Percutaneous mitral valvuloplasty in surgical high risk patients.

Among 126 consecutive patients undergoing percutaneous mitral valvuloplasty, 34 were judged to be at high risk for surgery on the basis of age greater than 70 years (n = 13), New York Heart Association functional class IV (n = 11), ejection fraction less than or equal to 35% (n = 3), severe pulmonary hypertension (n = 7), need for associated coronary bypass (n = 4) or additional valve surgery (n = 20) or severe pulmonary disease (n = 3). Baseline features of the high risk group were substantially worse than those of the other patients: age (65 +/- 11 versus 49 +/- 12 years; p = 0.0001) and echocardiographic score (9.4 +/- 1.8 versus 8.2 +/- 1.5; p = 0.005) were higher, whereas cardiac output (2.9 +/- 0.9 versus 4.1 +/- 1.2 liters/min; p = 0.0001) and mitral valve area (0.9 +/- 0.4 versus 1.1 +/- 0.3 mm2; p = 0.002) were lower. Three high risk patients experienced technical failures and three others had major complications. Among the remaining 28 patients, 18 (65%) had a complete hemodynamic success, 4 (14%) an incomplete success and 6 (21%) hemodynamic failure. Stepwise logistic regression analysis retained echocardiographic score as the only factor independently predictive of success. The percent increase in mitral valve area also correlated with echocardiographic score (r = 0.51, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Asymptomatic Cardiac Ischemia Pilot (ACIP) study: effects of coronary angioplasty and coronary artery bypass graft surgery on recurrent angina and ischemia. The ACIP investigators.

OBJECTIVES: The Asymptomatic Cardiac Ischemia Pilot (ACIP) study showed that revascularization is more effective than medical therapy in suppressing cardiac ischemia at 12 weeks. This report compares the relative efficacy of coronary angioplasty or coronary artery bypass graft surgery in suppressing ambulatory electrocardiographic (ECG) and treadmill exercise cardiac ischemia between 2 and 3 months after revascularization in the ACIP study. BACKGROUND: Previous studies have shown that coronary angioplasty and bypass surgery relieve angina early after the procedure in a high proportion of selected patients. However, alleviation of ischemia on the ambulatory ECG and treadmill exercise test have not been adequately studied prospectively after revascularization. METHODS: In patients randomly assigned to revascularization in the ACIP study, the choice of coronary angioplasty or bypass surgery was made by the clinical unit staff and the patient. RESULTS: Patients assigned to bypass surgery (n = 78) had more severe coronary disease (p = 0.001) and more ischemic episodes (p = 0.01) at baseline than those assigned to angioplasty (n = 92). Ambulatory ECG ischemia was no longer present 8 weeks after revascularization (12 weeks after enrollment) in 70% of the bypass surgery group versus 46% of the angioplasty group (p = 0.002). ST segment depression on the exercise ECG was no longer present in 46% of the bypass surgery group versus 23% of the angioplasty group (p = 0.005). Total exercise time in minutes on the treadmill exercise test increased by 2.4 min after bypass surgery and by 1.4 min after angioplasty (p = 0.02). Only 10% of the bypass surgery group versus 32% of the angioplasty group still reported angina in the 4 weeks before the 12-week visit (p = 0.001). CONCLUSIONS: Angina and ambulatory ECG ischemia are relieved in a high proportion of patients early after revascularization. However, ischemia can still be induced on the treadmill exercise test, albeit at higher levels of exercise, in many patients. Bypass surgery was superior to coronary angioplasty in suppressing cardiac ischemia despite the finding that patients who underwent bypass surgery had more severe coronary artery disease.

Balloon mitral commissurotomy in patients aged > or = 70 years.

