[Platypnea-orthodeoxia revealed by recurrent syncope episodes]. / Platypnée-orthodéoxie révélée par des syncopes à répétition.

Platypnea-orthodeoxia is a rare clinical condition which must be examined as a differential diagnosis for any bout of faintness occurring during standing or dyspnea that is exacerbated by standing. This syndrome is often associated with a patent foramen ovale. Its physiopathology is not univocal and the association of many anatomical criteria seems to be mandatory. Contrast echocardiography confirms diagnosis and closure of the patent foramen ovale during interventional catheterization and is currently the therapeutic method of choice. After closure of the foramen ovale, clinical improvement is spectacular and durable.

Hypoxaemia associated with an enlarged aortic root: a new syndrome?

OBJECTIVE: To assess the mechanisms through which an enlarged aortic root may facilitate right to left shunting through a patent foramen ovale. PATIENTS: 19 patients with the platypnoea-orthodeoxia syndrome (POS) were compared with 30 control patients without platypnoea. INTERVENTIONS: Multiplane transoesophageal echocardiography. MAIN OUTCOME MEASURES: The aortic root diameter, atrial septal dimension behind the aortic root, and amplitude of the phasic oscillation of the septum were measured. Four groups of patients were compared: 12 platypnoeic patients with a dilated aortic root (POS-D), 7 platypnoeic patients with a normal aortic root (POS-N), 15 control patients with a dilated aortic root (CONT-D), and 15 control patients with a normal aortic root (CONT-N). RESULTS: In POS-D and CONT-D patients, the apparent atrial septal dimension was 16.3 (2.7) mm and 17.4 (5.9) mm respectively, compared with 24.4 (5.2) mm in POS-N patients and 25 (4) mm in CONT-N (p < 0.005). Furthermore, the amplitude of septal oscillation was 14.7 (2.5) mm in the POS-D group versus 5.8 (2.4) mm in CONT-N (p < 0.001) compared with 23.3 (3) mm in seven patients with an atrial septal aneurysm (p < 0.001). CONCLUSION: Patients with an enlarged aorta have an apparently smaller dimension and increased mobility of the atrial septum. These findings appear to result from compression by the aortic root and decreased septal tautness. Consequently, a "spinnaker effect" with the inferior vena caval flow may take place, opening the foramen ovale and leading to sustained right to left shunting.

[Multicentre study of percutaneous closure of interventricular muscular defects with the aid of an Amplatzer duct occluder prosthesis]. / Etude multicentrique de la fermeture percutanée des communications interventriculaires musculaires à l'aide d'une prothèse Amplatzer duct occluder.

Percutaneous closure of interventricular defects is an alternative or adjunct to surgery with the disadvantage of a sometimes prolonged and difficult catheterisation only during which the choice of prosthesis can be determined. Despite the existence of an occlusion prosthesis, the Amplatzer Septal Defect Occluder, specifically conceived for this purpose, an arterial canal occlusion prosthesis such as the Amplatzer Duct Occluder is sometimes better suited for the occlusion of certain interventricular defects. Since 1999, 11 Amplatzer Duct Occluders were used for the closure of interventricular muscular defects, during 10 catheterisations in 9 patients with a median age of 2.5 (0.1 to 43.9) years. In 5 cases there were residual septal defects after failure of initial surgery. 10 were successful with prostheses of 6/4 mm to 12/10 mm while in one patient the interventricular communication had to be closed surgically because the 14/12 mm prosthesis could not be positioned due to a tortuous introduction route. The only complication was a pericardial effusion requiring surgical drainage in one infant. After a median follow up of 2.1 (0.3 to 4.2) years, all of the patients had a satisfactory functional status, with minimal residual shunt on echocardiography in 2 cases. The Amplatzer Duct Occluder therefore seems better adapted for the closure of post-operative residual interventricular communications, with a thickened interventricular septum or even when the tricuspid valve is very close to the right ventricular side of the orifice.

[Percutaneous pulmonary valve replacement: towards a modification of the prosthesis]. / Remplacement valvulaire pulmonaire par voie percutanée: vers une modification de la prothèse.

