Clinical and ultrasound results after aortic valve replacement: intermediate-term follow-up with the St. Jude Medical prosthesis.

Mortality, morbidity, quality of life, and left ventricular (LV) function were evaluated in 49 patients after aortic valve replacement with the St. Jude prosthesis. Total follow-up was 2577 patient-months; survivors were followed-up for 4 to 7 years by clinical examination and echocardiography. The actuarial survival rate at 6 years was 79.6%, and there were no valve-related deaths. The linearized rates for thromboembolism and hemorrhage were 0.93% and 3.26% per patient-year, respectively. In 34% of the survivors the quality of life was poor. In the first three postoperative months, patients with aortic stenosis (n = 12) had a significant decrease in the muscle cross-sectional area (p less than 0.01) and patients with aortic regurgitation (n = 11) had decreases in both LV end-diastolic diameter (p less than 0.05) and cross-sectional area (p less than 0.001). All of these results were maintained at 5 years without modification of LV systolic function. Despite the good overall results, six patients deteriorated and had major LV dilatation. Multivariate logistic regression analysis identified two independent preoperative variables associated with a poor outcome defined as death of LV dysfunction (p less than 0.05): age and end-diastolic diameter. Thus meticulous follow-up showed a high incidence of hemorrhage and a poor quality of life in many of the survivors. It was concluded that in high-risk patients (age and end-diastolic diameter) surgery should probably be considered earlier.

[Echographic evaluation of the severity of aortic stenosis in cases with associated mitral stenosis]. / Appréciation échographique de la sévérité du rétrécissement aortique en cas de sténose mitrale associée.

The echocardiographic findings of six patients with pure mitral stenosis associated with pure aortic stenosis were compared with the findings from a series of ten cases of pure aortic stenosis without mitral disease. Each patient also underwent haemodynamic studies in order to quantitate the severity of the stenoses. The aortic stenosis was of the same degree of severity in both series (0.71 +/- 0.24 cm2 and 0.73 +/- 0.16 cm2). The systolic separation of the aortic valve was greater than 1 cm in 4 of the 6 cases on echocardiography, corresponding to a false negative of tight aortic stenosis. This appearance corresponded to a doming of the aortic valve on 2D echocardiography. The wall thickness was significantly less in the AS + MS series than in pure SA series (1.13 +/- 0.13 cm compared with 1.52 +/- 0.21 cm; p less than 0.01). The wall was found to be thicker, the tighter the MS. Overall, the diagnostic criteria of the severity of AS on echocardiography (restricted opening of the valve and the severity of ventricular wall hypertrophy) were absent in the association of AS + MS. The absence of myocardial hypertrophy can not be fully explained. It could be related to a decreased filling on the left ventricle and therefore a smaller systolic ejection volume because of the mitral obstruction.

[Right coronary ostial stenosis in homozygotic hypercholesterolemia. Coronarographic and echocardiographic diagnosis]. / Sténoses ostiales coronaires droites dans l'hypercholestérolémie homozygote. Diagnostic coronarographique et échocardiographique.

Ostial stenosis of the right coronary artery was discovered in 2 patients with homozygous familial hypercholesterolaemia. The lesion was confirmed in one case at post-mortem examination and in the other case by cross-sectional echocardiography. In both patients the stenosis could not be visualized at coronary arteriography when the right coronary vessel was selectively injected, but the lack of reflux of the contrast medium into the aortic sinus proved very useful for the diagnosis. To recognize this sign is important since the other criteria of ostial stenosis are not always present, notably in essential hypercholesterolaemia where post-stenosis dilatation is absent due to diffuse parietal lesions of the arteries. In addition, ostial stenoses are associated with a characteristic stenosis localized to the proximal aorta above the coronary ostia. Owing to the dangers of overlooking ostial stenoses, echocardiography and aortography should be performed before coronary arteriography, and the lack of reflux of the contrast medium should be acknowledged as a diagnostic sign.

[Differential diagnosis between constrictive pericarditis and cardiac amyloidosis by computerized M-mode echocardiography]. / Diagnostic différentiel entre péricardite constrictive et amylose cardiaque par échocardiographie TM digitalisée.

A diastole is a non specific haemodynamic syndrome which may result from constrictive pericarditis or from a restrictive cardiomyopathy. The aim of this study was to differentiate these two types of condition by analysis of computerised M mode recordings of the left ventricle. Three groups of patients were studied: 5 cases of confirmed cardiac amyloidosis (Am); 5 cases of constrictive pericarditis confirmed surgically (CP) and 10 normal subjects (NL). The study was based on analysis of parameters of ventricular filling and of diastolic thinning of the LV free wall. A significant difference was observed between AM and CP but not between PC and NL. Amyloidosis was characterised by a reduction in the maximum velocity of endocavitary diameter lengthening (AM 0,84 +/- 0,56 cir/sec; PC 3,95 +/- 0,77, p less than 0,01), prolongation of the rapid filling phase (AM 0,42 +/- 0,17 sec; PC 0,16 +/- 0,06 sec, p less than 0,02) and a decrease in maximum velocity of free wall thinning (AM 0,45 +/- 0,23 th/syst/sec; PC 4,79 +/- 2,1, p less than 0,01). The diastolic thickness of the free wall was greater in the amyloidosis group (AM 1,73 +/- 0,61 cm; PC 1,05 +/- 0,21, p less than 0,05) and correlated with the reduction of maximum velocity of free wall thinning. Parameters of global diastolic filling did not distinguish the two conditions. The M mode recordings were therefore digitalised to provide graphs of chamber filling and wall thinning and their derivatives.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral systolic anterior motion and left ventricular function in obstructive cardiomyopathy]. / Avancée mitrale systolique et fonction ventriculaire gauche dans la myocardiopathie obstructive.

