Christine Savoye

Effect of mitral valve surgery on exercise capacity, ventricular ejection fraction and neurohormonal activation in patients with severe mitral regurgitation

OBJECTIVES The purpose of this study was to prospectively investigate the effects of surgical correction of mitral regurgitation (MR) on exercise performance, cardiac function and neurohormonal activation. BACKGROUND Little is known about the effect of surgical correction of MR on functional status or on neurohormonal activation. METHODS Cardiopulmonary exercise test, radionuclide angiography and blood samples for assessment of neurohormonal status were obtained in 40 patients with nonischemic MR before and within one year (216+/-80 days) after surgery. Twenty-four patients underwent mitral valve repair (MVr), and 16 underwent valve replacement (VR) with anterior chordal transection. RESULTS Despite an improvement in New York Heart Association functional class, exercise performance did not change (peak oxygen consumption: 19.3+/-6.1 to 18.5+/-5.6 ml/kg/min, percentage of maximal predicted oxygen consumption: 79.5+/-18.2% to 76.8+/-16.9%). After surgery, left ventricular (LV) ejection fraction (EF) decreased (64.2+/-10.3% to 59.9+/-11.4%, p = 0.003) while right ventricular (RV) EF increased (41.4+/-9.6% to 44.7+/-9.5%, p = 0.03). Left ventricular EF did not change after MVr (64.3+/-11.5% to 61.5+/-12.2%), but RVEF improved (40.4+/-9.2% to 46.0+/-10.0%, p = 0.02). In contrast, VR was associated with an impairment of LV function in the apicolateral area and a decrease in LVEF (64.1+/-8.5% to 57.4+/-10.0%, p = 0.01), whereas RVEF did not change (42.9+/-10.3% to 42.8+/-8.6%). Moreover, there was only a slight decrease in neurohormonal activation after surgery. CONCLUSIONS Despite an improvement in symptomatic status, exercise performance was not improved seven months after either MVr or VR for MR, and neurohormonal activation persisted. Compared with MVr, VR resulted in a significant impairment of cardiac function in this study.

Tissue Doppler Echocardiography in Patients with Long QT Syndrome

BACKGROUND Congenital long QT syndrome (LQTS) is a well-defined clinical entity associated with a high mortality among untreated patients. Tissue Doppler (TD) echocardiography that has been recently introduced, facilitates wall motion analysis. Therefore, to further characterize myocardial velocity abnormalities associated with LQTS, using TD and conventional echocardiography, we compared control subjects and LQTS patients. METHODS AND RESULTS Ten patients with mild LQTS and 14 control subjects were examined with standard and TD echocardiography. We studied myocardial velocities in basal and mid-segments of the septal, lateral, inferior and anterior walls. Peak velocity and time intervals were measured in each segment. We confirmed previously described M-mode abnormalities, demonstrated by an increase of the wall thickening time index. TD analysis demonstrated increased systolic and diastolic peak velocities for all segments in LQTS patients. Regional isovolumic relaxation time and systolic velocity half time (VHT) were significantly longer in LQTS group associated with a prolonged late systolic phase, resulting in a plateau morphology. CONCLUSION We demonstrated that TD allows the characterization of myocardial velocity abnormalities in LQTS patients. TD measurements could become part of the routine clinical evaluation for patients potentially affected by the LQTS as a new phenotypic marker.

Ten-year echocardiographic and clinical follow-up of aortic Carpentier-Edwards pericardial and supraannular prosthesis: a case-match study

BACKGROUND There are little comparative data on Carpentier-Edwards supraannular and pericardial second-generation bioprostheses. The aim of this work was to compare their hemodynamic and clinical outcomes in patients with aortic stenosis. METHODS We conducted a retrospective study including 150 patients operated on for aortic stenosis between 1989 and 1993. Patients undergoing aortic valve replacement with either a Carpentier-Edwards supraannular or pericardial prosthesis were matched for sex (49% male), age (72 +/- 8 years), body surface area, valve size, associated procedures, and left ventricular ejection fraction. RESULTS Mean follow-up was 6.5 +/- 3.3 years, giving a total follow-up of 983 patient-years. Thirty-day mortality and 10-year actuarial survival were, respectively, 8% and 51% in the supraannular group and 6.7% and 43.4% in the pericardial group. At 10 years, freedom from thromboembolism, structural failure, and all valve-related events were, respectively, 88.7%, 88.9%, and 68.7% in the supraannular group and 85%, 100%, and 82.2% in the pericardial group. There were four (5.3%) structural failures, and four (5.3%) reoperations for degeneration (n = 3) and endocarditis (n = 1) in the supraannular group. Freedom from structural dysfunction or reoperation was 87.3% in the supraannular group and 100% (p < 0.05) in the pericardial group. Echocardiographic review of 62 of 76 survivors (81.5%) demonstrated a trend toward a better hemodynamic profile of pericardial valves at the end of follow-up. CONCLUSIONS Ten years after aortic valve replacement for aortic stenosis, Carpentier-Edwards pericardial prostheses give comparable and probably better results than Carpentier-Edwards supraannular prostheses.

