How to manage patients with severe left ventricular dysfunction and valvular regurgitation

BACKGROUND AND AIMS OF THE STUDY

The purpose of this study is to analyze treatment options for valvular regurgitation with severe left ventricular dysfunction.

MATERIAL AND METHODS

Results of valvular surgery in 98 patients with mitral or aortic regurgitation and severe systolic left ventricular dysfunction (LVD) were analyzed. Selection criteria were the absence of significant coronary heart disease and a resting ejection fraction (EF) < 40% for aortic and < 50% for mitral regurgitation.

RESULTS

In patients with aortic regurgitation (n = 46) operative mortality was higher but not significantly so than in a control group of 238 cases (6.5% vs. 3.4%). The actuarial survival rates at five and 10 years were 84% and 55% vs. 84% and 67%, respectively. Independent preoperative predictors of severe postoperative LVD were rheumatic etiology and increased left ventricular end-systolic diameter. In patients with mitral regurgitation (n = 52), operative mortality was not significantly different from that of a control group of 273 cases (3.8% vs. 2.6%), whether the surgical procedure was valve replacement or valve repair. Perioperative morbidity was frequent (30% of cases), mainly low cardiac output, after valve replacement. The actuarial survival rates at eight years were respectively for the groups with and without LVD: 81% and 89% after valve repair, 60% and 75% after valve replacement. Independent predictors of severe postoperative LVD were increased left ventricular end-systolic volume and the type of surgery. Better results were observed after valve repair.

CONCLUSIONS

It is concluded that a low EF is not a predictive factor of operative mortality but it influences late survival as do the degree of left ventricular dilatation, etiology in aortic and type of surgery in mitral regurgitation. Alternatives to valvular surgery have been envisaged but information on vasodilators in these patients is scant and results of heart transplantation are known only from a few small series.

Value of multiplane transesophageal echocardiography in determining aortic valve area in aortic stenosis

Aortic valve area determination by transesophageal planimetry and by the continuity equation was compared with hemodynamic measurements in 45 patients with symptomatic aortic stenosis. The correlations between transesophageal echocardiography and hemodynamics were dependent on the amount of valvular calcium, whereas the continuity equation correlated well with hemodynamics in all patients.

[Spontaneous intracardiac contrast and embolic risk]

Spontaneous contrast in the form of smokey echos in the cardiac chambers is considered to be a risk factor for thromboembolism. The aggregation of red blood cells results in larger target which diffuse a measurable in vitro ultrasonic signal. The phenomenon of erythrocytic aggregation is dependent on the red cells themselves, the plasma fibrinogen and conditions of blood flow. The other constituents of the blood only reflect a small amount of ultrasound, usually undetectable. Transoesophageal echocardiography with high frequency transducers (5 MHz) positioned in close proximity to the cardiac chambers, has become the reference method for detecting spontaneous contrast. This phenomenon is almost exclusively observed in the left atrium and left auricle and rarely in the other cardiac chambers or descending aorta. In pathological situations, spontaneous contrast is essentially implicated in two conditions: mitral valve obstacles and non-valvular atrial fibrillation. Conversely, moderate to severe mitral regurgitation is a negative predictive factor of spontaneous contrast. However, a purely qualitative appreciation of spontaneous contrast which may be influenced by the gain setting and technical specifications of the echocardiograph, and the subjectivity of the operator, is an important limitation. Therefore, the identification of quantitative markers of spontaneous contrats and new therapeutic antithrombotic protocols remain essential.

Functional results 5 years after successful percutaneous mitral commissurotomy in a series of 528 patients and analysis of predictive factors

OBJECTIVES

This study sought to assess late functional results after successful percutaneous mitral commissurotomy and to determine their predictors.

BACKGROUND

Few studies have reported late results of percutaneous mitral commissurotomy or have analyzed their late results regardless of immediate results, despite the fact that late deterioration may well be related either to a decrease in valve area or to poor initial results.

