[Carcinoid heart disease]

Carcinoid cardiac disease is a common complication of metastatic carcinoid tumours. It is characterized by tricuspid regurgitation and pulmonary stenosis. A 68 years old woman with a metastatic carcinoid tumour was admitted to hospital for congestive cardiac failure secondary to severe tricuspid regurgitation. Typical carcinoid lesions of the tricuspid and pulmonary valves were observed at echocardiography. A double valve replacement was performed with a favourable outcome. Postoperative echocardiography showed a significant improvement in right ventricular function. Surgical management of carcinoid valvular heart disease of NYHA Stage III patients is associated with an improved 2 years survival (from 8 to 40%) despite a high operative mortality (about 27%). Cardiac surgery remains the only hope of long-term survival with a spectacular improvement in symptoms.

[Recommendations of the French Society of Cardiology for the training of echocardiographers and performing echocardiograms]

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.

[5 years results of percutaneous mitral commissurotomy. Apropos of a series of 606 patients; late results after mitral dilatation]

The long-term results of percutaneous mitral commissurotomy were evaluated in 606 patients with a mean age of 48 +/- 14 years. One hundred and eleven patients (48%) had a history of surgical commissurotomy. At echocardiography, 91 patients (15%) had flexible leaflets and little subvalvular apparatus, and 180 (30%) have calcified valves. The procedure was performed with a single balloon in 21 patients, a double balloon in 402 patients and Inoue's balloon in 183 patients. A good immediate, result, defined as a mitral valve surface area > or = 1.5 cm2 without > 2/4 mitral regurgitation, was obtained in 528 patients (87%). Five hundred and eighty patients (96%) were followed up for an average of 30 +/- 18 months. The actuarial 5 year rates were: survival 94 +/- 4%; survival without surgery 74 +/- 6%; survival without surgery with a good functional result (NYHA Classe I and II) 66% +/- 6%. Factors predictive of a good functional result were the valvular anatomy (p = 0.01), the NYHA Class before the procedure (p = 0.02), the cardiothoracic ratio before the procedure (p = 0.005) and mitral valve surface area after the procedure (p = 0.007). The type of balloon had no influence on the result (p = 0.54). The authors conclude that the 5 year results of percutaneous mitral commissurotomy are good in a population of patients with varied characteristics. The persistence of good functional results depends on anatomical and functional data and the quality of the initial result, but not on variables related to the procedure.

Immediate results of percutaneous mitral commissurotomy. A predictive model on a series of 1514 patients

BACKGROUND

The wide use of percutaneous mitral commissurotomy (PMC) underlines the need to identify the predictive factors of the results. Using a large series allowed us to develop a multivariate model that can be applied to improve patient selection.

METHODS AND RESULTS

Between 1986 and 1995. PMC was undertaken in 1514 patients. Mean age was 45 +/- 15 years. Echocardiography showed that 245 patients (16%) had pliable valves and mild chordal thickening (group 1), 886 (59%) had extensive subvalvular disease (group 2), and 383 (25%) had calcified valves (group 3). PMC failed in 22 patients; it was performed with a single balloon in 30 patients, a double balloon in 586, and the Inoue balloon in 876. Good immediate results were defined as a valve area > or = 1.5 cm2 with mitral regurgitation Sellers' grade < or = 2 and were obtained in 1348 patients (89%). A logistic model developed from the first 1088 cases identified the following predictors of immediate results: age (P = .004), echocardiographic group (P < .0001), valve area (P < .0001), and effective balloon dilating area (EBDA) (P = .03). Two interactions were significant: age at previous commissurotomy (P = .013) and EBDA by initial mitral regurgitation (P = .034). The type of balloon was of borderline significance (P = .09). The model was validated on an independent sample comprising the subsequent 426 procedures. For a threshold of probability of good results of .75, sensitivity was 92%, specificity 25%, and predictive accuracy 87%.

CONCLUSIONS

Prediction of the immediate results of PMC is multifactorial. The predictive model developed and validated can be contributive in decision making for individual patients.

