[Relation between cavo-tricuspid isthmus anatomy studied by transesophageal echocardiography and the immediate outcome of radiofrequency ablation of common atrial flutter]. / Relation entre l'anatomie de l'isthme cavo-tricuspide étudiée par échocardiographie trans-oesophagienne et les résultats immédiats de l'ablation par radiofréquence du flutter auriculaire commun.

Radiofrequency ablation is the only curative treatment of common atrial flutter. The aim of the treatment is to create a line of bidirectional block at the level of the cavo-tricuspid isthmus. This objective can be achieved in the vast majority of the patients. However, it may difficult or even not possible to create an isthmus block. The anatomy of the right atrium is subject to important variations, especially at the isthmus level. We therefore tested the hypothesis that these anatomic variations might influence the immediate outcome of cavo-tricuspid isthmus ablation. The anatomy of cavo-tricuspid isthmus was studied by trans-oesophageal echocardiography. The shape of the isthmus (concave or not), the presence of diverticula and the degree of development of the Eustachian ridge were analysed. From these data, the cavo-tricuspid anatomy was classified as simple or complex. The immediate outcome of radiofrequency ablation was reviewed in 94 patients (mean age of 63 years) according to the anatomy, simple or complex. When the anatomy was classified as simple, the success rate of radiofrequency ablation was 95.6%; when the anatomy was complex, the success rate was 76.9% (overall success rate for the entire population equal to 90.4%). The length of the cavo-tricuspid isthmus did not influence the outcome of radiofrequency ablation. In summary, it appears that the anatomy of cavo-tricuspid isthmus seems to play a role in the immediate outcome of radiofrequency ablation of cavo-tricuspid isthmus.

[Rupture of a sinus of Valsalva aneurysm in the left atrium]. / Rupture d'un anévrisme des sinus de Valsalva dans l'oreillette gauche.

Ruptures of sinus of Valsalva aneurysms are a rare complication, and very few cases of rupture in the left atrium have been described. In this clinical case we report the case of a patient hospitalised with a scenario of cardiac insufficiency revealing a very large posterior sinus of Valsalva aneurysm, associated with a bicuspid aortic valve, and rupture in the left atrium. The diagnosis was by transthoracic and transoesophageal multiplan echocardiography, and the treatment surgical, with a good result.

Occlusive and aneurysmal peripheral arterial disease: assessment of a stent-graft system.

PURPOSE: To assess the use of a recently developed stent-graft system for treatment of occlusive lesions and aneurysms in the iliac and femoropopliteal arteries. MATERIALS AND METHODS: The stent-graft consisted of a nitinol stent framework covered by a thin-walled polyester fabric. The device was used in 105 patients with symptomatic peripheral vascular disease. Implant locations were iliac artery (n = 38), femoral artery (n = 62), and popliteal artery (n = 5). RESULTS: Initial technical success was achieved in all patients except one with occlusive disease and one with aneurysmal disease. Residual stenosis after stent-graft implantation was 0.5% +/- 3. Mean ankle-brachial index increased from 0.53 to 0.98. Complications were hematoma (n = 3), pseudoaneurysm (n = 2), puncture site thrombosis (n = 1), early graft thrombosis (n = 8), graft misplacement (n = 1), distal embolization (n = 2), delayed thrombosis (n = 14), pain and fever (n = 27). At the iliac level, primary patency was 97% and secondary patency was 100%. At the femoral level, primary patency was 59% and secondary patency was 81%. CONCLUSION: Endoluminal bypass with a percutaneously delivered stent-graft is feasible. Technical results are good, and the number of complications is few at the iliac level. At the femoropopliteal level, patency is not as good and the number of complications is higher.

[5 years results of percutaneous mitral commissurotomy. Apropos of a series of 606 patients; late results after mitral dilatation]. / Résultats à 5 ans de la commissurotomie mitrale percutanée. A partir d'une série de 606 patients; résultats tardifs après dilatation mitrale.

