Journal - Presse médicale (Paris, France : 1983) (France )

Abstract :

GENERAL PRINCIPLES: The first step is to determine the absence or the minimal nature of the functional impairment from history taking and, for doubtful cases, with an exercise test. Therapeutic indications differ depending on the valvular lesion. AORTIC STENOSIS: Surgery is indicated only for severe aortic stenosis or in cases with a particular risk. Indications for surgery are: false asymptomatic patients with a positive exercise test, patients with abnormal hemodynamic and/or rhythm response to an exercise test (decrease in systolic pressure > 10 mmHg, severe ventricular arrhythmia), aortic stenosis with left ventricular ejection fraction < 50%, aortic stenosis associated with severe coronary artery disease amendable with bypass surgery. MITRAL STENOSIS: The advent of percutaneous mitral commissurotomy has totally changed the treatment of mitral stenosis. This new method can be proposed for stenotic but flexible mitral valves with no major lesion of the lower valvular apparatus or for more advanced valve disease with a risk of hemodynamic failure or thromboembolism. MITRAL INSUFFICIENCY: When mitral leakage is the only valvular defect, surgery is indicated if the volume regurgitated is important as assessed clinically and by echocardiography. Conservative surgery is preferred due to the low risk and the high probability of good long term outcome. Factors to take into account include: the experience of the surgical team in this field, the etiology of mitral insufficiency, the impact on the cardiac condition. Surgery should be performed before the development of atrial fibrillation, major cardiomegaly, left ventricular dilatation (end systolic diameter > 45 mm), or an alteration of the ejection fraction (< 60%). AORTIC INSUFFICIENCY: Cases of the aortic insufficiency should be differentiated according to the state of the ascending aorta. Annuloaortic ectasia requires surgery when the diameter reaches = 50-55 mm (depending on the authors). For valve dysplasia with non aneurysmal cylindrical dilatation of the ascending aorta, the indication for surgery depends on the progressive aggravation of the aortic dilatation. For cases with unique valve lesions, the indication for surgical repair of aortic insufficiency depends on the impact on the left ventricle. Indications for surgery include major radiographic cardiomegaly (cardio-thoracic ratio > 0.58), echocardiographic evidence of major left ventricular dilatation (end diastolic diameter > 75 mm and end systolic diameter > 55 mm), or an alteration of the systolic function (ejection fraction < 0.50 or 0.55). SPECIAL SITUATIONS: In disease states associating stenosis and insufficiency, valve replacement is often the only possibility. Careful patient selection is the rule. Surgery is often needed for cases with multiple valve involvement where different therapeutic options can be used for the different valves. The dominant lesion and the degree of heart dilatation and dysfunction guide decision making.

Journal - Archives des maladies du coeur et des vaisseaux (FRANCE )

Journal - Annales de cardiologie et d'angéiologie (FRANCE )

Abstract :

This type of disease has benefited considerably, over recent decades, from progress in ultrasound technique and new methods of medical and surgical treatment. The aetiologies of mitral incompetence can be classified into 4 categories according to their mechanism: 1. Mutilating valve lesions, usually secondary to bacterial endocarditis, but sometimes secondary to trauma (percutaneous valvuloplasty). 2. Rupture of chordae tendineae, either spontaneous or bacterial, in a context of pre-existing valvular heart disease, usually degenerative. 3. Papillary muscle lesions, usually corresponding to rupture of a papillary muscle or the head of a papillary muscle, associated with myocardial infarction. 4. Biological or mechanical valve prosthesis dysfunction. The consequences of acute mitral incompetence depend on its aetiology and the presence or absence of previous mitral valve disease. Three factors determine the clinical presentation and prognosis: the volume of regurgitation, left ventricular function and left atrial compliance. In pure forms, such as those occurring after rupture of chordae tendineae, the haemodynamic profile consists of a marked elevation of left ventricular filling pressures, left atrial mean and systolic pressures (large V wave), and a reduction of the cardiac output. The left ventricular end-diastolic volume is moderately increased, while the end-systolic volume is normal or decreased and the ejection fraction is increased. The clinical picture is that of acute left ventricular failure with a systolic murmur of mitral regurgitation and a pulmonary hypertension syndrome. The absence of left ventricular hypertrophy on the electrocardiogram and the absence of left-sided dilatation on radiological examination indicate the recent nature of the haemodynamic disturbances. The diagnosis of acute IM is confirmed by Doppler ultrasound, which defines the mechanism and sometimes eliminates the need for an invasive investigation. The clinical course depends on the aetiology, the volume of regurgitation, left ventricular function and the treatment implemented. First-line treatment must include vasodilators. Sodium nitroprussate infusion decreases the left ventricular end-diastolic volume and the volume of regurgitation and increases the cardiac output. It allows a rapid reduction of pulmonary artery and capillary hypertension. When this treatment is not sufficient, intra-aortic counterpulsation may be useful. Emergency surgery is sometimes necessary, but usually after improvement of the haemodynamic state by vasodilators. Depending on the aetiology, surgery may consist of valve replacement or surgical repair, which can give excellent results even in the presence of active bacterial endocarditis. In other cases, following control of the acute phase by medical treatment, mitral incompetence will become chronic.

