Five-year follow-up after balloon pulmonary valvuloplasty

We hypothesized that gender and intrauterine growth retardation (IUGR) have greater effects than birth order on mortality and morbidity rates of very low birth weight (< 1501 gm) twins. Neonatal data were collected on 44 pairs of twins born alive between January 1984 and December 1987. Birth weight was 1018 +/- 289 gm and gestational age was 28.1 +/- 2.5 weeks. The male/female ratio was 46:42; 24 infants had IUGR, and 64 were appropriate in size for gestational age. Of the 88 infants, 61 (69%) survived. Birth order had no effect on outcome. Female twin pairs had a longer gestation than either male twin pairs or twins with discordant sex (29.2 +/- 2.5 weeks vs 27.4 +/- 2.0 weeks and 27 +/- 3 weeks, respectively; p < 0.002). They also had a lower mortality rate (14% vs 47% and 25%; p < 0.001) and a lower incidence of bronchopulmonary dysplasia (22% vs 57% and 50%; p < 0.02). Infants with IUGR had an increased mortality rate (50% vs 23%; p < 0.02) and an increased sepsis rate (61% vs 25%; p < 0.02) compared with infants with appropriate size for gestational age who were matched for gestational age. Multiple logistic regression analysis to assess the independent effects of gestational age, gender, and IUGR on mortality rate, bronchopulmonary dysplasia, and intraventricular hemorrhage revealed that gestational age was the most significant contributor to all three outcome variables; IUGR contributed to an increased mortality rate, and male gender contributed to the occurrence of bronchopulmonary dysplasia.     

Sympathetic activity in children undergoing balloon valvuloplasty of pulmonary stenosis

We studied the influence of balloon valvuloplasty on alpha- and beta-adrenoceptor densities, plasma catecholamine, and cAMP levels in children and infants with pulmonary stenosis before and 10 min after balloon dilatation, employing as controls children undergoing transcatheter occlusion of patent ductus arteriosus (PDA) with Qp/Qs ratio < 1.5. In the PDA group, the alpha-adrenoceptor density (Bmax) was 3.75 +/- 0.72 fmol/10(7) cells (n = 15) before occlusion and remained unchanged at 3.35 +/- 0.47 fmol 10 min thereafter. In the pulmonary stenosis patients (n = 31), the receptor density was 59% higher (p < 0.05) before, and decreased to PDA levels 10 min after, the procedure. The control beta-adrenoceptor density was 64.8 +/- 11.0 fmol/10(6) cells before, and 71.2 +/- 13.2 fmol 10 min after, occlusion. In the study group, the density was 23% lower (p < 0.07) and increased to the PDA levels 10 min after the dilatation. Compared with the PDA, pre- and postdilatation plasma norepinephrine levels were not significantly changed; epinephrine was slightly elevated before, but increased by 73% after, dilatation; dopamine was 80% (p < 0.05); and cAMP was 37% higher before, and remained elevated at 70 and 23% above the PDA values after, the procedure. Accordingly, alpha-adrenoceptor density is significantly elevated in children with pulmonary stenosis and decreases significantly immediately after balloon valvuloplasty. On the other hand, beta-adrenoceptor density is attenuated and increases toward normal levels after the procedure. The immediate reversal of the receptor levels after balloon valvuloplasty suggests that this procedure exerts acute effects on the sympathetic functional level in this disease.     

Consequences of intramyocardial arterial lesions in aortic valvular stenosis

Proliferative lesions, which included collagen deposition, developed with age in intramyocardial arteries of 27 patients with aortic stenosis and matched controls. Those with the most extensive intramyocardial artery lesions developed massive subendocardial infarcts during surgery. Using histologic quantitation, the percent of intramyocardial arteries with lesions in a patient was correlated with decreases in the amount of muscle in arterioles between the subepicardial and subendocardial zones of the left ventricle. The mean decrease in arteriolar muscle was 43% in patients with aortic stenosis and 19% in controls. Blood pressures correlate with the amount of muscle in arterioles, so subendocardial perfusing pressures were presumably low in those with aortic stenosis. Patients with the greatest decrease in arteriolar muscle across the myocardium had the most impaired left ventricular function, i.e., highest end diastolic pressures, lowest ejection fractions, and lowest mean fiber shortening rates.     

