Bicuspid leaflet morphology as identified on echocardiography can predict valvular function and aortic dilation [51], with a prospective group of 852 patients with bicuspid valve having aortic regurgitation (23%) related to valve prolapse (OR: 5.16, P < . 0001), and aortic stenosis (22%) associated with fused right and noncusps, (OR: 2.09, P < . 001), and the presence of raphe (OR: 2.75, P < 0.001). Gradation of valve abnormality (eg, mild, moderate, or severe aortic stenosis) is predominantly obtained by echocardiography. Echocardiographic assessment of early bioprosthetic valve failure can be addressed systematically with correlation to surgical changes [52]. Patient prosthesis mismatch has been associated with raised transprosthetic pressure after mitral valve replacement, although only when calculated by the continuity equation (P = . 021) [53]. Doppler parameters may be useful in estimating LV filling pressure in patients with mitral annular calcification [54]; in a group of 50 patients with mitral annular calcification, the ratio of early-to-late diastolic filling velocity (mitral E/A) showed the best correlation, (r = 0.66; P < . 001), whereas the ratio of early diastolic filling velocity-to-mitral annulus velocity (E/e') demonstrated weak correlation (r = 0.42; P = . 003). Large-scale screening of populations revealed newly identified VHD in 51% of 2,500 patients >65 years of age, although this was commonly mild [55], with cardiac auscultation by general practitioners showing modest sensitivity and specificity (44% and 69% , respectively) in asymptomatic patients, even in the setting of significant disease [56]. TTE 3-D techniques may improve assessment of mitral or aortic valve dysfunction, with a systematic review showing the strongest evidence for estimating the mitral valve area in patients with rheumatic mitral valve stenosis and the vena contracta area in patients with mitral insufficiency [57].
Dyspnea Suspected Cardiac Origin Ischemia Already Excluded . Bicuspid leaflet morphology as identified on echocardiography can predict valvular function and aortic dilation [51], with a prospective group of 852 patients with bicuspid valve having aortic regurgitation (23%) related to valve prolapse (OR: 5.16, P < . 0001), and aortic stenosis (22%) associated with fused right and noncusps, (OR: 2.09, P < . 001), and the presence of raphe (OR: 2.75, P < 0.001). Gradation of valve abnormality (eg, mild, moderate, or severe aortic stenosis) is predominantly obtained by echocardiography. Echocardiographic assessment of early bioprosthetic valve failure can be addressed systematically with correlation to surgical changes [52]. Patient prosthesis mismatch has been associated with raised transprosthetic pressure after mitral valve replacement, although only when calculated by the continuity equation (P = . 021) [53]. Doppler parameters may be useful in estimating LV filling pressure in patients with mitral annular calcification [54]; in a group of 50 patients with mitral annular calcification, the ratio of early-to-late diastolic filling velocity (mitral E/A) showed the best correlation, (r = 0.66; P < . 001), whereas the ratio of early diastolic filling velocity-to-mitral annulus velocity (E/e') demonstrated weak correlation (r = 0.42; P = . 003). Large-scale screening of populations revealed newly identified VHD in 51% of 2,500 patients >65 years of age, although this was commonly mild [55], with cardiac auscultation by general practitioners showing modest sensitivity and specificity (44% and 69% , respectively) in asymptomatic patients, even in the setting of significant disease [56]. TTE 3-D techniques may improve assessment of mitral or aortic valve dysfunction, with a systematic review showing the strongest evidence for estimating the mitral valve area in patients with rheumatic mitral valve stenosis and the vena contracta area in patients with mitral insufficiency [57].