Journal - European heart journal (ENGLAND )

Abstract :

Optimal timing of surgery in infective endocarditis (IE) depends mainly on the haemodynamic tolerance of the patient. Emergency surgery is required in cases of refractory heart failure due to valvular lesions, intracardiac fistulas and high grade cardiac conduction abnormalities caused by septal abscesses. Surgery must be considered in all patients who have undergone a transient episode of heart failure such as a pulmonary oedema and it must be early--within 2 or 3 weeks of starting antibiotic therapy in patients with aortic regurgitation. Bacteriological indications are less frequent: persistent sepsis beyond the first week in spite of medical therapy, mycotic IE or prosthetic valve endocarditis caused by Gram-negative or staphylococcal organisms. Some complications may swing the argument in favour of surgery: detection of root abscesses or mycotic aneurysms using transoesophageal echocardiography, and systemic embolisms with persistent, large and mobile vegetative lesions. Mortality rate depends on the haemodynamic status but also on the severity of anatomical lesions, on the type of endocarditis (native or prosthetic valve), on the type of surgery and on bacterial aetiologies. It varies between 5% and 30%. The late postoperative outcome is good. The actuarial survival rate at 8 years was 70% in our series of 31 patients with aortic regurgitation and early surgery. In mitral regurgitation, conservative surgery is possible in most cases. In our department, 48 patients with mitral bacterial lesions have been operated on with conservative surgery without operative mortality. IE was active in 14, recent in 12 and had occurred earlier in 22.(ABSTRACT TRUNCATED AT 250 WORDS)

Journal - Archives des maladies du coeur et des vaisseaux (FRANCE )

Abstract :

In 1993, infectious endocarditis (IE) remains a common and serious condition. Surgery has become an essential feature of treatment in many cases. The choice and optimal timing depend on many factors: the tolerance of the underlying cardiac disease is an important feature, surgery being indicated not only in cases of necessity (refractory cardiac failure) but also as treatment of choice in cases of episodic decompensation even if temporary when related to valvular dysfunction. In these conditions, if the lesion is severe aortic incompetence, surgery can be programmed in two or three weeks after initiating antibiotic therapy; the bacteriological indications are less common: fungal endocarditis, prosthetic valve endocarditis due to gram-negative bacilli or staphylococcus aureus endocarditis, or IE on native valves with persistent signs of sepsis after one week of antibiotic therapy; the occurrence of some complications may require urgent surgery: high degree atrioventricular block, septal perforation, ring or perivalvular abscess detected at echocardiography, single or multiple systemic embolism with persistence of large, mobile vegetations at echocardiography. Conversely, tricuspid valve endocarditis usually respond well to medical treatment alone: surgery (valvuloplasty with excision of vegetations, valvulectomy or, preferably, bioprosthetic valve replacement) is sometimes indicated in septic states related to certain pathogenic organisms. The operative indications in 1993 have become more extensive and earlier: analysis of surgical results shows that operative mortality depends mainly on the haemodynamic status at the time of operation, but also on the severity of the anatomical lesions, the nature of surgery, the type of endocarditis, native or prosthetic valve, and the causal organism.(ABSTRACT TRUNCATED AT 250 WORDS)

Journal - Archives des maladies du coeur et des vaisseaux (FRANCE )

Abstract :

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)

Journal - Archives des maladies du coeur et des vaisseaux (FRANCE )

Abstract :

The aim of this study was to analyse the evolution of the aetiologies of operated valvular heart disease over a 20 year period and to assess the consequences. Two thousand five hundred and ninety eight patients who underwent conservative surgery or valve replacement were included. This population was classified according to the date of surgery into 4 groups, each corresponding to a 5 year period. Analysis of these results, especially in the groups operated between 1970 and 1974 and between 1985 and 1989 shows: 1) a change in aetiology: decreased incidence of rheumatic valvular disease (36 versus 61%) and an increased incidence of degenerative lesions (43 versus 23%) (p less than 0.0001); 2) a change in the valvular lesions operated, aortic stenosis has become the commonest operated condition (43 versus 27%) (less than 0.001); 3) an increased age (59 +/- 14 versus 49 +/- 13 years, p less than 0.0001) with a higher proportion of patients over 70 years of age (22 versus 1%, p less than 0.001); 4) a higher incidence of mixed coronary and valvular surgery (11 versus 2%, p less than 0.001).