The long-term results of percutaneous mitral commissurotomy were evaluated in 606 patients with a mean age of 48 +/- 14 years. One hundred and eleven patients (48%) had a history of surgical commissurotomy. At echocardiography, 91 patients (15%) had flexible leaflets and little subvalvular apparatus, and 180 (30%) have calcified valves. The procedure was performed with a single balloon in 21 patients, a double balloon in 402 patients and Inoue's balloon in 183 patients. A good immediate, result, defined as a mitral valve surface area > or = 1.5 cm2 without > 2/4 mitral regurgitation, was obtained in 528 patients (87%). Five hundred and eighty patients (96%) were followed up for an average of 30 +/- 18 months. The actuarial 5 year rates were: survival 94 +/- 4%; survival without surgery 74 +/- 6%; survival without surgery with a good functional result (NYHA Classe I and II) 66% +/- 6%. Factors predictive of a good functional result were the valvular anatomy (p = 0.01), the NYHA Class before the procedure (p = 0.02), the cardiothoracic ratio before the procedure (p = 0.005) and mitral valve surface area after the procedure (p = 0.007). The type of balloon had no influence on the result (p = 0.54). The authors conclude that the 5 year results of percutaneous mitral commissurotomy are good in a population of patients with varied characteristics. The persistence of good functional results depends on anatomical and functional data and the quality of the initial result, but not on variables related to the procedure.

Immediate results of percutaneous mitral commissurotomy. A predictive model on a series of 1514 patients.

BACKGROUND: The wide use of percutaneous mitral commissurotomy (PMC) underlines the need to identify the predictive factors of the results. Using a large series allowed us to develop a multivariate model that can be applied to improve patient selection. METHODS AND RESULTS: Between 1986 and 1995. PMC was undertaken in 1514 patients. Mean age was 45 +/- 15 years. Echocardiography showed that 245 patients (16%) had pliable valves and mild chordal thickening (group 1), 886 (59%) had extensive subvalvular disease (group 2), and 383 (25%) had calcified valves (group 3). PMC failed in 22 patients; it was performed with a single balloon in 30 patients, a double balloon in 586, and the Inoue balloon in 876. Good immediate results were defined as a valve area > or = 1.5 cm2 with mitral regurgitation Sellers' grade < or = 2 and were obtained in 1348 patients (89%). A logistic model developed from the first 1088 cases identified the following predictors of immediate results: age (P = .004), echocardiographic group (P < .0001), valve area (P < .0001), and effective balloon dilating area (EBDA) (P = .03). Two interactions were significant: age at previous commissurotomy (P = .013) and EBDA by initial mitral regurgitation (P = .034). The type of balloon was of borderline significance (P = .09). The model was validated on an independent sample comprising the subsequent 426 procedures. For a threshold of probability of good results of .75, sensitivity was 92%, specificity 25%, and predictive accuracy 87%. CONCLUSIONS: Prediction of the immediate results of PMC is multifactorial. The predictive model developed and validated can be contributive in decision making for individual patients.

Clinical experience with a new nitinol self-expanding stent in peripheral arteries.

PURPOSE: To evaluate a new self-expanding nitinol coil stent in stenotic or occluded peripheral arteries. METHODS: Seventy-three symptomatic patients (58 men; mean age 67 years) were treated with nitinol stents for lesions in the iliac artery (9 stenoses); superficial femoral artery (SFA) (39 stenoses, 6 occlusions); popliteal artery and tibioperoneal trunk (9 stenoses, 7 occlusions); and 3 bypass grafts. Mean diameter stenosis was 84.4% +/- 9.9% (range 75% to 100%), and mean lesion length was 45 +/- 23 mm (range 20 to 120 mm). RESULTS: Eighty-eight 40-mm-long stents with diameters between 5 and 8 mm were implanted percutaneously for suboptimal dilation (n = 45); dissection (n = 21); and restenosis (n = 7). All stents but one were implanted successfully; the malpositioned stent was removed, and another stent was successfully deployed. There were 3 (4.1%) failures due to thrombosis at 24 hours. During the mean 16-month follow-up (range to 44 months), 4 restenoses (3 femoral, 1 popliteal) have occurred; 2 were treated with repeat dilation and 2 underwent bypass. Primary and secondary patency rates at 18 months were 87% and 90%, respectively, for all lesions (iliac: 100% for both; femoral: 85% and 88%; popliteal: 87% and 100%). CONCLUSIONS: This new nitinol stent seems to be safe and effective with favorable long-term results, even in distal SFA lesions and popliteal arteries. Its flexibility and resistance to external compression allow its placement in tortuous arteries and near joints.

