Biomedical subjects

P Luxereau

Publications and source records attributed to P Luxereau.

At least 19 recordsLinked to original sources

PubMed2000

[Valvular stenosis: treatment by percutaneous dilatation].

For more than a decade, cardiologists have now used procedures for treating valvular stenosis. The most widely used, percutaneous mitral commissurotomy, is performed through the transseptal pathway, usually with the Inoue balloon. Subsequently, the valvular surface doubles and the incidence of serious complications is low in experienced teams. Evaluation of ten years of experience shows that long-term results are good if the dilatation was efficient immediately. In the other cases, surgery must be performed. Percutaneous mitral commissurotomy is the preferred solution in young patients with good valvular anatomy; in others, its indication should be discussed on a case-by-case basis. It is contraindicated in the presence of thrombosis of the left auricle or severe valvular calcification. The results of aortic valvuloplasty for calcified stenosis in the elderly subject are poor, with elevated mortality and morbidity. Valvuloplasty little affects the natural history of a tight aortic stenosis but can offer transitory functional improvement for several months. Its indications are rare.

Adult↗

PubMed2000

Late results of percutaneous mitral commissurotomy for calcific mitral stenosis.

The aim of this study was to assess late results of percutaneous mitral commissurotomy (PMC) in calcific mitral stenosis and to identify predictors to improve patient selection. We analyzed 422 patients who underwent PMC for calcific mitral stenosis. The extent of calcium was graded from 1 to 4 by fluoroscopy: 227 patients (53%) were graded 1, 125 (30%) graded 2, 55 graded 3 (13%), and 15 graded 4 (4%). The procedure failed in 15 patients, used a single balloon in 11, a double balloon in 126, and the Inoue balloon in 270. In-hospital mortality was 1.2%. Good immediate results (valve area >/=1.5 cm(2) without mitral regurgitation >2/4), were obtained in 321 patients (76%). Multivariate analysis identified 5 predictors of good immediate results: a younger age (p = 0.0004), a lesser degree of stenosis (p = 0.0005), a smaller extent of calcium (p = 0.04), the use of the Inoue balloon (p = 0.015), and a larger effective balloon dilating area (p = 0.006). Good functional results, defined as survival with no further intervention and in New York Heart Association class I or II, were 36 +/- 4% at 8 years. The predictors of good functional results after good immediate results were a younger age (p = 0.04), a lower pre-PMC New York Heart Association class (p <0.0001), sinus rhythm (p = 0.0006), a smaller extent of calcium (p = 0.02), and a lower gradient after PMC (p <0.0001). Despite a frequent deterioration on follow-up after PMC for calcific mitral stenosis, the predictive analysis suggests that PMC may be useful in deferring surgery in selected patients with mild to moderate calcific deposits, who have otherwise favorable characteristics.

Aged↗

PubMed2000

Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy: late efficacy and implications for patient selection.

OBJECTIVES: The results of percutaneous mitral commissurotomy were assessed in patients with restenosis after surgical commissurotomy. BACKGROUND: Balloon dilation is feasible in patients with restenosis after surgical commissurotomy, but little is known about its late efficacy. METHODS: We studied 232 patients who had undergone percutaneous mitral commissurotomy a mean of 16 +/- 8 years after surgical commissurotomy. Mean age was 47 +/- 14 years; 81 patients (35%) had valve calcification. All patients had restenosis with bilateral commissural fusion as assessed by echocardiography. Technical failure occurred in 9 patients and the procedure used a single balloon in 7 patients, a double balloon in 95, and the Inoue balloon in 121. RESULTS: Complications were death in 1 patient (0.4%) and mitral regurgitation >2/4 in 10 (4%); 191 patients (82%) had good immediate results (valve area > or =1.5 cm2 without regurgitation >2/4). Predictors of poor immediate results in multivariate analysis were older age (p < 0.001), lower initial valve area (p = 0.01) and the use of the double-balloon technique (p = 0.015). In the 175 patients who underwent follow-up, 8-year survival without operation and in New York Heart Association class I or II was 48 +/- 5%, and 58 +/- 6% after good immediate results. In this latter group, poor late functional results were predicted by higher cardiothoracic index (p < 0.0001), previous open-heart commissurotomy (p = 0.05) and lower final valve area (p < 0.0001) in a multivariate Cox model. CONCLUSIONS: Percutaneous mitral commissurotomy is safe and provides good immediate results in selected patients with restenosis after surgical commissurotomy. After good immediate results, the conditions of more than half of the patients remained improved at 8 years, enabling reoperation to be deferred.

