Reform of the 3rd cycle in surgery training.

The main objectives of the reform of the 3rd cycle of medical studies in France that was instituted in 2017 after eight years of preparation, are to train future specialists in a consistent and equitable fashion and to replace the previous time-based qualification by training based on the progressive acquisition of skills. This reform was an opportunity for the 13 different French surgical specialty Colleges involved to share reflections on what a surgeon actually was and to define training in surgical sub-specialties. The current reform is well adapted to these specifications and has fostered training models that are consistent with each other. This article discusses the historical construction of this reform, what will change in the training of future surgeons, as well as some points that warrant caution. The third cycle reform has also triggered a reform of the second cycle, which is expected to come into force for the 2020 academic year. Its objective will be to eliminate the guillotine effect created by the National Classifying Examinations and to allow students to better understand and test their desire and skills for a given specialty. It will be up to these same surgical Colleges to determine how to do this for the sub-specialties of the "surgery" discipline.

Quality of Life of Children with Congenital Heart Diseases: A Multicenter Controlled Cross-Sectional Study.

To assess the health-related quality of life (QoL) in children with congenital heart diseases (CHD) with a validated questionnaire in comparison with control children. We prospectively recruited 282 children with CHD aged from 8 to 18 years in two tertiary care centers (France and Belgium) and 180 same-age controls in randomly selected French schools. Children's QoL was self-reported with the KIDSCREEN-52 questionnaire and reported by parents with the KIDSCREEN-27. QoL scores of each dimension were compared between CHD and controls and between the classes of disease severity. Both centers were comparable for most demographic and clinical data. Age- and gender-adjusted self-reported QoL scores were lower in CHD children than in controls for physical well-being (mean ± SEM 45.97 ± 0.57 vs 50.16 ± 0.71, p < 0.0001), financial resources (45.72 ± 0.70 vs 48.85 ± 0.87, p = 0.01), peers/social support (48.01 ± 0.72 vs 51.02 ± 0.88, p = 0.01), and autonomy in the multivariate analysis (47.63 ± 0.69 vs 49.28 ± 0.85, p = 0.04). Parents-reported scores were lower in CHD children for physical (p < 0.0001), psychological well-being (p = 0.04), peers/social support (p < 0.0001), and school environment (p < 0.0001) dimensions. Similarly, the disease severity had an impact on physical well-being (p < 0.001), financial resources (p = 0.05), and peers/social support (p = 0.01) for self-reported dimensions, and on physical well-being (p < 0.001), psychological well-being (p < 0.01), peers/social support (p < 0.001), and school environment (p < 0.001) for parents-reported dimensions. However, in multivariate analysis on self-reported QoL, disease severity was significantly associated with the self-perception dimension only. Self-reported QoL of CHD children was similar to that of same-age healthy children in seven of 10 dimensions, but parents-reported QoL was impaired in four of five dimensions.

Assessment of team training in management of adverse acute events occurring during cardiopulmonary bypass procedure: a pilot study based on an animal simulation model (Fouilloux, Team training in cardiac surgery).

BACKGROUND: Successful cardiac surgery is highly dependent upon effective and efficient teamwork. Practical training and development will further enhance the team ability to react to a series of low-frequency occurring adverse events during cardiopulmonary bypass (CPB). One of our specialized educational programs focuses on training the whole team. This training is based on an original animal simulation model. The objective of this pilot study was to assess our method of training and learning in an attempt to optimize and improve team management and functioning. METHODS: Four members of the same cardiac surgery team joined our program. They performed a common procedure, with a cardiopulmonary bypass (CPB) circuit set up to produce several adverse incidents. Events management was analyzed and debriefed in technical and non-technical perspectives. RESULTS: Management of the adverse events was significantly improved. Discussion and debriefing time was fundamental in identifying the most appropriate management for each event. Rescue procedures were assimilated and team training was found to be effective, with the time reduced by up to 50% for 3 events and by up to 70% for air embolism. CONCLUSION: Our pilot program is an innovative, low-cost tool for the improvement of the management of adverse events occurring during CPB. It includes the different components of surgical education and training. Such an educational tool might be relevant for training. To confirm those encouraging results, it should be assessed in a larger surgical team panel. Further investigations are required for assessing efficiency in real conditions.

Fetal heart disease and interruption of pregnancy: factors influencing the parental decision-making process.

