[Study of the etiologic mechanism of valvular regurgitation using Doppler echography]

Doppler echocardiography is currently the method of choice for diagnosing and determining the mechanism and etiology of valvular regurgitation. The recent introduction of transesophageal echo coupled with color Doppler has increased the value of these ultrasonic methods. The analysis of the valvular lesion should be particularly precise and accurate in severe mitral insufficiency because of the possibility of surgical valvuloplasty, the indications of which are now much broader than was the case at the beginning of the nineteen eighties.

Detection of prosthetic valve thrombosis using 111indium platelet imaging

The diagnosis of prosthetic valve thrombosis (PVT) may be difficult in cases without valve obstruction. The aim of this study was to evaluate the diagnostic accuracy of 111indium-labelled autologous platelet imaging in the detection of PVT. We studied 41 patients with 45 prostheses, mechanical (37) or biological (8), in the mitral (26) or aortic (19) site. Mean age was 55 +/- 13 years. All these patients experienced one or several thromboembolic events (mean: 2.3 per patient). The mean interval between the last embolic event and indium test (IT) was 32 +/- 25 days. Scintigrams were recorded in two views daily for 5 days. IT showed an abnormal platelet deposition on the prosthetic area in 24 patients. Platelet half-life was 3.8 +/- 1.0 days for patients with a positive IT and 4.6 +/- 0.6 days for those with a negative IT (P less than 0.01). Anatomical data were obtained in 10 cases (surgery nine, autopsy one) 16 +/- 5 days after IT. All these patients had PVT, and IT was positive in eight cases. In the other 31 medically treated patients, recurrent embolism occurred within 12 months after IT in four cases, three of whom previously had a positive test. We conclude that IT is a useful means for detecting PVT.

[Echography in surgical mitral insufficiency. Pathologic diagnosis and provision of the surgical procedure]

The aim of this study was to determine the reliability of preoperative transthoracic and transesophageal echocardiography compared with the surgical findings in pure or dominant severe mitral regurgitation with respect to: the evaluation of the lesions, mechanism and etiology; the provision of the type of surgery (valve replacement or reconstruction); One hundred and fifty patients were divided into two groups: Group I (N = 120) in which preoperative assessment included transthoracic echo-Doppler coupled with color Doppler in the last 32 patients; Group II (N = 30) operated recently who underwent both transesophageal and transthoracic echo-Doppler examination. In Group I, the sensitivity of transthoracic echo in the evaluation of the etiological was 86% overall [100% in rheumatic valve disease (N = 28), 86% in degenerative or dystrophic valves (N = 72), 44% in endocarditis (N = 9), 87% in ischaemic dysfunction (N = 8)]. The echo evaluation of the mechanism of the regurgitation was also reliable with the exception of ruptured chordae in which direct visualisation of the rupture was only possible in 19 of the 64 cases (30%). The type of surgery predicted by echo was practiced in 87% of cases.

[Value of transesophageal echocardiography. From a preliminary experience of 532 cases]

Transesophageal echocardiography (TEE) was introduced recently in France. The aim of this study was to review the diagnostic value of this technique after 8 months' use in our cardiology department. A total of 532 TEE studies were carried out between April and December 1988 in 396 patients (average age 54 years, range 17 to 89 years) at Tenon Hospital. The failure rate was 1.8 per cent (N = 10), over half of which occurred at the beginning of the operator's experience. TEE was particularly valuable compared with the standard transthoracic approach in the following instances: the investigation of mitral stenosis, especially before percutaneous valvuloplasty (N = 75). A left atrial thrombus was demonstrated in 5 cases by TEE vs none by standard echocardiography. There was also a much higher diagnostic sensitivity for small interatrial shunts (40 vs 6) resulting from transseptal catheterisation. In the preoperative investigation of severe mitral regurgitation (N = 29). The etiology was accurately diagnosed in 29 vs 26 cases, and the mechanism of the regurgitation was correctly classified especially in cases of ruptured chordae (15 vs 6 cases). In endocarditis (N = 26) by the visualisation of abscess of the aortic ring (7 vs 1) and vegetations (19 vs 8). In prosthetic valve dysfunction (N = 65) by the demonstration of primary degeneration of bioprostheses (7 vs 4), perivalvular leaks (10 vs 4) and non-occlusive thrombi of mechanical prostheses (3 vs 0). In cases of intracardiac tumours, dissection of the thoracic aorta and atrial septal defects.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of percutaneous mitral commissurotomy in 200 patients

