Strokes in Young Adults

Occlusion of the internal carotid or middle cerebral artery was seen in 44 young adults of both sexes from a rural population in Ceylon over a period of four years. None had hypertension, diabetes, prediabetes, or hypercholesterolaemia. There were 19 men with internal carotid occlusions, most being due to atherosclerotic thrombosis. The high incidence of atherosclerosis in these patients on a marginal diet remains an enigma, and we suggest that carbohydrate-induced hyperlipidaemia might be an important aetiological factor. There were 13 men with middle cerebral occlusions, the aetiology of which remains obscure. Occult embolism or atherothrombosis are suggested as possible causative factors. Of the 12 women five had middle cerebral artery occlusions in the last trimester of pregnancy and two had internal carotid artery occlusions in the puerperium. The pattern of ischaemic strokes in women aged 15-45 was similar to that observed in Western countries, though our patients differed ethnologically and in dietary habits.     

The Results of Surgical Management of Extracranial Internal Carotid Artery Occlusion and Stenosis

Vascular reconstruction was attempted in 109 patients with carotid artery occlusion or stenosis. The follow-up on those with restored or improved flow was as long as nine years (average: two and one-half years).Arteriographic demonstration of lesions is mandatory. Complications were reduced by pre-arteriographic administration of anticoagulants and retrograde brachial arteriographic techniques.Although patients with stenosis are the best candidates, an attempt to restore flow in occluded vessels is warranted in all patients, except those with advanced disease or those who are drowsy and hemiplegic. Flow was restored in two-thirds of those who underwent early operation (under three days) and in one-quarter of those undergoing late operation. Even late operation restored flow in five of nine patients who presented with transient ischemic attacks.In completed strokes, operation should be limited to patients with: (1) minor strokes, (2) extensive strokes of short duration, and (3) extensive strokes of longer duration but with a worth-while outlook.When flow was restored or improved, symptoms were arrested in 93% of patients with transient ischemia, and at follow-up this result was maintained in 86%. Symptoms were arrested in 83% of those with strokes in evolution, and this was maintained at follow-up.Reconstruction combined with anticoagulant therapy of limited duration appears to be the optimal method of treatment.     

Prevalence and outcome of symptomatic carotid lesions in young adults. National Research Council Study Group.

OBJECTIVE--To estimate the prevalence and outcome of symptomatic internal carotid artery lesions in young adults. DESIGN--Multicentre hospital based observational study with five year follow up. SETTING--Seven neurological departments in northern and central Italy. SUBJECTS--240 patients (115 men) aged 15-44 with a recent transient ischaemic attack or stroke in the carotid territory. MAIN OUTCOME MEASURES--(a) Prevalence of symptomatic internal carotid artery stenosis or occlusion detected by continuous wave Doppler ultrasonography at entry; (b) incidence rates of cerebral, cardiac, and non-vascular death; non-fatal stroke; and non-fatal myocardial infarction. RESULTS--Carotid stenoses of 50-99% and occlusions were found in 38 patients (15.8%). Both conditions were significantly more frequent in patients aged over 35 and in those with hypertension, diabetes mellitus, and stroke at entry. The standardised mortality ratio at five years was 10.5 (95% confidence interval 5.0 to 19.3). Survival of patients with stenoses of 0-49% and occlusions was significantly better than that of patients with stenoses of 50-99%. Carotid stenosis of 50-99% was an independent predictor of death (hazard ratio 7.9; 95% confidence interval 2.2 to 29) and non-fatal stroke (hazard ratio 7.4; 1.5 to 37.4). CONCLUSIONS--The prevalence of carotid stenosis or occlusion in young adults after a cerebrovascular event is low. Though patients with high grade symptomatic carotid stenosis are at risk of non-fetal and fetal events, patients with internal artery occlusion apparently have a benign prognosis.     

Epileptic seizures after a first stroke: the Oxfordshire Community Stroke Project.