Modified technique for balloon valvuloplasty of critical pulmonary stenosis in the newborn

OBJECTIVES: We report our experience in eight consecutive neonates who underwent attempted balloon dilation as an initial therapy for critical valvular pulmonary stenosis, and we review in detail technical modifications that improved the success rate. BACKGROUND: Balloon dilation of the pulmonary valve has become the treatment of choice for valvular pulmonary stenosis in children and adults. There are few reports of its effectiveness in critical pulmonary stenosis in the newborn. In this setting, application of the technique of balloon dilation has been limited by the ability to advance the necessary guide wires and catheters across the stenotic, often near-atretic, pulmonary valve. METHODS: The pulmonary valve was crossed in all patients. When this could not be accomplished with an end-hole catheter, a soft guide wire was advanced directly across the pulmonary valve through the end-hole catheter positioned in the right ventricular outflow tract below the valve. Initial predilation was achieved in all patients by using a coronary dilation catheter in an effort to facilitate introduction of the definitive balloon dilation catheter. Definitive dilation with a balloon diameter of > or = 110% of the diameter of the pulmonary valve annulus was possible in six patients. RESULTS: Right ventricular pressure declined from a mean value of 108 +/- 32 mm Hg to a mean value of 49 +/- 11 mm Hg after balloon dilation, with no change in heart rate or aortic pressure in these six patients after definitive balloon dilation. CONCLUSIONS: The results of this small series suggest that critical valvular pulmonary stenosis in the newborn can be successfully treated by transluminal balloon valvuloplasty.     

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.     

Percutaneous transluminal balloon aortic and mitral valvuloplasty in 27 patients treated at Hermann Hospital

Percutaneous aortic and mitral valvuloplasty are recognized as alternative interventions in cases of severe symptomatic aortic and mitral stenosis. We described the acute hemodynamic results, immediate clinical outcomes, and complications in 27 patients treated consecutively at Hermann Hospital with either percutaneous balloon aortic or mitral valvuloplasty. We review the possible mechanisms of action of balloon valvulotomy and the current indications for either procedure. Balloon aortic valvuloplasty is indicated in elderly patients with severe aortic stenosis in whom open-heart surgery is contraindicated or carries excessive mortality. All patients with symptomatic mitral stenosis are potential candidates for balloon mitral valvulotomy. In centers with an experienced interventional team in transseptal catheterization and an active surgical program, balloon valvulotomy is the initial procedure of choice for significant mitral stenosis with mobile leaflets and minimal chordal thickening.     

The percutaneous transluminal balloon valvuloplasty of valvular stenosis of the pulmonary artery in treating tetralogy of Fallot as an alternative to the surgery of applying a systemic-pulmonary anastomosis

From January 1991 to May 1992 transluminal balloon valvuloplasty [correction of vulvoplasty] of severe valvular stenosis of the pulmonary artery was performed in 14 patients with Fallot's tetrad at the Institute of Cardiovascular Surgery named after A. N. Bakulev. Five of them had pulmonary artery hypoplasia, 2 had stenosis and hypofunction of the systemic-pulmonary anastomosis applied by the Blalock-Taussig, which made them perform balloon angioplasty of the narrowed distal portion of the anastomosis. The patients' age ranged from 11 months to 14 years (mean age 6.8 +/- 1.1 years). Arterial blood oxygen saturation varied from 51 to 72% (mean 69.2 +/- 2.4%). The diameter of a valvular ring was 8-13 mm. The diameter of a balloon catheter exceeded that of the valvular ring by 20-25%. After dilation, arterial blood oxygen saturation increased from 69.86 +/- 2.5 to 85.1 +/- 1.2%. The angiometry performed after pulmonary artery valvuloplasty in patients with pulmonary hypoplasia showed an increase in sizes of all pulmonary arterial segments on an average by 22.5 +/- 4.1%. Later on 5 patients were radically operated on. Thus, with the ultimate goal of preparation of patients with severe Fallot's tetrad for radical surgery, transluminal balloon valvuloplasty in some patients with severe valvular stenosis of the pulmonary artery may be alternative to a systemic-pulmonary anastomosing operation.     

Congestive heart failure in patients with valvular aortic stenosis. A clinical and echocardiographic Doppler study

The aim of this study was to evaluate echographically anatomic and functional features of the left ventricle in adult patients with valvular aortic stenosis according to the presence or absence of congestive heart failure and the level of ventricular performance. Fifty-six adult patients with moderate-to-severe aortic stenosis underwent echocardiographic Doppler examination in order to evaluate left ventricular mass and dimensions, systolic function and filling dynamics. Twenty-seven patients had no heart failure and were symptomatic for angina (5), syncope (4) or were symptom-free (group I); the other 29 had heart failure (group II): 16 with normal left ventricular systolic performance (fractional shortening > 25%, group IIa) and 13 with systolic dysfunction (fractional shortening < or = 25%, group IIb). Despite a similar left ventricular mass, compared to group IIa, group IIb showed a significant left ventricular dilatation (end-diastolic diameter: 61 +/- 6.5 vs. 45.5 +/- 6.1 mm, p < 0.001) and mild or no increase in wall thickness (11.5 +/- 1.6 vs. 14.9 +/- 2 mm, p < 0.001). Indices of left ventricular filling on Doppler transmitral flow were also significantly different between the two groups, with a higher early-to-late filling ratio and a shorter deceleration time of early filling in group IIb (2.8 +/- 1.9 vs. 1.2 +/- 0.85, p < 0.01, and 122 +/- 66 vs. 190 +/- 87 ms, p < 0.05, respectively), both indirectly indicating higher left atrial pressure. Finally, heart failure was generally more severe in group IIb patients. In some patients with aortic stenosis, symptoms of heart failure may be present despite a normal left ventricular systolic function and seem to depend on abnormalities of diastolic function. The presence of systolic or isolated diastolic dysfunction appears to be related to a different geometric adaptation of the left ventricle to chronic pressure overload.     

