Relationship of myocardial morphometry in aortic valve regurgitation to myocardial function and post-operative results.

In 24 patients with aortic insufficiency undergoing aortic valve replacement, a clinical and hemodynamic study was performed pre-operatively. Left ventricular biopsies were obtained perioperatively for morphometric study. No significant relations were found when morphometric data were compared to functional class, cardiothoracic radio and ECG findings. The percentage of interstitial fibrosis was not correlated with any of the measured hemodynamic parameters. Myocardial cell diameter was weakly correlated with left ventricular systolic function parameters. A decrease in the percentage of contractile material was strongly correlated with an impaired left ventricular function, assessed pre-operatively. During clinical follow-up, patients were divided into two groups: Group A (17 patients) included patients who were in class I or II of NYHA after surgery. Group B (seven patients) included patients who died or were in functional class III or IV. As compared with Group A, Group B patients had a significantly lower ejection fraction; their myocardial cell diameter was larger and the percentage of myofibrils, and the content of contractile material were significantly lower. This suggests that, in aortic regurgitation, left ventricular dysfunction is correlated with contractile material loss and not with interstitial fibrosis, and that morphometric changes are good predictors of follow-up after surgery.

[Chronic aortic and mitral valve regurgitation. Effects of isosorbide dinitrate on systolic function and passive elastic properties of the left ventricle (author's transl)]. / Valvulopathies aortiques et mitrales évoluées. Effets du dinitrate d'isosorbide sur la fonction systolique et les propriétés élastiques passives du ventricule gauche.

A haemodynamic and cineangiographic study was conducted in 20 patients with chronic aortic regurgitation alone or associated with mitral regurgitation before and during i.v. administration of isosorbide dinitrate 5 mg/hour. Freedom from coronary disease had been ascertained. The heart rate and aortic pressure (initially normal), cardiac index (initially low), pulmonary pressures and pulmonary and systemic resistances (slightly raised initially) remained unchanged. On the other hand, the left ventricular (LV) filling pressure, distinctly raised before treatment, was reduced by 17% (p less than 0.05). There was also a 10% reduction in LV end-diastolic volume (from 204 +/- 60- cm3.m2 to 184 +/- 56 cm3,m2; p less than 0.001) and a 14% reduction in LV end-systolic volume (from 104 +/- 39 cm3.m2 to 89 +/- 40 cm3.m3; p less than 0.001). LV geometry, stroke volume and regurgitation volume were unmodified. There was a significant improvement in ventricular function indices, globally reduced before treatment: + 8% for the fiber shortening amplitude (p less than 0.025), + 6% for the ejection fraction (p fiber shortening (p less than 0.01), and + 15% for the ESP: ESV ratio (p less than 0.05). The passive elasticity indices, all increased before treatment, also improved. It is concluded that isosorbide dinitrate improves LV systolic and diastolic functions in patients with chronic valve disease.

Hemodynamic and cineangiographic study before and after mitral valvuloplasty (Carpentier's technique).

Hemodynamic studies were performed in 26 patients 2-60 months after mitral valvuloplasty (average 14 months). All patients but one had an annular deformity requiring prosthetic ring annuloplasty. In addition, 25 patients had prolapsed leaflet or restricted leaflet motion requiring specific techniques of repair. All patients were asymptomatic after operation. Significant residual mitral insufficiency was present in only five patients. Roentgenograms showed a reduction in cardiothoracic ratio, from 0.62 +/- 0.07 preoperatively to 0.53 +/- 0.06 postoperatively (p less than 0.001). Mean pulmonary artery pressure decreased from 30 +/- 12 mm Hg to 18 +/- 6 mm Hg (p less than 0.001) and cardiac index returned to normal (2.7 +/- 0.7 1/min/m2 vs 3.1 +/- 0.7 1/min/m2, p less than 0.02). Angiocardiographic studies showed that end-diastolic volume index returned to normal (148 +/- 41 cm3/m2 vs 89 +/- 23 cm3/m2, p less than 0.001), with significant decreases in end-systolic volume index ( 63 +/- 27 cm3/m2 vs 43 +/- 16 cm3/m2, p less than 0.001), left ventricular mass (114 +/- 28 g/m2 vs 88 +/- 20 g/m2, p less than 0.001), ejection fraction (58 +/- 11% vs 52 +/- 11%, p less than 0.02) and mean velocity of fiber shortening (1.19 +/- 0.36 circ/sec vs 1.01 +/- 0.24 circ/sec, p less than 0.05). We conclude that mitral valvuloplasty provides good and stable midterm results and that the operation should be performed before irreversible myocardial lesions occur.

[Conservative surgery of the mitral valve. Pre- and post-operative hemodynamic and angiographic study of 20 cases]. / Chirurgie conservatrice de la valve mitrale. Etude hemodynamique et angiographique pre et post-operatoire de 20 cas.

Twenty patients with pure or prevalent mitral regurgitation, undergone mitral valve conservative surgery according to the Carpenter-technique from 1975 to 1979, have been studied. There are 19 women and 1 man, mean age of 25 years (range 11 to 65); 18 had a rheumatic fever; 2 had a mitral valve prolapse due to a degeneration of collagen within the central core of the cordae tendineae, which was the primarily responsible for cordae rupture in 1 case. The clinical and hemodynamic features were severe in a 50 per cent of cases (8 patients in N.Y.H.A. functional class III; 3 in class IV); there was pure mitral regurgitation in 12, combined mitral stenosis and regurgitation in 8; tricuspidalic regurgitation which needed annuloplasty in 5 patients. All the patients have been studied by hemodynamic and angiocardiographic study before and an average of 14 months after surgical treatment. Surgical conservative technique of mitral valve is described; the results are analyzed. All the patients are in N.Y.H.A. functional class I, 14 months after surgical valve therapy. In three cases, a systolic 3/6 murmur which was present immediately after surgical treatment and that not increased in time, remains. EKG left overload is still present in 2 cases; Heart-Chest ratio decreases in all the patients (range 0,61 to 0,51). Atrial fibrillation is present in 6 patients. Hemodynamic findings show: Pulmonary Systolic Pressure (PSP) decreases (45 +/- 4 to 27 +/- 1); Mean Pulmonary Capillary Wedge (PCW) pressure decreases (19 +/- 1 to 11 +/- 1); Total Peripheral Resistance (TRP) (2023 +/- 112 to 1595 +/- 70 dynes sec cm--5), Total Pulmonary Resistances (TPR) (742 +/- 89 to 351 +/- 36), Pulmonary Arterial Resistances (PArtR) (344 +/- 51 to 133 +/- 18 dynes sec cm--5), and Left Ventricle Diastolic Pressure (LVEDP) (12 +/- 1 to 8 +/- 1 mmHg) normalize. The Ejection Fraction (EF) decreases at the most operative control after surgery in 11 patients (56 +/- 3 to 50 +/- 1). Angiographic study shows no regurgitation in 4 patients, a least regurgitation in 13 cases and there is a 2/4 regurgitation in 3 cases only. The AA. have got to an excellent result in 17 patients; a 2/4 degree angiographic regurgitation persist in 3 cases, although a clear clinical improvement. The AA. consider of great utility this surgical valvular management according to a critical review of the efficacy and stability of the results.