Long-term results of pulmonary balloon valvulotomy in adult patients.

BACKGROUND AND AIM OF THE STUDY: The study aim was to define the long-term outcome of pulmonary balloon valvulotomy (PBV) in adult patients. METHODS: PBV was performed in 87 patients (46 females, 41 males; mean age 23+/-9 years; range: 15-54 years) with congenital pulmonary valve stenosis (PS). Intermediate follow up catheterization (mean 14.6+/-5.0; range: 6-24 months) was performed after PBV in 53 patients. Clinical and Doppler echocardiography examinations were carried out annually in 82 patients (mean 8.0+/-3.9; range: 2-15 years). RESULTS: There were no immediate or late deaths. The mean catheter peak pulmonary gradient (PG) before and immediately after PBV, and at intermediate follow up was 105+/-39, 34+/-26 (p <0.0001) and 17+/-14 (p <0.0001) mmHg, respectively. The corresponding values for right ventricular (RV) pressure were 125+/-38, 59+/-21 (p <0.0001) and 42+/-12 (p <0.0001) mmHg, respectively. The infundibular gradients immediately after PBV and at intermediate follow up were 31+/-23 and 14+/-9 mmHg (p <0.0001), whilst cardiac index improved from 2.68+/-0.73 to 3.1+/-0.4 l/min/m2 (p <0.05) at intermediate follow up. Doppler PG before PBV and at intermediate and long-term follow up were 91+/-33 (range 36-200) mmHg, 28+/-12 (range 10-60) mmHg (p <0.0001) and 26+/-11 mmHg (p = 0.2), respectively. New pulmonary regurgitation (PR) was noted in 21 patients (25%) after PBV. Five patients (6%) with a suboptimal result (immediate valve gradient > or =30 mmHg) developed restenosis and underwent repeat valvulotomy 6-12 months later using a larger balloon, and with satisfactory outcome. Moderate to severe tricuspid regurgitation (TR) in seven patients regressed after PBV. CONCLUSION: The long-term results of PBV in adults are excellent, with regression of concomitant, severe infundibular stenosis and/or severe TR. Hence, PBV should be considered as the treatment of choice for adult patients with PS.     

Serial assessment of mitral regurgitation by pulsed Doppler echocardiography in patients undergoing balloon aortic valvuloplasty

Mitral regurgitation was serially assessed by pulsed Doppler echocardiography in 144 patients undergoing balloon aortic valvuloplasty for symptomatic aortic stenosis. Regurgitant scores of 0, 1, 2 and 3 were assigned to pulsed Doppler patterns corresponding to no, mild, moderate and severe mitral regurgitation, respectively. Before balloon aortic valvuloplasty, mitral regurgitant score correlated significantly (p less than 0.005) but weakly with aortic valve area (r = -0.24), left ventricular ejection fraction (r = -0.34) and left ventricular systolic pressure (r = 0.23). There was no significant correlation between mitral regurgitation and either mean catheterization or mean Doppler aortic valve gradient. Balloon aortic valvuloplasty produced significant decreases in both catheterization and Doppler mean transvalvular aortic valve gradients (56 +/- 19 to 31 +/- 12 and 60 +/- 19 to 48 +/- 16 mm Hg, respectively; both p less than 0.0001) and a significant increase (p less than 0.0001) in aortic valve area assessed by catheterization (0.6 +/- 0.2 to 0.9 +/- 0.3 cm2). Left ventricular ejection fraction did not change, but cardiac output increased (p less than 0.001) and pulmonary capillary wedge pressure decreased (p less than 0.0001). Pulsed Doppler findings of mitral regurgitation were present in 102 of the 144 patients. Eighty-eight patients had a score compatible with mild or more severe degrees of mitral regurgitation, and 49 had a score indicative of moderate or severe valvular insufficiency. In the entire group of 144 patients, mitral regurgitant score decreased significantly from 1.1 +/- 1.0 to 1.0 +/- 1.0 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Analysis of the early rise in aortic transvalvular gradient after aortic valvuloplasty

