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Spinal Stenosis --- surgery.

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Pulmonary Valve Stenosis --- Pulmonary Valve Stenosis --- diagnosis --- therapy

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La valvuloplastie et l’angioplastie se sont progressivement imposées ces dernières années comme alternative à la chirurgie dans le traitement des lésions cardio-vasculaires congénitales sténotiques. Utilisée avec succès dans le traitement de la sténose valvulaire pulmonaire et considérée actuellement comme le traitement de choix de cette valvuloplastie chez l’enfant, l’application de cette technique dans la sténose valvulaire aortique suscite encore des controverses surtout dans le traitement de la forme critique du nouveau-né et du nourrisson. Certains auteurs émettent des réserves par rapport aux mécanismes d’action encore mal compris et imparfaits de la valvuloplastie au ballonnet, avec les risques de lésions valvulaires et d’insuffisance aortique secondaire que cette technique comporte. D’autres soulignent le nombre encore limité de cas, et malgré des résultats immédiats comparables à ceux de la commissurotomie, l’absence de suivi à long terme, les premiers cas de valvuloplastie aortique publiés datant de plus ou moins de 10 ans.
D’un autre côté, la commissurotomie chirurgicale a prouvé son efficacité mais reste associée, en dessous de l’âge d’un an et surtout dans la forme critique du nouveau-né, à une morbidité importante et une mortalité précoce variant entre 9% et 58% selon les séries et les techniques opératoires. Cette technique reste par ailleurs chez l’enfant, tout comme la dilatation au ballonnet, un traitement palliatif avec des risques d’insuffisance aortique secondaire et/ou de ré-sténose et la nécessité de r é-intervention et de remplacement valvulaire à plus ou moins long terme.
la sténose valvulaire aortique critique du nouveau-né concerne mois de 10% de tous les cas de l’enfant et constitue une entité à part. Le plus souvent elle comporte en effet un spectre d’anomalies associées, notamment une hypoplasie de l’anneau aortique et/ou du ventricule gauche, une dysplasie valvulaire aortique ou mitrale ainsi qu’une fibroélastose sous-endocardique plus ou moins importante. Le ventricule gauche est défaillant et l’état hémodynamique instable, généralement dépendant de la perméabilité du canal artériel. L’évolution spontanée conduit rapidement au décès en l’absence de traitement. Tout cela fait que l’approche thérapeutique de la sténose valvulaire aortique du nouveau-né et du nourrisson reste controversée, d’autant plus qu’il n’y a pas d’études prospectives comparant la valvulotomie chirurgicale et la valvuloplastie au ballonnet et que les résultats des rares études rétrospective dans ce groupe d’âge ne sont pas tranchées.
Les premières valvuloplasties aortiques ont été réalisées dans le Service de Cardiologie Pédiatrique de l’Université Catholique de Louvain (U.C.L.) dans les années 1985 et devant des résultats immédiats et à court terme encourageants, cette technique y a été de plus en plus utilisée comme traitement de première intention de la sténose valvulaire aortique. C’est pourquoi nous avons jugé utile de revoir tous les cas de valvotomie chirurgicale et de valvuloplastie au ballonnet traités dans le Service avant l’âge d’un an afin de :
- Evaluer nos résultats à court et moyen termes, particulièrement en ce qui concernent l’efficacité de la dilation, la survenue d’une insuffisance aortique, ainsi que le risque de ré-sténose et le délai de ré-intervention.
- Identifier les facteurs pouvant contribuer à l’élaboration d’un algorithme décisionnel dans la prise en charge de la sténose valvulaire aortique critique