OBJECTIVE: To describe the immediate and long term risk of epileptic seizures after a first ever stroke. DESIGN: Cohort study following up stroke survivors for 2 to 6.5 years; comparison with age specific incidence rates of epileptic seizures in the general population. SETTING: Community based stroke register. SUBJECTS: 675 patients with a first stroke, followed up for a minimum of 2 years. MAIN OUTCOME MEASURES: Occurrence of single and recurrent seizures. RESULTS: 52 patients had one or more post stroke seizures; in 25 the seizures were recurrent. The 5 year actuarial risk of a post stroke seizure in survivors (excluding 19 patients with a history of epilepsy and 3 patients in whom the seizure occurred shortly before death from another cause) was 11.5% (95% confidence interval 4.8% to 18.2%). The relative risk of seizures, in comparison with the general population, was estimated at 35.2 in the first year after stroke and 19.0 in year 2. The risk of seizures was increased in survivors of subarachnoid and intracerebral haemorrhage (hazard ratio for intracranial haemorrhage v cerebral infarction 10.2 (3.7 to 27.9)). The risk of seizures after ischaemic stroke was substantial only in patients presenting with severe strokes due to total anterior circulation infarction. Only 9 of 295 patients (3%) independent one month after stroke suffered a seizure between 1 month and 5 years (actuarial risk 4.2% (0.1% to 8.3%)). CONCLUSION: Stroke patients have about an 11.5% risk of single or recurrent seizures in the first 5 years after a stroke. Patients with more severe strokes or haemorrhagic strokes are at higher risk.     

Highly selective vagotomy and duodenal ulcers that fail to respond to H2 receptor antagonists

A study was conducted to see whether patients with duodenal ulcers that failed to heal in response to H₂ receptor antagonists had a higher incidence of recurrent ulceration after highly selective vagotomy than patients whose ulcers healed with these drugs. Between 1977 and 1983, 157 patients had a highly selective vagotomy for uncomplicated duodenal ulcer; in 57 patients the ulcer had failed to heal despite treatment with H₂ receptor antagonists (refractory group), 19 patients had developed recurrent ulceration while receiving maintenance treatment, 67 patients had remained healed while taking H₂ receptor antagonists but suffered frequent relapses when treatment was stopped, and 14 patients had not been given these drugs before operation. The overall incidence of recurrent ulceration was 6% after two years and 11% after five years of follow up. In the refractory group, however, the incidence of recurrent ulceration was 18% at two years and 34% after five years, whereas the incidence of recurrence was only 1.5% at two years and 3% after five years in patients whose ulcers had healed with H₂ receptor antagonists. Resistance to H₂ receptor antagonists was not related to preoperative basal or peak acid output but was related to cigarette smoking. Factors associated with recurrent ulceration after highly selective vagotomy were basal acid outputs before and after operation, cigarette smoking, and the surgeon who performed the operation.Duodenal ulcers that fail to respond to H₂ receptor antagonists represent a more severe ulcer diathesis, for which highly selective vagotomy is less effective.     

Conjugal disharmony: a hitherto unrecognised cause of strokes.

Two women of reproductive age suffered strokes. Neither was taking oral contraceptives, and investigations showed no other causal factors. The radiological findings were characteristic of traumatic internal carotid artery occlusion, but neither patient gave a history of trauma. Only after further inquiry into the patients'' social circumstances did it emerge that each had survived an attempt at strangulation by her husband. Such a cause of stroke in young women should be considered when other causes of carotid artery occlusion cannot be identified.     

Recurrent posterior circulation infarction caused by anomalous occipital bony process in a young patient

Background

Structural anomaly of the cervical spine or craniocervical junction has been reported as one of the rare causes of ischemic stroke. We report a case of a young patient with recurrent posterior circulation infarction that may have been associated with an anomalous occipital bony process compressing the vertebral artery.

Case presentation

A 23-year-old man experienced recurrent posterior circulation infarction 5 times over a period of 5 years. He had no conventional vascular risk factors. Young age stroke work-up including thorough cardiac, intra- and extracranial vascular evaluation and laboratory tests for the hypercoagulable state or connective tissue disease yielded unremarkable results. An anomalous bony process from the occipital base compressing the left vertebral artery was observed on brain CT. All the recurrent strokes were explainable by the arterial thromboembolism originating from the compressed left vertebral artery. Therefore, the left vertebral artery compressed by the anomalous occipital bony process may have been the culprit behind the recurrent thromboembolic strokes in our patient. Intractable recurrent strokes even under optimal medical treatment led us to make a decision for the intervention. Instead of surgical removal of the anomalous occipital bony process, the left vertebral artery was occluded permanently by endovascular coiling after confirming that this would cause no neurological deficits or flow disturbance in the posterior circulation. There was no recurrence of stroke for 2 years after permanent occlusion of the left vertebral artery.

