BackgroundMitral annular disjunction (MAD) consists of an altered spatial relation between the left atrial wall, the attachment of the mitral leaflets, and the top of the left ventricular (LV) free wall, manifested as a wide separation between the atrial wall-mitral valve junction and the top of the LV free wall. Originally described in association with myxomatous mitral valve disease, this abnormality was recently revisited by a surgical group that pointed its relevance for mitral valve reparability. The aims of this study were to investigate the echocardiographic prevalence of mitral annular disjunction in patients with myxomatous mitral valve disease, and to characterize the clinical profile and echocardiographic features of these patients.MethodsWe evaluated 38 patients with myxomatous mitral valve disease (mean age 57 ± 15 years; 18 females) and used standard transthoracic echocardiography for measuring the MAD. Mitral annular function, assessed by end-diastolic and end-systolic annular diameters, was compared between patients with and without MAD. We compared the incidence of arrhythmias in a subset of 21 patients studied with 24-hour Holter monitoring.ResultsMAD was present in 21 (55%) patients (mean length: 7.4 ± 8.7 mm), and was more common in women (61% vs 38% in men; p = 0.047). MAD patients more frequently presented chest pain (43% vs 12% in the absence of MAD; p = 0.07). Mitral annular function was significantly impaired in patients with MAD in whom the mitral annular diameter was paradoxically larger in systole than in diastole: the diastolic-to-systolic mitral annular diameter difference was -4,6 ± 4,7 mm in these patients vs 3,4 ± 1,1 mm in those without MAD (p < 0.001). The severity of MAD significantly correlated with the occurrence of non-sustained ventricular tachycardia (NSVT) on Holter monitoring: MAD›8.5 mm was a strong predictor for (NSVT), (area under ROC curve = 0.74 (95% CI, 0.5-0.9); sensitivity 67%, specificity 83%). There were no differences between groups regarding functional class, severity of mitral regurgitation, LV volumes, and LV systolic function.ConclusionsMAD is a common finding in myxomatous mitral valve disease patients, easily recognizable by transthoracic echocardiography. It is more prevalent in women and often associated with chest pain. MAD significantly disturbs mitral annular function and when severe predicts the occurrence of NSVT.

Notes excess (0.080 mol) of NaHCOs and the buffered solution was stirred for 15 min. Analysis of an aliquot showed 3.0 equiv of acid per mole of carbyl sulfate. (This was confirmed with poor precision by a bisulfite additon assay.) The neutralized solution was dried at 50°and reduced pressure and the resulting salt mixture was subjected to a 12-hr Soxhlet extraction with methanol. The extract, containing the organic salt, was divided into aliquots. One portion, treated with S-benzylthiuronium chloride, formed the corresponding vinylsulfonate salt, mp 145-146°from ethanol, in good agreement with the reported value.11 Another portion was dried; the white salt yielded (KBr pellet) major infrared maxima at 1190, 1045, 1620, and 755 cm™1, in the expected regions for -S02asymmetric and symmetric stretch, vinyl, and S-0 stretch, respectively. The remaining portion was examined in aqueous solution by nmr, yielding a seven-peak spectrum characteristic of vinyl splitting with Jgem s 0,12 The three vinylic protons appeared at 6.00, 6.04, and 6.86 ppm, similar to those found for methyl vinyl sulfone (5.95, 6.13, and 6.70 ppm)13 and reasonably close to the values predicted by the Pascual equa-tion14 for CH2=CH-SO2-(6.23, 6.43, and 6.86 ppm).Acid-base titrations were carried out using standard 0.10 N Na2C03 or NaOH. Since ethionic acid undergoes an acid-generating elimination in near-neutral solutions, it was found useful to make one or two preliminary range-finding titrations, prior to carrying out rapid analytical titrations to first end points.Reactions in dilute aqueous base were examined by addition of 2-3 mmol of pure carbyl sulfate to 100-ml portions of 0.10 N KOH, followed by titration with standard acid. At 25, 50, and 90°t he average values of the ratio (equivalents of acid formed-):(moles of carbyl sulfate reacted) were found to be 2.7, 2.6, and 2.7. (When carbyl sulfate is predissolved in 10 ml of dry dioxane and this solution is added to the aqueous base, this observed ratio falls to 2.0.) Identification of vinylsulfonate in the product mixture was made by infrared examination and by reaction with measured amounts of bisulfite ion to form potassium ethanedisulfonate.15Quantitative information on the elimination of sulfate by ethionate in near-neutral solutions was sought by combining solutions of ethionic acid and phosphate buffers, then assaying these for vinylsulfonate by the semiquantitative bisulfite method.15 Vinylsulfonate yields of 80-90% were obtained at pH 7.70, 70-78% at pH 7.01 and 8.90, 45-55% at pH 5.5 and 10.2, and 80-95% with authentic sodium vinylsulfonate. While these data suggest a maximum elimination in nearly neutral solutions, we were unable to obtain acceptably reproducible assays by this procedure.

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Stress-induced cardiomyopathy, also known as 'broken heart syndrome' or Takotsubo cardiomyopathy, is characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle, in the absence of significant coronary artery disease. We report the case of a 56-year-old male patient with chronic obstructive pulmonary disease (COPD), with stress-induced cardiomyopathy associated with the use of ipratropium bromide, administered in the context of an acute exacerbation of COPD.

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