Percutaneous balloon valvotomy in tricuspid stenosis

This report describes the first successful treatment of tricuspid stenosis by percutaneous double balloon valvotomy. There was a dramatic reduction of the tricuspid valve gradient, with an increase in calculated valve area, together with an increase in resting cardiac output and symptomatic relief. The feasibility of the non-surgical treatment of severe tricuspid stenosis was demonstrated unequivocally.     

Percutaneous double balloon valvotomy for bioprosthetic tricuspid stenosis

We report two cases of percutaneous balloon valvotomy of porcine tricuspid valves and review the brief literature. Both procedures were successful, but “restenosis” resulted in tricuspid valve replacement in patient 2. The explanted valve showed leaflet thickening and calcified cuspal nodules. Patient 1 is improved 10 months later. © Wiley-Liss, Inc.     

Percutaneous balloon valvotomy in tricuspid stenosis.

This report describes the first successful treatment of tricuspid stenosis by percutaneous double balloon valvotomy. There was a dramatic reduction of the tricuspid valve gradient, with an increase in calculated valve area, together with an increase in resting cardiac output and symptomatic relief. The feasibility of the non-surgical treatment of severe tricuspid stenosis was demonstrated unequivocally.     

Percutaneous double balloon tricuspid valvotomy for severe tricuspid stenosis: 3-year follow-up study

We performed percutaneous double balloon tricuspid valvotomy in four patients (36 +/- 12 years of age), with severe symptomatic rheumatic tricuspid stenosis and mild mitral valve disease. Two 9F Meditech balloon catheters, 15-20 mm diameter, were positioned simultaneously across the tricuspid valve and inflated up to five atmospheres pressure achieving valvotomy. After balloon valvotomy there was symptomatic improvement, and the Doppler tricuspid valve area was increased from a mean of 1 +/- 0.2 to 2.2 +/- 0.2 cm2 (P less than 0.001). At 3-year follow-up the symptomatic improvement persisted and the mean tricuspid valve area was maintained at 2.2 +/- 0.1 cm2. During the follow-up period there was no increase in degree of tricuspid regurgitation assessed by colour Doppler. We conclude that 3 years after balloon valvotomy of the tricuspid valve, the 120% increase in valve area persists, with no objective evidence of restenosis.     

Percutaneous balloon valvotomy for patients with severe mitral stenosis

Thirty-five patients with severe mitral stenosis underwent percutaneous mitral valvotomy (PMV). There were 29 female and six male patients (mean age 49 +/- 3 years, range 13 to 87). After transseptal left heart catheterization, PMV was performed with either a single- (20 patients) or double- (14 patients) balloon dilating catheter. Hemodynamic and left ventriculographic findings were evaluated before and after PMV. There was one death. Mitral regurgitation developed or increased in severity in 15 patients (43%). One patient developed complete heart block requiring a permanent pacemaker. PMV resulted in a significant decrease in mitral gradient from 18 +/- 1 to 7 +/- 1 mm Hg (p less than .0001) and a significant increase in both cardiac output from 3.9 +/- 0.2 to 4.6 +/- 0.2 liters/min (p less than .001) and in mitral valve area from 0.8 +/- 0.1 to 1.7 +/- 0.2 cm2 (p less than .0001) Effective balloon dilating diameter per square meter of body surface area correlated significantly with the decrease in mitral gradient but did not correlate with the degree of mitral regurgitation. There was no correlation of age, prior mitral commissurotomy or mitral calcification with hemodynamic results. PMV is an effective nonsurgical procedure for patients with mitral stenosis, including those with pliable valves, those with previous commissurotomy, and even those with mitral calcification.     