METHODS

Between 1986 and 1992, 528 patients underwent successful percutaneous mitral commissurotomy (mean [+/- SD] age 46 +/- 18 years; mean follow-up 32 +/- 18 months). A successful procedure was defined by a mitral valve area > or = 1.5 cm2 and no regurgitation > 2/4. Dilation was performed using a single balloon in 13 patients, a double balloon in 349 and the Inoue balloon in 166. Multivariate analysis was performed with a Cox model.

RESULTS

The survival rate for patients in New York Heart Association functional class I or II, with no cardiac-related deaths or need for mitral surgery or repeat dilation, was 76 +/- 6% at 5 years. By multivariate analysis, the independent predictors of good functional results were echocardiographic group (p = 0.01), functional class (p = 0.02) and cardiothoracic index (p = 0.005) before the procedure and valve area after the procedure (p = 0.007). The predictive model derived allowed estimation of the probability of good functional results according to the value of these four predictors for any given patient.

CONCLUSIONS

Good functional results were observed 5 years after successful percutaneous mitral commissurotomy in a large series of varied patients. The analysis of predictive factors may provide useful indications for follow-up results in patients undergoing this technique.

Early assessment by transesophageal echocardiography of left atrial appendage function after percutaneous mitral commissurotomy

Thirty-seven consecutively admitted patients with severe mitral stenosis underwent percutaneous mitral commissurotomy with a transthoracic and biplane or multiplane transesophageal echocardiographic examination before and between 24 and 48 hours after percutaneous mitral commissurotomy. Thirty patients (81%) were in sinus rhythm and 7 were in atrial fibrillation. Left atrial appendage (LAA) function was evaluated in both the transverse and the longitudinal planes by planimetry and pulsed Doppler echocardiographic interrogation at the LAA outlet. Percutaneous mitral commissurotomy resulted in a twofold increase in mitral valve area, and no severe mitral regurgitation occurred. With use of the planimetry method, there was no significant improvement in LAA ejection fraction, except in the transverse plane for patients in sinus rhythm (p = 0.03). With use of Doppler method, 3 distinct flow patterns were observed before the procedure: a "sinus pattern" in patients in sinus rhythm, and a "fibrillatory pattern" (n = 3) or a "no-flow pattern" (n = 4) in patients in atrial fibrillation. After commissurotomy, there was a marked increase in LAA peak Doppler velocity (+62%) and in LAA velocity time integral (+31%). Of the 4 patients in atrial fibrillation with a no-flow pattern, 2 had recovery of a typical effective fibrillatory flow pattern after the procedure. The increase in peak Doppler velocity after commissurotomy was related to the decrease or regression in left atrial spontaneous echo contrast, and correlated with the increase in mitral valve area, the decrease in tranmitral pressure gradient, and the increase in cardiac index; improvement in valve function after successful percutaneous mitral commissurotomy is associated with early improvement in LAA function.

The effect of left ventricular systolic function on long term survival in mitral and aortic regurgitation

To identify the predictive factors of left ventricular dysfunction (LVD) after surgery, we performed an uni- and multivariate analysis of the data concerning 286 patients operated for pure aortic regurgitation between 1980 and 1994 and 460 patients operated for pure non-ischemic mitral regurgitation over a period of 24 years. Among the aortic regurgitation patients, 28 developed left ventricular dysfunction not attributable to residual aortic valve dysfunction, another valvular lesion or hypertensive or ischemic heart disease. By univariate analysis identified predictive factors of LVD were duration of symptoms prior to surgery, duration of the history of diastolic murmur, NYHA class, cardiothoracic ratio, LV echographic diameters, fractional shortening of short axis, LV end-systolic volume and LV ejection fraction. Multivariate analysis identified three independent predictors: NYHA functional class, LV end-systolic diameter and LV ejection fraction. Of 428 operative survivors with non-ischemic mitral regurgitation 63 developed severe LVD. Univariate analysis identified functional class III or IV, duration of symptoms prior to surgery, atrial fibrillation, echo LV and LA diameters, angio LV volumes, LV ejection fraction, cardiac index and type of surgery as independent predictors of LVD. Multivariate analysis showed that type of surgery, LV ejection fraction, LV end-diastolic and end-systolic volume and echo LV end-systolic diameter were all independent predictors of LVD.