To assess the feasibility and efficacy of percutaneous mitral commissurotomy (PMC), the procedure was attempted in 200 patients with severe mitral stenosis. There were 154 women and 46 men, their mean age was 43 +/- 16 years (range 13 to 79) and 15 were older than 70 years of age. Forty-four had had previous surgical commissurotomy. Forty were in New York Heart Association class II, 152 in class III and 8 in class IV. In regard to valvular anatomy, 67 had calcified valves, 58 had pliable valves and only mild subvalvular disease, and 75 had flexible valves but extensive subvalvular disease. Grade 1+ mitral regurgitation was present in 62 and grade 2+ in 2. In 11 patients the procedure was discontinued because of complications in 3 and technical failure in 8. Six of the 8 technical failures occurred during the first 15 attempts. Effective PMC was performed in 189 patients using 1 balloon in 23 and 2 balloons in 166. After PMC, there was a significant improvement in mean left atrial pressure (21 +/- 7 to 12 +/- 5 mm Hg, p less than 0.0001), mean mitral gradient (16 +/- 6 to 6 +/- 2 mm Hg, p less than 0.0001), cardiac index (2.6 +/- 0.8 to 3.1 +/- 0.8 liters/min/m2, p less than 0.001) and valve area assessed by hemodynamics (1.1 +/- 0.3 to 2.2 +/- 0.5 cm2, p less than 0.0001) and 2-dimensional echocardiography (1 +/- 0.3 to 1.9 +/- 0.4 cm2, p less than 0.0001). No patient died. Embolism occurred in 8 (4%), with no further sequelae. Sixteen (8%) had atrial septal defect detected by oxymetry.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous valvuloplasty of aortic stenosis in adults. Immediate and mid-term results: apropos of 78 attempts]

Between February, 1986 and October, 1987 percutaneous aortic valvuloplasty was attempted in 78 patients: 25 men (32 p. 100) and 53 women aged from 61 to 89 years (mean 79.5 years). All patients were symptomatic; 9 were in class II, 49 in class III and 20 in class IV of the NYHA classification. The decision to try percutaneous valvuloplasty was determined by the high surgical risk associated with age (over 75 in 87 p. 100 of the patients), poor physiological condition or concurrent pathology, or by refusal of surgery. 70 dilatations could actually be made (90 p. 100) either by the brachial route (n = 39) or the femoral route (n = 18) or the transseptal route (n = 7) or by a combined brachial and femoral route which enabled the double balloon technique to be used (n = 6). The procedure comprised 5.6 +/- 3 inflations and lasted for 58 +/- 29 min. The diameter of the largest balloon utilized was greater than 20 mm in 75 p. 100 of the cases. Dilatation reduced the aortic gradient from 62 to 28 mmHg (p less than 0.001) without altering the cardiac index (2.36 to 2.32 l/min/m2) and significantly increased the aortic valve area from 0.49 to 0.76 cm2 (p less than 0.001). At the end of the procedure the aortic valve area was greater than 0.7 cm2 in 63 p. 100 and greater than 1 cm2 in 14 p. 100 of the patients. Five patients had to be operated upon within the month following dilatation (3 after technical failure, 2 for poor functional results).(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation by two-dimensional and doppler echocardiography of the results of percutaneous mitral valvuloplasty]

