[Malignant myoepithelial breast carcinoma: diagnosis and therapeutic difficulties]

Myoepithelial carcinoma of the breast is a rare and malignant tumor. Local recurrence and distant metastasis are common. Treatment is not consensual. Here, we report a case of a 61-year-old female who developed a myoepithelial carcinoma. Primary treatment was a local wide excision with clear pathological margins. Three years later, a local recurrence was treated by further wide excision. Neither recurrences nor distant metastasis were detected four years later. Regular following of patients with myoepithelial carcinoma is essential.

True percutaneous approach for transfemoral aortic valve implantation using the Prostar XL device: impact of learning curve on vascular complications

OBJECTIVES

The purpose of this study was to evaluate the incidence of vascular complications and the predictors of Prostar failure for a "true percutaneous approach" in transfemoral transcatheter aortic valve implantation (TAVI).

BACKGROUND

Safety and efficacy of a true percutaneous approach in transfemoral-TAVI has not been described in a large prospective cohort.

METHODS

Among 264 patients included in our prospective TAVI database (October 2006 to December 2010), transfemoral-TAVI was performed in 170 patients. True percutaneous approach was performed in 142 consecutive patients since March 2008. Successful closure with Prostar was defined as adequate hemostasis without Prostar-related vascular complications. We compared the incidence of vascular complications in our early and late experience.

RESULTS

Patients were 83.0±7.2 years old and with a EuroSCORE of 24.0±11.6%. The Edwards valve (Edwards Lifesciences, Irvine, California) (18- to 24-F) was used in 109 cases and the CoreValve (Medtronic, Minneapolis, Minnesota) (18-F) in 31. The sheath outer diameter to minimal femoral diameter ratio (SFAR) was 0.96±0.14. Successful closure was achieved in 90.7%, and was significantly increased (95.7% vs. 85.7%, p=0.047) in the late experience group. Cross-over to surgery was required in 3.6%. Vascular complications occurred in 20.0%, and were significantly lower in the late experience group (11.4% vs. 28.6%, p=0.012). Major vascular complications (2.9% vs. 14.3%, p=0.018) were decreased in the late experience group. Early experience (hazard ratio [HR]: 3.66, 95% confidence interval [CI]: 1.04 to 13.89, p=0.047) and SFAR (HR: 110.80, 95% CI: 1.15 to 10,710.73, p=0.044) predicted Prostar failure by univariate analysis.

CONCLUSIONS

Experience reduced major vascular complications in a true percutaneous approach for transfemoral-TAVI. Further application of this less invasive strategy is feasible and may be beneficial, in this high-risk patient cohort.

Late results of percutaneous mitral commissurotomy up to 20 years: development and validation of a risk score predicting late functional results from a series of 912 patients

BACKGROUND

Long-term follow-up after percutaneous mitral commissurotomy enables predictive factors of late results to be identified.

METHODS AND RESULTS

Late results of percutaneous mitral commissurotomy were assessed in 1024 consecutive patients. Good immediate results, defined as valve area ≥1.5 cm(2) without mitral regurgitation >2/4, were obtained in 912 patients (89%). These 912 patients were randomly split into 2 cohorts comprising 609 and 303 patients that were used to develop and validate, respectively, a scoring system predicting late functional results. The 20-year rate of good functional results (survival without cardiovascular death, mitral surgery, or repeat percutaneous mitral commissurotomy and in New York Heart Association class I or II) was 30.2 ± 2.0%. A multivariable Cox model identified 7 predictive factors of poor late functional results: higher final mean gradient (P<0.0001), interaction between age and final mitral valve area (P<0.0001) showing that the impact of valve area decreases with age, interaction between sex and valve calcification (P<0.0001) showing that the impact of valve anatomy is stronger in men, and interaction between rhythm and New York Heart Association class showing an impact of New York Heart Association class only in patients in atrial fibrillation (P<0.0001). A 13-point score enabled 3 risk groups to be defined, corresponding to predicted good functional results of 55.1%, 29.1%, and 10.5% at 20 years in the validation cohort.

CONCLUSIONS

Twenty years after percutaneous mitral commissurotomy in a population of patients with varied characteristics, 30% still had good functional results. Prediction of late functional results is multifactorial and strongly determined by age and the quality of immediate results. A simple validated scoring system is useful for estimating individual patient outcome.

Transfemoral aortic valve implantation new criteria to predict vascular complications

OBJECTIVES

This study sought to evaluate the incidence, impact, and predictors of vascular complications in transcatheter aortic valve implantation (TAVI).