Specifics of technique in percutaneous mitral commissurotomy in a case of dextrocardia and situs inversus with mitral stenosis.

Percutaneous mitral commissurotomy (PMC) was successfully performed in a 48-year-old woman with dextrocardia and situs inversus and a severe mitral stenosis. After PMC, the valve area increased from 0.97 to 1.89 cm2, and no complication occurred. This case shows that PMC is practicable in a case of dextrocardia with situs inversus. The procedure appears to be safer and easier when carried out with the inoue balloon, image inversion on the screen, and under transesophageal echocardiographic monitoring.

Stent placement in the renal artery: three-year experience with the Palmaz stent.

PURPOSE: To evaluate the long-term results of stent placement in the renal arteries. PATIENTS AND METHODS: From January 1990 to August 1994, 59 hypertensive patients underwent 64 stent placement procedures. Indications were residual stenosis after percutaneous transluminal renal angioplasty in 42 patients, restenosis in 20 patients, and acute dissection in two patients. Follow-up (mean, 14 months) was obtained in 54 patients. Six-month restenosis rates were based on results of arteriography, and even more long-term patency rates were based on duplex ultrasound. RESULTS: Technical success was achieved in all patients. Major complications occurred in two patients. No minor or puncture-site complications were observed. The overall 6-month restenosis rate was 1.6% (2.9% for ostial lesions). Survival analysis with the Kaplan-Meier method showed primary and secondary patency rates of 92% +/- 3.6 and 98% +/- 1.9, respectively, at 1 year and 79% +/- 8.8 and 92% +/- 6.1, respectively, at 2 years. Seventy-six percent of hypertensive patients benefited from the procedure. However, renal function was not improved by stent placement. CONCLUSION: Stent placement in renal arteries is a useful adjunct to percutaneous transluminal angioplasty for atherosclerotic renal-artery stenoses.

Value of multiplane transesophageal echocardiography in determining aortic valve area in aortic stenosis.

Aortic valve area determination by transesophageal planimetry and by the continuity equation was compared with hemodynamic measurements in 45 patients with symptomatic aortic stenosis. The correlations between transesophageal echocardiography and hemodynamics were dependent on the amount of valvular calcium, whereas the continuity equation correlated well with hemodynamics in all patients.

Functional results 5 years after successful percutaneous mitral commissurotomy in a series of 528 patients and analysis of predictive factors.

OBJECTIVES: This study sought to assess late functional results after successful percutaneous mitral commissurotomy and to determine their predictors. BACKGROUND: Few studies have reported late results of percutaneous mitral commissurotomy or have analyzed their late results regardless of immediate results, despite the fact that late deterioration may well be related either to a decrease in valve area or to poor initial results. METHODS: Between 1986 and 1992, 528 patients underwent successful percutaneous mitral commissurotomy (mean [+/- SD] age 46 +/- 18 years; mean follow-up 32 +/- 18 months). A successful procedure was defined by a mitral valve area > or = 1.5 cm2 and no regurgitation > 2/4. Dilation was performed using a single balloon in 13 patients, a double balloon in 349 and the Inoue balloon in 166. Multivariate analysis was performed with a Cox model. RESULTS: The survival rate for patients in New York Heart Association functional class I or II, with no cardiac-related deaths or need for mitral surgery or repeat dilation, was 76 +/- 6% at 5 years. By multivariate analysis, the independent predictors of good functional results were echocardiographic group (p = 0.01), functional class (p = 0.02) and cardiothoracic index (p = 0.005) before the procedure and valve area after the procedure (p = 0.007). The predictive model derived allowed estimation of the probability of good functional results according to the value of these four predictors for any given patient. CONCLUSIONS: Good functional results were observed 5 years after successful percutaneous mitral commissurotomy in a large series of varied patients. The analysis of predictive factors may provide useful indications for follow-up results in patients undergoing this technique.