Percutaneous mitral commissurotomy in the elderly

Immediate and mid-term results of percutaneous mitral commissurotomy (PMC) were assessed in 75 patients aged > or = 70 years (mean 75 +/- 4 (70 to 86)). Co-morbidities were present in 30 patients (40%), and 58 patients had calcified valves (77%). Technical failure occurred in two patients. PMC was performed in 73 patients, using a single balloon in five, two balloons in 28, and the Inoue balloon in 42. After PMC, valve area increased from 1.0 +/- 0.2 to 1.6 +/- 0.3 cm2 as assessed by 2D echo (P<0.001). Three procedural deaths occurred (4%). Good initial results (valve area > or = 1.5 cm2 with mitral regurgitation < or = 214) were obtained in 48 patients (66%). In multivariate analysis, predictors of poor initial results were previous commissurotomy (P=0.01) and valve calcification (P=0.04). Mean follow-up was 24 +/- 18 months. The 4-year actuarial results were: survival in 59 +/- 18%; no need for operation in 59 +/- 18%; and persistent good functional results (NYHA class I or II) in 34 +/- 16%. The only predictor of mid-term good functional results was the quality of initial results (P<0.002). In conclusion, PMC in the elderly results in moderate but significant improvement in valve function at an acceptable risk; although subsequent functional deterioration is frequent. PMC is a useful although only palliative treatment in these patients.

Echocardiography and indications for surgery

The decision to undertake surgery in patients with infective endocarditis is mainly based on clinical data. However, echocardiography, in particular using a transoesophageal approach, will offer important guidelines for diagnosis and management. Surgery must be considered in the following cases: ring abscesses or fistulae which make repair more difficult when they are diagnosed at too late a stage; severe valvular regurgitations resulting in a poor haemodynamic tolerance; large and mobile mitral valve vegetation when surgical repair seems feasible. However, it must be stressed that the decision to refer patients for surgery depends on many other parameters including the microorganism involved and physiological status.

[Indications for percutaneous mitral commissurotomy]

Percutaneous mitral dilatation is now recognized as a valid alternative to open heart surgery. Indications have been clearly established for symptomatic patients with major stenosis (1.5 cm2, or 1 cm2/m2 body surface area). In other cases, the level of functional impairment, the anatomic state of the valve and the patient's past history must all be taken into consideration. In Western countries, there is a relatively large number of elderly patients with a moderately or severely damaged mitral valve. A critical evaluation of immediate and long-term outcome is required to determine the precise indications for dilatation and for surgery. Finally, these two methods should not be considered as contradictory but rather as complementary tools to control the natural history of the disease.

Double mitral homograft for recurrent bacterial endocarditis of the mitral and tricuspid valves

A young patient suffering from acute bacterial endocarditis underwent reconstructive surgery of the mitral and tricuspid valves. One year later a recurrent endocarditis occurred that could not be controlled with antibiotic therapy. Two separate mitral homografts were used to replace both the mitral and the tricuspid valves. The homografts' papillary muscles were sutured side to side to the recipient's and a circumferential suture of the leaflet tissue was accomplished. Homograft implantation was associated with Carpentier ring annuloplasty of the atrioventricular valves. In the right sided position, the mitral homograft was oriented in an anti-anatomical manner and an inverted semi-rigid prosthetic ring of the mitral type was inserted. Clinical and echocardiographic follow up at four months was excellent.

[Guidelines of the French Society of Cardiology on the training of echocardiographers and the performing of echocardiography]

The considerable advances achieved in the field of echocardiography have made this investigation an essential diagnostic tool. Under the auspices of the French Society of Cardiology, the Working group on Echocardiography publishes its practical recommendations for optimising the training of echocardiographers (theoretical instruction and practical courses) and for performing echocardiography (understanding the clinical problem, referral to previous examinations, necessary recordings and measurements, and appropriate equipment). In the future, these recommendations should be updated to take into account continuing technical improvements and changes in methods of studying cardiac disease by echocardiography.