The relationship between dynamic changes in aortic valve gradient and left ventricular ejection performance in the early period after successful percutaneous aortic valvuloplasty has not been described in detail. Accordingly 20 adult patients with severe symptomatic calcific aortic stenosis underwent first-pass radionuclide angiography and Doppler echocardiography before, immediately after, and 2 to 4 days after the valvuloplasty procedure. A significant (p less than 0.001) reduction in peak-to-peak (72 +/- 24 mm Hg to 36 +/- 11 mmHg) and mean (60 +/- 20 mm Hg to 34 +/- 9 mm Hg) transaortic gradient and an increase in aortic valve area (0.5 +/- 0.2 cm2 to 0.8 +/- 0.2 cm2) were measured by high-fidelity micromanometer catheters immediately after aortic valvuloplasty. Results of Doppler echocardiography showed a significant (p less than 0.001) immediate decrease in peak instantaneous (81 +/- 22 mm Hg to 53 +/- 15 mm Hg) and mean (48 +/- 14 mm Hg to 31 +/- 9 mm Hg) aortic gradients. However, 2 to 4 days later a significant (p less than 0.001) return of peak (56 +/- 15 mm Hg to 65 +/- 20 mm Hg) and mean (31 +/- 9 mm Hg to 39 +/- 12 mm Hg) transvalvular gradient occurred. Aortic valve area as determined by the continuity equation also increased from 0.4 +/- 0.2 cm2 to 0.6 +/- 0.2 cm2 immediately after the procedure (p less than 0.001), then partially returned to baseline (0.5 +/- 0.2 cm2; p less than 0.005) at 2 to 4 days.(ABSTRACT TRUNCATED AT 250 WORDS)     

Accuracy of continuous wave Doppler predicted gradient in patients undergoing balloon pulmonary valvoplasty

14 patients who underwent balloon valvoplasty had trans-pulmonic gradient evaluated by continuous wave Doppler echocardiography. Maximum systolic gradients measured from Doppler flow velocities were correlated with peak to peak gradient obtained at cardiac catheterisation. Prior to valvoplasty, there was good correlation between the Doppler maximum gradient (92.85 +/- 34.7mm Hg) and the peak to peak catheter gradient (105.57 +/- 56.60 mm Hg), (r = 0.91, p = less than 0.001). Immediately after balloon valvoplasty, the maximum Doppler gradient did not correlate with the peak to peak catheter gradient (r = 0.33, p = NS). Exclusion of patients with infundibular gradients improved the correlation coefficient between the Doppler maximum and peak to peak catheter gradient to 0.69. At late restudy following valvoplasty, when regression of infundibular stenosis was noted in 6 out of 8 patients, the Doppler maximum and catheter peak to peak gradient had excellent correlation (r = 0.97, p = less than 0.001). In patients with lone valvular gradient immediately following valvoplasty and at late restudy, maximum Doppler gradients correlated well with catheter gradients in 14 estimations (r = 0.66, p = less than 0.01). This study shows that the non-invasive quantification of pulmonary valve stenosis can be reliably undertaken, using continuous wave Doppler echocardiography before balloon valvoplasty and during follow-up, after the procedure when the infundibular stenosis has regressed. The presence of an infundibular gradient immediately after balloon dilatation makes the Doppler prediction less reliable.     

Conventional and color Doppler echocardiography in mitral balloon valvotomy]

With the aim of assessing the value of conventional echocardiography and Doppler and colour Doppler during and in the follow-up of percutaneous mitral valvotomy we have studied prospectively 100 consecutive patients with 1 (90%), 6 (69%) and 12 (53%) months follow-up. Age was 50 years and 80% were women. The single balloon technique was used in 68%, mitral valve area increased from 0.9 +/- 0.2 to 1.8 +/- 0.3 cm2 and decrease in pulmonary artery pressure was 10 +/- 0.05 mmHg. We found that: 1) percutaneous mitral valvotomy produced and acute and transient decrease in left ventricular ejection fraction (pre 69 +/- 9%, post 61 +/- 10% p less than 0.001; 1 month 70 +/- 10; 2) a severe mitral regurgitation appeared in 4% of patients and 17% of patients had a moderate degree of regurgitation after valvotomy; 3) after valvular dilation an increase in the width of the aliasing greater than 29% predicted a successful procedure (final area greater than 1.5 cm2) with a sensibility 80% and specificity 94%, and 4) colour Doppler detected an atrial septal defect immediately after valvular dilation in 77% of patients, and permitted non invasive follow-up of the left to right shunt. At one year a left to right shunt at the atrial level persisted roughly in 1/3 of patients. We conclude that colour Doppler Echocardiography during percutaneous mitral valvotomy is useful for a rapid assessment of the increase in valve area, the detection and quantification of mitral regurgitation induced by valvular dilation and the follow-up in these patients.     