Early assessment by transesophageal echocardiography of left atrial appendage function after percutaneous mitral commissurotomy.

Thirty-seven consecutively admitted patients with severe mitral stenosis underwent percutaneous mitral commissurotomy with a transthoracic and biplane or multiplane transesophageal echocardiographic examination before and between 24 and 48 hours after percutaneous mitral commissurotomy. Thirty patients (81%) were in sinus rhythm and 7 were in atrial fibrillation. Left atrial appendage (LAA) function was evaluated in both the transverse and the longitudinal planes by planimetry and pulsed Doppler echocardiographic interrogation at the LAA outlet. Percutaneous mitral commissurotomy resulted in a twofold increase in mitral valve area, and no severe mitral regurgitation occurred. With use of the planimetry method, there was no significant improvement in LAA ejection fraction, except in the transverse plane for patients in sinus rhythm (p = 0.03). With use of Doppler method, 3 distinct flow patterns were observed before the procedure: a "sinus pattern" in patients in sinus rhythm, and a "fibrillatory pattern" (n = 3) or a "no-flow pattern" (n = 4) in patients in atrial fibrillation. After commissurotomy, there was a marked increase in LAA peak Doppler velocity (+62%) and in LAA velocity time integral (+31%). Of the 4 patients in atrial fibrillation with a no-flow pattern, 2 had recovery of a typical effective fibrillatory flow pattern after the procedure. The increase in peak Doppler velocity after commissurotomy was related to the decrease or regression in left atrial spontaneous echo contrast, and correlated with the increase in mitral valve area, the decrease in tranmitral pressure gradient, and the increase in cardiac index; improvement in valve function after successful percutaneous mitral commissurotomy is associated with early improvement in LAA function.

The effect of left ventricular systolic function on long term survival in mitral and aortic regurgitation.

To identify the predictive factors of left ventricular dysfunction (LVD) after surgery, we performed an uni- and multivariate analysis of the data concerning 286 patients operated for pure aortic regurgitation between 1980 and 1994 and 460 patients operated for pure non-ischemic mitral regurgitation over a period of 24 years. Among the aortic regurgitation patients, 28 developed left ventricular dysfunction not attributable to residual aortic valve dysfunction, another valvular lesion or hypertensive or ischemic heart disease. By univariate analysis identified predictive factors of LVD were duration of symptoms prior to surgery, duration of the history of diastolic murmur, NYHA class, cardiothoracic ratio, LV echographic diameters, fractional shortening of short axis, LV end-systolic volume and LV ejection fraction. Multivariate analysis identified three independent predictors: NYHA functional class, LV end-systolic diameter and LV ejection fraction. Of 428 operative survivors with non-ischemic mitral regurgitation 63 developed severe LVD. Univariate analysis identified functional class III or IV, duration of symptoms prior to surgery, atrial fibrillation, echo LV and LA diameters, angio LV volumes, LV ejection fraction, cardiac index and type of surgery as independent predictors of LVD. Multivariate analysis showed that type of surgery, LV ejection fraction, LV end-diastolic and end-systolic volume and echo LV end-systolic diameter were all independent predictors of LVD.

[Indications of coronary angioplasty after thrombolysis]. / Indications de l'angioplastie coronaire après thrombolyse.

