Objective -This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. Methods -Eight patients (6 men) Original ArticleFunctional mitral insufficiency (FMI) is not a rare complication of advanced dilated cardiomyopathy (DCM). It reflects changes in left ventricular (LV) geometry, the subvalvular apparatus, the mitral valve area and transvalvular pressures. Patients with DCM and FMI have refractory congestive heart failure and high mortality when in functional class (FC) III or IV. Blondhein et al 1 reported survival rates over 32 months of 59% in patients with DCM without FMI, 26% in those with DCM and discrete FMI, and 17% in patients with DCM and moderate-to-severe FMI.Although heart transplantation is the standard treatment for advanced DCM, the few available donor hearts are insufficient to supply all patients awaiting the organ. Stevenson et al 2 reported a mortality rate of 46% per year in patients with an indication for cardiac transplantation who were waiting for a donor. Others are excluded from the organ waiting list because of advanced age or clinical contraindications.Alternatives to heart transplantation have been proposed to improve quality of life and decrease mortality in these patients. FMI reflects the worst clinical evolution of DCM, and 2 techniques have been used to correct it. The first technique, mitral valve reconstruction, was proposed by Bolling et al 3 . This technique involves reduction of the dilated mitral annulus, thus, LV remodeling because of a decrease in the base diameter. The second technique, mitral valve replacement, was proposed by Buffolo et al 4 . This technique corrects valvular insufficiency and decreases LV base diameter. It involves implanting a small-diameter prosthesis and anchoring the 2 anterior valve hemileaflets, with their respective chordae tendineae, to the mitral annulus to assist the remodeling process.We used mitral valve replacement to treat patients with DCM and FMI in this study. Our primary objective was to evaluate the short-term effects of valve replacement with new positioning of the chordae tendineae on LV remodeling and FC. First, we altered the subvalvular apparatus to isolate 4 pillars with chordae tendineae, 2 from the anterior leaflet

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This technique of mitral valve replacement improved the left ventricle ejection fraction and decreased the end diastolic and systolic diameters and the end systolic diastolic volumes up to the third month of follow-up. From then on the variables stabilized.

Background In contrast with the setting of acute myocardial infarction, there are limited data regarding the impact of diabetes mellitus on clinical outcomes in contemporary cohorts of patients with chronic coronary syndromes. We aimed to investigate the prevalence and prognostic impact of diabetes according to geographical regions and ethnicity. Methods and results CLARIFY is an observational registry of patients with chronic coronary syndromes, enrolled across 45 countries in Europe, Asia, America, Middle East, Australia, and Africa in 2009–2010, and followed up yearly for 5 years. Chronic coronary syndromes were defined by ≥1 of the following criteria: prior myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischaemia, or prior revascularization procedure. Among 32 694 patients, 9502 (29%) had diabetes, with a regional prevalence ranging from below 20% in Northern Europe to ∼60% in the Gulf countries. In a multivariable-adjusted Cox proportional hazards model, diabetes was associated with increased risks for the primary outcome (cardiovascular death, myocardial infarction, or stroke) with an adjusted hazard ratio of 1.28 (95% confidence interval 1.18, 1.39) and for all secondary outcomes (all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, and coronary revascularization). Differences on outcomes according to geography and ethnicity were modest. Conclusion In patients with chronic coronary syndromes, diabetes is independently associated with mortality and cardiovascular events, including heart failure, which is not accounted by demographics, prior medical history, left ventricular ejection fraction, or use of secondary prevention medication. This is observed across multiple geographic regions and ethnicities, despite marked disparities in the prevalence of diabetes. ClinicalTrials identifier ISRCTN43070564

Introduction Left ventricular non-compaction (LVNC) is a relatively new cardiomyopathy, first reported by Chin et al. in 1990. Since then, much has been learned about this entity, but until now, there are some limitations for the diagnosis of this disease. Cardiac Magnetic Resonance Imaging is considered the gold standard for the diagnosis of LVNC, but echocardiography remains the first line imaging modality due to its availability and cost efficacy. Case report In this case, we report a case of an asymptomatic 21 years old young male with no personal or familiar history of cardiomyopathies. Two dimensional echocardiography (2D Echo) evidenced increased left ventricular trabeculation in the apical segments of lateral and anterior walls and a non compacted myocardium/ (compacted + non compacted myocardium) ratio of 0,33, compatible with LVNC according to Chin´s criteria. 3D Echo provided more detailed LV morphology analysis and 3D Echo Color Doppler evidenced ventricular flow within the intraventricular recesses. Strain analysis by speckle tracking (STE) evidenced global longitudinal strain = - 17% (Normal values < -18%), probably related to an incipient systolic dysfunction not evidenced by the evaluation of left ventricular ejection fraction by 2D Echo. Conclusions This case illustrates new echocardiographic modalities for LVNC diagnosis. 3D Echo and STE are new technologies that may play an incremental role in the evaluation of LVNC but need further investigation and validation. Abstract P697 Figure.