BACKGROUND

Vascular complications increase morbidity and mortality in transfemoral TAVI; however, there remains a paucity of data describing these serious events.

METHODS

We performed a prospective cohort study of 130 consecutive transfemoral TAVI recipients. Vascular complications were defined by the Valve Academic Research Consortium (VARC) criteria. The ratio of the sheath outer diameter (in millimeters) to the minimal femoral artery diameter (in millimeters) defined the sheath to femoral artery ratio (SFAR).

RESULTS

In our cohort of elderly patients (83.3 ± 5.9 years), the logistic EuroScore was 25.8% ± 11.9%. The Edwards valve was used in 102 cases (18- to 24-F) and the CoreValve in 27 (18-F). The minimal femoral artery diameter was 8.17 ± 1.14 mm, and the calcification (0 to 3) and tortuosity scores (0 to 3) were 0.58 ± 0.72 and 0.28 ± 0.53, respectively. The mean sheath diameter was 8.10 ± 0.82 mm, and the mean SFAR was 0.99 ± 0.16. Vascular complications occurred in 27.6% (VARC major: 17.3%, minor: 10.2%), and major vascular complications predicted 30-day mortality (22.7% vs. 7.6%, p = 0.049). The SFAR (hazard ratio [HR]: 186.20, 95% confidence interval [CI]: 4.41 to 7,855.11), center experience (HR: 3.66, 95% CI: 1.17 to 11.49), and femoral calcification (HR: 3.44, 95% CI: 1.16 to 10.17) predicted major complications by multivariate analysis. An SFAR threshold of 1.05 (area under the curve = 0.727) predicted a higher rate of VARC major complications (30.9% vs. 6.9%, p = 0.001) and 30-day mortality (18.2% vs. 4.2%, p = 0.016).

CONCLUSIONS

Vascular complications in transfemoral TAVI are relatively frequent. VARC major vascular complications increase 30-day mortality and are predicted by experience, femoral calcification, and SFAR. Routine application of SFAR will improve patient selection for transfemoral TAVI and may improve outcome.

Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

AIMS

To critically review the available transcatheter aortic valve implantation techniques and their results, as well as propose recommendations for their use and development.

METHODS AND RESULTS

A committee of experts including European Association of Cardio-Thoracic Surgery and European Society of Cardiology representatives met to reach a consensus based on the analysis of the available data obtained with transcatheter aortic valve implantation and their own experience. The evidence suggests that this technique is feasible and provides haemodynamic and clinical improvement for up to 2 years in patients with severe symptomatic aortic stenosis at high risk or with contraindications for surgery. Questions remain mainly concerning safety and long-term durability, which have to be assessed. Surgeons and cardiologists working as a team should select candidates, perform the procedure, and assess the results. Today, the use of this technique should be restricted to high-risk patients or those with contraindications for surgery. However, this may be extended to lower risk patients if the initial promise holds to be true after careful evaluation.

CONCLUSION

Transcatheter aortic valve implantation is a promising technique, which may offer an alternative to conventional surgery for high-risk patients with aortic stenosis. Today, careful evaluation is needed to avoid the risk of uncontrolled diffusion.

[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.

Percutaneous aortic valve replacement: new hope for inoperable and high-risk patients

Aortic stenosis is the most common valvular heart disease in the Western world and its prevalence is increasing with an aging population. Although medical therapy has little to offer in terms of prognosis or symptomatic relief, at least one-third of patients with severe aortic stenosis are denied valve surgery as a result of age and comorbidities. This review describes the development of the percutaneous aortic valve as an alternative therapy for such patients. The technique, initial results and the current limitations of the procedure are explained alongside the ongoing trials necessary in order that such therapy may eventually be made widely available.

Three-dimensional evaluation of the mitral valve area and commissural opening before and after percutaneous mitral commissurotomy in patients with mitral stenosis

AIMS

Management of patients with mitral stenosis (MS) relies on accurate evaluation of the mitral valve area (MVA). Planimetry (MVA(2D)) is considered as the reference method but must be performed at the tips of the leaflets with the correct plane orientation and therefore requires experienced operators. Real-time three-dimensional echocardiography (RT3DE) may overcome this limitation but its usefulness for experienced when compared with less experienced operators has not been evaluated. In addition, superiority of RT3DE for the evaluation of commissural splitting after percutaneous mitral commissurotomy (PMC) is unknown.

