H. Gamra

Percutaneous balloon mitral commissurotomy during pregnancy.

OBJECTIVE: To evaluate the effectiveness and safety of percutaneous balloon mitral commissurotomy for the treatment of pregnant women with severe mitral stenosis over a period of six years. DESIGN: Analysis of clinical, haemodynamic, and echocardiographic data before and immediately after the procedure, the pregnancy outcome, and the fate of newborn babies. SETTING: Academic cardiovascular centre in Monastir, Tunisia. PATIENTS: 44 pregnant patients who underwent percutaneous transvenous dilatation of the mitral valve between January 1990 and February 1996. Grade 2 mitral regurgitation was present in two patients and densely calcific valves in three (7%). RESULTS: Commissurotomy was successfully achieved in all cases. The total mean (SD) duration of teh procedure was 72 (18) minutes and that of fluoroscopy 16 (7) minutes. Left atrial pressure decreased from 28 (10) to 14 (7) mm Hg, mitral pressure gradient fell from 22 (8) to 5 (3) mm Hg. Cardiac output increased from 4.8 (1.1) to 6.3 (1.2) l/min and Gorlin mitral valve area from 0.96 (0.21) to 2.4 (0.4) cm2 (all P < < 0.001). Cross sectional echocardiographic mitral valve area increased from 1.07 (0.21) to 2.32 (0.36) cm2. There were no maternal or fetal deaths. Complications included a grade 4 mitral regurgitation in one patient that required early valve replacement. All patients delivered at full term, 42 vaginally and two (5%) by caesarean section; 41 babies were normal and three whose mothers had the procedure near term were relatively hypotrophic. At a mean follow up of 28 (12) months (range 2 to 26) all children had normal growth. CONCLUSIONS: During pregnancy, balloon mitral commissurotomy is the treatment of choice of severe pliable mitral stenosis in patients who are refractory to medical treatment.

Assessment of left ventricular function in severe scorpion envenomation: Combined hemodynamic and echo-Doppler study

ObjectiveTo assess left ventricular function in patients presenting with pulmonary edema following scorpion envenomation.DesignCohort study.Setting: Medical intensive care unit of a teaching hospital.Patients: Nine consecutive adult patients stung byAndroctonus australis and presenting with pulmonary edema entered the study. Fourteen normal volunteers comprised the control group.InterventionsUpon admission, all patients had right heart catheterization and, within the first 8 h, a Doppler echocardiographic study. Results of Doppler echocardiographic studies were compared to those of controls.Measurements and resultsUsual hemodynamic information (heart and vascular pressures, derived data and tissue oxygenation parameters), left ventricular dimensions and indicators of systolic function, and Doppler-derived parameters of left ventricular filling and diastolic function were obtained upon admission. Serial echocardiographic measurements were repeated daily until full clinical recovery (eight patients) or death (one patient). All patients had a hemodynamic profile of acute congestive heart failure (mean PAOP=24±2 mmHg; mean SVI=22±7 ml/m2; mean CI=2.5±0.5 l/min/m2). However, SVR were not increased (mean=22±3 U/m2). Left ventricle was hypokinetic in all patients with transient mitral regurgitation present in five patients. Left ventricular systolic function was markedly depressed (FS=12±6%; EF=26±12%). An associated diastolic dysfunction is suggested by Doppler records of mitral inflow. Left ventricular systolic function evolved toward normalization within 6±2 days preceded by full clinical recovery.ConclusionsThese data suggest that pulmonary edema in scorpion envenomation is of hemodynamic origin and is related to a severe and prominent impairment of left ventricular systolic function.

Results of percutaneous double-balloon mitral commissurotomy in one medical center in Tunisia.