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)     

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.     

Attempts at measuring pulmonary arterial pressure by means of Doppler echocardiography in patients with chronic lung disease

In 72 patients with severe chronic pulmonary or pulmonary vascular disease pulmonary arterial pressure was measured by means of right heart catheterization. Forty three patients had pulmonary hypertension, (32 +/- 11 mmHg) and 27 patients had normal pressure (14 +/- 3 mmHg). These patients were examined with continuous wave (CW) and pulsed wave (PW) Doppler echocardiography. The retrograde systolic tricuspid valve pressure gradient assessed with CW Doppler correlated with systolic pulmonary pressure (r = 0.92, p less than 0.001, SEE 7.7 mmHg) but was measurable in only 17 of the 70 patients. The flow velocity pattern in the right ventricular outflow tract could be recorded in 68 of the 70 patients. Acceleration time (AcT) from systolic flow onset to peak velocity correlated with mean pulmonary artery pressure (r = 0.72, p less than 0.001, SEE 8.3 mmHg). An AcT less than 90 msec had an 84% positive predictive value for pulmonary hypertension. Right ventricular isovolumic relaxation time could be measured in 59 of the 70 patients and correlated with systolic pulmonary artery pressure (r = 0.69, p less than 0.001, SEE 12.4 mmHg). No single Doppler method is at the same time easily applicable and accurate in prediction of pulmonary arterial pressure in patients with chronic lung diseases.     

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.     

Long-term results after balloon pulmonary valvuloplasty

BACKGROUND. The objective of this study was to determine the long-term outcome of patients after percutaneous balloon pulmonary valvuloplasty (BPV) treatment of congenital pulmonary valve stenosis. METHODS AND RESULTS. This study represents a case series with duration (mean +/- SD) of follow-up of 4.6 +/- 1.9 years. Forty-six patients with a median age of 4.6 years (range, 3 months to 56 years) had BPV at one academic institution between June 1981 and December 1986. Mean peak systolic pressure gradients from the right ventricle to the pulmonary artery were as follows: before BPV, 70 +/- 36 mm Hg; immediately after BPV, 23 +/- 14 mm Hg; at intermediate follow-up by cardiac catheterization or Doppler echocardiography at less than 2 years after BPV, 23 +/- 16 mm Hg (n = 33); and at long-term follow-up by Doppler at more than 2 years after BPV, 20 +/- 13 mm Hg (n = 42). BPV acutely reduced the gradient to less than 36 mm Hg for 41 of 46 (89%) patients. Available gradients at long-term follow-up were less than 36 mm Hg for 36 of 42 (86%) patients without additional procedures. A patient age of less than 2 years at the initial BPV was a significant risk factor for gradients over 36 mm Hg at follow-up. CONCLUSIONS. BPV provides long-term relief of pulmonary valvular obstruction in the majority of patients. Close follow-up of patients who require BPV at less than 2 years of age is warranted.     

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.     

Results of balloon valvuloplasty in typical and dysplastic pulmonary valve stenosis: Doppler echocardiographic follow-up