METHODS AND RESULTS

60 patients were prospectively evaluated by 2D and RT3DE before and after PMC by experienced operators. Before PMC, MVA(3D) was slightly higher than MVA(2D) (1.15 +/- 0.25 vs. 1.06 +/- 0.22 cm2, P = 0.0001) but correlation between methods was excellent (r = 0.73, P < 0.0001), mean difference was small (0.09 +/- 0.18 cm2) and clinically meaningless (three patients misclassified, two of whom had borderline MS severity). After PMC, MVA(3D) did not differ from and correlated well with MVA(2D) (1.87 +/- 0.37 vs. 1.85 +/- 0.32 cm2, P = 0.36; r = 0.76, P < 0.0001; mean difference 0.03 +/- 0.24 cm2). Twenty-five additional patients were also evaluated both by an experienced and a less experienced operators. Bland-Altman analysis showed the better agreement between MVA(3D) measured by the less experienced operator and MVA(2D) measured by the experienced operator than between MVA(2D) measured by the less experienced and the experienced operators (mean difference 0.03 +/- 0.34 vs. - 0.13 +/- 0.46 cm2, P = 0.03). When compared with RT3DE, 2DE underestimated the degree of commissural opening in 33% of patients and agreement between methods was weak (kappa = 0.41).

CONCLUSION

RT3DE provides accurate MVA measurements similar to 2D planimetry performed by experienced operators. Thus, it does not provide a real advantage for experienced operators, whereas it seems particularly helpful for less experienced operators. In addition, RT3DE improves the description of valvular anatomy.

Evaluation of mitral valve area by the proximal isovelocity surface area method in mitral stenosis: could it be simplified?

AIM

One limitation for a wider use of the proximal isovelocity surface area method (PISA) for the evaluation of the mitral valve area (MVA) in patients with mitral stenosis (MS) is the requirement of an angle correction factor (angle alpha between the mitral leaflets) which cannot be obtained using the machine's built-in software and requires a manual measurement. The aim of the present study was to evaluate if the use of a fixed angle could provide an acceptable MVA estimation.

METHODS AND RESULTS

In 48 patients (53 +/- 14 years, 75% female and 32% atrial fibrillation), MVA was prospectively measured by planimetry (MVA(2D)) and PISA (PISA(mes)). The angle alpha was manually measured on paper prints using a protractor. MVA(2D) was 1.38 +/- 0.56 cm(2) [0.5-2.40]. PISA(mes) (alpha = 104 +/- 13 degrees inter-quartiles 90-115) was 1.34 +/- 0.64 cm(2) [0.31-2.95] and did not differ from and correlated well with MVA(2D) (P = 0.25; r = 0.93, P < 0.0001). MVA estimated using the PISA method and a fixed angle value from 90 to 110 (MVA(alpha)(=90) to MVA(alpha)(=110)) progressively increased from 1.20 +/- 0.66 to 1.48 +/- 0.81 cm(2). Only MVA(alpha)(=100) (1.34 +/- 0.74 cm(2)) did not differ from and correlated well with both MVA(2D) and PISA(mes) (both P > 0.35 and r > 0.90, P < 0.0001).

CONCLUSION

The angle formed by the mitral leaflet only slightly changes in between patients and use of a fixed angle value of 100 degrees provides an accurate estimation of the MVA by the PISA method in patients with MS. This simplification would facilitate and extend the use of the PISA as an additional method for the assessment of MS severity in routine practice.

Echocardiographic Evaluation of the Mitral Valve Area Before and After Percutaneous Mitral Commissurotomy: The Pressure Half-time Method Revisited

BACKGROUND

Doppler pressure half-time (PHT) is widely used for mitral valve area (MVA) assessment but its accuracy has not been fully evaluated before and after percutaneous mitral commissurotomy (PMC) in a large series of patients.

METHODS

In 120 patients with severe mitral stenosis, MVA(PHT) was prospectively evaluated before and 24 to 48 hours after PMC and compared with 2-dimensional planimetry (MVA(2D)) as a reference method.

