Balloon coarctation angioplasty in adolescents and adults: early and intermediate results.

Twenty-three adolescent and adult patients with native coarctation of the aorta underwent balloon dilatation. Dissection of the aorta developed in one patient. Data were collected on the remaining 22 patients. They ranged in age from 15 to 55 years (mean 23 +/- 9.2 years). Invasive measurement of the peak systolic gradient (PSG) and biplane angiography were performed before and immediately after angioplasty and at follow-up 4 to 48 months (mean 15 months) later. PSG before dilatation was 37 to 100 mm Hg (mean 66.9 +/- 19.9 mm Hg) and decreased to 0 to 30 mm Hg (mean 9.1 +/- 11 mm Hg) immediately after dilatation (p less than 0.001). Restenosis occurred in two patients 6 months after dilatation, and one patient had an incomplete dilatation. These three patients underwent successful redilatation and remained improved 12 to 19 months later. There was no significant change in gradient at repeat catheterization in the remaining 20 patients. PSG was 0 to 20 mm Hg (mean 5.8 +/- 7.2 mm Hg). Angiography showed that a small aneurysm developed in one patient immediately after dilatation and in another 6 months later. Eleven patients were restudied more than once, and no change in gradient or size of the aneurysm was noted at mean follow-up 25 months after dilatation. This study demonstrated that balloon angioplasty is an effective method of treating adolescent and adult patient with native coarctation of the aorta. However, because of the uncertain natural history of aneurysm after dilatation, this procedure should be considered investigational until much longer follow-up times are available.     

Balloon angioplasty of the aorta in Takayasu's arteritis: initial and long-term results.

Percutaneous transluminal balloon angioplasty for stenosis of the aorta was performed in 36 patients with Takayasu's arteritis (age range, 8 to 36 years; mean, 19.1 +/- 7.7 years). Balloon dilatation was successful in 34 patients and resulted in a decrease in the mean peak systolic pressure gradient (PSG) from 75.2 +/- 29.1 mm Hg to 24.8 +/- 19 mm Hg (p less than 0.001) and a mean increase in the diameter of the stenosed segments from 4.5 +/- 2.2 mm to 9.6 +/- 3.8 mm (p less than 0.001). Hemodynamic and angiographic restudy, which was performed in 20 patients at a mean follow-up period of 7.7 +/- 4.1 months (range, 3 to 24 months), showed a further decrease in PSG (greater than or equal to 15 mm Hg) in seven patients (from 40.0 +/- 11.2 mm Hg to 15.7 +/- 10.2 mm Hg; p less than 0.01), no significant change in PSG in 12 patients (17.1 +/- 13.6 mm Hg vs 16.6 +/- 12.7 mm Hg; p = NS), and an increase in PSG from 15 mm Hg to 85 mm Hg in one patient. The patient who showed restenosis underwent successful redilatation. Six patients who underwent late recatheterization and angiography at 36 to 60 months (mean, 43 +/- 9.4 months) show continued relief of stenosis (mean PSG, 8.8 +/- 7.8 mm Hg). Patients with short-segment (less than 4 cm) stenosis experience more relief than patients with long-segment (greater than or equal to 4 cm) stenosis (residual PSG, 18.6 +/- 8.2 mm Hg vs 40 +/- 16 mm Hg; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon valvuloplasty for pulmonary valvular stenosis: a long-term follow-up study using pulsed Doppler echocardiography

