Percutaneous mitral valvuloplasty through a Carpentier-Edwards ring.

The authors report the case of a young girl with a Carpentier-Edwards annuloplasty ring for severe rheumatic mitral disease who presented 4 years later with mitral restenosis due to commissural fusion. She underwent successful percutaneous mitral commissurotomy with an Inoue balloon. Technical specificities and the safety of the procedure are briefly discussed.

Percutaneous mitral valvuloplasty in patients with low cardiac output at high surgical risk.

Among 1146 patients undergoing percutaneous mitral valvuloplasty for symptomatic mitral stenosis, 8 (4 men and women) were at high risk for surgery on the basis of the New York Heart Association functional class IV (n=8), severe pulmonary hypertension (n=5). All these patients aged 30+/-23.6 years had signs of right heart failure, high echocardiographic score (9.6+/-3.6) and low mitral valve area (0.50+/-0.19 cm(2)). The procedure resulted in an increase in mitral valve area (1.55+/-0.17 cm(2)) with a concomitant reduction in pulmonary artery systolic pressure (58.7+/-9.9 mm Hg) and decrease in tricuspid regurgitation. At follow-up (mean 14+/-3 months), one patient with renal failure... presented with a mitral restenosis is scheduled for mitral valve replacement, two patients with severe tricuspid regurgitation required tricuspid annuloplasty. In conclusion, percutaneous mitral valvuloplasty is feasible and safe in patients at high surgical risk and can be considered as an acceptable alternative to surgery.

[Left main coronary artery angioplasty: report of five cases illustrating the current indications]. / Angioplastie du tronc commun: a propos de cinq cas illustrant les indications actuelles.

OBJECTIVES: The purpose of our study is to illustrate by five original observations the various situations where the stenting of the left main coronary artery can be proposed in alternative to aortocoronary bridging with encouraging results in short- and long-term. MATERIALS AND METHODS: We report a retrospective study relating to five cases with left main disease treated by stenting between 1996 and 2002 at our institution. In two cases the left main stem was unprotected. In two other cases, the left main trunk was protected. And the last case was an emergency stenting for an iatrogenic dissection of the left main coronary artery. RESULTS: The stenting was carried out successfully among the five patients without major in-hospital complication. During the follow-up of 29 months at mean, no death was deplored, and no target lesion revascularization was required on the left main coronary artery (with a left main trunk permeable on three coronarographic controls). CONCLUSIONS: In the light of these results, and basing on the published data, we conclude that stenting for the left main coronary disease may be a safe and effective alternative to coronary artery bypass surgery in particular cases among "selected" patients (refusal or surgical contraindication, protected left main coronary artery, spontaneous or iatrogenic acute occlusion of the left main coronary artery).

[Percutaneous mitral commissurotomy and Lutembacher syndrome]. / Commissurotomie mitrale percutanée et syndrome de Lutembacher.

INTRODUCTION: Lutembacher syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. This condition is usually treated surgically by mitral valve operation with concomitant closure of the atrial septal defect. MATERIALS AND METHODS: Between 1993 and 2003, 4 patients with congenital Lutembacher syndrome had percutaneous mitral commissurotomy without closure of the atrial septal defect at our institution. The 4 patients were very symptomatic with right-sided heart failure signs and NYHA functional class III-IV. RESULTS: The procedure was carried out successfully for the four patients. Mitral valve area increased from 0.87 to 1.97 cm2 at mean; left atrial pressure decreased from 28.2 to 12.7 mmHg and the mean valve mitral gradient was reduced from 15.5 to 3.9 mmHg. Functional and clinical improvement was observed in all the cases. During a mean follow up of 55 +/- 29 months, our 4 patients remain pauci symptomatic under medical treatment. CONCLUSION: The percutaneous treatment of the Lutembacher syndrome is currently a possible alternative to the surgery among patients having an anatomy favourable to the procedure.

[Percutaneous transluminal renal angioplasty in hypertension]. / Angioplastie transluminale des artères rénales dans l'hypertension artérielle rénovasculaire.

