The ischemic mitral regurgitation is defined by a left ventricular muscle disease affecting the function of normal mitral valve leaflets. This kind of mitral regurgitation is founded in about 20% of the ischemic cardiomyopathy and is attributed to the remodelling of the left ventricular shape. Its development is associated to a significantly worse prognosis. Frequently this ischemic mitral regurgitation will be associated to episode of acute heart failure decompensation. Its diagnosis is sometimes challenging as the degree of regurgitation might be extremely variable and affected by loading conditions. Echocardiography and especially exercise stress echocardiography has been demonstrated as an extremely powerful tool for its diagnosis and the prognostic evaluation. Its treatment should include the pharmacological treatment of the chonic heart failure and we are still waiting data in regard to the prognostic role of surgical mitral valvuloplastie. Works are still ongoing.

L'insuffisance mitrale ischémique est une fuite qui affecte une valve structurellement normale: de ce fait, elle constitue plus une «ventriculopathie» qu'une valvulopathie. Elle affecte environ 20% des cardiopathies ischémiques, et est secondaire au remodelage ventriculaire gauche défavorable post-infarctus. Sa présence grève lourdement le pronostic à court et à long terme, et est pourvoyeuse de fréquentes décompensations cardiaques. L'importance de la fuite est variable en fonction des conditions de charge, de l'activité, du traitement médical… ce qui rend son évaluation échocardiographique difficile. Les récentes avancées de l'échocardiographie ont permis d'améliorer la prise en charge de cette pathologie: ainsi, l'échocardiographie tridimensionnelle a permis d'en mieux comprendre les mécanismes et l'échocardiographie d'effort, d'en déterminer des facteurs de mauvais pronostic permettant d'identifier une population à haut risque d'évènements cardiovasculaires. Le traitement médicamenteux de l'insuffisance cardiaque permet de diminuer l'importance de la régurgitation, mais n'a aucun effet curatif. Le traitement chirurgical, basé sur la revascularisation et la plastie valvulaire, améliore le pronostic et les résultats de l'intervention semblent meilleurs depuis l'introduction de nouvelles techniques chirurgicales de plastie mitrale. Cependant, le risque opératoire élevé chez ces patients peut parfois amener à discuter d'autres techniques moins à risque, dont certaines sont encore en évaluation.

Objectives: This study compared chronic right ventricular (RV) pacing at the septum versus apex. Background: Chronic RV apical pacing may be detrimental to ventricular function. This randomized, pilot study examined whether, compared with apical, permanent septal pacing preserves cardiac function. Methods: Ablation of the atrioventricular junction for permanent AF, followed by implantation of a DDDR pacemaker connected to two ventricular leads was performed in 28 patients. One lead screwed into the septum and another placed at the apex were connected to the atrial and ventricular port, respectively. Septum or apex was paced by programming AAIR or VVIR modes, respectively. Patients were randomly assigned, 4 months later, to pacing at one site for 3 months, and crossed over to the other for 3 months. New York Heart Association class, QRS width and axis, left ventricular ejection fraction (LVEF), exercise duration, and peak oxygen uptake were measured. Results in patients with LVEF >45% and ≤45% were compared. Results: Septal pacing was associated with shorter QRS (145 ± 4 msec vs 170 ± 4 msec, P < 0.01) and normal axis (40°± 10° vs −71 ± 4°, P < 0.01). At 3 months, among patients with baseline LVEF ≤45%, LVEF was 42 ± 5% after septal pacing versus 37 ± 4% after apical pacing (P < 0.001). Conclusion: In contrast to RV apical pacing, chronic RV septal pacing preserved LVEF in patients with baseline LVEF ≤45%.