Percutaneous balloon mitral commissurotomy was attempted in Tunisia, where rheumatic fever is still endemic, in 463 consecutive patients with severe rheumatic mitral valve stenosis. Their mean age +/- SD was 33 +/- 12 years (range 8 to 68), 324 patients (70%) were women, and 327 (71%) were in sinus rhythm. Valvotomy was technically successful in 454 patients (98%). The mean mitral valve gradient decreased from 20 +/- 7 to 6 +/- 4 mm Hg, mean left atrial pressure decreased from 27 +/- 8 to 15 +/- 6 mm Hg, cardiac index increased from 3.0 +/- 0.7 to 3.6 +/- 0.8 L/min/m2, and Gorlin mitral valve area, from 0.97 +/- 0.19 to 2.2 +/- 0.4 cm2 (all p < 0.001). Two-dimensional echocardiographic mitral valve area increased from 1.03 +/- 0.18 to 2.15 +/- 0.36 cm2 (p < 0.00001). A final valve area of > or = 1.5 cm2 was achieved in 98% of patients. Multivariate analysis identified a pre-mitral valve area < 0.8 cm2 and an echocardiographic score (echo score) > or = 12 as the strongest predictors of residual stenosis (final mitral valve area < 1.5 cm2). Major procedural complications included mortality (0.4%), tamponade (0.7%), thromboembolism (2.0%), severe mitral regurgitation (4.6%), significant (pulmonary to systemic flow ratio > or = 1.5) interatrial shunt (4.8%). Four hundred thirty patients were followed up between 6 and 82 months (mean 37 +/- 22): 95% were in functional class I to II without reintervention, and 7 patients died (1.6%); restenosis (echocardiographic mitral valve area < 1.5 cm2) occurred in 10.4% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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

AIMSnTo evaluate the safety, efficacy and long-term actuarial results of balloon mitral commissurotomy in young patients with severe rheumatic mitral stenosis.nnnMETHODS AND RESULTSnEvent-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=0.15nnnCONCLUSIONnBalloon 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.

Balloon valvotomy for mitral stenosis associated with moderate mitral regurgitation

In summary, the possibility of developing moderate to severe (3+) MR after balloon dilatation was greater in patients with preexisting moderate MR. Nevertheless, improvements in hemodynamics and increases in mitral valve area can be equally achieved using balloon mitral valvotomy for treatment of mitral stenosis in patients with or without moderate MR.

Nodule rhumatoïde responsable d’un bloc auriculoventriculaire complet : diagnostic par l’échocardiographie transœsophagienne

Resume Nous rapportons le cas d’une patiente âgee de 48 ans ayant depuis 8 ans une polyarthrite rhumatoide arrivee au stade de deformations osteoarticulaires. Son dernier traitement comporte de la prednisone 5xa0mg/j, de la chloroquine (200xa0mg/j) depuis 6 mois et qui consulte a nos urgences pour syncope, avec a l’electrocardiogramme un bloc auriculoventriculaire completxa0. Une echocardiographie transœsophagienne realisee dans le cadre du bilan montre un nodule hyperechogene de 6xa0×xa02,5xa0mm, siegeant au niveau du septum interventriculaire, pouvant correspondre a un nodule rhumatoide fibreux et expliquer ce bloc auriculoventriculaire par envahissement du tissu conductif. La patiente a ete appareillee par un pacemaker definitif double chambre. La chloroquine, autre facteur possible de trouble conductif, ne parait pas etre incriminee. Les troubles de la conduction au cours de la polyarthrite rhumatoide doivent etre depistes de facon systematique en cas de polyarthrite rhumatoide evoluee.xa0L’echocardiographie transthoracique fait partie de son bilan. L’echocardiographie transœsophagienne peut s’averer necessaire pour depister les nodules rhumatoides fibroses.