The purpose of this study was to determine the value of two-dimensional echocardiography and doppler ultrasound in the evaluation of the results and mechanism of percutaneous mitral valvuloplasty. The study involved 200 patients (77 p. 100 female) of mean age 43 +/- 15 years (range 13 to 79 years), most of whom were in NYHA class III or IV. The patients were divided into three groups according to the severity of the anatomical lesions. Group I patients (n = 58) had flexible valves and only minor alterations of the subvalvular structures; group II patients (n = 75) had flexible valves but deeply altered subvalvular structures; group III patients (n = 67) had calcified valves. Following valvuloplasty, the mean transmitral doppler gradient fell from 16 to 5 mmHg (p less than 0.0001) and the mitral valve area, as measured by two-dimensional echocardiography, increased from 1 to 1.9 cm2 (p less than 0.00001); the corresponding values at doppler measurement were 1 and 2 cm2 respectively. In patients successfully dilated, two-dimensional echocardiography showed that the mechanism involved was complete opening of one or both commissures. Before dilatation, 68 patients (34 p. 100) had an usually small degree of mitral regurgitation. After dilatation, grade 3/4 mitral regurgitation was observed in 9 patients (4.5 p. 100). The quality of the results obtained depended on the anatomical lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective study of catheter-related infection during prolonged arterial catheterization

Ninety-six arterial catheters from 75 different anatomical sites in 56 surgical ICU patients were studied prospectively to determine the rate of catheter-related infection associated with prolonged arterial catheterization (defined as greater than 96 h). Every 96 h, all catheters were semiquantitatively (SQ) cultured and the percutaneous entry site was swab cultured. Sites were used indefinitely by exchanging the catheters over a guide-wire every 96 h as long as arterial monitoring was necessary and SQ cultures remained negative (less than or equal to 15 colonies). No sites used less than 96 h developed skin colonization, while 14/51 (27%) sites used greater than 96 h developed positive swab cultures. No SQ cultures were positive in sites with negative swab cultures (p less than .001). Catheter-related infection (a positive SQ culture) developed in 4/42 (9.5%) radial or femoral sites compared to 4/9 (44%) axillary sites used greater than 96 h (p less than .01). It is concluded that arterial catheter-related infection develops in less than 10% of radial or femoral sites used greater than 96 h, and 90% of radial and femoral sites may be used safely for prolonged periods if skin colonization at the percutaneous sites is controlled and SQ catheter cultures remain negative. Skin site swab cultures may be useful for determining when arterial catheters should be removed and SQ cultured.

[Hemorrhagic risk in intravenously administered thrombolytic treatment in acute myocardial infarction]

163 patients aged from 27 to 70 years (mean 52 +/- 10 years), including 152 men and 11 women, received a thrombolytic treatment within the first 6 hours (mean 192 +/- 73 mn) of a myocardial infarction. 61 patients received streptokinase (SK) intravenously (group 1), 64 patients, single-chain rt-PA (group 2), 11 patients, two-chain rt-PA (group 3), 11 patients, rt-PA followed by intracoronary streptokinase (group 4), and 16 patients, acyl enzyme (group 5). In addition, all patients had heparin and 86 (53%) had aspirin. Immediately after thrombolysis, coronary arteriography was performed in 95 patients (58%), and this was followed by transluminal angioplasty in 49 of them (30%). The infarction was either anterior (n = 81) or inferior (n = 78) or lateral (n = 4). No fatal or neurological bleeding occurred. 17 haemorrhagic complications were observed; 5 of these (3%) were severe, requiring blood transfusion and, in 1 case, surgery; 12 were significant (7.4%) and produced changes in haematocrit. Nine of the 17 haemorrhages were associated with catheterization and localized to the site of arterial puncture. Severe bleeding occurred in patients treated with intravenous SK (3/61) or with rt-PA followed by intracoronary SK (2/11). There was a significant difference in the incidence of spontaneous bleeding between the SK group (4/61) and the single-chain rt-PA group (0/64; p less than 0.05). In the latter group, the minimum fibrinogen level was lower in patients who had a haemorrhagic complication.(ABSTRACT TRUNCATED AT 250 WORDS)

[Actilyse: biological aspects]