OBJECTIVE: To identify factors influencing parental decision when a fetal cardiac disease is diagnosed. METHOD: All pregnancies with fetal cardiac abnormalities diagnosed at three academic hospitals of Marseille, France, between 2004 and 2008, were retrospectively studied. The association between maternal and fetal variables (maternal age, parity, ethnicity, gestational age at diagnosis, nuchal translucency, fetal gender, chromosomal and extra cardiac abnormalities, and severity of the cardiopathy) and parental decision was tested using univariate and multivariate statistical methods RESULTS: One hundred eighty-eight cases of fetal cardiac disease were analysed, of which 63 were interrupted pregnancies (IP) and 125 continued pregnancies (CP). Four factors were important in the parental decision-making process: the severity of cardiac malformation, the ethnic origin of the parents, the gestational age at diagnosis and the chromosomal abnormalities. CONCLUSION: Counselling of parents following the diagnosis of a congenital heart disease should take into account that, in addition of the severity of the congenital heart disease (CHD), ethnicity, gestational age at diagnosis and chromosomal abnormalities influence parental decision regarding pregnancy continuation or interruption.

[Infective endocarditis in children without underlying heart disease: a retrospective study analyzing 11 cases]. / Endocardite infectieuse sur coeur sain chez l'enfant: étude rétrospective de 11 cas.

The aim of our study was to determine the different characteristics of infective endocarditis in children without underlying heart disease. This was a descriptive, retrospective study including all cases of infective endocarditis without underlying heart disease occurring in children under 18 years of age, hospitalized at the Timone Children's Hospital in Marseille, France, between 1997 and 2008. The clinical, microbiological, and echocardiography data; treatment; and outcome were reviewed for each case. Over an 11-year period, 26 children were hospitalized with infective endocarditis. Eleven children (7 boys) had no underlying heart disease (42 %). Their mean age was 8 years and 3 months. Underlying conditions including neoplasm, preterm birth, and central venous catheter were found in 6 cases. A heart murmur was observed in 82 % of the children. A microorganism was isolated in 10 children (91 %). Staphylococcus aureus was the most common agent (45 %), followed by fungi (18 %). Echocardiography detected cardiac complications in 7 cases (64 %). Ninety-one percent of the children received intravenous antibiotics for a mean duration of 45 days. Eighty-two percent of our patients required surgical intervention. In our series, 91 % of the patients met the modified Duke criteria defining infective endocarditis. In-hospital mortality was 11 %. Embolic complications were seen in 5 cases (45 %), patients whose cultures yielded S. aureus or fungal organisms were more likely to present complications. Infective endocarditis without heart disease has particular features that differ from those of congenital heart disease. This diagnosis must be considered when predisposing factors are present.

[Candida albicans endocarditis after pulmonary artery banding]. / Endocardite àCandida albicans sur cerclage de l'artère pulmonaire.

Endocarditis is uncommon in infants and is exceptionally related to Candida albicans on pulmonary banding. We report on a case in a 7-month-old infant who had pulmonary artery banding for a ventricular septal defect and who presented with candidal endocarditis. Banding was chosen because of the patient's poor trophic and unstable status, which could be risky for surgery involving extracorporeal circulation. A few weeks after the banding, the patient developed systemic Candida infection, which was treated successfully. At 7 months, cardiac failure appeared without fever or inflammatory signs. Cardiac echography showed that the banding was not protective as well as a hyperechogenic image on the pulmonary bifurcation. The angioscan showed a hypodense thrombus. Emergency surgery was performed consisting of pulmonary artery exploration, thrombectomy, and ventricular septal defect closure. The exploration showed a pulmonary artery perforation caused by the infected pseudoaneurysm and the migration of the banding into the pulmonary artery. The anatomopathologic analysis of the vegetation identified multisensitive Candida albicans. After surgery and prolonged antifungal treatment, progression was satisfactory.

[A monocenter experience of ventricular septal defects treated by catherization]. / Expérience monocentrique de la fermeture par cathétérisme interventionnel des communications interventriculaires.

