Percutaneous mechanical mitral commissurotomy with a newly designed metallic valvulotome: immediate results of the initial experience in 153 patients.

BACKGROUND: Percutaneous balloon valvotomy has become a common treatment of mitral stenosis, but the cost of the procedure remains a limitation in countries with restricted financial resources, leading to a frequent reuse of the disposable catheters. To overcome this limitation, a reusable metallic valvotomy device has been developed with the goals of both improving the mitral valvotomy results and decreasing the cost of the procedure. METHODS AND RESULTS: The device consists of a detachable metallic cylinder with 2 articulated bars screwed onto the distal end of a disposable catheter whose proximal end is connected to an activating pliers. By the transseptal route, the device is advanced across the valve over a traction guidewire. Squeezing the pliers opens the bars up to a maximum extent of 40 mm. The clinical experience consisted of 153 patients with a broad spectrum of mitral valve deformities. The procedure was successful in 92% of cases and resulted in a significant increase in mitral valve area, from 0.95+/-0.2 to 2. 16+/-0.4 cm2. No increase in mitral regurgitation was noted in 80% of cases. Bilateral splitting of the commissures was observed in 87%. Complications were 2 cases of severe mitral regurgitation (1 requiring surgery), 1 pericardial tamponade, and 1 transient cerebrovascular embolic event. In this series, the maximum number of consecutive patients treated with the same device was 35. CONCLUSIONS: The results obtained with this new device are encouraging and at least comparable to those of current balloon techniques. Multiple uses after sterilization should markedly decrease the procedural cost, a major advantage in countries with limited resources and high incidence of mitral stenosis.

[Detection of acute rejection of heart transplantation by Doppler color imaging]. / Détection du rejet aigu myocardique après transplantation cardiaque par Doppler couleur tissulaire.

Doppler tissue imaging is a new technique of measuring the velocities of myocardial wall motion. In order to assess its value in the diagnosis of acute rejection, the velocities of the interventricular septum and left ventricular posterior wall were measured in systole and early diastole in 34 cardiac transplant patients at the time of their endomyocardial biopsy, using an M mode left parasternal short axis view. During 40 episodes of acute rejection (26 mild and/or moderate, 10 sub-severe and 4 severe), the wall velocities decreased significantly (p < 0.001) both in the interventricular septum and endocardium of the posterior wall. Myocardial velocities were significantly slower in sub-severe or severe rejection than in mild or moderate rejection. The most sensitive criterion was the measurement of posterior wall endocardial velocity in early diastole, a decrease of 10% having a sensitivity of 92% whereas the sensitivity of usual Doppler echocardiographic parameters is only 73%. Acute rejection, even mild cases, can be diagnosed with excellent sensitivity by measuring myocardial velocities by Doppler tissue imaging. This technique has the advantage of being non-invasive, reproducible and reliable in the follow-up of cardiac transplant patients.

[Blood flow in the isovolumetric relaxation phase in heart transplant patients. Its use in the noninvasive diagnosis of acute rejection]. / Flux en phase de relaxation isovolumétrique chez le transplanté cardiaque. Apport dans le diagnostic non invasif de rejet aigu.

The aim of this study was to assess a Doppler-echocardiographic parameter which has not been previously reported for the diagnosis of acute cardiac rejection. The parameter was left ventricular isovolumic relaxation blood flow. Eighty patients who had undergone orthoptic cardiac transplantation were followed up regularly with echocardiography for a period of 2 years. In all, 495 echocardiographic studies were performed and the results compared with those of endomyocardial biopsy performed on the same day (11.4 echocardiographic studies per patient). In the absence of cardiac rejection, isovolumic relaxation Doppler signal was recorded in all patients (364/387 echo studies). This was a positive signal directed towards the apex detected by continuous mode Doppler in the apical position, arising along the interventricular septum in the mid part of the left ventricle (82% of cases) or from the basal region of the septum (18% of cases) and lasting throughout the phase of isovolumic relaxation. The maximal velocity was 0.53 +/- 0.08 m/s (range 0.32 to 0.73 m/s) : the velocity-time integral was 34 +/- 33 cm. This signal was associated with medioventricular endosystolic acceleration of blood flow in 75% of cases. The incidence of the isovolumic relaxation flow signal decreased in cardiac rejection with no significant changes in the other usual Doppler-echocardiographic parameters except for a significant decrease in the ejection fraction in the group with severe rejection. In the group with mild rejection (n = 89) an isovolumic relaxation flow signal was only observed in 52 cases (including 29 in whom immunosuppressive treatment was not increased). In patients with moderate rejection (n = 12) there were only 5 cases in which a isovolumic relaxation flow signal was recorded, and in the group with severe rejection (n = 7), the signal could only be recorded in 1 case. The authors conclude that the absence of an isovolumic relaxation blood flow signal in a cardiac transplant patient is a reliable sign of cardiac rejection with an excellent specificity (94%). The absence of this signal is a sensitive indicator of severe rejection (86%) but less so for moderate (58%) or mild rejection (42%).