The aim of our study was assess anatomical and functional results of renal artery angioplasty with and without stenting in 25 hypertensive patients (8 female and 16 male, 42.6 and 61.6 years old respectively) with significative renal artery stenosis (RAS) (atherosclerotic: 22; fibrodysplastic: 3). Eleven patients had simple angioplasty and 13 had stenting. The rate of angioplasty success was 96%. In the stent group, the anatomical result was better: 2% of residual stenosis versus 24% in the other group (p < 0.001). Restenosis occurred in 2 patients. Immediately after revascularisation arterial blood pressure decreased from 195/105 +/- to 150/85 +/- mmHg in-group without stent (p < 0.001) and from 190/100 to 145/85 mmHg in the group (p < 0.001). The value of serum creatinine concentration in patient with renal failure didn't change after revascularization.

[Homocysteine, lipoprotein (a): risk factors for coronary heart disease]. / Homocystéine, lipoprotéine (a): acteurs de risque de l'athérosclérose coronarienne.

Our data suggest that the hyperhomocysteinemia and/or increased plasma level of lipoprotein Lp(a) are risk factors for coronary heart disease. We investigated 178 patients who underwent complete cardiac examination comprising coronary angiography and biological analysis (CT, HDL-c, LDL-c, TG, and apoAI, apoB, homocysteine and Lp(a)). Patients presenting a significant stenosis of the coronary artery ( 50% of the vascular lumen) were considered as cases (113 patients). Those without stenosis or with non-significant stenosis (< 50% of the vascular lumen) were used as controls (65 subjects). Homocysteinemia was significantly higher in cases than in control subjects (8.26 mol/L (2.34 versus 17.85 (2.34, p < 0.001). A strong association between coronary heart disease and homocystein has been found (Eta(2) = 0.76). The OR were 0.16 when homocystein level was lower than 15 mol/L, and 27.78 when homocysteine level was upper than or equal to 15 mol/L. The RR was 5.16 (95% IC = 3.66-6.66, p < 0.001). Even though there was a significant correlation between tabagic impregnation and homocysteinemia (Spermann's rho = 0.37, p < 0.05), there was no interactive effect between these two factors and coronary disease (Wald khi2 = 0.086, p > 0.05). Therefore, no association was found between homocyteinemia and other coronary heart disease risk factors. The Lp(a) levels were significantly higher in cases than in controls subjects (188 (84 mg/L in control subjects versus 590 (199 in cases, p < 0.001). A stronger relationship was noted between coronary heart disease and Lp(a) (Eta (2) = 0.66). The OR were 0.09 when lipoprotein (a) levels were lower than 350 mg/L, and 5,88 when Lp(a) levels were higher than or equal to 350 mg/L. The estimate RR was 6.47 (95% IC = 4.39-8.55, p < 0.001). The level of Lp(a) was positively correlated with the severity of coronary heart disease (Spermann's rho = 0.95, p < 0.001). A weak correlation between Lp(a) and LDL-c was observed (Spermann's rho = 0.12, p = 0.048). But the multivariate analysis didn't show interactive effect between these two factors and coronary disease (khi2 de Wald = 0.264, p > 0.05). No association was noted between Lp(a) and the others risk factors. Moreover, a positive correlation between the levels of homocysteine and those of Lp(a) was found (Spermann's rho = 0.54, p < 0.001). In contrast their effect on coronary heart disease seems to be independant (Wald khi2 = 2.957, p > 0.05). Thus, these two parameters appear as independant risk factors for coronary heart disease.

Difficult percutaneous mitral commissurotomy: failure of the Inoue balloon technique and successful double-balloon technique.

From December 1994 to May 1999, 487 patients underwent percutaneous transvenous mitral commissurotomy according to the Inoue balloon technique for tight mitral stenosis. In three cases, the Inoue balloon technique was not possible because the catheter balloon could not enter the mitral orifice and the double-balloon technique was performed instead. In two cases, a flow-guided balloon catheter met the mitral orifice and the double-balloon technique was effective. In the third case, passing the valve with a flow balloon catheter was impossible, a 0.032" Terumo straight wire crossed the valve, which was dilated with a single balloon the first time and a double balloon the second time. The mitral valve area increased in the three cases from 0.8 to 1.8 cm2, from 0.7 to 1.6 cm2, and from 0.5 to 1.5 cm2, respectively. There were no complications.