s S55 Eur J Echocardiography Abstracts Supplement, December 2006 analysed by 2 separate observers. TOE and RT-3DE images were acquired digitally on the Phillips IE33 ultrasound machine and stored for off line analysis. The RT-3DE datasets were analysed with Phillips Qlab software (version 4.0). Leaflet segments and commissures were displayed in short axis en-face and long axis views. Echocardiographic results were validated intraoperatively. Results: Five patients did not have image quality suitable for analysis with RT-3DE and were excluded from analysis. This left a sample size of 39 patients (mean age 52±11 years, 19 male). Twenty five patients had mitral valve repair and 9 mitral valve replacement. In total, 54 out of 334 analysed mitral valve segments were diseased. Prolapse of a single mitral valve segment was present in 25 patients. 14 patients had complex disease involving 2 or more segments. Sensitivity, specificity and accuracy for TOE in identification of diseased segments were 94%, 100% and 96% respectively. The same values for RT-3DE were 91%, 100%, 94%. The differences were not statistically significant. Accuracies were not significantly different according to segment location. Ruptured chordae was confirmed at surgery in 20 patients. Sensitivity for the diagnosis of ruptured chordae was 90% for TOE and 72% for RT-3DE (p=0.03). Specificity was comparable by both techniques (89% TOE vs 83% RT-3DE). Interobserver agreement was 92% (for TOE (k=0.85) and 86% for RT-3DE (k=0.83, p=non significant). The mean procedure time for TOE was 27±6 minutes. This was significantly longer than the procedure time for RT-3DE (7±3 minutes, p=0.03). The mean 3D reconstruction time was 15±8 minutes. Conclusions: RT-3DE is feasible with comparative accuracy to TOE for precise anatomical localisation of prolapsing mitral valve segments. However, the technique is limited by poor image quality in a small proportion of patients. TOE remains superior for diagnosis and localisation of chordal rupture.

Cardiac resynchronisation therapy (CRT) is indicated in refractory cardiac failure with electrical asynchrony defined by QRS complexes > or =120 ms duration. The search for mechanical asynchrony is proposed for better selection of patients for CRT. Ischaemic and non-ischaemic cardiomyopathy do not necessarily show the same form of asynchrony. The authors studied the differences in correlation between electrical and mechanical asynchrony in these two patient populations. Fifty patients (34 dilated non-ischaemic and 16 ischaemic cardiomyopathy) in NYHA Classes III and IV, LVEF < 35%, consecutively implanted for CRT in 2004, were included. The trans-thoracic echocardiography, the ECG and clinical parameters (NYHA, 6 minute walk test, VO2 max) were compared. A non-significant improvement of the correlation between the aortic pre-ejection time and QRS duration was observed in the non-ischaemic group (r = 0.78, p< 0.0001) compared with the ischaemic cardiomyopathy group ( r = 0.56, p = 0.019). Similarly, intraventricular asynchrony seemed to be correlated with the duration of QRS in the non-ischaemic group (r = 0.65, p < 0.0001) unlike the ischaemic cardiomyopathy group (ns). Sub-group analysis of patients with QRS durations < 150 ms and > or =150 ms showed an electromechanical correlation irrespective of the QRS duration in the non-ischaemic group but this was only observed with the aortic pre-ejection time with QRS > or =150 ms in the ischaemic group. The authors conclude that there is a significant correlation between electrical and mechanical asynchrony in patients with non-ischaemic cardiomyopathy. This correlation only applies to intraventricular asynchrony with QRS durations > or =150 ms in the ischaemic group. A decision for CRT requires echocardiographic evaluation in ischaemic cardiomyopathy.

L’echocardiographie est utilisee quotidiennement en milieu hospitalier comme en pratique liberale pour quantifier la fonction ventriculaire gauche. Nous abordons ici, l’etude de la fonction contractile et non les proprietes de relaxation du ventricule gauche. Il est usuel d’utiliser le mode TM (temps-mouvement) et la mesure de la fraction d’ejection par voie apicale. Recemment, le mode 3-D temps reel a ete propose, ainsi que l’utilisation des produits de contraste pour ameliorer la fiabilite et la reproductibilite des mesures de la fonction globale du ventricule gauche. Une approche regionale est aussi possible et repose aujourd’hui essentiellement sur l’etude en post-traitement des vitesses et des deformations myocardiques regionales.