Adult↗

PubMed1999

Percutaneous mitral valve dilatation with the Multi-Track System.

We developed the Multi-Track System for percutaneous mitral valvotomy and described the preliminary results in 1995. Here we report the first 100 consecutive cases after the original publication. Two separate balloon catheters are positioned on a single guidewire. The first catheter, with only a distal guidewire lumen, is introduced into the vein and then advanced into the mitral orifice. Subsequently, a rapid exchange balloon catheter running on the same guidewire is inserted and lined up with the first catheter so the two are positioned side by side. Both balloons are then inflated simultaneously. Age of the patients was 31 +/- 12.8 years and weight 50 +/- 14 kg. Valve area increased 0.75 +/- 0.22 cm(2) to 2.00 +/- 0.32 cm(2)and mean left atrial pressure dropped from 27 +/- 8 to 11 +/- 5 mm Hg. One patient had significant mitral insufficiency after dilatation, which did not require surgery. The Multi-Track System is a valid alternative to the existing procedures for the treatment of mitral stenosis and uses simpler and less costly catheters. Cathet. Cardiovasc. Intervent. 48:178-183, 1999.

Adolescent↗

PubMed1997

[Conservative surgery in rheumatic aortic insufficiency].

The mechanism of rheumatic aortic regurgitation is retraction of the three cusps leading to lack of coaptation. The authors describe a technique of aortic valve repair by extension of the cusps using autologous pericardium, undertaken in 52 patients (mean age 21 +/- 5 years) and report the short and medium term results. There were no operative deaths or reoperation for technical failure. The postoperative echocardiographic examinations showed absent or minimal aortic regurgitation in 45 patients (87%) and moderate regurgitation in 7 patients (13%). The echocardiographic results at 2 years were stable: no patient was reoperated for deterioration of the valvuloplasty. This technique is reproducible and reliable is selected patients.

Adolescent↗

PubMed1996

How to manage patients with severe left ventricular dysfunction and valvular regurgitation.

BACKGROUND AND AIMS OF THE STUDY: The purpose of this study is to analyze treatment options for valvular regurgitation with severe left ventricular dysfunction. MATERIAL AND METHODS: Results of valvular surgery in 98 patients with mitral or aortic regurgitation and severe systolic left ventricular dysfunction (LVD) were analyzed. Selection criteria were the absence of significant coronary heart disease and a resting ejection fraction (EF) < 40% for aortic and < 50% for mitral regurgitation. RESULTS: In patients with aortic regurgitation (n = 46) operative mortality was higher but not significantly so than in a control group of 238 cases (6.5% vs. 3.4%). The actuarial survival rates at five and 10 years were 84% and 55% vs. 84% and 67%, respectively. Independent preoperative predictors of severe postoperative LVD were rheumatic etiology and increased left ventricular end-systolic diameter. In patients with mitral regurgitation (n = 52), operative mortality was not significantly different from that of a control group of 273 cases (3.8% vs. 2.6%), whether the surgical procedure was valve replacement or valve repair. Perioperative morbidity was frequent (30% of cases), mainly low cardiac output, after valve replacement. The actuarial survival rates at eight years were respectively for the groups with and without LVD: 81% and 89% after valve repair, 60% and 75% after valve replacement. Independent predictors of severe postoperative LVD were increased left ventricular end-systolic volume and the type of surgery. Better results were observed after valve repair. CONCLUSIONS: It is concluded that a low EF is not a predictive factor of operative mortality but it influences late survival as do the degree of left ventricular dilatation, etiology in aortic and type of surgery in mitral regurgitation. Alternatives to valvular surgery have been envisaged but information on vasodilators in these patients is scant and results of heart transplantation are known only from a few small series.

Adult↗

PubMed1992

Ventricular arrhythmias in aortic valve disease before and after surgery.