From June 1984 to March 1987, percutaneous balloon valvuloplasty (PBV) was performed for 22 patients with congenital pulmonary valvular stenosis. It was successful for 20 patients, and there were significant decreases of transvalvular pressure gradients; 72 +/- 30 mmHg before PBV, and 30 +/- 12 mmHg immediately after PBV (p less than 0.001). In a follow-up study, pulsed Doppler echocardiography and cardiac catheterization were used to examine changes in long-term hemodynamic findings after PBV. One year follow-up evaluation was performed for 14 patients, and two year follow-ups for seven patients. One year after PBV the transvalvular pressure gradients were evaluated during cardiac catheterization in 11 patients, and using pulsed Doppler echocardiography in the remaining three patients. The gradients of the seven patients at two year intervals after PBV were evaluated using pulsed Doppler echocardiography. The pressure gradients of two patients improved further one year later due to the anatomical degradation in the right ventricular outflow tracts. For seven patients, two year follow-up evaluations were performed, and the transvalvular pressure gradient reduced from 84 +/- 23 to 33 +/- 15 mmHg (p less than 0.001) immediately afterwards; to 27 +/- 22 mmHg (p less than 0.01) one year later; and further to 12 +/- 5 mmHg (p less than 0.001) two years after PBV. Second PBV was performed for three patients in whom a residual gradient was recognized, with the good results. On auscultation, a pulmonary regurgitant murmur was recognized in 28% of 18 patients immediately after PBV, but 80% of this resolved one year later. Two patients had pulmonary regurgitation with pulmonary valvular stenosis before PBV.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous pulmonary valvuloplasty. Short-term and long-term results

Percutaneous angioplasty was performed in twenty consecutive patients, with congenital pulmonary valve stenosis. Ages ranged from eight months to thirty-two years (mean 9.5 years old). We achieved a valvular gradient dropping from 91 +/- 39 to 19 +/- 11 mm Hg (P less than 0.001) in early post angioplasty level and it was practically unchanged at three months and one year later. (19 +/- 12, 19 +/- 17 mm Hg) (P less than 0.001). Similar change was observed in the right ventricle systolic pressure which was diminished in a progressive way during the follow-up from 113 +/- 37 to 39 +/- 35 (P less than 0.001), 59 +/- 18 and 53 +/- 25 mm Hg (P less than 0.001) immediately, three months and one year later, respectively. The ratio right ventricle systolic pressure/left ventricle was diminished from 0.96 +/- 29 to 0.63 +/- 0.35 in the early post angioplasty period and later from 0.50 +/- 0.16 and 0.44 +/- 0.22 (P less than 0.001). Only one case had restenosis one year later and we repeated the angioplasty with good results. Most of the patients are asymptomatic, the pulmonary murmur features changed. We observed improvement in electrocardiographic and echocardiographic signs. One patient died of anesthetic complications. The remainder of patients did not have severe complications and they were discharged from 48 to 72 hours after angioplasty. In conclusion, valvuloplasty is an effective procedure in a short and long term basis. We considered valvuloplasty in congenital pulmonary valve stenosis the treatment of choice in this group of patients.     

Balloon catheter dilation of severe pulmonary restenosis 11 years after surgical valvulotomy

A young girl who underwent repair of an atrial septal defect and pulmonary valvulotomy when 6 years of age, presented with clinical and haemodynamic signs of pulmonary restenosis 11 years later: right ventricular systolic pressure (RVSP) of 130 mmHg with a systolic RV/PA pressure gradient of 105 mmHg. Pulmonary valvuloplasty was performed using a balloon catheter (20 mm X 40 mm). Two inflations were necessary to correct the hour glass deformity of the balloon caused by the stenosis. After valvuloplasty the RVSP was 75 mmHg and the RV/PA gradient 55 mmHg. The calculated pulmonary valve surface area increased from 0.36 cm2 to 0.72 cm2. Angiography performed immediately after dilatation showed improved valvular mobility but here was persistant severe infundibular hypertrophy. The intensity of the pulmonary systolic murmur decreased. The good result obtained in this case shows that percutaneous valvuloplasty may be considered when restenosis occurs several years after surgical valvulotomy. Control catheterisation performed two months after dilatation confirmed the good initial haemodynamic result.     

