim of this study was to characterize left ventricular (LV) mechanics in symptomatic and asymptomatic patients with moderate-to-severe or severe aortic regurgitation (AR) and preserved ejection fraction (left ventricular ejection fraction) using two-dimensional speckle tracking echocardiography (2D-STE). The association between baseline LV strain and development of indications for surgery in asymptomatic patients was also evaluated.

Methods and results A total of 129 patients with moderate-to-severe or severe AR and LVEF >50% (age 55 ± 17 years, 64% male, 53% asymptomatic at baseline) were included. Standard echocardiography and 2D-STE were performed at baseline. Compared with asymptomatic patients, symptomatic patients had significantly impaired LV longitudinal (−14.9 ± 3.0 vs. −16.8 ± 2.5%, P < 0.001), circumferential (−17.5 ± 2.9 vs. −19.3 ± 2.8%, P = 0.001), and radial (35.7 ± 12.2 vs. 43.1 ± 14.7%, P = 0.004) strains. Among 49 asymptomatic patients who were followed up, 26 developed indications for surgery (symptoms onset or LVEF ≤50%). These patients had comparable LV volumes, LVEF, and colour Doppler assessments of AR jet at baseline, but more impaired LV longitudinal ( P = 0.009) and circumferential ( P = 0.017) strains compared with patients who remained asymptomatic. Impaired baseline LV longitudinal (per 1% decrease, HR = 1.21, P = 0.04) or circumferential (per 1% decrease, HR = 1.22, P = 0.04) strain was independently associated with the need for surgery.

Conclusion Multidirectional LV strain was more impaired in symptomatic than in asymptomatic patients with moderate-to-severe or severe AR, despite preserved LVEF. In asymptomatic AR patients, longitudinal and circumferential strains identified patients who would require surgery during follow-up.

/pdf/detection-of-subtle-left-ventricular-systolic-dysfunction-in-5djom1t2qf.pdf

Detection of subtle left ventricular systolic dysfunction in patients with significant aortic regurgitation and preserved left ventricular ejection fraction: speckle tracking echocardiographic analysis

Cross sectional echocardiograms were recorded within one week of death in seven patients with valvular heart disease, four with coronary artery disease, and nine with congenital heart disease. Regional echo amplitude was measured from the cross sectional display by constructing histograms of pixel intensity. Parietal pericardium was used as an internal standard for setting the gain of the instrument. At necropsy myocardium was taken from the free wall of the left ventricle, the papillary muscles, and the septum. Fibrosis was assessed histologically and biochemically as hydroxyproline content. In individual samples histological and biochemical estimates were correlated. In all regions other than the septum in patients with left ventricular hypertrophy, log [collagen] correlated with median pixel intensity. The amplitude of reflected echoes from the hypertrophied septum was significantly higher than that from other samples but was similarly correlated with collagen content. Agreement between echo amplitude and histological grade was significantly less good. Thus in chronic left ventricular disease myocardial collagen content appears to be the major determinant of regional echo intensity. Reproducibility of measurements and more rigorous definition of tissue abnormalities will, however, require further study.

https://heart.bmj.com/content/heartjnl/51/1/46.full.pdf

Relation between regional echo intensity and myocardial connective tissue in chronic left ventricular disease.

The timing of surgery in chronic aortic regurgitation remains a difficult problem. To identify variables predictive of postoperative haemodynamic improvement, changes in left ventricular mass, volume, morphology, and histochemistry were analysed in 67 patients undergoing surgery for chronic aortic regurgitation. Patients were divided into two groups: those in whom the left ventricular echo diameters returned to normal after operation (51 patients, group A), and those with postoperative dilatation (16 patients, group B). A preoperative biopsy was obtained in all patients; postoperative tissue samples were available in 13 patients (five from group A, eight from group B). Data were correlated with the postoperative clinical, haemodynamic state over a follow-up period of three years. Regression of hypertrophy was usually incomplete. Echocardiographic and angiographic data could not define the type and degree of dysfunction which was irreversible. Massive fibre hypertrophy (mean 34.1 micrometers), moderately or severely increased interstitial fibrous tissue, reduced levels of the myofibrillar and mitochondrial enzymes adenosine triphosphates and succinate dehydrogenase in pre- and post-operative tissue samples correlated with persistent dilation, cardiac failure, and early death (group B). Irreversible morphological and functional changes contributed to a depressed cardiac function after operation. Preoperative ventricular biopsies are thus of prognostic importance in volume overload.

https://heart.bmj.com/content/heartjnl/48/6/589.full.pdf

Irreversible morphological changes contributing to depressed cardiac function after surgery for chronic aortic regurgitation.

The serial application of electrocardiography and echocardiography to 67 selected patients undergoing valve replacement for chronic severe aortic regurgitation, documented regression of hypertrophy and chamber size within six to twelve months of surgery in all cases experiencing haemodynamic improvement. Those patients who had persistently increased patterns of myocardial hypertrophy and abnormal end-diastolic dimensions in the presence of normal prosthetic (homograft) function usually had persistent, irreversibly depressed myocardial function postoperatively. Preoperative noninvasive and angiographic characteristics could not predict ventricular function after surgery. Thus we could not precisely define what level of depressed ventricular performance or what degree of dilatation and myocardial hypertrophy constituted an irreversible state from this data. Although operative factors such as myocardial protection during cardiopulmonary bypass may influence postoperative cardiac performance, preoperative histological and histochemical data was useful in delineating irreversible morphological and function changes contributing to a depressed cardiac function, and therefore may be of prognostic importance.

Left ventricular mass, volume and biopsy analysis in prediction of ventricular function after surgery for chronic aortic regurgitation.

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Irreversible morphological changes contributing to depressed cardiac function after surgery for chronic aortic regurgitation.

Left ventricular mass, volume and biopsy analysis in prediction of ventricular function after surgery for chronic aortic regurgitation.