[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.

Long-term clinical and hemodynamic results of molsidomine treatment in patients with refractory heart failure.

In this report we describe the clinical and hemodynamic response of refractory cardiac failure to molsidomine. In the first part of the study the hemodynamic effects of a single oral dose of 2 or 4 mg of molsidomine were compared with placebo control in 23 patients. In the second phase the dose 8 to 24 mg/24 hours was used in nine patients with functional class III or IV symptoms over an average period of 28 months (range 7 to 42 months); a hemodynamic control study was performed. These data demonstrate that molsidomine has a hemodynamic effect on pulmonary artery pressure for 5 to 6 hours, that the peak effect is reached between 1 and 1 1/2 hours after oral intake, and that the clinical and hemodynamic benefits of molsidomine may be maintained in the long term in patients with particularly severe cardiac failure. The conditions of seven patients were clinically improved with treatment; significant reductions in mean right atrial, pulmonary artery, and pulmonary capillary pressures were observed.

[Long-term clinical and hemodynamic results of the treatment of refractory cardiac failure with molsidomine]. / Résultats à long terme, cliniques et hémodynamiques, du traitement de l'insuffisance cardiaque réfractaire par la molsidomine.

Molsidomine, one of the sydnonimine group of drugs; the object of this study was to evaluate its efforts in refractory cardiac failure. In the first part of the study, the haemodynamic effects of a single oral dose of 2 or 4 mg of molsidomine were compared with placebo controls in 23 patients. This showed molsidomine to be an active venous vasodilator reducing pulmonary artery and right atrial pressures without changing cardiac index or systemic pressures. The peak effect was observed after 1 to 1,5 hours. In the second phase, molsidomine was used in 9 patients aged 32 to 71 years (mean 47 +/- 12 years) over an average period of 19 months (3,5 to 42 months). The maintenance dose varied from 8 to 24 mg/24 hours. These patients had refractory cardiac failure secondary to primary cardiomyopathy with dilatation (6 cases) or ischemic heart disease (3 cases). The 9 patients were in functional classes IV (5 cases) or III (4 cases). Four patients were theoretically good indications for transplantation. Haemodynamic control was performed 1,8 +/- 5 months after a washout period of 8 hours, and after initial right heart catheterisation, the measurements were repeated 1 hour after oral administration of a 4 mg dose of molsidomine. Two patients did not respond initially to molsidomine; one died, the other remained in functional Class III. Another patient who responded initially was improved for over two years but died in cardiac failure after 42 months' treatment. The other six patients have been significantly improved and were in functional Class II at their last control.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of correction by receiving gains in the determination of mitral valve surface area by two-dimensional echocardiography]. / Intérêt de la correction par les gains à la réception dans la détermination de la surface mitrale en échocardiographie bidimensionnelle.

Distorsion due to inappropriate gain settings interferes significantly with the measurement of mitral valve surface area by 2D echocardiography. The problem is general and applies equally to all makes of echocardiographs whether they are mechanical or phased array scanners. The measured mitral surface area may even be false if the level of the recording gain is disregarded. We established a graph of the global distorsion of a system comprising an Aloka SSD 800 phased array sector scanner and a Tektronics hard copy recorder using a "tissue-equivalent" model and only varying the level of gain. Using these results a computerised program for automatic correction of the mitral surface area, with respect to the gain level used, was developed. The program was validated on a series of 56 patients with mitral stenosis by comparison with the catheter results obtained with the Gorlin formula, peroperative and pathological findings on resected valves. With this echo system in the zone of gain settings studied there was a significant underestimation of the uncorrected surface area. After correction, the distinction between severe and moderate stenosis was better and an improved correlation with the anatomical surface area was obtained. It would therefore appear necessary to calibrate the system used taking both the echocardiography and the recorder into account. Despite certain limitations, we believe that distorsion curves could be established using "tissus-equivalent" models.

[Aneurysm of the membranous septum, left ventricular-right atrial communication and arrhythmias]. / Anévrisme du septum membraneux, communication VG-OD et troubles du rythme.

An aneurysm of the membranous part of the interventricular septum associated with a complex congenital malformation of the endocardial cushions was diagnosed in a 39 year old woman who presented with syncope. Diagnosis was made by echocardiography and confirmed by angiography. The operative findings were: a double aneurysm of the membranous septum, a left ventricular--right atrial fistula and two hemivalves attached to papillary muscles. The usfulness of echocardiography in the diagnosis of aneurysm of the membranous interventricular septum and in the follow up of ventricular septal defects from which they arise is emphasised. The pathogenesis of the arrhythmias observed (accelerated idioventricular rhythm, reciprocating tachycardias and syncope possibly related to transient heart block) is discussed.

