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cases, there is a long asymptomatic phase, followed by subtle limitation of activity Pregnancy and its associated increase in cardiac output and the increased transmitral pressure gradient that results often precipitate symptoms Toward the end of pregnancy, the cardiac output is also maintained by an increase in heart rate, further increasing the mitral gradient Patients with moderate to severe mitral or aortic stenosis should have the condition corrected prior to becoming pregnant if possible Patients who become symptomatic can undergo successful surgery, preferably in the third trimester, although balloon valvuloplasty is the treatment of choice if the mitral valve is amenable The onset of atrial fibrillation often precipitates more severe symptoms, which usually improve with control of the ventricular rate or restoration of sinus rhythm Conversion to and subsequent maintenance of sinus rhythm are most commonly successful when the duration of atrial fibrillation is brief (< 6 12 months) and the LA is not severely dilated (diameter < 45 cm) Once atrial fibrillation occurs, the patient should receive warfarin anticoagulation therapy even if sinus rhythm is restored, since atrial fibrillation often recurs even with antiarrhythmic therapy and 20 30% of these patients will have systemic embolization if untreated Systemic embolization in the presence of only mild to moderate disease is not an indication for surgery but should be treated with warfarin anticoagulation Indications for intervention focus on symptoms such as an episode of pulmonary edema, a decline in exercise capacity, or any evidence for pulmonary hypertension Some experts believe that the presence of atrial fibrillation should be a consideration for an intervention Open mitral commissurotomy is now rarely performed and has given way to percutaneous balloon valvuloplasty Ten-year follow-up data comparing surgery to balloon valvuloplasty suggest no real difference in outcome between the two modalities Replacement of the valve is indicated when combined stenosis and regurgitation are present or when the mitral valve echo score is > 8 Percutaneous mitral valvuloplasty has a very low mortality rate (< 05%) and low morbidity rate (3 5%) Operative mortality rates are also low: 1 3% in most institutions Repeat valvuloplasty can be done if the morphology of the valve is suitable A Maze procedure may be done at the same time to reduce recurrent atrial arrhythmias Mechanical mitral prosthetic valves are more prone to thrombosis than aortic valves Bioprosthetic valves degen-.

Intervention Valsalva Standing Handgrip or squatting Supine position with legs elevated Exercise Hypertrophic Obstructive Cardiomyopathy Aortic Stenosis or or or or Mitral Regurgitation or or Mitral Prolapse or

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Programming in languages such as C and C++ provides programmers with lots of power However, this power comes at a price In C and C++, one of the biggest costs is that the developer must keep track of all dynamic memory used in a program and make sure the memory is deallocated correctly when it is no longer needed In theory, this process sounds simple; but in practice, it can be tricky to get right, especially as programs grow in size Other programming languages, like Java and LISP, address this limitation by implementing garbage collectors, which track memory allocations and reclaim memory when needed You can track an application s runtime memory usage manually, or programmatically using specialized libraries that you add at compile or runtime These libraries replace the default allocation routines with custom calls.

, increased; , decreased; , unchanged Modified, with permission, from Paraskos JA Combined valvular disease In: Valvular Heart Disease Dalen JE, Alpert JS (editors) Little, Brown, LWW, 2000

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ing atrial fibrillation Mitral regurgitation may predispose to infective endocarditis Clinically, mitral regurgitation is characterized by a pansystolic murmur maximal at the apex, radiating to the axilla and occasionally to the base; a hyperdynamic LV impulse and a brisk carotid upstroke; and a prominent third heart sound due to the increased volume returning to the LV in early diastole (Tables 10 1, 10 2) Mitral valve prolapse ( floppy or myxomatous mitral valve) is usually asymptomatic but may be associated with nonspecific chest pain, dyspnea, fatigue, or palpitations Most patients are female, many are thin, and some have skeletal deformities such as pectus excavatum or scoliosis A hyperadrenergic syndrome has been described, especially in young females, that may be responsible for some of the noncardiac symptoms observed This syndrome attenuates with age Some patients have findings of a systemic collagen abnormality (Marfan or Ehlers-Danlos syndrome) In these conditions, a dilated aortic root and aortic regurgitation may coexist with the mitral valve prolapse On auscultation, there are characteristic mid-systolic clicks that emanate from the chordae or redundant valve tissue and that may be multiple If leaflets fail to come together properly, the clicks will be followed by a late systolic murmur As the mitral regurgitation worsens, the murmur is heard more and more throughout systole The smaller the LV chamber, the greater the degree of prolapse, and thus auscultatory findings are often accentuated in the standing position The diagnosis is primarily clinical but can be confirmed echocardiographically Infective endocarditis may occur, primarily in patients with murmurs; such patients should have antibiotic prophylaxis prior to dental work and surgical procedures, though the data supporting the use of antibiotic prophylaxis are actually quite poor -Adrenergic blocking agents are often effective for supraventricular arrhythmias and may be useful if there are symptoms of the hyperadrenergic syndrome Sudden death is rare in mitral prolapse, but when symptomatic ventricular tachycardia is present, aggressive management with an implantable cardioverter-defibrillator is usually indicated An association between mitral prolapse and embolic cerebrovascular events has also been reported but has not been confirmed in subsequent studies Echocardiographic evidence of marked thickening or redundancy of the valve is associated with a higher incidence of most complications.

erate after about 10 12 years and percutaneous balloon valvuloplasty procedures cannot be done on bioprosthetic valves should stenosis occur Younger patients and those with end-stage renal disease do least well with bioprosthetic heart valves Endocarditis prophylaxis is always indicated Percutaneous balloon valvuloplasty can safely be done during pregnancy if symptoms warrant

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