Mitral and tricuspid are increasingly prevalent. Doppler echocardiography not only detects the presence of regurgitation but also permits to understand mechanisms of regurgitation, quantification of its severity and repercussions. The present document aims to provide standards for the assessment of mitral and tricuspid regurgitation.

Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Echocardiography has become the primary non-invasive imaging method for the evaluation of valvular regurgitation. The echocardiographic assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy, and function as well as the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation thus largely integrates the results of echocardiography. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing regurgitation.

In patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.

Treatment of hepatorenal syndromes (HRSs) is currently based on vasopressin analogs. The aim of this pilot study was to evaluate the efficacy and safety of noradrenalin (NA) in the treatment of type 1 HRS. Between 1998 and 2000, 12 consecutive patients with type 1 HRS (7 men, 5 women; mean age, 54 ؎ 11 years; mean Child-Pugh score, 11.3 ؎ 1.7) were treated with intravenous NA (0.5-3 mg/h), in combination with intravenous albumin and furosemide. NA was given for 10 ؎ 3 days, at a mean dose of 0.8 ؎ 0.3 mg/h. Reversal of HRS was observed in 10 of 12 patients (83%; 95% confidence interval, 52%-98%) after a median of 7 days (range, 5-10 days). Serum creatinine levels fell from 358 ؎ 161 to 145 ؎ 78 mol/L (P < .001), creatinine clearance rose from 13 ؎ 9 to 40 ؎ 15 mL/min (P ‫؍‬ . H epatorenal syndrome (HRS) is a frequent and major complication of end-stage cirrhosis. It is considered as a functional renal failure caused by marked renal vasoconstriction, related to peripheral (mainly splanchnic) arterial vasodilation. 1 Type 1 HRS usually occurs in patients with end-stage liver disease and shows a poor prognosis. The median survival time is about 10 days. It is defined as rapidly progressive renal failure with a 50% reduction in initial creatinine clearance to below 20 mL/min within 15 days. 2 Type 2 HRS occurs instead in patients with refractory ascites and is characterized by moderate and more stable impairment of renal function. Liver transplantation is the only treatment to improve survival in patients with type I HRS 3 ; however, because of the very poor prognosis of type 1 HRS and because of organ shortage, a donor is usually not found quickly enough to avoid death. HRS management thus focuses on improving renal function and thereby extending survival pending liver transplantation. This has recently been addressed by assessing the effects of vasoconstrictors that, combined with plasma expanders, restore the collapse of systemic vascular resistances (SVRs) underlying HRS. 1,4-9 Thus, vasopressin analogs such as ornipressin 4-6 and terlipressin 7-9 improve renal perfusion and glomerular filtration in patients with HRS by inducing vasoconstriction of the splanchnic circulation.Noradrenalin (NA) is a catecholamine with predominantly ␣-adrenergic activity. Given its vasoconstricting effects in venous and arterial systems, and its limited action on the myocardium, it is currently the drug of choice for vasoplegic shock. These pharmacologic properties suggest that NA might also counteract the collapse in SVRs leading to HRS. After a case report of successful treatment of HRS with a combination of NA and dopamine, 10 we conducted a pilot study to Abbreviations: HRS, hepatorenal syndrome; SVR, systemic vascular resistance; NA, noradrenalin; CVP, central venous pressure; MAP, mean arterial pressure. From the

Background-Dobutamine stress hemodynamics (DSH) has the potential to stratify operative risk in low-gradient aortic stenosis (AS), but little is known about the relation between left ventricle contractile reserve and postoperative left ventricular ejection fraction (LVEF). We sought to assess the value of DSH to predict postoperative improvement in LVEF. Methods and Results-Sixty-six consecutive patients with symptomatic severe AS (aortic valve area Յ1 cm 2 ), LVEF Յ40%, and mean pressure gradient Յ40 mm Hg prospectively enrolled in the French multicenter study on low-gradient AS and who survived to aortic valvular replacement (AVR) were included. Preoperative contractile reserve was present in 46 patients (group I; 70%) and absent in 20 patients (group II; 30%). In the overall sample, 58% of patients improved by 2 New York Heart Association (NYHA) classes after AVR. Mean LVEF improved from 29Ϯ6% to 47Ϯ11% (PϽ0.0001). LVEF improved by Ն10 EF units in 38 patients (83%) in group I and in 13 patients (65%) in group II. Mean LVEF improvement was similar in the 2 groups (19Ϯ10% versus 17Ϯ11%; Pϭ0.54). On multivariable analysis, multivessel coronary artery disease (Pϭ0.05) and baseline mean transaortic pressure gradient (Pϭ0.01) were related to LVEF improvement, whereas contractile reserve was not. Conclusions-LVEF increases in the majority of patients with low-gradient AS who survive after AVR. Although the absence of contractile reserve on DSH is related to high operative mortality, it does not predict the absence of LVEF recovery in patients surviving to AVR. These data further support the concept that surgery should not be contraindicated on the basis of absence of contractile reserve alone.

Background-The management of patients with asymptomatic severe aortic stenosis remains controversial. We sought to develop a continuous risk score for predicting the midterm development of symptoms or adverse events in this setting. Methods and Results-We prospectively followed 107 patients with asymptomatic aortic stenosis (aged 72 years [63 to 77]; 35 women; aortic-jet velocity, 4.1 m/s [3.5 to 4.4]) at a single center in France. Predefined end points for assessing outcome were the occurrence within 24 months of death or aortic valve replacement necessitated by symptoms or by a positive exercise test. Variables independently associated with outcome were used to build a score that was validated in an independent cohort of 107 patients from Belgium. Independent predictors of outcome were female sex, peak aortic-jet velocity, and B-type natriuretic peptide at baseline. Accordingly, the score could be calculated as follows: Scoreϭ[peak velocity (m/s)ϫ2]ϩ(natural logarithm of B-type natriuretic peptideϫ1.5)ϩ1.5 (if female sex). Event-free survival after 20 months was 80% for patients within the first score quartile compared with only 7% for the fourth quartile. Areas under the receiver operating characteristic curve for the score were 0.90 and 0.89 in the development and validation cohorts, respectively. Conclusions-If further validation is achieved, this score may be useful to predict outcome in individual patients with asymptomatic aortic stenosis to select those who might benefit from early surgery. (Circulation. 2009;120:69-75.)

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Combination of AS and TTR-CA may occur in elderly patients particularly those with a low-flow low-gradient AS pattern and carries bad prognosis. Diagnosis of TTR-CA in AS is relevant to discuss specific treatment and management.