[Prognostic factors for idiopathic macular hole surgery: Report of 107 eyes (Approach by univariate statistical analysis)]

PURPOSE

To identify prognostic factors influencing the success of idiopathic macular hole surgery, including initial visual acuity, hole size and stage, and type of gas used for tamponade.

PATIENTS AND METHODS

Retrospective single-center descriptive analysis of all patients with an idiopathic macular hole operated by the same surgeon, treated in the ophthalmology department of Mulhouse hospital, between January 2004 and July 2014. Patients whose functional and anatomical results could be confounded by the coexistence of other ocular pathologies and patients with secondary macular holes were excluded.

RESULTS

We included and followed 107 eyes of 104 patients for at least 6 months. Initial closure after the first surgery was obtained in 92 eyes (85.98 %), allowing 2 groups to be defined, the cases of success and failure. Initial visual acuity, hole size, stage according to Gass, Gaudric and IVTS classifications, and presence or absence of a PVD, were statistically significant prognostic factors (P<0.05) CONCLUSION: Our univariate statistical analysis identified multiple prognostic factors. These factors may predict success and the choice of surgical technique, including whether to peel the internal limiting membrane, the choice of gas for tamponade, and postoperative positioning.

[Radial approach in the elderly]

Due to the steady increase in life expectancy, the number of patients over 80 years of age proposed for coronary angioplasty is increasing significantly. The elderly patient is a patient at high cardiovascular risk and high risk of bleeding; whose severity of prognosis depends of comorbidities. The radial approach presents particularities and technical difficulties that have to be known in this part of the population, but reduce vascular and hemorrhagic complications, as well as mortality. Because of greater safety, the radial approach is therefore the first choice for the elderly.

Ameliorating effects of Nigella sativa oil on aggravation of inflammation, oxidative stress and cytotoxicity induced by smokeless tobacco extract in an allergic asthma model in Wistar rats

BACKGROUND

The comparison of smokeless tobacco (ST) exposure versus Ovalbumin (Ova) sensitized rats or asthmatic patients has hardly been studied in the literature. Thus, the present study aims to investigate the aggravation of inflammation, exacerbation of asthma, oxidative stress and cytotoxicity induced by ST.

METHODS

ST was given at the dose of 40mg/kg in an allergic asthma model in Wistar rats. Furthermore, the effects of oral administration of Nigella sativa oil (NSO), at a dose of 4mL/kg/day, were investigated.

RESULTS

The obtained results showed that ST clearly enhanced lung inflammation through interleukin-4 (IL-4) and Nitric oxide (NO) increased production. Actually, ST was found to intensify the oxidative stress state induced by Ova-challenge in rats, which was proven not only by augmenting lipid peroxidation and protein oxidation, but also by altering the non-enzymatic and enzymatic antioxidant status. Furthermore, the aggravation of inflammation and oxidative stress was obviously demonstrated by the histopathological changes observed in lung. In contrast, NSO administration has shown anti-inflammatory effects by reducing IL-4 and NO production, restoring the antioxidant status, reducing lipid peroxidation and improving the histopathological alterations by both protein oxidation and NSO treatment.

CONCLUSIONS

Our data have proven that severe concurrent exposure to allergen and ST increases airway inflammation and oxidative stress in previously sensitized rats. They also suggest that the oral NSO treatment could be a promising treatment for asthma.

At least seven days delayed stenting using minimalist immediate mechanical intervention (MIMI) in ST-segment elevation myocardial infarction: the SUPER-MIMI study

AIMS

The aim of this study was to ascertain whether a minimalist immediate mechanical intervention (MIMI) aiming to restore an optimal Thrombolysis In Myocardial Infarction (TIMI) flow in the culprit artery, followed ≥7 days later by a second percutaneous coronary intervention with intentional stenting, is safe in patients with ST-segment elevation myocardial infarction and large thrombotic burden.

METHODS AND RESULTS

SUPER-MIMI was a prospective, observational trial conducted between January 2014 and April 2015 in 14 French centres. A total of 155 patients were enrolled. The pharmacological therapy was left to the operator's discretion. Eighty-one patients (52.3%) had glycoprotein IIb/IIIa inhibitors (GPI) initiated before the end of the first procedure. The median (interquartile range [IQR]) delay between the two procedures was eight (seven to 12) days. Infarct-related artery reocclusion between the two procedures (primary endpoint) occurred in two patients (1.3%), neither of whom received GPI treatment. TIMI flow was maintained or improved between the end of the first procedure and the beginning of the second procedure in all patients. Thrombotic burden and stenosis severity diminished significantly between the two procedures. Stents were ultimately implanted in 97 patients (62.6%).