Percutaneous pulmonary valve replacement has recently been introduced as an alternative to surgery, pushing back the frontiers of interventional catheterisation. The authors report their experience in this field and focus on the complications of the method. From September 2000 to November 2002, 14 patients with a failing artificial pulmonary outflow tract were included in this protocol of clinical research. The authors attempted pulmonary implantation of a bovine jugular vein valve fitted in a vascular stent under general anaesthesia. The implantation was possible in all patients. Three had dynamic obstruction due to the implanted valve. This was due to infiltration of blood between the valve and the stent. The problem was resolved by: implanting a second valve in one patient: redialating the valve stent in two other patients. However, the last patient had to be reoperated 7 weeks after the implantation because of recurrence of the obstruction. One valve had to be explanted one year after implantation because of severe infectious endocarditis after unprotected dental treatment. Two patients experienced fracture of the stent but without valve dysfunction. Despite these complications, the clinical state of all patients improved during follow-up. The authors conclude that non-surgical pulmonary valve replacement is feasible, thereby increasing the therapeutic arsenal of interventional catheterisation. Simple modifications should result in fewer problems of dynamic obstruction and stent fracture, and lead to proposing this technique for native pulmonary outflow tracts.

[Percutaneous closure of a mid-muscular residual ventricular septal defect using the Amplatzer(TM) device]. / Cierre percutáneo de una comunicación interventricular muscular residual mediante el dispositivo tipo Amplatzer.

We present the case of a 6-year old boy with a mid-muscular residual ventricular septal defect (VSD) of difficult surgical access, who underwent transcatheter closure using the Amplatzer(TM) VSD occluder. Transcatheter closure was guided by transthoracic echocardiography and successful closure was achieved with a 12 mm diameter VSD occluder, with no complications. Chest radiography showed a considerable decrease in cardiomegaly and normalization of pulmonary vascular markings before 24 hours, and echocardiography showed correct positioning of the Amplatzer(TM) VSD device without residual shunt through the device and minimal residual shunt in an apical VSD. After a 3-month follow-up, the patient was asymptomatic and echocardiography showed that the device was correctly positioned with minimal residual apical shunt.

[Percutaneous closure of a paravalvular mitral regurgitation with Amplatzer and coil prostheses]. / Fermeture percutanée d'une fuite paravalvulaire mitrale avec prothèses d'Amplatzer et coil.

The authors report a case of percutaneous closure of paravalvular mitral regurgitation in a 9 year old child. This patient had complete atrioventricular canal with levo-isomerism completely repaired with replacement of the left atrioventricular valve by a mechanical prosthesis. One year after an episode of infectious endocarditis, the patient was readmitted because of jaundice due to haemolysis attributed to paravalvular mitral regurgitation. Transoesophageal echocardiography demonstrated a crescent-shaped dehiscence of the prosthesis opposite the left atrial appendage associated with a small paraseptal regurgitation. First of all, a 6 mm Amplatzer Septal Occluder and a 5 x 5 coil were introduced by retrograde catheterisation to treat the regurgitation due to the valve dehiscence. This procedure was completed 3 months later by the implantation of a second 8 mm Amplatzer prosthesis for persistent haemolysis. Closure of the paraseptal regurgitation resulted in a reduction of the patient's transfusional requirements.

Coronary angiography using 4 or 6 French diagnostic catheters: a prospective, randomized study.