Specifics of technique in percutaneous mitral commissurotomy in a case of dextrocardia and situs inversus with mitral stenosis

Percutaneous mitral commissurotomy (PMC) was successfully performed in a 48-year-old woman with dextrocardia and situs inversus and a severe mitral stenosis. After PMC, the valve area increased from 0.97 to 1.89 cm2, and no complication occurred. This case shows that PMC is practicable in a case of dextrocardia with situs inversus. The procedure appears to be safer and easier when carried out with the inoue balloon, image inversion on the screen, and under transesophageal echocardiographic monitoring.

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.

Indications and outcome of valvuloplasty

Balloon valvuloplasty is widely practiced, but its result depends on the pathology considered. Percutaneous mitral balloon valvuloplasty evolved from the earlier development of percutaneous balloon valvotomy of the pulmonic valve into an effective method for the treatment of patients with mitral stenosis. Percutaneous aortic balloon valvotomy has been used as an alternative to aortic valve replacement in elderly patients with degenerative calcific aortic stenosis, but immediate results are suboptimal and the short-term rate of restenosis is high. In congenital pulmonary valve stenosis, balloon valvotomy produces a dramatic relief of the pressure gradient with excellent long-term follow-up results.

[Detection of thrombosis of the left atrium in mitral valve stenosis. Particular value of transesophageal echography]

This retrospective study assessed the prevalence of left atrial thrombi in mitral stenosis and evaluated the diagnostic value ot the main means of investigation Five hundred and eighty-one patients underwent open heart surgery over a 10 year period. The prevalence of atrial thrombi was 7%, the majority (60%) being located in the left atrial appendage. The sensitivity of transthoracic echocardiography for detecting thrombi in the left atrial cavity was satisfactory (65%) but was very poor for detecting thrombi in the left atrial appendage (4%). The results of invasive investigations (atrial angiography and coronary angiography) are no better. Without any doubt, transoesophageal echocardiography, performed in 101 patients in this series, has transformed these results (sensitivity 83%, specificity 97%). False negatives in this study mainly concerned small thrombi adherent to the atrial wall. Under these conditions, it would seem reasonable to propose transoesophageal echocardiography to all patients with mitral stenosis complicated by an embolic event or for those for whom percutaneous commissurotomy is suggested.

Transoesophageal echocardiography in the assessment of percutaneous mitral commissurotomy

The aim of this study was to assess the value of transoesophageal echo (TEE) in comparison with transthoracic echocardiography (TTE) in selecting candidates and evaluating the results of percutaneous mitral commissurotomy (PMC). One hundred and ten patients (pts) were examined by TEE and TTE before PMC. PMC was not performed in eight pts who had a thrombus in the left atrium detected by TEE but not by TTE. Out of the 102 other pts, TEE was better than TTE in detecting mild mitral regurgitation (MR) (84 vs 38, P less than 0.01). Spontaneous contrast was only shown by TEE in 70 pts. On the other hand, planimetry of the valvular area was only possible with TTE. This technique was also better in the assessment of the commissural area. During PMC, TEE enabled the interatrial septum to be punctured in two pts. After PMC, MR was trivial in 49 TEE cases compared with 36 by TTE and was moderate in 20 TEE pts compared with 12 by TTE (P less than 0.02). Transoesophageal colour Doppler showed a trivial atrial shunt in 63% of cases vs 13% by TTE (P less than 0.01).A small atrial septal defect was found in 30 cases only by TEE, and a spontaneous contrast persisted in all pts but six with moderate MR. In conclusion, TEE provides useful information in the ultrasonic assessment of PMC in particular with left atrial thrombi, mitral regurgitation, and the post PMC atrial septal defect. However, both methods are complementary and only TTE enables calculation of valve area.