In order to evaluate the incidence and prognostic value of ventricular arrhythmias in patients with aortic valve disease, 24 hour ambulatory electrocardiographic recordings were obtained in 374 patients without coronary artery disease (aortic stenosis n = 194, aortic regurgitation n = 103, combined aortic stenosis and regurgitation n = 77). Following aortic valve replacement, repeat recordings were obtained in a subgroup of 96 patients at 13 +/- 4 days and 18 +/- 7 months. Ventricular arrhythmias were classified in all cases according to Lown and were compared with clinical, echocardiographic and hemodynamic data. Preoperatively, ventricular premature beats were observed in 329 patients (88%), and were found to be frequent (>30 ventricular premature beats/hour) in 83 (22%). Multiformity was found in 105 (28%), couplets in 75 (20%) and ventricular tachycardia in 45 (12%). The occurrence of ventricular arrhythmias was not related to the type or severity of the valve lesions. Patients with severe ventricular arrhythmias (Lown class 3 or 4: 36.5%) had a higher ventricular wall thickness (interventricular septum thickness 14.2 +/- 1.8 mm vs. 11.9 +/- 2.0 mm, p < 0.01, a higher LV mass (178 +/- 32 g/m2 vs. 142 +/- 35 g/m2, p < 0.001) and a lower left ventricular ejection fraction (48% +/- 9% vs. 56.5% +/- 10%, p < 0.001); while in patients with aortic regurgitation a higher end-diastolic LV volume (224 +/- 38 ml/m2 vs. 178 +/- 42 ml/m2, p < 0.02) and a higher end-systolic LV diameter (56 +/- 7 mm vs. 46 +/- 8 mm, p < 0.02) were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic Valve↗

PubMed1992

[Should mitral valve diseases, without or with few symptoms, be treated surgically?].

Our approach to the treatment of valvular heart disease, and mitral valve disease in particular, has been deeply modified by the experience acquired since the introduction of cardiac surgery and the technical advances in this field in the last decade and by new methods of investigative and interventional cardiology. In pure severe mitral regurgitation alone, the treatment of choice is reconstructive surgery. In the experience of our group, 191 patients out of 342 operated since 1970 for this type of valve lesion were referred for reconstructive surgery. Taking the results into consideration (72% 15 year survival), it is now justified to refer patients at a stage when the valvular disease is asymptomatic or pauci-symptomatic. A certain number of factors has to be assessed to evaluate the surgical indication: the experience of the surgical team, the etiology of the mitral regurgitation, the type of anatomical lesion, the stage of the cardiac disease and the patient's age. In mitral stenosis, in preference to surgical commissurotomy, percutaneous mitral valvuloplasty may be proposed in certain asymptomatic or pauci-symptomatic patients if the stenosis is severe, if the anatomical lesions are optimal and if there is a hemodynamic (pregnancy) or thromboembolic risk (arrhythmias, spontaneous contrast on transoesophageal echocardiography). In mixed mitral valve disease or very calcific stenoses, analysis of long-term results of valve replacement indicates that the late prognosis depends more on the stage of the cardiac disease at the time of surgery than on the type of prosthesis. It is advisable not to wait until an advanced stage before operating these patients when the valvular dysfunction is severe and there are hemodynamic consequences.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1992

Ventricular arrhythmias in aortic valve disease before and after aortic valve replacement.

