Application effect of thoracoscopic tricuspid valvuloplasty in geriatric patients with tricuspid valve disease

BACKGROUND Thoracoscopic-assisted technology can ensure that doctors can implement minimally invasive treatment through the right intercostal incision or small incision of the lower sternum.This approach not only can achieve a cardiac correction effect equivalent to that of a thoracotomy but also has the benefit of a clear surgical field ensuring the safety of surgical treatment.AIM To investigate the effect of thoracoscopic tricuspid valvuloplasty in patients with tricuspid valve disease.METHODS A total of 41 patients with tricuspid valve disease underwent traditional thoracotomy treatment between January 2018 and June 2020.Forty-one patients with tricuspid valve disease who underwent thoracoscopic tricuspid valvuloplasty treatment between July 2020 and June 2021 in our hospital were selected as controls for our retrospective analysis.The study group underwent thoracoscopic tricuspid valvuloplasty,while traditional thoracotomy was performed in the control group.The operation conditions(the duration of extracorporeal circulation,aorta blocking,endotracheal intubation,and surgery),inflammatory response-related indices(C-reactive protein and white blood cell count)before and after surgery,parameters related to myocardial injury(myocardial troponin T,creatine kinase isoenzyme,creatine kinase,and lactate dehydrogenase),and the incidence of adverse events in the two groups was counted.RESULTS The duration of extracorporeal circulation(109.35±50.31 min),aortic occlusion(94.26±59.61 min),endotracheal intubation(12.59±3.54 h),and hospital stay(5.29±2.34 d)in the study group were shorter than those in the control group(114.91±46.98 min,101.37±61.44 min,13.11±4.01 h,7.09±3.11 d,respectively).The difference in hospital stay between the two groups was statistically significant(P<0.05).Serum C-reactive protein level(4.69±1.35 mg/L)and white blood cell count(6.21±1.97×10^(9)/L)in the study group were found to be not significantly different than those in the control group(5.01±1.18 mg/L,5.98±2.01×10^(9)/L,respectively;P>0.05).Myocardial troponin T(0.04±0.02 ng/mL),creatine kinase isoenzyme(4.02±1.11 mg/mL),creatine kinase(91.35±10.44 U/L),and lactate dehydrogenase(179.81±60.04 U/L)in the study group were also not statistically significant different than those in the control group(0.05±0.03 ng/mL,3.97±1.05 mg/mL,89.69±13.05 U/L,186.35±56.96 U/L;P>0.05).After the operation,serum C-reactive protein level(7.89±1.73 mg/L)and white blood cell count(10.76±2.35×10^(9)/L)in the study group were significantly lower than those in the control group(9.96±2.04 mg/L,14.84±3.07×10^(9)/L,respectively)(P<0.05).In addition,myocardial troponin T(0.89±0.32 ng/mL),creatine kinase isoenzyme(26.96±4.95 mg/mL),creatine kinase(608.32±202.33 U/L),and lactate dehydrogenase(282.56±101.34 U/L)in the study group were lower than those in the control group(2.61±0.69 ng/mL,34.37±6.87 mg/mL,689.94±214.64 U/L,369.15±114.46 U/L)(P<0.05).The incidence of adverse events in the study group(4.88%)was lower than that in the control group(19.51%)(P<0.05).CONCLUSION Thoracoscopic tricuspid valvuloplasty can achieve good results in treating patients with tricuspid valve disease,reduce the risk of adverse events,and promote the rapid recovery of patients.