Aortic Valve Stenosis --- Infant --- Catheterization

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PURPOSE: To evaluate the evidence on screening and treating asymptomatic adults for carotid artery stenosis (CAS) for the U.S. Preventive Services Task Force (USPSTF). DATA SOURCES: PubMed/MEDLINE, the Cochrane Library, EMBASE, and trial registries through September 2013; reference lists of published literature; MEDLINE searches for trials were updated through March 2014. STUDY SELECTION: Two investigators independently selected studies reporting on asymptomatic adults with CAS, including randomized, controlled trials (RCTs) of screening for CAS; RCTs of carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAAS) versus medical treatment; RCTs of medications versus placebo added to current standard medical therapy; multi-institution trials or cohort studies reporting harms; relevant systematic reviews; and studies that attempted to externally validate risk stratification tools. DATA EXTRACTION: One reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings using predefined criteria. DATA SYNTHESIS: No RCTs compared screening with no screening, CAAS with medical treatment, or assessed intensification of medical therapy. Given the specificity of ultrasound (range 88% to 94% for CAS e50% to e70%), its use in low-prevalence populations would yield many false-positive results. Only one fair-quality study attempted external validation of a risk stratification tool to distinguish persons who are more likely to have CAS; the tool's discrimination was inadequate (c-statistic for e50% CAS, 0.60; 95% CI, 0.56 to 0.64). Our meta-analyses of RCTs comparing CEA with medical therapy found an absolute risk reduction of 5.5 percent (95% CI, 3.9 to 7.0) for any nonperioperative stroke over approximately 5 years. Meta-analyses for perioperative (30-day) stroke or death after CEA found rates of 2.4 percent (95% CI, 1.7 to 3.1) using all trials of CEA, regardless of the comparator; and 3.3 percent (95% CI, 2.7 to 3.9) using cohort studies (7 studies; n=17,474). Rates of perioperative stoke or death after CAAS were similar or slightly higher. Other important potential harms of CEA or CAAS include nonfatal perioperative myocardial infarction (approximately 0.8% rate after CEA), cranial nerve injury, pulmonary embolism, pneumonia, local hematoma requiring surgery, and psychological harms (e.g., anxiety or labeling). Externally validated, reliable risk stratification tools that can distinguish persons with asymptomatic CAS who have increased or decreased risk for ipsilateral stroke or harms after CEA or CAAS are not available. LIMITATIONS: Medical therapy in trials varied and often lacked treatments that are now standard. For this reason, and because advances in medical therapy have reduced the rate of stroke in persons with asymptomatic CAS in recent decades, the true reduction of stroke or composite reduction of cardiovascular events is unknown. Trials utilized highly selected surgeons. No trials focused on a population identified by screening in primary care. Harms may be underreported. CONCLUSION: Current evidence does not sufficiently establish incremental overall benefit of CEA, CAAS, or intensification of medical therapy beyond current standard medical therapy. Potential for overall benefit is limited by low prevalence in the general asymptomatic population and by harms from screening and treatment. Evidence is insufficient to allow reliable risk stratification.

Carotid Stenosis --- diagnosis. --- United States

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BACKGROUND: Cerebrovascular disease is the third leading cause of death in the U.S. The proportion of all strokes attributable to previously asymptomatic carotid stenosis is low. In 1996, the United States Preventive Services Task Force concluded that there was insufficient evidence to recommend for or against screening of asymptomatic persons for CAS using physical exam or carotid ultrasound. PURPOSE: To examine the evidence of benefits and harms of screening asymptomatic patients with duplex ultrasound and treatment with carotid endarterectomy (CEA) for carotid artery stenosis (CAS). DATA SOURCES: MEDLINE and Cochrane Library searches (January 1994-April 2007), recent systematic reviews, reference lists of retrieved articles, and expert suggestions. STUDY SELECTION: English language studies were selected to answer the following: Is there direct evidence that screening with ultrasound for asymptomatic CAS reduces strokes? What is the accuracy of ultrasound to detect CAS? Does intervention with CEA reduce morbidity or mortality? Does screening or CEA result in harm? The following study types were selected: randomized controlled trials (RCT) of screening for CAS; RCTs of CEA versus medical treatment; systematic reviews of screening tests; observational studies of harms from CEA. DATA EXTRACTION: Studies were reviewed, abstracted, and rated for quality using predefined USPSTF criteria. DATA SYNTHESIS: There have been no RCTs of screening for CAS. According to systematic reviews, the sensitivity of ultrasound is approximately 94% and the specificity is approximately 92%. Treatment of CAS in selected patients with selected surgeons could lead to an approximately 5% absolute reduction in strokes over 5 years. Thirty-day stroke and death rates from CEA vary from 2.7% to 4.7% in RCTs; higher rates have been reported in observational studies (up to 6.7%). LIMITATIONS: There is inadequate evidence to stratify people into categories of risk for clinically important CAS. The RCTs of CEA versus medical treatment were conducted in selected populations with selected surgeons. CONCLUSIONS: The actual stroke reduction from screening asymptomatic patients and treatment with CEA is unknown; the benefit is limited by a low overall prevalence of treatable disease in the general asymptomatic population and harms from treatment.

Carotid Stenosis --- diagnosis. --- United States