[Angioplasty and endoprosthesis of the left coronary artery. Report of a case]. / Angioplastie et endoprothèse du tronc coronaire gauche. A propos d'un cas.

The authors report the case of a 70 year old woman followed up in our Department for ischaemic heart disease since 1991 and admitted to the Intensive Care Unit in November 1996 for unstable angina. Coronary angiography showed significant stenosis of the left main coronary artery, a severe stenosis of the LAD and occlusion of the right coronary artery. Angioplasty of the middle segment of the LAD and left main coronary arteries with implantation of a stent was performed because of resistance to medical therapy and a contra-indication to surgery. Four months later, recurrent anginal pain led to a repeat angioplasty of the LAD with a satisfactory immediate result. The initial procedure on the left main coronary artery was successful and follow up was uncomplicated.

[Percutaneous transluminal valvuloplasty in congenital pulmonary stenosis in adults. Apropos of 34 cases]. / Valvuloplastie transluminale percutanée des sténoses pulmonaires congénitales chez l'adulte. A propos de 34 cas.

Percutaneous pulmonary valvulotomy is the treatment of choice for isolated congenital pulmonary valvular stenosis in childhood. However, experience of this procedure in the adult is much more limited. Between January 1984 and December 1994, 34 patients with severe or moderate pulmonary valvular stenosis underwent percutaneous transluminal valvuloplasty. The age of the patients ranged from 20 to 47 years (mean 22 +/- 4 years). Cardiac catheterisation was performed using the femoral vein in 27 cases and the internal jugular vein in 7 cases. Success was obtained in 28 patients (81% of cases). Pulmonary artery-right ventricular pressure gradient decreased from 113 +/- 35 to 32 +/- 13 mmHg (p < 0.001) after valvuloplasty with one or two balloon catheters. The tolerance of transluminal valvuloplasty was generally good. The poor results were explained by cases of dysplasic valves or of infundibular reactions. There was one death which occurred 24 hours after the procedure. Clinical and echocardiographic follow-up was obtained in 20 patients, 3 to 36 months after valvuloplasty (average: 23 +/- 13 months). No cases of restenosis were observed. Percutaneous transluminal pulmonary valvuloplasty in the adult is feasible and gives good results which are maintained at medium-term; it has become the treatment of choice of valvular pulmonary stenosis and gives good results which are maintained at medium-term, thereby avoiding surgical valvulotomy.

[Coronary aneurysm in Behcet's disease. Report of a case]. / Anévrisme coronaire au cours de la maladie de Behçet. A propos d'un cas.

Cardiac involvement is rare in Behçet's disease. The authors report the case of a young patient with Behçet's disease and multiple cardiac complications. The remarkable feature of this case was the presence of a coronary artery (first diagonal) aneurysm associated with multiple venous thromboses. Anticoagulant therapy was changed for a platelet aggregant. Surgery was not indicated because of the fragility of the vessels.

[An experience of lipoprotein (a) dosage in a Moroccan population of 184 subjects]. / Expérience du dosage de la lipoprotéine (a) dans une population marocaine de 184 sujets.

One hundred and eighty-four patients underwent complete lipid analysis (total cholesterol, HDL and LDL cholesterol, triglycerides, apolipoproteins A1 and B, lipoprotein (a)) and coronary angiography, in order to evaluate the discriminant value of the lipoprotein (a). Subjects with non-significant coronary stenoses (< 50% of the lumen) were used as a control group (n = 84). The others were considered to be pathological. The total cholesterol, HDL cholesterol and triglycerides were measured by an enzymatic colorimetric method. The LDL cholesterol was calculated by Friedewald's formula. The apolipoprotein A1 and B were measured by immunoturbidimetry and the lipoprotein (a) by an Elisa. The results showed a relationship between the different lipid levels, especially between high lipoprotein (a), and the severity of the coronary disease. A quantitative and qualitative study showed no significant influence of the other risk factors on the mean lipoprotein (a) level. Gender and age had no influence. Therefore, the higher the lipoprotein (a) level, the greater was the coronary risk, independently of the other associated risk factors.