Isolated mitral valve replacement with Guangdong-Ⅰ porcine bioprostheses in rheumatic heart valve disease: analysis of 166 cases with long-term follow-up

Objective To study the long-term effects of mitral valve replacement with bioprostheses in rheumatic heart valve disease. Methods 166 patients with rheumatic heart valve disease underwent isolated mitral valve replacement from Jan. 1978 to Dec. 1985. 79 Patients were male and 87 female. Patients’ age ranged from 11 to 53 years [mean (29.4 ± 9.9) years]. The patients were classified into two groups: group 1 (age【 30 years) included 84 patients, group 2 (age≥30 years) 82 cases. Mean CTR is 0.68 *0.08. Most patients were in NYHA function class Ⅲ-Ⅳ. 76. 3% of patients had atrial fibrillation. 6 patients had pre-operative cerebral vascular accidents. Postoperative deaths were excluded. Follow-up extended from 0.4 year to 19.4 years. Results Actuarial estimate of survival rate at 14 years is (52.5 ± 7.0)%. Heart function was improved to class Ⅰ - Ⅱ in most of patients. Late structural valve deterioration occurred in 89 patients. Among them, 59 were re-operated. Actuarial estimate of freedom from

Effect of pulmonary autograft transplantation in the surgical treatment of aortic valve disease

Background Aortic root replacement with pulmonary autograft （Ross procedure） has the advantages of good haemodynamics and growth potential without the need for anticoagulation. In this study, we reviewed our experience of the Ross procedure for patients with aortic valve disease. Methods From October 1994 to January 2005, 42 Ross procedures were performed in our centre. There were 30 males and 12 females. The mean age was 28＋15 years （range, 5-56 years）. Congenital heart disease （CHD） with aortic valve stenosis （AS） and/or aortic valve insufficiency （AI） in 40 cases including one associated with ventricular septal defect （VSD）, degenerated aortic valve disease with AS in 1 and subacutive bacterial endocarditis （SBE） with AI in 1 were studied. The diagnosis was made by ultracardiography （UCG） in all patients. The mean aortic valve annulus diameter （AVD） was （2.45±0.31） cm and pulmonary valve annulus diameter （MPVD） was （2.34±0.21） cm. All patients had normal pulmonary valves. The New York Heart Association （NYHA） function class was Ⅱ in 36 cases and Ⅲin 6 cases. The operation was performed under moderate hypothermic cardiopulmonary bypass （CPB） with aortic root replacement using pulmonary autograft and pulmonary valve replacement with a homograft. Results There was no early hospital mortality. Postoperative UCG showed normal aortic valve function in all our patients. The mean gradient across the aortic valve was （6.11±0.12） mmHg. The left ventricular diastole diameter （LVDD） decreased significantly from （62±5） mm to （56±3） mm （P 〈0.001）. The mean postoperative left ventricular ejective fraction （LVEF） was 0.49±0.23. All patients were in NYHA class Ⅰ-Ⅱ. Follow-up was completed in 38 cases for a mean period of 3.2 years （range 1-10 years）. All survivors were in NYHA class Ⅰ with normal neo-aortic and pulmonary valve function. One patient died after secondary operation due to homograft fungal endocarditis 1 year after the Ross procedure. The cause of death was uncontrolled bleeding. Another patient suffered from cardiogenic shock and was on extracorporeal membrane oxygenation （ECMO） for 10 days postoperatively. This patient was subsequently self-discharged from hospital due to financial issues and he was excluded from follow-up. Conclusion The Ross procedure is an excellent technique to treat aortic valve disease. Our data show that it can be performed safely with good early and mid-term clinical outcomes.

Valves replacement operation in treatment of electrical storm induced by rheumatic valves disease

Objective： To present a case of electrical storm （ES） in a female patient with rheumatic valve disease. Methods： A female patient with severe rheumatic valve disease suffered an unexpected ES. She received more than 50 electrical shocks for repeated cardiac arrests due to ES over 16 hours. Then she received beta-blocking agent treatment and had an operation of double valves replacement. Results： ES was suppressed by sympathetic blockade with beta-receptor blocker and finally disappeared after the double pathological valves had been replaced. Conclusion： Increased sympathetic activity plays an important role in the genesis of electrical storm and sympathetic blockade may effectively suppress ES. However, the most important thing in the treatment of ES is to identify and eliminate the underlying cause of ES.