RESULTS

After PMC, MVA(2D) significantly increased (1.81 +/- 0.30 vs 1.03 +/- 0.23 cm2, P < .0001), mean transmitral gradient decreased (5 +/- 3 vs 10 +/- 5 mm Hg, P < .0001), and a good valve opening (MVA(2D) > or = 1.5 cm2) was observed in 107 patients (89%). Before PMC, correlation between MVA(PHT) and MVA(2D) was only fair overall (r = 0.52, P < .0001) and weak in subgroups of older patients (> or = 60 years; r = 0.16, P = .37) and in patients in atrial fibrillation (r = 0.38, P < .05). After PMC, MVA(PHT) (1.62 +/- 0.39 cm2) was significantly lower than MVA(2D) (P < .0001) and correlation was poor overall (r = 0.30, P = .0004; mean difference 0.33 +/- 0.30 cm2) and in all subgroups (r < 0.35). However, for the prediction of a good valve opening, a PHT less than 130 milliseconds (observed in 43 patients, 36%) had an excellent specificity (100%) despite a poor sensitivity (44%).

CONCLUSION

For MVA assessment, the PHT method should be used cautiously even before PMC, especially in older patients or those in atrial fibrillation. After PMC, it does not provide an accurate MVA evaluation but can still be used as a semiquantitative method: a PHT less than 130 milliseconds is associated with a good valve opening, which can be useful in difficult cases.

Recommendations for the management of patients after heart valve surgery

Approximately 50,000 valve replacement operations take place in Europe annually and almost as many valve repair procedures. Previous European guidelines on management of patients after valve surgery were last published in 1995 and were limited to recommendations about antithrombotic prophylaxis. American guidelines covering the broader topic of the investigation and treatment of patients with valve disease were published in 1998 but devoted relatively little space to post-surgical management. This document represents the consensus view of a committee drawn from three European Society of Cardiology (ESC) Working Groups (WG): the WG on Valvular Heart Disease, the WG on Thrombosis, and the WG on Rehabilitation and Exercise Physiology. In almost all areas of patient management after valve surgery, randomized trials and meta-analyses do not exist. Such randomized trials as do exist are very few in number, are narrowly focused with small numbers, have limited general applicability, and do not lend themselves to meta-analysis because of widely divergent methodologies and different patient characteristics. Recommendations are therefore almost entirely based on non-randomized studies and relevant basic science.

[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.

Temporal trends in percutaneous mitral commissurotomy over a 15-year period

AIMS

To evaluate temporal trends in percutaneous mitral commissurotomy (PMC) in terms of changes in patient characteristics and their impact on immediate results.

METHODS AND RESULTS

From 1986 to 2001, PMC was indicated in 2773 consecutive patients. Patient characteristics and results were compared each year and linear trends were analysed. There were significant trends toward an increase in mean age (p <0.0001) and the proportion of patients in NYHA class I or II before PMC (p <0.0001), and toward a decrease in the proportion of atrial fibrillation (p <0.0002) and favourable valve anatomy (p < 0.0001), but no change in initial valve area ( p < 0.22). Technical failure occurred in 32 patients (1.2%). The failure rate decreased from 6.4% in 1986-1987 to 3.6% in 1988 and was less than 1.5% from then on (p < 0.0001). The frequency of good immediate results (valve area > or =1.5 cm(2) without regurgitation >2/4) did not differ over the years ( p < 0.22), with a mean rate of 89.5% of effective procedures and 88.5% of all procedures.

CONCLUSION

Over this 15-year period, candidates for PMC became older and had a less favourable anatomy, but underwent PMC at an earlier functional stage. The stability of the results, despite the less favourable characteristics, may be related to the role of experience in improving the technique and patient selection.

Contemporary results of mitral valve repair for infective endocarditis

OBJECTIVES

We sought to evaluate the feasibility and immediate and late results of mitral valve repair (MVRep) for acute and healed endocarditis.

BACKGROUND

Improvements in techniques of MVRep have extended its feasibility in complex lesions, but experience with endocarditis is limited.

METHODS

Among 78 patients operated on for mitral endocarditis between 1990 and 1999, 63 underwent MVRep. The repair was performed for acute endocarditis in 25 patients (40%) at a median of 20 days after the onset of treatment and in 38 patients (60%) for healed endocarditis after a median of 11 months.

RESULTS

Repair of the mitral valve was feasible in 63 patients (81%). This repair involved annuloplasty in 61 patients (97%), valve resection in 49 (78%), shortening or transposition of chordae in 29 (46%), suture of perforation in 18 (29%), a pericardial patch in 12 (19%), and a partial mitral homograft in 7 (11%). Associated procedures were aortic valve replacement in 11 patients, bypass grafting in 3, and tricuspid repair in 2. Early complications were two deaths (3.2%), one re-operation for severe mitral regurgitation and one re-operation for subsequent aortic endocarditis. The seven-year rate of event-free survival was 78 +/- 6% in the global series. Multivariate predictors of event-free survival were hypertension (p < 0.006) and intervention for acute endocarditis (p < 0.026). Five-year survival rates were 96 +/- 4% after MVRep for acute endocarditis and 91 +/- 5% for healed endocarditis.