Of 280 patients treated by balloon mitral commissurotomy (BMC) between 1987 and 1991, 28 (10%) were > or = 70 years old. Two patients with associated significant aortic stenosis were excluded from the study. Older patients more often were in New York Heart Association class III or IV (84 vs 67%; p < 0.007) and atrial fibrillation (61 vs 36%; p < 0.0001), and had a higher echocardiographic score (9.3 +/- 2 vs 8 +/- 1.6; p < 0.0004) and a lower baseline cardiac index (2.1 +/- 0.6 vs 2.4 +/- 0.6 liters/min/m2; p < 0.03) than younger ones. Baseline mean pulmonary pressure (37 +/- 11 vs 34 +/- 12 mm Hg), transmitral gradient (14 +/- 4 vs 14 +/- 5 mm Hg) and valve area (1.0 +/- 0.4 vs 1.1 +/- 0.3 cm2) were not different between older and younger patients (p = NS). Acute complications during the procedure (including cardiac perforation, embolism, severe mitral regurgitation and surgical atrial shunt), and 30-day mortality after BMC were more frequent in older than younger patients (27 vs 9% [p < 0.01], and 12 vs 0.8% [p < 0.005], respectively). A complete success, defined as a mitral valve area increase > 25% and postmitral valve area > 1.5 cm2 was obtained in 16 of the 22 older patients (72%) with the completed procedure (compared with 81% of younger ones; p = 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic significance of progression of coronary artery disease.

Angiographically documented coronary artery disease (CAD) can progress. Although progression itself is frequently recognized in patients who have undergone repeat cardiac catheterization, its prognostic significance remains unclear. To evaluate the influence of progression on survival, 313 patients with CAD who underwent catheterization twice (39 +/- 25 months apart) were followed for 3 to 129 months (mean 41 +/- 30) after the second angiogram. At the time of the second angiogram, 21, 91, 113 and 88 patients had 0-, 1-, 2- and 3-vessel CAD, respectively. The mean ejection fraction (EF) of the group was 55 +/- 13%. Progression was noted in 139 patients (44%). Of the 313 patients, 33 died and 39 had acute myocardial infarction (AMI) during follow-up. Four-year survival was estimated at 94% and 83% in the nonprogression and progression groups, respectively. Progression was predictive of survival by (univariate) long-rank test (p less than 0.01), but only EF (p less than 0.001), number of diseased vessels (p less than 0.01) and percent stenosis in the left main coronary artery (p less than 0.05) were independently significant by (multivariate) Cox regression analysis. Four-year survival without AMI was 89% and 73% in the nonprogression and progression groups, respectively. Progression was related to survival without AMI (p less than 0.001) by log-rank test. Cox regression analysis provided 3 independent predictors of survival without AMI: number of diseased vessels (p less than 0.01), progression (p less than 0.01), relative risk = 2.28) and EF (p less than 0.01). Results were similar when analyzing only the 39 AMIs.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term (9 to 33 months) echocardiographic follow-up after successful percutaneous mitral commissurotomy.

Late results after successful percutaneous mitral commissurotomy were assessed by prospective clinical and echocardiographic follow-up. Fifty-seven patients were followed for a mean of 19 +/- 6 months (range 9 to 33) after the procedure. Mitral valve area (measured by Doppler half-time method) increased from 1.0 +/- 0.2 to 2.2 +/- 0.5 cm2 immediately after commissurotomy, and then decreased to 1.9 +/- 0.5 cm2 at follow-up (p less than 0.05), whereas gradient did not change after its immediate postcommissurotomy reduction. Echocardiographic restenosis (mitral valve area less than or equal to 1.5 cm2 with greater than 50% reduction of initial gain) was seen in 12 of 57 patients (21%). Atrial shunting, detected by transthoracic color Doppler in 61% of patients immediately after the procedure (color flow jet through atrial septum), persisted in 30% at follow-up. Restenosis by univariate analysis correlated with age, smaller valve area after the procedure, and higher echocardiographic score. Multivariate analysis identified leaflet mobility and calcifications as the components of a score that was predictive for restenosis. Magnitude of shunt (pulmonary-to-systemic flow ratio greater than 1.5), use of a Bifoil balloon (2 balloons on 1 shaft), and smaller valve area after the procedure were predictors by multivariate analysis of the persistence of atrial shunting. Clinical improvement persisted at long-term follow-up (mean New York Heart Association class 1.6 +/- 0.6 vs 2.6 +/- 0.6 before commissurotomy). Improvement of greater than or equal to 1 functional class was seen in 75% of patients (80% of those without and 58% of those with restenosis); patients with a shunt did not differ from the entire group.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon mitral commissurotomy for mitral restenosis after surgical commissurotomy.