[Association of coronary-pulmonary fistula and intercoronary fistula. Apropos of a case]. / Association fistule coronaro-pulmonaire et fistule intercoronaire. A propos d'un cas.

The authors present the case of a 30-year-old woman admitted to hospital for investigation of a systolodiastolic murmur. Assessment revealed a fistula between the trunk of the left coronary artery and the pulmonary artery, with an aneurysm on the left anterior descending artery (LAD), associated with an intercoronary anastomosis between the left conus artery and the LAD. Thallium myocardial scintigraphy demonstrated reversible decreased uptake in the anterolateroapical region. Simple coronaro-pulmonary fistulas are a rare disease. The positive diagnosis is suggested by echocardiography and confirmed by coronary angiography. The clinical course is generally favourable, except in the presence of complications such as aneurysm, heart failure or coronary insufficiency. This case raises the difficult problem of the operative indication in these young, usually asymptomatic patients.

[Mitral valve prolapse and myocardial ischemia. Apropos of 2 cases]. / Prolapsus valvulaire mitral et ischémie myocardique. A propos de deux cas.

The authors report two cases of severe myocardial ischaemia with healthy coronary arteries associated with mitral valvular prolapse (MVP). The first case was a 43-year-old woman treated with beta-blockers following the discovery of MVP. This patient was admitted to hospital six months later with persistent chest pain in a context of cardiogenic shock. The response to treatment was rapid and spectacular. The second case was a 44-year-old hypertensive smoker man in whom assessment of chest pain revealed several signs of myocardial infarction as well as MVP. This rare combination of MVP and myocardial ischaemia raises pathophysiological as well as therapeutic problems.

[Hemangio-endotheliosarcoma of the right atrium]. / Hémangio-endothéliosarcome de l'oreillette droite.

In reporting a case of haemangiosarcoma of the right atrium the authors emphasize the problems encountered in the diagnosis of primary tumours of the heart. The patient was a 50-year old woman who complained of digestive disorders and palpitations. Physical examination showed signs of right heart failure associated with a systolic murmur on the right side of the sternum. ECG gave normal results. Echocardiography displayed a pouch with liquid ultrastructure communicating with the right atrium. Angiography confirmed the presence of a cavity with irregular borders communicating with the right atrium. Coronary arteriography showed an abnormal disorderly distribution of the right coronary artery branches with newly formed vessels extending toward the tumour. At exploratory thoracotomy a large liquid tumour was found which bled at the slightest touch and was attached to the mediastinum and the right pericardium. The pleura and the lung contained several nodules of the same venous colour as the mother tumour. Extemporaneous biopsy and pathological analysis were in favour of a haemangiosarcoma. The patient died a few days after the thoracotomy.

[Percutaneous transluminal valvuloplasty of mitral stenosis. Apropos of 17 cases]. / Valvuloplastie transluminale percutanée des sténoses mitrales. A propos de 17 cas.

Percutaneous mitral commissurotomy using balloon catheters was attempted in 17 patients (16 of whom were women) with rheumatic mitral valve stenosis. The patients' age ranged from 15 to 34 years (men 21 years). Functionally, 15 of the patients were in stage III of the New York Heart Association classification, and 2 were in stage II. Sinus rhythm was present in all cases. Slight mitral regurgitation was noted in 2 cases, associated with mild aortic disease in one of them; 3 other patients presented with slight aortic regurgitation. In all 17 cases the mitral stenosis was tight, uncalcified, with flexible valves and little or no alteration of the subvalvular system. One single balloon catheter was used in 11 patients and 2 balloon catheters were introduced simultaneously in the remaining 6 patients. The new therapeutic method was successful in all patients. Following valvuloplasty, the mean transmitral gradient was reduced from 25 +/- 3 to 11 +/- 2 mmHg (P less than 0.001), the mean capillary pressure fell from 26.8 +/- 7.1 to 13.5 +/- 3.7 mmHg (P less than 0.001) and the cardiac index increased from 3.3 +/- 1 to 4.2 +/- 1.2 l/min/m2 (P less than 0.001). The mitral valve area, measured by two-dimensional echocardiography, increased from 1.0 +/- 02 to 2.1 +/- 0.3 cm2 (P less than 0.001). The mitral valve regurgitation observed in 2 patients before valvuloplasty was aggravated, although still moderate, in one of them and remained stable in the other.