Background LVNC and HCM are cardiomyopathies with distinct clinical presentation that may present common genetic mutations. Some studies suggest a common genetic basis between HCM and LVNC and the possibility of a phenotypic association of these two cardiomyopathies in the same patient. Case report A 39 year old man was referred to our hospital with syncope. His past medical history was unremarkable. His father died of sudden death, at age 49, without investigation of Left ventricular non compaction (LVNC) or Hypertrophic cardiomyopathy (HCM). Physical examination was unremarkable. Electrocardiogram showed sinus rhythm with left chambers overload and isolated ventricular extrasystoles. Transthoracic Echocardiogram (TTE) evidenced significant left ventricular (LV) hypertrophy predominantly in the apical region and inferolateral wall, in the absence of a significant intraventricular gradient at rest and after provocative maneuvers, with preserved LV function, suggesting non-obstructive HCM. Cardiac magnetic resonance imaging (CMRI) showed LV hypertrophy predominantly in the lateral wall, with a maximum thickness of 35 mm, no signs of left ventricular outflow tract (LVOT) obstruction and prominent apical trabeculation, compatible with the association of LVNC and HCM. A genetic test was performed on this patient with inconclusive results. Conclusions The association of diagnostic criteria in cardiac imaging tests (TTE and CMRI) compatible with LVNC and HCM in the same patient is uncommon. This patient shows an infrequent location of the most prominent hypertrophy in the inferolateral wall.This case highlights the importance of integrating cardiac imaging methods in the diagnosis of these two disctinct and rare cardiomyopathies. Legend Figure 1: 2D TTE evidencing prominent hypertropfhy and intraventricular recesses at apical region and inferolateral wall (red arrows), abnormalities suggesting HCM and LVNC at LV apex (blue arrows) in Paraesternal Long Axis (A and B), Short Axis View (C to F), Apical 4 Chambers (G and H) and Apical 2 Chambers View (I and H). Speckle tracking analysis evidencing incipient LV systolic dysfunction by reduced global longitudinal strain (GLS:-8,9%) despite the preserved LVEF (K to N). CMR evidencing findings compatible with the association of LVNC (blue arrows) and HCM (red arrow) in 4 Chambers (O and P), 2 Chambers (Q and R) and Short Axis Views (S to V). Abstract 1102 Figure 1

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A 38 year old man with a huge unruptured sinus of Valsalva aneurysm, complicated with severe valvar aortic regurgitation, is described. The aneurysm was detected by echocardiography in the asymptomatic patient who presented with an intense precordial diastolic rumble after a road traYc accident. The patient had successful surgery for the aneurysm and aortic valve replacement. Possible aetiologies for the aneurysm and a brief revision of clinical aspects and treatment are discussed. (Heart 1999;82:e5) Keywords: sinus of Valsalva aneurysm; valvar disorders; trauma A 38 year old man was admitted to hospital after a road traYc accident. He had multiple lesions including thoracic trauma with rib fracture and deceleration injuries-that is, plexus brachial stretching. Although he had no previous cardiac complications, a heart murmur was detected, and he was therefore referred to the cardiology department. Examination revealed divergent arterial pressure, hyperkinetic arterial pulse, and a long diastolic heart murmur. Transthoracic echocardiography with Doppler colour flow mapping showed normal cardiac chambers, dilatation of the aortic root (the saccular image suggested a sinus of Valsalva aneurysm), morphologically normal valves, good left ventricular systolic function, and a moderate to severe aortic regurgitation with no other abnormal flows. A transoesophageal echocardiogram was taken for a better image and showed a huge unruptured aneurysm (fig 1), which appeared to involve two Valsalva sinuses (non-coronary and right), and severe aortic regurgitation. Cardiac catheterisation indicated a similar pathology to that seen in the echocardiogram; other coronary vessels were normal (fig 2). Surgery revealed the aneurysm to be non-coronary and it was therefore corrected by direct sewing; the aortic valve was replaced with a St Jude prosthesis. There were no postoperative complications and the patient was discharged on the seventh day.An echocardiogram taken after the operation shows the para-aortic image in the right coronary cusp, and corresponds to the sinus of Valsalva aneurysm without interior flow (fig 3). The aortic mechanical prosthesis had normal gradients and the cardiac chambers had normal dimensions; systolic left ventricular function was maintained and the patient was free from cardiac symptoms. DiscussionSinus of Valsalva aneurysms are rare among cardiac surgery patients and it is extremely unusual to find them unruptured or asymptomatic. They are saccular pathological dilata- AO, aorta; VE, left ventricle. Heart 1999;82:e5