Assessment of the “long sheath” technique for percutaneous aortic balloon valvuloplasty

A 100 cm-long 16.5 F valvuloplasty catheter introducer was assessed as an adjunct for percutaneous transluminal aortic valvuloplasty (PTAV) via the femoral artery in 31 patients with severe aortic stenosis. Observed improvements in peak systolic gradient (81.6 ± 29.9 mm Hg vs. 35.5 ± 16.0 mm Hg, P < 0.000001) and aortic valve area (0.6 ± 0.4 cm² vs. 1.0 ± 0.6 cm², P < 0.00001) were similar to those achieved in a control group (C) of 17 patients in which no femoral sheath was used. However, a shorter procedure duration (211 ± 81 min vs. 117 ± 30 min, P < 0.001) and a reduced rate of vascular complications at the femoral puncture site (41% vs. 6.5%) were observed in patients in whom the long sheath (LS) technique was used. The frequency of other PTAV-related complications was comparable (C = 35%, LS = 29%, P = n.s.). Other technical advantages of this device are: 1) prevention of looping and bending of the balloon catheter in tortuous vessels and easy positioning of the balloon across the aortic orifice provided by the LS trackability, 2) stabilisation of the balloon during inflation, 3) monitoring of supravalvular aortic pressure provided by the side-arm of the LS and reliable measurement of systolic gradient, and 4) the ability to perform aortograms without the need of another catheter in the ascending aorta. Thus, in our experience, the long sheath technique is a valuable adjunct for PTAV.     

Percutaneous transluminal valvuloplasty in calcific aortic stenosis: the double balloon technique

The double balloon technique for aortic valvuloplasty using a combined brachial and femoral artery approach with readily available angioplasty equipment is described. Online hemodynamic assessment of the patient during the procedure was provided by continuous, reflective spectorphotometric monitoring of the pulmonary artery mixed venous oxygen saturation and the arterial pressure in the femoral sheath. Successful valvuloplasty was achieved in 10 patients with the transaortic peak-to-peak systolic gradient reduced from 77.6 +/- 28 to 27.8 +/- 15 mmHg (P less than 0.001), the mean gradient from 62.0 +/- 24 to 26.0 +/- 15 mmHg (P less than 0.0007), and the aortic valve area increased from 0.56 +/- 0.3 to 1.03 +/- 0.6 cm2 (P less than 0.05). No significant complications were encountered. The double balloon technique for aortic valvuloplasty is an acceptable alternative method to the single balloon technique.     

Balloon valvuloplasty for critical aortic stenosis in the newborn: influence of new catheter technology

Between 1986 and July 1990, balloon valvuloplasty was attempted in eight newborns (less than 28 days of age) with isolated critical aortic valve stenosis. Balloon valvuloplasty could not be successfully accomplished in any of the three infants presenting before 1989. Since March 1989, when improved catheter technology became available, all five neonates presenting with critical aortic stenosis were treated successfully by balloon valvuloplasty. A transumbilical approach was utilized in all four infants in whom umbilical artery access could be obtained. One newborn who was 25 days of age underwent transfemoral balloon valvuloplasty. Balloon valvuloplasty was immediately successful in all five newborns, as evidenced by a decrease in valve gradient and improvement in left ventricular function and cardiac output. Peak systolic gradient was reduced by 64% from 69 +/- 8 to 25 +/- 3 mm Hg (p = 0.005). Left ventricular systolic pressure decreased from 128 +/- 9 to 95 +/- 9 mm Hg (p = 0.02) and left ventricular end-diastolic pressure decreased from 20 +/- 2 to 11 +/- 1 mm Hg (p = 0.02). Moderate (2+) aortic regurgitation was documented in two infants after valvuloplasty. The time from first catheter insertion to valve dilation averaged 57 +/- 14 min (range 26 to 94) and the median length of the hospital stay was 4 days. With the use of recently available catheters, the transumbilical technique of balloon valvuloplasty can be performed quickly, safely and effectively in the newborn with critical aortic stenosis. It does not require general anesthesia, cardiopulmonary bypass or a left ventricular apical incision and it preserves the femoral arteries for future transcatheter intervention should significant aortic stenosis recur.     