The term hypertrophic cardiomyopathy with obstruction encompasses a wide range of clinico-pathological conditions. The mildest forms have localised septal hypertrophy and obstruction only during pharmacodynamic stimulation. The more severe forms have major wall hypertrophy and are obstructive under basal conditions. Mitral systolic anterior motion (SAM) recorded at echocardiography is generally attributed to obstruction. However, the construction of this image by subvalvular structures and the relationship between the obstruction and anatomical deformation led us to study left ventricular haemodynamics with respect to the presence or absence of SAM under basal conditions. Thirty one cases of hypertrophic obstructive cardiomyopathy were divided into 2 groups: -- Group 1 without basal SAM (11 cases); -- Group 2 with SAM under basal conditions (20 cases). Under basal conditions there was no significant difference in LVEDP or ventricular volume between the two groups. An intraventricular pressure gradient was commoner in Group 2 (65% compared to 27%) as was mitral incompetence (53% compared to 27% in the 30 patients undergoing selective left ventriculography). Left ventriculography in the right anterior oblique plane distinguished two types of LV deformation: systolic biloculation of the chamber and systolic apical obliteration. The second form was mainly observed in Group 2. The effect of isoproterenol on LVEDP was studied in 9 cases in Group 1 and 13 cases in Group 2: LVEDP decreased from 14 +/- 6 mmHg to 8 +/- 6 mmHg in Group 1, and increased from 14.5 +/- 6 to 23.5 +/- 6.5 mmHg in Group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Calculation of the peak systolic wall stress at the equator of the left ventricle by coupled M mode echo and pressure recordings]. / Calcul du pic de contrainte systolique à l'équateur du ventricule gauche par le couplage écho TM/pression.

The peak systolic wall stress at the equator of the left ventricle (sigma max) is the maximum load that the myocardial fibres bear during contraction. It is an index of the adaptation of the left ventricle to cardiac disease, and, when elevated, it indicates cardiac decompensation. sigma max was calculated by coupled M mode echo-LV pressure recordings in 51 cases: 11 patients without LV disease, 14 patients with aortic stenosis (AS), 14 patients with aortic incompetence (AI), 7 patients with severe mitral incompetence (MI) and 5 patients with cardiomyopathy with dilatation (CMP). sigma max was calculated from Mirsky's formula, the length of the long axis being deduced from the short axis and the diastolic:systolic ratio of these two axes from ventriculography. The normal value of sigma max by this method is 220 dynes 10(3)/cm2 +/- 30 with an upper limit of normal of 280 dynes 10(3)/cm2. sigma max was normal in patients with AS and AI, and increased in the cases of MI and CMP, in positive correlation with LV volume (r = 0,47) and the shape of the LV (long:short axis ratio). No correlations were found between sigma max and maximum LV pressure. The relatively low values of sigma max compared to the results obtained from coupled echo-angio recordings are partly due to the thick walled LV model and, to a large extent, to the lower values of short axis when measured by echo compared to angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

[Angiographic morphological study of the left ventricle in obstructive cardiomyopathy. Comparison with haemodynamic data (author's transl)]. / Etude angiographique de la morphologie du ventricule gauche dans la myocardiopathie obstructive. Comparaison avec les résultats hémodynamiques.

The right anterior oblique ventriculographs of 20 patients with obstructive cardiomyopathy were reviewed, and the images obtained during systole were divided into three groups: (1) bilocular left ventricular cavity with midventricular stenosis; (2) obliteration of the ventricle reduced to its infra-sigmoidal portion, with atrophy or even amputation of the apical portion; and (3) subnormal image. Haemodynamically, the most common abnormality (5/8 patients) in group 1 was the presence of a gradient in the basal state. In group 2, this gradient was only found in 2/8 patients, but the left ventricular telediastolic pressure was much higher in the basal state or after stimulation than in group 1. Haemodynamic changes were moderate in group 3. The abnormalities in left ventricular telediastolic pressure in this type of cardiomyopathy are interpreted as reflecting disorders in compliance which would then be maximal in group 2. This study is part of an attempt to classify the various characteristics of the left ventricle with the view of identifying some forms amenable to surgical treatment.

A study of the incidence of epilepsy following ECT.

In a group of 166 patients who had received electroconvulsive therapy more than one year previously the prevalence of epilepsy did not differ significantly from that found in the community as a whole. The findings suggest that a kindling process is not a clinical hazard following repeated electrically induced seizures.