Difficult percutaneous mitral commissurotomy: failure of the Inoue balloon technique and successful double-balloon technique

From December 1994 to May 1999, 487 patients underwent percutaneous transvenous mitral commissurotomy according to the Inoue balloon technique for tight mitral stenosis. In three cases, the Inoue balloon technique was not possible because the catheter balloon could not enter the mitral orifice and the double-balloon technique was performed instead. In two cases, a flow-guided balloon catheter met the mitral orifice and the double-balloon technique was effective. In the third case, passing the valve with a flow balloon catheter was impossible, a 0.032" Terumo straight wire crossed the valve, which was dilated with a single balloon the first time and a double balloon the second time. The mitral valve area increased in the three cases from 0.8 to 1.8 cm2, from 0.7 to 1.6 cm2, and from 0.5 to 1.5 cm2, respectively. There were no complications.

[Angioplasty and endoprosthesis of the left coronary artery. Report of a case]

The authors report the case of a 70 year old woman followed up in our Department for ischaemic heart disease since 1991 and admitted to the Intensive Care Unit in November 1996 for unstable angina. Coronary angiography showed significant stenosis of the left main coronary artery, a severe stenosis of the LAD and occlusion of the right coronary artery. Angioplasty of the middle segment of the LAD and left main coronary arteries with implantation of a stent was performed because of resistance to medical therapy and a contra-indication to surgery. Four months later, recurrent anginal pain led to a repeat angioplasty of the LAD with a satisfactory immediate result. The initial procedure on the left main coronary artery was successful and follow up was uncomplicated.

[Percutaneous transluminal valvuloplasty in congenital pulmonary stenosis in adults. Apropos of 34 cases]

Percutaneous pulmonary valvulotomy is the treatment of choice for isolated congenital pulmonary valvular stenosis in childhood. However, experience of this procedure in the adult is much more limited. Between January 1984 and December 1994, 34 patients with severe or moderate pulmonary valvular stenosis underwent percutaneous transluminal valvuloplasty. The age of the patients ranged from 20 to 47 years (mean 22 +/- 4 years). Cardiac catheterisation was performed using the femoral vein in 27 cases and the internal jugular vein in 7 cases. Success was obtained in 28 patients (81% of cases). Pulmonary artery-right ventricular pressure gradient decreased from 113 +/- 35 to 32 +/- 13 mmHg (p < 0.001) after valvuloplasty with one or two balloon catheters. The tolerance of transluminal valvuloplasty was generally good. The poor results were explained by cases of dysplasic valves or of infundibular reactions. There was one death which occurred 24 hours after the procedure. Clinical and echocardiographic follow-up was obtained in 20 patients, 3 to 36 months after valvuloplasty (average: 23 +/- 13 months). No cases of restenosis were observed. Percutaneous transluminal pulmonary valvuloplasty in the adult is feasible and gives good results which are maintained at medium-term; it has become the treatment of choice of valvular pulmonary stenosis and gives good results which are maintained at medium-term, thereby avoiding surgical valvulotomy.

[Association of coronary-pulmonary fistula and intercoronary fistula. Apropos of a case]

The authors present the case of a 30-year-old woman admitted to hospital for investigation of a systolodiastolic murmur. Assessment revealed a fistula between the trunk of the left coronary artery and the pulmonary artery, with an aneurysm on the left anterior descending artery (LAD), associated with an intercoronary anastomosis between the left conus artery and the LAD. Thallium myocardial scintigraphy demonstrated reversible decreased uptake in the anterolateroapical region. Simple coronaro-pulmonary fistulas are a rare disease. The positive diagnosis is suggested by echocardiography and confirmed by coronary angiography. The clinical course is generally favourable, except in the presence of complications such as aneurysm, heart failure or coronary insufficiency. This case raises the difficult problem of the operative indication in these young, usually asymptomatic patients.