Success determining factors in percutaneous transluminal balloon valvuloplasty of pulmonary valve stenosis

Twenty-two percutaneous transluminal balloon valvuloplasty procedures were performed on 21 patients with congenital pulmonary valve stenosis. The peak systolic pressure gradient was immediately reduced from 79.1 +/- 7.4 to 22.2 +/- 1.8 mmHg, (P less than 0.0001) and follow-up cardiac catheterization at 5.3 +/- 0.4 months in 19 patients revealed no further significant change in gradient (23.5 +/- 3.2 mmHg). The best results were obtained when balloons larger than the pulmonary annulus were used, i.e. an immediate residual transvalvular gradient of 22.0 +/- 2.2 mmHg with a balloon/annulus ratio greater than 1, as opposed to 44.2 +/- 5.4 with a balloon/annulus ratio = 1 (P less than 0.001). The angiographically determined cusp thickness of the stenotic pulmonary valves was significantly greater than that of the control group of 24 patients without pulmonary valve stenosis (1.21 +/- 0.09 vs 0.59 +/- 0.02 mmHg, P less than 0.00001). The relationship between this parameter and the residual transvalvular gradient at follow-up was found to be significant (r = 0.77, P less than 0.001). It is concluded that balloon size is a determinant factor in achieving good results with percutaneous balloon valvuloplasty although cusp thickness, a factor to which scant regard has hitherto been paid, also plays a significant role in the residual transvalvular gradient measured at follow-up.     

Percutaneous transluminal angioplasty in aortic coarctation in adolescents and adults. Mid-term results]

From October 1985 to February 1992 we performed 80 percutaneous transluminal angioplasty (PTA) in 76 patients with coarctation of the aorta (CoAo). Sixteen of them with ages ranging from 12 to 62 years (mean = 21.1). We describe the experience in these cases. Fifteen with native and one with post-surgical coarctation. The gradient decreased from 72 +/- 33 to 18 +/- 17 mmHg immediately after dilation, in the follow-up (1 to 69 months m = 25) was 23 +/- 20 mmHg. In one patient we performed simultaneously angioplasty of CoAo and mitral valvuloplasty with excellent results in both lesions. We redilated two cases for residual gradient successfully. We had one failure in a patient with long coarctation. He needed surgery. In the initial experience we had one severe complication (cerebral stroke). No deaths or aneurysms. In conclusion we believe that PTA is an adequate alternative in adolescents and adults with native or post-surgical coarctation of the aorta with minimum incidence of complications.     

Follow-up of balloon aortic valvuloplasty in young adults--a combined hemodynamic and Doppler echocardiographic study

Percutaneous Balloon Valvuloplasty was performed in 25 patients with severe aortic stenosis (Aortic valve area index: 0.23 to 0.70, mean 0.36 +/- 0.11 cm2/m2). The mean age was 23 +/- 15 (range 6-66) years, and majority (n = 18) had noncalcific valves. Valve morphology was bicuspid in 14, tricuspid in 6 and indeterminate in 5. Valvuloplasty resulted in a fall of peak systolic gradient (PSG) from 112 +/- 35 to 34 +/- 16 mmHg (p less than 0.001), and an increase in aortic valve area (index) (AVAI) from 0.36 +/- 0.11 to 0.82 +/- 0.43 cm2/m2 (p less than 0.001). Follow-up data at 16 +/- 6 months were available for 18 patients, 80 per cent of whom registered symptomatic improvement. Repeat catheterization, performed in 12 cases, showed increase of PSG to 53 +/- 22 mmHg and a fall in AVA (1) to 0.62 +/- 0.24 cm2/m2, as compared to the results immediately following the procedure. In addition, 3 patients had their valve areas estimated by doppler echocardiography. Forty-six per cent of these 15 patients (n = 7) showed evidence of restenosis. Four out of these 7 cases had calcific valves, whereas none of the patients who had sustained improvement had calcification. Tricuspid morphology was present in 50 per cent of the group with sustained improvement, as compared to 20 per cent of the group that restenosed. Our preliminary data shows sustained hemodynamic improvement after balloon dilatation in young patients with severe aortic stenosis with noncalcific and tricuspid aortic valve.     