Conclusion

Arterial thromboembolism originating from the left vertebral artery compressed by the anomalous occipital bony process is a rare but not to be overlooked cause of posterior circulation infarction. When intractable to medical treatment, endovascular occlusion of the vertebral artery without flow disturbance to the posterior circulation may be a useful treatment option when surgical removal is not feasible.

     

Incidence of AIDS and excess of mortality associated with HIV in haemophiliacs in the United Kingdom: report on behalf of the directors of haemophilia centres in the United Kingdom.

OBJECTIVE--To estimate the cumulative incidence of AIDS by time since seroconversion in haemophiliacs positive for HIV and to examine the evidence for excess mortality associated with HIV in those who had not yet been diagnosed as having AIDS. DESIGN--Analysis of data from ongoing national surveys. SETTING--Haemophilia centres in the United Kingdom. PATIENTS--A total of 1201 men with haemophilia who had lived in the United Kingdom during 1980-7 and were positive for HIV. INTERVENTION--None. END POINTS--Diagnosis of AIDS; death in those not diagnosed as having AIDS. MEASUREMENTS AND MAIN RESULTS--Estimation of cumulative incidence of AIDS and number of excess deaths in seropositive patients not diagnosed with AIDS. Median follow up after seroconversion was 5 years 2 months. Eight five patients developed AIDS. Cumulative incidence of AIDS five years after seroconversion was 4% among patients aged less than 25 at first test positive for HIV, 6% among those aged 25-44, and 19% among those aged greater than or equal to 45. There was little evidence that type or severity of haemophilia or type of factor VIII or IX that had caused HIV infection affected the rate of progression to AIDS. Mortality was increased among those who had not been diagnosed as having AIDS, especially among those with "AIDS related complex." Thirteen deaths were observed among 36 patients diagnosed as having AIDS related complex against 0.65 expected, and 34 deaths in 1080 other patients against 22.77 expected; both calculations were based on mortality rates observed in haemophiliacs in the United Kingdom in the late 1970s. CONCLUSIONS--Rate of progression to AIDS depended strongly on age. There is a substantial burden of fatal disease among patients positive for HIV who have not been formally diagnosed as having AIDS.     

Mouse Model of Intraluminal MCAO: Cerebral Infarct Evaluation by Cresyl Violet Staining

Stroke is the third cause of mortality and the leading cause of disability in the World. Ischemic stroke accounts for approximately 80% of all strokes. However, the thrombolytic tissue plasminogen activator (tPA) is the only treatment of acute ischemic stroke that exists. This led researchers to develop several ischemic stroke models in a variety of species. Two major types of rodent models have been developed: models of global cerebral ischemia or focal cerebral ischemia. To mimic ischemic stroke in patients, in whom approximately 80% thrombotic or embolic strokes occur in the territory of the middle cerebral artery (MCA), the intraluminal middle cerebral artery occlusion (MCAO) model is quite relevant for stroke studies. This model was first developed in rats by Koizumi et al. in 1986 ¹. Because of the ease of genetic manipulation in mice, these models have also been developed in this species ^2-3.Herein, we present the transient MCA occlusion procedure in C57/Bl6 mice. Previous studies have reported that physical properties of the occluder such as tip diameter, length, shape, and flexibility are critical for the reproducibility of the infarct volume ⁴. Herein, a commercial silicon coated monofilaments (Doccol Corporation) have been used. Another great advantage is that this monofilament reduces the risk to induce subarachnoid hemorrhages. Using the Zeiss stereo-microscope Stemi 2000, the silicon coated monofilament was introduced into the internal carotid artery (ICA) via a cut in the external carotid artery (ECA) until the monofilament occludes the base of the MCA. Blood flow was restored 1 hour later by removal of the monofilament to mimic the restoration of blood flow after lysis of a thromboembolic clot in humans. The extent of cerebral infarct may be evaluated first by a neurologic score and by the measurement of the infarct volume. Ischemic mice were thus analyzed for their neurologic score at different post-reperfusion times. To evaluate the infarct volume, staining with 2,3,5-triphenyltetrazolium chloride (TTC) was usually performed. Herein, we used cresyl violet staining since it offers the opportunity to test many critical markers by immunohistochemistry. In this video, we report the MCAO procedure; neurological scores and the evaluation of the infarct volume by cresyl violet staining.     