[Conservative surgery in the treatment of infectious mitral valve insufficiency]

In order to analyse the results of conservative mitral valve surgery in the treatment of mitral regurgitation due to infective endocarditis, the authors reviewed the cases of 48 patients operated between 1974 and April 1993 (36 operations having been performed after 1989, a period during which only 3 patients underwent mitral valve replacement for the same indication). Thirty-four patients were operated after sterilisation of the infective endocarditis, and 14 patients were treated during the active phase. There were 32 men and 16 women with an average age of 45 +/- 13 years. In two thirds of the cases, the causative organism was a streptococcus. Half of the patients were operated during the acute stage because of their poor haemodynamic status, 5 because of residual bacterial vegetations after one or more embolic events and two because of the infection itself. On the other hand, patients were operated after the infective phase because of severe mitral regurgitation, responsible for severe symptoms (NYHA Class III) in 16 cases. From the anatomical point of view, the peroperative finding of 14 patients operated in the acute phase included dilatation of the annulus (N = 9), ruptured chordae (N = 9), perforation (N = 8) or vegetations (N = 8); in the patients operated later, the incidence of perforation and vegetations was much lower (20%) whereas dilatation of the annulus was almost constant (91%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of transesophageal echocardiography in the follow-up of successful percutaneous mitral valvotomy]

This study was undertaken to determine the value of transoesophageal echocardiography in the follow-up of patients with severe mitral stenosis having undergone successful percutaneous mitral commissurotomy as defined as a final valve surface area > 1.5 cm2 without > 2/4 mitral regurgitation (MR). Eighty one patients who had undergone successful procedures were studied by transthoracic (TTE) and transoesophageal echocardiography (TOE) before, immediately after (24 to 48 hours) and at medium term (8 +/- 4 months) after balloon commissurotomy. The three main parameters studied were the degree of MR, presence of inter-atrial shunt and spontaneous left atrial contrast. Immediately after commissurotomy the MR was graded 0/4 in 6 patients (7.5%), 1/4 in 48 patients (59%) and 2/4 in 27 patients (33.5%). The TOE showed small traumatic lesions (localised valve tears, rupture of an accessory chordae tendinae) in 9 cases (11%). At medium term follow-up, the MR was stable in 75 patients (93%), decreased by one grade in 3 patients (3.5%), without the occurrence of severe MR. Interatrial shunts were more frequently observed by TOE than by TTE or oximetry with a prevalence of 57%. They usually disappeared at medium term follow-up. There were 3 factors associated with its persistence: a shunt visible at TTE, immediately after commissurotomy, visualisation of an atrial septal defect and a shunt jet width > or = 5 mm at TOE immediately after commissurotomy. Spontaneous contrast was common before the procedure (65%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Early transesophageal echocardiography after mitral valve replacement. Significance of minor abnormal signals]

The aim of this study was to determine the frequency, significance and prognosis of small, abnormal, strand-like echos observed by early transoesophageal echocardiography after mitral mechanical valve replacement with hemi-disc prostheses. One hundred and twenty nine consecutive patients operated between October 1988 and June 1992 underwent transoesophageal echocardiography on average 15 +/- 7 days after surgery. A second transoesophageal echocardiography was performed in 52 patients on average 8 months after the first postoperative examination. The frequency of small strand-like echos and of non-obstructive thromboses of the valve at the initial transoesophageal examination was 43% and 8.5% respectively. A multivariate analysis showed that the only independent predictive factor for prosthetic valve strands was spontaneous intra-atrial contrast (p < 0.01). The presence of strands was significantly related to the prevalence of early thrombo-embolic events (confirmed non-obstructive valve thrombosis and systemic embolism). Strands were observed in 80% of cases with early thromboembolic complications compared with only 38% of cases with no early thromboembolic events (p < 0.04). Univariate analysis showed that the protamine/heparin ratio at the end of cardiopulmonary bypass and the percentage of ineffective postoperative heparinisation were higher in patients with these small, abnormal echos (p < 0.05 and p < 0.001, respectively). These appearances disappear at long-term transoesophageal echocardiographic control examinations in about half the cases. The authors conclude that the majority of these small, abnormal echos are thrombotic in nature and are associated with a higher thromboembolic risk, justifying effective anticoagulation in the first postoperative hours whenever possible, considering the risk of bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasonography in the diagnosis of bacterial endocarditis: value and limits]