INTRODUCTION: Studies on ventricular septal defects closure by catheterization confirm its feasibility without reporting clearly the indications and difficulties encountered. PATIENTS AND RESULTS: From 2001 to end-2006, 22 patients benefited from 26 ventricular septal defects closure (15 muscular and 7 membranous) at a median age and weight of 2.1 years and 12.5 kg, respectively. A perventricular catheterization was performed in 2 cases. Eighteen patients (82%) benefited from 21 prostheses with success. The closure was associated to surgery in 9 cases (41%) whereas it substituted surgery in the other 13 cases (59%). The median duration of the procedure was significantly longer in case of muscular ventricular septal defects (215 min (175-510) vs. 170 min (120-225), p=0.04). Major complications are reported in 5 cases out of 26 catheterization (19%), including one death related to conduction block, occurring after the implantation of two prostheses in a patient with aortopulmonary transposition. All other associated cardiac diseases have been corrected. A prosthetic emboli occurred in one case, 1.5 months after implantation. It had been retrieved by catheterization. Two patients died afterwards from non-procedure-related causes. After a median follow-up of 1.1 years, the 17 other patients remained asymptomatic. One child with a perimembranous prosthesis presents a paroxystic atrio-ventricular block. CONCLUSION: Even though indispensable for the curative treatment of several congenital cardiac diseases including non-operable ventricular septal defects, this procedure is related to a substantial rate of mortality and morbidity. The risk of atrio-ventricular block must be adequately considered in case of membranous ventricular septal defects.

[Long-term results of complete atrio-ventricular canal correction]. / Résultats à long terme du traitement chirurgical du canal atrioventriculaire complet.

OBJECTIVES: To assess the prognosis of surgically corrected complete atrio-ventricular canal and determine risk factors for death and redo surgery. PATIENTS: and method: From January 1984 to March 2006, 126 patients were distributed in 3 groups according to their date of intervention: group I (1984-1991), group II (1992-1999) and group III (2000-2006). They were operated at mean age of 8.35 + 13.3 months. Down syndrome was present in 99 patients (79%). A partial or total closure of the left atrio-ventricular valvular cleft was performed in 47 patients (37%). RESULTS: The in-hospital mortality was at 14.28% (18 patients), including 23.7% in group I, 16.2% in group II and 4.4% in group III (p=0.06). The predictive factors of survival were the Down syndrome (p<0.05) and surgery of the left atrio-ventricular valvular cleft (p=0.05). An early reoperation was required in 6 cases, for a severe leak of this valve (n=4) or an important residual shunt (n=2). After a mean follow-up of 9.5+6.9 years, the survival rate was at 83.6% and 10 patients (9.9%) had a redo surgery for a leak of the left atrio-ventricular valve (n=6) or sub-aortic stenosis (n=4). The rate of no-redo surgery for valve insufficiency was at 94.2% at 5 years, 91.1% at 10 years and 87.6% at 15 years. CONCLUSION: The surgical treatment of complete atrio-ventricular canal became more and more efficient with poor rates of mortality and redo surgery during these last years. The closure of the left atrio-ventricular valve cleft, mostly partial, is frequently performed. Patients with the Down syndrome have a better vital prognosis and lower rates of long-term redo surgery.

[Rehabilitation of hypoplastic pulmonary arteries in pulmonary atresia with ventricular septal defect. Medium term results]. / Réhabilitation des artères pulmonaires hypoplasiques dans l'atrésie pulmonaire avec communication interventriculaire. Résultats à moyen terme.

The treatment of pulmonary atresia with ventricular septal defect, hypoplasia of the native pulmonary arteries and major aorto-pulmonary collaterals is controversial with a wide range of options from symptomatic treatment to surgical correction, but usually unifocal surgery. However, the collateral vessels used in the reconstruction are often tortuous and stenosed, resulting in a problematic haemodynamic result. The authors report the results of medico-surgical rehabilitation of the native pulmonary arteries in three stages. Since 1990, patients with an average Nakata index of 27.5 +/- 16.7 mm2/m2 underwent elective surgical connection of the native pulmonary arteries to the right ventricle (1st stage) followed by their rehabilitation with catheter occlusion of the collaterals (2nd stage) with the aim of preparing surgical correction (3rd stage). The first surgical stage at an median age of 5 months (0.1 to 25.2) was complicated by one death. After an average of 2.1 +/- 1 catheterisations, 17 patients underwent surgical correction at an median age of 2.18 (0.6 to 10.3) years with an average Nakata index of 207 +/- 91 mm2/m2. All survived surgery with three late deaths in patients with poor haemodynamic results (right ventricular/left ventricular pressure ratio>80%). After an median follow-up of 9.2 (3.5 to 17) years, the 14 survivors are in NYHA Class I or II with a good haemodynamic result in 10 patients. The authors conclude that despite some late deaths and raised right ventricular and pulmonary artery pressures in a minority of patients, the rehabilitation of the pulmonary arteries is an effective management of this cardiopathy.

