Retrograde nontransseptal balloon mitral valvuloplasty: immediate results and intermediate long-term outcome in 441 cases--a multicenter experience

OBJECTIVES: Our aim was to present the immediate and intermediate long-term results of the application of retrograde nontransseptal balloon mitral valvuloplasty (RNBMV) in four cooperating centers from Greece and India. BACKGROUND: RNBMV is a purely transarterial method of balloon valvuloplasty, developed with the aim to avoid complications associated with transseptal catheterization. Only single-center experience with RNBMV has been previously reported. METHODS: The procedure was attempted in 441 patients with symptomatic mitral stenosis (320 women, 121 men, mean age [+/-SD] 44+/-11 years, mean echocardiographic score [+/-SD] 7.7+/-2.0) from 1988 to 1996. Three hundred eighty-five patients with successful immediate outcome were followed clinically for a mean [+/-SD] of 3.5+/-1.9 (range, 0.5-9.1) years. RESULTS: A technically successful procedure was achieved in 388 (88%) cases. The echocardiographic score (p < 0.001), male gender (p=0.005), preprocedural mitral regurgitation (p=0.007) and previous surgical commissurotomy (p=0.029) were unfavorable predictors of immediate outcome. Complications included death (0.2%), severe mitral regurgitation (3.4%) and injury of the femoral artery (1.1%). Event-free (freedom from cardiac death, mitral valve surgery, repeat valvuloplasty and NYHA class > II symptoms) survival rates (+/-SEM) were 100%, 96.9+/-0.9%, 89.8+/-1.9% and 75.5+/-5.5% at 1, 2, 4 and 9 years, respectively. The echocardiographic score (p < 0.001), NYHA class (p=0.008) and postprocedural mitral valve area (p=0.009) were significant independent predictors of intermediate long-term outcome. CONCLUSIONS: Multicenter experience indicates that RNBMV is a safe and effective technique for the treatment of symptomatic mitral stenosis. As with the transseptal approach, patients with favorable mitral valve anatomy derive the greatest immediate and intermediate long-term benefit from this procedure.     

Zinc dependent activation of cAMP-specific phosphodiesterase (PDE4A)

OBJECTIVES: This study was undertaken to determine whether the presence of calcium in the mitral valve commissures, as demonstrated echocardiographically, could predict outcome and to compare this with an established echocardiographic scoring system. BACKGROUND: Percutaneous mitral balloon valvotomy is an effective form of treatment for mitral valve stenosis. It is important to identify patients who would benefit from this procedure. Commissural splitting is the dominant mechanism by which mitral valve stenosis is relieved by this technique, and thus commissural morphology may predict outcome. METHODS: One hundred forty-nine consecutive patients who underwent percutaneous mitral balloon valvotomy at the Mayo Clinic were evaluated retrospectively. The morphology of the mitral valve apparatus on the baseline echocardiograms was scored in blinded manner using a semiquantitative grading system of leaflet thickening, mobility, calcification and subvalvular thickening (Abascal score). Additionally, each of the medial and lateral commissures was graded for the presence or absence of calcification. End points were death, New York Heart Association functional class, repeat percutaneous mitral balloon valvotomy and mitral valve replacement at follow-up. RESULTS: The mean follow-up period was 1.8 years (maximum 7.9 years). Univariate predictors of death and all events combined included age, the use of a double-balloon technique, the presence of calcium in a commissure and the Abascal score, as continuous variables. Patients with an Abascal score < or = 8 showed a trend toward improved survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (78 +/- 6% vs. 67 +/- 8%, p = 0.07) and free of all events combined (75 +/- 6% vs. 64 +/- 8%, p = 0.07) versus those patients with a score > 8. However, survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (86 +/- 4% vs. 40 +/- 4%) and free of all events combined (82 +/- 5% vs. 38 +/- 10%) at follow-up was significantly different between patients without commissural calcium and those with commissural calcium (p < 0.001). In a Cox regression model with Abascal score and commissural calcium and their interaction, calcification emerged as the only significant variable (p < 0.01). CONCLUSIONS: The presence of commissural calcium is a strong predictor of outcome after percutaneous mitral balloon valvotomy. Patients with evidence of calcium in a commissure have a lower survival rate and a higher incidence of mitral valve replacement and all end points combined. Thus, the simple presence or absence of commissural calcification assessed by two-dimensional echocardiography can be used to predict outcome.     

