AimsCurrent guidelines for the diagnosis of heart failure with normal or preserved ejection fraction (HFpEF) are based on measurements at rest. However, in HFpEF ventricular dysfunction is more apparent on exercise. We hypothesized that Mitral annular plane systolic excursion (MAPSE) which is easy to acquire on exercise could be used to detect occult left ventricular (LV) impairment. Methods and resultsCardiopulmonary exercise testing and 2D-Doppler echocardiography were performed at rest and on exercise. MAPSE was assessed by using M-mode (apical four-chamber view). Sixty-two patients with HFpEF [LV ejection fraction (LVEF)¼60 + 7%] with reduced VO 2 max (18.6 + 5.2 mL/min/kg) and 36 control subjects (LVEF¼62 + 7%, VO 2 max 29.4 + 4.8 mL/min/kg) were studied. MAPSE at rest was significantly lower in patients (10.9 + 2.1 vs. 12.1 + 2.2 mm in controls, P ¼ 0.008) which was even more pronounced on exercise (12.0 + 2.2 mm and 16.2 + 2.7 mm, respectively, P , 0.001). At rest MAPSE correlated with longitudinal strain (r ¼ 0.432, P ¼ 0.001), peak systolic myocardial velocity (r ¼ 0.545, P , 0.001), and early diastolic myocardial velocity (r ¼ 0.322, P ¼ 0.02) and on exercise with LV apical rotation (r ¼ 0.582, P , 0.001), longitudinal strain (r ¼ 0.589, P , 0.001), and myocardial tissue velocities (P , 0.001). The area under the receiver operating characteristic curve for MAPSE was 0.655 (confidence interval 0.540 -0.770) at rest and 0.901 (confidence interval 0.835-0.967) on exercise, to differentiate between patients and controls. ConclusionMitral annular plane systolic excursion at rest and on exercise correlates well with more sophisticated measurements of ventricular function in HFpEF patients. It is potentially a useful and easily acquired measurement, especially on exercise, for the diagnosis of HFpEF.--

We report two cases of severe mitral stenosis where percutaneous mitral commisurotomy was performed within pregnancy. The first case involves an emergency procedure for a new diagnosis of severe mitral stenosis in a woman presenting with pulmonary oedema at 27 weeks' gestation. The second case is of a woman known to have mitral stenosis who underwent a semi-elective procedure for deterioration in symptoms. This procedure is not commonly performed in the United Kingdom because of low incidence of rheumatic heart disease. In addition, percutaneous mitral commisurotomy during pregnancy is rarely performed in the United Kingdom because of the improved healthcare system where majority of the women with moderate to severe mitral stenosis (even asymptomatic) will undergo planned interventions (percutaneous mitral commisurotomy or mitral valve surgery) before contemplating pregnancy. These cases highlight both the acute and chronic presentations of mitral stenosis and the impact pregnancy has on this condition. In addition, these cases show the importance of retaining skills in performing percutaneous mitral commisurotomy within our United Kingdom cardiologists.

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Cholesterol is a fatty substance manufactured by the body (mainly the liver) which plays a vital role in functioning of cell membranes. Hypercholesterolaemia is the presence of raised or abnormal levels of cholesterol in the blood. Cholesterol levels are found in a continuum within a population. Higher total cholesterol levels lead to increased risk of cardiovascular disease (CVD). Lowering cholesterol is effective for both primary and secondary prevention of all forms of CVD.