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.     

Midterm results of balloon dilation of congenital aortic stenosis: predictors of success

OBJECTIVES: We evaluated patient and procedural characteristics that influence the midterm success of balloon dilation of congenital aortic stenosis. BACKGROUND: Balloon dilation is a new treatment for congenital aortic stenosis. Factors that influence midterm success are unknown. METHODS: We performed a retrospective review of 148 children >1 month old who underwent balloon dilation for aortic stenosis. RESULTS: Balloon dilation was successful in 87% of patients, with a procedural mortality rate of 0.7%. The average immediate peak to peak gradient reduction was 56.4 +/- 19.9% (mean +/- SD). Prior valvotomy was the only factor that significantly reduced the immediate gradient reduction after dilation (47.1 +/- 21.8% vs. 57.8 +/- 19.6%, p < 0.01). Survival after dilation was 95% at 8 years. Seventy-five percent of patients were free of repeat intervention 4 years after dilation, whereas 50% remained free of repeat intervention at 8 years. Asymmetrically thick valve leaflets (risk ratio [RR] 0.17, p < 0.01) and prior aortic valvotomy (RR 0.35, p = 0.02) decreased the risk of repeat intervention. Aortic regurgitation grade > or = 3 (RR 4.27, p = 0.04) and residual gradient after dilation (RR 1.63 for 10 mm Hg, p < 0.01) increased the risk. CONCLUSIONS: The 8-year survival rate after dilation was 95% with 50% of patients free of repeat intervention. Factors that increased the risk for repeat intervention included symmetrically thin or thick aortic valve leaflets, regurgitation grade > or = 3 after dilation and a high residual gradient after dilation. The incidence of repeat intervention after dilation was high owing to its palliative nature.     

Late results of balloon pulmonary valvuloplasty in adults

We have assessed a new method to evacuate saline completely from the laryngeal mask airway (LMA) cuff and tested the hypothesis that intracuff pressures, fibreoptic position and oropharyngeal leak pressures are similar for saline compared with air during nitrous oxide-oxygen anaesthesia. Eight size 4 LMA were inflated with saline 30 ml. After syringe evacuation, median residual weight was 0.56 (range 0.24-0.98) g; after additional manual cuff squeezing it was 0.26 (0.21-0.35) g; and after drying for 12 h at 60 degrees C with the valve open it was -0.02 (-0.05-0.04) g. Pressure-volume curves of four size 3-5 LMA showed that compliance was lower for the saline-filled cuff. A clinical study of 20 patients allocated randomly to have saline or air in the cuff showed a significant increase in intracuff pressure with air, but not saline, during nitrous oxide-oxygen anaesthesia. The fibreoptic position of the LMA changed more frequently in the air, compared with the saline-filled group (four of 10 vs none of 10; P = 0.04). Oropharyngeal leak pressures were similar between groups. We conclude that the saline-inflated LMA cuff was reliably emptied and more stable in terms of intracuff pressures and possibly fibreoptic position. Filling the LMA cuff with saline is a viable option during laser surgery to the airway.     

Clinical factors useful in predicting aortic valve structure in patients > 40 years of age with isolated valvular aortic stenosis

A number of reports have described the frequency of coronary arterial narrowing in patients with valvular aortic stenosis. No published reports have examined the structure of the stenotic aortic valve in adults and related the valve structure to variables, including coronary arterial narrowing, useful in predicting that structure. One hundred eighty-eight patients having aortic valve replacement for isolated valvular aortic stenosis were studied. All patients were > 40 years of age at the time of aortic valve replacement, all had coronary angiograms preoperatively, and of 182 patients (97%) measurements of serum total cholesterol had been obtained and 184 (98%) had body mass index calculated. The structure of the operatively excised valve was classified as unicuspid or bicuspid (congenitally malformed), or tricuspid aortic valve. A logistic regression model was developed that found 4 factors (age, serum total cholesterol, angiographic coronary artery disease and body mass index) to be predictive of aortic valve structure: (1) Patients with at least 3 or all 4 factors high or present (i.e., age > 65 years, serum total cholesterol > 200 mg/dl, body mass index > 29 kg/m2 and coronary artery disease) had a low probability (10 to 29%) of having a congenitally malformed valve; (2) patients with at least 3 or all 4 factors low or absent (i.e., age < or = 65 years, serum total cholesterol < or = 200 mg/dl, body mass index < or = 29 kg/m2, and no coronary artery disease) had a high probability (72 to 90%) of having a congenitally malformed valve.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.