Treatment of severe mitral stenosis with percutaneous balloon valvotomy in pregnant patients

BACKGROUND: Pregnancy can cause life-threatening complications in women with mitral stenosis. Frequently, there is an urgent need to increase the mitral valve area mechanically. In selected cases, percutaneous mitral balloon valvotomy (PMBV) has emerged as a safe and effective alternative to surgical commissurotomy. HYPOTHESIS: The study evaluates the effects of PMBV by the Inoue technique in nine pregnant patients with severe symptomatic mitral stenosis. METHODS: The patients were in New York Heart Association (NYHA) functional class II to IV and had echocardiographic scores of < or = 8. The mean gestational age was 24.8 +/- 6.1 weeks. The patient's pelvic and abdominal regions were covered with a lead apron to protect the fetus from radiation. A stepwise dilatation technique was used. Fluoroscopy time was kept to 10 to 15 min. RESULTS: One patient developed severe mitral regurgitation requiring emergency valve replacement. The remaining eight patients showed marked immediate symptomatic and hemodynamic improvement. After dilatation, the transmitral pressure gradient decreased from 20.8 +/- 6.5 to 7.3 +/- 1.4 mmHg (p = 0.001) and the calculated mitral valve area increased from 0.9 +/- 0.1 to 1.8 +/- 0.4 (p < 0.001). All patients had uneventful term deliveries of normal babies. On follow-up they were in NYHA functional class I. CONCLUSIONS: Percutaneous mitral balloon valvotomy is a safe and effective procedure for selected pregnant patients with severe mitral stenosis. The procedure is well tolerated by the fetus. Severe mitral regurgitation requiring immediate surgery may occur occasionally. The possible harmful effects to the fetus from its exposure to radiation during PMBV are unknown.     

Percutaneous balloon valvuloplasty in mitral restenosis after previous surgical commissurotomy

OBJECTIVES: The aim of this study was to determine the safety profile, mitral valve outcome and follow-up functional status after percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral restenosis post-surgical commissurotomy. METHODS: Sixteen patients with symptomatic mitral restenosis after previous surgical commissurotomy underwent valvuloplasty using the Inoue balloon stepwise dilatation method. Echocardiography was performed before and after the procedure to evaluate the mitral valve area. RESULTS: All procedures were successfully completed without cardiac perforation, thromboembolism, resultant severe mitral regurgitation or death. The mitral valve area improved from 0.9 +/- 0.2 to 1.6 +/- 0.3 (p = 0.0001), accompanied by a significant immediate reduction in the left atrial pressure and transmitral gradient. Compared with PBMV in patients without past mitral surgery, patients with mitral restenosis undergoing PBMV experienced less valve area improvement but the difference was not significant (p = 0.137). Optimal valve enlargement resulting in mild mitral stenosis was achieved in 12 of the 16 patients. Midterm symptomatic benefit was observed in almost all patients. CONCLUSIONS: In view of the excellent success rate, low complication risk, the optimal haemodynamic results and favourable functional outcome afforded by mitral balloon valvuloplasty in patients with mitral restenosis after prior surgical commissurotomy, it is logical that balloon mitral valvuloplasty, where available, should be the initial treatment modality in this group of patients with suitable valve morphology before considering repeat mitral surgery.     

Predictors of systemic embolism in patients with mitral stenosis. A prospective study

BACKGROUND: Most studies of the predictors of systemic embolism in patients with mitral stenosis have been retrospective. OBJECTIVE: To prospectively study factors associated with systemic embolism in mitral stenosis. DESIGN: Prospective cohort study. SETTING: University-affiliated medical institution with 3000 beds. PATIENTS: 534 consecutive patients with a mitral valve area of 2.0 cm2 or less; 132 patients were in sinus rhythm, and 402 were in atrial fibrillation. MEASUREMENTS: Nine clinical and 10 echocardiographic variables were assessed for prediction of systemic embolism over a mean (+/- SD) follow-up of 36.9 +/- 22.5 months. Diagnosis of systemic embolism was based on symptoms and signs (sudden onset of peripheral arterial ischemic or neurologic manifestations without prodromes) and on findings on computed tomography, angiography, and surgery. RESULTS: For patients in sinus rhythm, age (relative risk [RR], 1.12 [95% CI, 1.04 to 1.21]), the presence of a left atrial thrombus (RR, 37.1 [CI, 2.82 to 487.8]), mitral valve area (RR, 16.9 [CI, 1.53 to 187.0]), and the presence of significant aortic regurgitation (RR, 22.4 [CI, 2.72 to 184.8]) were positively associated with embolism. For patients in atrial fibrillation, previous embolism (RR, 3.11 [CI, 1.66 to 5.85]) was positively associated with embolism; percutaneous balloon mitral commissurotomy (RR, 0.37 [CI, 0.18 to 0.79]) was a negative predictor. CONCLUSIONS: It may be prudent to give anticoagulants not only to patients in atrial fibrillation and patients with previous systemic embolism but also to those showing a left atrial thrombus or significant aortic regurgitation on echocardiography. Early percutaneous balloon mitral commissurotomy may also help prevent systemic embolism in patients with mitral stenosis.     

Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures

OBJECTIVE: This study was carried out to evaluate the long-term results of mitral valve repair for mitral regurgitation caused by myxomatous disease of the mitral valve and the late effects of chordal replacement with expanded polytetrafluoroethylene sutures in this operation. METHODS: A total of 324 patients with mitral regurgitation caused by myxomatous disease underwent mitral valve repair from 1981 to 1995; the group comprised 241 men and 83 women whose mean age was 58 +/- 14 years. Chordal replacement with expanded polytetrafluoroethylene sutures has been performed in 165 patients since 1985. Most of the patients who had chordal replacement with expanded polytetrafluoroethylene sutures had prolapse of the anterior leaflet or prolapse of both leaflets, whereas most patients who had mitral valve repair without chordal replacement had prolapse of the posterior leaflet. Patients were followed up at annual intervals and had a Doppler echocardiographic study. The follow-up was complete and extended from 6 to 156 months (mean 36 +/- 30 months). RESULTS: Two operative and 21 late deaths occurred (14 cardiac and 7 noncardiac). At 10 years the actuarial survival was 75% +/- 5%, the freedom from stroke was 94% +/- 2%, the freedom from transient ischemic attacks was 92% +/- 4%, the freedom from endocarditis was 99% +/- 1%, the freedom from mitral valve reoperation was 96% +/- 1%, and the freedom from severe mitral regurgitation was 93% +/- 3%. Chordal replacement with expanded polytetrafluoroethylene sutures had no effect on any of these end points. CONCLUSIONS: Mitral valve repair was feasible in most patients with mitral regurgitation caused by myxomatous disease and it was associated with low rates of valve-related complications. Chordal replacement with expanded polytetrafluoroethylene had no adverse effect on the late outcome and was believed to have increased the probability of mitral valve repair.     

Long-term follow-up of open commissurotomy versus bileaflet valve replacement for rheumatic mitral stenosis

OBJECTIVE: Despite the achievements of third generation mechanical cardiac valve prostheses, conservative procedures are still considered the best surgical option for rheumatic mitral valve stenosis. To compare long-term results of open mitral commissurotomy (Group A) and mitral valve replacement with bileaflet prostheses (Group B) a 15-year follow-up study was carried out. METHODS: From January 1981 to May 1996, 540 consecutive patients with pure isolated rheumatic mitral stenosis underwent mitral valve surgery: 300 had mitral commissurotomy and 240 valve replacement. The follow-up was 99.05% complete and ranged between 1 and 185 months in Group A and from 1 to 171 months in Group B. RESULTS: Hospital mortality was 2% in Group A and 2.08% in Group B. Late mortality was 1% in Group A and 3% in Group B. The 10-year survival rates were 98.7% +/- 1% in Group A and 93.7% +/- 3% in Group B. There was a statistically significant difference of freedom from reoperation in Group B (97.7% +/- 1%) versus Group A (88.1% +/- 2%) (P = 0.04). In group A 14 embolic events occurred (93.7% +/- 2%), and 15 (6.52%) in Group B (83.9% +/- 7%). Haemorrhagic events were observed in 2 patients (0.68%) of Group A (99.3% +/- 0.5%) and in 3 patients (1.3%) of Group B (98.4% +/- 1%). CONCLUSIONS: Long term results of mitral commissurotomy were more satisfactory than those obtained with bileaflet valves. Reoperation rate was higher in mitral commissurotomy.     

