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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{

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

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.

For more than a decade, cardiologists have now used procedures for treating valvular stenosis. The most widely used, percutaneous mitral commissurotomy, is performed through the transseptal pathway, usually with the Inoue balloon. Subsequently, the valvular surface doubles and the incidence of serious complications is low in experienced teams. Evaluation of ten years of experience shows that long-term results are good if the dilatation was efficient immediately. In the other cases, surgery must be performed. Percutaneous mitral commissurotomy is the preferred solution in young patients with good valvular anatomy; in others, its indication should be discussed on a case-by-case basis. It is contraindicated in the presence of thrombosis of the left auricle or severe valvular calcification. The results of aortic valvuloplasty for calcified stenosis in the elderly subject are poor, with elevated mortality and morbidity. Valvuloplasty little affects the natural history of a tight aortic stenosis but can offer transitory functional improvement for several months. Its indications are rare.

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 mechanism of rheumatic aortic regurgitation is retraction of the three cusps leading to lack of coaptation. The authors describe a technique of aortic valve repair by extension of the cusps using autologous pericardium, undertaken in 52 patients (mean age 21 +/- 5 years) and report the short and medium term results. There were no operative deaths or reoperation for technical failure. The postoperative echocardiographic examinations showed absent or minimal aortic regurgitation in 45 patients (87%) and moderate regurgitation in 7 patients (13%). The echocardiographic results at 2 years were stable: no patient was reoperated for deterioration of the valvuloplasty. This technique is reproducible and reliable is selected patients.

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)

The aim of this study was to analyse the evolution of the aetiologies of operated valvular heart disease over a 20 year period and to assess the consequences. Two thousand five hundred and ninety eight patients who underwent conservative surgery or valve replacement were included. This population was classified according to the date of surgery into 4 groups, each corresponding to a 5 year period. Analysis of these results, especially in the groups operated between 1970 and 1974 and between 1985 and 1989 shows: 1) a change in aetiology: decreased incidence of rheumatic valvular disease (36 versus 61%) and an increased incidence of degenerative lesions (43 versus 23%) (p less than 0.0001); 2) a change in the valvular lesions operated, aortic stenosis has become the commonest operated condition (43 versus 27%) (less than 0.001); 3) an increased age (59 +/- 14 versus 49 +/- 13 years, p less than 0.0001) with a higher proportion of patients over 70 years of age (22 versus 1%, p less than 0.001); 4) a higher incidence of mixed coronary and valvular surgery (11 versus 2%, p less than 0.001).

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.

One hundred and fifty-five patients with isolated mitral regurgitation were referred from our Department of Cardiology for mitral valve repair between 1972 and 1990. Men were in the majority (59%), the mean age was 51 years and 61% of the patients were in NYHA class III or IV. Degenerative or dystrophic etiologies predominated, followed by rheumatic origins (17%) and bacterial endocarditis (14%). Surgical repair was performed using Carpentier's techniques: insertion of a prosthetic ring (87%) valvular resection (73%), valvular mobilization (11%), closure of a perforation (4,5%) and resection of vegetations (4,5%). Two patients died during surgery and 7 were lost to follow-up; the others were followed for an average of 4 years, i.e., a cumulative follow-up of 584 years/patients. The overall results at 11.5 years were satisfactory: 84.5% survival rate and 64.5% with good valvular function. The linearized rates of endocarditis, thromboemboli, hemorrhagic complications (51 patients were taking anticoagulants) and repeated interventions were, respectively: 0.35, 1.54, 0.17 and 2.05%/patient-year. Residual mitral regurgitation was sought by clinical and Doppler examinations: 55.5% of the patients had none, 26% had mild, 10.3% had moderate and 8.2% had severe regurgitation. Analysis of the latter two groups identified 3 influencing factors: rheumatic origin of the regurgitation, surgery on the anterior cusp and the year surgery was performed (the post-surgical incidence has decreased in recent years). Other, less-well-known complications were also found: left ventricular outflow tract obstruction, progressive evolution towards mitral stenosis, development of aortic regurgitation (usually discreet) and formation of left atrial thrombi.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-four endomyocardial biopsies performed during surgical correction of valvulopathies were compared with ventricular function. Patients were divided into three groups: group I without anomalies of ventricular function, group II with a slight decrease of the ventricular ejection fraction, group III with a low ventricular ejection fraction. Morphometric analysis was carried out using electron microscopic photographs and an image analyser. The results were correlated with those of functional studies. In patients of the second group, the small number of mitochondria with respect to the increased myofibrillary area seemed to indicate mitochondrial dysfunction. In patients of the third group, alterations of myocontractility expressed a myofibrillary deficiency unable to be corrected by the multiplication and the increased exchange areas of mitochondria.