Balloon mitral commissurotomy (BMC) was performed in 113 patients. Of these patients, 27 (24%) (25 women and 2 men, aged 49 +/- 13 years) had recurrent mitral stenosis 13 +/- 6 years (range 5 to 29) after surgical commissurotomy. Eleven patients (41%) were considered at high risk for surgery. BMC resulted in an increase in mitral valve area from 1.1 +/- 0.3 to 1.9 +/- 0.7 cm2 (p < 0.0001), and a decrease in mean mitral gradient from 16 +/- 7 to 6 +/- 3 mm Hg (p < 0.0001). An optimal result of BMC (increase in valve area > or = 25% with a post-BMC valve area > or = 1.5 cm2) was obtained in 18 patients (67%). The results did not differ from those observed in the 86 patients of our entire series without prior surgical commissurotomy. Patients with an optimal result of BMC had a more recent surgical commissurotomy and lesser morphologic alterations of the mitral valve than did those with a nonoptimal result. Patients with echocardiographic scores < 10 had an 80% success rate of BMC; however, this rate decreased to 29% for those with scores > or = 10. One patient (4%) died from a cerebrovascular accident. Clinical follow-up at 1 year showed persistent clinical improvement in 89% of patients with an optimal result of BMC; 72% were in New York Heart Association class I and 17% in class II.(ABSTRACT TRUNCATED AT 250 WORDS)

Restenosis after successful percutaneous transluminal coronary angioplasty: the Montreal Heart Institute experience.

Repeat coronary angiography was performed within 6 months after successful percutaneous transluminal coronary angioplasty (PTCA) in 178 of our first 181 patients (98%). The remaining 3 patients were symptom free, had negative treadmill exercise test results and were considered not to have had restenosis. A second follow-up angiogram was performed in 107 patients (59%), including all patients with persistent or recurrent anginal symptoms, between 7 and 18 months after PTCA. Fifty-one of the 181 patients (28%) had restenosis on 51 of 205 successfully dilated segments (25%). The stenosis was greater than or equal to 70% in 49 of these 51 segments; it was 65% and 55%, respectively, in the 2 remaining patients. Restenosis was documented angiographically at a median time of 4.7 +/- 4 months. However, 47 patients (92%) had restenosis documented within 6 months, 2 between 7 and 12 months and 2 between 13 and 18 months after PTCA. Stepwise logistic regression analysis selected the following factors as independent predictors of restenosis after PTCA: variant angina, multivessel disease, severity of residual stenosis and less reduction in the diameter of the stenosis on the angiogram immediately after PTCA. Of these 4 factors, the degree of residual stenosis immediately after PTCA was by far the most significant. It is concluded that restenosis occurs in approximately 25% of patients, almost always within the first 6 months, after successful PTCA. The degree of residual stenosis after PTCA is the most important predictor of restenosis. Increased experience and improved instrumentation may eventually lead to less residual stenosis and better late results after PTCA.

Comparison of subgroups assigned to medical regimens used to suppress cardiac ischemia (the Asymptomatic Cardiac Ischemia Pilot [ACIP] Study).

This report focuses on the subset of 235 patients from the Asymptomatic Cardiac Ischemia Pilot (ACIP) study receiving randomly assigned medical therapy to treat angina and suppress ischemia detected on ambulatory electrocardiography: 121 patients received the sequence of atenolol and nifedipine, and 114 diltiazem and isosorbide dinitrate. After 12 weeks of therapy, the primary end point (absence of ambulatory electrocardiographic (ECG) ischemia and no clinical events) was reached in 47% of atenolol/nifedipine- versus 31% of diltiazem/isosorbide dinitrate-treated patients (adjusted p = 0.03). A trend to increased exercise time to ST depression was seen in the atenolol and nifedipine versus diltiazem and isosorbide dinitrate regimens (median treadmill duration 5.8 vs 4.8 minutes; p = 0.04). However, when adjusted for baseline imbalances in ambulatory ECG ischemia, the 2 medical combinations were similar in suppression of ambulatory ECG ischemia. In both medication regimens, an association between mean heart rate and ischemia on ambulatory electrocardiography after 12 weeks of treatment was observed so that patients on either regimen with a mean heart rate > 80 beats/min had ischemia detectable almost twice as often as those with a mean heart rate < 70 beats/min (p < 0.001).

The Carpentier-Edwards pericardial bioprosthesis: clinical experience with 600 patients.

