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Aims To evaluate temporal trends in percutaneous mitral commissurotomy (PMC) in terms of changes in patient characteristics and their impact on immediate results. Methods and results From 1986 to 2001, PMC was indicated in 2773 consecutive patients. Patient characteristics and results were compared each year and linear trends were analysed. There were significant trends toward an increase in mean age (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(p{

We are now able to analyze follow-up data up to 10 years after percutaneous mitral commissurotomy (PMC). In clinical terms, several large single-center series confirm the late efficacy of the procedure in a large population, comprising a variety of patient subsets. When the immediate results are unsatisfactory, prognosis is poor and surgery should be carried out when the clinical conditions allow it. Conversely, if PMC is initially successful, the clinical results are excellent and late deterioration is mainly related to restenosis. Preliminary series have shown that repeat balloon commissurotomy may be performed successfully in such patients. The prediction of late results after balloon commissurotomy is multifactorial and based on clinical parameters, valve anatomy, and the immediate results of the procedure. Randomized studies have shown that the long-term results of balloon commissurotomy are as good as those of surgery in patients with favorable characteristics. In the others, there has been no comparative study and patient selection should take into account the multifactorial nature of the prediction of late results. Overall, these good long-term results have led to an increased use of balloon commissurotomy in the treatment of patients with mitral stenosis.

The aim of this study was to assess late results of percutaneous mitral commissurotomy (PMC) in calcific mitral stenosis and to identify predictors to improve patient selection. We analyzed 422 patients who underwent PMC for calcific mitral stenosis. The extent of calcium was graded from 1 to 4 by fluoroscopy: 227 patients (53%) were graded 1, 125 (30%) graded 2, 55 graded 3 (13%), and 15 graded 4 (4%). The procedure failed in 15 patients, used a single balloon in 11, a double balloon in 126, and the Inoue balloon in 270. In-hospital mortality was 1.2%. Good immediate results (valve area >/=1.5 cm(2) without mitral regurgitation >2/4), were obtained in 321 patients (76%). Multivariate analysis identified 5 predictors of good immediate results: a younger age (p = 0.0004), a lesser degree of stenosis (p = 0.0005), a smaller extent of calcium (p = 0.04), the use of the Inoue balloon (p = 0.015), and a larger effective balloon dilating area (p = 0.006). Good functional results, defined as survival with no further intervention and in New York Heart Association class I or II, were 36 +/- 4% at 8 years. The predictors of good functional results after good immediate results were a younger age (p = 0.04), a lower pre-PMC New York Heart Association class (p

OBJECTIVES The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy. BACKGROUND Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy. METHODS We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 ± 8 years after surgical commissurotomy. Mean age was 47 ± 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121. RESULTS Complications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area ≥1.5 cm2 without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p CONCLUSIONS Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

One hundred and fifty-five patients with isolated mitral regurgitation were referred from our cardiology department for mitral valve repair between 1972 and 1990. Men were predominant (59%), mean age was 51 years, and 61% of the patients were in NYHA class III or IV. Degenerative aetiology was predominant (65%). Surgical repair was performed according to the Carpentier techniques. Two operative deaths occurred (1.3%). The survivors were followed-up for an average of 4 years, and the rates of survival and good functional results at 11.5 years, were respectively 84.5% and 64.5%. The linearized rates of endocarditis, thromboembolic events and re-operations were respectively 0.35%, 1.54% and 2.05% pt-yrs. Residual mitral regurgitation was looked for by clinical and Doppler examination: there was no regurgitation in 55.5% of patients, mild regurgitation was found in 26%, moderate in 10.3% and severe in 8.2%. Analysis of moderate and severe residual regurgitation identified three promoting factors: rheumatic origin of the regurgitation, surgery of the anterior leaflet and time of surgery (the incidence after surgery has been lower in recent years). Other 'less well known' complications were encountered: left ventricular outflow tract obstruction, progressive evolution towards mitral stenosis, appearance of aortic regurgitation and formation of left atrial thrombi. Despite these complications, we must stress the satisfactory results of the technique, in particular in mitral valve endocarditis; 22 patients were operated on for this reason, six during the acute phase of the disease, and no surgical death, or recurrence of endocarditis, and only one case of severe residual regurgitation was observed.