Middle cerebral artery occlusion in Macaca fascicularis: acute and chronic stroke evolution

BACKGROUND: An intravascular stroke model designed for magnetic resonance imaging was developed in Macaca fascicularis (M. fascicularis) to characterize serial stroke lesion evolution. This model produces a range of stroke lesion sizes which closely mimics human stroke evolution. This paper describes the care of animals undergoing this stroke procedure, the range of outcomes we experienced and the cause of mortality in this model. METHODS: Anesthesia was induced with atropine and ketamine and maintained with isoflurane or propofol. Non-invasive blood pressure, oxygen saturation, heart rate, respiration rate, temperature and end tidal CO2 were monitored continuously. The stroke was created by occluding a distal branch of the middle cerebral artery. During catheter placement animals were heparinized and vasospasm was minimized using verapamil. RESULTS: Anesthetic induction and maintenance were smooth. Animals with small strokes showed very rapid recovery, were able to ambulate and self-feed within 2 hours of recovery. Animals with strokes of >or=4% of the hemispheric volume required lengthy observation during recovery and parenteral nutrition. Large strokes resulted in significant brain edema, herniation and brainstem compression. CONCLUSIONS: Intracerebral hemorrhage and or subarachnoid hemorrhage coupled with a stroke of any size was acutely fatal. In the absence of an effective acute stroke therapy, the spectrum of outcomes seen in our primate model is very similar to that observed in human stroke patients.     

扩散性抑制对脑缺血后海马迟发性神经元死亡的影响

目的为了研究阻断大鼠局灶性脑缺血诱导的扩散性抑制对同侧海马迟发性神经元死亡的影响。方法颈内动脉插线法制备大鼠大脑中动脉缺血再灌注模型,采用电生理学方法记录扩散性抑制波,尼氏染色和TUNEL染色检测海马迟发性神经元死亡;观察阻断局灶性脑缺血再灌注诱导的扩散性抑制对海马迟发性神经元死亡的影响。结果不给予SD阻断剂,大脑中动脉缺血模型有39%的动物出现海马迟发性神经元死亡;用MK-801阻断扩散性抑制后仅10%的动物出现海马迟发性神经元死亡,机率明显减小。结论局灶性脑缺血引起的海马迟发性神经元死亡可能与扩散性抑制由缺血区不断向远隔部位播散有关。     

Perioperative and early postoperative neurological deficit in older patients during carotid artery thrombendarterectomy

Cerebrovascular accidents, strokes in particular, are among the most frequent causes of death today in developed countries. In the last two decades, stroke was the second most frequent cause of death in Primorsko-Goranska Region in Croatia. In older patients, individuals older than 65 years of age have an increased risk of stroke, mainly because the degree of carotid artery stenosis increases with age. The most frequent complication of the high percent stenosis of the carotid arteries is thrombosis in the area of atherosclerotic changes of blood vessels. With the increase in the age of the population, there is also an increase in the number of risk factors of cerebrovascular accident. Doppler ultrasound sonography and Multi Slice CT scans have the most prominent role in the early detection of atherosclerotic changes and in the assessment of the degree of carotid artery narrowing. Today, in Croatia as well as worldwide, thrombendarterectomy holds the most important place in stroke prevention. Between 2006 and 2009, 209 patients underwent surgical intervention at the Clinical Hospital Center in Rijeka for high degree of carotid artery narrowing. In the group younger than 65 years of age, which consisted of 53 patients, a neurological deficit was noted in 4 patients (7.54%) in the perioperative and early postoperative course. In the group of individuals older than 65 years of age, which consisted of 156 patients, a neurological deficit was noted in 9 patients (5.76%). There was no significant statistical difference in the incidence of neurological deficit, nor in the mortality in individuals older than 65 years of age during carotid arteries thrombendarterectomy.     