Carpentier-Edwards pericardial bioprostheses were implanted in 600 patients: 416 aortic valve replacement, 115 mitral valve replacement, 6 isolated tricuspid, and 63 multiple valve replacements. The survival rates were 70% at 10 years after aortic valve replacement, 62% 8 years after mitral valve replacement, and 57% at 8 years with multiple valve replacement. Overall, 69 patients suffered one or more valve-related complications. The 10-year freedom rates from embolism were 91% (aortic valve replacement), 92% (mitral valve replacement), and 89% (multiple valve replacement), and those from endocarditis were 95%, 93%, and 85%, respectively. In 18 of the 35 patients, reoperation was due to primary valve dysfunction. Freedom from primary dysfunction was 87% at 10 years with aortic valve replacement, and at 8 years, it was 79% with mitral valve replacement and 77% with multiple valve replacement. A direct correlation was found between freedom from valve dysfunction and age of the patient at operation, with a 10-year-free rate of 90% among patients older than 59 years. This bioprosthesis has an excellent durability up to 10 years in the aortic position. More data regarding its long-term durability in the mitral position are needed. It is currently our valve substitute of choice when a bioprosthesis is indicated.

Porcine versus pericardial bioprostheses: a comparison of late results in 1,593 patients.

From 1976 to 1988, 1,593 patients underwent valve replacement with a porcine (878 patients) or a pericardial bioprosthesis (715 patients). There were 701 aortic, 678 mitral, and 214 multiple-valve replacements. Follow-up was obtained for 1,559 patients (98%). Early mortality was 9% (79 patients) in the porcine valve group and 5% (37 patients) among patients with a pericardial valve (p less than 0.01). Late survival after replacement with porcine valves was 80% +/- 1% and 62% +/- 3% at 5 and 10 years, respectively. With pericardial valves, 5-year survival was 79% +/- 2%. Among valve-related complications, rates of freedom from thromboembolism, endocarditis, and hemorrhage after 6 years were similar for both valve groups. Freedom from reoperation at 6 years was also similar after aortic (96% versus 91%) or multiple-valve replacement (95% versus 88%). However, for mitral valve replacement, freedom from reoperation was significantly better with porcine valves than with pericardial valves at 6 years (92% versus 68%; p less than 0.001). This difference was mainly due to the Ionescu-Shiley valve, which accounted for 83% of primary tissue failures among pericardial bioprostheses implanted in the mitral position (10/12 patients). After 6 years, freedom from primary tissue failure of mitral valves was 92% +/- 2% with porcine and 70% +/- 11% with pericardial bioprostheses (p less than 0.0001). The degree of clinical improvement among survivors was similar with both valve types. Thus, in the aortic position, pericardial valves compare with porcine valves up to 6 years, whereas in the mitral position, the durability of the former is significantly less, mainly because of the suboptimal performance of the Ionescu-Shiley pericardial bioprosthesis.

Lymphocyte subpopulation monitoring in cyclosporine-treated patients following heart transplantation.

Circulating lymphocyte subpopulations were studied in 18 consecutive patients treated with cyclosporine-prednisone immunosuppression during the first month following heart transplantation. Eleven patients showed no evidence of graft rejection. There were eight episodes of acute rejection demonstrated at endomyocardial biopsy in 7 patients. Three patients were treated with corticosteroids, 3 were treated with rabbit antithymocyte globulin (RATG), and 1 died before treatment (early mortality: 5.6%). Using the monoclonal antibody technique, 150 determinations of lymphocyte subpopulations were performed and were correlated with 72 endomyocardial biopsy specimens. Cyclosporine immunosuppression caused a significant (p less than 0.05) decrease in total lymphocyte count (38%) and in the number of OKT3 (52%) and OKT4 cells (55%). During acute rejection, total lymphocytes and OKT3, OKT4, and OKT8 cells all increased significantly, but the T4 to T8 ratio did not change significantly. Treatment of rejection with corticosteroids resulted in a moderate but not significant decrease in all T-cell types, whereas RATG caused a marked but not selective decrease in all T-cell groups. In conclusion, T cells decrease with cyclosporine immunosuppression and with treatment of rejection and increase at onset of rejection, but the T4 to T8 ratio has no predictive value for the diagnosis and severity of rejection, and the sensitivity of the method does not permit its use to assess the degree of immunosuppression with cyclosporine following heart transplantation.