[Medium and long-term results of anatomical correction of transposition of the great arteries in Marseille]. / Résultats à moyen et long terme de la correction anatomique de la transposition des gros vaisseaux à Marseille.

The object of this study was to evaluate the results of anatomical correction of transposition of the great arteries (TGA) in an inter-regional centre. The characteristics of 220 patients operated between 1985 and 2002 were analysed. Prenatal diagnosis of TGA was made in 38 patients (17%) including 36 of the 109 patients operated since 1995 (33%) and leading to earlier atrial septostomy in this situation (p= 0.046). Since 1995, the global early mortality of 12.3% has been significantly reduced to 5.5% (N= 6) including 4.4% (3/68 cases) of simple TGA (p= 0.002). In multivariate analysis, the only independent risk factor for early mortality was the occurrence of a major per-operative complication (p< 0.0001). The average follow-up was 4.8 +/- 4.5 years with an 86% survival at 5, 10 and 15 years and 97% survival at 5 years for patients operated after 1995. There were 22 reoperations including 14 on the right ventricular outflow tract. The non-reoperation rate at 10 years was 80% for simple TGA versus 70% in complex TGA (p= 0.0001). Survivors are asymptomatic with a normal ECG and normal LV function on echocardiography. Five patients have significant pulmonary stenosis and 4 have mild aortic regurgitation. The exercise stress tests performed between the ages of 7 and 10 were all normal. The authors conclude that that modern and reproducible management of TGA is possible in an inter-regional centre with results comparable to those of surgical centres of reference.

[Value of the Norwood-Sano compared with the classical Norwood procedure in hypoplastic left heart syndrome]. / Intérêt de l'intervention de Norwood-Sano par rapport à l'intervention classique de Norwood dans l'hypoplasie du coeur gauche.

Palliative treatment of the hypoplastic left heart syndrome is rarely practiced in France because of the poor prognosis of the first surgical stage of the Norwood procedure. The recent modification proposed by Sano seems to give more promising results. The authors report their experience with the Norwood-Sano procedure compared with the classical Norwood procedure in 13 neonates with hypoplasia of the left heart. From 1999 to 2005, 8 patients underwent the classical Norwood procedure (1999-2001) and 5 had the Sano modification (2002-2005). During the preoperative period, there was 1 case of a very restrictive interatrial septum and 5 patients required mechanical ventilation. The patients were operated at an average age of 8.5 +/- 12 days. The results showed that survival after the first surgical stage was significantly better with the Sano modification (12.5% versus 80%; p= 0.03). All patients who survived the first stage went on to the second stage with a bi-directional right superior cavo-pulmonary derivation at an average of 6.1 +/- 2.4 months. Despite the infundibulotomy of the Sano modification, no arrhythmia or right ventricular dysfunction was observed after an average follow-up of 21.7 +/- 7.6 months. The authors conclude that the Sano modification improved survival of patients with hypoplasia of the left heart after the first palliative surgical procedure. The long-term follow-up of patients operated by this technique should particularly look out for arrhythmias and right ventricular dysfunction.

[Unusual outcome of mitral valve infectious endocarditis in a premature infant]. / Evolution inhabituelle d'une endocardite infectieuse mitrale chez un prématuré.

The authors report a case of Staphylococcus Aureus infectious endocarditis in a premature baby. Echocardiography on the 8th day of life showed a large vegetation on the anterior mitral leaflet without significant regurgitation. Intravenous antibiotics and platelet antiaggregant therapy were given. At three weeks of age the vegetation split into two, one part attached to the foramen ovale and the other to the anterior mitral leaflet. At one month, the development of severe mitral regurgitation led to surgical valvuloplasty in a 2 kg neonate, the vegetation on the foramen ovale having spontaneously fragmented. The ablation of the mitral vegetation associated with commissuroplasty reduced the mitral regurgitation. At 3 months after surgery, the child was asymptomatic with a minimal mitral regurgitation.

[Medico-surgical treatment of occlusion of the left pulmonary artery by extension of ductal tissue (pulmonary coarctation)]. / Traitement médico-chirurgical de l'occlusion de l'artère pulmonaire gauche par extension de tissu ductal (coarctation pulmonaire).