The medtronic intact porcine valve: ten-year clinical review

OBJECTIVE: Our objective was to assess the long-term mortality and morbidity associated with the Medtronic Intact valve (Medtronic, Inc, Minneapolis, Minn). METHOD: Between 1983 and 1996, 447 patients (280 men and 167 women) received 466 Intact valves: 280 aortic, 156 mitral, and 30 tricuspid. The mean age was 57 years (median 63 years), with 45% younger than 60 years. The mean New York Heart Association class was 3.1. The follow-up was 98% complete and extended for 39 months (1-154 months) and 1324 patient-years. There were 32 valves at risk at 10 years after implantation. Doppler echocardiography was performed whenever possible in patients followed up for longer than 4 years (mean 8 years) after implantation. RESULTS: Ten-year overall actuarial survival was 30% +/- 6% (14% +/- 7% for New York Heart Association classes IV-V and 39% +/- 8% for classes I-III). At 10 years freedom from infective endocarditis was 92% +/- 3%, freedom from thromboembolism was 80% +/- 5%, and freedom from nonstructural valve deterioration was 95% +/- 2%. Ten-year freedom from explantation was 64% +/- 6%, freedom from valve-related events was 51% +/- 6%, and freedom from valve-related death was 88% +/- 3%. There were 26 examples of structural valve deterioration, mainly caused by leaflet calcification (in 17 cases) and by buttress detachment (in 6 cases). In the aortic position at 10 years freedom from structural valve deterioration was 81% +/- 9%, but with only 1 event in patients older than 40 years (freedom 92% +/- 8%) and 100% freedom in patients older than 60 years. There was also 100% freedom from structural valve deterioration in the tricuspid position. In the mitral position freedom was 65% +/- 8%, with no significant difference between age groups. CONCLUSION: The Intact valve provides superior results in the aortic position in patients older than 40 years and in the tricuspid position at all ages.     

Prognosis of patients after open mitral commissurotomy. Actuarial analysis of late results in 100 patients

The continuing controversy between proponents of open and closed commissurotomy might be clarified by analysis of late follow-up with modern actuarial techniques that provide a true perspective of patient risk. We have used open mitral commissurotomy exclusively for 15 years in 100 patients. There was one operative death from pancreatitis and one late death from cancer; the actuarially projected survival rate (+/- the standard error) at 10 years is 97 per cent (+/- 2). Thirteen patients had preoperative emboli, 6 of whom were in sinus rhythm and 7 in atrial fibrillation. Two patients had postoperative emboli, both in sinus rhythm. The actuarial chance of remaining free of embolism at 10 years is 97 per cent (+/- 2). Sixteen patients required reoperation on the mitral valve for functional deterioration. The remaining survivors were in Class I or II when last seen. The actuarial chance of not requiring a reoperation after 5 years is 91 per cent (+/- 4) and at 10 years, 38 per cent(+/- 16). Results in different centers are difficult to compare for many reasons, but imprecise statistical methods further obscure such comparisons. The use of actuarial techniques may help to define the role of open mitral commissurotomy.     

Late results of mitral valve repair for mitral regurgitation due to degenerative disease

From June 1981 to August 1992, 184 patients with mitral regurgitation due to degenerative disease underwent mitral valve repair. The mean age was 57 years, and 74% were men. One-third of the patients were in atrial fibrillation, and 71% were in New York Heart Association classes III and IV. The mitral regurgitation was due to prolapse of the posterior leaflet in 97 patients (53%), prolapse of the anterior leaflet in 42 (23%), and prolapse of both leaflets in 45 (24%). The degree of myxomatous changes was assessed intraoperatively as mild in 125 patients (68%), moderate in 27 (15%), and severe in 32 (17%). Mitral valve repair was accomplished largely by techniques described by Carpentier. Ring annuloplasty was performed in 160 patients (66 with Carpentier ring and 94 with Duran ring). There was one operative death, and 5 patients experienced life-threatening complications. Patients were followed up from 5 to 132 months (mean, 41 months). The actuarial survival at 8 years was 88% +/- 4%. The freedom from stroke at 8 years was 94% +/- 2%, and the freedom from transient ischemic attacks was 86% +/- 6%. Age greater than 60 years was the only factor associated with higher risk of thromboembolic complications by logistic regression analysis. The actuarial freedom from reoperation at 8 years was 95% +/- 2%. Advanced myxomatous changes in the leaflets of the mitral valve was the only significant factor associated with a higher risk of reoperation. Most patients were in New York Heart Association class I at the last follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)     