Transluminal balloon dilatation for discrete subaortic stenosis in adults and children: early and intermediate results

Seven patients (four adults, three children) with discrete subaortic membranous stenosis underwent balloon dilatation using a single or double balloon technique with reduction in systolic gradient across the membrane from 100.42 +/- 19.23 to 29.14 +/- 12.54 mmHg (P less than 0.001). Echocardiography demonstrated thin membranes in all the patients and postprocedure torn fragments could be visualized. The excellent hemodynamic benefits are sustained during 4-24 months follow-up. The results indicate that transluminal balloon dilatation can be a safe and effective treatment for thin subaortic membrane.     

Value of ventricular geometry in the evaluation of direct ventricular pressure

OBJECTIVE: To determine the echocardiographic end-systolic ventricular geometry value in evaluating right ventricular systolic pressure (RVSP). MATERIAL AND METHODS: We studied prospectively 68 patients (mean age = 6.0 +/- 5.0 years), submitted to cardiac catheterization for cardiac disorders not involving left ventricular (LV) outflow tract obstruction, within 24 hours after two-dimensional echocardiographic (2D echo) examination. 2D echo evaluation of RVSP was performed using end-systolic LV transverse orthogonal diameters (TDR). The LV transverse orthogonal diameters (antero-posterior and supero-inferior) were measured on a parasternal short-axis image, at the tips of papillary muscles. 2D echo semi-quantitative evaluation of RVSP was tested correlating TDR with hemodynamic RVSP/LV systolic pressure (LVSP) ratio--group 1. We also used regression equation derived from the first 35 patients to quantify RVSP in the last 33 patients--group 2. In these cases, systolic systemic arterial pressure measured by sphygmomanometry was taken as LVSP. RESULTS: The TDR ranged from 1.0 to 2.1 (mean = 1.5 +/- 0.3) and the RVSP/LVSP ratio from 0.3 to 1.7 (mean = 0.7 +/- 0.4). All patients with RVSP/LVSP greater than or equal to 65% have TDR greater than or equal to 1.3 and when RVSP less than or equal to 35 mmHg we always obtained TDR less than or equal to 1.2. The correlation between 2D echo estimated and catheter measured RVSP shows, for group 1, r = 0.88 and y = 1.1X-0.88 and, for group 2'. r = 0.88. CONCLUSION: In the absence of LV systolic obstruction, TDR is a reliable non invasive method in evaluating the RVSP.     

Aortic valve area evolution after percutaneous aortic valvuloplasty. A prospective trial using a combined Doppler echocardiographic and haemodynamic method

