Association of peripheral neuropathy with circulating advanced glycation end products, soluble receptor for advanced glycation end products and other risk factors in patients with type 2 diabetes.

BACKGROUND: The pathogenesis of diabetic peripheral neuropathy remains uncertain and nonenzymatic glycoxidation is one of the contributing mechanisms. The aim of this study was to assess the respective relationship of diabetic peripheral neuropathy with glycoxidation, compared with other identified risk factors, in patients with type 2 diabetes. METHODS: We included 198 patients with type 2 diabetes and high risk for vascular complications. Circulating concentrations of three advanced glycation end products (carboxymethyllysine, methyl-glyoxal-hydroimidazolone-1, pentosidine) and of their soluble receptor (sRAGE) were measured. Peripheral neuropathy was assessed by the neuropathy disability score and by the monofilament test and defined as either an abnormal monofilament test and/or a neuropathy disability score ≥6. Multivariate regression analyses were performed adjusting for potential confounding factors for neuropathy: age, gender, diabetes duration, current smoking, systolic blood pressure, waist circumference, height, peripheral arterial occlusive disease, glycated haemoglobin, estimated glomerular filtration rate and lipid profile. RESULTS: Prevalence of peripheral neuropathy was 20.7%. sRAGE and carboxymethyllysine were independently and positively associated with the presence of peripheral neuropathy. No significant association was found between peripheral neuropathy and methyl-glyoxal-hydroimidazolone-1 or pentosidine. Waist circumference, height and peripheral arterial occlusive disease were independently associated with peripheral neuropathy. CONCLUSIONS: Carboxymethyllysine and sRAGE were independently associated with peripheral neuropathy in patients with type 2 diabetes. Although the conclusions are limited by the absence of a healthy control population, this study confirms the relationship between advanced glycoxidation and diabetic peripheral neuropathy, independently of other risk factors.

Influence of peripheral vascular calcification on efficiency of screening tests for peripheral arterial occlusive disease in diabetes--a cross-sectional study.

AIMS: Pulse palpation and ankle brachial index are recommended to screen for peripheral arterial occlusive disease in people with diabetes. However, vascular calcification can be associated with false negative tests (arteriopathy present despite normal screening tests). We therefore studied the impact of peripheral vascular calcification on the performance of these tests. METHODS: This cross-sectional study included 200 people with diabetes at high risk of cardiovascular disease. The main exclusion factor was an estimated glomerular filtration rate < 30 ml/min. Peripheral arterial occlusive disease was diagnosed by colour duplex ultrasonography and peripheral vascular calcification scored by computed tomography scan. We measured sensitivity, specificity, predictive values, accuracy and likelihood ratios of pulse palpation and ankle brachial index, and looked for the impact of calcification on false negative tests (arteriopathy present despite normal screening tests). RESULTS: Ankle brachial index alone had poor sensitivity and negative predictive value and high negative likelihood ratio. Pulse palpation had higher sensitivity and negative predictive value. An abnormal pulse palpation, defined by weak or missing pulses, combined with an abnormal ankle brachial index, had the highest sensitivity and negative predictive value (92.3 and 89.8%, respectively). Vascular calcification score was higher in patients with false negative tests, for both pulse palpation and ankle brachial index (P < 0.0001 for all). Ankle systolic blood pressure was higher in patients with false negative tests for pulse palpation (P = 0.004). CONCLUSIONS: Below-knee vascular calcification gave a high rate of false negative results for ankle brachial index. Refined pulse palpation combined with ankle brachial index remained the best strategy to screen for peripheral arteriopathy.

[Prevalence and severity of erectile dysfunction in a population with coronary insufficiency: monocentric study]. / Prévalence et sévérité de la dysfonction érectile dans une population d'insuffisants coronariens : étude monocentrique.