Upregulation of Cartilage Oligomeric Matrix Protein and Bone Morphogenetic Protein-2 May Associate with Calcific Aortic Valve Disease

Objective:Calcific aortic valve disease(CAVD)affects millions of elderly people,and there is currently no effective way to stop or slow down its progression.Therefore,exploring the pathogenesis of CAVD is very important for prevention and treatment.Cartilage oligomeric matrix protein(COMP)have important role in cell phenotype change.This study is aimed to confirm whether COMP participate in CAVD and try to find the possible mechanisms.Methods:Human aortic valve tissues from Nanjing First Hospital(CAVD group,n=20;control group,n=11)were harvested.The expression level of COMP was tested by western blot and immunohistochemistry.Dual immunofluorescence staining was used for locating COMP.Bone morphogenetic protein-2(BMP2)signalling were tested by western blot.The animal model was also used to detect COMP level by immunohistochemistry.Results:The results showed that the expression level of COMP was significantly increased in the calcific valve samples when compared with that of the control valve(P<0.05);COMP was expressed near the calcific nodules and co-localized with a-smooth muscle actin(a-SMA).The protein levels of BMP2 and p-Smads 1/5/9 were markedly more highly expressed in the CAVD group than the control group(P<0.05).Furthermore,immunofluorescence detection showed that COMP and BMP2 were co-located in calcific valves.Conclusions:The above results suggested that upregulation of COMP and BMP2 may be associated with aortic valve calcification and that COMP may become a potential therapeutic target in human CAVD.

The Characterization of Aortic Valve Calcification at Different Stage of Disease

Cardiac valve calcification is a common disease,especially among the elderly.Calcification can affect valve function and cause heart failure and sudden death(Adler et al.,2002).Aortic valve calcification is alsorelated to arteriosclerosis and coronary heart disease(Rashedi et al.,2015).However,the origin of valve calcification is still unclear.This study characterized the

Clinical results of tricuspid valve replacement—a 21-case report

Objective： To summarize the clinical experiences of 21 patients treated with tricuspid valve replacement （TVR） and investigate the surgical indications and methods. Methods： Data from 21 patients who underwent TVR from December 2002 to March 2009 were retrospectively collected and analyzed. The mean age was 48.86± 15.37 years （range： 20-72 years）. The underlying disease of the patients was classified as rheumatic （n = 10）, congenital （n = 8）, endocarditis （n = 2） or chest trauma （n = 1）. Previous cardiac surgery had been performed in 12 patients （57.14%）. Results： In-hospital death occurred in two patients （9.52%）. Postoperative morbidities included cardiac failure （n = 2）, bleeding related re-operation （n = 1）, and plural effusion （n = 2）. Conclusion： The early outcomes of TVR were acceptable. At the present time TVR can be performed through optimal perioperative management.

A Clinicopathological Study on Aortic Valves in Children

In order to investigate the clinicopathological characteristics of aortic valve disease in children, all the native surgically excised aortic valves obtained between January 2003 and December 2005 were studied macroscopically and microscopically. The patients’ medical records were reviewed and the clinical information was extracted. According to preoperative echocardiography, intraopera- tive assessment, and postoperative pathology, combined with clinical symptoms and signs, aortic valve diseases were divided into three categories: aortic stenosis (AS), aortic insufficiency (AI), and aortic stenosis with insufficiency (AS-AI). The etiology was determined according to the macro- scopic, microscopic and clinical findings. The results showed that among 70 aortic valves, patient age ranged from 6 to 18 years, with a mean of 15.4 years, and there were 56 boys and 14 girls (male: fe- male=4:1). Forty-four children only had pure aortic valve disease, and the other 26 children had aor- tic valve disease associated with other heart valve diseases. There were 5 cases of AS (7.14%), 60 cases of AI (85.71%) and 5 cases of AS-AI (7.14%). The causes were congenital aortic valve mal- formation (32 cases, 45.71%), rheumatic disease (28 cases, 40%), infective endocarditis (7 cases, 10%), Marfan syndrome (2 cases, 2.86%), and undetermined (1 case, 1.43%). It was concluded that the common causes of aortic valve disease in order of frequency in children were congenital aortic valve malformation, rheumatic disease, infective endocarditis, and Marfan syndrome. AI was more common in children with aortic valve disease. Compared with adult patients, congenital bicuspid aor- tic valve in children was often AI. Histologically, the leaflets of congenital bicuspid aortic valve were mainly myxomatous, fibrosis and calcification less seen. AI was frequently found in rheumatic dis- ease, mostly associated with other heart valve diseases. Macroscopic and microscopic examinations together with clinical information, echocardiographic findings and operative details were important in evaluating the etiology of aortic valve disease.

