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J Acar

Publications and source records attributed to J Acar.

At least 19 recordsLinked to original sources
PubMed1992

[Percutaneous mitral commissurotomy].

Since it was introduced, in 1984, as an alternative to surgical commissurotomy, percutaneous balloon mitral commissurotomy has been performed in a large number of patients with mitral valve stenosis, significantly improving the valvular function with a final area of 2 square centimetres. The quality of the result obtained basically depends on valve anatomy. The incidence of complications is globally low, with a mortality of 0.5 to 3 percent, and severe mitral regurgitation in 5 percent of the cases. Left-to-right atrial shunts are detected by oxymetry in 20 percent of the patients, but they subsequently vanish in two-thirds of them. For the moment, only medium-term results are available: when the initial result is good functional improvement is the rule, and the incidence of restenosis is low. Conversely, when the result is insufficient or severe mitral regurgitation develops secondary surgery is usually necessary. Before deciding to perform percutaneous commissurotomy, the contre-indications of this method (left atrial thrombosis, moderate to severe mitral insufficiency) must be excluded. In view of the encouraging results obtained, percutaneous commissurotomy can be advocated as first-line treatment of soft valve mitral stenosis. In patients with calcified valve mitral stenosis, valve replacement remains the principal treatment, percutaneous commissurotomy being reserved for special cases.

Adult↗
PubMed1992

Ventricular arrhythmias in aortic valve disease before and after surgery.

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, p < 0.01, a higher LV mass (178 +/- 32 g/m2 vs. 142 +/- 35 g/m2, p < 0.001) and a lower left ventricular ejection fraction (48% +/- 9% vs. 56.5% +/- 10%, p < 0.001); while in patients with aortic regurgitation a higher end-diastolic LV volume (224 +/- 38 ml/m2 vs. 178 +/- 42 ml/m2, p < 0.02) and a higher end-systolic LV diameter (56 +/- 7 mm vs. 46 +/- 8 mm, p < 0.02) were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic Valve↗
PubMed1992

[Should mitral valve diseases, without or with few symptoms, be treated surgically?].

Our approach to the treatment of valvular heart disease, and mitral valve disease in particular, has been deeply modified by the experience acquired since the introduction of cardiac surgery and the technical advances in this field in the last decade and by new methods of investigative and interventional cardiology. In pure severe mitral regurgitation alone, the treatment of choice is reconstructive surgery. In the experience of our group, 191 patients out of 342 operated since 1970 for this type of valve lesion were referred for reconstructive surgery. Taking the results into consideration (72% 15 year survival), it is now justified to refer patients at a stage when the valvular disease is asymptomatic or pauci-symptomatic. A certain number of factors has to be assessed to evaluate the surgical indication: the experience of the surgical team, the etiology of the mitral regurgitation, the type of anatomical lesion, the stage of the cardiac disease and the patient's age. In mitral stenosis, in preference to surgical commissurotomy, percutaneous mitral valvuloplasty may be proposed in certain asymptomatic or pauci-symptomatic patients if the stenosis is severe, if the anatomical lesions are optimal and if there is a hemodynamic (pregnancy) or thromboembolic risk (arrhythmias, spontaneous contrast on transoesophageal echocardiography). In mixed mitral valve disease or very calcific stenoses, analysis of long-term results of valve replacement indicates that the late prognosis depends more on the stage of the cardiac disease at the time of surgery than on the type of prosthesis. It is advisable not to wait until an advanced stage before operating these patients when the valvular dysfunction is severe and there are hemodynamic consequences.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

[Other indications of thrombolysis: thrombolysis in the elderly, late thrombolysis].

Thrombolytic therapy has been shown to preserve left ventricular function and reduce mortality in the acute phase of myocardial infarction. When the usual inclusion criteria are respected, only about 30% of patients can benefit from this form of treatment. The "excluded" cases are more numerous and have a worse prognosis. This has led to a review or the indications, especially with respect to age and the maximum time delay before instituting treatment. The data currently available comes mainly from large from retrospective analyses of subgroups taken from large scale thrombolytic trials, and must be confirmed by randomized studies specifically designed to analyse these problems. In elderly patients, the benefits in terms of mortality are important but the haemorrhagic risk is also greater and has to be accurately evaluated. Age by itself should not be considered to be an absolute contraindication to thrombolytic therapy which may be undertaken in elderly patients with large infarcts after having carefully excluded the other contraindications frequently observed in this age group. Late thrombolysis probably acts by mechanisms other than limitation of infarct size. The results are less impressive than when thrombolysis is instituted early require confirmation by the randomised studies currently under way. However, at present, is seems justified to prescribe thrombolytic therapy after the 6th hour in patients with large infarcts who continue to have chest pain. The limitations of thrombolytic therapy with regards to age and delay of administration should, therefore, be reconsidered taking into account the individual risk benefit ratio.