PURPOSE: To study prevalence and severity of erectile dysfunction (ED) in a population of men treated in emergency for a coronaropathy. MATERIAL: The files of 200 patients who underwent a coronarography in urgency before the 1st of January 2007 were reviewed retrospectively. The following data were collated: epidemiological data and detailed breakdown of affected coronary arteries. The following patients were excluded from the current study: age over 65, past history of prostate surgery or pelvic external beam radiation therapy. The international index of erectile function (IIEF-5) questionnaire was sent by regular mail. Patients were classified according to the severity of ED: "no ED" between 21 and 25 inclusive, "mild ED" less than 21, "moderate ED" less than 17 and "strong ED" less than 10. RESULTS: Overall, 78 patients were included with a median age of 58 years. Prevalence of DE was 0.82 and median length of evolution was 9 months before coronary syndrome. Forty-nine patients (62.8%) had an ED classified between moderate and strong. ED was significantly associated with the group of patients smoking more than 20 cigarettes a day for at least 10 years (N = 44; P = 0.01) and with the group of patients older than 60 years (N = 38; P = 0.02). There was an association between the severity of the coronary disease and an ED classified between moderate and strong (P = 0.03). CONCLUSION: This study corroborates the existence of a strong link between ED and coronary disease, notably in patients under 65 years of age. In addition, it seems that the severity of ED is directly related with the anatomical severity of coronary disease.

Late results of percutaneous mitral commissurotomy in a series of 1024 patients. Analysis of late clinical deterioration: frequency, anatomic findings, and predictive factors.

BACKGROUND: The optimal use of percutaneous mitral commissurotomy (PMC) in a wide range of patients requires accurate evaluation of late results and identification of their predictors. METHODS AND RESULTS: Late results of PMC were assessed in 1024 patients whose mean age was 49+/-14 years. Echocardiography showed that 141 patients (14%) had pliable valves and mild subvalvular disease, 569 (55%) had extensive subvalvular disease, and 314 (31%) had calcified valves. A single balloon was used in 26 patients, a double balloon in 390, and the Inoue Balloon in 608. Good immediate results were defined as valve area >/=1.5 cm2 without regurgitation >2/4 (Sellers' grade) and were obtained in 912 patients. Median duration of follow-up was 49 months. The 10-year actuarial rate of good functional results (survival with no cardiovascular death and no need for surgery or repeat dilatation and in New York Heart Association [NYHA] class I or II) was 56+/-4% in the entire population. Follow-up echocardiography was available in 90% of the patients who experienced poor functional results after good immediate results and showed restenosis in 97% of these. In multivariate analysis, the predictors of poor functional results were old age (P=0.0008), unfavorable valve anatomy (P=0.003), high NYHA class (P<0.0001), atrial fibrillation (P<0.0001), low valve area after PMC (P=0.001), high gradient after PMC (P<0.0001), and grade 2 mitral regurgitation after PMC (P=0.04). CONCLUSIONS: PMC can be performed with good late results in a variety of patient subsets. Prediction of late events is multifactorial. Knowledge of these predictors can improve patient selection and follow-up.

Functional results 5 years after successful percutaneous mitral commissurotomy in a series of 528 patients and analysis of predictive factors.

OBJECTIVES: This study sought to assess late functional results after successful percutaneous mitral commissurotomy and to determine their predictors. BACKGROUND: Few studies have reported late results of percutaneous mitral commissurotomy or have analyzed their late results regardless of immediate results, despite the fact that late deterioration may well be related either to a decrease in valve area or to poor initial results. METHODS: Between 1986 and 1992, 528 patients underwent successful percutaneous mitral commissurotomy (mean [+/- SD] age 46 +/- 18 years; mean follow-up 32 +/- 18 months). A successful procedure was defined by a mitral valve area > or = 1.5 cm2 and no regurgitation > 2/4. Dilation was performed using a single balloon in 13 patients, a double balloon in 349 and the Inoue balloon in 166. Multivariate analysis was performed with a Cox model. RESULTS: The survival rate for patients in New York Heart Association functional class I or II, with no cardiac-related deaths or need for mitral surgery or repeat dilation, was 76 +/- 6% at 5 years. By multivariate analysis, the independent predictors of good functional results were echocardiographic group (p = 0.01), functional class (p = 0.02) and cardiothoracic index (p = 0.005) before the procedure and valve area after the procedure (p = 0.007). The predictive model derived allowed estimation of the probability of good functional results according to the value of these four predictors for any given patient. CONCLUSIONS: Good functional results were observed 5 years after successful percutaneous mitral commissurotomy in a large series of varied patients. The analysis of predictive factors may provide useful indications for follow-up results in patients undergoing this technique.

Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy: late efficacy and implications for patient selection.

OBJECTIVES: The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy. BACKGROUND: Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy. METHODS: We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 +/- 8 years after surgical commissurotomy. Mean age was 47 +/- 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121. RESULTS: Complications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area > or =1.5 cm2 without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p < 0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 +/- 5%, and 58 +/- 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p < 0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p < 0.0001) in a multivariate Cox model. CONCLUSIONS: Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

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.

Acute and delayed hormonal changes in mitral stenosis treated by balloon valvulotomy.

The role of left atrial and aortic pressures on the secretion of the main hormones controlling blood volume is still subject to debate in humans. Because of increased mean left atrial pressure and decreased mean aortic pressure produced by balloon inflation in patients with mitral stenosis treated with balloon valvulotomy, the hormonal changes occurring acutely (group II of patients) were measured. The same studies (group I patients) were also performed 48 hours after this treatment, a period at which left atrial pressure permanently diminished. Inflation of the balloon resulted in a decrease in plasma renin activity and increases in plasma atrial natriuretic factor (ANF) and plasma arginine vasopressin (AVP). Forty-eight hours after balloon valvulotomy, which had produced a decrease in left atrial pressure, plasma ANF was lower (58.9 +/- 7.9 vs 95.3 +/- 11.9 pg/ml; p < 0.001), and plasma renin activity (2,575 +/- 533 vs 960 +/- 113 pg/ml/hour; p < 0.01), plasma angiotensin II (25.0 +/- 4.1 vs 9.3 +/- 1.3 pg/ml; p < 0.001) and plasma aldosterone (181.7 +/- 36.7 vs 139.9 +/- 19.8 pg/ml; p < 0.05) were higher than their respective control levels 24 hours before treatment of the stenosis. In contrast, plasma AVP (3.7 +/- 0.25 vs 4.4 +/- 0.31 pg/ml; p = 0.001) diminished moderately along with plasma osmolality (282.4 +/- 0.1 vs 286.2 +/- 0.6 mOsm/kg; p < 0.001). Urinary sodium excretion was also examined before and after balloon valvulotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Late results of percutaneous mitral commissurotomy for calcific mitral stenosis.

The aim of this study was to assess late results of percutaneous mitral commissurotomy (PMC) in calcific mitral stenosis and to identify predictors to improve patient selection. We analyzed 422 patients who underwent PMC for calcific mitral stenosis. The extent of calcium was graded from 1 to 4 by fluoroscopy: 227 patients (53%) were graded 1, 125 (30%) graded 2, 55 graded 3 (13%), and 15 graded 4 (4%). The procedure failed in 15 patients, used a single balloon in 11, a double balloon in 126, and the Inoue balloon in 270. In-hospital mortality was 1.2%. Good immediate results (valve area >/=1.5 cm(2) without mitral regurgitation >2/4), were obtained in 321 patients (76%). Multivariate analysis identified 5 predictors of good immediate results: a younger age (p = 0.0004), a lesser degree of stenosis (p = 0.0005), a smaller extent of calcium (p = 0.04), the use of the Inoue balloon (p = 0.015), and a larger effective balloon dilating area (p = 0.006). Good functional results, defined as survival with no further intervention and in New York Heart Association class I or II, were 36 +/- 4% at 8 years. The predictors of good functional results after good immediate results were a younger age (p = 0.04), a lower pre-PMC New York Heart Association class (p <0.0001), sinus rhythm (p = 0.0006), a smaller extent of calcium (p = 0.02), and a lower gradient after PMC (p <0.0001). Despite a frequent deterioration on follow-up after PMC for calcific mitral stenosis, the predictive analysis suggests that PMC may be useful in deferring surgery in selected patients with mild to moderate calcific deposits, who have otherwise favorable characteristics.