Transoesophageal echocardiography has shown a high incidence on non-obstructive thrombosis after mitral valve replacement with a mechanical prosthesis. The unpredictable outcome and the period during which the complication arises make treatment difficult. The aim of this study was to assess the tolerance and efficacy of the association of long-term heparin and oral anticoagulation, as recommended in this indication.All patients undergoing mitral valve replacement with a mechanical prosthesis between June 1999 and July 2001 were systematically included and studied by transoesophageal echocardiography in the immediate postoperative period. Those with non-obstructive thrombosis at least 5 mm in size were treated by heparin and oral coagulation until the thrombus disappeared on transoesophageal echocardiography.One hundred and fourteen patients undergoing 120 mitral valve replacements (6 reoperations) underwent transoesophageal echocardiography and non-obstructive thrombi measuring at least 5 mm were found on 26 occasions (21.7%). The association of heparin and oral coagulation was maintained for 7 to 115 days (average 20 days). No thromboembolic or haemorrhagic complications and no deaths were observed during this period. Two patients were treated with danaparoid and oral anticoagulation because of heparin-induced thrombocytopenia before the diagnosis. None of the patients died during follow-up (average 49 months); there were 4 recurrent non-obstructive thromboses, three of which were complicated by thromboembolic events with no sequellae in the first 8 months, again treated effectively with the association of heparin and oral anticoagulants; two cerebral embolic events without sequellae were observed without a demonstrable non-obstructive thrombus on transoesophageal echocardiography.The authors conclude that the association of heparin and oral anticoagulants seems well tolerated and effective in this small population and this would justify a large scale clinical trial.

Objectives: To identify predictors of operative and postoperative mortality and of functional reversibility after aortic valve replacement (AVR) in patients with aortic stenosis (AS) and severe left ventricular (LV) systolic dysfunction.Methods and results: Between 1990 and 2000, 155 consecutive patients (mean (SD) age 72 (9) years) in New York Heart Association (NYHA) heart failure functional class III or IV (n=138) and with LV ejection fraction (LVEF)<= 30% underwent AVR for critical AS (mean (SD) valve area index 0.35 (0.09) cm(2)/m(2)). Thirty day mortality was 12%. NYHA class (3.7 (0.6) v 3.2 (0.7), p=0.004), cardiothoracic ratio (CTR) (0.63 (0.07) v 0.56 (0.06), p<0.0001), pulmonary artery systolic pressure (63 (25) v 50 (19) mm Hg, p=0.03), and prevalence of complete left bundle branch block (22% v 8%, p=0.03) and of renal insufficiency (p=0.001) were significantly higher in 18 non-survivors than in 137 survivors. In multivariate analysis, the only independent predictor of operative mortality was a CTR >= 0.6 (odds ratio (OR) 12.2, 95% confidence interval (CI) 5.4 to 27.4, p=0.002). The difference between preoperative and immediate postoperative LVEF (early-Delta EF) was >10 ejection fraction units (EFU) in 55 survivors. In multivariate analysis, CTR (OR 5.95, 95% CI 3.0 to 11.6, p=0.006) and mean transaortic gradient (OR 1.05, 95% CI 1.0 to 1.1, p<0.05) were independent predictors of an early-Delta EF>10 EFU. During a mean (SD) follow up of 4.6 (3) years, 50 of 137 (36%) 30 day survivors died, 31 of non-cardiac causes. Diabetes (OR 3.8, 95% CI 2.4 to 6.0, p=0.003), age >= 75 years (OR 2.6, 95% CI 2.1 to 4.5, p=0.004), and early-Delta EF <= 10 EFU (OR 0.96, 95% CI 0.94 to 0.97, p=0.01) were independent predictors of long term mortality. Among 127 survivors, the percentage of patients in NYHA functional class III or IV decreased from 89% preoperatively to 3% at one year. The decrease in functional class was significantly greater in patients with an early-Delta EF>10 EFU than patients with an early-Delta EF <= 10 EFU (p=0.02). In addition, the mean (SD) LVEF at one year was 53 (11)% in patients with an early-Delta EF>10 EFU and 42 (11)% in patients with early-Delta EF <= 10 EFU (p<0.001).Conclusions: Despite a relatively high operative mortality, AVR for AS and severely depressed LVEF was beneficial in the majority of patients. Early postoperative recovery of LV function was associated with significantly greater relief of symptoms and longer survival.