CONCLUSIONS

Deferred stenting (≥7 days) in patients with a high thrombus burden was safe on a background of GPI therapy.

[Management of high-risk pulmonary embolism with pulmonary artery trunk mobile thrombus]

The presence of a right intraventricular thrombus is a marker of severity of pulmonary embolism (PE), and is associated with high mortality. We report the case of a young patient with a PE postoperative of patellar tendon surgery. The cardiac echocardiography at its admission revealed a voluminous mobile thrombus of 1.7cm diameter located on the pulmonary trunk. Systemic thrombolysis was performed because of respiratory deterioration allowing a rapid disappearance of the thrombus and recovery. Our case emphasizes the value of a complete ultrasound analysis centered on the pulmonary trunk in the case of intermediate-risk PE. No recommendation exists on the management of these right ventricular thrombi, thrombolysis appearing to be the first-line treatment.

Effects of transcranial random noise stimulation (tRNS) on affect, pain and attention in multiple sclerosis

PURPOSE

Pain and cognitive impairment are frequent symptoms in patients with multiple sclerosis (MS). Neglecting experimental pain and paying attention to demanding tasks is reported to decrease the pain intensity. Little is known about the interaction between chronic neuropathic pain and attention disorders in MS. Recently, transcranial direct current stimulation (tDCS) was used to modulate various cognitive and motor symptoms in MS. We aimed to study the effects of transcranial random noise stimulation (tRNS), a form of transcranial electric stimulation, over the left dorsolateral prefrontal cortex (DLPFC) on attention and neuropathic pain in MS patients.

METHODS

16 MS patients were included in a randomized, sham-controlled, cross-over study. Each patient randomly received two tRNS blocks, separated by three weeks of washout interval. Each block consisted of three consecutive daily sessions of either active or sham tRNS. The patients were evaluated for pain, attention and mood and further underwent an electrophysiological evaluation.

RESULTS

Compared to sham, tRNS showed a trend to decrease the N2-P2 amplitudes of pain related evoked potentials and improve pain ratings. Attention performance and mood scales did not change after stimulations.

CONCLUSIONS

This study suggests the role of tRNS in pain modulation, which could have been more evident with longer stimulation protocols.

Effects of left DLPFC versus right PPC tDCS on multiple sclerosis fatigue

BACKGROUND AND OBJECTIVE

Fatigue is a frequent and debilitating symptom in patients with multiple sclerosis (MS). Its classical treatments are still faced with limited benefits and numerous side effects. Hence, we aimed to evaluate the effects of transcranial direct current stimulation (tDCS), a noninvasive brain stimulation technique, on such a challenging symptom. Our secondary outcomes included the assessment of tDCS impact on mood and attentional performance.

METHODS

Ten fatigued MS patients were enrolled in a double-blind, sham-controlled, and cross-over study. Each patient randomly received three anodal tDCS blocks: active stimulation over the left dorsolateral prefrontal cortex (DLPFC), active stimulation over the right posterior parietal cortex (PPC), and sham stimulation over either cortical site. Both cortical targets are key components in the MS fatigue networks. The blocks consisted of five consecutive daily sessions and were held apart by a washout interval of three weeks.

RESULTS

Only active left DLPFC stimulation significantly ameliorated fatigue. Mood improvement was exclusively obtained following active right PPC stimulation. Neither intervention had effects on attention.

CONCLUSION

Our study supports the role of anodal tDCS over the left prefrontal in treating MS fatigue. The lack of tDCS effects on attention might be related to the heterogeneity of the studied cohort, the relatively small sample size, the protocol design and duration. Modifying these variables and coupling tDCS with neuroimaging might improve the clinical outcomes and enhance our understanding of the tDCS mechanism of actions.