[Percutaneous coronary angioscopy in the diagnosis of cardiac graft coronary disease: comparison with the results of angiography]. / Place de l'angioscopie coronaire percutanée dans le diagnostic de la maladie coronaire du transplanté. Comparaison avec l'angiographie.

Coronary disease in cardiac transplant patients is a major factor in the limitation of long term survival. The aim of this study was to compare the results of angioscopy with those of coronary angiography performed systematically every 18 months in our center. Twenty-nine patients (31 angioscopies) were assessed 38 +/- 21 months after transplantation. The appearance observed by angioscopy were: 1) normal, 2) yellow pigmentation of the arterial surface, 3) elevated plaque < 50%, 4) elevated plaque > or = 50% stenosis. Angiography was: 1) normal, 2) iregularities of the lumen or < 50% stenosis, 3) > or = 50% stenosis. The films were viewed by two independent investigators. Angioscopy was performed on the left anterior descending artery (N = 35), the left circumflex (N = 24) and the right coronary artery (N = 9). One to three arterial segments were examined per vessel (total of 117 segments: average 3.8 segments per patient). Angioscopy was uniterpretable in 13/117 (11%) of cases. Of the 81 (78%) segments considered normal at coronary angiography, only 55 seemed normal at angioscopy (68%). Of the 23 segments considered to be abnormal at coronary angiography, all were also considered to be abnormal at angioscopy. The authors conclude that coronary angioscopy seems to be more sensitive than coronary angiography for the detection of coronary disease due to chronic rejection. Prospective studies are required to determine whether the infra-angiographic angioscopic lesions correspond to earlier stages of coronary disease of the cardiac graft.

Angioscopic evaluation of rotational atherectomy followed by additional balloon angioplasty versus balloon angioplasty alone in coronary artery disease: a prospective, randomized study.

OBJECTIVES: This study sought to compare, by angioscopy, the morphologic changes induced by rotational atherectomy, followed by additional angioplasty, with those observed after balloon angioplasty alone. BACKGROUND: Rotational atherectomy and balloon angioplasty act by different mechanisms, which could explain the difference in morphologic changes induced by these two techniques. METHODS: The study group included 50 patients with 50 lesions who were randomly assigned to undergo rotational atherectomy (n = 24) or balloon angioplasty (n = 26). Rotational atherectomy with a single burr (approximately equal to 70% of coronary diameter) was systematically followed by additional balloon angioplasty. Angioscopy was performed immediately after the procedure. Abnormal angioscopic findings were 1) flaps, graded from 1 to 3 (1 = intimal flap; 2 = flap protruding into < 50% of the lumen; 3 = flap protruding into > or = 50% of the lumen); 2) thrombi, graded from 1 to 3 (1 = flat deposits; 2 = protruding but nonocclusive thrombus; 3 = occlusive thrombus); 3) subintimal hemorrhage; 4) longitudinal dissection. The two groups were comparable for clinical and angiographic baseline data. RESULTS: On angioscopy, flaps were observed less frequently after rotational atherectomy followed by additional balloon angioplasty (8 [33%] of 24 lesions) than after balloon angioplasty alone (14 [54%] of 26 lesions, p = 0.08) and were also less severe (grade 1 in 6 lesions, grade 2 in 2 and grade 3 in none vs. grade 1 in 4 lesions, grade 2 in 5 and grade 3 in 5). Longitudinal dissections were also significantly less frequent: one versus six (p = 0.05). There was no difference in the incidence of angioscopic thrombi (p = 0.16) or subintimal hemorrhage (p = 0.15), but the power to detect a significant difference was low for these variables (37% and 26%, respectively). CONCLUSIONS: Rotational atherectomy followed by additional balloon angioplasty leads to fewer angioscopic dissections and a trend toward fewer intimal flaps than balloon angioplasty alone. However, our angioscopic differences did not lead to an outcome difference between the two groups.

