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Ann Thorac Surg 2006;82:1721-1727
© 2006 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Beneficial Hemodynamic and Clinical Effects of Surgical Ventricular Restoration in Patients With Ischemic Dilated Cardiomyopathy

Sven A.F. Tulner, MDa,b, Jeroen J. Bax, MD, PhDa, Gabe B. Bleeker, MDa, Paul Steendijk, PhDa,*, Robert J.M. Klautz, MD, PhDb, Eduard R. Holman, MD, PhDa, Martin J. Schalij, MD, PhDa, Robert A.E. Dion, MD, PhDb, Ernst E. van der Wall, MD, PhDa

a Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
b Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands

Accepted for publication May 11, 2006.

* Address correspondence to Dr Steendijk, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands. (Email: p.steendijk{at}lumc.nl).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Surgical ventricular restoration is increasingly applied in patients with ischemic dilated cardiomyopathy. Previous studies show promising results with regard to survival and clinical outcome. However, a comprehensive midterm analysis of this approach on left ventricular (LV) and right ventricular function is not yet available. We investigated biventricular function and clinical status at 6-month follow-up.

METHODS: We investigated the effects of surgical ventricular restoration on clinical variables, LV volume, right ventricular reverse remodeling, LV dyssynchrony, tricuspid regurgitation, and pulmonary artery pressure in 21 patients with ischemic dilated cardiomyopathy (New York Heart Association class III or IV) who underwent surgical ventricular restoration and coronary artery bypass grafting. Additional surgery included mitral annuloplasty (n = 14) and tricuspid valve annuloplasty (n = 8). Clinical variables (New York Heart Association class, quality-of-life questionnaire, 6-minute hall-walk test) and echocardiographic variables were assessed at baseline and at 6 months.

RESULTS: At 6-month follow-up, all clinical variables were significantly improved. Left ventricular ejection fraction improved from 0.27 ± 0.10 to 0.36 ± 0.11 (p < 0.01), LV end-diastolic volume decreased from 248 ± 78 mL to 152 ± 50 mL (p < 0.001), and LV end-systolic volume decreased from 186 ± 77 mL to 101 ± 50 mL (p < 0.001). Left ventricular dyssynchrony decreased from 61 ± 41 ms to 12 ± 12 ms (p < 0.001). Right ventricular annular diameter decreased from 30 ± 7 mm to 27 ± 6 mm, right ventricular short-axis from 30 ± 9 mm to 27 ± 7 mm, and right ventricular long-axis from 90 ± 7 mm to 79 ± 10 mm (all p < 0.05). Finally, significant reductions in severity of tricuspid regurgitation (from 1.3 ± 1.1 to 0.9 ± 0.6; p = 0.001) and pulmonary artery pressure (42 ± 11 mm Hg to 28 ± 10 mm Hg; p = 0.015) were observed.