Percutaneous balloon valvuloplasty for aortic stenosis: improved quality of life for elderly patients

From September 1986 to September 1987 percutaneous balloon valvuloplasty was performed in 20 patients with critical aortic stenosis. The mean age was 74, range 54 to 90 years. Two patients were NYHA class II, 10 patients were functional class III and eight were class IV. After percutaneous balloon valvuloplasty, using 15, 18 or 20 mm diameter balloon catheters via a 14F vascular sheath from the femoral artery, one patient was class I, 11 class II and seven were class III. One patient, who had only minimal reduction of aortic valve gradient from 120 to 100 mmHg, remained in class IV. The systolic gradient was reduced by 50% from 70 +/- 26 (+/- SD) to 35 +/- 22 mmHg (P less than 0.001) after valvuloplasty and the aortic valve area increased by 43% from 0.51 +/- 0.12 to 0.73 +/- 0.25 cm2 (P less than 0.001). There were no procedural or 30 day deaths nor any embolic events. Percutaneous balloon valvuloplasty is a relatively safe and effective treatment for the older adult with symptomatic aortic stenosis.     

Use of a 3 French system for balloon aortic valvuloplasty in infants.

For infants with valvar aortic stenosis, balloon aortic valvuloplasty has supplanted surgical valvotomy as the initial treatment of choice at most institutions. Technological innovations have resulted in further miniaturization of balloon dilation catheters, allowing this procedure to be performed through smaller sheath sizes. Currently, the Tyshak-Mini balloon dilation catheter (B. Braun Medical) allows passage of up to an 8 mm dilation balloon catheter through a 3 Fr hemostatic sheath. The efficacy of this system for the treatment of valvar aortic stenosis in infants less than 6 months of age was evaluated in 20 patients undergoing 22 procedures. Mean age at the time of intervention was 26 +/- 46 days. Mean transvalvar gradient was 76 +/- 22 mm Hg prior to balloon dilation. Following balloon valvuloplasty, residual gradient was 26 +/- 12 mm Hg, reflecting a mean change in peak-to-peak gradient of 49 +/- 19 mm Hg. Postintervention increase in aortic insufficiency was one grade or less in 19/22 procedures, two grades in 2 procedures, and three grades in 1 procedure. There were no significant vascular complications reported immediately following the procedure. Repeat valvuloplasty was performed in three patients in which the 3 Fr system was used in two patients. The 3 Fr system for balloon aortic valvuloplasty in infants less than 6 months of age is effective and safe.     

Valvuloplasty of congenital aortic stenosis

While percutaneous transluminal valvuloplasty has largely replaced open commissurotomy for congenital pulmonary valve stenosis, the experience with valvuloplasty for congenital aortic stenosis is limited. Between August, 1984 and June, 1987, a total of 27 valvuloplasties were carried out in 25 patients with congenital aortic stenosis; nine infants and 16 patients ranging in age from four to 25 years (mean age 13 +/- 6 years). The indication for valvuloplasty was established on the basis of congestive heart failure or severe stenosis in infants and in the presence of a pressure gradient in excess of 60 mm Hg in those older than one year of age. In eight infants, valvuloplasty reduced the transvalvular pressure gradient from 73 +/- 5 to 36 +/- 9 mm Hg (p less than 0.01; Figure 1). In the 16 patients older than one year of age, the pressure gradient was reduced from 93 +/- 25 to 49 +/- 15 mm Hg (p less than 0.01; Figure 2). The size of the balloon chosen was based on two-dimensional echocardiographic measurements of the aortic ring diameter from inner edge to inner edge. In infants, coronary artery dilating catheters and balloon catheters with an inflated diameter of 4.2 to 8 mm were employed; in children, the balloon diameter selected was 1 to 3 mm less than that of the valve ring diameter, in 15 cases a single-balloon catheter and in one a trefoil catheter. After puncture of the femoral artery and retrograde advancement of a guide-wire into the left ventricle, the balloon catheter was positioned via the guide-wire across the aortic valve.(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of balloon valvuloplasty in the treatment of congenital valvar pulmonary stenosis in children