Concurrent double balloon valvotomy for combined rheumatic mitral and tricuspid stenosis

We expanded the application of percutaneous balloon valvotomy (PBV) to 4 adults (age 14 to 30 years, average 22.2 years) with combined rheumatic mitral and tricuspid stenosis. Double balloon dilatation reduced the transmitral gradient from 17.36 +/- 3.54 to 5.52 +/- 0.89 (P less than 0.025) and transtricuspid gradient from 12.65 +/- 2.67 to 3.67 +/- 0.95 (P less than 0.025). Mitral and tricuspid valve area increased from 0.73 +/- 0.20 to 2.57 +/- 0.67 (P less than 0.005) and from 0.77 +/- 0.24 to 2.67 +/- 0.24 cm2 (P less than 0.005), respectively. The procedures were well tolerated, with no significant increase in valvular regurgitation or left to right shunt across the atrial septum. The excellent symptomatic and haemodynamic benefits are sustained at 3-24 months follow-up. It is concluded that combined dilatation of stenotic valves by double balloon technique can emerge as an alternative to surgery in selected patients with polyvalvar rheumatic heart disease.     

Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis

Background

Significant tricuspid regurgitation (TR) is occasionally associated with severe mitral stenosis and has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery. However, the effect of successful mitral balloon valvotomy (MBV) on significant TR is not fully elucidated. The aim of this study was to investigate TR after MBV in patients with severe mitral stenosis.

Methods

We analyzed the data of 53 patients with significant TR (grade ≥2, on a 1 to 3 scale) from the mitral balloon valvotomy database at our hospital. Patients were evaluated by Doppler echocardiography before valvotomy and at follow-up 1 to 13 years after MBV. Patients were divided into group A (27 patients), in whom TR regressed by ≥1 scale, and group B (26 patients), in whom TR did not regress.

Results

The Doppler-determined pulmonary artery systolic pressure was initially higher and decreased at follow-up more in group A (from 70.7 ± 23.8 to 36.5 ± 8.3 mm Hg; P < .0001) than in group B (from 48.7 ± 17.8 to 41.6 ± 13.1 mm Hg; P = NS). Compared with patients in group B, patients in group A were younger (25 ±10 vs 35 ± 11 years; P < .005), had higher prevalence of functional TR (85% vs 8%; P < .0001), and had lower incidence of atrial fibrillation (7% vs 38%; P < .005). Significant decrease in right ventricular end-diastolic dimension after MBV was noted in group A but not in group B. The mitral valve area at late follow-up was larger in group A than in group B (1.8 ± 0.3 vs 1.6 ± 0.3 cm²; P < .05).

Conclusions

Regression of significant TR after successful MBV in patients with severe mitral stenosis was observed in patients who had severe pulmonary hypertension. This improvement in TR occurred even in the presence of organic tricuspid valve disease.     

Percutaneous mitral balloon valvotomy

Percutaneous balloon mitral valvotomy is a technique that allows relief of mitral stenosis without thoracotomy. Commissurotomy of the mitral valve with proper sized balloons that are placed antegrade by means of a transseptal catheterization results in good immediate and midterm results in most patients. Younger patients with echocardiographic scores of 8 or lower and who are without atrial fibrillation, mitral regurgitation or valvular calcification, and histories of surgical commissurotomy are the best candidates for PMV. Nevertheless, many patients who are not ideal candidates for PMV also derive substantial relief from this procedure. Mortality and morbidity related to the procedure are low in most experienced centers. Complications include pericardial tamponade, thromboembolism, rhythm abnormalities, left to right shunting, and mitral regurgitation. The survival with freedom from mitral valve replacement at 2 years after PMV is 84%. In addition to history and physical examination, echocardiography has a central role in the selection of patients for PMV.     