CONCLUSIONS

Mitral valve repair is frequently feasible and gives good results in patients with infective endocarditis. Patients operated on for acute endocarditis experience more events during follow-up than those operated on after healed endocarditis but have excellent late survival.

Percutaneous mitral commissurotomy: technique, results, and selection of patients

Fifteen years of experience with percutaneous valve dilatation for mitral stenosis have shown the following: it is an effective treatment in a wide range of patients; its risk is low when it is performed by experienced teams, and more than 10 years follow-up demonstrates excellent durability of the procedure; the prediction of the immediate and long-term results is multifactorial and based on clinical and anatomic variables which should be taken into account when selecting the candidates for the procedure. Today balloon commissurotomy is a substitute for surgical commissurotomy and a complement to valve replacement.

Sequential assessment of mitral valve area during diastole using colour M-mode flow convergence analysis: new insights into mitral stenosis physiology

AIMS

In mitral stenosis (MS) transvalvular flow and velocity continually change throughout diastole but for mitral valve area (MVA), flow-dependent variations (valve reserve) are unknown. These physiologic changes can be studied by the proximal isovelocity surface area (PISA) method, using the high temporal resolution of colour M-mode, essential for simultaneous measurements of flow and velocity. Hence, we aimed to validate the colour M-mode PISA method for measurement of MVA in MS and to define using this method the physiologic flow-dependent changes of MVA during diastole.

METHODS AND RESULTS

In 50 patients with native MS, MVA was measured by planimetry (MVA-2D), Doppler pressure half-time (MVA-PHT), and two-dimensional PISA (2D-PISA). MVA measurement by colour M-mode PISA in early diastole (M-PISA) (1.27+/-0.46 cm(2)) with rigorously timed flow and velocity measurements by continuous wave Doppler did not differ and correlated well with MVA-2D (1.29+/-0.44 cm(2), p=0.59; r=0.85, p<0.001) and MVA-PHT (1.30+/-0.41 cm(2), p=0.52; r=0.80, p<0.001). In contrast a trend towards underestimation of MVA by 2D-PISA was observed (1.23+/-0.42 cm(2); p=0.10 and p=0.07). Timed analysis of transvalvular haemodynamics at early, mid, mid-late, and late diastole showed marked changes in flow and velocities (both p<0.0001) but not in MVA (respectively 1.27+/-0.46, 1.29+/-0.47, 1.28+/-0.51 and 1.27+/-0.49 cm(2); ns).

CONCLUSIONS

In MS, the high temporal resolution of colour M-mode PISA allows accurate MVA measurements. It also allows for the first time, sequential MVA assessment during diastole. Notwithstanding marked flow and velocities changes, MVA remained unchanged throughout diastole underscoring the lack of flow-related valvular reserve in MS.

[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.

Echocardiographic Criteria in Selection of Patients for Percutaneous Mitral Commissurotomy

The purpose of this report is to review the role of echocardiography in the selection of patients for percutaneous mitral commissurotomy (PMC). Echocardiography has become the standard for the assessment of the severity of mitral stenosis and of its consequences. PMC is usually performed only in patients with a valve area of < 1.5 cm(2), whereas pulmonary hypertension or spontaneous echo contrast in the left atrium may lead to intervention in patients with few symptoms. The next step of the echocardiographic evaluation is to eliminate contraindications: left atrial thrombosis (by the systematic performance of a transesophageal examination before PMC), mitral regurgitation >/= 2/4, severe aortic valve disease, mixed tricuspid valve disease, and massive or bicommissural calcification. Finally, echocardiography allows the classification of patients into different anatomic groups for prognostic consideration. There is controversy regarding the best echo score system in the prediction of the results of PMC. Scores using a global evaluation of the valve anatomy are the most widely used, whereas more recently, scores taking into account the uneven distribution of the disease have had promising preliminary results. Overall, echo scores are useful criteria for selecting candidates for PMC, but they should be considered together with the other clinical and procedural variables. Thus, echocardiography has an important role in the selection of patients for PMC, as well as for the guidance of the procedure, the evaluation of the results, and surveillance.

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.