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

Selective coronary angiography was carried out in 110 patients (68 women, 42 men; average age 57 +/- 8 years) with significant, isolated, non-ischaemic mitral valve disease. The indication for coronary angiography was angina or myocardial infarction in 42 cases and the investigation was carried out routinely in the other 68 cases. Coronary stenosis greater than 50 p. 100 was demonstrated in 25 cases (22.7 p. 100), 18 single vessel, 5 double or triple vessel disease and 2 cases of stenosis of the left main stem. The incidence of coronary artery disease was higher in patients with cardiovascular risk factors (0 factors: 13 p. 100; 1 factor: 22 p. 100, 2 or 3 factors: 45 p. 100; p less than 0.01). The coronary patients had higher mean pulmonary artery pressures (33 +/- 16 mmHg vs 25 +/- 8 mmHg, p 0.001), higher left ventricular end diastolic pressures (12.5 +/- 7 mmHg vs 9 +/- 5 mmHg, p less than 0.01) and greater left ventricular end diastolic volumes (83 + 40 ml/m2 vd 59 +/- 29 ml/m2, p less than 0.01). There was no difference in segmental wall motion between coronary and non coronary patients. 89 patients were referred for surgery, 17 of whom had coronary artery disease. 5 patients underwent coronary bypass surgery. The incidence of peroperative cardiac complications (low output, ventricular arrhythmias, myocardial infarction) was higher in the coronary patients (53 p. 100 vs 18 p. 100, p less than 0.01). The 6 year survival rate was 75 +/- 8 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)

36 patients with a total of 39 pericardial Ionescu-Shiley bioprostheses (20 aortic, 13 mitral and 3 double valve replacements) were studied. The population consisted if 12 women and 24 men with an average age of 33 +/- 11 years. The control was performed on average 7 +/- 4 months after surgery. At the time of investigation all patients were in functional classes I or II of the NYHA. The average cardio-thoracic ratio was 0.51 +/- 0.05. The catheter data showed a mean pulmonary capillary pressure of 10 +/- 2.7 mmHg, a mean cardiac index of 3.2 +/- 0.9 l/min/m2, a mean end diastolic volume of 132 +/- 33 ml/m2 and a mean ejection fraction of 0.53 +/- 0.12. Haemodynamic data was obtained under basal conditions and during intravenous infusion of isoproterenol. The average transvalvular pressure gradient was measured by transseptal catheterisation. The cardiac output was measured by dye dilution and the functional surface area calculated using the Gorlin formula (k = 44.5 for the aortic valve and k = 31 for the mitral valve). Perivalvular leaks were excluded by selective left ventriculography or aortography. The average transvalvular pressure gradients for the aortic valve prostheses (no 19 = 1, no 21 = 4, no 23 = 3, no 25 = 7, no 27 = 8) were 17 +/- 7 mmHg for no 19 and 21, 12 +/- 5 mmHg for no 23 and 25, and 9.7 +/- 2.7 mmHg for no 27.(ABSTRACT TRUNCATED AT 250 WORDS)