The aortic valve area was serially evaluated in 45 patients, mean age 78 years, suffering from severe aortic stenosis who underwent percutaneous aortic valvuloplasty. The aortic valve area was calculated from haemodynamic data prior to and immediately after the procedure using the mean gradient. Serial determinations of the aortic valve area were also obtained 1 day before, 1 day after and 2 months after valvuloplasty from the thermodilution cardiac output and Doppler echocardiography mean left ventricle-to-aorta gradient. The mean gradient significantly decreased from 75 +/- 24 to 42 +/- 16 mmHg (P less than 0.01) when measured from haemodynamic data and from 63 +/- 20 to 41 +/- 13 mmHg (P less than 0.01) when estimated from Doppler-derived data. It rose to 48 +/- 15 mmHg at 2 months (NS). The aortic valve area increased significantly from 0.48 +/- 0.13 to 0.67 +/- 0.29 cm2 (P less than 0.01) when calculated from haemodynamic data, and from 0.53 +/- 0.18 to 0.74 +/- 0.23 cm2 (P less than 0.01) when estimated from Doppler-derived data. It declined to 0.69 +/- 0.27 cm2 at 2 months (NS). Aortic valve area values determined from haemodynamic data and from Doppler-derived data correlated well before valvuloplasty (r = 0.80, P less than 0.01) but poorly afterwards (r = 0.57, P less than 0.01). The aortic valve area was not influenced by valvuloplasty in eight patients. At 2 months, restenosis was apparent in eight patients out of 32 that were re-evaluated. Three patients died within 5 days of the procedure. After an average 12 months' follow-up, eight more patients died. Symptoms were not influenced or recurred in 17 patients, while 17 others remained improved by at least one NYHA functional class. Seven patients were operated on, and there was one operative death. The calculated aortic valve area was significantly greater at the end of the procedure in the patients with persistent improvement compared with those with a poor result (0.83 +/- 0.29 cm2 vs 0.65 +/- 0.14 cm2, P less than 0.05). In conclusion, in this study one third of the patients submitted to percutaneous aortic valvuloplasty had no objective improvement in calculated valve area or early restenosis after 2 months. Functional improvement was observed in one third of the patients. Immediate re-estimation of the aortic valve area from haemodynamic data at the end of the procedure may not reflect the actual effect of valvuloplasty on the aortic orifice.     

Factors influencing late course of residual valvular and infundibular gradients following pulmonary valve balloon dilatation.

BACKGROUND: Though acute and follow-up benefits of pulmonary valve balloon dilatation (PVBD) for pulmonic valve stenosis are well known, the late course of residual gradients at individual valvular and infundibular levels is not well described. Furthermore, the factors influencing this late course have not been studied. MATERIALS AND METHODS: We assessed the transpulmonary gradients by echo-Doppler in 96 patients (61 male, mean age 10.7 years) at a mean follow-up interval of 58.8+/-32.1 months (minimum 2 years) following PVBD. The patients were divided into three groups based on the residual gradients at valvular and infundibular levels immediately following PVBD as assessed by pull-back of an end-hole catheter across the right ventricular outflow tract: Group A with minor pressure gradients at both valvular and infundibular levels of less than 30 mmHg (n=60, 62.5%), Group B with predominantly infundibular gradients of more than 30 mmHg with a valvular gradient of less than 30 mmHg (n=27, 28.1%), and Group C with a residual valvular gradient of greater than 30 mmHg irrespective of the infundibular gradient (n=9, 9.4%). Demographic characteristics, hemodynamic parameters and procedural variables were correlated with the change in gradient at follow-up (late fall) and with long-term results. RESULTS: The mean follow-up trans-pulmonary gradient was 20+/-14 mmHg which was significantly lower than that immediately post-PVBD (43+/-32 mmHg), P<0.001. The late fall (mean 24+/-29, range -55 to 110 mmHg) varied widely depending upon the acute result group: patients in Groups A and B showed significant late fall of 9+/-12 mmHg (P<0.05 for follow-up gradient compared to that following PVBD) and 58+/-31 mmHg (P<0.0001), respectively, while patients in Group C showed an insignificant late fall of 14+/-37 mmHg (P=0.21). In particular, each one of the patients in Group B showed decrease in trans-pulmonary gradients. On multivariate analysis, the extent of infundibular gradient emerged as the most important predictor of late fall (coefficient of determination 75%, P<0.0001). Patients who underwent PVBD at less than 2 years of age had a significantly greater late fall (41+/-33 mmHg) as compared to older patients (22+/-25 mmHg), P<0.05. A sub-optimal long-term result (transpulmonary gradient >25 mmHg, n=24) was significantly related to older age (P<0.001), dysplastic valve morphology (P=0.002), greater baseline trans-pulmonary gradients (P<0.001) and higher post-PVBD gradients (P=0.04). CONCLUSIONS: The long-term course of patients following PVBD depends upon the site and magnitude of the residual gradients. Even high residual infundibular gradients show marked reduction at follow-up, especially in infancy.     