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)

Ventricular arrhythmias in aortic valve disease before and after surgery.

In order to evaluate the incidence and prognostic value of ventricular arrhythmias in patients with aortic valve disease, 24 hour ambulatory electrocardiographic recordings were obtained in 374 patients without coronary artery disease (aortic stenosis n = 194, aortic regurgitation n = 103, combined aortic stenosis and regurgitation n = 77). Following aortic valve replacement, repeat recordings were obtained in a subgroup of 96 patients at 13 +/- 4 days and 18 +/- 7 months. Ventricular arrhythmias were classified in all cases according to Lown and were compared with clinical, echocardiographic and hemodynamic data. Preoperatively, ventricular premature beats were observed in 329 patients (88%), and were found to be frequent (>30 ventricular premature beats/hour) in 83 (22%). Multiformity was found in 105 (28%), couplets in 75 (20%) and ventricular tachycardia in 45 (12%). The occurrence of ventricular arrhythmias was not related to the type or severity of the valve lesions. Patients with severe ventricular arrhythmias (Lown class 3 or 4: 36.5%) had a higher ventricular wall thickness (interventricular septum thickness 14.2 +/- 1.8 mm vs. 11.9 +/- 2.0 mm, p < 0.01, a higher LV mass (178 +/- 32 g/m2 vs. 142 +/- 35 g/m2, p < 0.001) and a lower left ventricular ejection fraction (48% +/- 9% vs. 56.5% +/- 10%, p < 0.001); while in patients with aortic regurgitation a higher end-diastolic LV volume (224 +/- 38 ml/m2 vs. 178 +/- 42 ml/m2, p < 0.02) and a higher end-systolic LV diameter (56 +/- 7 mm vs. 46 +/- 8 mm, p < 0.02) were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of left ventricular systolic function on long term survival in mitral and aortic regurgitation.

To identify the predictive factors of left ventricular dysfunction (LVD) after surgery, we performed an uni- and multivariate analysis of the data concerning 286 patients operated for pure aortic regurgitation between 1980 and 1994 and 460 patients operated for pure non-ischemic mitral regurgitation over a period of 24 years. Among the aortic regurgitation patients, 28 developed left ventricular dysfunction not attributable to residual aortic valve dysfunction, another valvular lesion or hypertensive or ischemic heart disease. By univariate analysis identified predictive factors of LVD were duration of symptoms prior to surgery, duration of the history of diastolic murmur, NYHA class, cardiothoracic ratio, LV echographic diameters, fractional shortening of short axis, LV end-systolic volume and LV ejection fraction. Multivariate analysis identified three independent predictors: NYHA functional class, LV end-systolic diameter and LV ejection fraction. Of 428 operative survivors with non-ischemic mitral regurgitation 63 developed severe LVD. Univariate analysis identified functional class III or IV, duration of symptoms prior to surgery, atrial fibrillation, echo LV and LA diameters, angio LV volumes, LV ejection fraction, cardiac index and type of surgery as independent predictors of LVD. Multivariate analysis showed that type of surgery, LV ejection fraction, LV end-diastolic and end-systolic volume and echo LV end-systolic diameter were all independent predictors of LVD.

Small abnormal echos after mitral valve replacement with bileaflet mechanical prostheses: predisposing factors and effect on thromboembolism.