[Purulent pericarditis in a patient with diabetes mellitus treated by percutaneous pericardiocentesis]

Purulent pericarditis seldom occurs in Western countries, yet its mortality rate remains high between 20 and 35 % despite early treatment. We report the case of a 43-year-old patient admitted in the intensive cardiologic care unit with a pre-tamponade, requiring an immediate percutaneous pericardiocentesis allowing the drainage of a purulent effusion. Evolution with antibiotic therapy adapted according to the bacteriological findings was favorable and 3-months follow-up shows a near complete regression of the effusion. This case recalls us this rare diagnosis entity and illustrates the possibility of a mere percutaneous pericardial drainage with the condition of a strict medical surveillance.

Prefrontal tDCS Decreases Pain in Patients with Multiple Sclerosis

Background: In the last few years, transcranial direct current stimulation (tDCS) has emerged as an appealing therapeutic option to improve brain functions. Promising data support the role of prefrontal tDCS in augmenting cognitive performance and ameliorating several neuropsychiatric symptoms, namely pain, fatigue, mood disturbances, and attentional impairment. Such symptoms are commonly encountered in patients with multiple sclerosis (MS).

Objective: The main objective of the current work was to evaluate the tDCS effects over the left dorsolateral prefrontal cortex (DLPFC) on pain in MS patients.Our secondary outcomes were to study its influence on attention, fatigue, and mood.

Materials and Methods: Sixteen MS patients with chronic neuropathic pain were enrolled in a randomized, sham-controlled, and cross-over study.Patients randomly received two anodal tDCS blocks (active or sham), each consisting of three consecutive daily tDCS sessions, and held apart by 3 weeks. Evaluations took place before and after each block. To evaluate pain, we used the Brief Pain Inventory (BPI) and the Visual Analog Scale (VAS). Attention was assessed using neurophysiological parameters and the Attention Network Test (ANT). Changes in mood and fatigue were measured using various scales.

Results: Compared to sham, active tDCS yielded significant analgesic effects according to VAS and BPI global scales.There were no effects of any block on mood, fatigue, or attention.

Conclusion: Based on our results, anodal tDCS over the left DLPFC appears to act in a selective manner and would ameliorate specific symptoms, particularly neuropathic pain. Analgesia might have occurred through the modulation of the emotional pain network. Attention, mood, and fatigue were not improved in this work. This could be partly attributed to the short protocol duration, the small sample size, and the heterogeneity of our MS cohort. Future large-scale studies can benefit from comparing the tDCS effects over different cortical sites, changing the stimulation montage, prolonging the duration of protocol, and coupling tDCS with neuroimaging techniques for a better understanding of its possible mechanism of action.

Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk

BACKGROUND

Patients at high risk for bleeding who undergo percutaneous coronary intervention (PCI) often receive bare-metal stents followed by 1 month of dual antiplatelet therapy. We studied a polymer-free and carrier-free drug-coated stent that transfers umirolimus (also known as biolimus A9), a highly lipophilic sirolimus analogue, into the vessel wall over a period of 1 month.

METHODS

In a randomized, double-blind trial, we compared the drug-coated stent with a very similar bare-metal stent in patients with a high risk of bleeding who underwent PCI. All patients received 1 month of dual antiplatelet therapy. The primary safety end point, tested for both noninferiority and superiority, was a composite of cardiac death, myocardial infarction, or stent thrombosis. The primary efficacy end point was clinically driven target-lesion revascularization.

RESULTS

We enrolled 2466 patients. At 390 days, the primary safety end point had occurred in 112 patients (9.4%) in the drug-coated-stent group and in 154 patients (12.9%) in the bare-metal-stent group (risk difference, -3.6 percentage points; 95% confidence interval [CI], -6.1 to -1.0; hazard ratio, 0.71; 95% CI, 0.56 to 0.91; P<0.001 for noninferiority and P=0.005 for superiority). During the same time period, clinically driven target-lesion revascularization was needed in 59 patients (5.1%) in the drug-coated-stent group and in 113 patients (9.8%) in the bare-metal-stent group (risk difference, -4.8 percentage points; 95% CI, -6.9 to -2.6; hazard ratio, 0.50; 95% CI, 0.37 to 0.69; P<0.001).

CONCLUSIONS

Among patients at high risk for bleeding who underwent PCI, a polymer-free umirolimus-coated stent was superior to a bare-metal stent with respect to the primary safety and efficacy end points when used with a 1-month course of dual antiplatelet therapy. (Funded by Biosensors Europe; LEADERS FREE ClinicalTrials.gov number, NCT01623180.).