Évaluation de l’irradiation ionisante des opérateurs en cardiologie interventionnelle

Resume Les rayonnements ionisants (RI) sont largement utilises en pratique medicale aussi bien a des fins diagnostiques que therapeutiques. Toutefois, ils ne sont pas denues d’effets indesirables sur la sante des operateurs exposes. De ce fait, nous nous proposons d’evaluer l’exposition du personnel hospitalier en cardiologie interventionnelle. Pour cela, nous avons effectue une etude transversale descriptive au cours du premier trimestre 2003 a l’aide des dosimetres electroniques de type L36, Dosicard et DMC100 a l’unite de cardiologie interventionnelle du CHU de Monastir. L’analyse des temps de scopies a permis de noter une variabilite en fonction de l’acte et de l’operateur soit 6,06 min pour la coronarographie et 21,41 min pour l’angioplastie. Le calcul des doses equivalentes par acte a note que l’exposition des mains etait superieure a celle des autres parties du corps. En effet, le niveau d’irradiation des mains etait pres de 99,5 μSv contre 14 μSv au niveau du cou et 34 μSv au niveau des pieds. Nous avons note aussi que le niveau d’exposition de la main gauche etait correle a la technique abordee. Le calcul des doses equivalentes annuelles a permis de constater que le niveau d’exposition chez tous les operateurs etait largement en deca des normes de radioprotection. En effet, l’exposition du cristallin et des membres superieurs etait respectivement de l’ordre de 1,93 mSv/an et de 14,02 mSv/an. De meme, l’estimation de la dose efficace annuelle nous a permis de constater un bas niveau d’exposition chez tous les operateurs avec une dose maximale de 2,5 mSv. En conclusion, meme si le niveau d’exposition des operateurs en cardiologie interventionnelle en temps reel reste largement en deca des normes preconisees, une radioprotection efficace reste toujours indispensable.

Successful weaning from mechanical ventilation following balloon mitral commissurotomy.

Abstract Successful weaning from mechanical ventilation (MV) following percutaneous balloon mitral commissurotomy (BMC) is reported in a 59-year-old woman with severe symptomatic rheumatic mitral stenosis. The patient was admitted to the Intensive Care Unit for acute respiratory failure secondary to pulmonary edema requiring intubation and mechanical ventilation. After resolution of the acute phase, she became completely dependent on mechanical ventilatory support. In spite of the reinforcement of conventional therapy (diuretics, digitalis, vasodilators), weaning attempts were unsuccessful because of persisting elevated left atrial pressure. Percutaneous BMC was performed with favorable hemodynamic results, allowing the removal of external ventilatory support 24 h later and discharge from the Intensive Care Unit the same day.

Percutaneous closure of persistent ductus arteriosus in small weight infants

Introduction The persistent ductus arteriosus remains a common congenital pathology. If percutaneous closure of wide channels by Amplatzer duct occluder is an attractive alternative to the surgical treatment, this prosthesis is however not recommended for infants less than 6xa0kg. Purpose Our objective was to evaluate the efficacy and the safety of use of this prosthesis in low-weight children. Patients and methods The records of children less than 6xa0kg who underwent closure by the Amplatzer Duct Occluder prosthesis between January 2010 and December 2015 were retrospectively analyzed. Results Fourteen patients [mean weight 5.7xa0kg (4.8 to 6); mean age 6.5 months (3–12)] have been included. The average diameter angiographic persistent ductus arteriosus was 3.5xa0mm (3–6xa0mm) with a good correlation with that found on ultrasound (rxa0=xa00.68). The prosthesis was implanted successfully in 92.8% of cases. The immediate angiographic occlusion rate was 71.4%. The average duration of the procedure was 46xa0±xa012xa0min. Three children had a type of channel C of the classification Krichenko. Two complications occurred in two of our patients. Persistent ductus arteriosus C-type (tubular) and a diameter ratio of the persistent ductus arteriosus/weight of higher child 0.95 were significantly associated with a failure of intervention and/or major complications throughout the percutaneous closure of register having included 67 patients, while a weight of less than 6xa0kg was not retained as a predictor of failure of the procedure. No late embolisation occurred after 11 months of median follow up. During this monitoring, we noted a marked clinical improvement with normalization of pulmonary pressure. Conclusion Our study includes the few records reported in the literature assessing the feasibility of percutaneous closure in persistent ductus arteriosus in infants less or equal to 6xa0kg. It confirms the effectiveness of the procedure with a relatively low prevalence of complications.