Early transesophageal echocardiography (TEE) after mitral valve replacement can detect symptomless, non-obstructive thrombus on prosthetic valves and also small filamentous abnormal echoes (SAE). The object of this study is to evaluate their respective frequency and predisposing factors. Between October 1988 and June 1992, 129 consecutive patients underwent mitral valve replacement with a bileaflet prosthesis and had transesophageal echocardiography at an average of 15 +/- 7 days (range: 6-35 days) after surgery. Details of postoperative anticoagulation were analyzed in 99 patients from five surgical centers having comparable postoperative anticoagulation protocols. Among those patients presenting with SAE, 76% had a second transesophageal echocardiography at an average of 145 +/- 166 days after the first examination. Mean age was 56 +/- 13 years. Small filamentous echoes were found in 55 patients (43%). In univariate analysis, independent predictors were age, absence of systolic regurgitation across the mitral prosthesis as observed with continuous Doppler, and the presence of spontaneous echo contrast (SC) in the left atrium: 54 +/- 14 years in the absence vs. 59 +/- 10 in the presence of SAE (p < 0.05); 54% of systolic leak vs. 36% (p < 0.05); 43% of SC vs. 75% (p < 0.00001). In multivariate analysis, spontaneous echo contrast was the only independent predictor for SAE (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognosis of valve replacement for aortic stenosis with or without coexisting coronary heart disease: a comparative study.

Between January 1978 and June 1992, 798 patients underwent isolated AVR for hemodynamically significant calcific aortic stenosis. Preoperative coronary angiography was performed in 687 patients, of whom 229 had coronary stenosis > 40% and were divided into three (I, IIa and IIb) groups. Group I consisted of 144 patients undergoing AVR plus coronary artery bypass grafts (CABG); 39 patients in Group IIa had AVR only in the presence of coronary stenoses < 60%, and 46 patients in Group IIb had AVR only in the presence of coronary stenoses > 60%. Group III consisted of 144 matched patients selected from the remaining 458 patients with no coronary disease, or stenoses less than 40%, according to five matching criteria (age, sex, functional status, ejection fraction and year of surgery) with patients in Group I. Early mortality was 10.4% in Group I, 7.7% in Group IIa, 13% in Group IIb and 4.9% in Group III. Although the differences in operative mortality are apparent, they did not reach statistical significance. A difference in long term survival could only be detected between Groups I and III (actuarial survival at nine years 66% and 78.9%, respectively, p < 0.01). Similarly, late coronary events were more frequent in Group I than in Group III (13.9% vs. 5.1%, p < 0.03). It is concluded that revascularization should be as complete as possible for severe coronary stenoses coexisting with significant calcific aortic stenosis. However, bypassing of moderate coronary lesions (stenoses in the order of 50%) in association with AVR does not appear justified on current evidence. Further studies on this important aspect are clearly required.

How to manage patients with severe left ventricular dysfunction and valvular regurgitation.

BACKGROUND AND AIMS OF THE STUDY: The purpose of this study is to analyze treatment options for valvular regurgitation with severe left ventricular dysfunction. MATERIAL AND METHODS: Results of valvular surgery in 98 patients with mitral or aortic regurgitation and severe systolic left ventricular dysfunction (LVD) were analyzed. Selection criteria were the absence of significant coronary heart disease and a resting ejection fraction (EF) < 40% for aortic and < 50% for mitral regurgitation. RESULTS: In patients with aortic regurgitation (n = 46) operative mortality was higher but not significantly so than in a control group of 238 cases (6.5% vs. 3.4%). The actuarial survival rates at five and 10 years were 84% and 55% vs. 84% and 67%, respectively. Independent preoperative predictors of severe postoperative LVD were rheumatic etiology and increased left ventricular end-systolic diameter. In patients with mitral regurgitation (n = 52), operative mortality was not significantly different from that of a control group of 273 cases (3.8% vs. 2.6%), whether the surgical procedure was valve replacement or valve repair. Perioperative morbidity was frequent (30% of cases), mainly low cardiac output, after valve replacement. The actuarial survival rates at eight years were respectively for the groups with and without LVD: 81% and 89% after valve repair, 60% and 75% after valve replacement. Independent predictors of severe postoperative LVD were increased left ventricular end-systolic volume and the type of surgery. Better results were observed after valve repair. CONCLUSIONS: It is concluded that a low EF is not a predictive factor of operative mortality but it influences late survival as do the degree of left ventricular dilatation, etiology in aortic and type of surgery in mitral regurgitation. Alternatives to valvular surgery have been envisaged but information on vasodilators in these patients is scant and results of heart transplantation are known only from a few small series.