Diagnostic catheter size has been progressively decreased in order to reduce complications (particularly access-site complications) and permit early ambulation after coronary angiography. However, excessive down-sizing can result in poor catheter conformation and poor imaging quality of coronary angiograms (CA). This study randomly compared the accuracy and angiographic quality (QUAL) of CA performed with 4 French (Fr) vs. 6 Fr diagnostic catheters. Injections were done manually using a low-viscosity, non-heated, low-osmolality contrast media (Iomeprol). CAs were performed via the femoral approach using Judkins catheters. Handling, torque, selectively and stability were graded from 1 (excellent) to 4 (unacceptable) by the operator. QUAL was also graded from 1 (unacceptable) to 10 (excellent) by the operator in all patients and by an independent Core laboratory in 50 patients matched for gender and weight. Between January and April 1997, a total of 405 consecutive patients were randomized. Mean age was 63.4 +/- 11.1 years and 79% were male. Clinical characteristics of patients, quality of left coronary catheter and cross-over rates (1.5% with 6 Fr vs. 3.9% with 4 Fr catheters) were similar in both groups. Using the right coronary catheters, the only difference was handling, which was found to be easier with 6 Fr catheters (1.16 +/- 0.55 vs. 1.34 +/- 0.77, respectively; p = 0.007). Similarly, handling difficulty using the pigtail catheter was the only significant difference between the two groups (1.16 +/- 0.50 vs. 1.33 +/- 0.77, respectively; p = 0.009), but no cross-over was necessary in either group. The QUAL of CA was slightly but significantly better with 6 Fr than with 4 Fr catheters but considered non-diagnostic (< 7/10) in 1.4% vs. 6.8% of left CAs (p = NS). Procedural time (21.0 +/- 7.2 minutes vs. 19.0 +/- 8.1 minutes; p = 0.007) was shorter with 4 Fr catheters, but x-ray exposure, compression times and amount of contrast media used were similar. Ambulation was obtained at 2 hours in 15.1% vs. 34.0% of patients (p < 0.001) and at 4 hours in 43.8% vs. 52.4% (p < 0.05), respectively. The incidence of the worst access-site complication (moderate hematoma) was similar (1%) in both groups. CA can be performed using 4 Fr catheters and manual injections of low-viscosity contrast media with acceptable angiographic results in the majority of cases. This is associated with a shorter procedural time and earlier ambulation, and a decreased but acceptable angiographic quality.

Outcome after combined reperfusion therapy for acute myocardial infarction, combining pre-hospital thrombolysis with immediate percutaneous coronary intervention and stent.

BACKGROUND: Primary therapies in acute myocardial infarction (thrombolysis and angioplasty) have inherent limitations which may be overcome by combining them. So far, no trial has demonstrated a clinical benefit in combining mechanical and pharmacological treatment strategies. METHODS: From January 1995 to December 1999, out of 1010 patients admitted to our institution for acute myocardial infarction, 148 had received pre-hospital full dose thrombolysis within 12 h of onset. One hundred and thirty-one patients were included and underwent immediate angioplasty and stenting when suitable, independent of the infarct-artery patency (TIMI grade flow 0-3). In-hospital outcome was assessed and clinical information was collected for a mean (+/-SD) of 2+/-1 years. RESULTS: Ninety-minute angiography revealed a patent (TIMI grade 3) infarct artery in 65 patients (49%). Immediate angioplasty was performed in 119 patients (91%) with stent implantation in 114 (96%). Angioplasty achieved TIMI 2, 3 flow in 98%, and complete patency (TIMI 3 flow) in 92%. Six other patients underwent deferred revascularization (surgery in one patient, angioplasty in five) and six received medical treatment. Stent thrombosis and reinfarction occurred in three patients (2.3%). In-hospital death occurred in six patients (4.6%), including four patients presenting with cardiogenic shock. Major bleeding was observed in 2.3% of cases. No patient had emergency surgery. Freedom from death and reinfarction at 2 years was 90% and freedom from death, reinfarction and target vessel revascularization was 83%. CONCLUSION: A strategy of combined reperfusion using full dose pre-hospital thrombolysis and immediate angioplasty with stent implantation in a non-selected acute myocardial infarction population is safe and achieves high and early patency rates. This preliminary experience suggests that a combined strategy in acute myocardial infarction may have a significant impact on both early and long-term outcomes.

Hypoxemia related to right-to-left shunting through a patent foramen ovale: successful percutaneous treatment with the CardioSeal device.

Hypoxemia related to right-to-left shunting through a patent foramen ovale (PFO) is not rare. It can be observed in correlation with a specific situation such as pneumonectomy and can occur even with normal pulmonary pressure. This article reports the experience of 12 patients in which a transcatheter closure with the CardioSeal device was done successfully. Clinical improvement is often obtained, despite incomplete occlusion of the defects. The author demonstrated that transcatheter closure of PFO can be performed safety and should be considered as an efficient alternative to surgery in cyanotic patients with PFO.