This cooperative study recensed 148 patients who had infective endocarditis (IE) with anatomopathological correlations. The infection was on native valves in 89 cases and prosthetic valves in 59 cases. Transoesophageal echocardiography diagnosed vegetations on native valves with a sensitivity, specificity, positive predictive and negative predictive values of 89%, 87%, 88% and 90% respectively, whereas for transthoracic echocardiography the results were 68%, 83%, 81% and 72% respectively. With respect to prosthetic valve vegetations, transoesophageal echocardiography had a sensitivity, specificity, positive predictive and negative predictive values of 67%, 84%, 48% and 92% respectively compared with 56%, 84%, 44% and 83% respectively for transthoracic echocardiography. These results underline the difficulties in differentiating degeneration and endocarditis of bioprostheses. Transoesophageal echocardiography diagnosed aneurysm formation and valvular perforation with a sensitivity, specificity, positive and negative predictive values of 61%, 93%, 91% and 72% respectively compared with 35%, 96%, 98% and 58% respectively for transthoracic echocardiography. The false negative results of transoesophageal echocardiography were usually observed in lesions of the posterior leaflet or commissures. In this series, the 6 aortic cusp perforations were undiagnosed by both transthoracic and transoesophageal echocardiography. With respect to aortic ring abscess, the sensitivity, specificity, positive and negative predictive values of transoesophageal echocardiography were 89%, 100%, 100% and 93% respectively, compared with 27%, 100%, 100% and 62% for transthoracic echocardiography. The false negative results of transoesophageal echocardiography were observed in cases of anterior abscesses or of calcific aortic valves. These results demonstrate the superiority of transesophageal over transthoracic echocardiography in the diagnosis of infective endocarditis and its complications. However, the limitations of the method should be recognized in the situations described.

Prognosis of valve replacement for aortic stenosis with or without coexisting coronary heart disease: a comparative study

Between January 1978 and June 1992, 798 patients underwent isolated AVR for hemodynamically significant calcific aortic stenosis. Preoperative coronary angiography was performed in 687 patients, of whom 229 had coronary stenosis > 40% and were divided into three (I, IIa and IIb) groups. Group I consisted of 144 patients undergoing AVR plus coronary artery bypass grafts (CABG); 39 patients in Group IIa had AVR only in the presence of coronary stenoses < 60%, and 46 patients in Group IIb had AVR only in the presence of coronary stenoses > 60%. Group III consisted of 144 matched patients selected from the remaining 458 patients with no coronary disease, or stenoses less than 40%, according to five matching criteria (age, sex, functional status, ejection fraction and year of surgery) with patients in Group I. Early mortality was 10.4% in Group I, 7.7% in Group IIa, 13% in Group IIb and 4.9% in Group III. Although the differences in operative mortality are apparent, they did not reach statistical significance. A difference in long term survival could only be detected between Groups I and III (actuarial survival at nine years 66% and 78.9%, respectively, p < 0.01). Similarly, late coronary events were more frequent in Group I than in Group III (13.9% vs. 5.1%, p < 0.03). It is concluded that revascularization should be as complete as possible for severe coronary stenoses coexisting with significant calcific aortic stenosis. However, bypassing of moderate coronary lesions (stenoses in the order of 50%) in association with AVR does not appear justified on current evidence. Further studies on this important aspect are clearly required.

[Percutaneous mitral commissurotomy during pregnancy]