Enhanced protection by melatonin and meloxicam combination in a middle cerebral artery occlusion model of acute ischemic stroke in rat

Mixed efficacy of neuroprotective drugs in clinical trials has led to the emergence of the approach of combination therapy in stroke. The present study was carried out to investigate the effect of the combination of melatonin (potent antioxidant) and meloxicam (preferential inhibitor of cyclooxygenase-2 enzyme) against a middle cerebral artery occlusion model of stroke in rats. Male Wistar rats in the weight range of 250-300 g were used. Rats were anesthetized using chloral hydrate (400 mg/kg i.p) and subjected to 2 h of transient middle cerebral artery occlusion. Melatonin was administered at a dose of 20 mg/kg i.p. four times: at the time of middle cerebral artery occlusion, 1.5 h after middle cerebral artery occlusion, at the time of reperfusion, and 1 h after reperfusion. Meloxicam (2.5 mg/kg) was administered 4 h after middle cerebral artery occlusion. Motor performance tests (grip test, foot fault test, rotarod performance test, spontaneous locomotor activity), markers of oxidative stress, and triphenyltetrazolium chloride staining were carried out 24 h after middle cerebral artery occlusion. A vehicle-treated group was run in parallel. It was observed that melatonin treatment improved the motor performance and significantly attenuated the levels of malondialdehyde (MDA) as compared with the middle cerebral artery occluded group. Meloxicam treatment at the dose used neither showed significant improvement on the motor performance nor decreased the levels of MDA significantly as compared with the middle cerebral artery occluded group. However, when the combination of the two drugs was used, better protection was observed as was evident by the significant decrease in the percent foot fault errors, the increase in the time spent on the rotarod, and the increase in the six-point neurological score and grip test score. There was also a significant decrease in the levels of MDA in the combination group. The results of the present study demonstrate that enhanced protection is observed with the use of a combination of melatonin plus meloxicam in the middle cerebral artery occlusion model of acute ischemic stroke in rats.     

Course of angina pectoris after an acute coronary event.

The course of postcoronary angina pectoris was examined in 555 men who had survived a first attack of myocardial infarction or unstable angina. Patients were aged less than 60 and were followed up yearly for up to 17 years. Only 25 (4.5%) had coronary artery bypass surgery. Most patients with angina were treated by nitrates alone. One year after infarction 24.1% of survivors (124/515) reported the presence of angina pectoris, and the proportions at five, 10, and 15 years were 29.9%, 30.4%, and 43.5% respectively. Seventeen years after the initial event 35.3% of the survivors had never reported postcoronary anginal symptoms. The patients who experienced anginal symptoms in the year after their coronary attack had a poorer long term survival than the group who were symptom free over the first year. These patients also had longer subsequent periods with angina, though in 41.7% angina resolved before death after a median of 2.9 years. Throughout follow up mortality during periods in which patients experienced angina was higher than in the symptom free periods. This long term follow up study of patients after a coronary event confirms that the presence or absence of angina may vary considerably over time in patients treated medically and that the presence of angina is associated with a poorer prognosis. These findings have important implications when assessing the effects of various treatment modalities on postcoronary angina, including coronary artery bypass surgery.     

Observations on Anticoagulant Therapy in Thromboembolic Disease of the Brain

According to a recently reported study, anticoagulant therapy appears to be ineffective in thrombotic cerebrovascular disease when viewed from the standpoint of mortality, although it does control thrombosis in animals, recurrent ischemic attacks and progression of infarction in patients with stuttering strokes. The efficacy of anticoagulant therapy in preventing a catastrophic stroke is analyzed in the present report. Of 92 untreated patients followed up for an average period of 36 months, 28 suffered a recurrent stroke, only two of these being trivial. One trivial and 12 catastrophic strokes occurred in the first 16 months. Of 103 patients treated with anticoagulants for an average period of 16 months, seven had recurrent strokes, but five of these were trivial. In the first 16 months one catastrophic and four trivial strokes occurred. Anticoagulant therapy appears to be useful in preventing catastrophic strokes in selected patients in whom the risk of recurrent strokes justifies the risks involved in this treatment.     

Striatal Infarction Elicits Secondary Extrafocal MRI Changes in Ipsilateral Substantia Nigra