Stenting of bifurcation lesions: a rational approach.

The occurrence of stenosis in or next to coronary bifurcations is relatively frequent and generally underestimated. In our experience, such lesions account for 15%-18% of all percutaneous coronary intervention > (PCI). The main reasons for this are (1) the coronary arteries are like the branches of a tree with many ramifications and (2) because of axial plaque redistribution, especially after stent implantation, PCI of lesions located next to a coronary bifurcation almost inevitably cause plaque shifting in the side branches. PCI treatment of coronary bifurcation lesions remains challenging. Balloon dilatation treatment used to be associated with less than satisfactory immediate results, a high complication rate, and an unacceptable restenosis rate. The kissing balloon technique resulted in improved, though suboptimal, outcomes. Several approaches were then suggested, like rotative or directional atherectomy, but these techniques did not translate into significantly enhanced results. With the advent of second generation stents, in 1996, the authors decided to set up an observational study on coronary bifurcation stenting combined with a bench test of the various stents available. Over the last 5 years, techniques, strategies, and stent design have improved. As a result, the authors have been able to define a rational approach to coronary bifurcation stenting. This bench study analyzed the behavior of stents and allowed stents to be discarded that are not compatible with the treatment of coronary bifurcations. Most importantly, this study revealed that stent deformation due to the opening of a strut is a constant phenomenon that must be corrected by kissing balloon inflation. Moreover, it was observed that the opening of a stent strut into a side branch could permit the stenting, at least partly, of the side branch ostium. This resulted in the provocative concept of "stenting both branches with a single stent." Therefore, a simple approach is currently implemented in the majority of cases: stenting of the main branch with provisional stenting of the side branch. The technique consists of inserting a guidewire in each coronary branch. A stent is then positioned in the main branch with a wire being "jailed" in the side branch. The wires are then exchanged, starting with the main branch wire that is passed through the stent struts into the side branch. After opening the stent struts in the side branch, kissing balloon inflation is performed. A second stent is deployed in the side branch in the presence of suboptimal results only. Over the last 2 years, this technique has been associated with a 98% angiographic success rate in both branches. Two stents are used in 30%-35% of cases and final kissing balloon inflation is performed in > 95% of cases. The in-hospital major adverse cardiac events (MACE) rate is around 5% and 7-month target vessel revascularization (TVR) is 13%. Several stents specifically designed for coronary bifurcation lesions are currently being investigated. The objective is to simplify the approach for all users. In the near future, the use of drug-eluting stents should reduce the risk of restenosis.

Issues in transcatheter treatment of critical aortic stenosis in the newborn infant.

Critical aortic valve stenosis is not a frequently seen disease. In most cases, these patients are in critical condition. Transcatheter dilatation is one of the therapeutic options for treatment. This article addresses important issues in transcatheter dilatation in the newborn infant.

Systematic use of transradial approach or suture of the femoral artery after angioplasty: attempt at achieving zero access site complications.

Access site complications occur in 5-15% of cases according to the various series. The predictive factors most often reported in the literature are the size of the puncture site and the intensity of the antiplatelet or anticoagulant treatment associated with the angioplasty procedure. Six senior cardiologists in a high volume Cardiology center (>1,500 procedures a year) with an individual experience >500 procedures in either the radial approach or the percutaneous suture of the femoral artery with the Techstar/Prostar system, conducted a prospective study from January 1 to December 31, 1999. The aim of this study was to eliminate the occurrence of access site complications by using either one of two techniques that were at the operator's discretion, i.e., systematic radial approach, or percutaneous suture of the femoral artery. A total of 956 patients were included over the study period; 60.7% of these patients had percutaneous arterial closure of the femoral artery and the remaining 39.3% were treated via the radial approach; 88.7% were stented. The patients were administered a mean 9,000 IU of heparin during the procedure; 1.9% had been fibrinolyzed and Reopro was used in 5.9%. No complications were documented in the radial group. Of the 580 patients in the femoral suture group, 96.9% had femoral suture, immediately effective in 508 cases (90.4%). Only 3 patients required additional prolonged compression. One significant hematoma (0.2%) necessitating blood transfusion was reported in the femoral group. Infection at the puncture site with subsequent antibiotic treatment was reported in 2 patients (0.3%). No further access site complications were observed at one-month follow-up. After completion of the learning curve, the two techniques (radial approach and percutaneous arterial suture) permit the almost total elimination of access site complications.