CONCLUSIONS: Surgical ventricular restoration resulted in improvement of clinical variables, significant LV volume reduction, and reduced LV dyssynchrony at 6-month follow-up. In addition, right ventricular reverse remodeling was noted with reductions in tricuspid regurgitation and pulmonary artery pressure.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Chronic heart failure a major health-care problem both in terms of patient numbers, hospitalizations, and economic costs [1]. The prognosis is extremely poor, with a 5-year survival rate of less than 40% [2]. Recently, it has been demonstrated that surgical ventricular restoration (SVR) improves symptoms and long-term survival in patients with ischemic cardiomyopathy and severe heart failure [3]. Several studies have reported beneficial effects of SVR, including left ventricular (LV) volume reduction with an improvement in LV ejection fraction (LVEF), associated with a reduction in ventricular arrhythmias and reduced mitral regurgitation [4–6]. In addition, recent studies have shown that SVR results in an acute reduction of LV mechanical dyssynchrony [7, 8]. In patients with valvular insufficiencies, additional mitral and or tricuspid valve repair may be needed to optimize patient outcome [9]. Therefore, our current approach in patients undergoing SVR is to always correct mild to moderate mitral and tricuspid regurgitation using annuloplasty. Although preliminary data indicate acceptable survival, larger studies are required to establish survival rate. In addition, comprehensive data on clinical and hemodynamic status at midterm follow-up are limited. Therefore, we analyzed clinical status and biventricular function in patients with ischemic dilated cardiomyopathy before and 6 months after surgery. In particular, we report the effects of our approach on LV volume, LV dyssynchrony, right ventricular (RV) reverse remodeling, and RV functional variables.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Patients and Study Protocol
We studied 21 patients with ischemic dilated cardiomyopathy who underwent SVR and who had complete echocardiographic follow-up including tissue Doppler imaging (TDI) at 6 months. All patients had severe heart failure symptoms, and 13 patients (62%) had accompanying angina pectoris. In particular, 13 (62%) patients were in New York Heart Association (NYHA) class III and 8 (38%) were in class IV. All patients had a previous anteroseptal infarction, and the interval between infarction and surgery averaged 2.5 years (range, 0.25 to 12 years). All patients had coronary artery disease (on average, 2.4 ± 0.9 stenoses) and were scheduled for additional coronary artery bypass grafting. Patients with severe mitral or tricuspid regurgitation underwent additional mitral or tricuspid valve repair. Patients who underwent valvular repair were evaluated before and immediately after surgery by transesophageal echocardiography (TEE). Baseline characteristics are presented in Table 1. In all patients, before SVR and 6 months after surgery, two-dimensional transthoracic echocardiography at rest was performed to calculate LV volumes and LVEF, and to assess RV chamber size. Next, TDI was performed to evaluate LV dyssynchrony. At the same time, clinical status was assessed using NYHA classification, the Minnesota quality-of-life questionnaire, and the 6-minute hall-walk test. The institutional review board approved the study protocol, and all patients provided informed consent.


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  		Table 1. Patient Characteristics
 
Surgical Procedures
The surgical procedures were performed using normothermic cardiopulmonary bypass with intermittent antegrade warm blood cardioplegia. After median sternotomy, patients underwent conventional coronary artery bypass grafting, using internal mammary arteries whenever possible. Next, SVR was performed by endoventricular circular patch plasty as previously described [10]. Briefly, the LV was opened through the infarcted area to determine the margins for SVR in both dyskinetic and akinetic infarcts. An endocardial encircling suture was placed at the transitional zone between scarred and normal tissue. A balloon containing 55 mL/m2 saline was introduced, and the suture was tightened to approximate the ventricular wall to the balloon. A tailored oval polyethylene terephthalate fiber (Dacron) patch was used to close the residual orifice. Care was taken to obtain an elliptical-shaped residual LV cavity. The excluded scar tissue was closed over the patch to ensure hemostasis. In patients with concomitant severe mitral regurgitation (grade ≥2), additional restrictive mitral annuloplasty with implantation of an undersized (aiming at downsizing the annulus by two sizes), complete, semirigid Carpentier-Edwards Physio annuloplasty ring (Edwards Lifesciences, Saint-Prex, Switzerland) was performed through the transseptal approach. After weaning, TEE was performed to exclude residual mitral regurgitation and to assess the length of mitral leaflet coaptation (aiming at ≥0.8 cm). In patients with severe tricuspid annular dilatation (>3.5 cm) or regurgitation (grade ≥2), a concomitant tricuspid annuloplasty using an Edwards MC3 annuloplasty ring (Edwards Lifesciences) was performed.

Echocardiography
Echocardiography and TDI were performed at baseline (preoperatively), and at 6-month follow-up. Images were obtained with patients in the left lateral decubitus position using a commercially available system (Vingmed system-7, GE-Vingmed, Chalfont St. Giles, United Kingdom). Images were obtained using a 3.5-MHz transducer, at a depth of 16 cm in the parasternal and apical views (standard long-axis and two-chamber and four-chamber images). Standard two-dimensional and color-Doppler data, triggered to the QRS complex, were saved in cine loop format. Left ventricular volumes and LVEF were calculated from the apical two-chamber and four-chamber images, using the biplane Simpson's technique.