Differential hemodynamic effects of Hypaque-76 and Renografin-76 during coronary angiography: the role of calcium-binding additives

Hypaque-76 (H76) and Renografin-76 (R76) are nearly identical ionic contrast media, except that R76 binds more calcium than H76 because of the presence of sodium citrate and EDTA in R76. To determine whether the calcium-binding additives in ionic contrast media contribute to the hemodynamic effects of contrast media during coronary angiography, left coronary angiography was performed in anesthetized dogs. In nine closed-chest dogs, 10 cc of H76 and R76 were injected in each dog in a blinded, randomized fashion. The effect of H76 and R76 on left ventricular systolic pressure (LVSP) and left ventricular diastolic pressure (LVDP), on mean aortic pressure (MAP), and on left ventricular (LV) dp/dt was recorded. Compared with H76, R76 produced a greater decrease in the LVSP (77 +/- 25 mmHg vs 48 +/- 17 mmHg P less than .05), MAP (72 +/- 24 mmHg vs 38 +/- 18 mmHg P less than .01), and LV dp/dt (747 +/- 87 mmHg/sec vs 460 +/- 81 mmHg/sec P less than .01). In nine additional open-chest dogs, left coronary angiography was performed 1 hour after occlusion of the proximal LAD coronary artery. Seven cc R76 produced a 35 +/- 15 mmHg decrease in LVSP, compared with 20 +/- 9 mmHg with H76 (P less than .01). The LV dp/dt decreased 720 +/- 387 mmHg/sec with R76, compared with 462 +/- 222 mmHg/sec with H76 (P less than 0.05). Thus, R76 produces significantly greater hemodynamic abnormalities than H76. Contrast media lacking calcium-binding agents may be preferable for coronary angiography.     

Percutaneous mitral commissurotomy: immediate and short-term results]

31 symptomatic patients with mitral stenosis were selected for percutaneous transvenous mitral commissurotomy using Inoue catheter. The patients were selected using the echocardiographic score for: leaflets mobility, leaflets thickening, subvalvular thickening, degree of calcifications. All patients had a score less than or equal to 8 and represented 17.5% of the patients studied in our echocardiographic laboratory for mitral stenosis. We were able to perform the commissurotomy in 30 of them. Mean left atrial pressure decreased from 26 +/- 5.2 mmHg to 14.6 +/- 6 mmHg (p less than 0.001). The mean mitral diastolic pressure gradient decreased from 8.9 +/- 3.1 mmHg to 3.9 +/- 1.3 mmHg (p less than 0.001). The mitral valve area, using the echocardiographic Pressure Half Time (PHT), increased from 0.94 +/- 0.17 cmq to 1.96 +/- 0.33 cmq (p less than 0.001). Mitral regurgitation, angiographically evaluated in 29 patients, increased in 11 (38%), being of degree + + + in 3 patients. There were 2 heart tamponades and 5 cases (16.6%) of left-to-right shunt with Qp / Qs less than 2. After 3 months, the follow-up showed improvement of one or more functional classes in 96.6% of all patients. The mitral valve area, determined after 6 months in 24 patients by PHT, was stable (1.98 +/- 0.31 vs 1.93 +/- 0.25) (p = 0.5); we did not find mitral stenosis recurrence in any instance. In the first 10 patients, after 1 year, the results are stable (1.85 +/- 0.28 cmq vs 1.93 +/- 0.21 cmq) (p = 0.5) without mitral stenosis recurrence. These data suggest that in selected tight mitral stenosis the percutaneous transvenous commissurotomy may be alternative to the open surgical solution. Using an Inoue catheter, the percutaneous transvenous mitral commissurotomy is easier and the complications are few. The major procedural hazards derive from the transseptal technique.     

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.     