Three-year outcome after balloon aortic valvuloplasty. Insights into prognosis of valvular aortic stenosis

BACKGROUND: To identify predictors of long-term outcome after balloon aortic valvuloplasty, we analyzed data on 674 adults (mean age, 78 +/- 9 years; 56% were women) undergoing this procedure at 24 clinical centers who had a mean initial increase in aortic valve area of 0.3 cm2. METHODS AND RESULTS: Baseline data included clinical, echocardiographic, and catheterization variables. Follow-up data included mortality, cause of death, rehospitalization, 6-month echocardiography, and functional status. Kaplan-Meier curves and log-rank tests were used to evaluate survival in subgroups. Multivariate Cox regression models were used to identify independent predictors of survival. Overall survival was 55% at 1 year, 35% at 2 years, and 23% at 3 years, with the majority of deaths (70%) classified as cardiac by an independent review committee. Rehospitalization was common (64%), although 61% of survivors at 2 years reported improved symptoms. Echocardiography at 6 months (n = 115) showed restenosis from the postprocedural valve area of 0.78 +/- 0.31 cm2 to 0.65 +/- 0.25 cm2 (P < .0001). With stepwise multivariate analysis, sequentially adding clinical, echocardiographic, and catheterization variables, the overall model identified independent predictors of survival as baseline functional status, baseline cardiac output, renal function, cachexia, female gender, left ventricular systolic function, and mitral regurgitation. Baseline and postprocedural variables were examined to identify which subgroup of patients has the best outcome after aortic valvuloplasty. A "lower-risk" subgroup (28% of the study population), defined by normal left ventricular systolic function and mild clinical functional limitation, had a 3-year survival of 36% compared with 17% in the remainder of the study group. CONCLUSIONS: Long-term survival after balloon aortic valvuloplasty is poor with 1- and 3-year survival rates of 55% and 23%, respectively. Although survivors report fewer symptoms, early restenosis and recurrent hospitalization are common.     

Effects of percutaneous balloon mitral valvuloplasty and exercise training on the kinetics of recovery oxygen consumption after exercise in patients with mitral stenosis

AIMS: Kinetics of recovery oxygen consumption after exercise plays an important role in determining exercise capacity. This study was performed to assess the kinetics of recovery oxygen consumption in mitral stenosis and evaluate the effects of percutaneous balloon mitral valvuloplasty and exercise training on the kinetics. METHODS AND RESULTS: Thirty patients with mitral stenosis (valve area < or =1.0 cm2) and same sized age- and size-matched healthy volunteers were included for this study. All subjects performed maximal upright graded bicycle exercise. Thirty consecutive patients who underwent successful percutaneous balloon mitral valvuloplasty (valve area > or =1.5 cm2 and mitral regurgitation grade < or =2), were randomized to an exercise training group or non-training group. The exercise group performed daily exercise training for 3 months. Half-recovery time of peak oxygen consumption was significantly delayed in mitral stenosis as compared to normal subjects (120+/-42 s vs 59+/-5, P<0.01). Peak oxygen consumption (ml x min(-1) x kg(-1)) was significantly increased in both the training (16.8+/-4.9 to 25.3+/-6.9) and non-training groups (16.3+/-5.1 to 19.6+/-6.0) 3 months after percutaneous balloon mitral valvuloplasty. Half-recovery time of peak oxygen consumption was significantly shortened in the training group (124+/-39 to 76+/-13, P<0.01), but not in the non-training group (114+/-46 to 109+/-44 s, P=0.12) at 3 months follow-up. The degrees of symptomatic improvement after percutaneous balloon mitral valvuloplasty were more closely correlated with the changes of the half-recovery time of peak oxygen consumption than those of peak oxygen consumption. CONCLUSION: Kinetics of recovery oxygen consumption was markedly delayed in mitral stenosis, which was improved after exercise training but not after percutaneous balloon mitral valvuloplasty alone. These results suggest that adjunctive exercise training may be useful for improvement of recovery kinetics and subjective symptoms after percutaneous balloon mitral valvuloplasty.     