Echocardiographic follow-up after Ross procedure in 100 patients.

The Ross procedure could provide an ideal aortic valve replacement method in children and young adults. We evaluated midterm echocardiographic results to assess pulmonary homograft function as well as pulmonary autograft dimensions and function. In all, 105 patients (26 women and 79 men) underwent the Ross procedure; median age at implant was 29 years. All patients underwent free root replacement. Transvalvular gradients and autograft dimensions were measured at 3 levels (annulus, sinuses of Valsalva, and proximal aorta) at discharge, at 6 months, and annually thereafter. Perioperative mortality was 4.7%. The mean period for echocardiographic follow-up in 100 patients was 32.7 months (range 0.5 to 7 years), during which 4 noncardiac-related deaths occurred. Two patients underwent late reintervention. No moderate or severe regurgitation was recorded. There was 1 case of mild homograft regurgitation and 4 of mild autograft regurgitation at late follow-up. Autograft peak gradients were low and reproducible (5 +/- 2.8 mm Hg at discharge vs 5.5 +/- 3.5 mm Hg at last follow-up, p = NS). Homograft peak gradients increased significantly without severe obstruction (7.8 +/- 5.7 mm Hg at discharge vs 15.8 +/- 9.2 mm Hg at last follow-up). The diameter of the autograft annulus was stable during follow-up, whereas autograft dimensions at sinuses and proximal aorta increased significantly. One group of patients was identified with sinus diameter increases >20% (group A). The 90 remaining patients were classified into group B. The only parameter significantly different between the 2 groups was the sinus diameters measured at discharge (1.74 cm/m2 (group A) vs 1.92 cm/m2 (group B); p = 0.036). In 100 patients and with echocardiographic follow-up for up to 7 years, the Ross procedure showed excellent results. For 10% of patients, we observed a 20% dilation of sinus diameters, but in only 3 patients (3%) was this beyond the upper normal limit.

Ross operation for active culture-positive aortic valve endocarditis with extensive paravalvular involvement

BACKGROUND We evaluated the midterm results of the Ross operation in active advanced endocarditis. METHODS Between June 1994 and June 2000 a pulmonary autograft aortic root replacement was performed in 11 consecutive patients who had urgent or emergent procedures for active endocarditis with extensive involvement of the aortic root (10 native, 1 prosthetic). Patients ranged in age from 26 to 45 years (median, 33 years). Indications for operation were uncontrolled infection (n = 5), hemodynamic deterioration (n = 3), or both (n = 3). Four patients were in the New York Heart Association class III, 6 in class IV, and 1 was operated on while in cardiogenic shock. Four patients (36%) suffered an embolic cerebrovascular accident preoperatively. The endocarditis affected the mitral valve in 2 patients and the tricuspid valve in 1 patient. RESULTS There was no early or late death. Recurrent endocarditis was not detected in any of the patients during the follow-up period ranging up to 72 months (median, 40 months). CONCLUSIONS The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis.

Aortic root replacement with a pulmonary autograft in young adults: medium-term results in 70 patients

BACKGROUND Pulmonary autograft aortic valve replacement has been introduced in our institution in selected adult patients in light of the known disadvantages and limitations of conventional prosthetic valves. METHODS We prospectively evaluated the use of the pulmonary autograft in a series of 70 young adults (31.2+/-8.7 years, range 16 to 49 years) operated on from March 1992 to April 1997 with aortic root replacement only. RESULTS There were no in-hospital deaths and two noncardiac-related late deaths during follow-up of up to 62 months (mean 33 months). Thromboembolic complications were not observed. One patient required reoperation for infective endocarditis 4.3 years after surgery. Discharge echo-Doppler studies showed normal autograft and allograft valve function. Serial echo-Doppler studies showed no significant progression of aortic insufficiency and no dilatation of the autograft. A severe stenosis of the pulmonary allograft developed in 1 patient. CONCLUSION Aortic root replacement with a pulmonary autograft, although more complex than conventional prosthetic valve replacement, is a safe, effective, and reproducible procedure in properly selected adult patients. Long-term results remain to be evaluated.