Clinical and hemodynamic results with the Carpentier-Edwards porcine bioprosthesis.

Carpentier-Edwards bioprostheses were implanted in 605 patients, 509 of whom had a single valve replacement, and 96 of whom had a multiple valve replacement. There were 54 early deaths (8.9%) and 26 late deaths (4.3%). The five-year actuarial survival was 87% for aortic valve replacement, 83% for mitral valve replacement, and 81% for multiple valve replacement. Of the 525 survivors, all but 3 were followed for a total of 964 patient-years; 354 patients (68%) remained asymptomatic, and 95 patients (18%) were improved. The incidence of thromboembolism, endocarditis, and reoperation due to primary tissue failure of the bioprosthesis were 2.0, 1.3, and 0.1% per patient-year, respectively. The actuarial probability of being free of all valve-related complications was 93% after five years. Satisfactory hemodynamic performance of the bioprosthesis was demonstrated by postoperative studies done in 70 patients. Thus, the Carpentier-Edwards porcine valve provides good clinical improvement, with a low incidence of valve-related complications and tissue failure at five years postoperatively.

Experience with the 19-mm Carpentier-Edwards pericardial bioprosthesis in the elderly.

BACKGROUND: Valve replacement in small aortic root remains a surgical challenge. The objective of this study was to compare results of the 19-mm bioprosthesis with those of larger prostheses in the elderly. METHODS: The 443 patients, 70 years of age and older, who underwent aortic valve replacement with Carpentier-Edwards pericardial bioprostheses were reviewed. RESULTS: There were 93 patients with a mean age of 76+/-4 years with implantation of 19-mm prostheses and 350 patients with a mean age of 75+/-4 years with larger bioprostheses. Associated aortoplasty was performed in 10 patients (11%) with 19-mm bioprostheses and in 8 patients (2%) with larger bioprostheses (p = 0.001). There were 11 deaths (12%) within 30 days of surgery in patients with 19-mm prostheses and 22 deaths (6%) among those with larger prostheses (p = 0.1). The 7-year survival rate averaged 61%+/-7% in patients with 19-mm prostheses and 67%+/-4% in those with larger prostheses (p = 0.8). The 7-year freedom rates from all valve-related events averaged 96%+/-2% and 93%+/-2%, respectively (p = 0.6). CONCLUSIONS: Aortic valve replacement with the 19-mm Carpentier-Edwards pericardial bioprosthesis offers excellent midterm results in the elderly.

Aortic valve replacement with mechanical and biologic prosthesis in middle-aged patients.

BACKGROUND: Mechanical prostheses are used in young patients and bioprostheses in the elderly because of the higher rate of structural failure of bioprostheses. The objective of the present study was to compare results after aortic valve replacement with mechanical (Carbo-Medics) and biologic (Carpentier-Edwards pericardial) in middle-aged patients. METHODS: Five hundred twenty-one patients, aged between 55 and 65 years, who underwent aortic valve replacement with mechanical (n = 363) or biologic (n = 158) prostheses were reviewed. RESULTS: The 10-year actuarial survival rate averaged 66%+/-6% in patients implanted with mechanical valves compared with 75%+/-4% in patients implanted with biologic valves (p = 0.2). The 10-year freedom rate from thromboembolism, hemorrhage, and endocarditis averaged 92%+/-7%, 97%+/-2%, and 99%+/-1%, respectively, in patients with mechanical valves compared with 91%+/-3% (p = 0.03), 99%+/-1% (p = 0.4), and 95%+/-2% (p = 0.01), respectively, in those with biologic valves. The 10-year freedom rate from all valve-related complications averaged 90%+/-7% and 83%+/-4%, respectively (p = 0.01). CONCLUSIONS: The freedom rate from all valve-related complications was higher among patients with mechanical valves compared with biologic valves 10 years after aortic valve replacement in middle-aged patients.

Clinical relevance of the low correlations between Doppler and hemodynamic measurements before and after balloon mitral commissurotomy.