[Mitral valve prolapse and myocardial ischemia. Apropos of 2 cases]

The authors report two cases of severe myocardial ischaemia with healthy coronary arteries associated with mitral valvular prolapse (MVP). The first case was a 43-year-old woman treated with beta-blockers following the discovery of MVP. This patient was admitted to hospital six months later with persistent chest pain in a context of cardiogenic shock. The response to treatment was rapid and spectacular. The second case was a 44-year-old hypertensive smoker man in whom assessment of chest pain revealed several signs of myocardial infarction as well as MVP. This rare combination of MVP and myocardial ischaemia raises pathophysiological as well as therapeutic problems.

[Hemangio-endotheliosarcoma of the right atrium]

In reporting a case of haemangiosarcoma of the right atrium the authors emphasize the problems encountered in the diagnosis of primary tumours of the heart. The patient was a 50-year old woman who complained of digestive disorders and palpitations. Physical examination showed signs of right heart failure associated with a systolic murmur on the right side of the sternum. ECG gave normal results. Echocardiography displayed a pouch with liquid ultrastructure communicating with the right atrium. Angiography confirmed the presence of a cavity with irregular borders communicating with the right atrium. Coronary arteriography showed an abnormal disorderly distribution of the right coronary artery branches with newly formed vessels extending toward the tumour. At exploratory thoracotomy a large liquid tumour was found which bled at the slightest touch and was attached to the mediastinum and the right pericardium. The pleura and the lung contained several nodules of the same venous colour as the mother tumour. Extemporaneous biopsy and pathological analysis were in favour of a haemangiosarcoma. The patient died a few days after the thoracotomy.

[Percutaneous transluminal valvuloplasty of mitral stenosis. Apropos of 17 cases]

Percutaneous mitral commissurotomy using balloon catheters was attempted in 17 patients (16 of whom were women) with rheumatic mitral valve stenosis. The patients' age ranged from 15 to 34 years (men 21 years). Functionally, 15 of the patients were in stage III of the New York Heart Association classification, and 2 were in stage II. Sinus rhythm was present in all cases. Slight mitral regurgitation was noted in 2 cases, associated with mild aortic disease in one of them; 3 other patients presented with slight aortic regurgitation. In all 17 cases the mitral stenosis was tight, uncalcified, with flexible valves and little or no alteration of the subvalvular system. One single balloon catheter was used in 11 patients and 2 balloon catheters were introduced simultaneously in the remaining 6 patients. The new therapeutic method was successful in all patients. Following valvuloplasty, the mean transmitral gradient was reduced from 25 +/- 3 to 11 +/- 2 mmHg (P less than 0.001), the mean capillary pressure fell from 26.8 +/- 7.1 to 13.5 +/- 3.7 mmHg (P less than 0.001) and the cardiac index increased from 3.3 +/- 1 to 4.2 +/- 1.2 l/min/m2 (P less than 0.001). The mitral valve area, measured by two-dimensional echocardiography, increased from 1.0 +/- 02 to 2.1 +/- 0.3 cm2 (P less than 0.001). The mitral valve regurgitation observed in 2 patients before valvuloplasty was aggravated, although still moderate, in one of them and remained stable in the other.

[Percutaneous transluminal valvuloplasty of pulmonary stenoses. Apropos of 35 cases]