Age Factors↗
PubMed1992

[Prognosis of reoperation for prosthesis dysfunction].

Between 1969 and 1990, 75 adults living in mainland France underwent reoperation for bioprosthetic valve dysfunction. The average time between the initial operation and reoperation was 65 +/- 41 months. The average age was 44 years and half of the patients were severely symptomatic (NYHA Stages III or IV in half the cases). Dysfunction of an aortic valve prosthesis was observed in 65% of cases (N = 49) and of a mitral valve prosthesis in 35% of cases (N = 26). The causes of reoperation were: 50 primary degenerations (67%), 19 infectious endocarditis (25%) and 6 perivalvular leaks (8%). Valve replacement was performed in 74 cases and suture of the sewing ring in 1 case. An associated procedure was performed in 24 cases: 12 drainage of abscess, 10 double valve replacements and 2 tricuspid valvuloplasties. The operative mortality was 9.3% and early morbidity was 46%. Univariate and multivariate analysis identified two factors predictive of operative mortality: the duration of cardiopulmonary bypass and the cardiothoracic ratio. During follow-up, which lasted 36 +/- 31 months, there were 12 deaths, 4 of cardiac failure; 4 sudden deaths, 3 deaths related to the prosthesis and 1 extracardiac death. The 6 year actuarial survival rate was 71%. The cardiothoracic ratio, the preoperative ejection fraction and the bypass time were factors predictive of global showed bypass time and the cardiothoracic ratio to be prognostic factors. The 6 year survival without cardiac events was 40%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Features of patients with severe mitral stenosis with respect to atrial rhythm. Atrial fibrillation in predominant and tight mitral stenosis.

The aim of this study was to assess the features of patients with severe mitral stenosis in relation to atrial rhythm. Six hundred and fifty patients (pts) with severe mitral stenosis (MS) (valve area less than or equal to 1.5 cm2) who underwent percutaneous balloon commissurotomy (n = 600) or surgery (n = 50) were classified into 3 groups according to their atrial rhythm (AR): group A: sinus rhythm (SR) (n = 379), group B: SR with episodes of transient atrial fibrillation (AF) (n = 65), group C: permanent AF (n = 206). Uni- and multivariate analysis of clinical, echocardiographic and hemodynamic parameters with respect to the atrial rhythm was performed. Some parameters were comparable in all 3 groups: sex, pulmonary, right and left atrial pressures, mitral valve area, incidence of associated aortic valve disease. Nine parameters were different: mean age, NYHA class III or IV, previous commissurotomy, previous embolism, cardiac index, mitral regurgitation, tricuspid regurgitation, left atrium diameter, mitral calcification. Multivariate analysis, identified age, left atrial diameter and presence of mitral calcification as independent predictors of atrial fibrillation. Transoesophageal echocardiography was performed in 167 cases. A spontaneous echo contrast was recorded in 106 cases (63.5%) and was significantly correlated with a history of embolism and or left atrial thrombi detected by echocardiography. Atrial fibrillation, size of left atrium, severity of mitral stenosis and cardiac index were found to be independent predictive factors of spontaneous echo contrast.

Adult↗
PubMed1992

Ventricular arrhythmias in aortic valve disease before and after aortic valve replacement.

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.

Adult↗
PubMed1992

[Etiologic course of heart valve diseases surgically treated during 20 years in France].

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).

Adult↗
PubMed1991

Long-term results of mitral valve repair for non-ischaemic mitral regurgitation.

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.

Adolescent↗
PubMed1991

Indications for surgery in mitral regurgitation.

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.

Aged↗
PubMed1991

Transoesophageal echocardiography in the assessment of percutaneous mitral commissurotomy.

The aim of this study was to assess the value of transoesophageal echo (TEE) in comparison with transthoracic echocardiography (TTE) in selecting candidates and evaluating the results of percutaneous mitral commissurotomy (PMC). One hundred and ten patients (pts) were examined by TEE and TTE before PMC. PMC was not performed in eight pts who had a thrombus in the left atrium detected by TEE but not by TTE. Out of the 102 other pts, TEE was better than TTE in detecting mild mitral regurgitation (MR) (84 vs 38, P less than 0.01). Spontaneous contrast was only shown by TEE in 70 pts. On the other hand, planimetry of the valvular area was only possible with TTE. This technique was also better in the assessment of the commissural area. During PMC, TEE enabled the interatrial septum to be punctured in two pts. After PMC, MR was trivial in 49 TEE cases compared with 36 by TTE and was moderate in 20 TEE pts compared with 12 by TTE (P less than 0.02). Transoesophageal colour Doppler showed a trivial atrial shunt in 63% of cases vs 13% by TTE (P less than 0.01).A small atrial septal defect was found in 30 cases only by TEE, and a spontaneous contrast persisted in all pts but six with moderate MR. In conclusion, TEE provides useful information in the ultrasonic assessment of PMC in particular with left atrial thrombi, mitral regurgitation, and the post PMC atrial septal defect. However, both methods are complementary and only TTE enables calculation of valve area.