Transluminal balloon valvuloplasty was used in the treatment of congenital valvar pulmonary stenosis in 19 children, aged 5 months to 18 years. The right ventricular (RV) systolic pressure and RV outflow tract gradient decreased significantly immediately after the procedure (95 +/- 29 vs 59 +/- 14 mm Hg, p less than 0.01, and 78 +/- 27 vs 38 +/- 13 mm Hg, p less than 0.01). Seven of these patients were evaluated at cardiac catheterization 1 year after balloon valvuloplasty. No significant change occurred in RV systolic pressure or RV outflow tract gradient at follow-up evaluation compared with measurements immediately after balloon valvuloplasty (60 +/- 5 mm Hg vs 56 +/- 12 mm Hg and 39 +/- 5 vs 38 +/- 10 mm Hg). In addition, follow-up evaluation was performed using noninvasive methods and included electrocardiography (n = 13), vectorcardiography (n = 11) and Doppler echocardiography (n = 11) Doppler echocardiography in 11 patients 15 +/- 9 months after balloon valvuloplasty showed a continued beneficial effect with a mild further decrease in RV outflow tract gradient. Thus, balloon valvuloplasty is effective in the relief of pulmonary stenosis.     

Comparison of single and double balloon valvuloplasty in children with aortic stenosis

To compare the effectiveness of the single and double balloon techniques, the short-term results of percutaneous balloon valvuloplasty were assessed in two consecutive groups of children with valvular aortic stenosis. In 16 children (aged 3 months to 17 years) the single balloon technique was utilized; the ratio of balloon diameter to valve anulus diameter was 0.96 +/- 0.03 (mean +/- SEM). In 11 children (aged 3 months to 21 years) the double balloon technique was utilized in which two balloons are positioned across the valve and inflated simultaneously; the ratio of the balloon diameter sum to valve anulus diameter was 1.32 +/- 0.05. The groups were similar in age, weight, cardiac output, prevalvuloplasty gradient and valve anulus diameter. Overall, valvuloplasty reduced the peak systolic gradient by 53% from 80 +/- 4 to 38 +/- 3 mm Hg (p less than 0.0001). In the single balloon group the gradient decreased from 82 +/- 6 to 46 +/- 4 mm Hg (p less than 0.0001), whereas in the double balloon group the gradient decreased from 76 +/- 5 to 26 +/- 4 mm Hg (p less than 0.0001). The peak systolic gradient after valvuloplasty was 43% lower in the double balloon group (p less than 0.01). Furthermore, the single balloon technique reduced the gradient by an average of 43% compared with a 67% reduction with the double balloon technique (p less than 0.001). The short-term complications of valvuloplasty were similar, with an increase in aortic insufficiency occurring in three children in each group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon pulmonary valvuloplasty in the management of cyanotic congenital heart defects.

Twenty-three children with cyanotic congenital heart defects, aged 3 days to 11.5 years, weighing 2.9 to 30 kg, underwent percutaneous balloon pulmonary valvuloplasty to improve pulmonary oligemia. The patients were divided into two groups: group I with intact ventricular septum and group II with ventricular septal defect. In 12 group I patients, there was an increase of systemic arterial oxygen saturation [83 +/- 8% (mean +/- SD) vs. 94 +/- 5%, P less than 0.001] and pulmonary-to-systemic flow ratio (0.7 +/- 0.1 vs. 1.0 +/- 0.2, P less than 0.001). Peak systolic pressure gradient across the pulmonary valve decreased (P less than 0.001) from 105 +/- 48 to 25 +/- 18 mm Hg. In 11 group II patients, arterial oxygen saturation (67 +/- 13 vs. 83 +/- 13%, P less than 0.01) and pulmonary-to-systemic flow ratio (0.7 +/- 0.4 vs. 1.2 +/- 0.5, P less than 0.02) increased following valvuloplasty. Peak systolic pressure gradient across the pulmonic valve (52 +/- 16 vs. 32 +/- 22 mm Hg, P less than 0.05) decreased while infundibular and total pulmonary outflow tract gradients were unchanged (P greater than 0.1). Immediate surgical intervention was avoided in all cases in both groups. On follow-up, 1 to 36 months after valvuloplasty, arterial oxygen saturation, pulmonary-to-systemic flow ratio, and pulmonary valve gradients remain improved in both groups. However, in group I, repeat balloon valvuloplasty was required in two children. In group II, six children with tetralogy of Fallot (TOF) underwent successful total surgical correction 4 months to 2 years after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Carotid artery approach for balloon dilation of aortic valve stenosis in the neonate: a preliminary report