[Scleral buckling for inferior rhegmatogenous retinal detachments]

PURPOSE

To investigate the epidemiological, clinical, therapeutic and prognostic factors in cases of inferior rhegmatogenous retinal detachments (RD) treated by scleral buckling surgery.

PATIENTS AND METHODS

A retrospective chart review was performed on 45 patients (45 eyes) with inferior RD with only inferior tears (4:00-8:00), who had been treated by scleral buckling surgery over a 6-year period from 2006 to 2011. The parameters studied included patient demographics, refractive status, time until consultation, clinical exam data, treatment modalities and functional and anatomic results.

RESULTS

Forty-five cases were included in this study (45 eyes), with an average patient age of 44.5 years (14 to 75 years) and a slight male predominance (56%). Myopia was observed in 60%. Mean time until consultation was 3.5 months. Visual acuity on admission was less than 1/10 in 53.33%. Macular detachment was found in 80%. Causative lesions were holes in 26 eyes. Proliferative vitreoretinopathy was essentially stage B in 48.9%. Scleral buckling surgery was performed in all patients, with drainage of subretinal fluid in 37.8%. Retinal reattachment was obtained in 36 eyes (80%) with a final visual acuity greater than or equal to 1/10 in 71.11%. The mean follow-up in our study was 6.62 months.

CONCLUSION

Inferior retinal detachment has a predilection for young myopes. The time until consultation is often long, and extraocular surgery, although difficult, exhibits documented efficacy.

[Exceptional location of hydatid cyst: primary hydatid disease of the mesentery]

The hydatid cyst of the mesentery is a rare localization of hydatid disease; most often it is secondary to a hydatid cyst of the liver. Its primitive form remains exceptional and is due to an arterial haematogenous dissemination. We report a case of primary hydatid cyst of the mesentery in a patient of 43 years. The diagnosis was established by ultrasonography and computed tomography with positive hydatid serology. The aim of this work is to remind, through this observation and a literature review, clinical aspects and therapeutic management of this disease.

[Acute intestinal obstruction in pregnancy - about five cases]

L’occlusion intestinale survient rarement au cours de la grossesse mais elle s’accompagne d’une morbidité et mortalité maternelle et fœtale élevées souvent dues au retard diagnostic et thérapeutique. Les auteurs rapportent cinq cas d’obstruction intestinale gravidique, et revoient la littérature afin de discuter les mécanismes physiopathologiques, les difficultés diagnostiques et thérapeutiques et de proposer une conduite à tenir adéquate.

[Conjunctival melanoma and xeroderma pigmentosum, a rare association]

Ocular involvement in the xeroderma pigmentosum (XP) can be located on the eyelids, conjunctiva or cornea. Malignant melanoma of the conjunctiva is a rare tumor, and even more so in children. Only five cases associated with XP have been published since 1960. We report a sixth case occurring in a girl aged 14. Surgical treatment consisted of an orbital exenteration extended to the eyelids and the evolution is marked by a good healing of the orbital cavity without local recurrence after four months.

[Tolerance of porous polyethylene orbital implants in children]

INTRODUCTION

The purpose of our study is to determine the incidence of orbital complications that occurred after insertion of orbital porous polyethylene implant in children under the age of 15 years.

MATERIAL AND METHODS

We report a series of 21 eyes of 21 patients younger than 15 years and in which a porous polyethylene implant is used for reconstruction of the orbital cavity after enucleation between January 2003 and December 2008.All patients were operated on by the same surgeon using the same technique.

RESULTS

These 11 boys and 10 girls, whose average age is 5.7 years. Histopathologic diagnoses after enucleation are dominated by the retinoblastoma (10 eyes) and phthisis bulbi (6 eyes). After a mean follow up of 23 months it was observed two cases of implant extrusion in children enucleated for retinoblastoma. No cases of orbital cellulitis or enucleated syndrome have been reported.

DISCUSSION

The most common complication of porous polyethylene implants in children is exposure. Risk factors may be related to surgical technique, infection, the implant, use of wrapping material and the association with adjuvant chemotherapy. Using a porous polyethylene implant uncovered remains an appropriate technique in children under 15 years for the reconstruction of the anophthalmic cavity, provided a rigorous surgical technique.