Thrombolysis is the most widely used method of coronary reperfusion in the acute phase of myocardial infarction. The indications of angioplasty after thrombolysis have been subject of considerable controversy over the last few years. Three randomised trials (TIMI 2, TAMI, ECSG) have shown that it is not desirable to perform systematic immediate angioplasty after intravenous thrombolysis with rt-PA. Angioplasty may be carried out as a "salvage" procedure in cases of failure of thrombolysis. The validity of this approach was confirmed recently by the "RESCUE" trial in anterior myocardial infarction. The practical application of its results is confronted by logistical problems inherent to the practice of angioplasty in the acute phase of myocardial infarction and to the inadequacy of non-invasive methods for the detection of coronary reperfusion after thrombolysis. Angioplasty may also be necessary in cases of left ventricular failure or cardiogenic shock. The efficacy of a rapid angioplasty in cases of recurrence of ischaemia after thrombolysis has been proved in reducing mortality and preserving left ventricular function. The results of TIMI IIB and SWIFT trials show that secondary angioplasty, several days after thrombolysis, is only usually indicated in patients with residual clinical ischaemia or positive stress tests. This attitude should however be modulated in the light of the "open artery" theory and the limitations of methods of evaluating myocardial viability. The present strategies will no doubt be modified with the introduction of new thrombolytic and/or antithrombotic agents and the use of coronary stents.

Percutaneous mitral commissurotomy in the elderly.

Immediate and mid-term results of percutaneous mitral commissurotomy (PMC) were assessed in 75 patients aged > or = 70 years (mean 75 +/- 4 (70 to 86)). Co-morbidities were present in 30 patients (40%), and 58 patients had calcified valves (77%). Technical failure occurred in two patients. PMC was performed in 73 patients, using a single balloon in five, two balloons in 28, and the Inoue balloon in 42. After PMC, valve area increased from 1.0 +/- 0.2 to 1.6 +/- 0.3 cm2 as assessed by 2D echo (P<0.001). Three procedural deaths occurred (4%). Good initial results (valve area > or = 1.5 cm2 with mitral regurgitation < or = 214) were obtained in 48 patients (66%). In multivariate analysis, predictors of poor initial results were previous commissurotomy (P=0.01) and valve calcification (P=0.04). Mean follow-up was 24 +/- 18 months. The 4-year actuarial results were: survival in 59 +/- 18%; no need for operation in 59 +/- 18%; and persistent good functional results (NYHA class I or II) in 34 +/- 16%. The only predictor of mid-term good functional results was the quality of initial results (P<0.002). In conclusion, PMC in the elderly results in moderate but significant improvement in valve function at an acceptable risk; although subsequent functional deterioration is frequent. PMC is a useful although only palliative treatment in these patients.

[Value of transesophageal echocardiography in the follow-up of successful percutaneous mitral valvotomy]. / Intérêt de l'échographie transoesophagienne dans le suivi des commissurotomies mitrales percutanées réussies.

This study was undertaken to determine the value of transoesophageal echocardiography in the follow-up of patients with severe mitral stenosis having undergone successful percutaneous mitral commissurotomy as defined as a final valve surface area > 1.5 cm2 without > 2/4 mitral regurgitation (MR). Eighty one patients who had undergone successful procedures were studied by transthoracic (TTE) and transoesophageal echocardiography (TOE) before, immediately after (24 to 48 hours) and at medium term (8 +/- 4 months) after balloon commissurotomy. The three main parameters studied were the degree of MR, presence of inter-atrial shunt and spontaneous left atrial contrast. Immediately after commissurotomy the MR was graded 0/4 in 6 patients (7.5%), 1/4 in 48 patients (59%) and 2/4 in 27 patients (33.5%). The TOE showed small traumatic lesions (localised valve tears, rupture of an accessory chordae tendinae) in 9 cases (11%). At medium term follow-up, the MR was stable in 75 patients (93%), decreased by one grade in 3 patients (3.5%), without the occurrence of severe MR. Interatrial shunts were more frequently observed by TOE than by TTE or oximetry with a prevalence of 57%. They usually disappeared at medium term follow-up. There were 3 factors associated with its persistence: a shunt visible at TTE, immediately after commissurotomy, visualisation of an atrial septal defect and a shunt jet width > or = 5 mm at TOE immediately after commissurotomy. Spontaneous contrast was common before the procedure (65%).(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of percutaneous mitral commissurotomy on left atrial spontaneous contrast of mitral stenosis.