Features of patients with severe mitral stenosis with respect to atrial rhythm. Atrial fibrillation in predominant and tight mitral stenosis.

The aim of this study was to assess the features of patients with severe mitral stenosis in relation to atrial rhythm. Six hundred and fifty patients (pts) with severe mitral stenosis (MS) (valve area less than or equal to 1.5 cm2) who underwent percutaneous balloon commissurotomy (n = 600) or surgery (n = 50) were classified into 3 groups according to their atrial rhythm (AR): group A: sinus rhythm (SR) (n = 379), group B: SR with episodes of transient atrial fibrillation (AF) (n = 65), group C: permanent AF (n = 206). Uni- and multivariate analysis of clinical, echocardiographic and hemodynamic parameters with respect to the atrial rhythm was performed. Some parameters were comparable in all 3 groups: sex, pulmonary, right and left atrial pressures, mitral valve area, incidence of associated aortic valve disease. Nine parameters were different: mean age, NYHA class III or IV, previous commissurotomy, previous embolism, cardiac index, mitral regurgitation, tricuspid regurgitation, left atrium diameter, mitral calcification. Multivariate analysis, identified age, left atrial diameter and presence of mitral calcification as independent predictors of atrial fibrillation. Transoesophageal echocardiography was performed in 167 cases. A spontaneous echo contrast was recorded in 106 cases (63.5%) and was significantly correlated with a history of embolism and or left atrial thrombi detected by echocardiography. Atrial fibrillation, size of left atrium, severity of mitral stenosis and cardiac index were found to be independent predictive factors of spontaneous echo contrast.

Ventricular arrhythmias in aortic valve disease before and after aortic valve replacement.

In order to evaluate the effect of aortic valve replacement on the incidence of ventricular arrhythmias in patients with aortic valve disease, 24-hour ambulatory electrocardiographic recordings were obtained before surgery in 96 patients without coronary artery disease (aortic stenosis n = 50, combined aortic stenosis and regurgitation n = 19 and aortic regurgitation n = 27). Following aortic valve replacement, repeat recordings were obtained after 13 +/- 4 days and 18 +/- 7 months. Ventricular arrhythmias were in all cases classified according to Lown and were compared with clinical, echocardiographic and hemodynamic data. Preoperatively, ventricular premature beats were observed in 85 patients (89%) and were frequent (greater than 30 ventricular premature beats/hour) in 20 (21%). Multiformity was found in 27 (28%), couplets in 18 (19%) and ventricular tachycardia in 11 (11.5%). The occurrence of ventricular arrhythmias was not related to the type or severity of valve lesions. Patients with severe ventricular arrhythmias (Lown class 3 or 4: 37%) had a greater thickness of their interventricular septum 13.9 +/- 2.5 mm, vs 11.7 +/- 2.6 (p less than 0.05); a higher LV mass 176 +/- 34 g/m2, vs 134 +/- 39 (p less than 0.05) and a lower left ventricular ejection fraction 47 +/- 12%, vs 57 +/- 11, (p less than 0.01). Two weeks postoperatively, the incidence and severity of ventricular arrhythmias had increased: ventricular premature beats were noted in 92% and were severe in 50%. No correlation was found between ventricular arrhythmias and preoperative or operative data. Eighteen months after surgery, ventricular premature beats were still observed in 81% of patients but remained frequent in 7% only. Severe ventricular arrhythmias were noted in 27%. Patients with severe ventricular arrhythmias had at the time of this late recording a lower radionuclide left ventricular ejection fraction 57 +/- 14%, vs 73 +/- 9 (p less than 0.02) and a higher enddiastolic diameter 63 +/- 15 mm, vs 48 +/- 7, (p less than 0.01). This study indicates that ventricular arrhythmias are common in patients with aortic valve disease. The severity of arrhythmias is influenced by the LV consequences of valve lesion both pre- and late postoperatively. The frequency and severity of ventricular arrhythmias increase early after surgery and do not correlate with preoperative or operative data.