Pulmonary orifice stenosis: the medical solution. Apropos of 62 cases

Sixty two patients with moderate or severe stenosis of the pulmonary orifice (SPO) underwent balloon catheter valvuloplasty. Thirty one were aged under 5 years. The mean right ventricle-pulmonary artery trunk (RV-PAT) gradient fell from 75 (+/- 26) to 23 (+/- 10) mmHg (p less than 0.001). All dilatations except one were effective with only a few incidents and no mortality. Six (+/- 2) months later, hemodynamic evaluation of 45 patients (70%) showed stability of the RV-PAT gradient at 26 (+/- 18) as compared with 23 (+/- 11) mmHg. Ten patients required a second dilatation because of a residual gradient of greater than 35 mmHg. The result was favourable in all ten cases, the RV-PAT gradient falling from 53 (+/- 17) to 13 (+/- 8) mmHg (p less than 0.001). This series confirmed the efficacy, reproducibility and safety of this technique which led to a lowering of ventriculo-pulmonary gradient, persistent at six months, to an infra-surgical level, at the price of pulmonary incompetence (27%) which was always well tolerated in the mid-term. This valvuloplasty may be suggested for all cases of SPO with a gradient of greater than 35 mmHg.     

Percutaneous valvuloplasty of congenital pulmonary stenosis in adults over 50 years of age

The authors report three cases of congenital pulmonary stenosis in adults over 50 years of age treated by percutaneous balloon valvuloplasty. Three symptomatic women aged 74, 80 and 51, had systolic pressure gradients ranging from 107 to 113 mmHg between the right ventricle and pulmonary artery. After valvuloplasty with two balloons or one trefoil balloon, the transvalvular pressure gradient fell to 25 to 30 mmHg. It was only 14 mmHg in one patient controlled after one year's follow-up. The cardiac index was initially decreased and did not change very much immediately after the procedure, increasing from 1.68 1/m2/mn to 1.77 1/m2/mn. The pulmonary valve surface area increased from 0.22 to 0.43 cm2. There were no complications and in one patient, reviewed two years later, the clinical improvement was maintained. Percutaneous valvuloplasty is indicated in severe and/or poorly tolerated pulmonary stenosis. With the 10 other previously reported cases of patients over 50 years of age, the procedure was successful in 12 out of 13 patients (92%). In these patients of 51 to 80 years of age, the systolic pressure gradient between the right ventricle and pulmonary artery was reduced from 112 +/- 46 mmHg to 43 +/- 26 mmHg (-62%). Slight pulmonary regurgitation appeared in 5 out of 9 cases. Valvuloplasty was usually well tolerated and there were no fatalities. There were no signs of restenosis in 5 cases controlled 10 days to 1 year after dilatation. In the future, systematic Doppler echocardiographic examinations should help comparison of cardiac haemodynamics before, immediately after valvuloplasty and at long-term.(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon dilatation of the pulmonary valve. Short-, middle- and long-term results

BACKGROUND: Immediate and long-term results after balloon dilatation of pulmonary valve stenosis in our unit. METHODS AND PATIENTS: All 111 patients (1 day-18 years) who have had balloon dilatation of a pulmonary valvar stenosis between 12/1987 and 8/1997 were divided into 4 groups: Typical valvar pulmonary stenosis (group A; n = 78), stenosis with dysplastic pulmonary valve (group B; n = 10), critical pulmonary stenosis (group C; n = 16) and pulmonary atresia after transcatheter or operative opening of the valve (group D; n = 7). Patients with pulmonary stenosis and complex congenital heart disease were excluded. RESULTS: The average systolic transvalvular gradient was reduced from 68.5 to 27.2 mmHg (60%) immediately after balloon dilatation. After a follow up of 48.8 +/- 37 months 101 patients could be reevaluated. In group A (n = 69 at FU) and C (n = 16 at FU) 81% showed a systolic transvalvular gradient < 30 mmHg after one and 83% (A) respective 94% (C) after two balloon dilatations. In group B (n = 9 at FU) 44% exhibited a systolic gradient < 30 mmHg after one and 56% after two balloon dilatations. In group D (n = 7 at FU) 57% showed a systolic gradient < 30 mmHg with no further improvement by a second dilatation. Over all, 80% of our patients could be treated sufficiently by transcatheter means. The rate of major complications was 7.3% with no lasting residuals at follow up and no deaths. CONCLUSION: Balloon dilatation of the pulmonary valve is secure and effective. Best results are obtained in patients with typical pulmonary valve stenosis and in newborns and infants with critical pulmonary valve stenosis.     