[Peripheral and coronary artery dissections in a young woman. A rare case of type IV Ehlers-Danlos syndrome]. / Dissections artérielles périphériques et coronaires chez une femme jeune. Un cas exceptionnel de syndrome d'Ehlers-Danlos de type IV.

Spontaneous coronary dissection is rare and the diagnosis is usually post-mortem. Less than 60 cases have been diagnosed at coronary angiography. The authors report, to the best of their knowledge, the first case of multiple spontaneous coronary artery dissections in a type IV Ehlers-Danlos syndrome in a young woman admitted to hospital for acute myocardial infarction. She had a previous history of regressive complete tetraplegia due to dissection of the basilar artery and episodes of dizziness related to a dissecting aneurysm of the left vertebral artery. The diagnosis of type IV Ehlers-Danlos syndrome was established after skin biopsy had shown typical histological changes. The patient died several months later after an acute abdominal syndrome probably related to dissection of the aorta. An autopsy was refused by her family. The authors believe this to be the first case of spontaneous coronary dissection related to a type IV Ehlers-Danlos syndrome.

[Coronary bypass in patients with severe left ventricular dysfunction (EF < or = 25%). Apropos of 111 patients]. / Pontage coronaire chez les patients avec dysfonction ventriculaire gauche sévère (FE < or = 25%). A propos de 111 patients.

One hundred and eleven patients with severe left ventricular dysfunction (EF < or = 25%) underwent coronary bypass surgery between January 1984 and December 1994. The selection criteria were based on the measurement of an EF < or = 25%, LVEDP and CI. All patients had angina and 83 had signs of pulmonary oedema or episodes of congestive failure. Patients with valvular disease, left ventricular aneurysms, reoperations, surgery for arrhythmias and prior angioplasty, were excluded. The coronary disease usually involved all three vessels. Seventeen patients had lesions of the left main stem associated with lesions of the right coronary artery. The average number of bypass grafts was 2.6 +/- 1.6 per patient. The average duration of aortic clamping was 60 +/- 19 minutes. Operative mortality (first month after surgery) was 10 patients (9%). The operative risk factors were: gender, stage of cardiac failure, emergency surgery, LVEDP > 23 mmHg (p < 0.05), CI < 21/min/m2 (p < 0.05). The mean follow-up period was 42 +/- months (3 lost to follow-up). Late mortality was 42 patients. The one year actuarial survival was 88 +/- 5.3%, 76 +/- 9% at 3 years, and 56 +/- 18% at 6 years. Long-term functional results were related to: preoperative stage of cardiac failure (NYHA stage IV) and the association of raised LVEDP and low CI. Surgical results remained satisfactory, however, and the surgical indication was justified in selected patients despite severe left ventricular dysfunction in cases usually with stable invalidating or unstable angina, in the knowledge that myocardial deterioration is progressive in the medium-term with a high incidence of cardiac failure.

[Coronary involvement in systemic lupus erythematosus]. / Atteinte coronarienne au cours du lupus Erythémateux systeémique.

BACKGROUND: Coronary artery disease is an uncommon event in lupus erythematosus. The mechanisms responsible for coronary occlusion are probably complex and intermixed. We report three patients with lupus erythematosus and antiphospholipid antibodies who had coronary artery disease diagnosed with coronary angiogram. OBSERVATION: Coronary artery disease occurred in three young patients aged from 21 to 35 years 3 to 11 years after the onset of lupus. They all had antiphospholipid antibodies. They had been treated with corticosteroids for 6 to 36 months. Two of them were smokers. Angiograms showed coronary occlusion two patients while the third one had probable myocardial microvasculopathy. The lupus was quiescent in all cases when coronary artery disease occurred. DISCUSSION: Antiphospholipid antibodies associated with smoking may be involved in the pathogenesis of coronary artery disease in these 3 patients.