Balloon valvuloplasty in neonates with severe aortic valve stenosis is limited by difficulties in catheter manipulation around the arch and across the valve and by the risk of femoral artery complications. A right common carotid artery cutdown was utilized for balloon aortic valvuloplasty in five neonates 1 to 20 days of age, weighing 3.1 to 3.9 kg. Standard balloon valvuloplasty was performed through a 6F sheath inserted in the right carotid artery. The arteriotomy was repaired at the end of the procedure. Mean left ventricular systolic pressure was reduced from 142 to 97 mm Hg, with a decrease in mean peak systolic pressure gradient from 76 to 33 mm Hg. Only one patient developed mild aortic regurgitation. One patient with a hypoplastic left ventricle died, and one patient required open valvotomy. All four survivors have a normal carotid pulse and no neurologic sequelae. Two of these patients required repeat balloon dilation to treat residual aortic valve stenosis at 8 and 10 months of age, respectively. Balloon valvuloplasty using a carotid artery approach is feasible and was safe in five neonates with severe aortic valve stenosis.     

Balloon aortic valvuloplasty: results of the Valvuloplasty and Angioplasty of Congenital Anomalies Registry

Data from 204 children and infants who underwent aortic balloon valvuloplasty between 1982 and 1986, reported to the Valvuloplasty and Angioplasty of Congenital Anomalies Registry, were reviewed. Valvuloplasty was successful in 192 of 204 children, reducing the peak systolic left ventricular ejection gradient from 77 +/- 2 to 30 +/- 1 mm Hg, p less than 0.001. The same degree of aortic stenosis gradients reduction was noted in both the 38 children under 1 year of age and in the 166 children over 1 year of age. Significant complications included death, aortic regurgitation and femoral artery thrombosis or damage. The incidence of these complications correlated with the age of the child, the ratio of valvuloplasty balloon size/anulus size, or both. The data suggest that percutaneous balloon valvuloplasty provides effective acute relief of valvar aortic stenosis in both infants and children. However, long-term follow-up data are necessary before balloon valvuloplasty can be established as a treatment of choice for congenital valvar aortic stenosis.     

Gradient reduction, aortic valve regurgitation and prolapse after balloon aortic valvuloplasty in 32 consecutive patients with congenital aortic stenosis

From 1986 to 1988, balloon aortic valvuloplasty was performed in 32 patients with congenital valvular aortic stenosis. The patients ranged in age from 2 days to 28 years (mean +/- SD 8.3 +/- 5.9). One balloon was used in 17 patients and two balloons were used in 15 patients. Immediately after valvuloplasty, peak systolic pressure gradient across the aortic valve decreased significantly from 77 +/- 27 to 23 +/- 16 mm Hg (p less than 0.01), a 70% reduction in gradient. At early follow-up study (4.1 +/- 3.3 months after valvuloplasty), there was a 48 +/- 20.5% reduction in gradient compared with that before valvuloplasty, and at late follow-up evaluation (19.2 +/- 5.6 months), a reduction in gradient of 40 +/- 29% persisted. Echocardiography showed evidence of significantly increased aortic regurgitation in 10 patients (31%) and aortic valve prolapse in 7 patients (22%). There was no correlation between the balloon/anulus ratio and the subsequent development of aortic regurgitation or prolapse. In fact, no patient who showed a significant increase in aortic regurgitation had had a balloon/anulus ratio greater than 100%. It is concluded that balloon aortic valvuloplasty effectively reduces peak systolic pressure gradient across the aortic valve in patients with congenital aortic stenosis. However, subsequent aortic regurgitation and prolapse occur in a significant number of patients, even if appropriate technique and a balloon size no greater than that of the aortic anulus are used.     

Intermediate-term effectiveness of balloon valvuloplasty for congenital aortic stenosis. A prospective follow-up study.