Immediate and mid-term results of percutaneous mitral commissurotomy

The results of percutaneous mitral commissurotomy (PMC) were assessed in a series of 600 patients (pts) with mitral stenosis. Their mean age was 43 +/- 15 years (13-86). One hundred and eight had had a previous surgical commissurotomy; 464 were in NYHA class III or IV; atrial fibrillation was present in 188. One hundred and fifty-nine had valvular calcification and angiography disclosed a mild regurgitation (MR) (1/4) in 255. Technical failure occurred in 19 pts. In the remainder, PMC improved valve function: valve area (VA) increased from 1.1 +/- 0.3 cm2 to 2.2 +/- 0.5 cm2 (P less than 0.0001) as assessed by haemodynamics, and from 1 +/- 0.2 to 2 +/- 0.4 cm2 (P less than 0.0001) as assessed by two-dimensional echocardiography. Complications were as follows: death (0.5%), haemopericardium (0.8%), severe MR (3.8%), embolism (3.3%), atrial shunt (14%). Secondary surgery for complications following PMC was necessary in 4.8% of cases. There were poor results (VA less than 1.5 cm2 and/or MR greater than 2/4) in 13%; their predictors being valve anatomy (P less than 0.001), initial valve area (P less than 0.01) and previous surgical commissurotomy (P less than 0.05). Among the 437 pts resident in France, 98% were followed-up 15 +/- 11 months after PMC (range 1-48). After 42 months, the actuarial rates of survival, freedom from need for reoperation and good functional results were respectively: 87 +/- 6%, 81 +/- 3% and 72 +/- 6%.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of left atrial thrombi in mitral stenosis--usefulness of ultrasound techniques compared with other methods

The purpose of this study was to evaluate various methods of diagnosis of left atrial thrombi (LAT) in patients (pts) with mitral stenosis (MS). From 1980 to 1990, 581 pts with MS have undergone open mitral commissurotomy (n = 169) or valve replacement (n = 412). All pts had transthoracic 2D echocardiography (TTE), 101 transoesophageal echocardiography (TEE), 192 a left atrial angiography (A) (from a left ventricular injection if associated mitral regurgitation grade 3 (n = 154) or from an injection in the pulmonary artery (n = 38) and 229 a coronary angiography (CA). Tomodensitometry (TD), nuclear magnetic resonance (NMR) and 111 Indium platelet imaging (IPI) were performed in some cases, 2, 8 and 5 respectively. All these examinations were carried out in the month before surgery. LAT was found by the surgeon in 43 pts (7%). The site was left atrial appendage in 26 cases (60%) and left atrial cavity in 17 cases. Sensitivity (Se), specificity (Sp) of TTE/TEE/A/CA were the following: TTE, Se% 28, Sp% 99; TEE, Se% 83, Sp% 97; A, Se% 28, Sp% 99; CA, Se% 14, Sp% 100. Specificity was high with all methods but sensitivity was high only with TEE and poor with other methods because of difficulty in detecting thrombi of the left atrial appendage. Specificity and sensitivity of TD, NMR and IPI require more information. False-negative cases are possible with NMR (1 case) and IPI (1 case) in well established LAT. We conclude: TEE is the easiest way to detect LAT, particularly when located in the left atrial appendage. It should be carried out systematically before percutaneous mitral valvuloplasty or surgery.

Indications for surgery in mitral regurgitation

Present day indications for surgery in mitral regurgitation have to take into account changes in aetiology, advances in pre-operative evaluation of mitral lesions, technical progress in mitral valve repair and better knowledge of pre-operative predictive factors of surgical results. The results of a series of 294 patients operated on between 1970 and 1990 show that surgery is advisable before patients reach Functional Class III or IV, and before they develop atrial fibrillation, an ejection fraction of under 0.55, or marked left ventricular and atrial enlargement. Surgical indications depend on two factors: the possibility of valve repair evaluated by transthoracic and transoesophageal echocardiography, and the experience of the surgical team in this kind of surgery. Valve repair is the best treatment in many patients, particularly those with degenerative valve lesions, poor ejection fraction, elderly people and some cases of infective endocarditis.