Intermediate-term outcome of mitral reconstruction in cardiomyopathy

OBJECTIVE: Severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy that contributes to heart failure and predicts a poor survival. We studied the intermediate-term outcome of mitral reconstruction in 48 patients who had cardiomyopathy with severe mitral regurgitation and were operated on between June 1993 and June 1997. METHODS: Ages ranged from 33 to 79 years (63 +/- 6 years) with left ventricular ejection fractions of 8% to 25% (16% +/- 3%). All patients were receiving maximal drug therapy and were in New York Heart Association class III-IV with severe, refractory 4+ mitral regurgitation. Operatively, all 48 had undersized flexible annuloplasty rings inserted, 7 had coronary bypass grafts for incidental disease, 11 had prior bypass grafts, and 11 also had tricuspid valve repair. RESULTS: One operative death occurred as a result of right ventricular failure. Postoperative transesophageal echocardiography revealed mild mitral regurgitation in 7 patients and no mitral regurgitation in 41. There were 10 late deaths, 2 to 47 months after mitral reconstruction. The 1- and 2-year actuarial survivals have been 82% and 71%. At a mean follow-up of 22 months, the number of hospitalizations for heart failure has decreased, and 1 patient has had heart transplantation. Significantly, New York Heart Association class improved from 3.9 +/- 0.3 before the operation to 2.0 +/- 0.6 after the operation. Twenty-four months after the operation, left ventricular volume and sphericity have decreased, whereas ejection fraction and cardiac output have increased. CONCLUSION: Whether this favorable modification of left ventricular function and geometry will persist remains unknown. However, mitral repair for cardiomyopathy with mitral regurgitation allows new strategies for these patients.     

Short and long term results of pulmonary balloon valvuloplasty in children

Percutaneous balloon valvuloplasty is an alternative to surgical valvotomy for congenital pulmonary valve stenosis. Between 1985 and 1997, 73 valvuloplasties were performed in 70 patients, age range 1 day to 24.7 years. We reviewed the short- and long-term results in regard to transvalvular gradient and pulmonary insufficiency. The gradient was measured pre- and immediately post-valvuloplasty at catheterization and by Doppler echocardiography, and by echocardiography only at follow-up. Valvuloplasty was successful in 61/70 patients whereas surgical valvotomy was necessary in 9/70 because of a very dysplastic valve. A second valvuloplasty was performed in 3 patients presenting with restenosis. A 60% decrease in the gradient was noted immediately after the procedure, from 78.3 +/- 24.5 to 33.7 +/- 19.7 mm Hg (p < 0.05). A follow-up of more than 2 years (4.2 +/- 2.2 years) was obtained in 35 patients. A further decrease in the gradient was noted, to 20 +/- 12 mm Hg, and the degree of pulmonary insufficiency was mild in all patients except 2 with a moderate leak. The mortality was 0% and only 1 patient had a complication (endocarditis). The short- and long-term results of pulmonary percutaneous balloon valvuloplasty are excellent. It can be considered the therapy of choice. The gradient shows a further decrease during follow-up due to regression of the infundibular muscular stenosis. Failure is attributed to very dysplastic valves and these patients may require, in a second stage, a surgical approach (patch enlargement and/or valvulectomy).     

Prediction of change in mitral valve area after mitral balloon commissurotomy using cine computed tomography

RATIONALE AND OBJECTIVES: Mitral balloon commissurotomy (MBC) can successfully increase the mitral valve area (MVA) in mitral stenosis, but the outcome is variable. In multicenter studies, qualitative echocardiographic scores obtained before MBC are only weakly predictive of the increase in MVA after MBC. METHODS: To evaluate whether the change in MVA after MBC can be predicted by evaluating mitral valve morphology using cine computed tomography (CT), we studied 12 women with mitral stenosis and 11 female control subjects. RESULTS: In the patients with mitral stenosis, MVA increased from 1.13 +/- 0.24 to 1.93 +/- 0.56 cm2 (P < .0001) after MBC. A standard echocardiographic score assessment of mitral valve morphology before MBC was not associated with the change in MVA after MBC in these patients (P > .20). However, the total mitral valve morphology score evaluated by cine computed tomography was strongly associated with the change in MVA after MBC (r = -.87; P < .0005). In addition, the individual morphologic characteristics of mitral valve mobility (P < .0025), leaflet thickness (P < .05), and subvalvular disease (P < .05) were significant predictors of the change in MVA after MBC. CONCLUSION: Cine computed tomography may be useful for predicting immediate increases in MVA in patients after MBC and may be helpful for preoperative assessment of these patients.     