This report analyses the efficacy and tolerance of percutaneous mitral commissurotomy (PMC) in 10 pregnant women with severe mitral stenosis. Pregnancy was the cause of decompensation of the mitral stenosis and surgery was not considered because of the foetal risk. PMC was undertaken after an average of 26 +/- 4 weeks of gestation (range 23-33 weeks). The average age of the patients was 28 +/- 6 years (range 20-41 years). Six patients were in NYHA Class III and 4 in Class IV despite medical treatment. Five patients had mild mitral regurgitation. Foetal protection was ensured by covering the mother's abdomen with a lead apron. The double balloon technique was used in 4 cases and Inoue's balloon in 6 patients. The average duration of fluoroscopy was 17 +/- 10 minutes (range 6-37 minutes). After PMC, the mean pulmonary artery pressure decreased from 47 +/- 12 mmHg to 31 +/- 11 mmHg (p = 0.005); two dimensional echocardiography showed an increase in mitral valve surface area from 1 +/- 0.2 cm2 to 2 +/- 0.3 cm2 (p = 0.005). There were no complications related to the procedure. The foetal heart rate was monitored continuously and no significant modification suggestive of foetal distress was recorded. The abdominal cutaneous dose of irradiation was less than 0.2 millisievert, which was minimal. All patients experienced a functional improvement after PMC. Nine delivered after an average gestation of 38 +/- 2 weeks (range 36-42 weeks) without cardiac decompensation. The average birth weight of the babies was 3.1 +/- 0.3 kg (range 2.9-3.7 kg).(ABSTRACT TRUNCATED AT 250 WORDS)

Small abnormal echos after mitral valve replacement with bileaflet mechanical prostheses: predisposing factors and effect on thromboembolism

Early transesophageal echocardiography (TEE) after mitral valve replacement can detect symptomless, non-obstructive thrombus on prosthetic valves and also small filamentous abnormal echoes (SAE). The object of this study is to evaluate their respective frequency and predisposing factors. Between October 1988 and June 1992, 129 consecutive patients underwent mitral valve replacement with a bileaflet prosthesis and had transesophageal echocardiography at an average of 15 +/- 7 days (range: 6-35 days) after surgery. Details of postoperative anticoagulation were analyzed in 99 patients from five surgical centers having comparable postoperative anticoagulation protocols. Among those patients presenting with SAE, 76% had a second transesophageal echocardiography at an average of 145 +/- 166 days after the first examination. Mean age was 56 +/- 13 years. Small filamentous echoes were found in 55 patients (43%). In univariate analysis, independent predictors were age, absence of systolic regurgitation across the mitral prosthesis as observed with continuous Doppler, and the presence of spontaneous echo contrast (SC) in the left atrium: 54 +/- 14 years in the absence vs. 59 +/- 10 in the presence of SAE (p < 0.05); 54% of systolic leak vs. 36% (p < 0.05); 43% of SC vs. 75% (p < 0.00001). In multivariate analysis, spontaneous echo contrast was the only independent predictor for SAE (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of percutaneous mitral commissurotomy on left atrial spontaneous contrast of mitral stenosis

To assess the influence of percutaneous mitral commissurotomy (PMC) on left atrial spontaneous echo contrast of mitral stenosis, transesophageal echocardiography was performed before and 24 to 48 hours after the procedure, and on average, 6 months later in 82 patients. Fifty-nine patients (72%) were in stable sinus rhythm and 23 in permanent atrial fibrillation. Eleven patients (13%) had history of embolism, and 31 were on long-term anticoagulant therapy. The intensity of spontaneous contrast was graded as follows: 0 = no contrast; 1 = slight contrast; and 2 = intense contrast with the typical aspect of "smoke." PMC resulted in a twofold increase in the valve area irrespective of the method of evaluation used (2 cm2 after vs 1.05 before; p < 0.0001). Severe mitral regurgitation occurred in 3 patients who were operated on within 3 months after PMC. Left atrial spontaneous contrast was noted before the procedure in 53 patients (65%). Multivariate analysis showed left atrial size and cardiac index to be predictive factors of its presence (both p < 0.05). At early post-PMC investigation, the incidence of contrast was 50%, and at 6 months, only 28%. Sinus rhythm appeared to be the only independent predictive factor of the disappearance of contrast by multivariate analysis. In patients in atrial fibrillation, the prevalence of spontaneous contrast was 100% before PMC, 91% at early post-PMC investigation (p = NS), and 89% at the late study (p = NS); the rates were 51, 34 (p < 0.005) and 4% (p < 0.0001), respectively, in patients in sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

[Should mitral valve diseases, without or with few symptoms, be treated surgically?]