The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy.Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy.We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 +/- 8 years after surgical commissurotomy. Mean age was 47 +/- 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121.Complications were death in 1 patient (0.4%) and mitral regurgitation2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve areaor =1.5 cm2 without regurgitation2/4). Predictors of poor immediate results in multivariate analysis were older age (p0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 +/- 5%, and 58 +/- 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p0.0001) in a multivariate Cox model.Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

The aetiologies of mitral regurgitation were reviewed in 336 patients operated on between 1970 and 1990. The relative frequency of rheumatic fever has decreased and the most common cause is now primary mitral valve prolapse (PMVP) which accounts for 60% of all patients. The increasing age of the surgical population seems to be one of the main factors of this change. Conservative surgical repair according to Carpentier's technique is now performed in 60% of all patients with mitral regurgitation and 80% of cases of PMVP. The aetiology of PMVP is still under discussion. Surgical description seems to indicate the existence of two different morphological aspects with significantly different rates and localizations of chordae ruptures, but our study failed to demonstrate any other anatomical, clinical or histological differences between the two groups.

The purpose of this study is to analyze treatment options for valvular regurgitation with severe left ventricular dysfunction.Results of valvular surgery in 98 patients with mitral or aortic regurgitation and severe systolic left ventricular dysfunction (LVD) were analyzed. Selection criteria were the absence of significant coronary heart disease and a resting ejection fraction (EF)40% for aortic and50% for mitral regurgitation.In patients with aortic regurgitation (n = 46) operative mortality was higher but not significantly so than in a control group of 238 cases (6.5% vs. 3.4%). The actuarial survival rates at five and 10 years were 84% and 55% vs. 84% and 67%, respectively. Independent preoperative predictors of severe postoperative LVD were rheumatic etiology and increased left ventricular end-systolic diameter. In patients with mitral regurgitation (n = 52), operative mortality was not significantly different from that of a control group of 273 cases (3.8% vs. 2.6%), whether the surgical procedure was valve replacement or valve repair. Perioperative morbidity was frequent (30% of cases), mainly low cardiac output, after valve replacement. The actuarial survival rates at eight years were respectively for the groups with and without LVD: 81% and 89% after valve repair, 60% and 75% after valve replacement. Independent predictors of severe postoperative LVD were increased left ventricular end-systolic volume and the type of surgery. Better results were observed after valve repair.It is concluded that a low EF is not a predictive factor of operative mortality but it influences late survival as do the degree of left ventricular dilatation, etiology in aortic and type of surgery in mitral regurgitation. Alternatives to valvular surgery have been envisaged but information on vasodilators in these patients is scant and results of heart transplantation are known only from a few small series.

In order to evaluate the incidence and prognostic value of ventricular arrhythmias in patients with aortic valve disease, 24 hour ambulatory electrocardiographic recordings were obtained in 374 patients without coronary artery disease (aortic stenosis n = 194, aortic regurgitation n = 103, combined aortic stenosis and regurgitation n = 77). Following aortic valve replacement, repeat recordings were obtained in a subgroup of 96 patients at 13 +/- 4 days and 18 +/- 7 months. Ventricular arrhythmias were classified in all cases according to Lown and were compared with clinical, echocardiographic and hemodynamic data. Preoperatively, ventricular premature beats were observed in 329 patients (88%), and were found to be frequent (30 ventricular premature beats/hour) in 83 (22%). Multiformity was found in 105 (28%), couplets in 75 (20%) and ventricular tachycardia in 45 (12%). The occurrence of ventricular arrhythmias was not related to the type or severity of the valve lesions. Patients with severe ventricular arrhythmias (Lown class 3 or 4: 36.5%) had a higher ventricular wall thickness (interventricular septum thickness 14.2 +/- 1.8 mm vs. 11.9 +/- 2.0 mm, p0.01, a higher LV mass (178 +/- 32 g/m2 vs. 142 +/- 35 g/m2, p0.001) and a lower left ventricular ejection fraction (48% +/- 9% vs. 56.5% +/- 10%, p0.001); while in patients with aortic regurgitation a higher end-diastolic LV volume (224 +/- 38 ml/m2 vs. 178 +/- 42 ml/m2, p0.02) and a higher end-systolic LV diameter (56 +/- 7 mm vs. 46 +/- 8 mm, p0.02) were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