BACKGROUND. Percutaneous balloon valvuloplasty has proven to be acutely effective in the treatment of congenital valvar aortic stenosis; however, the intermediate- and long-term effectiveness of the procedure remain to be documented. METHODS AND RESULTS. To assess the intermediate-term effectiveness of balloon valvuloplasty, repeat catheterization was performed in 27 of 30 children 1.7 +/- 0.1 years after balloon valvuloplasty for congenital aortic stenosis (AS). In 33 children the peak AS gradient was reduced acutely by 55% from 77 +/- 4 to 35 +/- 3 mm Hg (p less than 0.001), and left ventricular systolic pressure was reduced from 176 +/- 4 to 138 +/- 4 mm Hg (p less than 0.001). Despite a technically adequate valvuloplasty procedure, three patients had inadequate relief of obstruction and required complex surgical intervention. Twenty-seven of the 30 patients available for late reevaluation (90%) enrolled in the follow-up study. The peak AS gradient remained significantly reduced compared with that present before valvuloplasty (29 +/- 3 versus 77 +/- 4 mm Hg, p less than 0.001). Furthermore, there was no difference in peak AS gradient at follow-up compared with that immediately after valvuloplasty. The greatest increase in gradient at reevaluation was 14 mm Hg. Twenty of 27 patients (74%) had no change in the degree of aortic insufficiency at follow-up compared with that present before valvuloplasty. At follow-up, 16 patients had no aortic insufficiency at all, and only two had moderate-to-severe (3-4+) insufficiency. Femoral artery injury was documented in four patients, three of whom were under 12 months of age at valvuloplasty. CONCLUSIONS. Balloon aortic valvuloplasty provides safe and effective intermediate-term gradient relief without early restenosis in children and adolescents with congenital AS.     

Short- and midterm results of balloon valvuloplasty for valvular aortic stenosis in children.

During a 27-month period, 21 consecutive children (aged 0.1 to 15.7 years) with isolated valvular aortic stenosis underwent percutaneous transfemoral balloon valvuloplasty. Ten children had undergone earlier surgical valvulotomy. The indication for treatment was ST-T-segment changes at rest or during bicycle-ergometry, a continuous-wave Doppler-derived transvalvular gradient greater than 60 mm Hg or syncope, or a combination. Mean peak systolic left ventricular pressure decreased from 165 +/- 19 to 131 +/- 19 mm Hg (p less than 0.001). Mean end-diastolic left ventricular pressure did not change significantly (12 +/- 3 vs 11 +/- 5 mm Hg). Mean peak systolic valve gradient decreased from 71 +/- 23 to 22 +/- 11 mm Hg (p less than 0.001). Mean cardiac index remained unchanged (2.9 +/- 0.8 vs. 3.0 +/- 0.7 liters.min-1.m-2). Aortic valve regurgitation on angiography appeared or increased in 9 patients (up to grade 3 in 3 children). Noninvasive follow-up studies were performed for 2 to 4.2 years (mean 2.8). ST-T changes on the electrocardiogram at rest or during exercise were present in 6 patients before balloon valvuloplasty and had disappeared in all at 6-month follow-up. Reoccurrence of ST-T changes after a longer follow-up was associated with severe valve regurgitation. Syncope was not observed after balloon valvuloplasty. The continuous-wave Doppler gradient decreased from 94 +/- 36 to 49 +/- 15 mm Hg (p less than 0.001). After a follow-up of 2 to 4.2 years (mean 2.8) it remained unchanged (43 +/- 13 mm Hg; p = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)     

Combined percutaneous aortic valvuloplasty and transluminal coronary angioplasty in adult patients with calcific aortic stenosis and coronary artery disease

Of 120 consecutive balloon aortic valvuloplasty procedures for critical aortic stenosis, valvuloplasty was performed in combination with coronary angioplasty in nine patients (average age 76 years). All nine patients were symptomatic with angina and congestive heart failure before combined procedures. Aortic valvuloplasty was performed with 20 to 23 mm balloon catheter advanced retrogradely from the femoral artery and resulted in an improvement in peak aortic valve gradient (60 +/- 19 to 33 +/- 13 mm Hg; p less than or equal to .01) and calculated aortic valve area (0.7 +/- 0.1 to 1.1 +/- 0.3 cm2; p less than or equal to .01). Single-vessel coronary angioplasty was performed via the femoral approach, with 2.0 to 3.5 mm balloon catheters, and resulted in a mean reduction of a critical coronary stenosis in each patient from 91 +/- 4% to 29 +/- 8%. The site of coronary angioplasty was the left anterior descending artery in three patients, the circumflex artery in three patients, the right coronary artery in two patients, and a bypass graft to the right coronary artery in one patient. Combined procedures were performed with a mean arterial time of 108 min. Complications included groin hematomas (n = 2), transient left bundle branch block (n = 1), and transient atrial fibrillation (n = 1). No patient experienced prolonged chest pain, myocardial infarction, major increase in aortic insufficiency, or embolic phenomena. Eight of the nine patients treated with combined procedures noted significant improvement in symptoms of angina and congestive heart failure and were discharged.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical and Doppler echocardiographic follow-up after percutaneous balloon valvuloplasty for aortic valve stenosis