[Surgery for bacterial endocarditis. When?]. / Chirurgie de l'endocardite bactérienne. Quand?

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)

[Risk of bacterial endocarditis and native heart diseases]. / Risque d'endocardite infectieuse et cardiopathies natives.

Although there are no epidemiological studies allowing precise evaluation of the risk of infective endocarditis in given cardiac pathologies, a review of the literature allows classification of different conditions in three groups of decreasing risk: 1: high risk group: cyanotic, congenital heart disease, patients with previous infective endocarditis, aortic valve disease, mitral regurgitation and unoperated left-to-right shunts apart from atrial septal defects; 2: moderate risk group: mitral valve prolapse with myxoid valves or a systolic murmur, mitral stenosis, tricuspid valve disease, pulmonary stenosis, hypertrophic obstructive cardiomyopathy; 3: low or negligible risk: isolated atrial septal defect, operated or unoperated (bypass graft) ischaemic heart disease, operated left-to-right shunts without residual shunt, mitral valve prolapse with normal valve thickness and without a murmur, mitral ring calcification without regurgitation.

[The best of 2001. Valve diseases]. / L'essentiel de 2001 en valvulopathies.

The publications in 2001 regarding valvulopathies have concerned all sectors of this pathology. Aortic valvulopathies are the object of new work supporting the relationship between aortic sclerosis or stenosis and cardiovascular risk factors. They confirm the analogy between lesions of inflammatory origin observed on calcified valves and atherosclerotic plaques (Mohlner). They find higher rates of serum lipids in the case of valvular replacement for stenosis than for aortic insufficiency albeit in an older population (Novaro). Monin shows the possibility of a better pre-operative prognostic approach for advanced aortic stenoses at low transvalvular gradient with left ventricular dysfunction, for which the post-operative results are better when low dose stress echocardiography has shown the existence of a contractile reserve. For the results of aortic surgery with biological prostheses it is widely reported that they behave as homografts (O'Brien), stented heterografts (Puvimanasinghe) or stent-less (Hubaut). A controversy exists on the subject of the degenerative mechanism of bioprostheses between the supporters of the immunological hypothesis (Human) and those of the purely degenerative hypothesis (Mitchell). This controversy is far from being insignificant because the infectious or other risks run by patients with bioprostheses are conceivable with the addition of an immuno-suppressant treatment. Among the mitral valvulopathies, insufficiencies with an ischaemic origin have a harmful effect on the long term prognosis even for medium leaks (Grignoni). As for the method of repairing these ischaemic leaks, consensus has not been reached between the proponents of exclusive revascularisation, plasty or replacement (Mickleborough, Otsuji). The quality of the very long term results for mitral plasty by Carpentier's technique for rheumatic mitral insufficiency (Chauvaud) or non-rheumatic (Braunberger, Mohty) is confirmed, especially for the latter. Its feasibility by a minimally invasive approach is reported (Schroeyers). Anticoagulation for prostheses remains one of the challenges for valvular surgery. The addition of a platelet anti-aggregant is not accepted by all, due to the increased haemorrhagic risk. A meta-analysis of 2,199 operations seems in favour of this addition if the dose is weak (Massel). It's a question of an attitude having become normal practice across the Atlantic, but not in Europe (Englberger).