The authors report the results of surgical treatment completed by interventional catheterisation of occlusion of the left pulmonary artery by extension of ductal tissue. Since 2001, 7 patients operated for occlusive coarctation of the left pulmonary artery at an average age of 11 months (3 to 37 months) had a restenosis. The cardiac malformation was pulmonary atresia with ventricular septal defect (N=4), tetralofy of Fallot (N=2) and critical pulmonary valvular stenosis (N=1). Pulmonary artery surgery consisted of resection anastomosis in 4 cases and a plasty in 3 cases. A primary angioplasty was performed 5 to 170 months (median 12 months) later, at an average age and weight of 3.4 years (0.7 to 16.9 years) and 14 Kg (8 to 52 Kg) with implantation of 3 stents. The median diameter increased from 5 mm (1 to 9 mm) to 10 mm (6 to 16 mm). Tc-99m scintigraphy showed an increase in mean left pulmonary perfusion from 9% (6 to 28%) to 28% (18 to 42%). Secondarily, 3 repeat angioplasties were necessary with a total of 6 stents implanted in 7 patients. After an average of 2.9 years (0.8 to 6.3 years) follow-up, the patients were asymptomatic with normal right ventricular pressures and a mean left pulmonary perfusion of 33% (24 to 45%). The authors conclude that the treatment of left pulmonary occlusion by coarctation requires a medico-surgical approach in which angioplasty and stenting complete successfully the surgical revascularisation.

[Results of surgery for coarctation of the aorta in children under one year of age]. / Résultats de la chirurgie de la coarctation aortique chez l'enfant de moins de 1 an.

The aim of this study was to determine the surgical results of repair of coarcta tion of the aorta in children under 1 year of age and to assess the risk of recoarctation. Between 1984 and 2004, 206 children under 1 were operated for coarctation of the aorta. Three groups of patients were identified: Group I (isolated coarctation, N=99), Group II (associated ventricular septal defect, N=63), and Group III (complex congenital heart disease, N=44). The transverse aorta was hypoplastic in 51% of cases. Uni- and multivariate analysis of the risk factors for mortality and recoarctation was performed. An extended resection anastomosis was performed in 206 patients. Reconstruction of the transverse aorta was performed in 32 cases. The hospital mortality was 3.9% (N=8). The presence of a complex intracardiac anomaly was a risk factor for mortality on multivariate analysis (p=0.023). In univariate analysis, a two-step management of patients in Group III was a significant risk factor for mortality (p=0.036). Thirty patients (14.6%) had recoarctation (gradient > 20 mmHg, follow-up 40 +/- 44 months). On multivariate analysis the severity of the immediate postoperative gradient was the only risk factor for recoarctation. The authors conclude that surgery for coarctation of the aorta is associated with excellent results in children under 1 year of age. The prognosis is related to the presence of associated severe cardiac malformations. Survival seems to be better if treatment is carried out in a single stage in this group. The risk of recoarctation is related to the immediate postoperative transisthmic gradient which justifies extensive repair of hypoplastic aortic arches.

[Extracorporeal assistance in paediatric intensive care]. / Assistance extracorporelle en réanimation pédiatrique.

OBJECTIVE: For 3 years we have used extracorporeal assistance in intensive care frequently. This study evaluates our results. METHOD: We studied the patient records for those treated between January 2002 and January 2005. The method used, indications and morbidity/mortality were analysed. RESULTS: We performed 24 circulatory assistance procedures in 20 patients (median age: 5 months), arterio-venous with oxygenation (n=18), veino-venous with oxygenation (n=3) or biventricular (n=3). The indications were post cardiotomy cardio-respiratory failure (Group I; n=20, 16 patients), pure respiratory failure (Group II: n=1), or pre-transplant/recovery (Group III: n=3). Five procedures (4 from group I and 1 from group III) required cardiac massage (no fatalities). The average duration of assistance was 7 +/- 6 days (2 to 20 days). Treatment was successfully discontinued in sixteen patients 80%), one of them thanks to heart transplant. Four (20%) died during assistance. The morbidity essentially consisted of further surgery for haemostasis, multiple transfusions, and infections. Three patients (15%) died later (1 at 17 months after discontinuation) from complications unrelated to the assistance. No neurological sequelae were noted in the survivors. CONCLUSION: These results confirm the usefulness of circulatory assistance when medical treatment has failed, particularly in the post-operative period of paediatric cardiac surgery or while awaiting transplantation.

[Efficacy of angioplasty of native coarctations of the aorta of the big infant and of the adult with systematic endoprosthesis implantation]. / Efficacité de l'angioplastie des coarctations natives de l'aorte du grand enfant et de l'adulte avec implantation systématique d'endoprothèse.