A multicentre retrospective study of 467 cases of operated aortic valve disease was undertaken to define the indications of coronary arteriography in the pre-operative work-up. Significant coronary artery disease was present in 15% of all cases or, more precisely, in 17% of cases with angina and in 8% when investigation was only routine. Coronary artery disease was more frequent in males, in patients with clinical or electrical evidence of previous myocardial infarction, in patients with ST-T wave changes, and when angina was severe (more than one attack per day). None of these factors was specific. It is therefore difficult to limit coronary arteriography to these patients or there would be a risk of missing significant lesions in a small number of cases. It is important to give the surgeon all the necessary information before aortic valve replacement and so coronary arteriography should be widely practiced in this context. However exceptions may be made for young patients and also those in congestive cardiac failure in whom coronary arteriography represents an unnecessary risk before surgery.

Cardiopulmonary bypass (CPB) may be a cause of myocardial damage in a small number of patients undergoing valve replacement (4 out of 1576 valve replacements). The responsibility of CPB can only be presumed when: the degree of myocardial dysfunction after surgery can be quantified, other causes of myocardial dysfunction are excluded. the type of valvular disease is taken into consideration. Variations in load after correction of certain lesions (mitral regurgitation) makes changes of LV systolic function difficult to interpret. The first case concerned a 23 year old patient operated for aortic regurgitation (Björk prosthesis) under local and general hypothermia and followed-up for 1 year after surgery. Ventricular extrasystoles and left bundle branch block were observed during surgery and radiological and echocardiographic LV dilatation persisted with deterioration of echographic, isotopic, haemodynamic and angiographic parameters of LV function: ejection fraction fell from 62% before surgery to 35% with diffuse hypokinesia and persistent LV dilatation (191 vs 188 ml). In the absence of prosthetic valve dysfunction, associated valve lesions or coronary artery disease, LV deterioration was attributed to CPB and inadequate myocardial protection. In two other cases (60 and 62 years) correction of aortic stenosis (Starr 1260) with coronary perfusion was followed by cardiac failure with left bundle branch block, deterioration of LV function, and death after 3 years in one case and precarious survival at 10 years in the other. In a fourth case (mixed mitral valve disease corrected by a Starr prosthesis under aortic clamping), the variation of cardiac load before and after surgery made changes in LV function difficult to interpret. (ABSTRACT TRUNCATED AT 250 WORDS)

The frequent coexistence in adults of a tight aortic stenosis and coronary arterial lesions raises problems of therapeutic and diagnostic approach. In an attempt at selecting indications for coronary arteriography, we studied 253 patients with severe aortic stenosis who were explored by that method. 177 patients (70 p. 100) had no coronary disease (group I); 76 patients (30 p. 100) had significant coronary lesions (group II). Group II patients differed from group I patients in several respects: they were older: 65 +/- 9 years on average as against 61 +/- 9 years (p less than 0.01); there was a greater proportion of men in that group: 76 p. 100 vs 58 p. 100 (p less than 0.01); more patients had a history of myocardial infarction: 7 p. 100 vs 0.5 p. 100 (p less than 0.05); calcifications of the coronary arteries were found in 43 p. 100 of the cases as against 15 p. 100 in group I (p less than 0.001); the transvalvular pressure gradient was lower: 50 +/- 30 mmHg vs 72 +/- 31 mmHg (p less than 0.01). There were no other significant differences in risk factors between the two groups, except for overweight which was greater in group II. Attacks of angina were not statistically more frequent in group II (80 p. 100) than in group I (73 p. 100, N.S.). A multifactorial analysis enabled us to establish a discriminant relation involving the patient's age, sex and history of infarction as well as coronary calcifications.(ABSTRACT TRUNCATED AT 250 WORDS)