[Radiological diagnosis of ventrycular aneurysms. A report on 36 operated cases (author's transl)]. / Diagnostic radiologique des anévrysmes ventriculaires. A propos d'une série de 36 patients opérés.

The value of different radiological examinations in the diagnosis of left ventricular aneurysms following infarcts is assessed using the results obtained in 36 operated cases. By correlating radiological and surgical findings the orientation value of standard examinations can be determined: almost constant cardiomegaly, irregularity of the borders of the heart, and more rarely, myocardial calcification, are significant signs. The two essential examinations are ventriculography and coronarography. Ventriculography can demonstrate anatomical abnormalities (protrusion), or dynamic changes only (hypokinesia, akinesia, systolic expansion). This remarkably reliable examination showed a predominance of anterior and anterolateral aneurisms (87% of cases), and enables definition of the critical cardiac surface area (about 25%) above which the aneurysm is operable. Coronarography shows that the anterior interventricular artery (A.I.V.) is affected in a large proportion (90%) of aneurysms. These two examinations can be used to select those patients suitable for surgery. Results were good and only one death occurred. In the other cases, the disorders of rhythm were reduced and the manifestations of cardiac insufficiency disappeared.

[Echocardiography in the diagnosis of mitral valve insufficiency due to valve mutilations or chordal ruptures. 41 cases with anatomical findings]. / Apport de l'échocardiographie dans les insuffisances mitrales par mutilations valvulaires ou ruptures de cordages. A propos de 41 cas avec corrélations anatomiques.

This study analyses the echocardiographic findings in 41 cases of severe mitral regurgitation due to chordal rupture (33 cases), elongation of chordae (4 cases) or valve trauma (4 cases). The operative findings are given. It was possible to make the diagnosis of chordal rupture in 60% of cases by recording one or more of the following signs:--For the anterior cusp: amplitude of motion equal to or greater than 38 mm; co-existence of chaotic diastolic fluttering and multiple systolic echoes; recording of several diastolic wave forms of the anterior cusp, out of phase and crossing each other;--For the posterior cusp: paradoxical movement of the cusp in systole and diastole; presence of an echo in the left atrium in systole. The group studied was compared with a group of 40 normal subjects and 48 cases of other types of mitral regurgitation which were severe and received surgery. The various signs had good specificity. The sensitivity of the different signs varied from 33 to 50% of cases. It was greater when the number of chordal ruptures was greater. Whichever cusp was affected, it was sometimes the site of high frequency and large amplitude systolic vibrations, which were found in a quarter of the patients. The specificity of this sign is discussed. The diagnosis of rupture of chordae is possible in a large proportion of cases and the causes of error are analysed.

[Contribution of echocardiography to the study of stenotic mitral valve diseases in adults]. / Apport de l'échocardiographie dans l'étude des valvulopathies mitrales sténosantes de l'adulte.

The "time motion" echocardiographic findings in 133 patients, with stenotic mitral valve defects were compared with the anatomical and haemodynamic findings. The information was derived either by monosound, or after a multiscan survey, selecting the lines in two perpendicular planes. A morphological analysis of VMA has allowed us to define a statistical profile according to the type of valve defect: a single diastolic slope in the pure uncalcified stenoses, 2 slopes with the first being more rapid than the second, in other mitral conditions. The cinetics of VMP were related to the presence of associated regurgitation and to the type of fusion. In cases with multiple diastolic slopes, the degree of stenosis was correlated only with the first slope, whilst the second was fairly closely related to the left ventricular end-diastolic pressure. The degree of valvular involvement can be predicted on the coexistence of a thick contour with multiple images, or in their absence on the diminution of amplitude of opening (less than 12 mm) and on the maximum speed of opening (less than 250 mm/s). By contrast, the sub-valvular lesions are underestimated whichever technique is used.

[Importance of echocardiography in aortic valve disorders]. / Intérêt de l'échocardiographie dans les valvulopathies aortiques

It would seem that, despite certain limitations, echocardiography may be considered to be an important method of investigation in the diagnosis and prognosis of aortic valve disease. Quantitative measurements may possible study of the progression of the lesions. Nevertheless, echocardiography only appears to be a simple technique and emphasis should be placed on the importance of a complete investigation as well as the quality of the recordings to be studied.