The aim of this study was to evaluate the clinical consequences of the poor correlations between Doppler and hemodynamic measurements before and after balloon mitral commissurotomy (BMC). From March 1987 to December 1991, 317 patients with symptomatic mitral stenosis were selected for BMC at the Montreal Heart Institute. Despite the low correlation coefficients between Doppler and hemodynamic measurements before BMC (transmitral gradient: r = 0.57, mitral valve area: r = 0.35, mitral regurgitation: r = 0.33), the positive predictive value of Doppler echocardiography to select patients for BMC was 96%. Hemodynamic success, defined as a final mitral valve area greater than 1.5 cm2 and an increase in mitral valve area of more than 25% was obtained in 204 (80%) of the 253 patients who completed the procedure without complications. Doppler and hemodynamic mitral valve area increase were poorly correlated (r = 0.2) but the sensitivity and specificity of Doppler in the diagnosis of hemodynamic success were 86% and 63% respectively. A prospective six month echocardiography and hemodynamic re-examination was performed in our 50 patients first treated by BMC. Hemodynamic restenosis, defined as a loss of more than 50% of the gain achieved in mitral valve area and a mitral valve area of less than 1.5cm2 were diagnosed in 12 (26%) of the 46 patients with initially successful BMC. Despite a low correlation between Doppler and hemodynamic mitral valve area measurements (r = 0.28), the sensitivity and specificity of echocardiography in the diagnosis of hemodynamic restenosis were 66% and 88% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Results following valve replacement for ischemic mitral regurgitation.

BACKGROUND: Although several authors have favoured mitral repair in ischemic mitral regurgitation (IMR), mitral valve replacement is a valuable option and most often a necessity in patients with structural IMR. OBJECTIVE: To review the authors' experience with valve replacement for patients with acute and chronic IMR. The effect of preserving the valve leaflets and the subvalvular apparatus during replacement was also evaluated. PATIENTS AND METHODS: The authors' experience with mitral valve replacement for IMR between 1990 and 1999 was retrospectively analyzed at the Montreal Heart Institute, Montreal, Quebec. Results obtained with mitral valve replacement due to degenerative disease were used for comparative purposes. RESULTS: Ninety-two patients with IMR and 213 patients with degenerative mitral regurgitation underwent valve replacement with mechanical prostheses (262 of 305 [86%]) or biological prostheses (43 of 305 [14%]). Fifteen patients (15 of 92 [16%]) died within 30 days of mitral valve replacement among IMR patients compared with eight (eight of 213 [4%)] among patients with degenerative mitral valve disease (P=0.01). The seven-year survival average following mitral valve replacement was 66+/-7% in patients with ischemic disease compared with 72+/-4% in patients with degenerative disease (P=0.07). Cardiopulmonary bypass time (odds ratio [OR] 1.01) and emergency operation (OR 2.5) were correlated with the 30-day mortality; the patient's age (OR 1.04) was the only risk factor correlated with the seven-year mortality after valve replacement. The five-year survival of patients with papillary muscle rupture averaged 59+/-12% compared with 78+/-7% in those with functional IMR. CONCLUSIONS: Preoperative risk factors and higher early mortality in patients with mitral valve replacement for ischemic disease contribute to a lower seven-year survival than with mitral valve surgery for degenerative disease. The short and long term survival of the patients in the acute structural mitral disease subgroup was significantly worse.

Influence of age on late results of valve replacement with porcine bioprostheses.

From 1976 to 1987, 877 patients, aged 13 to 80 years, underwent valve replacement with a Carpentier-Edwards porcine bioprosthesis--330 aortic, 421 mitral, and 126 multiple replacements. Patients were divided into 4 age groups, according to their age at the time of surgery: group I, less than 45 years (190 patients), group II, 45 to 54 years (203 patients), group III, 55 to 64 years (304), and group IV, 65 to 80 years (180 patients). Follow-up was 97.5 complete, averaged 85 months, and totalled 5624 patient-years. There were 79 early deaths (9%), and 181 late deaths. Overall survival was 80% and 64% at 5 and 10 years. Operative mortality increased significantly with age, and late survival was significantly better for group I. Intrinsic structural deterioration was the most common cause for reoperation and was responsible for 91% of the 143 reoperations. Incidence of intrinsic structural deterioration and of reoperation decreased significantly with increasing age, with respective freedom rates at 10 years of 57 and 54 in group I compared to 93 and 92% in group IV. Freedom from treatment failure (including early deaths, valve-related deaths, and valve-related complications with permanent disability) was similar for all 4 groups ranging from 78 to 85%, without any correlation with age of the patient. At last follow-up, a similar proportion of patients of each group remained asymptomatic, patients in functional class I ranging from 50 to 55%. Thus, age is a major determinant of durability of bioprostheses, but it does not appear to have a significant role in the overall success of valve replacement.