The morphologic and hemodynamic datas are compared in 24 patients with mitroaortic valvular cardiopathy. The morphologic study was carried out on left ventricular biopsies and consisted first of all in ultrastructural analysis. Thus, 5 degrees of alterations were determined with regard to myofibrillar and, accessorily, to mitochondrial changes. The microscopic data, especially rarefaction of the Z material on semifine sections stained with Toluidine Blue and the demonstration of phospholipids by staining with acid hematein, are consistent with the ultrastructural gradient. Also, in cases with the most advanced electronic gradient, histoenzymology revealed important anomalies in the activity of the myofibrillar ATPase and of the S.D.H. The correlation between the so-established morphologic gradient and the preoperative hemodynamic data proved satisfying in the majority of cases which points out the interest of the morphologic tests for the appreciation of the functional value of the myocardium.

The case reported here concerns a female of 33 who presented, during the course of an acute bacterial aortitis which had been treated, with an inflammatory perforation of the membranous septum. The clinical picture consisted of an association of very severe heart failure with severe aortic incompetence, an apical pansystolic murmur, and atrioventricular conduction defects. Although it was carried out in the presence of active endocarditis (valve cultures positive for streptococci), operative intervention (Patch + Starr) allowed rapid healing and excellent cardiovascular function after a 30 month follow-up period. Careful study of this case and of the eleven others in the literature has enabled us to underline the following points:--the sudden appearance, in a case with infective aortic incompetence, of a gross pansystolic murmur associated with atrial or intraventricular conduction defects, should be taken as suggesting a septal perforation;--examination of the haemodynamic system in such a case runs certain risks, and should never be allowed to delay the operation, which must always be carried out urgently;--despite the unfavourable operative conditions, the results strongly support the need for surgical intervention in these patients in good time.

The aim of this study was to assess the outcome of 79 patients operated for chronic, pure, severe aortic incompetence with little or no symptoms (Grades I or II of the NYHA Classification). The average age of the patients was 42 years (range 14 to 76 years) and the average follow-up period was 59.4 months (range 3 to 190 months). The preoperative left ventricular volumes on angiography were: end diastolic volume 224 +/- 47 ml/m2, end systolic volume 121 +/- 39 ml/m2. The ejection fraction was 48 +/- 10 p. 100. Forty two mechanical prostheses and 37 bioprostheses were implanted. There were no operative deaths. The 8 year survival rate was 87 p. 100. Ninety four per cent of the survivors remained asymptomatic; 91 p. 100 have had no thromboembolic complications and 90 p. 100 have not been reoperated. The incidence of myocardial dysfunction was 8.8 p. 100 during this period. The most significant poor prognostic factor was a preoperative ejection fraction of less than 40 p. 100. These results show that early surgery in patients with aortic incompetence and little or no symptoms has a low operative risk and a low incidence of late myocardial dysfunction despite severe left ventricular dilatation with decreased left ventricular function.

The timing of surgery in chronic aortic regurgitation depends to a large extent on the operative results that may be expected in this type of valve disease. In 88 cases of chronic aortic regurgitation submitted to surgery there were 6 operative deaths (6.8%). Five years after operation the actuarial survival was 58% for the whole of the group and 68% for cases of rheumatic aortic regurgitation. Analysis of the causes of failures, late deaths, persistence or recurrence of severe impairment of activity, and of serious disturbances of ventricular rhythm, showed that the most important cause was myocardial dysfunction, which was responsible for two thirds of the bad results. Analysis of the late prognosis as a function of the various pre-operative parameters revealed the bad influence of cardiomegaly as measured by radiological examination (cardio-thoracic ratio and cineangiography) and of disturbances in left ventricular function. The actuarial survival curves showed very significant differences according to whether the cardiothoracic ratio was greater or smaller than 58%, and according to the amount of heart failure pre-operatively. Similarly, an end-diastolic volume index of 240 ml/m2 and an ejection fraction less than. 40 seemed to be serious findings. These facts, taken in conjunction with the natural history of this valve lesion, suggest that the indications for surgery should not only be symptomatic aortic regurgitation but also well tolerated regurgitation in which cardiomegaly, end-diastolic volume and/or the ejection fraction have reached a certain level.