Evaluation of mitral and tricuspid regurgitation
In patients with severe mitral or tricuspid regurgitation (grade ≥2) on transthoracic echocardiography, additional TEE was performed within 5 days before surgery. Transesophageal echocardiography was performed without anesthesia to avoid underestimation of regurgitation severity. The severity of regurgitation was graded semiquantitatively from color-flow Doppler in the conventional parasternal long-axis and apical four-chamber images. Regurgitation was classified as mild = 1+ (jet area/atrial area <10%); moderate = 2+ (10% to 20%); moderately severe = 3+ (20% to 45%); or severe = 4+ (>45%) [11]. Immediately after surgery, TEE was repeated to assess residual regurgitation, transmitral diastolic gradient (determined from continuous-wave Doppler), and length of coaptation of the mitral leaflets. Six months after surgery, possible recurrence of mitral and tricuspid regurgitation was assessed by TEE. Continuous-wave Doppler examination was performed to estimate pulmonary artery systolic pressure from the transtricuspid maximal regurgitant flow velocity. All measurements were analyzed in random order by two independent observers without knowledge of the clinical status of the patient.

Assessment of right ventricular chamber size
Right ventricular end-diastolic chamber size was assessed using three variables [12]: first, the diameter of the annulus of the tricuspid valve, defined as the point of attachment of the septal and posterior leaflets to the atrioventricular junction; second, the maximal dimension of the middle third of the RV, parallel to the tricuspid annulus; third, the major axis of the RV, defined as the distance between the RV apex to the midpoint of the tricuspid annulus. Interobserver and intraobserver agreement were 98% and 96% for the tricuspid valve annular diameter, 90% and 92% for the RV short axis, and 94% and 95% for the RV long axis, respectively.

Tissue Doppler imaging
Tissue Doppler imaging was performed to assess LV dyssynchrony. Color-Doppler frame rates varied between 80 and 115 frames/s depending on the sector width of the range of interest; pulse repetition frequencies were between 500 Hz and 1 kHz, resulting in aliasing velocities between 16 and 32 cm/s. Tissue Doppler imaging variables were measured from color images of three consecutive heart beats by offline analysis. Data were analyzed using commercial software (Echopac 6.1, GE-Vingmed, Chalfont St. Giles). To determine LV dyssynchrony, the sample volume was placed in the basal portions of the septum and the LV lateral wall; peak systolic velocities and time-to-peak systolic velocities were obtained, and the delay in peak velocity between septum and lateral wall was calculated as an indicator of LV dyssynchrony (septal-to-lateral delay). Interobserver and intraobserver agreement for assessment of the septal-to-lateral delay were 90% and 96%, respectively [13]. To assess RV function, the sample volume was placed in the basal part of the lateral RV free wall. The peak systolic velocity of the RV wall was calculated and used as a marker of RV systolic function.

Assessment of Functional Status
Functional status was assessed by NYHA classification, quality-of-life score (Minnesota quality-of-life questionnaire) and 6-minute hall-walk test. The QRS duration was measured from the surface electrocardiogram using the widest QRS complex from the leads II, V1, and V6. The electrocardiograms were recorded at 25 mm/s and evaluated by two independent observers without knowledge of the patient's clinical status. All variables were assessed within 1 week before surgery and approximately 6 months after surgery.

Statistical Analysis
Data are presented as mean ± standard deviation, and compared using the paired or unpaired Student's t test when appropriate. A probability value less than 0.05 was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Twenty-one patients were evaluated: 12 patients (57%) had dyskinesia and 9 patients (43%) had akinesia. Perioperative data and early operative complications (<30 days) are summarized in Table 2. In the associated 2-year interval, a total of 39 NYHA class III or IV heart failure patients underwent SVR in our center: the operative mortality in this group was 10.3%, and 6-month survival was 87%. Note that in the present study we only included a selected group of patients with complete echocardiographic data and 6-month follow-up in our center. Therefore, our findings reflect only patients who survived 6-month follow-up.


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  		Table 2. Surgical Information and Complications
 
Clinical Variables
At 6-month follow-up a significant improvement in clinical status was observed. New York Heart Association class improved significantly from 3.4 ± 0.5 to 1.4 ± 0.5 (p < 0.001), the Minnesota quality-of-life score improved from 39 ± 21 to 15 ± 23 (p < 0.001), and the 6-minute walking distance improved from 234 ± 124 m to 416 ± 106 m (p < 0.001). The QRS duration at baseline was 107 ± 28 ms (range, 80 to 202 ms) and remained unchanged (111 ± 22 ms; range, 90 to 172 ms; p = 0.35) at 6-month follow-up.

