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The findings of the present study suggest that the MRI-derived assessment of OMR can better identify patients with severe OMR and adverse outcome than ECHO-derived integrative approach warranting close follow-up and perhaps, early mitral valve surgery.

In this large cohort of patients TTE (SH) is as accurate as TEE for the detection of PFO and late right-to-left shunts. If the only purpose of TEE is the detection of PFO such as in young cryptogenic stroke patients and in divers, TEE can be replaced by TTE (SH).

We aimed to prospectively and quantitatively assess the effects of aortic valve replacement (AVR) for aortic stenosis (AS) on mitral regurgitation (MR) and to examine the determinants of the changes in MR. Fifty-two patients with AS scheduled for AVR were included if holosystolic MR not being considered for replacement or repair was detected. MR was quantified using the proximal isovelocity surface area method before and 8 ؎ 4 days after surgery. Mitral valvular deformation parameters did not change significantly, but the mitral effective regurgitant orifice (ERO) and regurgitant volume decreased from 11 ؎ 6 mm 2 to 8 ؎ 6 mm 2 and from 20 ؎ 10 ml to 11 ؎ 9 ml, respectively (both p <0.0001). Using multiple linear regression analysis, preoperative severity of MR, mitral leaflet coaptation height, and end-diastolic volume decrease were independently associated with postoperative reduction in MR, whereas changes in mitral valve morphology after surgery were not. Mitral regurgitation (MR) is a common finding in patients with aortic stenosis (AS). The severity of the MR increases over time in relation to the increase in transaortic pressure gradient.1 At the time of aortic valve replacement (AVR), up to two-thirds of patients with AS exhibit varying degrees of MR.2 Because combined aortic and mitral valve replacement markedly increases the operative risk and affects longterm morbidity and mortality, 3,4 it has been suggested that MR does not require specific treatment because downgrading of MR usually occurs after isolated AVR. In fact, AVR for AS, by reducing left ventricular (LV) afterload, might have the potential to improve mitral valve competence through reverse LV remodeling and reduced mitral annular size. Several authors 2,5-13 have attempted to determine predictive factors for MR changes after surgery. However, these studies, mostly limited by their retrospective nature and/or by the qualitative or semi-quantitative assessment of MR, have given conflicting results. Indeed, the percentage of patients with reduced MR ranges from Ͼ80% 9 to Ͻ30%.8 No study has used a quantitative method for assessing MR in this setting. The extent and determinants of changes in MR after AVR, therefore, remain to be determined. Whether postoperative changes in MR reflect LV hemodynamics or LV and mitral valve geometric changes is unknown. We therefore aimed to prospectively and quantitatively assess the effects of AVR on MR severity and to examine the determinants of postoperative changes in MR. MethodsPatients were included in this multicenter study if they presented with severe AS and were scheduled for AVR and had at least mild holosystolic MR. Patients with MR being considered for a concomitant mitral valve procedure were excluded, as were patients with previous mitral valve surgery, technically inadequate echocardiogram, or greater than moderate aortic regurgitation (vena contracta width Ͼ6 mm). Patients were also subsequently excluded from the study if any surgical procedure on the mitral valve (repair or replacement) was pe...

NotesOnline First articles must include the digital object identifier (DOIs) and date of initial publication. establish publication priority; they are indexed by PubMed from initial publication. Citations to may be posted when available prior to final publication Summary:Mitral regurgitation is a frequent finding in patients with aortic stenosis scheduled for aortic valve replacement. Detection of mitral regurgitation in such patients has important implications, as it can independently affect functional status and prognosis. When mitral regurgitation is moderate-to-severe, a decision to operate on both valves should only be made following a careful clinical and echocardiographic assessment. Indeed, double-valve surgery increases peri-and post-operative risks, and mitral regurgitation may improve spontaneously after isolated aortic valve replacement. Better understanding of the determinants of these changes appears particularly crucial in the light of recent advances in percutaneous aortic valve replacement. IntroductionAt the time of aortic valve replacement (AVR), many patients with aortic stenosis (AS) exhibit varying degrees of mitral regurgitation (MR). The aetiology of the MR is often functional in nature, occurring in the absence of any significant intrinsic valvular lesion. Increased afterload, left ventricular (LV) remodelling, fluid overload and concomitant ischaemic heart dysfunction may account for the development of functional MR. When there is intrinsic mitral valve disease, this may result from calcification of the mitral leaflets or annulus, particularly in the elderly, but also from rheumatic involvement, or from myxomatous degeneration. MR associated with AS should not be overlooked, as it can worsen functional status and independently affect prognosis. Moreover, a surgeon's decision to operate on both valves should only be made after careful clinical and echocardiographic assessment, because double-valve surgery increases the perioperative risk, and MR can improve spontaneously after isolated AVR. Greater awareness of the determinants of these changes appears particularly crucial in the light of recent advances in percutaneous AVR. In this article, we review current knowledge on the pathophysiology, incidence, and prognostic value of MR in severe AS, as well as the natural history of MR after isolated AVR.