Brice Letac

PERCUTANEOUS TRANSLUMINAL VALVULOPLASTY OF ACQUIRED AORTIC STENOSIS IN ELDERLY PATIENTS: AN ALTERNATIVE TO VALVE REPLACEMENT?

Percutaneous transluminal balloon catheter aortic valvuloplasty (PTAV) was carried out in three elderly patients with acquired severe aortic valve stenosis. Transvalvular systolic pressure gradient was considerably decreased at the end of the procedure, during which there were no complications. Increased valve opening was confirmed by angiography and echocardiography. Subsequent clinical course showed a pronounced functional improvement. PTAV is recommended as a simple alternative to aortic valve replacement in elderly and/or high-risk patients.

Radiofrequency Catheter Ablation of Atrial Flutter Further Insights Into the Various Types of Isthmus Block: Application to Ablation During Sinus Rhythm

BACKGROUND Radiofrequency ablation of type 1 atrial flutter (AF1) has recently evolved toward an anatomically guided procedure directed to isthmuses at the lower part of the right atrium (RA). However, different types of block at these isthmuses may be observed and potentially correlated with different late outcomes. In addition, because the ablation is anatomically guided, ablation should be possible during sinus rhythm. METHODS AND RESULTS Forty-four patients underwent ablation of type 1 AF1 performed during ongoing tachycardia (33 patients) or sinus rhythm (11 patients). Evidence of inferior vena cava-tricuspid annulus isthmus block was assessed by changes in RA impulse propagation while pacing from both sides of the ablation site. Apparent complete isthmus block was achieved in 43 of 44 patients with 9 +/- 7 pulses. However, incomplete block mimicking complete block because of intra-atrial conduction delay but leading to a different low RA activation pattern was individualized. At the end of the procedure, isthmus block was complete in 35 patients and incomplete in 8, but since AF1 reinduction was no longer possible, patients were discharged. During a follow-up period of 12.1 +/- 5.5 months, 4 patients experienced AF1 recurrence; all had shown incomplete or no block. CONCLUSIONS Detailed multiple-point low RA mapping is necessary to differentiate incomplete from complete isthmus block. Complete block is the best marker for long-term success of AF1 ablation, although incomplete block may be sufficient to prevent recurrence in a significant number of cases. Isthmus block is achievable during sinus rhythm, and AF1 induction is not mandatory.

Percutaneous transluminal balloon valvuloplasty of adult aortic stenosis: Report of 92 cases

Percutaneous transluminal balloon valvuloplasty was attempted in 92 adult patients with severe calcific aortic stenosis. The mean age was 75 +/- 11 years (range 38 to 91) and 35 patients were more than 80 years old. Most of the patients were severely disabled; 66 were in New York Heart Association functional class III or IV, 27 had syncopal attacks and 21 had severe angina pectoris. Because of unacceptably high surgical risk or contraindication to thoracic surgery, 42 patients could not be considered for valve replacement. Other patients either were in a category of high operative risk or refused the surgical intervention. Valvuloplasty was performed by way of the femoral route (82 patients) or the brachial route (10 patients). Catheters of size 15, 18 and 20 mm were successively placed across the aortic valve and three inflations were usually done with each of them, lasting 80 seconds on average, until a decrease in peak to peak systolic pressure gradient to 40 mm Hg or less was attained, a result considered satisfactory. The inflated balloons were not totally occlusive in most cases and clinical tolerance of inflation was good. Valvuloplasty resulted in a reduction of mean systolic gradient from 75 +/- 26 to 30 +/- 13 mm Hg (p less than 0.001); the final gradient was less than 40 mm Hg in 78 patients. Mean calculated aortic valve area increased from 0.49 +/- 0.17 to 0.93 +/- 0.36 cm2 (p less than 0.001). Immediately after the procedure, ejection fraction increased from 48 +/- 16 to 51 +/- 16% (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

A new treatment for severe pulmonary embolism: percutaneous rheolytic thrombectomy.