Echocardiography
Echocardiographic results at baseline and at 6-month follow-up are summarized in Table 3.


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  		Table 3. Echocardiographic Data
 
Left ventricular dyssynchrony
At 6-month follow-up, TDI demonstrated a significant reduction in septal-to-lateral delay from 61 ± 41 ms to 12 ± 12 ms (p < 0.001), indicating improved LV mechanical synchrony.

Left ventricular volume reduction
Significant LV volume reduction was shown at 6-month follow-up. Left ventricular end-diastolic volume decreased from 248 ± 78 mL to 152 ± 50 mL (p < 0.001), whereas LV end-systolic volume decreased from 186 ± 77 mL to 101 ± 50 mL (p < 0.001). This resulted in an increase of the LVEF from 0.27 ± 0.10 to 0.36 ± 0.11 (p = 0.007).

Right ventricular remodeling
At 6-month follow-up, significant reverse remodeling of the RV was demonstrated: all variables reflecting RV size showed a significant decrease. The tricuspid valve annulus diameter decreased from 30 ± 7 mm to 27 ± 6 mm (p = 0.04), the RV short axis decreased from 30 ± 9 mm to 27 ± 7mm (p = 0.03), and the RV long axis showed a reduction from 90 ± 7 mm to 79 ± 10 mm (p < 0.001). Moreover, after surgery, pulmonary artery pressure significantly decreased from 42 ± 11 mm Hg to 28 ± 10 mm Hg (p = 0.02), whereas RV function assessed by RV myocardial peak systolic velocity improved significantly from 3.9 ± 2.0 cm/s to 4.8 ± 1.4 cm/s (p < 0.02).

Mitral and tricuspid regurgitation
In 14 patients additional restrictive mitral annuloplasty (median ring size, 24; range, 24 to 28) was performed. In 9 (43%) of these patients, severe (grade 3 to 4+) mitral regurgitation was present; the other 5 (24%) patients had grade 2+ mitral regurgitation. In the latter, provocative testing was performed in the operating room, resulting in grade 3 to 4+ mitral regurgitation in all patients. No patients had primary organic valvular disease. The mechanism underlying mitral regurgitation was systolic restrictive leaflet motion with annular dilatation, which resulted in coaptation failure (resulting in a central regurgitant jet). The patients who underwent mitral valve repair (n = 14) had grade 2.8 ± 0.7 mitral regurgitation on preoperative TEE, which improved to grade 0.1 ± 0.3 immediately after restrictive mitral annuloplasty. Transthoracic echocardiography after 6 months showed no or grade 1 regurgitation in 12 patients, 2 patients had grade 2, and none had grade 3 or 4 residual mitral regurgitation (mean 0.9 ± 0.7). In these patients, preoperative TEE showed a mean length of coaptation of 0.23 ± 0.06 cm, and 0.8 ± 0.1 cm after restrictive mitral annuloplasty, with a mean transmitral diastolic gradient of 3.1 ± 1.5 mm Hg. No systolic anterior movement of the anterior leaflet was observed in any patient. In the patients who did not receive additional mitral valve repair (n = 7), mitral regurgitation was unchanged at 6-month follow-up (mitral regurgitation grade 1.3 ± 0.9 at baseline versus 1.1 ± 0.8 at follow-up; p = 0.604). In the group as a whole, mitral regurgitation was grade 2.0 ± 1.0 at baseline, and 1.0 ± 0.7 at 6-month follow-up (p = 0.001).