Identification of an immunoglobulin A binding motif located in the beta-antigen of the c protein complex of group B streptococci

Between September 1987 and December 1994, 80 patients with multiple myeloma (MM) received high-dose busulfan and cyclophosphamide without (n = 57) or with modified total body irradiation (n = 23) followed by marrow from allogeneic donors. At transplant, 71% of the patients had disease that was refractory to chemotherapy. Thirty-five patients died of transplant-related causes within 100 days and 11 deaths occurred later. The actuarial probabilities of survival and progression-free survival were .24 +/- 0.17 and .20 +/- 0.10 at 4.5 years. Complete remissions were obtained in 36% of patients who had actuarial probabilities of survival and event-free survival of .50 +/- 0.21 and .43 +/- 0.17 at 4.5 years. In a multivariate analysis, adverse risk factors for outcome endpoints included: transplantation greater than 1 year from diagnosis; beta-2 microglobulin > 2.5 at transplant; female patients transplanted from male donors; patients who had received greater than eight cycles of chemotherapy before transplant and Durie stage 3 disease at the time of transplant. These results indicate that allografting for patients with MM can result in long-term disease-free survival for a minority of patients. Efforts to reduce transplant-related mortality should focus on earlier transplantation, less toxic treatment regimens, better supportive care, and improved prevention and treatment of graft-versus-host disease (GVHD).     

Long-term outcome of mitral valve repair of dystrophic mitral regurgitation

Between January 1984 and December 1994, 130 patients underwent mitral valvuloplasty for pure dystrophic mitral regurgitation. There were 94 men and 36 women with a mean age of 61 +/- 9 years: 52 patients were in atrial fibrillation; 91% of patients were in NYHA Classes III or IV. At preoperative echocardiography, the regurgitation was assessed as Grade III or IV and classified using the Carpentier classification according to type I (dilatation of the annulus) or II (mitral valve prolapse); 95% of patients had isolated prolapse of the posterior leaflet, 3% had isolated prolapse of the anterior leaflet and 2% had prolapse of the two leaflets. After valvuloplasty, a prosthetic ring was implanted in 124 patients (95%). The early mortality was 3%; 5.3% of patients had early complications. All patients underwent control transthoracic echocardiography in the first postoperative week. They were reviewed with a second transthoracic echocardiography after a mean follow-up of 5 +/- 0.3 years and a cumulative follow-up of 657 years-patients. At the immediate postoperative echocardiography, 24 minimal residual regurgitations were observed; at long-term, 20 new mitral regurgitations developed, all mild without any clinical symptoms and 98% of patients were in the NYHA Classes I or II. At 10 years, the actuarial survival was 73 +/- 16%; absence of thromboembolic complications 95 +/- 3%, absence of reoperation 95 +/- 5%. This study confirms the efficacy of mitral valvuloplasty and the postoperative stability of repaired valvular lesions. These results suggest that the operative indications should be considered at an earlier stage.     

Properties of the catalytic center of a secretory 28kDa protein (1-cys peroxiredoxin) from rat olfactory epithelium

BACKGROUND: Percutaneous mitral valvuloplasty with the Inoue balloon is conventionally performed with double vascular access: arterial and venous. However, in patients with a good echogenic window it may be performed with venous access only and the procedure monitored by 2D-echocardiography and colour flow mapping. This should result in early ambulation and hospital discharge with reduced arterial complications. AIMS: To compare retrospectively the immediate results of percutaneous mitral valvuloplasty with the Inoue balloon in two groups of patients: Group I: venous access only (no arterial access, n = 102) and Group II: conventional double vascular access (arterial and venous access, n = 275). METHODS AND RESULTS: The baseline characteristics of the two groups were comparable for age, sex, clinical, echocardiographic, radiological and haemodynamic variables. The mitral valve area (Group I: 1.1 +/- 0.3 to 1.85 +/- 0.5 cm2 vs Group II: 1.05 +/- 0.2 to 1.85 +/- 0.5 cm2, P = ns) and transmitral gradient (Group I: 11 +/- 4 to 4.7 +/- 2 mmHg vs Group II: 12 +/- 4 to 4.8 +/- 2 mmHg, P = ns) before and after mitral valvuloplasty were not statistically different. A good immediate result, defined as mitral valve area > 1.5 cm2 and mean mitral gradient < 5 mmHg with mitral regurgitation < or = 2+ at the end of the procedure, was observed in 77% of the cases in the venous-only group and 79% in the double access group (P = ns). The incidence of severe mitral regurgitation (Grade III or IV) was not statistically significant. Procedural duration (71 +/- 24 min vs 109 +/- 26 min, P < 0.01), fluoroscopic time (12.5 +/- 5.5 min vs 18.5 +/- 6 min, P < 0.01) and hospital stay (2.8 +/- 1.5 days vs 4.8 +/- 2.6 days, P < 0.001) were significantly shorter in the venous-only group than in the conventional Inoue series. CONCLUSION: Single venous access balloon mitral valvuloplasty is as equally safe and effective as double vascular access. The additional advantages of single venous access are shorter procedural duration, fluoroscopic time and hospital stay. We recommend that it be performed by an experienced operator (minimum of 100 trans-septal punctures) in patients without major thoracic deformity and a good echogenic window.     