[Björk-Shiley-Monostrut prosthesis of the aortic valve. Mid-term development]

From July 84 to June 88, 100 patients underwent an isolated aortic valve replacement by a Monostrut-Björk-Shiley prosthesis. Fifty-one had calcified aortic stenosis, 24% aortic insufficiency, 25% mixed aortic lesions. Pre-operatively, their mean age was 57 years, 68% were male, 46% were in NYHA class II or IV, 43% had angina, all were in sinus rhythm. Operative mortality was 4%. All the survivors were followed-up for a mean period of 22 months (6 to 58) with a cumulative follow-up of 183 patients-years. All patients were placed on a long-term regimen of anticoagulant therapy. Two late deaths occurred (1 myocardial infarction, 1 cerebral hemorrhage). The 4 years survival rate was 94%. Postoperative functional results were excellent. Nearly all patients were asymptomatic. Concerning valve related complications: the 4 years actuarial rate of patients free from thromboembolism, hemorrhage, valve thrombosis, periprosthetic leakage and endocarditis were respectively 97%, 97%, 100%, 100% and 100%. No patient were reoperated on. Valvular function was evaluated by mean transprothetic gradient on echo-doppler (61 cases) and by the calculation of the valvular area with transseptal catheterization (21 cases). For small sizes prosthesis (annulus diameter of 19 or 21 mm), medium size prosthesis (23 or 25 mm), large size prosthesis (27 to 29 mm), mean transprothetic gradient were respectively 16, 10 and 6.9 mmHg and valvular aortic area were respectively 1.5, 1.9 and 2.4 cm2. Mid term results of the Monostrut-Björk-Shiley prosthesis on aortic position are good with a low rate of valve related complications and good hemodynamic results, even with the small valve size.

[Percutaneous mitral valvuloplasty]

Since its introduction as an alternative to surgical commissurotomy, percutaneous mitral valvuloplasty (PMV) has been performed in a large number of patients with mitral valve stenosis. PMV significantly improves valvular function, the final increase in mitral valve area being about 2 sq cm. The quality of the results obtained is principally related to the anatomy of the valve. The overall incidence of complications is low. The mortality rate ranges from 0.5 to 4 p. 100 in severe mitral stenosis. Left-to-right atrial shunting is detected by oximetry in 20 p. 100 of the cases, but it subsequently disappears in two thirds of the patients; late results are only known at medium term. When the initial result is satisfactory functional improvement is the rule and the incidence of restenosis is low. When the initial result is insufficient, or when mitral stenosis develops open heart surgery is usually necessary. The decision to perform PMV should only be made after exclusion of its contraindications: left atrial thrombosis, moderate to severe mitral stenosis. Because of the encouraging results obtained, PMV can be envisaged as first choice treatment of mitral stenosis with flexible cusps. In calcified mitral stenosis the standard treatment is mitral valve replacement, PMV being reserved to some particular cases.

[Percutaneous mitral valvuloplasty]

Since its introduction as an alternative to surgical commissurotomy, percutaneous mitral valvuloplasty (PMV) has been preformed in a wide range of patients. PMV improves valve function significantly, and provides a final valve area of 2 cm2. The quality of the results is mainly related to valve anatomy. The incidence of complications is relatively low: death 0.5%, severe mitral incompetence 4%, and left to right shunts, as assessed by oximetry 20% of which two thirds disappear during follow-up. As of now, only mid-term follow-up results are available. If the initial result is good, functional improvement occurs in most cases and re-stenosis is rare. On the other hand, secondary surgery is most often necessary in case of poor initial result or severe mitral regurgitation complicating PMV. These favorable results lead us to propose PMV as the first treatment for mitral stenosis with pliable valves. On the contrary, valve replacement remains the main treatment in calcific stenosis, PMV being restricted to particular cases: mild calcification, high surgical risk or even refusal of surgery. Finally, the decision of PMV can only be taken after exclusion of contraindications: left atrial thrombosis, moderate to severe mitral regurgitation.