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.

[Value of transesophageal echocardiography in the follow-up of successful percutaneous mitral valvotomy]. / Intérêt de l'échographie transoesophagienne dans le suivi des commissurotomies mitrales percutanées réussies.

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)

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)

[Dystrophic aortic valve insufficiency]. / Les insuffisances aortiques dystrophiques.

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.

[Echography in surgical mitral insufficiency. Pathologic diagnosis and provision of the surgical procedure]. / L'échographie des insuffisances mitrales chirurgicales. Diagnostic lésionnel et prévision du type de chirurgie.

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]. / Intérêt de l'échographie cardiaque par voie transoesophagienne. A partir d'une expérience préliminaire de 532 cas.

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)

[Evaluation by two-dimensional and doppler echocardiography of the results of percutaneous mitral valvuloplasty]. / Evaluation par échographie bidimensionnelle et doppler des résultats de la valvuloplastie mitrale percutanée.

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)

[Transesophageal echography. Value of the technic apropos of a preliminary experiment in 320 patients (385 examinations)]. / L'échographie par voie oesophagienne. Intérêt de la technique à propos d'une expérience préliminaire concernant 320 patients (385 examens)

The authors discuss the clinical utility and feasibility of trans-esophageal echocardiography. Between April and October 1988, 385 examinations were performed in 320 patients (mean age: 54 yr, range: 17-89). In 9 patients (2.4 p. 100), the transesophageal transducer could not be introduced. The only complication was one case of bacteremia without sequela, that occurred early in our use of this technique. Transesophageal echocardiography proved to be useful in the following indications: mitral stenosis (n = 50), mainly by detecting thromboses of the left atrium (n = 5); infectious endocarditis (n = 21), especially for diagnosing aortic ring abscesses (n = 3); severe mitral insufficiency (n = 26), to assess the mechanism of regurgitation and to visualize chordal rupture (n = 13). We conclude from this preliminary study that transesophageal echocardiography is particularly useful in the pathologies described above as a complementary procedure to conventional echocardiography.

[Unusual development of ventricular aneurysms. Echocardiographic diagnosis]. / Anévrysmes ventriculaires à développement inhabituel. Diagnostic échocardiographique.

Two cases of posterior left ventricular aneurysms compressing the left atrium diagnosed by 2D echocardiography are reported. The diagnosis was made on visualisation of an abnormal intra-left atrial cavity, contiguous with the mitral ring, exhibiting systolic expansion, which could not be opacified by peripheral venous injection of echo-contrast.

[Chronic disseminated intravascular coagulation in a case of ventricular aneurysm. Correction by low-dose heparin]. / Coagulation intravasculaire disséminée chronique dans un cas d'anévrysme ventriculaire.

A case of intravascular coagulation in a patient with a very large ventricular aneurysm is reported. Biological signs of defibrination with a low serum fibrin of 0,80 g/1, thrombocytopaenia of 80,000/mm3 and the presence of soluble complexes and FDPs were detected after recurrent haematuria. Low dose heparin (0,15 to 0,20 ml x 2/day by subcutaneous injection) led to normalisation of the fibrinogen levels, increased the platelet count and reversed the consumptive coagulopathy. Each withdrawal of heparin (5 attempts over 16 months) led to a biological relapse. At the final withdrawal of therapy, the biological abnormalities remained minor; the consumption of fibrinogen and platelets was well compensated. Similar cases have been published in aortic aneurysms with and without dissection, but the association with a cardiac aneurysm has not been reported previously. The physiopathological mechanism of the coagulopathy is discussed and the authors suggest routine study of the coagulation system in all patients with cardiac aneurysms. This case illustrates the efficacity of moderate doses of heparin in a patient with "biological hypercoagulability" well documented by laboratory investigations.

[Operated aortic stenosis. Evaluation of the long-term prognosis using clinical and hemodynamic parameters in a series of 249 cases]. / Les sténoses aortiques opérées. Appréciation du pronostic à distance de l'intervention en fonction des paramètres cliniques et hémodynamiques dans série de 249 cas.

The long-term results and the prognostic factors in aortic valve replacement for aortic stenosis were assessed from a series of 249 operated cases (comprising 199 pure or dominant stenosis and 50 mixed aortic lesions) followed up for a maximal period of 9 years. The postoperative survival rate, 71% at 5 years, 62,6% at 8 years, including the operative mortality, is better than in a comparable series of pure chronic aortic incompetence (58% at 5 years) despite a higher average age. In the same age group the difference is significant at the 6th year. However, no difference was observed between mixed aortic disease and aortic stenosis. Irreversible myocardial dysfunction is relatively rare (6,6% of survivors at 1 month, 24% of poor results or late deaths) and much less common than in aortic incompetence of which it represents the main cause of failure. Even in these cases, prolonged symptomatic improvement may be observed. 3 prognostic factors affect the operative and late mortality. They act to variable degrees and independantly of each other. They are : age, cardiomegaly and heart failure. The actuarial 5 year survival is: 81,77% and 53% for under 50, 50 to 65 and over 65 years age group respectively; 88%, 78% and 48% for cardiothoracic ratios of less than 0,50, between 0,50 and 0,58 and greater than 0,58 respectively; 83%, 65% and 47% for patients without signs of heart failure, with a history of pulmonary oedema, and with a history of congestive cardiac failure respectively. These results encourage a liberal attitude towards surgery, even in old patients with severe valvular lesions.