Risk Factors for Prognosis after the Maze Ⅳ Procedure in Patients with Atrial Fibrillation Undergoing valve Surgery

The present study evaluated risk factors related to persistent atrial fibrillation(AF)at discharge(AF-d)and recurrent atrial fibrillation(rAF)and all-cause death after the maze IV procedure.Two hundred nineteen patients(63 female,aged 52.5±8.8 years)with valve disease and persistent AF undergoing valve surgery and the maze IV procedure in our center between 2015 and 2016 were included.Baseline demographic and clinical data were obtained by review of medical records.The median follow-up period was 27 months(interquartile range 21-34 months)in our patient cohort.The primary end point was all-cause death.The secondary end point was AF-d or rAF.rAF is defined as AF recurrence at 3 months or later after the procedure.Twenty-eight patients(12.8%)died during follow-up.Multiple logistic regression analysis showed that thrombocytopenia,elevated serum total bilirubin level,a larger right atrium,AF-d,and rAF were independent determinants for all-cause death after the maze IV procedure after adjustment for age,sex,and clinical covariates,including New York Heart Association class III/IV disease,hypertension,and aortic regurgitation,while valvular disease duration and left atrial diameter greater than 80.5 mm were independent determinants for AF-d,and thrombocytopenia,elevated serum total bilirubin level,higher mean pulmonary artery pressure,and AF-d were independent predictors for rAF.In conclusion,thrombocytopenia,elevated serum total bilirubin level,an enlarged right atrium,AF-d,and rAF are independent predictors of all-cause death in patients undergoing the maze IV procedure.

Accuracy of the Logistic EuroSCORE in Predicting Long-Term Survival Following Isolated Aortic Valve Replacement

Objective: To assess the ability of the logistic EuroSCORE to predict long- term mortality of patients undergoing isolated Surgical Aortic Valve Replacement (SAVR). Methods: A retrospective review of all patients undergoing SAVR between September 1999, and March 2018 was done. Results: 2018 patients were eligible for inclusion in the study. Patients were grouped according to risk: low (n = 506), intermediate (n = 609), and high-risk (n = 903) depending on their logistic EuroSCORE values. The 30-day mortality of the low- risk group was 0.47%. The one-, five-, 10-, 15-, and 20-year mortality was 1.66%, 4.9%, 14.9%, 24.3%, and 43.8%, respectively. Intermediate-risk group 30-day mortality was 0.66%. The one-, five-, 10-, 15-, and 20-year mortality was 3.28%, 11.9%, 32%, 54.8%, and 82.6%, respectively. The 30-day mortality of the high- risk group was 3.99%. The one-, five-, 10-, 15-, and 20-year mortality was 8.2%, 27%, 55.4%, 78.6%, and 87%, respectively. Conclusion: Our results confirm that the lES is accurate in predicting long-term mortality outcomes of SAVR. This real-world data provides evidence of the potential usefulness of the EuroSCORE to help the heart team and patients decide on appropriate interventions for aortic stenosis.

Effect of aortic valve replacement on ventricular recovery and functional class in patients with reduced left ventricular function