Late autograft and homograft endocarditis after the ross operation

Pulmonary autografts and leftand right-sided cryopreserved homografts are widely known for their resistance to infection. We report here on the first case of endocarditis occuring in one of 86 patients who underwent aortic root replacement with a pulmonary autograft at our institution between March 1992 and December 1997. Clinical summary. A 34-year-old man with congenital bicuspid aortic valve stenosis and no history of endocarditis underwent elective aortic root replacement with a pulmonary autograft (Ross procedure) in October 1992. The right ventricular outflow tract (RVOT) was reconstructed with a cryopreserved pulmonary homograft provided by the European Homograft Bank. The patient’s postoperative course was uneventful and he was periodically monitored at our institution by clinical examination and Doppler echocardiography. At his most recent examination, in October 1996, Doppler echocardiographic analysis showed normal autograft and homograft function. The patient was readmitted to the hospital 4.3 years after the Ross procedure, in January 1997, with fever and left-sided congestive heart failure caused by active endocarditis causing aortic insufficiency. Initial transesophageal echocardiography revealed grade 2 autograft regurgitation, and a small vegetation (2 by 5 mm) was found on the left coronary cusp. The mitral, tricuspid, and pulmonary valves were all normal. Blood cultures showed Streptococcus gordonii, with anamnesis revealing a dental procedure (scaling), without antibiotic prophylaxis, 3 weeks before the patient’s readmission to the hospital. The patient was first treated with appropriate antibiotics (ampicillin 12 g/24 hr intravenously, given continuously, and gentamicin 1 mg/kg intravenously every 8 hours). However, after 10 days, surgical treatment was considered because of a persistent inflammatory syndrome and hemodynamic deterioration. Magnetic resonance imaging of the brain and abdominal computed tomographic densitometry scans revealed no metastatic infection. A second transesophageal echocardiogram showed the progressive development of lesions on the autograft with a resulting grade 3 regurgitation and detected a vegetation (5 by 15 mm) on the posterior leaflet of the right-sided pulmonary homograft. The patient underwent surgery 24 hours later. Intraoperative transesophageal echocardiography was performed immediately before the start of cardiopulmonary bypass and showed a dramatic increase in autograft and homograft lesions. Pathologic observations corresponding to the echocardiographic appearance were noted during the operation. Two cusps of the autograft were torn, with a 5 by 8 mm vegetation on the left coronary cusp and an 8 by 10 mm vegetation on the right coronary cusp. The noncoronary cusp was unaffected and absolutely normal, and there was no annular or perivalvular involvement. The pulmonary homograft was extensively damaged, and the RVOT was obstructed by large cauliflower-shaped vegetations. All leftand right-sided suture lines from the previous operation were healed. All infected and necrotic tissue was excised, such that the autograft wall was conserved while the homograft wall was completely removed. Inasmuch as no homografts were available at the time of the operation, the autograft valve was replaced with a mechanical prothesis (27 mm, St. Jude Medical, Inc., St. Paul, Minn.) and the RVOT was reconstructed with a stentless porcine bioprosthesis (27 mm Medtronic Freestyle bioprosthesis, Medtronic Inc., Minneapolis, Minn.). Streptococcus gordonii was cultured from the vegetations excised from both valves. Fungal endocarditis was not documented on the pulmonary homograft. Microscopic studies of the excised cusps from the autograft showed no calcification, normal cellularized fragments, and few foci From the Departments of Cardiac Surgery, Anesthesiology, and the Echocardiography and Ultrasound Laboratory, Lille University Heart Center, Lille, France, and the European Homograft Bank, Brussels, Belgium.

Prevalence and correlates of non-optimal secondary medical prevention in patients with stable coronary artery disease

BACKGROUND In patients with coronary artery disease (CAD), non-optimal use of evidence-based medications is associated with an increased risk of adverse outcome. AIMS To assess the prevalence and correlates of non-optimal secondary medical prevention in patients with stable CAD. METHODS We included 4184 consecutive outpatients with stable CAD. Treatment at inclusion was classified as optimal/non-optimal regarding the four major classes of secondary prevention drugs: antithrombotics; statins; angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs); and beta-blockers. For each treatment, the prescription was considered non-optimal if the drug was missing despite a class IA indication according to international guidelines. To assess the information globally, non-optimal secondary prevention was defined as at least one major treatment missing. RESULTS The proportions of patients with non-optimal treatment were 0.7%, 7.8%, 12.9% and 10.3% for antithrombotics, statins, ACE inhibitors/ARBs and beta-blockers, respectively. Non-optimal secondary medical prevention was observed in 16.8% of cases. By multivariable analysis, the correlates of non-optimal secondary medical prevention were long time interval since last coronary event (P<0.0001), older age (P<0.0001), diabetes mellitus (P<0.0001), hypertension (P<0.0001), no history of myocardial infarction (P=0.001), no history of coronary revascularization (P=0.013) and low glomerular filtration rate (P=0.042). CONCLUSIONS Although most patients with stable CAD are receiving evidence-based medications according to guidelines, there remain subgroups at higher risk of non-optimal treatment. In particular, it might be feasible to improve prevention by focusing on patients in whom a long time has elapsed since the last coronary event.