[Orbital location of multivisceral Langerhans-cell histiocytosis]

Langerhans-cell histiocytosis is a rare disease accounting for less than 1% of orbital tumours. We report the case of an 18-month-old infant presenting with exophthalmos of the left eye lasting for 3 months in a context of deterioration of the general condition, polydipsia, and polyuria. The computed tomographic scan revealed an orbital cellular mass with a lytic bone lesion within the orbital roof and infiltration of frontopalpebral soft tissue. In addition, other secondary lesions were found at the skull, ribs, skin, liver, and spleen. The cytological study after biopsy showed infiltrates of histiocytes derived from Langerhans cells. Because the disease was multivisceral, the child was treated with chemotherapy (vinblastine) combined with a steroid and progressed well. At 30 months of follow-up, there was no evidence of recurrence or systemic involvement.

[Post electrocution cataract. Case report]

INTRODUCTION

Cataract caused by high tension electric trauma remains a rare entity. It is often bilateral and late-onset especially if the electric current passes through the head.

PATIENTS AND METHODS

We report a case of a bilateral cataract secondary to high tension electric trauma.

RESULTS

A 13-year-old child presented with bilateral cataract secondary to high tension electric trauma (22 000sVolts) two years earlier accidentally on the railroad. The electric current has crossed the head and both upper limbs. This had resulted in immediate burns on the right scalp and hand. Ophthalmological examination found a total white cataract in the RE and anterior subcapsular lens opacities in the LE.

CONCLUSION

Cataract is a rare but serious complication of severe electric trauma requiring regular and prolonged eye monitoring owing to its possible late occurrence.

Acute Myocarditis Mimicking Lateral Myocardial Infarction

We report a case of myocarditis mimicking acute lateral myocardial infarction and treated as such initially, which was complicated by ventricular fibrillation a few hours after admission to the intensive care unit. The correct diagnosis was rapidly made using a low-dose delayed-enhanced cardiac multidetector computed tomography scan performed immediately after a normal coronary angiogram, demonstrating typical myocardial late hyperenhancement and good correlation with delayed enhanced magnetic resonance imaging. This case suggests that myocarditis can be accurately diagnosed by delayed-enhanced cardiac multidetector computed tomography in an emergency setting. The other lesson from this case is that patients presenting with severe clinical symptoms, important ECG signs and high myocardial enzyme levels should be closely monitored for at least 72 hours, even when myocardial infarction has been excluded.

Mandibular bone alterations of ovariectomized rats under vitamin D insufficiency

Experimental osteoporosis was studied in mandible bone by means of ovariectomy and vitamin D insufficiency.

METHODS

42 female Wistar rats were divided into the following four groups: (1) ovariectomized rats maintained in 12h day-night light conditions (ov-l), (2) ovariectomized rats maintained in 24h dark light conditions (ov-ob), (3) sham-operated rats maintained in 12h day-night light conditions (ch-l) and (4) sham-operated rats maintained in 24 h dark conditions (ch-ob). 12 weeks later the animals were sacrificed, the mandibles were excised, cleaned and weighed, the right side of the mandibles were histologically examined and the left side of the mandibles were prepared for mineral phase analysis by X-ray diffraction. Immunohistochemical analysis was performed to detect apoptotic cells by anti-PARP p85 antibody.

RESULTS

In group 2, the weight of mandibles significantly decreased. Chondroid areas were observed in ovariectomized groups and polarized light observation validated the collagen distribution disturbance in these groups (groups 1 and 2). Apoptotic osteoblasts were localized in groups 1, 2 and 4. They were numerous in group 2. The mineral phase analysis did not find differences between the groups.

CONCLUSION

This study validates a new model of osteoporotic animal associating estrogens deficiency and vitamin D insufficiency where matrix synthesis and osteoblast biology are altered, but not biomineralization.

[Pseudoexfoliation syndrome in Moroccan patients with cataract scheduled for sugery]

PURPOSE

To evaluate the prevalence of pseudoexfoliation syndrome (PES) in Moroccan patients with age-related cataract scheduled for surgery.

PATIENTS AND METHODS

In a retrospective study, 837 consecutive eyes with age-related cataract scheduled for surgery were evaluated for the prevalence of PES, type of cataract, intraocular pressure (IOP) and operative complications.