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Twenty patients with peripartum cardiomyopathy were followed up for a period ranging from 6-14 months (mean 6 +/- 2 months). At initial evaluation, 16 patients were in New York Heart Association Class IV and the remainder in Class III. During follow up, 12 patients improved to Class I, 7 patients either failed to improve or deteriorated and one patient died. Certain variables at initial evaluation were related to prognosis. The patients who deteriorated, as compared to those who improved, were significantly older (30 +/- 6.8 vs 24 +/- 3 years, P less than 0.01), of higher parity (3 +/- 1 pregnancies vs 1.5 +/- 5 pregnancies, P less than 0.001) and had later onset of symptoms after delivery (7.6 +/- 4 weeks vs 3 +/- 1.3 weeks, P less than 0.001). They also had higher echocardiographic left ventricular end diastolic dimensions (7.0 +/- 8.4 cm vs 3.0 +/- 0.8 cm, P less than 0.001) and higher mean pulmonary arterial (38 +/- 4 mmHg vs 28 +/- 6 mmHg, P less than 0.001) and pulmonary arterial wedge pressures (24 +/- 2 mmHg vs 20 +/- 2 mmHg, P less than 0.001) at cardiac catheterization. Conduction defects were present on the surface electrocardiogram in all the patients who deteriorated, as compared to 4 patients who improved. In conclusion, certain variables at initial evaluation can help in identifying high risk subsets with peripartum cardiomyopathy.     

Hemodynamic findings during exercise on a bicycle ergometer following balloon valvuloplasty of pulmonary stenosis in children and adolescents.

Eleven patients (4 female, 7 male), age range 3.3 to 24.8 years (mean 11.10 years) treated for isolated pulmonary stenosis underwent cardiac catheterization and percutaneous transluminal balloon valvuloplasty (PTVP). The right ventricular systolic pressure (RVSP) before valvuloplasty ranged from 31 to 127 mmHg (mean 79 mmHg) decreasing to 28 to 62 mmHg (mean 42 mmHg) immediately after the dilatation. The peak systolic gradient of the pulmonary valve (delta p RV-PA) before valvuloplasty ranged from 22 to 107 mmHg (mean 61 mmHg) and decreased to a range of 14 and 45 mmHg (mean 23 mmHg) immediately after the dilatation. Balloon valvuloplasty was performed using balloons of 13 to 31 mm in diameter. On 11 patients cardiac catheterization and Doppler echocardiography were repeated between 11 months and 5.3 years (mean 3.11 years) after the balloon valvuloplasty showed a further significant fall in the gradient of pressure. The right ventricular systolic pressure ranged from 20 to 51 mmHg (mean 31.7 mmHg) while the transpulmonary gradient varied from 3 to 24 mmHg (mean 11.6 mmHg). At the time of follow-up examination the patients were aged between 7.2 and 25.7 years (mean 15.9 years). On average the second catheterization was performed 3.11 years following the first hemodynamic study. The follow-up examination encompassed clinical examination, electrocardiogram, Doppler echocardiography, and right heart cardiac catheterization. During right heart cardiac catheterization the children exercised on a bicycle ergometer for three min at 50 or 100 W depending on their body surface area. During this exertion, pressures of the right ventricle and the pulmonary artery as well as heart rate and oxygen saturation were recorded.(ABSTRACT TRUNCATED AT 250 WORDS)