Percutaneous balloon valvuloplasty has been shown to increase the aortic orifice area and to improve clinical symptoms. However, there are only few data concerning long-term results after balloon valvuloplasty. In this study, 36 patients (11 men, 25 women, mean age 75 +/- 8 years) were followed after balloon valvuloplasty for a period of up to 18 months by means of clinical parameters and repeated Doppler echocardiographic measurements after 1, 3, 6, 12 and 18 months. Invasive measurements revealed a decrease of the systolic peak gradient from 78 +/- 24 to 38 +/- 13 mm Hg (p less than 0.001), and an increase in the aortic orifice area from 0.58 +/- 0.23 to 0.93 +/- 0.2 cm2 (p less than 0.001). The Doppler echocardiographic approach revealed that the maximal instantaneous gradient decreased from 96 +/- 26 to 67 +/- 22 mm Hg (p less than 0.001). The aortic orifice area increased from 0.49 +/- 0.16 to 0.73 +/- 0.21 cm2 (p less than 0.001). Three patients (8%) died in the hospital. After hospital discharge, 16 patients (44%) died and 8 patients (22%) underwent successful aortic valve replacement after a mean follow-up of 8 +/- 6 months. Nine patients (25%) were alive after a follow-up period of 18 months. Seven of these (19%) remained clinically improved. During follow-up, the Doppler echocardiographic results revealed a continuous trend toward the preprocedural severity of the aortic valve stenosis. Progression of restenosis assessed by Doppler echocardiographic measurements was accelerated in the group of patients who subsequently died or underwent repeat balloon valvuloplasty or aortic valve replacement.     

Percutaneous transluminal aortic valvuloplasty--the acute outcome and follow-up of 149 patients who underwent the double balloon technique

Double balloon percutaneous transluminal aortic valvuloplasty (PTAV) was performed on 149 patients (76 male (51%), mean age 76 +/- 11 years) whose symptoms included severe congestive heart failure in 127 cases (82%), syncope in 21 (14%) and angina in six (4%). Significant changes (P less than 0.05) in peak systolic (83 +/- 36 to 38 +/- 30 mmHg) and mean gradient (68 +/- 25 to 36 +/- 21 mmHg), and aortic valve area (0.6 +/- 0.2 to 1.0 +/- 0.4 cm2) were achieved in 130/149 patients (87%). Complications included an overall in-hospital mortality of 13%, (10.0% excluding the six deaths occurring in 18 moribund patients), a neurologic deficit incidence of 3%, and surgical arterial entry site repair 3.0% (14/47) of patients. Multivariate analysis identified congestive heart failure (NYHA Class IV), left ventricular ejection fraction, cardiac output and coronary artery disease as independent variables significantly affecting in-hospital mortality. Predictors of poor long-term survival were degree of heart failure, and coronary artery disease. The cumulative probability of survival at 24 months was 52 +/- 5% (excluding non-cardiac deaths, was 66 +/- 3%). Follow-up (mean time: 16 +/- 7 months) of 130 patients discharged alive revealed 41 late deaths (26 cardiac related). Sixty-two patients (70%) were symptomatically improved; 17 patients had symptom recurrence and underwent repeat valvuloplasty, and 10 patients valve replacement. Follow-up catheterization of 18 asymptomatic patients revealed that 11 patients had silently restenosed. These data indicate that aortic valvuloplasty is a palliative therapy for elderly patients, who are poor surgical candidates, with symptomatic calcific aortic stenosis with reasonable clinical success and long-term survival when considering their clinical status, but with a significant restenosis rate.     