To assess the usefulness of balloon valvuloplasty in patients with a dysplastic pulmonary valve, the files of 36 patients (aged 1 day to 18.5 years) who had two-dimensional echocardiography before and continuous wave Doppler echocardiography late after balloon valvuloplasty (balloon diameter greater than or equal to 20% anulus diameter) were reviewed. Results of relief of pulmonary stenosis were graded by catheter gradient in the catheterization laboratory and compared with Doppler echocardiographic findings at follow-up. There were 32 patients with typical pulmonary stenosis and 4 with a dysplastic valve. In the 32 patients with typical pulmonary stenosis, transvalvular gradient changed from a mean of 67 +/- 32 to 20 +/- 20 mm Hg (p less than 0.0001, mean reduction 72.6%). The gradients at follow-up by Doppler echocardiography averaged 20 mm Hg including 15 that increased, 3 that were unchanged and 14 that decreased. Only 3 (9%) of 32 patients had a gradient greater than 25 mm Hg at follow-up and only one gradient was greater than 35 mm Hg. All four patients with a dysplastic valve had a gradient that decreased with valvuloplasty from a mean of 85 +/- 33 to 33 +/- 20 mm Hg (p less than 0.05); gradient reduction in this group ranged from 40 to 85% (mean 57.5%). The gradient at follow-up increased in three of these four patients and decreased in one (the only late gradient less than 25 mm Hg). Late gradient was less than 35 mm Hg in two of the four patients and was reduced by 43 and 57%, respectively, in the other two.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic evaluation of mitral valve structure and function in patients followed for at least 6 months after percutaneous balloon mitral valvuloplasty

Although beneficial results have been reported immediately after percutaneous mitral balloon valvuloplasty, little information is available concerning the longer-term outcome of this procedure. The anatomic and functional results of percutaneous mitral valvuloplasty were assessed in 20 patients, in whom two-dimensional and Doppler echocardiographic examination could be obtained both immediately and 6 to 11 months (mean 7.5 +/- 2.0) after balloon dilation. Mean valve area measured by planimetry decreased slightly but significantly from 1.90 +/- 0.59 cm2 immediately after valvuloplasty to 1.62 +/- 0.55 cm2 (p less than 0.001) at follow-up. Individual changes in valve area were variable, and in four patients valve area decreased by greater than 25%. Echocardiographic scores of valvular morphology were obtained by assigning scores of 0 to 4 (with increasing abnormality) to each of four morphologic characteristics of the valve, namely, leaflet mobility, thickening, calcification and subvalvular thickening. This score was higher in the four patients with a decrease in valve area greater than 25% at follow-up than in the other patients (11 +/- 2 versus 7 +/- 2, p less than 0.002). Multiple regression analysis of several hemodynamic and echocardiographic factors identify first the echocardiographic score and second the valve area postvalvuloplasty as the only significant predictors of the percent decrease in valve area (r = 0.70, p less than 0.006). Mitral regurgitation graded by pulsed Doppler ultrasound decreased from 1.9 +/- 1.2 immediately after valvuloplasty to 1.0 +/- 0.9 (p less than 0.003) at follow-up, whereas there was no change in mean transmitral pressure gradient by Doppler echocardiography (5 +/- 2 versus 6 +/- 3 mm Hg, p = NS) and left atrial volume (74 +/- 34 versus 72 +/- 27 cm3, p = NS). Thus, 6 to 11 months after balloon mitral valvuloplasty, mean mitral valve area decreases slightly. Individual changes in valve area, however, are variable. Valvular morphology assessed by two-dimensional echocardiography may be useful for identifying those patients who have an increased likelihood of developing valvular restenosis.     

Percutaneous valvotomy in critical neonatal pulmonary stenosis. Results and mid-term follow up]

INTRODUCTION: Catheter-balloon valvotomy has been proposed as an alternative to surgical valvotomy in the critical pulmonary stenosis in newborns. OBJECTIVES: The present report describes the results, complications and follow-up of this technique at our center. METHODS AND RESULTS: From May 1993 to June 1998, fourteen consecutive patients with critical pulmonary stenosis underwent balloon valvotomy. Their mean ages were 8.7 +/- 5.8 days. Each of them was cyanotic and ten of the fourteen were on prostaglandin E1 therapy and three of them required endotracheal intubation and ventilation. The diameters of balloons were 9.6 +/- 2.1 mm (range, 5 to 12 mm) and the balloon/annulus diameter ratio was 1.3 +/- 0.2 (range, 0.8 to 1.5). By means of this technique, right ventricle systolic pressure decreased from 95.2 +/- 22.4 mmHg to 51 +/- 23.2 mmHg (p < 0.001) and the right ventricle/aortic pressure ratio decreased from 1.5 +/- 0.4 to 0.8 +/- 0.3 (p < 0.001). Surgical valvotomy was performed in two patients (cases 1 and 8) at 5-months and 3 days, respectively, from the balloon valvotomy. One patient (case 4) required a blalock-taussig shunt. Complications included cardiac tamponade in one patient. One patient died seven days after successful valvotomy by extracardiac complications. All eleven patients are currently symptom free 26.6 +/- 17.1 months later (range, 5 to 56) and Doppler residual gradient ranges from 0 to 29 mmHg (11.1 +/- 10.4 mmHg). CONCLUSIONS: Balloon pulmonary valvotomy is an effective and relatively safe technique for treatment of critical pulmonary stenosis in newborns with low index complication and mid-term relief of valvular obstruction.     