Mitral balloon valvotomy for the treatment of mitral stenosis in octogenarians

OBJECTIVES: To study the safety and benefit of mitral balloon valvotomy (MBV) in patients aged > or =80 years. SETTING: A tertiary cardiac centre DESIGN: A retrospective study of 20 octogenarians (mean age 83, range 80-89 years) in whom percutaneous MBV was performed as a definitive or palliative treatment for severe mitral stenosis. All were in New York Heart Association (NYHA) symptom class III or IV. Fourteen had been judged unfit for cardiac surgery. Hemodynamic data was recorded before and after MBV. Symptomatic outcome was documented at 1 month for all patients. Outcome at 1 year was available for 16 patients. RESULTS: Dilatation of the mitral valve was achieved in all patients without major complications. Mean mitral valve area increased 106% from 0.81 (+/-0.3) to 1.67 (+/- 0.8) cm2, transvalvular gradient decreased from 11.8 (+/- 4.8) to 5.6 (+/-2.9) mm Hg, cardiac output increased from 3.1 (+/- 0.6) to 4.1 (+/- 1.4) l/min (all P<.01). Eight of these 20 patients obtained a valve area > or =1.5 cm2, and 16 obtained an area > or = 1.2 cm2. One month after BMV, all patients were alive, and 16 of the 20 patients were improved by at least one NYHA class. This improvement was sustained in 7 of 16 patients followed up for 1 year. More severe mitral valve degenerative change, determined by echocardiography, was associated with poorer outcome. CONCLUSIONS: In this group of very old and frail patients, MBV was safe and resulted in significant immediate improvement. Sustained symptomatic benefit at 1 year was obtained in those with less extensive leaflet and subvalvular disease. In patients with severe degenerative valve disease on echocardiography, but unacceptable surgical risk, MBV offers short-term palliation.     

Percutaneous mitral balloon valvotomy.

Percutaneous mitral balloon valvotomy (PMBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, PMBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of PMBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0-0.5%), cerebral accident (0.5-1%), mitral regurgitation (MR) requiring surgery (1.6-3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with PMBV and surgical commissurotomy. Restenosis after PMBV ranges from 4 to 70% depending on the patient selection, valve morphology, and duration of follow up. Restenosis was encountered in 21% of the author's series at mean follow-up 6 +/- 4.5 years and the 10 and 15 years restenosis-free survival rates were (70 +/- 3)% and (44 +/- 5)%, respectively, and were significantly higher for patients with favorable mitral morphology (85 +/- 3% and 65 +/- 6%), respectively (P < 0.0001). The 10 and 15 years event-free survival rates were (79 +/- 2)% and (43 +/- 9)% and were significantly higher for patients with favorable mitral morphology (88 +/- 2)% and (66 +/- 6)%, respectively (P < 0.0001). The effect of PMBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of PMBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.     

Percutaneous balloon valvuloplasty for concurrent mitral, aortic and tricuspid rheumatic stenosis

Percutaneous balloon valvuloplasty has been used with good resultsto treat rheumatic mitral stenosis. However, its use in degenerativeaortic stenosis has shown many limitations. There is littleinformation about balloon valvuloplasty in tricuspid and aorticrheumatic stenosis. This article describes two patients withcombined rheumatic mitral, aortic and tricuspid stenosis inwhich triple percutaneous valvuloplasty was performed in a singleprocedure.     

Percutaneous transvenous balloon valvotomy in a patient with severe calcific mitral stenosis

Percutaneous transvenous balloon mitral valvotomy was performed successfully in a 57 year old man with refractory congestive heart failure due to calcific mitral stenosis. Cardiac surgery was not an option because of other major medical problems. Balloon mitral valvotomy was performed using the transseptal technique. The interatrial septum was dilated with the use of an 8 mm balloon catheter to allow passage of larger balloon valvotomy catheters to the mitral anulus. The procedure resulted in a marked decrease in the diastolic transmitral gradient from 20 to 4 mm Hg. This decrease was associated with an increase in cardiac output from 3.4 to 5.7 liters/min. Mitral valve area increased from 0.7 to 2.5 cm2. Balloon valvotomy did not result in significant mitral regurgitation. This case indicates that further trials are warranted to evaluate percutaneous transseptal mitral valvotomy for the treatment of patients with mitral stenosis.     