Balloon valvuloplasty for recurrent aortic stenosis after surgical valvotomy in childhood: immediate and follow-up studies

The immediate and intermediate-term effects of balloon valvuloplasty were assessed at cardiac catheterization in nine children with recurrent stenosis after a previous surgical aortic valvotomy. At valvuloplasty the patients ranged in age from 0.35 to 16 years and had undergone surgical valvotomy 0.3 to 12.5 years previously. Balloon valvuloplasty immediately reduced the peak systolic aortic stenosis gradient by 53%, from 88 +/- 9 (mean +/- SEM) to 41 +/- 6 mm Hg (p = 0.004). The left ventricular systolic pressure was reduced from 189 +/- 8 to 157 +/- 8 mm Hg (p = 0.001) and the left ventricular end-diastolic pressure from 17 +/- 1 to 14 +/- 2 mm Hg (p = 0.025). The heart rate and cardiac index remained unchanged. Before valvuloplasty, one patient had 1 + and two patients had 2+ aortic insufficiency. In six of nine patients, balloon valvuloplasty caused no change in the degree of valvular insufficiency. Two patients had a 1 + increase (from 0 to 1 + insufficiency in both), and one patient with no insufficiency developed 2+ aortic insufficiency. Elective follow-up catheterization was performed 0.8 to 2.5 years (mean 1.5 +/- 0.2) after valvuloplasty. At follow-up, the peak aortic stenosis gradient remained significantly reduced from the gradient before valvuloplasty (37 +/- 5 versus 85 +/- 10 mm Hg, p = 0.002). The gradient had not changed significantly from that measured immediately after valvuloplasty (37 +/- 5 versus 38 +/- 5 mm Hg, p = 0.75). At follow-up, aortic insufficiency had decreased from that immediately after valvuloplasty in three patients and had increased in two.(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon catheter with check valves for experimental relief of acute aortic regurgitation.

To evaluate the ability of a newly designed balloon catheter with check valves to temporarily relieve hemodynamic deterioration in acute aortic regurgitation, we produced an experimental model of acute aortic regurgitation in closed-chest dogs using endomyocardial biopsy forceps. Aortic regurgitation was produced until an increase in aortic pulse pressure of over 50% was achieved. Left ventricular end-diastolic pressure rapidly increased after the production of aortic regurgitation. Immediately after the catheter began functioning, pulse pressure decreased from 133 +/- 1 to 78 +/- 5 mm Hg (mean +/- SEM) and left ventricular end-diastolic pressure also decreased from 26 +/- 1 to 13 +/- 1 mm Hg. These effects lasted as long as the catheter functioned. Although a mild (21 +/- 8 mm Hg) pressure gradient between the left ventricular peak systolic pressure and the aortic peak systolic pressure was observed when this catheter was used, forward stroke volume was no less than in the group in which the catheter had not been used. These findings suggest that the balloon catheter with check valves may effectively reduce aortic regurgitation.     

Hemodynamic effects of inhaled nitric oxide in women with mitral stenosis and pulmonary hypertension

Mitral stenosis (MS) is associated with elevated left atrial pressure, increased pulmonary vascular resistance (PVR), and pulmonary hypertension (PH). The hemodynamic effects of inhaled nitric oxide (NO) in adults with MS are unknown. We sought to determine the acute hemodynamic effects of inhaled NO in adults with MS and PH. Eighteen consecutive women (mean age 58 +/- 15 years) with MS and PH underwent heart catheterization. Hemodynamic measurements were recorded at baseline, after NO inhalation at 80 ppm, and after percutaneous balloon valvuloplasty (n = 10). NO reduced pulmonary artery systolic pressure (62 +/- 14 mm Hg [baseline] vs 54 +/- 15 mm Hg [NO]; p <0.001) and PVR (3.7 +/- 2.5 Wood U [baseline] vs 2.2 +/- 1.4 Wood U [NO]; p <0.001). NO had no effect on mean aortic pressure, left ventricular end-diastolic pressure, left atrial pressure, cardiac output, or systemic vascular resistance. Mitral valve area increased after valvuloplasty (0.9 +/- 0.2 cm2 [baseline] vs 1.6 +/- 0.3 cm2 [postvalvuloplasty]; p <0.001). A decrease in left atrial pressure (25 +/- 4 mm Hg [baseline] vs 17 +/- 4 mm Hg [after valvuloplasty]; p <0.001) and pulmonary artery systolic pressure (58 +/- 12 mm Hg [baseline] vs 45 +/- 8 mm Hg [after valvuloplasty]; p <0.001) was observed after valvuloplasty. No change in cardiac output or PVR was observed. Thus inhaled NO, but not balloon valvuloplasty, acutely reduced PVR in women with MS and PH. This suggests that a reversible, endothelium-dependent regulatory abnormality of vascular tone is an important mechanism of elevated PVR in MS.