Alterations of coagulation and fibrinolysis induced by administration of single or two chains rtPA are detailed from personal and published results. One should differentiate between the thrombolytic activity, responsible for the efficacy of the drug on thrombosis and the systemic fibrinolytic activity, inducing the decrease in fibrinogen and coagulation factors which probably contribute as to the risk of bleeding, mostly related to invasive explorations (arterial punctures, catheters...), but possibly spontaneous. Few assessments are made: a sufficient plasma level of rtPA should be present to obtain a good efficacy; the degree of fibrinogen decrease is variable between individuals, although it is moderate in most patients (80% of cases); results of the measurements of fibrin degradation products are disappointing and do not allow the laboratory diagnosis of thrombus dissolution. Concerning the risk of re-occlusion, a careful monitoring of heparin treatment may reduce this risk but further studies are needed.

Prognosis and long-term results of surgically treated aortic stenosis

A total of 675 patients (mean age 60 +/- 11 years, range 22-85, 71% males) with calcified pure aortic stenosis (490) or mixed lesions (185) had an aortic prosthesis: 290 Starr-Edwards, 147 Bjork, 18 other mechanical valves, 163 pericardial xenografts, 57 porcine xenografts; 76 patients simultaneously underwent a coronary bypass, 12 a replacement of ascending aorta, and six a mitral valvuloplasty. Preoperatively, 67% were in functional class III or IV (NYHA); 69.5% had a coronary arteriography: significant coronary stenosis was observed in 27% of patients. The operative mortality was 6.8% depending on the functional class at surgery, age (4.9% before 70 years, vs. 12.5% after), and the date of surgery (8.1% before 1983 vs. 3.7% after). The 10- and 15-year actuarial survival rates were 62 +/- 3% and 44 +/- 4%, respectively. No significant differences were observed between patients with pure aortic stenosis and mixed aortic lesions. In patients over 70 years, the survival rates were 71 +/- 5% at five years and 51 +/- 10% at 10 years. Age, functional class, degree of congestive heart failure, and degree of cardiomegaly were the main preoperative predictors of late death. At 10 years, 88% of patients were free from myocardial dysfunction, 87% from thromboembolic events, and 89% from haemorrhages. We conclude that in this type of valvulopathy, short- and long-term surgical results are good despite the fact that most patients are elderly and in an advanced functional class.

Treatment of calcified aortic stenosis: surgery or percutaneous transluminal aortic valvuloplasty?

A total of 546 patients with severe aortic stenosis (AS) were retrospectively reviewed to assess the efficacy of percutaneous transluminal valvuloplasty (PTV) and valve replacement (VR). Of these, 490 underwent VR between 1968 and 1986 (mean age 62 +/- 12 years, 71.7% were in NYHA class III or IV), 68.8% received mechanical prostheses, and in 11.8% a bypass graft was associated. The operative mortality was 6.9% (4% since 1983). The mean follow-up was 57.6 months. The actuarial survival rate was 77% at five years, 60% at 10 years, and 40% at 15 years. Over 70 years of age, operative mortality was 6.2% since 1983, and the actuarial survival rate was 67.5% at five years. From February 1986 to May 1987, PTV was attempted in 56 patients and was effective in 52 patients (mean age 79 +/- 5 years, 93% in Class III or IV). Immediate mortality was 7.1%. The morbidity was due to tamponade (1.8%), myocardial infarction (3.6%), vascular trauma (5.3%), or cerebrovascular accident (9%). Forty three patients were followed after PTV (mean value 4.2 +/- 3, range 1-14 months): 12 patients (28%) died and 46% were functionally improved in NYHA Class II. PTV significantly improved the aortic valve area as shown by haemodynamics (0.49-0.75 cm2; P less than 0.0001) and these findings were corroborated by Doppler study (0.46-0.70 cm2, P less than 0.001). In conclusion, this series shows that surgery provides satisfactory results in AS with a low mortality and good long-term results, even in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous transluminal valvuloplasty of the mitral valve]