[Percutaneous transluminal valvuloplasty of pulmonary stenoses. Apropos of 35 cases]. / Valvuloplastie transluminale percutanée des sténoses pulmonaires. A propos de 35 cas.

Thirty-five patients with moderate or severe valvular pulmonary stenosis underwent percutaneous transluminal valvuloplasty (PTV). The average age of the patients was 12 years (range 4 to 34 years). Sixty per cent were under the age of 10, 20 p. 100 were between 10 and 17 years old and 20 p. 100 between 18 and 34 years old. Systolic right ventricular pressures were greater than the pressures in the systemic circulation in 22 cases. The right ventricular-pulmonary artery pressure gradient was greater than 50 mmHg in 29 patients and less than or equal to 50 mmHg in the other 6 patients. The diameter of the balloon of the dilation catheter varied from 12 to 20 mm in 31 PTV; in the other 4 cases two dilating catheters were used simultaneously to dilate the pulmonary valves. The tolerance of PTV was generally good and the results were satisfactory: right ventricular pressures (RVP) fell from 140 +/- 45 to 77 +/- 25 mmHg (p less than 0.001); the RV-PA pressure gradient fell from 82 +/- 40 to 32.4 +/- 15 mmHg (p less than 0.001) and the ratio of RVP to systemic pressure from 1.2 +/- 0.4 to 0.65 +/- 0.2 (p less than 0.01). Clinical and haemodynamic reevaluation in 19 patients 4 to 16 months after PTV (mean 8.5 +/- 2 months) showed that RVP, RV-PA pressure gradients and RVP/systemic pressure ratios had significantly decreased respectively from 78 +/- 30 to 52 +/- 14 mmHg (p less than 0.001), from 27.7 +/- 7.7 to 21.8 +/- 7.3 mmHg (p less than 0.02) and from 0.6 +/- 0.2 to 0.4 +/- 0.1 (p less than 0.001). Pulmonary valvuloplasty is well tolerated, safe and may reduce the number of patients requiring surgical valvotomy.

[Traumatic rupture of the right anterior sinus of Valsalva into the right ventricle combined with aortic regurgitation]. / Rupture traumatique du sinus de Valsalva antéro-droit dans le ventricule droit, associée à une insuffisance aortique.

We report the case of a 14-year old boy who was stabbed with a knife and sustained a chest wound responsible for clinical tamponade. Surgery was performed as an extreme emergency, so that lesions could not be assessed preoperatively. During the operation, beside the pericardial blood collection a wound of the pulmonary infundibulum was discovered and sutured (closed heart surgery). One year later the patient was readmitted for global heart failure. Auscultation of the heart revealed a continuous left latero-sternal murmur. Two-dimensional echocardiography showed discontinuity between the right anterior sinus of Valsalva and the right ventricular outflow tract. Contrast echocardiography displayed a negative jet image in the right ventricular outflow tract. At that level, pulsed doppler ultrasound recorded continuous turbulence as well as diastolic turbulence in the left ventricular outflow tract. Tiered oxymetry showed a left-to-right shunt in the right ventricle with a pulmonary/systemic flow ratio of 1.9. The diagnosis was confirmed by angiography which demonstrated a fistula between the right anterior sinus of Valsalva and the right ventricular outflow tract, and aortic regurgitation. In a second operation, performed under extracorporeal circulation, the traumatic lesions were repaired, and the patient thereafter recovered. This unusual case highlights the value of combined two-dimensional echocardiography, pulsed doppler ultrasound and contrast echocardiography in the diagnosis of traumatic ventriculo-aortic lesions.