BACKGROUND The rheolytic thrombectomy catheter has been specially designed to remove intravascular thrombus from coronary and peripheral arteries. It demonstrates a practical application of Bernoullis principle relating to a low-pressure zone in the region of a high-velocity jet. In this device, this effect is created by direct high-pressure saline jets located at the tip. Thrombus is drawn into this region and, because of the large pressure difference, undergoes mechanical thrombolysis due to the powerful mixing forces. The resulting microparticles are aspirated through the same catheter and removed from the body. METHODS AND RESULTS We report the use of this device in two patients presenting with severe pulmonary embolism and contraindications to thrombolytic therapy. The two procedures were successfully performed with an excellent immediate angiographic result at the site of the rheolytic thrombectomy. In both cases, the clinical improvement was maintained at follow-up with the same good angiographic result and a decrease to a normal level of the systolic pulmonary pressure. CONCLUSIONS This preliminary results suggest that this easy technical method may be useful in the treatment of life-threatening pulmonary embolism in patients with absolute contraindications to thrombolytic therapy. A larger cohort of patients is necessary to determine whether this treatment should be proposed as an alternative to the use of fibrinolytics in selected patients.

Percutaneous balloon valvuloplasty in patients with severe aortic stenosis and low ejection fraction. Immediate results and 1-year follow-up.

The efficacy, morbidity, and 1-year follow-up of balloon aortic valvuloplasty in patients with low ejection fraction (less than 40%) were studied on a consecutive series of 55 patients (mean age, 77 years) treated from September 1985 to February 1987. Because of their age (20 patients greater than 80 years old), poor left ventricular function, and associated diseases, 45 patients were definitely not surgical candidates. Balloon dilatation with 15-23-mm diameter balloon catheters decreased the transvalvular gradient from 66 +/- 24 to 28 +/- 14 mm Hg (p less than 0.001) and increased the valve area from 0.47 +/- 0.15 to 0.83 +/- 0.27 cm2 (p less than 0.001). Immediately after dilatation, ejection fraction mildly increased from 29 +/- 7% to 34 +/- 9% (p less than 0.001) in 38 patients who had undergone a second left ventricular angiogram after dilatation. No significant change in the degree of aortic regurgitation was found after the procedure. Three patients died in hospital (femoral arterial complications in two, septicemia in one). Immediate clinical improvement was noted in 80% of the patients. During the follow-up (mean, 11 months), 22 patients died (heart failure in 15 patients, sudden death in five patients, myocardial infarction in one patient, cancer in one patient). Thirty patients survived, 21 with persistent clinical improvement. Repeat cardiac catheterization was performed at 6 months in 20 patients, of whom eight had recurrence of symptoms. Nine patients had restenosis: their hemodynamic indexes had returned to prevalvuloplasty values.(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior ST depression in inferior myocardial infarction: Correlation with results of intracoronary thrombolysis

Thirty-eight patients underwent left ventricular angiography and coronary arteriography within the first 6 hours of inferior myocardial infarction, in an attempt at intracoronary thrombolysis with streptokinase. Twenty-three of these patients presented with ST segment depression of more than 1 mm on the anterior leads (V1 to V4) of ECGs done immediately before the attempt at thrombolysis (group I), whereas 15 did not (group II). Quantitative analysis of left ventricular angiography showed an ejection fraction significantly lower in group I (51 +/- 10%) than in group II (59 +/- 7%; p less than 0.01). This difference was the result of inferior hypokinesia which was larger both in surface area (group I = 11.5 +/- 6.5 cm2; group II = 4.2 +/- 2.7 cm2; p less than 0.001) and in percentage of ventricular perimeter (group I = 46 +/- 14%; group II = 27 +/- 12%; p less than 0.001). The prevalence of a left anterior descending artery lesion and the degree of stenosis were the same in both groups. The success rate of thrombolysis was not significantly different. However, in cases of persistent success, there was an improvement of regional contraction only in group I, as opposed to absence of change in group II. These results suggest that patients with inferior myocardial infarction and ST anterior depression have an extensive ischemic area rather than anterior wall ischemia. An attempt at coronary thrombolysis seems to be worthwhile only in these patients, as it results in appreciable myocardial salvage when successful.

Aortic stenosis in elderly patients aged 80 or older. Treatment by percutaneous balloon valvuloplasty in a series of 92 cases.