In order to evaluate the effect of aortic valve replacement on the incidence of ventricular arrhythmias in patients with aortic valve disease, 24-hour ambulatory electrocardiographic recordings were obtained before surgery in 96 patients without coronary artery disease (aortic stenosis n = 50, combined aortic stenosis and regurgitation n = 19 and aortic regurgitation n = 27). Following aortic valve replacement, repeat recordings were obtained after 13 +/- 4 days and 18 +/- 7 months. Ventricular arrhythmias were in all cases classified according to Lown and were compared with clinical, echocardiographic and hemodynamic data. Preoperatively, ventricular premature beats were observed in 85 patients (89%) and were frequent (greater than 30 ventricular premature beats/hour) in 20 (21%). Multiformity was found in 27 (28%), couplets in 18 (19%) and ventricular tachycardia in 11 (11.5%). The occurrence of ventricular arrhythmias was not related to the type or severity of valve lesions. Patients with severe ventricular arrhythmias (Lown class 3 or 4: 37%) had a greater thickness of their interventricular septum 13.9 +/- 2.5 mm, vs 11.7 +/- 2.6 (p less than 0.05); a higher LV mass 176 +/- 34 g/m2, vs 134 +/- 39 (p less than 0.05) and a lower left ventricular ejection fraction 47 +/- 12%, vs 57 +/- 11, (p less than 0.01). Two weeks postoperatively, the incidence and severity of ventricular arrhythmias had increased: ventricular premature beats were noted in 92% and were severe in 50%. No correlation was found between ventricular arrhythmias and preoperative or operative data. Eighteen months after surgery, ventricular premature beats were still observed in 81% of patients but remained frequent in 7% only. Severe ventricular arrhythmias were noted in 27%. Patients with severe ventricular arrhythmias had at the time of this late recording a lower radionuclide left ventricular ejection fraction 57 +/- 14%, vs 73 +/- 9 (p less than 0.02) and a higher enddiastolic diameter 63 +/- 15 mm, vs 48 +/- 7, (p less than 0.01). This study indicates that ventricular arrhythmias are common in patients with aortic valve disease. The severity of arrhythmias is influenced by the LV consequences of valve lesion both pre- and late postoperatively. The frequency and severity of ventricular arrhythmias increase early after surgery and do not correlate with preoperative or operative data.

Present day indications for surgery in mitral regurgitation have to take into account changes in aetiology, advances in pre-operative evaluation of mitral lesions, technical progress in mitral valve repair and better knowledge of pre-operative predictive factors of surgical results. The results of a series of 294 patients operated on between 1970 and 1990 show that surgery is advisable before patients reach Functional Class III or IV, and before they develop atrial fibrillation, an ejection fraction of under 0.55, or marked left ventricular and atrial enlargement. Surgical indications depend on two factors: the possibility of valve repair evaluated by transthoracic and transoesophageal echocardiography, and the experience of the surgical team in this kind of surgery. Valve repair is the best treatment in many patients, particularly those with degenerative valve lesions, poor ejection fraction, elderly people and some cases of infective endocarditis.

A total of 546 patients with severe aortic stenosis (AS) were retrospectively reviewed to assess the efficacy of percutaneous transluminal valvuloplasty (PTV) and valve replacement (VR). Of these, 490 underwent VR between 1968 and 1986 (mean age 62±12 years, 71·7% were in NYHA class III or IV), 68·8% received mechanical prostheses, and in 11·8% a bypass graft was associated. The operative mortality was 6·9% (4% since 1983). The mean follow-up was 57·6 months. The actuarial survival rate was 77% at five years, 60% at 10 years, and 40% at 15 years. Over 70 years of age, operative mortality was 6·2% since 1983, and the actuarial survival rate was 67·5% at five years. From February 1986 to May 1987, PTV was attempted in 56 patients and was effective in 52 patients (mean age 79±5 years, 93% in Class III or IV). Immediate mortality was 7·1%. The morbidity was due to tamponade (1·8%), myocardial infarction (3·6%), vascular trauma (5·3%), or cerebrovascular accident (9%). Forty three patients were followed after PTV (mean value 4·2±3, range 1–14 months): 12 patients (28%) died and 46% were functionally improved in NYHA Class II. PTV significantly improved the aortic valve area as shown by haemodynamics (0·49–0·75 cm2 P