In 8 patients additional tricuspid annuloplasty (median ring size, 28; range, 28 to 32) was performed for severe tricuspid regurgitation or annular dilatation (preoperative TEE: grade 2.5 ± 0.5). The tricuspid regurgitation was successfully treated (postoperative TEE: grade 0.1 ± 0.1). At 6-month follow-up, 5 patients had grade 1 or less, and 3 had grade 2 residual regurgitation. In the group as a whole, tricuspid regurgitation was grade 1.3 ± 1.1 at baseline and 0.9 ± 0.6 at 6-month follow-up (p = 0.002).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Severe LV dilation and mitral or tricuspid regurgitation are frequently observed in heart failure patients, and conservative treatment is associated with a poor prognosis [14, 15]. Surgical therapies (SVR and if indicated mitral or tricuspid annuloplasty) to correct these complications have evolved and show acceptable survival rates. However, limited data are available about the effects on clinical status and LV and RV function. In the current study, we analyzed clinical status and biventricular function in a group of patients with ischemic dilated cardiomyopathy undergoing SVR and revascularization with, if needed, mitral or tricuspid valve repair before and 6 months after surgery.

Clinical Status
In the total group of patients, an improvement in heart failure symptoms was observed, illustrated by a significant reduction of NYHA class from 3.4 ± 0.5 to 1.4 ± 0.5, with all patients in NYHA class I or II at follow-up. Similar observations were reported previously [16, 17]. In addition, we evaluated more objective variables of symptoms, including quality-of-life score and 6-minute walking distance, which improved in parallel to the improvement in NYHA class.

Echocardiographic Evidence of Remodeling
Left ventricular function
Previous studies demonstrated improvement in LVEF and LV volume reduction after SVR. Maxey and colleagues [18] showed an acute increase in LVEF from 0.22 ± 0.03 to 0.33 ± 0.01 in 56 patients who underwent SVR combined with coronary artery bypass grafting. Qin and associates [19] reported an increase in LVEF from 0.27 ± 0.09 to 0.36 ± 0.11 at 6-month follow-up in patients who underwent SVR combined with mitral valve repair. A similar increase in LVEF (from 0.27 ± 0.10 to 0.36 ± 0.11; p < 0.001) was found in the current study. The improvement in LVEF was associated with a mean reduction of 39% in LV end-diastolic volume and 46% in LV end-systolic volume. Qin and coworkers [19] showed a comparable reduction in patients undergoing SVR and mitral valve repair; the LV end-diastolic volume decreased from 235 ± 87 mL at baseline to 156 ± 73 mL at discharge, whereas the LV end-systolic volume decreased from 175 ± 80 mL to 104 ± 63 mL. At 6-month follow-up, however, LV volume reduction was not fully maintained, and redilatation occurred, with final LV end-diastolic and end-systolic volumes of 177 ± 94 mL and 114 ± 66 mL, respectively. The redilatation was most noticeable in patients with recurrent mitral regurgitation, indicating that effective mitral valve repair is warranted in these patients to prevent redilatation. In our series, no significant recurrence of mitral regurgitation was found, which may have contributed to the significant reduction in LV volumes at 6-month follow-up. Additional factors promoting redilatation after SVR reported in the literature include excessive preoperative end-diastolic volume [20], the amount of fibrosis in the remote myocardium [21], and disruption of fiber orientation [22]. Recently, Fujii and colleagues [23] demonstrated that LV volume reduction may even be maintained long-term; in 14 patients undergoing SVR, LV end-systolic volume was significantly reduced from 165 ± 74 mL at baseline to 94 ± 70 mL at 3-year follow-up. Also, Yamaguchi and associates [24] demonstrated a long-term reduction in LV volumes at 5-year follow-up after SVR with mitral valve repair. These preliminary results suggest a long-term benefit from SVR and mitral annuloplasty, but additional studies with larger patient populations are needed. Previous studies indicate an acute volume reduction after SVR in a range between 33% and 40% [7, 8, 19, 23], which suggests that the 39% volume reduction found in our study at 6-month follow-up is achieved largely immediately after surgery.

