[Benign papilloma: is US-guided vacuum-assisted breast biopsy an alternative to surgical biopsy?]

The purpose of this study is to assess the value of US guided vacuum-assisted breast biopsy compared to surgery for management of intraductal papilloma. This retrospective study included 13 patients with hypoechoic nodular lesion corresponding to small benign intraductal papillomas on biopsy and visible by US. The lesions were removed using US-guided vacuum-assisted biopsy and all tissue material was reviewed at histology. The mean size of papillomas was 9.3 mm (5-16 mm). Vacuum-assisted tumor removal was considered total for all 13 lesions. Maximum follow-up was 57 months. Two patients had tumor recurrence at 22 and 28 months respectively. In one case, atypical ductal hyperplasia was present at the periphery of the papilloma, requiring complementary surgery. US-guided vacuum-assisted excision of small benign tumors such as solitary intraductal papillomas appears to be an alternative to surgical biopsy. Because of the large volume of tissue removed, total tumor excision is possible allowing detection of incidental associated lesions.

[Echocardiography in the catheterization unit]

Non-coronary interventional cardiology has for about ten years been undergoing significant development, with the arrival of new percutaneous procedures in various domains. Some of them have already been well validated, notably percutaneous mitral comissurotomy, percutaneous closure of inter-atrial (IA) communications and patent foramen ovale, trans-septal catheterisation, and alcohol septal ablation of hypertrophic obstructive cardiomyopathy. Other interventional techniques are still in the validation phase, such as the techniques for percutaneous occlusion of the left atrium, percutaneous implantation of valvular prostheses, or the new approaches to percutaneous treatment of mitral valvulopathy. The rapid development of these techniques has benefited widely from the use of echocardiography in the catheter suite, providing a very precise clarification of the anatomy and continuous guidance during procedures. This echocardiographic guidance provides optimal results for the interventional procedure and reduces the incidence of complications.

[Surgical treatment of aortic stenosis: which prosthesis for which patient?]

The long-term evolution following aortic valve replacement depends on the specific clinical context for each patient, but also on the type of prosthesis used. The increased hemorrhagic risk with mechanical prosthesis has to be weighed against the long-term risk of structural failure of bioprostheses. The patient's age will be a key determinant in the choice of the best suited prosthesis. Usually, bioprostheses are preferred after 70 years of age, while mechanical prostheses are chosen in patients under 65.

[Role of echocardiography prior to to conservative treatment of mitral valvulopathy]

Echography is a key investigation in the diagnosis and follow up of patients with mitral valvulopathy. Recent advances in transthoracic imaging allow precise evaluation of the entire mitral apparatus in the majority of patients, which avoids recourse to the esophageal route especially for mitral insufficiency. On the other hand, TEE remains systematic in cases of stenosis when percutaneous commissurotomy is envisaged to look for intra-cavitary thrombosis. Echographic analysis has the objectives of defining the anatomical mechanism of the leak or stenosis, addressing aetiological arguments, quantifying the valvular dysfunction, and finally appreciating its repercussions (size of the left atrium, left ventricular function, pulmonary pressures). These elements, as well as evaluation of the symptoms, influence the therapeutic indications. The feasibility of conservative action, for which the significance compared to valvular replacement is known, depends directly upon the anatomical lesion and influences the therapeutic indications, especially in asymptomatic subjects for whom recent recommendations have been published. The experience of the ultrasonographer in the evaluation of mitral valvulopathies and his knowledge of conservative techniques allows improvement of the therapeutic discussion with the patient, the surgeon and the catheteriser. Performing TEE in the operative suite prior to conservative mitral surgery is practiced in many centres, as well as checking at the end of the procedure, especially for complex plasties. Three dimensional echography can currently be performed routinely by the transesophageal route, and probably in the near future by the transthoracic route, thanks to the recent arrival of real time 3D. Exercise echography also promises an important development thanks to the commercialization of new effort tables, and will allow refinement of the therapeutic indications in patients with few symptoms or for whom there is a discordance between the objective data and the functional status, but the therapeutic implications of this investigation remain to be defined.