Adult↗
PubMed1991

Diagnosis of left atrial thrombi in mitral stenosis--usefulness of ultrasound techniques compared with other methods.

The purpose of this study was to evaluate various methods of diagnosis of left atrial thrombi (LAT) in patients (pts) with mitral stenosis (MS). From 1980 to 1990, 581 pts with MS have undergone open mitral commissurotomy (n = 169) or valve replacement (n = 412). All pts had transthoracic 2D echocardiography (TTE), 101 transoesophageal echocardiography (TEE), 192 a left atrial angiography (A) (from a left ventricular injection if associated mitral regurgitation grade 3 (n = 154) or from an injection in the pulmonary artery (n = 38) and 229 a coronary angiography (CA). Tomodensitometry (TD), nuclear magnetic resonance (NMR) and 111 Indium platelet imaging (IPI) were performed in some cases, 2, 8 and 5 respectively. All these examinations were carried out in the month before surgery. LAT was found by the surgeon in 43 pts (7%). The site was left atrial appendage in 26 cases (60%) and left atrial cavity in 17 cases. Sensitivity (Se), specificity (Sp) of TTE/TEE/A/CA were the following: TTE, Se% 28, Sp% 99; TEE, Se% 83, Sp% 97; A, Se% 28, Sp% 99; CA, Se% 14, Sp% 100. Specificity was high with all methods but sensitivity was high only with TEE and poor with other methods because of difficulty in detecting thrombi of the left atrial appendage. Specificity and sensitivity of TD, NMR and IPI require more information. False-negative cases are possible with NMR (1 case) and IPI (1 case) in well established LAT. We conclude: TEE is the easiest way to detect LAT, particularly when located in the left atrial appendage. It should be carried out systematically before percutaneous mitral valvuloplasty or surgery.

Adolescent↗
PubMed1991

Immediate and mid-term results of percutaneous mitral commissurotomy.

The results of percutaneous mitral commissurotomy (PMC) were assessed in a series of 600 patients (pts) with mitral stenosis. Their mean age was 43 +/- 15 years (13-86). One hundred and eight had had a previous surgical commissurotomy; 464 were in NYHA class III or IV; atrial fibrillation was present in 188. One hundred and fifty-nine had valvular calcification and angiography disclosed a mild regurgitation (MR) (1/4) in 255. Technical failure occurred in 19 pts. In the remainder, PMC improved valve function: valve area (VA) increased from 1.1 +/- 0.3 cm2 to 2.2 +/- 0.5 cm2 (P less than 0.0001) as assessed by haemodynamics, and from 1 +/- 0.2 to 2 +/- 0.4 cm2 (P less than 0.0001) as assessed by two-dimensional echocardiography. Complications were as follows: death (0.5%), haemopericardium (0.8%), severe MR (3.8%), embolism (3.3%), atrial shunt (14%). Secondary surgery for complications following PMC was necessary in 4.8% of cases. There were poor results (VA less than 1.5 cm2 and/or MR greater than 2/4) in 13%; their predictors being valve anatomy (P less than 0.001), initial valve area (P less than 0.01) and previous surgical commissurotomy (P less than 0.05). Among the 437 pts resident in France, 98% were followed-up 15 +/- 11 months after PMC (range 1-48). After 42 months, the actuarial rates of survival, freedom from need for reoperation and good functional results were respectively: 87 +/- 6%, 81 +/- 3% and 72 +/- 6%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

[What type of heart valve prosthesis after age 70].

The choice of a valve replacement in patients over 70 years of age must take into account various parameters: the type of valve disorder being operated, the probability of post-operative survival in view of the stage of the valve disease and the age of the subject, and the advantages and draws-backs related to the replacements used. In the case of mechanical replacements, the main risks are related to the embolic and hemorrhagic problems inherent in anticoagulant treatment. In the case of biological replacements, the problems are related to the primary degeneration of these valves, which appears to be less frequent the higher the age. In patients over 75 years of age, bioreplacements have more advantages than mechanical valves. In subjects between 70 and 75 years of age, a mechanical valve can be recommended if there is no contraindication to anticoagulant treatment, if there is some other grounds for long-term anticoagulation and if the life expectancy appears to be greater than 10 years. In other situations, a bioreplacement is recommended.

Age Factors↗
PubMed1991

[Long-term results of surgical valvuloplasty for non-ischemic mitral insufficiency. Apropos of 155 cases].

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)

Actuarial Analysis↗