In order to evaluate the effect of aortic valve replacement on the incidence of ventricular arrhythmias in patients with aortic valve disease, 24-hour ambulatory electrocardiographic recordings were obtained before surgery in 96 patients without coronary artery disease (aortic stenosis n = 50, combined aortic stenosis and regurgitation n = 19 and aortic regurgitation n = 27). Following aortic valve replacement, repeat recordings were obtained after 13 +/- 4 days and 18 +/- 7 months. Ventricular arrhythmias were in all cases classified according to Lown and were compared with clinical, echocardiographic and hemodynamic data. Preoperatively, ventricular premature beats were observed in 85 patients (89%) and were frequent (greater than 30 ventricular premature beats/hour) in 20 (21%). Multiformity was found in 27 (28%), couplets in 18 (19%) and ventricular tachycardia in 11 (11.5%). The occurrence of ventricular arrhythmias was not related to the type or severity of valve lesions. Patients with severe ventricular arrhythmias (Lown class 3 or 4: 37%) had a greater thickness of their interventricular septum 13.9 +/- 2.5 mm, vs 11.7 +/- 2.6 (p less than 0.05); a higher LV mass 176 +/- 34 g/m2, vs 134 +/- 39 (p less than 0.05) and a lower left ventricular ejection fraction 47 +/- 12%, vs 57 +/- 11, (p less than 0.01). Two weeks postoperatively, the incidence and severity of ventricular arrhythmias had increased: ventricular premature beats were noted in 92% and were severe in 50%. No correlation was found between ventricular arrhythmias and preoperative or operative data. Eighteen months after surgery, ventricular premature beats were still observed in 81% of patients but remained frequent in 7% only. Severe ventricular arrhythmias were noted in 27%. Patients with severe ventricular arrhythmias had at the time of this late recording a lower radionuclide left ventricular ejection fraction 57 +/- 14%, vs 73 +/- 9 (p less than 0.02) and a higher enddiastolic diameter 63 +/- 15 mm, vs 48 +/- 7, (p less than 0.01). This study indicates that ventricular arrhythmias are common in patients with aortic valve disease. The severity of arrhythmias is influenced by the LV consequences of valve lesion both pre- and late postoperatively. The frequency and severity of ventricular arrhythmias increase early after surgery and do not correlate with preoperative or operative data.

Adult↗

PubMed1992

[Etiologic course of heart valve diseases surgically treated during 20 years in France].

The aim of this study was to analyse the evolution of the aetiologies of operated valvular heart disease over a 20 year period and to assess the consequences. Two thousand five hundred and ninety eight patients who underwent conservative surgery or valve replacement were included. This population was classified according to the date of surgery into 4 groups, each corresponding to a 5 year period. Analysis of these results, especially in the groups operated between 1970 and 1974 and between 1985 and 1989 shows: 1) a change in aetiology: decreased incidence of rheumatic valvular disease (36 versus 61%) and an increased incidence of degenerative lesions (43 versus 23%) (p less than 0.0001); 2) a change in the valvular lesions operated, aortic stenosis has become the commonest operated condition (43 versus 27%) (less than 0.001); 3) an increased age (59 +/- 14 versus 49 +/- 13 years, p less than 0.0001) with a higher proportion of patients over 70 years of age (22 versus 1%, p less than 0.001); 4) a higher incidence of mixed coronary and valvular surgery (11 versus 2%, p less than 0.001).

Adult↗

PubMed1991

Aetiology of surgically treated mitral regurgitation.

The aetiologies of mitral regurgitation were reviewed in 336 patients operated on between 1970 and 1990. The relative frequency of rheumatic fever has decreased and the most common cause is now primary mitral valve prolapse (PMVP) which accounts for 60% of all patients. The increasing age of the surgical population seems to be one of the main factors of this change. Conservative surgical repair according to Carpentier's technique is now performed in 60% of all patients with mitral regurgitation and 80% of cases of PMVP. The aetiology of PMVP is still under discussion. Surgical description seems to indicate the existence of two different morphological aspects with significantly different rates and localizations of chordae ruptures, but our study failed to demonstrate any other anatomical, clinical or histological differences between the two groups.

Adult↗

PubMed1991

Long-term results of mitral valve repair for non-ischaemic mitral regurgitation.

One hundred and fifty-five patients with isolated mitral regurgitation were referred from our cardiology department for mitral valve repair between 1972 and 1990. Men were predominant (59%), mean age was 51 years, and 61% of the patients were in NYHA class III or IV. Degenerative aetiology was predominant (65%). Surgical repair was performed according to the Carpentier techniques. Two operative deaths occurred (1.3%). The survivors were followed-up for an average of 4 years, and the rates of survival and good functional results at 11.5 years, were respectively 84.5% and 64.5%. The linearized rates of endocarditis, thromboembolic events and re-operations were respectively 0.35%, 1.54% and 2.05% pt-yrs. Residual mitral regurgitation was looked for by clinical and Doppler examination: there was no regurgitation in 55.5% of patients, mild regurgitation was found in 26%, moderate in 10.3% and severe in 8.2%. Analysis of moderate and severe residual regurgitation identified three promoting factors: rheumatic origin of the regurgitation, surgery of the anterior leaflet and time of surgery (the incidence after surgery has been lower in recent years). Other 'less well known' complications were encountered: left ventricular outflow tract obstruction, progressive evolution towards mitral stenosis, appearance of aortic regurgitation and formation of left atrial thrombi. Despite these complications, we must stress the satisfactory results of the technique, in particular in mitral valve endocarditis; 22 patients were operated on for this reason, six during the acute phase of the disease, and no surgical death, or recurrence of endocarditis, and only one case of severe residual regurgitation was observed.