Percutaneous transluminal balloon valvuloplasty for mitral stenosis represents an alternative method of treatment to standard surgical procedures of open or closed commissurotomy as well as valve replacement. In this overview, our results will be reported with respect to derivation of a summary of indications and contraindications for the procedure. Valvuloplasty for mitral stenosis was carried out in 62 patients, mean age 43 +/- 17 years, 48 women and 14 men. In 14 of the patients surgical procedures had been performed previously including an open or closed commissurotomy or isolated aortic valve replacement. Nine patients were in NYHA class II, 50 in class III and three in class IV. Markedly impaired motion of the valve and calcification was present in 15 patients. In 47 patients, the valve motion was relatively good and associated with mild changes in the subvalvular apparatus in 29 and marked changes in 18. In 54 patients the valvuloplasty was carried out with a combination of two balloon catheters, one 3 X 10 mm trefoil catheter and a single-balloon catheter of 15 mm (n = 16) or 19 mm (n = 38) diameter. Both catheters were inserted via the right femoral vein. The procedure required an average of one and one-half hours. Before and after valvuloplasty, complete right heart catheterization with oxymetric determinations were carried out to detect possible shunts at the atrial level and left ventriculography for detection of mitral regurgitation was performed in addition to echocardiography and Doppler examinations with continuous, pulsed-wave and color Doppler studies.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of valvular replacement in chronic or paucisymptomatic aortic insufficiency. Apropos of 79 patients]

The aim of this study was to assess the outcome of 79 patients operated for chronic, pure, severe aortic incompetence with little or no symptoms (Grades I or II of the NYHA Classification). The average age of the patients was 42 years (range 14 to 76 years) and the average follow-up period was 59.4 months (range 3 to 190 months). The preoperative left ventricular volumes on angiography were: end diastolic volume 224 +/- 47 ml/m2, end systolic volume 121 +/- 39 ml/m2. The ejection fraction was 48 +/- 10 p. 100. Forty two mechanical prostheses and 37 bioprostheses were implanted. There were no operative deaths. The 8 year survival rate was 87 p. 100. Ninety four per cent of the survivors remained asymptomatic; 91 p. 100 have had no thromboembolic complications and 90 p. 100 have not been reoperated. The incidence of myocardial dysfunction was 8.8 p. 100 during this period. The most significant poor prognostic factor was a preoperative ejection fraction of less than 40 p. 100. These results show that early surgery in patients with aortic incompetence and little or no symptoms has a low operative risk and a low incidence of late myocardial dysfunction despite severe left ventricular dilatation with decreased left ventricular function.

[Fate of Starr-Edwards prostheses in the mitral position. Prognostic factors. Apropos of 309 cases]

The authors report the long-term results of 309 patients undergoing isolated mitral valve replacement with a 6120 Starr Edwards mitral valve prosthesis in the great majority of cases, mainly for rheumatic mitral valve disease, with predominant mitral regurgitation. The average age was 26 +/- 14 years with 25% of children. The operative mortality was 9% and late mortality after a mean follow-up period of 4 years was 13,5% mainly due to thromboembolic complications and to myocardial dysfunction. The long-term results with an average 45 month follow-up showed a 10 year survival rate of 70,6% with an excellent clinical result in 71% of cases and an acceptable result in 10%; 20% of patients were considered poor long-term results because of myocardial dysfunction and thromboembolic complications. Endocarditis and perivalvular leaks were rarely observed (9 cases). A study of preoperative parameters which could influence long-term results showed that the quality of long-term survival was significantly correlated to age, the duration of cardiac disease before surgery, cardiomegaly and the presence of preoperative cardiac failure and tricuspid regurgitation. The incidence of thromboembolism was 4,7% patient years and the frequency of these complications was not related to the quality of anti-vitamin-K therapy. Patients under effective anticoagulant therapy had the highest incidence of haemorrhage (10%). This study confirms that the Starr Edwards 6120 prosthesis is a satisfactory choice for mitral valve replacement considering its durability (no cases of abnormal wear) and the 70% ten year survival rate. The problem of myocardial dysfunction could be resolved by earlier surgery.(ABSTRACT TRUNCATED AT 250 WORDS)