Thirty-five patients with moderate or severe valvular pulmonary stenosis underwent percutaneous transluminal valvuloplasty (PTV). The average age of the patients was 12 years (range 4 to 34 years). Sixty per cent were under the age of 10, 20 p. 100 were between 10 and 17 years old and 20 p. 100 between 18 and 34 years old. Systolic right ventricular pressures were greater than the pressures in the systemic circulation in 22 cases. The right ventricular-pulmonary artery pressure gradient was greater than 50 mmHg in 29 patients and less than or equal to 50 mmHg in the other 6 patients. The diameter of the balloon of the dilation catheter varied from 12 to 20 mm in 31 PTV; in the other 4 cases two dilating catheters were used simultaneously to dilate the pulmonary valves. The tolerance of PTV was generally good and the results were satisfactory: right ventricular pressures (RVP) fell from 140 +/- 45 to 77 +/- 25 mmHg (p less than 0.001); the RV-PA pressure gradient fell from 82 +/- 40 to 32.4 +/- 15 mmHg (p less than 0.001) and the ratio of RVP to systemic pressure from 1.2 +/- 0.4 to 0.65 +/- 0.2 (p less than 0.01). Clinical and haemodynamic reevaluation in 19 patients 4 to 16 months after PTV (mean 8.5 +/- 2 months) showed that RVP, RV-PA pressure gradients and RVP/systemic pressure ratios had significantly decreased respectively from 78 +/- 30 to 52 +/- 14 mmHg (p less than 0.001), from 27.7 +/- 7.7 to 21.8 +/- 7.3 mmHg (p less than 0.02) and from 0.6 +/- 0.2 to 0.4 +/- 0.1 (p less than 0.001). Pulmonary valvuloplasty is well tolerated, safe and may reduce the number of patients requiring surgical valvotomy.

[Traumatic rupture of the right anterior sinus of Valsalva into the right ventricle combined with aortic regurgitation]

We report the case of a 14-year old boy who was stabbed with a knife and sustained a chest wound responsible for clinical tamponade. Surgery was performed as an extreme emergency, so that lesions could not be assessed preoperatively. During the operation, beside the pericardial blood collection a wound of the pulmonary infundibulum was discovered and sutured (closed heart surgery). One year later the patient was readmitted for global heart failure. Auscultation of the heart revealed a continuous left latero-sternal murmur. Two-dimensional echocardiography showed discontinuity between the right anterior sinus of Valsalva and the right ventricular outflow tract. Contrast echocardiography displayed a negative jet image in the right ventricular outflow tract. At that level, pulsed doppler ultrasound recorded continuous turbulence as well as diastolic turbulence in the left ventricular outflow tract. Tiered oxymetry showed a left-to-right shunt in the right ventricle with a pulmonary/systemic flow ratio of 1.9. The diagnosis was confirmed by angiography which demonstrated a fistula between the right anterior sinus of Valsalva and the right ventricular outflow tract, and aortic regurgitation. In a second operation, performed under extracorporeal circulation, the traumatic lesions were repaired, and the patient thereafter recovered. This unusual case highlights the value of combined two-dimensional echocardiography, pulsed doppler ultrasound and contrast echocardiography in the diagnosis of traumatic ventriculo-aortic lesions.

[Radioisotopic quantification of isolated mitral insufficiency]

A group of 23 consecutive patients with isolated mitral regurgitation confirmed by angiography, 8 of whom had normal and 15 abnormal coronary arteriographies, were compared with a control group of 27 subjects without valvular heart disease (normal coronary arteriography in 7 cases, abnormal coronary arteriography in 20 cases). After injection of technetium 99m labelled albumin, gamma-angiocardiography was performed in the left anterior oblique plane at equilibrium with electrocardiographic synchronisation. Fourier's analysis of the images excluded hepatic pulsation and dephasing of the two ventricles: amplitude images were used to trace the right and left ventricular zones of interest. The ratio of right to left ventricular ejection fraction was calculated in these zones from the radioactive count at end diastole and end systole. The ratio of the ejection fractions was 1.15 +/- 0.18 in subjects without valvular disease compared to 2.66 +/- 0.47 in patients with mitral regurgitation and normal coronary arteries, and 2.50 +/- 1.28 in mitral regurgitation with coronary artery disease (no significant difference between these two sub-groups). When compared with angiographic quantification of the mitral regurgitation, the ratio of ejection fractions increased progressively with the severity of the leak: 1.81 +/- 0.44 for grade I (9 cases), 2.37 +/- 0.80 for grade 2 (5 cases), 3.02 +/- 1.07 for grade 3 (4 cases) and 3.73 +/- 1.50 for grade 4 (5 cases). The differences between each sub-group are not statistically significant because of the small number of patients in each sub-group but all the values are significantly higher than the reference values.(ABSTRACT TRUNCATED AT 250 WORDS)