Our approach to the treatment of valvular heart disease, and mitral valve disease in particular, has been deeply modified by the experience acquired since the introduction of cardiac surgery and the technical advances in this field in the last decade and by new methods of investigative and interventional cardiology. In pure severe mitral regurgitation alone, the treatment of choice is reconstructive surgery. In the experience of our group, 191 patients out of 342 operated since 1970 for this type of valve lesion were referred for reconstructive surgery. Taking the results into consideration (72% 15 year survival), it is now justified to refer patients at a stage when the valvular disease is asymptomatic or pauci-symptomatic. A certain number of factors has to be assessed to evaluate the surgical indication: the experience of the surgical team, the etiology of the mitral regurgitation, the type of anatomical lesion, the stage of the cardiac disease and the patient's age. In mitral stenosis, in preference to surgical commissurotomy, percutaneous mitral valvuloplasty may be proposed in certain asymptomatic or pauci-symptomatic patients if the stenosis is severe, if the anatomical lesions are optimal and if there is a hemodynamic (pregnancy) or thromboembolic risk (arrhythmias, spontaneous contrast on transoesophageal echocardiography). In mixed mitral valve disease or very calcific stenoses, analysis of long-term results of valve replacement indicates that the late prognosis depends more on the stage of the cardiac disease at the time of surgery than on the type of prosthesis. It is advisable not to wait until an advanced stage before operating these patients when the valvular dysfunction is severe and there are hemodynamic consequences.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventricular arrhythmias in aortic valve disease before and after surgery

In order to evaluate the incidence and prognostic value of ventricular arrhythmias in patients with aortic valve disease, 24 hour ambulatory electrocardiographic recordings were obtained in 374 patients without coronary artery disease (aortic stenosis n = 194, aortic regurgitation n = 103, combined aortic stenosis and regurgitation n = 77). Following aortic valve replacement, repeat recordings were obtained in a subgroup of 96 patients at 13 +/- 4 days and 18 +/- 7 months. Ventricular arrhythmias were classified in all cases according to Lown and were compared with clinical, echocardiographic and hemodynamic data. Preoperatively, ventricular premature beats were observed in 329 patients (88%), and were found to be frequent (>30 ventricular premature beats/hour) in 83 (22%). Multiformity was found in 105 (28%), couplets in 75 (20%) and ventricular tachycardia in 45 (12%). The occurrence of ventricular arrhythmias was not related to the type or severity of the valve lesions. Patients with severe ventricular arrhythmias (Lown class 3 or 4: 36.5%) had a higher ventricular wall thickness (interventricular septum thickness 14.2 +/- 1.8 mm vs. 11.9 +/- 2.0 mm, p < 0.01, a higher LV mass (178 +/- 32 g/m2 vs. 142 +/- 35 g/m2, p < 0.001) and a lower left ventricular ejection fraction (48% +/- 9% vs. 56.5% +/- 10%, p < 0.001); while in patients with aortic regurgitation a higher end-diastolic LV volume (224 +/- 38 ml/m2 vs. 178 +/- 42 ml/m2, p < 0.02) and a higher end-systolic LV diameter (56 +/- 7 mm vs. 46 +/- 8 mm, p < 0.02) were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous mitral commissurotomy]

Since it was introduced, in 1984, as an alternative to surgical commissurotomy, percutaneous balloon mitral commissurotomy has been performed in a large number of patients with mitral valve stenosis, significantly improving the valvular function with a final area of 2 square centimetres. The quality of the result obtained basically depends on valve anatomy. The incidence of complications is globally low, with a mortality of 0.5 to 3 percent, and severe mitral regurgitation in 5 percent of the cases. Left-to-right atrial shunts are detected by oxymetry in 20 percent of the patients, but they subsequently vanish in two-thirds of them. For the moment, only medium-term results are available: when the initial result is good functional improvement is the rule, and the incidence of restenosis is low. Conversely, when the result is insufficient or severe mitral regurgitation develops secondary surgery is usually necessary. Before deciding to perform percutaneous commissurotomy, the contre-indications of this method (left atrial thrombosis, moderate to severe mitral insufficiency) must be excluded. In view of the encouraging results obtained, percutaneous commissurotomy can be advocated as first-line treatment of soft valve mitral stenosis. In patients with calcified valve mitral stenosis, valve replacement remains the principal treatment, percutaneous commissurotomy being reserved for special cases.