[Primary treatment of left coronary artery diseases by percutaneous implantation of stents]. / Traitement en première intention des lésions du tronc commun de la coronaire gauche par implantation percutanée d'une endoprothèse.

Left main coronary artery (LM) stenting has only been reported in bail-out situations or absolute contraindications so surgery. The authors report the immediate and midterm results of primary Palmaz-Schatz stent implantation in two young patients without contraindication to surgery. The first patient, 58 year-old, was admitted for unstable angina in October 1994. Coronary angiography showed an isolated severe ostial lesion of the LM. After conferring with the surgical team which remained on stand-by, angioplasty and stent implantation were performed with excellent results, no complications and no restenosis on angiographic controls at 3 and 12 months. The patient remained asymptomatic 24 months later. The second patient, 38 year-old, was admitted in June 1995 for unstable angina, and coronary angiography showed a severe isolated stenosis in the middle of a long and wide LM. Primary coronary stenting was also performed with excellent results, no complication and no restenosis on angiographic controls at 4 and 8 months. This patient was still asymptomatic 16 months after stenting. These excellent immediate and medium-term results are encouraging and suggest that this form of treatment might be extended to patients with an isolated whether primary LM stent implantation could become a suitable alternative to surgery in the future.

Mitral valve reconstruction: long-term results of 120 cases.

Between January 1977 and December 1992, 120 patients underwent mitral valve reconstruction for pure mitral valve regurgitation (n = 88), or associated with mitral stenosis (n = 32). The mean age was 57.6 years. Some 89 patients were in New York Heart Association (NYHA) class III and IV; 61% were in atrial fibrillation. Four mechanisms of mitral regurgitation were assessed: dilatation of the annulus (group I: n = 10); increased amplitude of valve motion (group II: n = 62); restriction of valve motion (group III: n = 23), and mixed lesions (group IV: n = 25). Mitral valve repair was carried out using techniques described by Carpentier. Ring annuloplasty was performed in all patients. There were two operative deaths, and six late deaths. Mean patient follow-up was 41 (range 2-142) months. The actuarial survival rate, excluding hospital deaths, was 91.7% at 5 years and 89.1% at 8 years. Actuarial freedom from reoperation at 8 years was 95(2)%. Freedom from all thromboembolic complications was 89.1% at 8 years. Most survivors had improved to NYHA class I or II and postoperative Doppler echocardiography revealed satisfactory mitral valve competence in 83 patients. Mitral valve reconstruction for mitral regurgitation using Carpentier techniques provides excellent long-term functional results and should be considered as the procedure of choice in patients referred for mitral regurgitation.

Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis.

OBJECTIVE: This study concerns patients who underwent one or several aortic balloon valvuloplasties at our institution and subsequently required cardiac surgery, either on an emergency basis after aortic valvuloplasty or due to the development of aortic stenosis. METHODS: Between February 1987 and December 1993, 137 patients (73 male, 64 female, mean age 72 +/- 9 years) underwent aortic valve replacement for calcified aortic stenosis after several percutaneous balloon aortic valvuloplasties. Thirty-one patients were in NYHA stage II, 70 in stage III and 36 in stage IV. Seventy patients had angina (23 stage I or II, 47 stage III or IV) and 24 patients presented syncope or lipothymia. Twenty-three percent had at least two of these three symptoms. The indications for balloon dilatation were non-definitive surgical contraindication or high surgical risk (73), personal choice (49), refusal of surgery (9) and emergency (5:2 massive aortic regurgitation, 1 left ventricle perforation, 1 cardiogenic shock, 1 endocarditis in cardiogenic shock). Seven patients received preoperative aortic valvuloplasty due to a very high operative risk. The average time between dilatation and surgery was 472 days and there was clinical improvement for an average period of 261 days. The aortic valve replacements consisted of 58 mechanical prostheses and 79 xenografts with 22 concomitant procedures. RESULTS: Operative mortality was eight patients (5.8%). During the follow-up (17.4 +/- 9.2 months), four patients died (3.6%), 91.2% of the patients were in class I and II and 95% were without angina. The actuarial survival rate was 90.5 +/- 6.6% including hospital mortality. CONCLUSIONS: Both our experience and the literature show that balloon aortic valvuloplasty is followed by an immediate improvement in hemodynamic status with a decrease in valve gradient and an increase in valve area. However, the hemodynamic benefit is typically short-lived with a very high restenosis rate. Balloon aortic valvuloplasty is not an alternative to aortic valve replacement, which remains the best treatment for calcified aortic stenosis; the benefits and long-term results of aortic valve replacement are well established, even in the elderly.