Objective: The aim of the study was to assess the effects of aortic valve replacement (AVR) in patients with aortic stenosis (AS) or regurgitation (AR) and left ventricular (LV) dysfunction. Patients and methods: Retrospective analysis identified 75 consecutive patients with left ventricular ejection fraction (LVEF) assessed by echocardiography < 40% who underwent AVR for AS (n = 40) or AR (n = 35) between 1994 and 2011. Exclusion criteria were previous myocardial infarction or concomitant valvular disorders other than aortic disease. Follow-up evaluated the New York Heart Association (NYHA) functional class, LVEF and survival rate. Results: Mean ages were respectively 56.5 ± 9.3 and 47.9 ± 11.7 years in AS and AR groups, p = 0.001. Before surgery, 88% and 75% of patients were in NYHA III-IV respectively in AS and AR. In the AS group, the mean LVEF and aortic valve area (AVA) were respectively 32.2% ± 8% and 0.65 ± 0.15 cm2. AR group had a mean LVEF of 33.8 ± 6.7% and a mean LV systolic diameter of 62 ± 8.8 mm. All patients underwent AVR under cardiopulmonary bypass. There were 5 operative deaths (12.5%) in AS group and 6 (17.6%) in AR group, p = 0.57. LVEF increased to 49% ± 14.7% and 51.2% ± 10.9% in the AS and AR groups after echocardiography control. The survival rates at 1, 5 and 10 years were respectively 94.4%, 87% and 80% in AS group and 95.2%, 93% and 89% in AR group. Conclusion: Despite higher perioperative mortality in patients with aortic valve disease (AS or AR) and LV dysfunction, long-term outcome is excellent. We, therefore, conclude that AVR can be performed and it should not be denied to patients on the basis of low EF alone.

Exercise stress echocardiography:Where are we now?

Exercise stress echocardiography(ESE)is a widely used diagnostic test in cardiology departments.ESE is mainly used to study patients with coronary artery disease;however,it has increasingly been used in other clinical scenarios including valve pathology,congenital heart disease,hypertrophic and dilated cardiomyopathies,athlete evaluations,diastolic function evaluation,and pulmonary circulation study.In our laboratories,we use an established methodology in which cardiac function is evaluated while exercising on a treadmill.After completing the exercise regimen,patients remain in a standing position or lie down on the left lateral decubitus,depending on the clinical questions to be answered for further evaluation.This method increases the quality and quantity of information obtained.Here,we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail.We also present alternatives to ESE that may be used and their advantages and disadvantages.We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.

Preoperative echocardiographic predictors for 1-year mortality in patients treated with standard endovascular aneurysm repair for abdominal aortic aneurysm

Background: Abdominal aortic aneurysm (AAA) and cardiovascular disease are intimately associated, the latter representing the most common cause of death in Sweden. Cardiac complications are held responsible for the majority of perioperative morbidity and mortality in patients undergoing repair of AAA. The importance of preoperative thorough cardiac assessment is therefore obvious. The aim of this study was to evaluate the prognostic significance of preoperative echocardiographic findings for 1-year mortality after elective endovascular aneurysm repair (EVAR) of infrarenal AAA. Design: Retrospective analysis. Methods: The 505 patients were identified in a prospective database for endovascular interventions between 1998 and 2011, and data were retrieved from patient records. Preoperative echocardiography reports in 380 patients were reviewed and findings were notified according to a predefined protocol. Results: The 1-year mortality rate was 6.7%. Severe valve disease was present in 8.7% of the patients, aortic valve stenosis being the leading cause of valve pathology. Severe valve disease (OR 3.5, 95% CI [1.2 - 10.7];p = 0.025) and chronic kidney disease grade ≥ 3 (OR 7.5, 95% CI [2.1 - 26.1];p = 0.002) were the only independent risk factors for increased mortality rate at 1-year. Conclusion: Echocardiography should be a part of the preoperative workup in AAA patients. Finding of severe valve disease should be further evaluated by a cardiologist prior to EVAR.