A European multicentric experience using the CardioSEal and Starflex double umbrella devices to close interatrial communications holes within the oval fossa.

In this review, we describe the experience from 13 European centres using the CardioSEAL and Starflex double umbrella devices to close interatrial communications within the oval fossa (so-called 'secundum' defects). Between October 1996 and April 1999, the procedure was attempted in 334 patients with a mean age of 12 years and a mean weight of 44kg. The mean measured stretched diameter of the defect was 15 mm. In the overall group, the defect was solitary in 245 patients (73%), multiple in 21 (6%), associated with an aneurysm of the flap valve in 15 (5 %), was represented by patency of the oval foramen in 44 (13%), and was a fenestration in a Fontan repair in 9 (3%). In all patients, the devices were inserted under general anesthesia, using fluoroscopic and transesophageal echocardiographic control. Implantation was achieved in 325 (97,3%). The device embolized within either a few minutes or a few hours in 13 patients (4%). Of these, uncomplicated surgical repair was undertaken in 10, while the device was retrieved in 3 using catheters and a second device was successfully implanted. Residual shunting was detected immediately after the procedure in 41% of the patients, with the incidence decreasing to 31% at discharge, 24% at 1 month, 21% at 6 months, and 20.5% at one year. During the period of follow-up, elective surgical repair became necessary in two patients, due to malposition of the device in one, and late embolization in the other. Fractures of arms were seen in 6.1 %, most commonly with the largest devices. All those with fractured arms of the device were asymptomatic, and no clinical complications related to the fractures were observed. There were no arrhythmias, endocarditis, valvar distortion, thromboembolic events, or other complications. After one year of follow-up, clinical success, defined as complete closure of the defect or presence of only a trivial leak, had been obtained in 92.5% of the patients. We conclude, therefore, that these devices produce excellent results when used to close defects of small to moderate size. Results are less than optimal, or else complications ensure, when attempts are made to close very large defects.

Coronary angioplasty using 5 French guiding catheters: preliminary experience.

In a retrospective study of 40 patients, we evaluated the effectiveness of the new 5 Fr 0.058" lumen diameter guiding catheter in routine PTCA. A total of 54 balloon angioplasties were performed. The mean age was 62.1+/-12.8 years, with 71% men. The artery dilated was the LAD in 50%, the RCA in 37%, and the circumflex in 13%. Sixty percent of the lesions dilated were proximal lesions, with only 25% defined as distal lesions. Significant calcifications were present in 20% of the lesions. Stents were implanted in 96%, and mean stent length was 14.0 mm, ranging from 8 to 24 mm. Mean balloon diameter was 2.7 mm, ranging from 2.0 to 3.5 mm. The procedure was a success in 95%, with only two failures. No other complications occurred. We concluded that the 0.058" 5 Fr guiding catheter could be suitable in the majority of noncomplex, selected PTCA cases. However, limitations and advantages over the standard 6 Fr technique are yet to be defined.

A randomized study comparing two guidewire strategies for angioplasty of chronic total coronary occlusion.

Chronic total coronary occlusions were more frequently crossed using the Crosswire as a primary guidewire strategy than with the conventional strategy. This strategy resulted in a lower number of guidewires being used, a trend toward shorter procedural and fluoroscopy times, and decreased use of contrast media.

Stenting of bifurcation lesions: classification, treatments, and results.