Infective endocarditis update experience from a heart hospital.

In a retrospective study of 50 patients with infective endocarditis (IE), we found an overall mortality of 44%: among the 26 patients with natural valves (NV) the mortality was 19%; among the 24 with prosthetic valves (PV) it was 71%. Congenital heart disease was recognized in 17 of our cases, with a significant clustering in the NV group (50% vs 17%, p = 0.029); the most frequently encountered malformation was the bicuspid aortic valve. The incidence of rheumatic heart disease was 46% in the NV group and 83% in the PV group (p = 0.015). Manifestations of IE were protean and multisystemic. We calculated an average of 4.6 symptoms and 4.7 signs for each patient. Although sepsis was abated with appropriate antibiotics, death often ensued from multiple complications: congestive heart failure, arrhythmia, stroke, embolic myocardial infarction, valvular destruction or dehiscence, coagulopathy. New features of natural valve infective endocarditis are a rising incidence in the elderly and a survival rate seemingly at its peak. Features of prosthetic valve infective endocarditis include overwhelmingly frequent embolization to the central nervous system (p = 0.004), spleen (p = 0.009) and kidney (p = 0.010). Advances in therapy for this disease may come from early surgery in late prosthetic valve endocarditis and from future prospective studies to define how the host response influences the outcome.

[Percutaneous mitral valvuloplasty. An analysis of the immediate results]. / Valvuloplastia mitral percutánea. Análisis de los resultados inmediatos.

Percutaneous mitral valvuloplasty (PMV) was performed by the anterograde transseptal approach in 113 patients with symptomatic mitral stenosis. Mean age was 53 +/- 14 years and 89% were female. PMV resulted in a marked decrease in mitral gradient from 16 +/- 5 to 6 +/- 3 mmHg (p less than 0.0001) and a significant increase in mitral valve area from 1.09 +/- 0.36 to 2.12 +/- 0.83 cm2 (p less than 0.0001). An optimal hemodynamic result (gain in valve area greater than or equal to 25% and post-PMV valve area greater than or equal to 1.5 cm2) was obtained in 82 patients (73%). Multivariate statistical analysis selected as independent predictors of an optimal result: normal cardiac index (p = 0.0001), NYHA functional class less than 3 (p = 0.002), smaller left atrial diameter (p = 0.005), and echocardiographic score less than or equal to 8 (p = 0.01). The lowest frequency of optimal results was observed in patients with echocardiographic scores greater than or equal to 11 (20%). Three patients died (2.6%). All deaths occurred among the first 34 patients and none in the last 79 (p less than 0.05). Morbidity was also influenced by a learning curve effect. Mitral regurgitation developed or increased in severity in 38% of patients. This increase was mild (1 degree) in 85% of cases. Although the incidence of atrial shunting was high (76% by indicator dilution curve and 33% by oximetry), their magnitude was usually small (mean Qp/Qs 1.23 +/- 0.23) and lacked clinical significance. In conclusion, PMV provides excellent immediate hemodynamic results with low mortality and morbidity risks, specially once experience has been gained with this technique. Patients with echocardiographic scores less than or equal to 8 and smaller left atrial diameters, usually younger and less symptomatic, are the best candidates for PMV.

[Coronary artery-right ventricular fistula in a patient with heart transplantation. A complication of endomyocardial biopsy]. / Fistules coronaro-ventriculaires droites chez le transplanté cardiaque. Une complication de la biopsie endomyocardique.

Two cases of coronary artery right ventricular fistula were diagnosed during the yearly check-up of 38 of the 66 cardiac transplant patients of the Montreal Heart Institute between September 1982 and April 1989. In one case, the fistula involved the right anterior ventricular branch of the right coronary artery and in the other case, a septal branch of the left anterior descending artery. Histological examination of the biopsy fragments obtained before diagnosis of the fistula showed the presence of small calibre arteries, which was not the case in 10 control transplant patients. A review of the literature indicates that the risks of endomyocardial biopsy are minimal (less than or equal to 0.5%). However, the possibility of a coronary artery right ventricular fistula should be added to the list of known complications. The resulting shunt is negligible and has no haemodynamic consequences.