Variance in male mating success and female choice for persuasive courtship displays

BACKGROUND: The aim of the study was to evaluate our clinical experience with the CarboMedics Heart Valve Prosthesis. METHODS: Nine hundred ninety-seven consecutive patients underwent mechanical valve implantation (aortic, 771; mitral, 169; double, 52; tricuspid, 5) with this prosthesis from September 1987 through December 1993. The mean age was 62.3+/-13.7 years (range, 0.4 to 84 years); 56.6% (564 patients) were men. Four hundred seventy patients (47.1%) underwent additional surgical procedures. Mean follow-up was 4.1+/-2.2 years (range, 0 to 8.3 years) with a total of 4,040 patient-years. RESULTS: Early mortality was 5.0% (50/997; aortic, 4.4%; mitral, 6.4%; double, 9.6%). Late mortality was 14.8% (140/947). Survival at 7 years was 75.9%+/-1.8% (aortic, 78.4%+/-2%; mitral, 70.7%+/-4.5%; double, 60.8%+/-7.4%). When matched for sex and age and compared with the normal Norwegian population, our patients had an increased standard mortality ratio in both men (1.9+/-0.4) and women (2.9+/-0.6). The linearized rate of major thromboembolism was 0.9% per patient-year, valve thrombosis 0.2% per patient-year, major bleeding event 0.6% per patient-year, paravalvular leak needing reoperation 0.5% per patient-year, prosthetic valve endocarditis 0.1% per patient-year, and of all reoperations 0.6% per patient-year. CONCLUSIONS: The CarboMedics Heart Valve Prosthesis has incidences of morbid events comparable with or better than reported for other mechanical valves.     

Comparison of immediate hemodynamic response to closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty in rheumatic mitral stenosis

The hemodynamic response to closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty was compared using 20 patients in each group. All patients had symptomatic rheumatic mitral stenosis with a mitral valve area < 1 cm2, without any left atrial clot, mitral valve calcification, or mitral regurgitation. There was a significant improvement in hemodynamics following intervention in all three groups. The mean pulmonary artery pressure decreased from 49.1 +/- 17.5 to 28.6 +/- 8.3 mm Hg (p < 0.001), 48.8 +/- 12.3 to 34.0 +/- 13.9 mm Hg (p < 0.001), and 46.7 +/- 18.0 to 26.3 +/- 13.7 mm Hg (p < 0.001) in the closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty groups, respectively. The mitral valve area increased from 0.62 +/- 0.27 to 1.5 +/- 0.5 cm2 (p < 0.001), 0.68 +/- 0.24 to 1.5 +/- 0.4 cm2 (p < 0.001), and 0.68 +/- 0.25 to 1.9 +/- 0.8 cm2 (p < 0.001) in the closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty groups, respectively. The increase in the mitral valve area was maximum in the group with double-balloon mitral valvuloplasty. In the closed mitral commissurotomy group there was a significant rise in left ventricular end-diastolic pressure, from 6.8 +/- 3.9 to 9.3 +/- 3.1 mm Hg (p < 0.001), but this remained unchanged in the single-balloon and double-balloon mitral valvuloplasty groups. Our study shows that single-balloon and double-balloon mitral valvuloplasty are comparable to closed mitral commissurotomy in the immediate hemodynamic response, with a larger valve area in the double-balloon mitral valvuloplasty group.