RESULTS

Exfoliation material was detected in 82 patients (9.8 %). The mean age was 69.3 years with no sex predilection. The condition was unilateral in 44 cases (53.7%) and bilateral in 38 cases (46.3%). The prevalence of PES increased with age (p=0.02). Patients with hypermature cataract had significantly more PES (p <0.001). Mean IOP was significantly higher in eyes with PES (17.7 +/- 6.4 mmHg) than those without PES (14.3 +/- 2.9 mmHg) (p<0.001). Operative complications occurred more frequently in patients with PES: 14 (17 %) than in those without PES: 58 (6.9 %).

DISCUSSION

PES is a generalized degenerative fibrillopathy bound to age. The ethiopathogeny remains even unknown. The epidemiological data concerning the prevalence of the SPE in the African populations are scarce, and have not been published in Morocco, what motivated this study. Our study shows that this syndrome is common in Moroccan patients scheduled for cataract surgery with a prevalence of 9.8%. Its presence constitutes an important risk factor of primary open-angle glaucoma, and exposes more to peroperative complications at the time of surgery of cataract, independently of the technique used.

CONCLUSION

There is great variation in the prevalence of PES among people of different regions and ethnic groups, although many factors interfere in the comparative analysis of results, hence the interest to achieve other complementary epidemiological studies.

Value of body mass index in the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters

BACKGROUND & AIMS

We have estimated the prevalence of severe malnutrition in groups of patients hospitalized for different medical causes and assessed the sensitivity of BMI in the diagnosis of severe malnutrition.

DESIGN

A prospective study enrolled 1052 patients: 396 patients with liver cirrhosis including 165 non-ascitic patients (NAP), 124 patients with mild ascites (MAP), 107 patients with tense ascites (TAP), 251 patients after cardiac surgery (SCP), 81 patients with cardiac diseases (MCP), 85 patients with stroke (SP), 36 patients with degenerative neurological diseases (DNP), 68 patients after surgery of a hip fracture (HFP), 91 patients with palliative care for cancer (CP) and 44 elderly patients with medical affections (EP). BMI, mid-arm muscular circumference (MAMC) and triceps skinfold thickness (TST) were measured within 48 h after admission. Patients with MAMC and TST below the 5th percentile of a reference population when aged < or = 74 or the 10th percentile when aged > or = 75 were defined as severely malnourished. Sensitivity of BMI < 20 to detect malnutrition was assessed.

RESULTS

The prevalence of severe malnutrition was the highest in TAP (39.1%) HFP (25.6%) and MAP (24.3%) and the lowest in SCP (4%), SP (4.8%), DNP (5.7%) and MCP (7.4%) (P < 10(-4)). In multivariate analysis, low TST was associated with female gender (P < 10(-4)) mild and tense ascites (P = 0.038, P = 0.0004), low MAMC with male gender (P < 10(-4)), low BMI with female gender (P = 0.0082), hip fracture (P = 0.0407) and cancer (P = 0.0059). The sensitivity of BMI to detect severe malnutrition was the highest in HFP, CP and EP (100%, 80% and 100% respectively) and the lowest in TAP, MCP and SP (40%, 33.3% and 50% respectively). After exclusion of TAP, sensitivity of BMI to detect malnutrition correlated significantly with the coefficient of correlation between MAMC and TST observed in each group (r = 0.821, P = 0.0066).

CONCLUSION

Ascitic cirrhotic patients and elderly patients after surgery of hip fracture had the highest prevalence of severe malnutrition. BMI had the highest sensitivity when both TST and MAMC were damaged to the same extent. BMI < 20 has a high sensitivity in the diagnosis of severe malnutrition in elderly and cancer patients but not in cirrhotic patients with tense ascites, cardiovascular and neurological patients.

Eighteen-year experience with echinococcosus of the heart: clinical and echocardiographic features in 14 patients

We present a retrospective analysis of clinical symptoms and echocardiographic features in 14 patients having cardiac hydatic cysts and screened during the 18 last years, with surgical correlations in 13. The heart was the sole location of the cyst in six patients. The revealing symptoms were precordial pain (six patients), dyspnea (two patients). A systolic murmur of false pulmonic stenosis was present in three patients. In 13 patients, two-dimensional echocardiographic images of hydatic cysts were those of masses of liquid content with a well-contrasted capsule, which was single in eight patients and multiple in five, one of which had a honeycomb appearance. The mass was solid and calcified in one patient. The outlines of the cysts were particularly sharp on transesophageal echocardiograms (six patients). The cyst size ranged from 1.8 to 11 cm in diameter. Cysts were located in the intramyocardium in 10 patients (left ventricle in four patients, interventricular septum in four patients, right ventricle in two patients), the pericardium in three and the mediatinum in one. There were a Doppler pulmonary valve gradient in three patients. Computed tomography (eight patients) and coronary arteriography (seven patients) have no additional diagnosis value than echocardiography. Nuclear magnetic resonance imaging (three patients) was helpful in determining extracardiac extension of the cysts. Transthoracic and transesophageal two-dimensional echocardiography have a central role in diagnosing cardiac hydatic cysts.