Balloon aortic valvuloplasty in elderly patients at high risk for surgery, or inoperable. Immediate and mid-term results.

Although aortic valve replacement is undoubtedly the treatment of choice for aortic valve stenosis, balloon aortic valvuloplasty may represent the only possible treatment for some frail elderly patients who may have additional medical problems. We evaluated immediate and 1-year results of balloon aortic valvuloplasty in 86 patients > or = 80 years with severe aortic stenosis. Mean age was 84 +/- 3 years. Forty-four % were 85 years or older. Mean gradient decreased from 68 to 26 mm Hg and valve area increased from 0.53 to 0.96 cm2 (P<0.05). There were two per-procedural deaths. No local vascular complication was observed. During the follow-up (13 +/- 9 months), 27 patients died, four had repeat balloon aortic valvuloplasty and eight underwent aortic valve replacement. Persistent clinical improvement was observed in 78% of the surviving patients. One-year actuarial survival rate was 73%. Balloon aortic valvuloplasty appears to be a safe and valuable technique in cases where surgery cannot be performed or carries a very high risk.

High incidence of left atrial thrombus detected by transoesophageal echocardiography in heart transplant recipients.

The aim of the study was the detection of spontaneous echo contrast (SEC) and left atrial thrombus by transoesophageal echocardiography (TEE) in patients who had undergone orthotopic heart transplantation. TEE was prospectively performed in 64 heart transplant recipients (53 males, 11 females, mean age 51 years). Since surgery (mean time: 31 months), all heart transplant recipients had received either aspirin (39), or dipyridamole (22), or both (3). Despite the antiplatelet treatment, an acute arterial embolism (two strokes, one popliteal and one mesenteric ischaemia) occurred in four patients who subsequently received an oral anticoagulant therapy. TEE was performed with a biplane high-frequency transducer after lidocaine pharyngeal anaesthesia, midazolam intravenous injection and antibiotic prophylaxis. Mean ejection fraction was 63 +/- 10%. None had evidence of rejection at endomyocardial biopsy performed on the same day as TEE and analysed in a blinded fashion. All were in sinus rhythm. Left atrial SEC was found in 35 patients (55%) and was associated with left atrial thrombus in 18 patients (28%). These thrombi were localized in the donor left atrial appendage in 10 cases, on the posterior wall of the left atrium in six cases, on the donor part of inter-atrial septum in one case and on the suture line in one case. They were not detected by transthoracic echocardiography (TTE). When compared with patients without thrombus, no difference was found concerning left atrial size, left ventricular ejection fraction, pulmonary artery pressure and number of previous episodes of rejection. However, cardiac index was significantly lower in patients with left atrial thrombus.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of repeated and prolonged inflations on immediate angiographic results and complications of coronary angioplasty. Prospective and randomized study]. / Effets de gonflages répétés et prolongés sur le résultat angiographique immédiat et sur les complications de l'angioplastie coronaire. Etude prospective et randomisée.