Adolescent↗

PubMed1991

Indications for surgery in mitral regurgitation.

Present day indications for surgery in mitral regurgitation have to take into account changes in aetiology, advances in pre-operative evaluation of mitral lesions, technical progress in mitral valve repair and better knowledge of pre-operative predictive factors of surgical results. The results of a series of 294 patients operated on between 1970 and 1990 show that surgery is advisable before patients reach Functional Class III or IV, and before they develop atrial fibrillation, an ejection fraction of under 0.55, or marked left ventricular and atrial enlargement. Surgical indications depend on two factors: the possibility of valve repair evaluated by transthoracic and transoesophageal echocardiography, and the experience of the surgical team in this kind of surgery. Valve repair is the best treatment in many patients, particularly those with degenerative valve lesions, poor ejection fraction, elderly people and some cases of infective endocarditis.

Aged↗

PubMed1991

[Long-term results of surgical valvuloplasty for non-ischemic mitral insufficiency. Apropos of 155 cases].

One hundred and fifty-five patients with isolated mitral regurgitation were referred from our Department of Cardiology for mitral valve repair between 1972 and 1990. Men were in the majority (59%), the mean age was 51 years and 61% of the patients were in NYHA class III or IV. Degenerative or dystrophic etiologies predominated, followed by rheumatic origins (17%) and bacterial endocarditis (14%). Surgical repair was performed using Carpentier's techniques: insertion of a prosthetic ring (87%) valvular resection (73%), valvular mobilization (11%), closure of a perforation (4,5%) and resection of vegetations (4,5%). Two patients died during surgery and 7 were lost to follow-up; the others were followed for an average of 4 years, i.e., a cumulative follow-up of 584 years/patients. The overall results at 11.5 years were satisfactory: 84.5% survival rate and 64.5% with good valvular function. The linearized rates of endocarditis, thromboemboli, hemorrhagic complications (51 patients were taking anticoagulants) and repeated interventions were, respectively: 0.35, 1.54, 0.17 and 2.05%/patient-year. Residual mitral regurgitation was sought by clinical and Doppler examinations: 55.5% of the patients had none, 26% had mild, 10.3% had moderate and 8.2% had severe regurgitation. Analysis of the latter two groups identified 3 influencing factors: rheumatic origin of the regurgitation, surgery on the anterior cusp and the year surgery was performed (the post-surgical incidence has decreased in recent years). Other, less-well-known complications were also found: left ventricular outflow tract obstruction, progressive evolution towards mitral stenosis, development of aortic regurgitation (usually discreet) and formation of left atrial thrombi.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗

PubMed1991

[Cardiomyocyte in valvular cardiopathies. Comparative morphometry of myofibrils and mitochondria. Functional correlations].

Twenty-four endomyocardial biopsies performed during surgical correction of valvulopathies were compared with ventricular function. Patients were divided into three groups: group I without anomalies of ventricular function, group II with a slight decrease of the ventricular ejection fraction, group III with a low ventricular ejection fraction. Morphometric analysis was carried out using electron microscopic photographs and an image analyser. The results were correlated with those of functional studies. In patients of the second group, the small number of mitochondria with respect to the increased myofibrillary area seemed to indicate mitochondrial dysfunction. In patients of the third group, alterations of myocontractility expressed a myofibrillary deficiency unable to be corrected by the multiplication and the increased exchange areas of mitochondria.

Heart Valve Diseases↗

PubMed1988

Prognosis and long-term results of surgically treated aortic stenosis.