Percutaneous transluminal balloon coronary angioplasty (PTCA) of coronary bifurcations is associated with a low success rate, high rate of complications, and high incidence of target vessel revascularization (TVR). The strategy of systematic coronary stenting in bifurcation lesions involving a side branch >/= 2.2 mm in diameter was prospectively evaluated in a single-center observational study during a 35-month inclusion period. All patients meeting these criteria were consecutively included. Bifurcation lesions and treatment were predefined in the study. The study included 366 patients (12.1% of PTCA) with 373 bifurcation lesions, mean age 63.7 +/- 11.6 years, 79.2% male, 46.7% with unstable angina, and 8.3% acute MI. The left anterior descending/diagonal bifurcation was involved in 55.2% of cases, circumflex/marginal 22. 2%, PDA/PLA 10.4%, left main bifurcation in 6.8%, and others 5.4%. The main branch (2.78 +/- 0.42 mm reference diameter) was stented in 96.3% of cases and the side branch (2.44 +/- 0.43 mm) in 63.2% (the two branches were stented in 59.5% of cases). Procedural success was obtained in 96.3% in both branches and 99.4% in the main branch. At1-month follow-up, The major cardiac event rate (MACE) was 4.8% (death 1.1%, emergency CABG 0.6%, Q-wave MI 0.9%, acute or subacute closure 1.4%, repeat PTCA 1.1%, and non-Q-wave MI 2.3%). At 7-month follow-up, the total MACCE rate was 21.6%, including a TVR rate of 17.2%. Analysis of the 7-month outcome according to two study periods (period I, 1 January 1996 to 31 August 1997, 182 patients; period II, 1 September 1997 to 30 June 1998, 127 patients) showed that the TVR rate decreased from 20.6% to 13.8% (P = 0.04) and the MACE rate from 29.2% to 17.1% (P < 0.01) in period I and II, respectively. This was associated by univariate analysis with an increasing use of tubular stents deployed in the main branch (94.2% vs. 59.1%, P < 0.001) and kissing balloon inflation after coronary stenting (75.4% vs. 18.1%, P < 0.001). Bifurcation lesions are frequent. Procedural success of coronary stenting is high with a low rate of in-hospital MACE. TVR rate at follow-up is relatively low. In-hospital and follow-up results are influenced not only by the learning curve but also by the use of tubular stents in the main branch and final kissing balloon inflation.

Transcatheter closure of apical ventricular muscular septal defect combined with arterial switch operation in a newborn infant.

This report describes a case of transposition of the great arteries and apical muscular ventricular septal defect in a newborn infant successfully treated by transcatheter closure of the septal defect with the Amplatzer duct occluder device followed by an arterial-switch operation within the first 2 weeks of life. Cathet. Cardiovasc. Intervent. 49:173-176, 2000.

[Immediate revascularization by angioplasty and coronary stents in patients over age 80 with myocardial infarction]. / Revascularisation immédiate par angioplastie et implantation d'une endoprothèse coronaire chez l'octogénaire victime d'un infarctus du myocarde.

The aim of this study was to assess the results of revascularisation by angioplasty and stenting in octogenarians in the acute phase of myocardial infarction. One hundred and four patients over 80 years of age were identified between January 1995 and April 1995 out of 906 patients admitted within 24 hours of the onset of myocardial infarction. The average age was 85 +/- 4 years with a female predominance (63.4%) and a high incidence of cardiogenic shock (28.8%). Ninety eight patients underwent angioplasty with coronary stenting in 81 patients (82.6%) within 39 +/- 35 min of hospital admission. A primary success was obtained in 96% of cases with restitution of TIMI 3 flow in 83.6% of cases. Hospital mortality was 26.5%, highly influenced by the presence of cardiogenic shock (60.7% versus 12.8% without shock). Univariate analysis showed cardiogenic shock (p < 0.0001) and ejection fraction (p = 0.009) to be predictive of mortality, and a tendency in favour of TIMI 3 flow (p = 0.07) and stent implantation (p = 0.09). Complications were rare: 1% of minor cerebrovascular accidents and 4% of vascular complications. There were no cases of emergency bypass surgery and only one patient had a recurrence of ischaemia at 30 days. The authors conclude that the results at 1 month in a high risk group of octogenarians seem to be in favour of an invasive management with coronary stenting in the acute phase of myocardial infarction.