Journal - Annales de cardiologie et d'angéiologie (FRANCE )

Abstract :

The choice of a valve replacement in patients over 70 years of age must take into account various parameters: the type of valve disorder being operated, the probability of post-operative survival in view of the stage of the valve disease and the age of the subject, and the advantages and draws-backs related to the replacements used. In the case of mechanical replacements, the main risks are related to the embolic and hemorrhagic problems inherent in anticoagulant treatment. In the case of biological replacements, the problems are related to the primary degeneration of these valves, which appears to be less frequent the higher the age. In patients over 75 years of age, bioreplacements have more advantages than mechanical valves. In subjects between 70 and 75 years of age, a mechanical valve can be recommended if there is no contraindication to anticoagulant treatment, if there is some other grounds for long-term anticoagulation and if the life expectancy appears to be greater than 10 years. In other situations, a bioreplacement is recommended.

Journal - European heart journal (ENGLAND )

Abstract :

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.

Journal - Archives des maladies du coeur et des vaisseaux (FRANCE )

Abstract :

Although dystrophic aortic regurgitation is considered to be a rare condition, if aortic regurgitation due to cystic media-necrosis which usually presents with annulo-aortic ectasia and regurgitation due to dystrophic aortic valves are included, it becomes a relatively common cause of aortic regurgitation. In the authors' experience of 313 patients operated for pure chronic aortic regurgitation, approximately 30% had dystrophic lesions and this was the second most common cause of aortic regurgitation after acute rheumatic fever. The clinical presentation is variable: excluding annulo-aortic ectasia, the other features of dystrophic aortic regurgitation are less well known. Eighty-nine cases without aneurysm of the ascending thoracic aorta were recensed and analysed in a French Cooperative study. They were divided into two groups with respect to the diameter of the ascending aorta measured by echocardiography. The incidence of late postoperative complications of the ascending aorta was higher in patients with a dilated aorta. The diagnosis of dystrophic aortic regurgitation is easy in patients with an aneurysm of the ascending aorta: in other cases, transoesophageal echocardiography is very useful for evaluating the valvular lesions. Surgical treatment of pure dystrophic aortic regurgitation with an aneurysm of the ascending aorta is well established but the best management of aortic regurgitation associated with only mildly dilated aorta is debatable.

Journal - Archives des maladies du coeur et des vaisseaux (FRANCE )

Journal - Archives des maladies du coeur et des vaisseaux (FRANCE )

Abstract :

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)

Journal - European heart journal (ENGLAND )

Abstract :

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)

Journal - Archives des maladies du coeur et des vaisseaux (FRANCE )

Journal - European Heart Journal

Abstract :

Abstract A French cooperative retrospective study analysed 155 pregnanciesin 103 women with prosthetic heart valves: 95 mechanical prosthesis(MP) and 60 bioprostheses (BP). Among them 13 MP and 10 BP werebivalvular and four were mixed implants. In all, 182 (108 MPand 74 BP) prostheses were exposed to the risk of pregnancy.Among the 108 MP-bearing patients, 16 thromboembolic accidents(TEA) were recorded: 10 thromboses in 13 mitral, two aorticand one pulmonary MP. TEA were four times more frequent underoral anticoagulant therapy. Among the 74 BP, seven sufferedpremature valve failure. Ninety-nine infants were born to 50MP-bearing women (53%) and 48 BP-bearing patients (80%) (P<0.001).Twenty miscarriages were reported; they occurred more oftenunder anticoagulant treatment (17%) than without it (4%) P<0.02).Coumarin-induced embryopathies were rare (only one definitivelyidentified). Because pregnancy with an MP under anticoagulanttherapy is dangerous for the mother and may effect the fetus,the therapeutic indications for women of child-bearing age mustbe taken into consideration. In a women already with an MP atthe time of conception, the duration of heparin therapy shouldbe limited to the following two periods: from the 6th to the12th week (coumarin-induced embryopathies) and during the last2 weeks of gestation (haemorrhages during delivery and the neonatalperiod).