Fluid-structure interaction simulation of pathological mitral valve dynamics in a coupled mitral valve-left ventricle model

Background Understanding the interaction between the mitral valve(MV)and the left ventricle(LV)is very important in assessing cardiac pump function,especially when the MV is dysfunctional.Such dysfunction is a major medical problem owing to the essential role of the MV in cardiac pump function.Computational modelling can provide new approaches to gain insight into the functions of the MV and LV.Methods In this study,a previously developed LV-MV model was used to study cardiac dynamics of MV leaflets under normal and pathological conditions,including hypertrophic cardiomyopathy(HOCM)and calcification of the valve.The coupled LV-MV model was implemented using a hybrid immersed boundary/finite element method to enable assessment of MV haemodynamic performance.Constitutive parameters of the HOCM and calcified valves were inversely determined from published experimental data.The LV compensation mechanism was further studied in the case of the calcified MV.Results Our results showed that MV dynamics and LV pump function could be greatly affected by MV pathology.For example,the HOCM case showed bulged MV leaflets at the systole owing to low stiffness,and the calcified MV was associated with impaired diastolic filling and much-reduced stroke volume.We further demonstrated that either increasing the LV filling pressure or increasing myocardial contractility could enable a calcified valve to achieve near-normal pump function.Conclusion The modelling approach developed in this study may deepen our understanding of the interactions between the MV and the LV and help in risk stratification of heart valve disease and in silico treatment planning by exploring intrinsic compensation mechanisms.

Oxidized phospholipids and lipoprotein-associated phospholipase A_2 as important determinants of Lp(a) functionality and pathophysiological role

Lipoprotein（a） [Lp（a）] is composed of a low density lipoprotein（LDL）-like particle to which apolipoprotein（a）[apo（a）] is linked by a single disulfide bridge. Lp（a） is considered a causal risk factor for ischemic cardiovascular disease（CVD） and calcific aortic valve stenosis（CAVS）. The evidence for a causal role of Lp（a） in CVD and CAVS is based on data from large epidemiological databases, mendelian randomization studies, and genome-wide association studies. Despite the well-established role of Lp（a） as a causal risk factor for CVD and CAVS, the underlying mechanisms are not well understood. A key role in the Lp（a） functionality may be played by its oxidized phospholipids（OxPL） content. Importantly, most of circulating OxPL are associated with Lp（a）; however, the underlying mechanisms leading to this preferential sequestration of OxPL on Lp（a） over the other lipoproteins,are mostly unknown. Several studies support the hypothesis that the risk of Lp（a） is primarily driven by its OxPL content.An important role in Lp（a） functionality may be played by the lipoprotein-associated phospholipase A_2（Lp-PLA_2）,an enzyme that catalyzes the degradation of OxPL and is bound to plasma lipoproteins including Lp（a）. The present review article discusses new data on the pathophysiological role of Lp（a） and particularly focuses on the functional role of OxPL and Lp-PLA_2 associated with Lp（a）.

Surgical intervention for advanced valvular heart disease in 227 cases

Background Although the results of surgical treatment in cardiac valve disease continue to improve, the postoperative mortality rate and the rate of complications in patients with advanced valvular heart disease (AVHD) are still very high. We did this retrospective study to summarize the surgical experience of heart valve replacement for patients with AVHD and discuss effective ways to improve the surgical outcome.Methods From January 1994 to October 2003, surgical procedures of heart valve replacement were performed on 227 (136 men and 91 women) patients with AVHD in our Department of Cardiothoracic Surgery. The clinical data of all patients were collected and analysed. Patients’ age ranged from 10 years to 77 years. In preoperative cardiac function grading, 157 cases were NYHA III and 70 cases NYHA IV. Fifty-one patients had had cardiac operations. The ultrasonic cardiac graphs showed that 145 patients suffered from moderate or severe pulmonary hypertension and 73 had combined giant left ventricle. Mitral valve replacement was performed in 32 cases, aortic valve replacement in 90, tricuspid valve replacement in 1, combined mitral and aortic replacement in 103 and combined mitral and tricuspid replacement in 1. Nineteen patients also received surgical corrections for other minor abnormalities during the operations. A logistic model was established to evaluate the influence of perioperative factors on the mortality rate. Results The operative mortality rate was 13.2% (30/227). The main causes of death included multiple organ dysfunction syndrome (MODS), low cardiac output syndrome and ventricular fibrillation. From the results of the binary noncounterpart multivariate logistic regression, the following statistically significant factors were found to influence the operative mortality rate: redo operation, age ≥55 years, preoperative NYHA cardiac function grading, extracorporeal circulation time ≥120 minutes and postoperative usage of GIK (glucose, insulin and potassium) solution. All factors were risk ones except postoperative application of GIK. The Hosmer-Lemeshow goodness of fit coefficient of this model was 0.976. Conclusions The risk factors associated with postoperative mortality rate in the patients with AVHD were redo operation, age ≥55 years, preoperative NYHA cardiac function grading and extracorporeal circulation time ≥120 minutes. Postoperative usage of GIK acted as a kind of metabolic therapy and will improve the recovery for patients with AVHD. Active perioperative management and care will play a very important role in reducing the operative risk and improving the short term outcome of surgical treatment for the patients with AVHD.