Right ventricular function
Our results illustrate that our surgical approach is associated with significantly increased peak systolic velocity of the RV myocardial wall, a significant reduction in pulmonary artery pressure, with reduction in severity of tricuspid regurgitation, and reverse RV remodeling. Currently, no other data are available regarding the effect of SVR and mitral or tricuspid annuloplasty on RV function in patients with heart failure. One could hypothesize that successful mitral valve repair may lead to a reduction in pulmonary artery pressure with a recovery in RV function [25]. Similarly, tricuspid annuloplasty would be expected to improve RV function [26]. In our study, 5 patients did not receive additional valve repair, 8 patients received mitral valve annuloplasty, 2 patients received tricuspid valve annuloplasty, and in 6 patients combined mitral and tricuspid valve annuloplasty was performed. Figure 1 shows the RV function and dimension variables for the subgroups with and without mitral annuloplasty, and those with and without tricuspid annuloplasty. Clearly, all subgroups show the same trends as found in the full group. Statistical analysis (Fig 1) could not demonstrate significant independent effects of mitral or tricuspid valve surgery; however, sample size is relatively small. The improvement in RV function is clinically important, inasmuch as decreased RV function and RV dilatation have been shown result in deterioration of heart failure symptoms with a worse prognosis [27, 28].


Figure 1
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  		Fig 1. Right ventricular function and dimension variables at baseline and 6-month follow-up. All variables changed significantly in the full group (ALL, see Table 3), but did not reach statistical significance in the subgroups. Multiple linear regression analysis did not show independent or interactive effects of additional valve surgery. (ALL = all patients; PAP = pulmonary artery pressure; –RMA/+RMA = patients without/with additional restrictive mitral annuloplasty; RV LAX = right ventricular long axis; RV PSV = right ventricular peak systolic velocity; RV SAX = right ventricular short axis; TV ANN = tricuspid valve annulus; –TVP/+TVP = patients without/with additional tricuspid annuloplasty.)

 
Left Ventricular Dyssynchrony
Left ventricular dyssynchrony is an important codeterminant of LV dysfunction in patients with heart failure [29]. Recently, Di Donato and coworkers [7] showed an acute reduction of LV mechanical dyssynchrony after SVR assessed by analysis of LV angiographic data. Similarly, Schreuder and colleagues [8] showed that the reduction in LV dyssynchrony after SVR induced acute improvements in contractile status, energy efficiency, and LV relaxation. In the current study, a significant reduction in LV dyssynchrony 6 months after surgery was shown using TDI. Septal-to-lateral delay assessed by TDI is currently widely used and generally regarded an accurate measure of intraventricular dyssynchrony [30]. It should be noted that septal-to-lateral delay was obtained in the basal regions of the LV. Thus, this index would not directly reflect the anteroseptal area, which was the target for surgical remodeling, but rather describe the properties of the viable remote myocardium. Therefore, this index would be expected to underestimate global LV dyssynchrony in this patient group, at least before surgery. However, improvements in the properties of the remote myocardium, presumably primarily induced by a reduction in wall stress after SVR, are essential in these patients.

In the present study both patients with dyskinesia and akinesia were enrolled. A subanalysis did not show significant differences between these two groups for any of the variables examined or for the changes in these variables induced by SVR, except for a slightly higher baseline NYHA class in the patients with dyskinesia (3.6 ± 0.5 versus 3.1 ± 0.3; p = 0.02).

Recent data suggest that in patients with heart failure, LV dyssynchrony was associated with a worse outcome, whereas LV resynchronization was associated with a better long-term prognosis [31]. Additional studies on LV dyssynchrony in patients undergoing SVR are needed to determine the clinical value of LV resynchronization.

Limitations of the Study
This study lacks acute volumetric data, and therefore we cannot compare midterm effects of SVR with effects immediately after surgery. The effects of additional valve procedures on biventricular function could not be adequately established as the number of patients in this study was too small and treatment was not randomized. Furthermore, as all patients underwent additional coronary artery bypass grafting the improvement of systolic function found in this study may be partly explained by positive effects on LV contractility by revascularization of hibernating or stunned myocardium.

In conclusion, SVR with, if indicated, additional mitral or tricuspid annuloplasty resulted in significant improvement of clinical status and heart failure symptoms at 6-month follow-up, combined with an improvement in LV function, a reduction in LV volume, and a reduction in LV dyssynchrony with minimal residual mitral regurgitation. In addition, a decrease in pulmonary artery pressure, RV reverse remodeling, and reduced tricuspid regurgitation were observed.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
This study was supported by grants from the Netherlands Heart Foundation (NHS2002B133 and NHS2002B109).


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

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