A total of 675 patients (mean age 60 +/- 11 years, range 22-85, 71% males) with calcified pure aortic stenosis (490) or mixed lesions (185) had an aortic prosthesis: 290 Starr-Edwards, 147 Bjork, 18 other mechanical valves, 163 pericardial xenografts, 57 porcine xenografts; 76 patients simultaneously underwent a coronary bypass, 12 a replacement of ascending aorta, and six a mitral valvuloplasty. Preoperatively, 67% were in functional class III or IV (NYHA); 69.5% had a coronary arteriography: significant coronary stenosis was observed in 27% of patients. The operative mortality was 6.8% depending on the functional class at surgery, age (4.9% before 70 years, vs. 12.5% after), and the date of surgery (8.1% before 1983 vs. 3.7% after). The 10- and 15-year actuarial survival rates were 62 +/- 3% and 44 +/- 4%, respectively. No significant differences were observed between patients with pure aortic stenosis and mixed aortic lesions. In patients over 70 years, the survival rates were 71 +/- 5% at five years and 51 +/- 10% at 10 years. Age, functional class, degree of congestive heart failure, and degree of cardiomegaly were the main preoperative predictors of late death. At 10 years, 88% of patients were free from myocardial dysfunction, 87% from thromboembolic events, and 89% from haemorrhages. We conclude that in this type of valvulopathy, short- and long-term surgical results are good despite the fact that most patients are elderly and in an advanced functional class.

Adult↗

PubMed1988

Treatment of calcified aortic stenosis: surgery or percutaneous transluminal aortic valvuloplasty?

A total of 546 patients with severe aortic stenosis (AS) were retrospectively reviewed to assess the efficacy of percutaneous transluminal valvuloplasty (PTV) and valve replacement (VR). Of these, 490 underwent VR between 1968 and 1986 (mean age 62 +/- 12 years, 71.7% were in NYHA class III or IV), 68.8% received mechanical prostheses, and in 11.8% a bypass graft was associated. The operative mortality was 6.9% (4% since 1983). The mean follow-up was 57.6 months. The actuarial survival rate was 77% at five years, 60% at 10 years, and 40% at 15 years. Over 70 years of age, operative mortality was 6.2% since 1983, and the actuarial survival rate was 67.5% at five years. From February 1986 to May 1987, PTV was attempted in 56 patients and was effective in 52 patients (mean age 79 +/- 5 years, 93% in Class III or IV). Immediate mortality was 7.1%. The morbidity was due to tamponade (1.8%), myocardial infarction (3.6%), vascular trauma (5.3%), or cerebrovascular accident (9%). Forty three patients were followed after PTV (mean value 4.2 +/- 3, range 1-14 months): 12 patients (28%) died and 46% were functionally improved in NYHA Class II. PTV significantly improved the aortic valve area as shown by haemodynamics (0.49-0.75 cm2; P less than 0.0001) and these findings were corroborated by Doppler study (0.46-0.70 cm2, P less than 0.001). In conclusion, this series shows that surgery provides satisfactory results in AS with a low mortality and good long-term results, even in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed1988

[Predictive factors of coronary lesions in aortic stenosis in adults].

The frequent coexistence in adults of a tight aortic stenosis and coronary arterial lesions raises problems of therapeutic and diagnostic approach. In an attempt at selecting indications for coronary arteriography, we studied 253 patients with severe aortic stenosis who were explored by that method. 177 patients (70 p. 100) had no coronary disease (group I); 76 patients (30 p. 100) had significant coronary lesions (group II). Group II patients differed from group I patients in several respects: they were older: 65 +/- 9 years on average as against 61 +/- 9 years (p less than 0.01); there was a greater proportion of men in that group: 76 p. 100 vs 58 p. 100 (p less than 0.01); more patients had a history of myocardial infarction: 7 p. 100 vs 0.5 p. 100 (p less than 0.05); calcifications of the coronary arteries were found in 43 p. 100 of the cases as against 15 p. 100 in group I (p less than 0.001); the transvalvular pressure gradient was lower: 50 +/- 30 mmHg vs 72 +/- 31 mmHg (p less than 0.01). There were no other significant differences in risk factors between the two groups, except for overweight which was greater in group II. Attacks of angina were not statistically more frequent in group II (80 p. 100) than in group I (73 p. 100, N.S.). A multifactorial analysis enabled us to establish a discriminant relation involving the patient's age, sex and history of infarction as well as coronary calcifications.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