To assess the influence of percutaneous mitral commissurotomy (PMC) on left atrial spontaneous echo contrast of mitral stenosis, transesophageal echocardiography was performed before and 24 to 48 hours after the procedure, and on average, 6 months later in 82 patients. Fifty-nine patients (72%) were in stable sinus rhythm and 23 in permanent atrial fibrillation. Eleven patients (13%) had history of embolism, and 31 were on long-term anticoagulant therapy. The intensity of spontaneous contrast was graded as follows: 0 = no contrast; 1 = slight contrast; and 2 = intense contrast with the typical aspect of "smoke." PMC resulted in a twofold increase in the valve area irrespective of the method of evaluation used (2 cm2 after vs 1.05 before; p < 0.0001). Severe mitral regurgitation occurred in 3 patients who were operated on within 3 months after PMC. Left atrial spontaneous contrast was noted before the procedure in 53 patients (65%). Multivariate analysis showed left atrial size and cardiac index to be predictive factors of its presence (both p < 0.05). At early post-PMC investigation, the incidence of contrast was 50%, and at 6 months, only 28%. Sinus rhythm appeared to be the only independent predictive factor of the disappearance of contrast by multivariate analysis. In patients in atrial fibrillation, the prevalence of spontaneous contrast was 100% before PMC, 91% at early post-PMC investigation (p = NS), and 89% at the late study (p = NS); the rates were 51, 34 (p < 0.005) and 4% (p < 0.0001), respectively, in patients in sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fortuitous discovery of the association of true and false aneurysm of the left ventricle after cardiogenic shock]. / Découverte fortuite de l'association d'un vrai et d'un faux anévrysme du ventricule gauche au décours d'un choc cardiogénique.

The authors report the fortuitous diagnosis of a true and a false left ventricular aneurysm in a 77 year old man with severe ischaemic heart disease and calcific aortic stenosis, admitted for cardiogenic shock. The association of these two forms of aneurysm is very rare. Clinical and paraclinical diagnosis is difficult. Conventional left ventriculography is the investigation of reference but the diagnosis has been facilitated by Technetium 99 cardiac scintigraphy and color Doppler echocardiography. Surgery may be considered in cases of true aneurysm especially in patients with left ventricular failure, but the indication is formal in cases of false aneurysm.

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.

[Mid-term results of heart valve replacement with 2 types of pericardial heterograft. Apropos of 208 cases]. / Résultats à moyen terme du remplacement valvulaire à l'aide de deux types d'hétérogreffes péricardiques. A propos de 208 patients.

Medium-term results of valve replacement with a pericardial bioprosthesis were analysed in 141 patients receiving an Ionescu-Shiley aortic prosthesis and in 67 patients receiving a Mitroflow aortic (42), mitral (21) or double mitro-aortic (4) bioprostheses. There were 8 deaths in the operative (5.7%) and medium term (56 months) follow-up periods in the Ionescu group and a cumulative survival of 625 patient-years. There were 16 late deaths, 8 of cardiac origin. The 8 year survival and good functional results rates were 71% and 53% respectively. The linear rates of thrombo-embolism, endocarditis, reoperation, valvular dysfunction and regurgitation were 3.5, 1.1, 2.6, 2.7 and 6.1% patient-years. The corresponding figures in the Mitroflow bioprostheses were 0.5, 1.0, 3.1, 3.1 and 5.6% patient-years, but the average follow-up was shorter (36 months) with a cumulative survival of 195 patient-years. These results underline the frequency of primary valve dysfunction the mechanisms of which are: early tear in areas of high mechanical stress and late calcification. However, the hemodynamic profiles of this type of prosthesis are better than those of porcine bioprostheses which make them a valuable alternative in elderly patients operated for calcific aortic stenosis with a small aortic ring.