[Isolated carcinoid tumor of the ovary disclosed by tricuspid insufficiency]

A 68-year old woman was hospitalised because of isolated right heart failure. Doppler echocardiography revealed severe tricuspid regurgitation with thickened, shortened, hypomobile leaflets. Pulmonary valve was thickened with mild pulmonary regurgitation. Mitral and aortic valves were normal. The patient was finally diagnosed with carcinoid heart disease from an isolated ovarian carcinoid cancer without hepatic metastases. Ovarectomy was performed and the patient was considered cured of her cancer. Because of refractory right heart failure, she underwent tricuspid valve replacement with a bioprosthesis. Such cardiovascular manifestations are rarely the presenting symptoms of carcinoid disease. Carcinoid heart disease from ovarian primary cancer is exceptional. In this circumstance, carcinoid cardiac lesions may develop in the absence of hepatic metastases because the venous blood from the ovaries drains into the inferior vena cava without hepatic first past effect. Surgical resection of primary ovarian carcinoid tumor is often curative and the prognosis depends mainly on the cardiac condition. The diagnosis of carcinoid syndrome should be discussed in patients with organic tricuspid regurgitation without left valvular disease.

Cardiac manifestations of rheumatoid arthritis: a case-control transesophageal echocardiography study in 30 patients

OBJECTIVES

Current knowledge of the cardiac manifestations of rheumatoid arthritis (RA) stems only from clinical and transthoracic echocardiography (TTE) studies. To determine the incidence and type of heart lesions in RA, we coupled TTE with transesophageal echocardiography (TEE), which is more sensitive and more accurate.

METHODS

Thirty unselected RA patients (26 women and 4 men aged 27 to 84 years, with a mean age of 57.8+/-15.1 years) free of known progressive heart disease underwent a chest radiograph, an electrocardiogram, laboratory tests, and TTE coupled with TEE. Results were compared with those in age- and sex-matched patients who were free of rheumatic disease and who underwent TEE to investigate a neurologic or cardiologic disorder.

RESULTS

Mitral regurgitation (MR) was evidenced in 24 cases (80%). Among the controls, only 11 (37%) had MR (P < 0.001). Aortic regurgitation was found in 10 cases (33%), versus 7 controls (not significant-NS). Seven cases (23%) versus only 2 controls (7%) had tricuspid valve abnormalities (NS). Pericarditis was found in 4 cases (13%) and in none of the controls. Eleven cases had evidence of cardiomyopathy (37%) and 12 (40%) had atheroma of the aorta, this last being missed by TTE in 10 patients. Echo-generating nodules were seen on a mitral valve in 2 cases and on an aortic valve in 1. We found no correlations linking cardiac lesions to clinical or laboratory features of RA.

CONCLUSION

Our study demonstrated that cardiac involvement, particularly of the mitral valve, is extremely common in RA patients.

[Echocardiography of heart valve diseases]

Echography can be considered as the gold standard method for quantifying a valvular dysfunction, evaluating its hemodynamic impact and assessing anatomy. Echocardiography is a major step in the diagnosis and the pretherapeutic evaluation of valvular disease.

Immediate and mid-term results of repeat percutaneous mitral commissurotomy for restenosis following earlier percutaneous mitral commissurotomy

AIMS

This study assessed the results of repeat percutaneous mitral commissurotomy for mitral restenosis following a first procedure.

METHODS AND RESULTS

Repeat balloon commissurotomy was performed in 53 patients who had symptomatic restenosis a mean of 6+/-2 years (2-11) after a successful first procedure; seven patients had mildly calcified valves. All patients had restenosis with a fusion of both commissures as assessed by echocardiography. A double-balloon was used in one case and the Inoue technique in 52. Complications were stroke in one patient and severe mitral regurgitation (Sellers grade 3) in two. Valve area increased from 1.03+/-0.22 to 1.82+/-0.21 cm(2)(P<0.0001) as assessed by planimetry. Good immediate results, defined as valve area >/=1.5 cm(2)with no regurgitation >2/4, were obtained in 48 patients (91%). The 5-year survival rate without operation and in NYHA class I or II was 69+/-11% in the whole population, and 76+/-11% in the 48 patients who had had good immediate results.

CONCLUSION

This study suggests that repeat balloon commissurotomy is a valid treatment for symptomatic restenosis after a first successful procedure. It gives good results in patients selected on the basis of favourable characteristics and the echocardiographic analysis of the mechanism of restenosis.

