Stress haemodynamics for asymptomatic mitral regurgitation: how much does it help?

Stress haemodynamics for asymptomatic mitral valve regurgitation may prove helpful in determining the optimal timing for surgery.

[Dobutamine hemodynamics for aortic stenosis with left ventricular dysfunction]. / Rôle de l'hémodynamique Doppler de stress dans la prise en charge des rétrécissements aortiques avec dysfonction ventriculaire gauche.

Patients with aortic stenosis (AS) and left ventricular (LV) systolic dysfunction have a poor short-term prognosis. In this setting, the decrease in transaortic gradients has an independent prognostic value for operative risk and long-term outcome. The 2 main issues for these patients are: (1) The real severity of AS; (2) How to stratify operative risk and evaluate long-term prognosis. Dobutamine Hemodynamics has the potential to address these issues. In case of relative AS, valve area is increased by dobutamine (final valve area > 1.2 cm2 with a mean pressure gradient <30 mmHg); on the basis of published data, medical treatment is justified in this case. Left ventricular contractile reserve is defined an increase in stroke volume, by 20% or more, under dobutamine. Operative risk is between 5 and 11% in case of LV contractile reserve and long-term outcome is improved by surgery in this case. In contrast, operative risk varies from 30 to 60% in case of exhausted reserve; this risk is also determined by other factors such as the presence of coronary artery disease and associated comorbidities. All these parameters are factored into risk-benefit analysis in order to determine the best therapeutic approach for each patient.

[Echocardiography in elderly patients]. / Echocardiographie du sujet âgé

IN THE CONTEXT OF AGEING: The Doppler echocardiography is a non-invasive technique that permits assessment of the "physiological" ageing of the cardiac and vascular structures, notably including a concentric remodelling of the left ventricle associated with relaxation abnormalities, dilatation of the left atrium, valvular reorganisation and a modification in the large vessels. IN A PATHOLOGICAL CONTEXT: The Doppler echocardiography also detects the various cardiovascular affections related to ageing: valvulopathies, notably calcified aortic stenosis and mitral failure due to mitral anulus calcification or prolapsus of the valve; primary hypertrophic cardiomyopathy or secondary to arterial hypertension or an amyloidosis, and possibly leading to heart failure with spared systolic function, frequent in elderly patients; ischemic cardiopathies that have benefited, as in younger patient, from new echographical stress testing techniques, which safely study the variability in myocardial ischemia. Transoesophageal echography can also be performed in elderly patients, but the indications of this more invasive and less well-tolerated examination must be assessed case by case. It is very useful when an intra-parietal aortic hematoma is suspected or during aortic dissection or infectious endocarditis.

[Localization of mitral valve prolapse zones with multiplane transesophageal echocardiography]. / Localisation des zones de prolapsus valvulaire mitral en échographie transoesophagienne multiplan.

CONTEXT: There are few literature data on the localization and extent of mitral valve prolapse zones with transesophageal echocardiography (TEE). AIM OF THE STUDY: To assess a standardized imaging technique for the localization and extent determination of prolapse zones, based on 3 easily reproducible views with multiplane TEE. METHODS: Seventy patients with severe mitral regurgitation due to valve prolapse requiring a multiplane TEE prior to surgery (valve repair or replacement) have been retrospectively assessed. Data of TEE on the localization and extent of prolapse zones have been confronted to per-operative anatomical observations (gold standard). RESULTS: The sensitivity of TEE for the identification of isolated P2 prolapse, prolapse with commisural extension, isolated rupture of the posterior commisure and bi-valvular prolapses were respectively at 96%, 88%, 86% and 80%. The corresponding specificities were from 98% to 100%. CONCLUSIONS: The use of a standardized technique with the use of 3 easily reproducible incidences with multiplane TEE allows a precise definition of the localization and extent of mitral valve prolapse zones, in order to potentially indicate valve repair.

[Calcified aortic stenosis with left ventricular dysfunction and low transvalvular gradients. Must one reject surgery in certain cases?]. / Rétrécissement aortique calcifié avec dysfonction ventriculaire gauche et faibles gradients transvalvulaires. Doit-on récuser la chirurgie dans certains cas?

The natural history of severe aortic stenosis (aortic valve area < 1 cm2 or < 0.6 cm2/m2) with left ventricular systolic dysfunction and low transvalvular gradients (mean gradient < 40 mmHg) is mediocre in the short term and the operative risk is high. Dobutamine echocardiography provides a reliable evaluation of the aortic obstacle by diagnosing the rare cases of relative aortic stenosis in which the valve surface area has been underestimated because of a low cardiac output (aortic surface area > 1.2 cm2 with a mean gradient < 30 mmHg with dobutamine): in this case, the limited available data suggests that medical therapy with strict follow-up of its efficacy is the best management. The other use of dobutamine echocardiography is to assess left ventricular contractile reserve, defined as a increase > or = 20% in stroke volume under dobutamine. Cases with a contractile reserve have an operative risk of 5 to 10% and the medium-term benefits of valve replacement have been demonstrated. In the absence of contractile reserve, the operative risk is much grater, 30 to 60%, and also depends on other parameters such as the mean basal transaortic pressure gradient (risk five times greater in cases with a mean gradient < 20 mmHg), the need for coronary bypass surgery and associated co-morbid conditions. The surgical contraindications are in fact relatively few and concern patients with several risk factors: absence of contractile reserve itself is not a definitive surgical contraindication.

Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low-dose dobutamine echocardiography.

OBJECTIVES: We sought to assess risk stratification by using dobutamine stress echocardiography (DSE) in patients with aortic stenosis (AS) and severe left ventricular (LV) dysfunction. BACKGROUND: Few data are available on risk stratification for valve replacement in patients with AS, LV dysfunction and low transvalvular gradients. METHODS: Low-dose DSE was performed in 45 patients (16 women and 29 men; median [quartile range] age in years: 75 [69 to 79]; left ventricular ejection fraction: 0.29 [0.23 to 0.32]; aortic valve area [cm2]: 0.7 [0.5 to 0.8]; mean transaortic gradient [mm Hg]: 26 [21 to 33]). Patients were classified into two groups: group I (n = 32, LV contractile reserve on DSE) and group II (n = 13, no contractile reserve). Valve replacement was performed in 24 and 6 patients in groups I and II, respectively. RESULTS: Perioperative mortality was 8% in group I and 50% in group II (p = 0.014). Survival at five years after the operation was 88% in group I. Compared with medical therapy, valve surgery was associated with better long-term survival in group I (hazard ratio for death [HR-D] 0.13, 95% confidence interval [CI] 0.002 to 0.49) and reduced survival in group II (HR-D 19.6, 95% CI 2.7 to 142). The effect of valve surgery on survival remained significant in both groups after adjustment for age, diabetes, respiratory disease and hypertension. Medical therapy had the same effect in both groups. CONCLUSIONS: In patients with AS, LV dysfunction and low transvalvular gradients, contractile reserve on DSE is associated with a low operative risk and good long-term prognosis after valve surgery. In contrast, operative mortality remains high in the absence of contractile reserve.

Prediction of functional recovery of viable myocardium after delayed revascularization in postinfarction patients: accuracy of dobutamine stress echocardiography and influence of long-term vessel patency.

OBJECTIVES: We sought to evaluate dobutamine stress echocardiography (DSE) for predicting recovery of viable myocardium after revascularization with cineangiography as a gold standard for left ventricular (LV) function. We studied the influence of late vessel reocclusion on regional LV function. BACKGROUND: Dobutamine stress echocardiography is a well established evaluation method for myocardial viability assessment. In previous studies the reference method for assessing LV recovery was echocardiography, long-term vessel patency has not been systematically addressed. METHODS: Sixty-eight patients with a first acute myocardial infarction (AMI) and residual stenosis of the infarct related artery (IRA) underwent DSE (mean +/- standard deviation) 21 +/- 12 days after AMI to evaluate myocardial viability. Revascularization of the IRA was performed in 54 patients by angioplasty (n = 43) or bypass grafting (n = 11). Coronary angiography and LV cineangiography were repeated at four months to assess LV function and IRA patency. RESULTS: Sensitivity and specificity of DSE for predicting myocardial recovery after revascularization were 83% and 82%. In the case of late IRA patency, specificity increased to 95%, whereas sensitivity remained unchanged. In the 16 patients with myocardial viability and late IRA patency, echocardiographic wall motion score index decreased after revascularization from 1.83 +/- 0.15 to 1.36 +/- 0.17 (p = 0.0001), and left ventricular ejection fraction (LVEF) increased from 0.52 +/- 0.06 to 0.57 +/- 0.06 (p = 0.0004), whereas in five patients, reocclusion of the IRA prevented improvement of segmental or global LV function despite initially viable myocardium. CONCLUSIONS: Dobutamine stress echocardiography is reliable to predict recovery of viable myocardium after revascularization in postinfarction patients. Late reocclusion of the IRA may prevent LV recovery and influence the accuracy of DSE.

[Left coronaro-ventricular fistula after septal myectomy]. / Fistule coronaro-ventriculaire gauche après myectomie septale.

The authors report the case of a 17 year old patient operated for valvular aortic stenosis associated with severe hypertrophy of the interventricular septum. The operation consisted of aortic valve replacement and septal myectomy. Color-flow imaging in the postoperative period showed a coronary artery--left ventricular fistula in the region of the septal myectomy. In view of the small size of the fistula on echocardiographic examination and the absence of a codified strategy of management of acquired coronary left ventricular fistula after surgery, a simple Doppler echocardiographic follow-up was proposed in this case.

[Nosocomial pneumonia following surgery of esophageal tumors (apropos of 50 cases)]. / Pneumonies nosocomiales après chirurgie pour tumeur de l'oesophage (à propos de 50 cas).

Esophagus cancer surgery often becomes complicated with fistulas and above all with infections. In 50 cases, the authors relate 7 fistulas and 60 nosocomial infections among which pneumonia takes the first place. The pneumonia diagnosis has been established on the criteria of the "National Nosocomial Infection Study" and on bacteriologic samples. Those mostly isolate Gram-bacilli and streptococci. The diagnosis and etiologic factors leading to prophylactic measures are studied.