Balloon mitral commissurotomy in juvenile rheumatic mitral stenosis: a ten-year clinical and echocardiographic actuarial results

AIMS

To evaluate the safety, efficacy and long-term actuarial results of balloon mitral commissurotomy in young patients with severe rheumatic mitral stenosis.

METHODS AND RESULTS

Event-free survival and freedom from restenosis were analyzed in 110 patients 20 years old or younger (group 1) and compared with those of 554 adults (group 2). Young patients were less frequently in atrial fibrillation (6% vs 35%, P<0.001) and had less mitral valve deformities (echo score 5.9+/-2.1 vs 7.5+/-3.0, P<0.0001). Mitral valve area index by 2D-echo was of 0.66+/-0.1cm(2)/m(2)in group 1 and 0.67+/-0.1cm(2)/m(2)in group 2 (P=ns) and was larger in group 1 (1.5 vs 1.3 cm(2)/m(2)) after the procedure (P<0.0001). There were more complications in group 2 (8.4% vs 0%, P=0.01). Procedural success was obtained in 110 (100%) patients of group 1 vs 501 (92%) patients of group 2 (P<0.0001). At follow-up mitral valve area index was 1.34 cm(2)/m(2)in group 1 and 1.16 cm(2)/m(2)in group 2 (P<0.0001). At 10 years, freedom from restenosis was 61% in group 1 vs 71% in group 2 (P=0.35) and event-free survival was 74% and 69% respectively (P=0.15

CONCLUSION

Balloon mitral commissurotomy is safe and effective in young with rheumatic mitral stenosis and provides better immediate results than in adults. However long-term outcome was similar between the 2 groups: 2/3 of patients were alive and free from clinical events at 10 years.

Predictors of long-term event-free survival and of freedom from restenosis after percutaneous balloon mitral commissurotomy

BACKGROUND

Most long-term studies after balloon mitral commissurotomy (BMC) were from industrialized countries. Less is known about the long-term results of BMC from developing countries where patients are younger with fewer mitral valve deformities.

METHODS

Between December 1987 and December 1998, we performed BMC in 654 patients whose mean age was 33 +/- 13 years. Baseline and postprocedural variables were evaluated to identify predictors of event-free survival (survival without repeat BMC or mitral valve replacement) and of freedom from restenosis defined as a mitral valve area (MVA) >/=1.5 cm(2) after BMC and <1.5 cm(2) at follow-up.

RESULTS

The actuarial survival rates were 98%, 98%, and 97% at 5, 7, and 10 years, respectively. The 5-, 7-, and 10-year event-free survival rates were 85%, 81%, and 72%. Multivariate predictors of a higher 10-year event-free survival rate were lower echocardiographic score (79% for a score </=8, 61% for a score of 9 to 11, 62% for a score >/=12, P <.001) and cardiac sinus rhythm (P =.04) before BMC, lower mean left atrial pressure (P <.001), lower mitral valve gradient (P <.001), and less than or equal to grade 2 mitral regurgitation (P =.036) after BMC. Restenosis occurred in 16% of patients. The restenosis-free rates were 88%, 80%, and 66% at 5, 7, and 10 years, respectively. A higher freedom from restenosis at 10 years was associated with a lower score (77% for a score </=8, 45% for a score of 9-11 and 50% for a score >/=12, P =.03) and a larger MVA before BMC (P =.03), a larger MVA (P <.001), and a lower mitral valve gradient (P =.04) after BMC.

CONCLUSIONS

BMC produces excellent 10-year results in patients with pliable mitral stenosis and good results in patients with semipliable or calcified mitral stenosis. BMC is the procedure of choice in patients with pliable valves and it is a reasonable treatment option in young patients with unfavorable mitral valve anatomy.