The long-term prognostic factors which determine the indications for surgery are studied on the basis of a series of 198 cases operated for chronic aortic incompetence, in terms of their influence on the actuarial long-term mortality rate due to heart disease and irreversible myocardial dysfunction. The mortality in the first month after surgery is 5 per cent. The factors which significantly modify the long-term outcome of operated patients are clinical (cardiomegaly, degree of preoperative heart failure, ventricular extrasystole, functional grade) and haemodynamic (mean pulmonary artery pressure, end-systolic and-end diastolic left ventricular pressures, left ventricular ejection fraction). Multifactorial studies have shown that ventricular dilatation is the most important prognostic factor. Left ventricular function is severely altered, even in patients with few or no symptoms, but, in the absence of marked functional disturbance, the prognosis is usually good, whatever the repercussions on the myocardium. Surgery should be performed routinely in patients with severe functional disturbance, in the absence of reliable individual criteria capable of predicting when the indications have been exceeded. Surgery is also legitimate in patients with few or no symptoms when investigations reveal severe effects on the left ventricular function.

The long-term results and the prognostic factors in aortic valve replacement for aortic stenosis were assessed from a series of 249 operated cases (comprising 199 pure or dominant stenosis and 50 mixed aortic lesions) followed up for a maximal period of 9 years. The postoperative survival rate, 71% at 5 years, 62,6% at 8 years, including the operative mortality, is better than in a comparable series of pure chronic aortic incompetence (58% at 5 years) despite a higher average age. In the same age group the difference is significant at the 6th year. However, no difference was observed between mixed aortic disease and aortic stenosis. Irreversible myocardial dysfunction is relatively rare (6,6% of survivors at 1 month, 24% of poor results or late deaths) and much less common than in aortic incompetence of which it represents the main cause of failure. Even in these cases, prolonged symptomatic improvement may be observed. 3 prognostic factors affect the operative and late mortality. They act to variable degrees and independantly of each other. They are : age, cardiomegaly and heart failure. The actuarial 5 year survival is: 81,77% and 53% for under 50, 50 to 65 and over 65 years age group respectively; 88%, 78% and 48% for cardiothoracic ratios of less than 0,50, between 0,50 and 0,58 and greater than 0,58 respectively; 83%, 65% and 47% for patients without signs of heart failure, with a history of pulmonary oedema, and with a history of congestive cardiac failure respectively. These results encourage a liberal attitude towards surgery, even in old patients with severe valvular lesions.

The effects of age on the risks and results of heart valve replacement are often discussed in aortic stenosis, a degenerative condition of elderly patients. We assessed this factor in a study based on two groups of patients operated consecutively between 1968 and 1980. Group A comprised 127 patients of over 65 years of age (range 66 to 79 years, mean 70 +/- 3 years), and Group B: 259 patients of less than 65 years of age (21 to 65 years, mean 53 +/- 9 years). Preoperative assessment showed a higher proportion of women and significantly more severe lesions in Group A: a greater number of patients in functional class 3 or 4, cases of congestive cardiac failure, greater cardiac volumes, lower cardiac index. The incidence of coronary artery disease was also higher. A greater number of aortic valve bioprostheses was used in Group A. Operative mortality was significantly higher in Group A (15 p. 100, compared to 6 p. 100 in Group B: p less than 0.01). The influence of age was independent of other risk factors as shown by a multifactorial analysis taking several prognostic factors into account simultaneously. Long term survival was significantly lower in Group A, but their life expectancy did not differ from that of a control group. The causes of postoperative or late death were the same in both groups. At the end of the 6th year, 66 p. 100 of the survivors of surgery in Group A were in functional classes I or II compared to 77 p. 100 in Group B (NS). These results justify this type of surgery in elderly patients, even at advanced stages of their disease.(ABSTRACT TRUNCATED AT 250 WORDS)