Live three-dimensional transesophageal echocardiography in mitral valve surgery

Background Live three-dimensional transesophageal echocardiography （live-3D-TEE） is a new technique, but its clinical value is unclear at present. This study aimed to investigate the feasibility, imaging quality and accuracy of live-3D-TEE for assessing mitral valve morphology to determine if live-3D-TEE has important value in mitral valve surgery.Methods Twenty-four patients with mitral valve disease （mean age （47.1±11.6） years, mean weight （64.7±10.5） kg） underwent live-3D-TEE and two dimensional transesophageal echocardiography （2D-TEE） before and after mitral valve surgery. Sensitivity, specificity, and total consistency rates of live-3D-TEE for diagnosing ruptured chordae were calculated and compared to surgeon＇s findings. We also compared the diagnostic accuracy of mitral valve disease between live-3D-TEE and 2D-TEE.Results Live-3D-TEE allowed visualization of the anatomic structure of the heart online and clearly identified the valvular apparatus and their defects. Sensitivity and specificity for the detection of ruptured chordae by live-3D-TEE were 87.5% and 100% respectively, and the total consistency rate was 95.8%. Additional defects not diagnosted by 2D-TEE were found in three cases （12.5%） preoperatively by live-3D-TEE. Live-3D-TEE could evaluate the function of prosthetic or native valves immediately after operation. One case was re-repaired （4.2%） using guidance by live-3D-TEE.Conclusion Live-3D-TEE enabled evaluation of mitral valve function and provided adequate valuable information before and after mitral valve surgery. We conclude that live-3D-TEE can play an important role in mitral valve surgery.

Incidence of coronary artery disease before valvular surgery in isolated severe aortic stenosis

Background Angina pectoris has been recognized as one of the principal symptoms of aortic valve stenosis （AS）,even in patients without significant coronary artery disease （CAD）.However,the incidence of angina pectoris and related CAD in such patients is controversial.There is continuing debate as to whether coronary angiography is necessary before aortic valve replacement （AVR） in patients with severe AS.The purpose of this study was to evaluate the incidence and predictors of CAD in patients with severe AS in a Korean population.Methods Data from all consecutive patients with severe AS undergoing AVR at a major tertiary cardiac and vascular center in Korea were entered in a prospective registry beginning in 1995.Clinical and echocardiographic follow-up data were recorded into the database annually.Significant CAD was defined as one or more major coronary arteries having an estimated narrowing of ≥70％ and left main coronary arteries having an estimated narrowing of ≥50％ on coronary angiography.We excluded patients with multiple valve disease,significant aortic regurgitation,or prior CAD or valve surgery.Results Totally 574 patients with severe AS （mean age,（65.9±9.6） years） were enrolled in this study.Significant CAD was found in 61 patients （10.6％）.Factors associated with increased likelihood of CAD were age,hypertension,diabetes mellitus,chronic renal failure,carotid disease,and aorta calcification.In Logistic regression analysis,the independent predictor of the presence of CAD was age （P=0.011）.The incidence of CAD increased significantly at 69.2 years of age.Having two risk factors for cardiovascular disease was the most useful cutoff to predict whether a patient was going to have significant CAD.Conclusions There was a low incidence of significant CAD in a population of Korean patients with severe AS.Therefore,coronary angiography before AVR will be considered in patients with multiple risk factors for cardiovascular disease or in patients more than 69 years of age without risk factors for cardiovascular disease.