The effects of the duration of balloon inflation on the immediate and mid-term results of angioplasty were assessed in a randomized study initiated in June 1992. To date, 239 lesions in 224 consecutive patients were allocated randomly into 2 groups according to the duration of balloon inflation: short duration (123 lesions): 3 or 4 successive inflations, each < or = 1 mn, for a total duration < or = 3 min; long duration (116 lesions): 3 to 5 inflations, each of 4 to 5 minutes each for a total duration > or = 12 min. Patients with acute myocardial infarction, restenosis and lesions of bypass grafts were excluded. Stenosis (% of reduction of the internal diameter) was calculated with a digitalised Philips DCI system. Success was defined by < 50% residual stenosis in the absence of severe complications: death, emergency bypass surgery, infarction and extensive and/or occlusive dissection. The baseline clinical, haemodynamic and angiographic parameters of the two groups were comparable. The residual stenosis after angioplasty in the "short duration" group was 33 +/- 11% and 29 +/- 11% in the "long duration" group (p < 0.05). The primary success rate was 75% in the "short duration" compared to 89% in the "long duration" group (< 0.001). Angiographic dissection after angioplasty was observed in 38 cases in the "short" but only in 17 cases in the "long duration" group (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prevalence of intra-auricular thrombi detected by transesophageal echocardiography in patients with cardiac transplants]. / Fréquence des thrombus intra-auriculaires détectés par l'échocardiographie transoesophagienne chez les transplantés cardiaques.

The aim of this study was to determine the prevalence of intra-atrial thrombi or spontaneous contrast by transoesophageal echocardiography in patients who underwent cardiac transplantation by Lower and Shumway's technique. Transoesophageal echocardiography was performed in 52 transplant patients (43 men, 9 women: average age 51 years) with a high frequency biplane transducer. After surgery, all patients received platelet antiaggregant therapy. Despite this treatment, 4 patients had a sudden systemic embolic episode and were then placed on oral anticoagulants. All patients were in sinus rhythm at the time of the examination and some had signs of acute rejection on endomyocardial biopsy performed the same day. Spontaneous contrast was observed in 27 patients (52%) and was associated with thrombosis in 15 patients (29%). These thrombi were located in the left atrial appendage in 8 cases, on the left atrial posterior wall in 5 cases and on the left atrial sutures in 2 cases. None of these thrombi had been detected by transthoracic echocardiography. No significant difference was observed between those with and those without thrombosis with respect to left atrial dimensions, left ventricular ejection fraction, cardiac index, pulmonary pressures and the number of episodes of acute rejection. The 4 patients with a history of arterial embolism all had an intra-atrial thrombus. This study demonstrates a high incidence of spontaneous contrast and intracardiac thrombi in the dilated left atrium of patients transplanted by Lower and Shumway's technique. It also underlines the value of transoesophageal echocardiography in the follow-up of transplant patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Angioscopic evaluation of the immediate result of coronary angioplasty in relation to balloon inflation time]. / Evaluation angioscopique du résultat immédiat de l'angioplastie coronaire en fonction de la durée des gonflages du ballonnet.

The aim of this study was to assess the effects of coronary angioplasty on the intima with respect to the duration of balloon inflation by percutaneous angioplasty. Twenty-seven patients were randomized according to the total duration of balloon inflation: Group I "standard" duration (total duration < or = 3 min, N = 13) and Group II: prolonged duration (total duration > or = 12 min, N = 14); the type and distribution of the lesions were comparable in the two groups. The results of angioplasty were evaluated immediately after dilatation by angiography and angioscopy. Angioscopy was performed without failure or complications with perfect definition of the images in all cases. Angioscopy showed 1) intimal tears, 2) thrombi, 3) longitudinal dissections. A classification in three grades was used taking the apparent gravity of the lesions into consideration. The mean duration of balloon inflation in Group I was 205 +/- 45 s and 958 +/- 129 s in Group II. The residual stenosis was 36 +/- 8% in Group I and 26 +/- 10% in Group II (p < 0.05). Angioscopy showed the frequency of intimal tears to be twice greater in Group I (9 cases) than in Group II (4 cases) (p = 0.05). Intravascular thrombi were observed in 13 cases, 6 in Group I and 7 in Group II. One case of longitudinal dissection was observed in each group: only one of these two cases was detected at angiography. The authors conclude that repeated and prolonged balloon inflations improve the immediate results of angioplasty with less residual stenosis at angiography and a lower incidence of intimal tears at angioscopy.

[Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis. A propos of 104 patients]. / Remplacement valvulaire aortique après valvuloplastie aortique pour rétrécissement aortique calcifié. A propos de 104 patients.

Between February 1987 and December 1990, 104 patients (48 men, 56 women) with an average age of 69 years, underwent aortic valve replacement (AVR) after one or several percutaneous aortic valve balloon dilatation. Thirty one patients were in Class II and 73 patients in Classes III and IV. Twenty two patients had angina (16 Class I-II, 6 Class III-IV) and 12 patients had syncope or near syncope on effort. The indications of valvuloplasty were: non-definitive contraindications of surgery or a surgical risk which was estimated to be excessive (46 patients), a personal choice (41 patients). Five patients underwent preoperative dilatation because of the high operative risk; 7 patients refused surgery and 5 patients were operated as an emergency (2 mas-sive aortic regurgitations, 1 left ventricular perforation, 1 cardiogenic shock, 1 endocarditis with cardiogenic shock). The inter-val between dilatation and surgery was on average 472 days. The patients were improved over an average period of 261 days. Apart form the emergency cases, the patients were operated because of restenosis. Surgery consisted of 53 mechanical and 51 bioprosthetic valve replacements. There was an associated procedure in 17 cases (17 single bypass grafts, 2 double bypass, 1 triple bypass graft, 1 left ventricular suture, 1 Bigelow procedure, 2 mitral valve replacements, 1 tricuspid annuloplasty, 1 carotid endarteriectomy, 1 replacement of the ascending aorta, 1 closure of ASD). The operative mortality was 7 patients (6.7%). The operative findings were 8 lesions related to dilatation, mainly valve tears or disinsertions requiring rapid (6 cases) or emergency (2 cases) surgery for massive aortic regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Current status of aortic valvuloplasty in patients aged 80 and over. Apropos of a recent series of 70 patients (1989-90)]. / Etat actuel de la valvuloplastie aortique chez l'octogénaire. A propos d'une série récente (1989-1990) de 70 patients.

In contrast with aortic valve replacement, the treatment of choice for severe aortic stenosis because of the better long-term results, percutaneous aortic valvuloplasty, has only limited indications, mainly because of the high rate of restenosis. However, in very elderly patients, the surgical risk is high, sometimes prohibitive. For this reason, the authors report their latest results with this technique in a series of octogenarians. Between January 1989 and December 1990, 70 aortic valvuloplasties were performed in octogenarians (average age 85 +/- 3 years). The indications were advanced age > or = 85 years (46%), poor left ventricular ejection fraction < 40% (20%), secere associated coronary artery disease (3%), associated extracardiac pathology (11%), poor general condition (11%) or refusal of surgery (4%). The great majority of these patients (83%) were very symptomatic: 70.5% had Grade III-IV dyspnoea, 20% had Grade III-IV angina and 20% had syncopal attacks. Valvuloplasty reduced the mean transvalvular pressure gradients from 61 +/- 23 to 30 +/- 11 mmHg (p < 0.01) and increased aortic valve surface area from 0.53 +/- 0.19 to 0.94 +/- 0.12 cm2 (p < 0.001). There were two deaths (2.9%) in the catheterization laboratory and 4 (5.7%) complications during the hospital period (myocardial infarction: 1, cerebrovascular accident: 1, severe aortic regurgitation: 1 and complete atrio-ventricular block: 1). There were no serious vascular complications. The average duration of the hospital period was 6 +/- 5 days. Clinical follow-up of 17 +/- 7 months was obtained in 97% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Extensive isolated aneurysm of the right coronary vessel developing within 4 years]. / Volumineux anévrisme isolé de la coronaire droite apparu en 4 ans.

The authors report the case of a 64 year old man on chronic haemodialysis therapy in whom coronary angiography showed a right coronary artery aneurysm. This patient had undergone coronary angiography 4 years previously and no aneurysm had been found on that occasion. The aneurysm occurred in the context of coronary atherosclerosis, coronary angiography showing typical appearances of double vessel disease. There were several special features of this aneurysm which contribute to the originality of the case: its rapid development within 4 years, its large size and the fact that it was an isolated finding on the right coronary artery. Several aetiologies are discussed but none can be formally confirmed.