Percutaneous mitral balloon valvotomy during pregnancy in a patient with severe mitral stenosis

Percutaneous mitral balloon valvotomy (PMV) was performed successfully in a 41-year-old pregnant patient with severe mitral stenosis. The patient had a 21-week gestation and was severely limited by symptoms resulting from critical mitral stenosis. PMV resulted in a decrease in the diastolic mitral gradient from 26 to 2 mm Hg and an increase in both cardiac output (from 4.2 to 5.7 l/min) and mitral valve area (from 0.7 to 3.7 cm2). She had marked symptomatic improvement, no further heart failure, and a full-term, normal delivery. This case report indicates that PMV may be the treatment of choice in the management of pregnant patients with incapacitating symptoms caused by severe mitral stenosis.     

Percutaneous valvotomy in the combination of mitral and tricuspid valve stenosis. Report of 3 cases

The authors report the results of a series of 3 cases of double valvuloplasty with a balloon catheter in young patients with combined mitral and tricuspid stenosis. Haemodynamic and Doppler echocardiographic evaluation after the procedure showed comparable results to those of surgical commissurotomy without significant secondary valvular regurgitation. Clinical and echocardiographic follow-up showed that valvular opening remained satisfactory in the 2 cases examined. Percutaneous valvuloplasty would seem to be a valuable alternative to surgical commissurotomy in selected patients with combined mitral and tricuspid valve stenosis.     

Neonatal isolated critical aortic valve stenosis: balloon valvuloplasty or surgical valvotomy

BACKGROUND: Open surgical valvotomy and transcatheter balloon valvuloplasty are recognised treatments for neonatal critical aortic stenosis. METHODS: A retrospective analysis was undertaken of all newborns with critical aortic valve stenosis between 1990 and 2000 presenting to a tertiary centre and who required intervention. The initial catheter and surgical intervention was generally based on the preference of the attending cardiologist and the anatomy of the aortic valve and in consultation with the cardiothoracic surgeon. The two groups were therefore not strictly comparable. Twelve were subjected to balloon valvuloplasty and thirteen to surgical valvotomy at a median age of 11 days (2-42 days) and 3.5 days (1-19 days) respectively. There was no significant difference in the timing of the procedure, weight of the infant, aortic annulus or left ventricular dimensions in either group. RESULTS: There was one unrelated hospital death in the balloon group compared to two in the surgical group both of whom had endocardial fibroelastosis. Mild to moderate aortic regurgitation was seen after both procedures. Four patients in the balloon valvuloplasty group, developed femoral artery thrombosis and two had cardiac perforation that resolved with non operative management. The mean Doppler gradient was reduced from 44+/-14 mmHg to 13.4+/-5 mmHg (p<0.01) in the valvuloplasty group compared to a reduction from 42+/-15 mmHg to 27+/-8 mmHg (p<0.05) in the surgical group. Five patients in the balloon group required re-intervention within 3 weeks to 21 months after the initial procedure. Two patients in the surgical group required a pulmonary autograft and Konno Procedure 3 and 5 years following surgical valvotomy. CONCLUSION: Both aortic valvuloplasty and valvotomy offered effective short and medium term palliation. Balloon valvuloplasty patients had a higher re-intervention rate but shorter hospital and intensive care stay, reduced immediate morbidity and were associated with less severe aortic regurgitation.     

Fate of tricuspid regurgitation after closed valvotomy for mitral stenosis

Rheumatic mitral valve disease is not infrequently associated with tricuspid regurgitation (TR). To determine the fate of TR following closed mitral valvotomy (CMV), we examined the records of 23 patients with variable degrees of TR and significant mitral stenosis (MS). Based on angiocardiographic assessment of TR, patients were divided into two groups: group 1 (15 patients) had mild-to-moderate TR, while group 2 (eight patients) had severe TR. After valvotomy, dyspnea lessened in all patients. Right ventricular (RV) failure signs (jugular venous distension and hepatomegaly) and the amounts of diuretics used diminished in 12 of 15 patients in group 1. Group 2 patients showed insignificant improvement at one-year follow-up period. Cardiac recatheterization was performed in four of group 2 patients three to five years later primarily for persistence of RV failure signs. The mitral valve areas varied from 1.4 to 2.7 cm2. There was mild mitral regurgitation in two patients. There was no deterioration of the left ventricular ejection fraction, but TR was at least moderate in all cases.