Very elderly patients with severe aortic stenosis will probably benefit from percutaneous balloon valvuloplasty. Ninety-two patients, aged 80 or older (mean age, 84 +/- 3.7 years) and all severely incapacitated (18 with an associated pathologic condition or in critical condition with terminal heart failure), underwent a valvuloplasty procedure. Femoral access was used in all cases except seven (8%), in whom the femoral route had to be abandoned and the brachial approach was used due to severe arterial tortuosity. Peak-to-peak ventriculoaortic gradient decreased from 71 +/- 27 to 27 +/- 15 mm Hg, and the aortic valve area increased from 0.48 +/- 0.16 to 0.91 +/- 0.35 cm2 (p less than 0.01). Thirty-two percent had a postprocedure aortic valve area more than or equal to 1 cm2. The final valve area was less than or equal to 0.7 cm2 in 30% of the patients. There were three deaths (ages, 82, 92, and 98 years) in the procedure room. One stroke occurred 1 day after the procedure. Hematoma or thrombosis at the femoral puncture site was observed in 14 cases (15%), requiring surgical repair in only five cases. Three patients died in the hospital; the total in-hospital mortality was 6.5%. Among the 62 patients about whom information could be obtained at a mean follow-up interval of 13 +/- 5 months, there were 18 late deaths (mean age, 85 +/- 11 years). The majority of the surviving 44 patients experienced marked symptomatic improvement. The results indicate that balloon valvuloplasty can be offered to very elderly patients with severe aortic stenosis and can produce improvement in hemodynamic and clinical status.

Hemodynamic and angiographic evaluation of aortic regurgitation 8 and 27 months after aortic valve replacement.

Eighteen patients with chronic aortic insufficiency were evaluated hemodynamically and angiographically 8 months after aortic valve replacement. Both the pulmonary artery diastolic pressure and the left ventricular end-diastolic volume decreased significantly (p < 0.001), but the mean ejection fraction and the cardiac output remained identically lowered, though some individual cases showed improvement. The relative reduction in end-diastolic volume correlated only with the preoperative ejection (p < 0.05) and regurgitation fractions (p < 0.02).In the 10 patients whose left ventricular volume remained high or ejection fraction low, a second evaluation was performed 27 months after surgery. The left ventricular end-diastolic volume was significantly lowered (from 151 to 120 mI/m2, p < 0.05) back to normal in five cases. The systolic and diastolic ventricular shape returned to normal. Cardiac index and ejection fraction were unchanged.These results show a marked improvement a few months after aortic valve replacement, with a further improvement several months later, as shown mainly by the decrease of left ventricular end-diastolic volume and the return to normal of left ventricular cavity shape. However, in most cases, the ejection fraction remained at its preoperative value, suggesting that surgery should be performed early, before myocardial deterioration appears.

Progressive decrease in myocardial ischemia assessed by intracoronary electrocardiogram during successive and prolonged coronary occlusions in angioplasty

Progressive decrease in chest pain and surface ECG changes are commonly observed during successive balloon inflations in coronary angioplasty, which suggests a decrease in myocardial ischemic response. To assess this hypothesis, we continuously recorded intracoronary ECGs during four balloon inflations; each of the inflations was maintained to a minimum of 120 seconds in 19 patients who had significant stenosis in the left anterior descending artery and normal left ventricular function. Three successive QRS-T complexes were analyzed on surface and intracoronary ECGs for measurements of ST-segment elevation 60 milliseconds after the J point. Surface ECG changes were compared with intracoronary ECG changes. On intracoronary ECG, ST area (in square millimeters) and T wave amplitude (in millimeters) were also computed. Chest pain was noted as present or absent during each successive balloon inflation. Ability of intracoronary ECG to detect myocardial ischemia, which was defined as ST-segment elevation greater than 1 mm during balloon inflations 1 to 4, was 89%, 89%, 84%, and 74%, respectively and was higher than that of surface ECG, which was 68%, 63%, 68%, and 58%, respectively. On intracoronary ECG, when compared with the first balloon inflation, a significantly smaller increase in ST-segment elevation was noted during each subsequent balloon inflation, whereas a significantly smaller increase in ST area and T wave amplitude was noted only during balloon inflation 4. The number of patients who experienced chest pain decreased from 15 to 13, 10 and 6 from the first to the fourth balloon inflation. This report demonstrates a progressive decrease in myocardial ischemic response during successive and prolonged balloon occlusions.(ABSTRACT TRUNCATED AT 250 WORDS)