The angioplasty of native coarcatations of the aorta remains a controversial treatment due to recurrences and the potential risk of aneurysm or of descending aorta dissection during catheterization. The interest of a systematic implantation of an endoprothesis is poorly documented. We report our experience in a small series of 3 patients aged from 7, 28 to 52 years at the moment of the angioplasty of their native aortic coarctation. In all the three cases it corresponded to a "membranous" type, localized a the level of the isthmus without hypoplasia of the aortic arch. All presented a refractory hypertension. One patient presented an intermittent claudication related to a low perfusion of lower limbs. The angioplasty was performed with BIB balloon, associated at the same time with the implantation of a Palmaz P308 stent in two cases and Genesis PG2910P in the last patient. The efficacy was immediate in all the 3 cases with stopping antihypertensive drugs at the very day of the procedure. The immediate results were complicated by a bilateral hematoma of the scarpa in a context of excessive anticoagulation in one patient requiring blood tranfusion. After a follow-up of one, 12 and 21 months, all the 3 patients are asymptomatic without any significant residual hypertension. The control scan of the infant confirmed the absence of re-coarctation. In conclusion, the angioplasty followed by systematic implantation of an endoprosthesis is a safe and effective technique for treating simple forms of native coarctations of the aortic isthmus. It can be proposed as a first line treatment for big infants and adults affected by localized types.

[Results of the surgery of the truncus arteriosus: present implications]. / Résultats de la chirurgie du tronc artériel commun: implications actuelles.

We report our results of truncus arteriosus surgical reparation in a period of 10 years. From January 1993 to November 2003, 17 patients were operated with a median age and weight of 66 days and 3.5 kg respectively. According to the Van Praagh classification there were 13 cases of type A1, 2 cases of type A2 and 2 cases of A4. The connection between the right ventricle and the pulmonary artery was performed by a homograft (n = 12), a Contegra tube (n = 1) or a Barbero-Marcial intervention (n = 4). In one case, a plasty of the truncus was performed. Patients were classified in two groups: group A for those operated between 1993 and 1997 (n = 8) and group B for those operated after 1997 (n = 9). Five patients died (29%) in the post-operative period, 4 in the group A (50%) and one in group B (11%). The mean duration of intensive care stay was 12.2 (+ 7.4) days. Statistical analysis did not reveal any difference between both groups, especially concerning post-operative treatment or prognosis. In the multivariate analysis, an age below 30 days was a risk factor of post-operative death (OR = 16.5, 95% CI = 1.09 - 250; p = 0.043). After a mean follow-up of 3.9 (+ 3.5) years, 2 patients required a redo intervention for replacement of the pulmonary artery homograft. All 12 suvivors are asymptomatic without any pulmonary hypertension. In conclusion, the results of surgical reparation of the truncus arteriosus seem to improve with experience. According to recent progresses in surgery and intensive care, the intervention can be scheduled beyond the neonatal period without additive risk and with potentially less consecutive redo interventions.

[Medico-economic study of percutaneous and surgical closure of ostium secundum type interatrial communications]. / Etude médico-économique de la fermeture percutanée et chirurgicale des communications interauriculaires de type ostium secundum.

The aim of this study was the medico-economic evaluation of the closure of ostium secundum type interatrial communications in 32 patients, treated by cardiac catheterisation (group A: n = 17) or by surgery (group B: n = 15). The success rate was 100% with the 2 techniques. With national cost scale data we evaluated the overall cost of the 2 treatments using the information system medical program, starting from homogenous groups of patients: 150 catheterisation, 169 and 170 surgery. As the value for the homogenous group of 150 patients was much lower than the price of the material used for catheterisation, an adjusted group of 150 patients including the price of this material was created. An evaluation in terms of an artificial index of activity was also performed. The average duration of hospital stay for group A was reduced by 6.1 days compared to group B (p < 0.001). The overall cost was lower in group A than in group B (p < 0.001), using the real and "adjusted" homogenous group of 150 patients, with a respective reduction of 7,582 Euros and 3,731 Euros. Surgery and catheterisation scored 8,167 points (17,756 Euros) and 2,726 points (5,926 Euros) per patient respectively on the artificial activity index. In conclusion, catheterisation reduced the duration of hospital stay and brought an economic benefit for the Assurance Maladie compared to surgery. However, surgery is more profitable for the hospital than catheterisation because of the high cost of the prosthesis, which is not taken into account with a homogenous group of non-specific patients. This could hamper the development of this innovative technique in a hospital subjected to overall budgetary constraints.