Focal ischemia may induce pathological alterations in brain areas distant from the primary lesion. In animal models, exofocal neuron death in the ipsilateral midbrain has been described after occlusion of the middle cerebral artery (MCA). Using sequential magnetic resonance imaging (T2- and diffusion-weighted) at 3 Tesla, we investigated acute ischemic stroke patients on days 1, 2, 6, 8, and 10 after stroke onset. Sixteen consecutive patients who had suffered a stroke involving the caudate nucleus and/or putamen of either hemisphere were recruited into the study. Four additional patients with strokes sparing the caudate nucleus and putamen but encompassing at least one-third of the MCA territory served as controls. Ischemic lesions involving striatal structures resulted in hyperintense lesions in ipsilateral midbrain that emerged between days 6 and 10 after stroke and were not present on the initial scans. In contrast, none of the control stroke patients developed secondary midbrain lesions. Hyperintense lesions in the pyramidal tract or the brain stem caused by degeneration of the corticospinal tract could be clearly distinguished from these secondary midbrain gray matter lesions and were detectable from day 2 after ischemia. Co-registration of high-resolution images with a digitized anatomic atlas revealed localization of secondary lesions primarily in the substantia nigra pars compacta. Apparent diffusion coefficient (ADC) values in the secondary lesions showed a delayed sharp decline through day 10. Normalization of ADC values was observed at late measurements. Taken together, our study demonstrates that striatal infarction elicits delayed degenerative changes in ipsilateral substantia nigra pars compacta.     

SIGNIFICANCE OF ANGIOGRAPHIC ABSENCE OF LEFT ANTERIOR DESCENDING CORONARY ARTERY IN A LEFT VENTRICLE WITH INTACT ANTERIOR WALL

Fifteen patients having total occlusion of the proximal left anterior descending coronary artery were studied. All fifteen had normal left ventricular anterior walls. The electrocardiogram was normal in eight patients; old inferior wall infarction was evident in one; anterior ischemia in five; and left anterior hemiblock in one. Collateral circulation was found in twelve patients (80%). These findings suggest that an angiographically non-visualized left anterior descending (LAD) vessel is patent and bypassable in patients where the anterior ventricular wall is intact, thus representing an additional criterion for aortocoronary bypass surgery.     

Transient impaired glucose tolerance in Pima Indians: is it important?

As part of a continuing epidemiological study of non-insulin dependent diabetes among Pima Indians 154 subjects who had had a transient impairment of glucose tolerance were followed up for 1.2-16.9 (median 5.8) years after their glucose tolerance had returned to normal. Of these, 49 subsequently developed diabetes; 26 subsequently developed impaired glucose tolerance; and 79 had normal glucose tolerance at the last examination. The cumulative incidence of diabetes was 16% and 48% at five and 10 years of follow up respectively, compared with 3% and 8% for a control group of 1245 members of the same population. After adjustment for age, sex, body mass index, and plasma glucose concentration two hours after glucose loading the incidence of diabetes among the subjects who had had transient impaired glucose tolerance was 3.0 times that among the controls (95% confidence interval 2.1 to 4.3). Proportional hazards function analysis indicated that obesity was the most important predictor of subsequent development of diabetes. The results suggest that transient impairment of glucose tolerance indicates, at least in some subjects, a predisposition to diabetes and should not be considered clinically unimportant.     

Complications of ileal conduit diversion in adults with cancer followed up for at least five years.

A total of 111 adults with malignant disease of the bladder were studied to determine the long term complications of ileal conduit diversion. Each patient had survived at least five years (mean 10 years) after cystectomy. At final follow up the radiological appearance of one or both kidneys had deteriorated in 50 (47%) of 107 patients: deterioration worsened significantly (p less than 0.01) with increasing duration of follow up. Eighteen patients (16%) developed biochemical evidence of impaired renal function, of whom four died of complications of renal failure. Bilateral upper tract dilatation was noted in 30 patients (28%), and in 21 its cause was obscure. Ten patients formed renal stones, and an additional 12 required further operations on the conduit or stoma. Despite the age of patients with bladder cancer and the poor prognosis of those with invasive tumours clinically important side effects were observed in a significant proportion of the long term survivors. Further efforts to determine the aetiology of upper tract dilatation in patients with an ileal conduit diversion are justified.     

Surgical Treatment of Mitral Insufficiency

Sixty-four patients with pure mitral insufficiency were operated upon. Thirty of them had torn chordae tendineae. It was possible to repair the mitral valve in 57 patients and there were five operative deaths. One patient had a femoral artery embolus and another had a cerebral embolus. The incidence of peripheral embolization was 4 per cent compared with 40 per cent reported for ball valve replacement.Forty-eight of the 57 patients with repair (84 per cent) were living and well with at most a grade II/VI apical systolic murmur up to seven and a half years after operation. There has been no evidence of recurrence in these patients.In approximately 90 per cent of patients with pure mitral insufficiency, repair should be performed. When feasible, repair is more satisfactory than valvular replacement, with not only excellent long-term results, but far less morbidity than is reported with ball valve replacement.