Late results of percutaneous mitral commissurotomy for calcific mitral stenosis

The aim of this study was to assess late results of percutaneous mitral commissurotomy (PMC) in calcific mitral stenosis and to identify predictors to improve patient selection. We analyzed 422 patients who underwent PMC for calcific mitral stenosis. The extent of calcium was graded from 1 to 4 by fluoroscopy: 227 patients (53%) were graded 1, 125 (30%) graded 2, 55 graded 3 (13%), and 15 graded 4 (4%). The procedure failed in 15 patients, used a single balloon in 11, a double balloon in 126, and the Inoue balloon in 270. In-hospital mortality was 1.2%. Good immediate results (valve area >/=1.5 cm(2) without mitral regurgitation >2/4), were obtained in 321 patients (76%). Multivariate analysis identified 5 predictors of good immediate results: a younger age (p = 0.0004), a lesser degree of stenosis (p = 0.0005), a smaller extent of calcium (p = 0.04), the use of the Inoue balloon (p = 0.015), and a larger effective balloon dilating area (p = 0.006). Good functional results, defined as survival with no further intervention and in New York Heart Association class I or II, were 36 +/- 4% at 8 years. The predictors of good functional results after good immediate results were a younger age (p = 0.04), a lower pre-PMC New York Heart Association class (p <0.0001), sinus rhythm (p = 0.0006), a smaller extent of calcium (p = 0.02), and a lower gradient after PMC (p <0.0001). Despite a frequent deterioration on follow-up after PMC for calcific mitral stenosis, the predictive analysis suggests that PMC may be useful in deferring surgery in selected patients with mild to moderate calcific deposits, who have otherwise favorable characteristics.

Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy: late efficacy and implications for patient selection

OBJECTIVES

The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy.

BACKGROUND

Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy.

METHODS

We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 +/- 8 years after surgical commissurotomy. Mean age was 47 +/- 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121.

RESULTS

Complications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area > or =1.5 cm2 without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p < 0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 +/- 5%, and 58 +/- 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p < 0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p < 0.0001) in a multivariate Cox model.

CONCLUSIONS

Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

Late results of percutaneous mitral commissurotomy in a series of 1024 patients. Analysis of late clinical deterioration: frequency, anatomic findings, and predictive factors

BACKGROUND

The optimal use of percutaneous mitral commissurotomy (PMC) in a wide range of patients requires accurate evaluation of late results and identification of their predictors.

METHODS AND RESULTS

Late results of PMC were assessed in 1024 patients whose mean age was 49+/-14 years. Echocardiography showed that 141 patients (14%) had pliable valves and mild subvalvular disease, 569 (55%) had extensive subvalvular disease, and 314 (31%) had calcified valves. A single balloon was used in 26 patients, a double balloon in 390, and the Inoue Balloon in 608. Good immediate results were defined as valve area >/=1.5 cm2 without regurgitation >2/4 (Sellers' grade) and were obtained in 912 patients. Median duration of follow-up was 49 months. The 10-year actuarial rate of good functional results (survival with no cardiovascular death and no need for surgery or repeat dilatation and in New York Heart Association [NYHA] class I or II) was 56+/-4% in the entire population. Follow-up echocardiography was available in 90% of the patients who experienced poor functional results after good immediate results and showed restenosis in 97% of these. In multivariate analysis, the predictors of poor functional results were old age (P=0.0008), unfavorable valve anatomy (P=0.003), high NYHA class (P<0.0001), atrial fibrillation (P<0.0001), low valve area after PMC (P=0.001), high gradient after PMC (P<0.0001), and grade 2 mitral regurgitation after PMC (P=0.04).

CONCLUSIONS

PMC can be performed with good late results in a variety of patient subsets. Prediction of late events is multifactorial. Knowledge of these predictors can improve patient selection and follow-up.

[Carcinoid heart disease]

Carcinoid cardiac disease is a common complication of metastatic carcinoid tumours. It is characterized by tricuspid regurgitation and pulmonary stenosis. A 68 years old woman with a metastatic carcinoid tumour was admitted to hospital for congestive cardiac failure secondary to severe tricuspid regurgitation. Typical carcinoid lesions of the tricuspid and pulmonary valves were observed at echocardiography. A double valve replacement was performed with a favourable outcome. Postoperative echocardiography showed a significant improvement in right ventricular function. Surgical management of carcinoid valvular heart disease of NYHA Stage III patients is associated with an improved 2 years survival (from 8 to 40%) despite a high operative mortality (about 27%). Cardiac surgery remains the only hope of long-term survival with a spectacular improvement in symptoms.

[Recommendations of the French Society of Cardiology for the training of echocardiographers and performing echocardiograms]

The considerable advances achieved in the field of echocardiography have made this investigation an essential diagnostic tool. Under the auspices of the French Society of Cardiology, the Working group on Echocardiography publishes its practical recommendations for optimising the training of echocardiographers (theoretical instruction and practical courses) and for performing echocardiography (understanding the clinical problem, referral to previous examinations, necessary recordings and measurements, and appropriate equipment). In the future, these recommendations should be updated to take into account continuing technical improvements and changes in methods of studying cardiac disease by echocardiography.

[5 years results of percutaneous mitral commissurotomy. Apropos of a series of 606 patients; late results after mitral dilatation]

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.

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.