Clinical usefulness of intravenous albunex for the Doppler assessment of aortic stenosis

Optimal Doppler recordings of stenotic aortic flow are not always easy to obtain. Therefore, the present study investigated how useful intravenous Albunex injections were for improving the Doppler assessment of pressure gradients for aortic stenosis in 20 consecutive patients who underwent Doppler and left-heart catheterization studies within a 1-week period. Continuous-wave Doppler echocardiography was performed using both a 2.5 MHz duplex and a 1.9MHz independent transducer before and after Albunex injections. The maximum and mean pressure gradients were calculated from the highest Doppler velocity tracings using the simplified Bernoulli equation. Pullback catheterization pressure tracings from the left ventricle to the ascending aorta were superimposed for determination of the maximum instantaneous and mean pressure gradients. The Doppler-derived peak and mean pressure gradients showed significant underestimation compared with the catheterization gradients (23+/-17 mmHg and 11+/-7 mmHg, respectively). However, this underestimation disappeared with Albunex injection (-2+/-7 mmHg and -1+/-4mmHg, respectively). Although the Doppler-derived instantaneous and mean pressure gradients correlated well with the catheterization gradients (r=0.909 and r=0.879, respectively), they became much closer with Albunex (r=0.987 and r=0.963, respectively). The improvements in the Doppler-derived peak pressure gradients were significant from an apical window (n=12, 84-120mmHg, p<0.001). but less so from non-apical windows (n=8, 84-91 mmHg, p=0.0146). Accordingly, Albunex is most useful for Doppler recordings of stenotic aortic flow available from the apical window, but not less so from other acoustic windows.     

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.     

Percutaneous transluminal valvuloplasty of pulmonary stenoses. Apropos of 35 cases

Thirty-five patients with moderate or severe valvular pulmonary stenosis underwent percutaneous transluminal valvuloplasty (PTV). The average age of the patients was 12 years (range 4 to 34 years). Sixty per cent were under the age of 10, 20 p. 100 were between 10 and 17 years old and 20 p. 100 between 18 and 34 years old. Systolic right ventricular pressures were greater than the pressures in the systemic circulation in 22 cases. The right ventricular-pulmonary artery pressure gradient was greater than 50 mmHg in 29 patients and less than or equal to 50 mmHg in the other 6 patients. The diameter of the balloon of the dilation catheter varied from 12 to 20 mm in 31 PTV; in the other 4 cases two dilating catheters were used simultaneously to dilate the pulmonary valves. The tolerance of PTV was generally good and the results were satisfactory: right ventricular pressures (RVP) fell from 140 +/- 45 to 77 +/- 25 mmHg (p less than 0.001); the RV-PA pressure gradient fell from 82 +/- 40 to 32.4 +/- 15 mmHg (p less than 0.001) and the ratio of RVP to systemic pressure from 1.2 +/- 0.4 to 0.65 +/- 0.2 (p less than 0.01). Clinical and haemodynamic reevaluation in 19 patients 4 to 16 months after PTV (mean 8.5 +/- 2 months) showed that RVP, RV-PA pressure gradients and RVP/systemic pressure ratios had significantly decreased respectively from 78 +/- 30 to 52 +/- 14 mmHg (p less than 0.001), from 27.7 +/- 7.7 to 21.8 +/- 7.3 mmHg (p less than 0.02) and from 0.6 +/- 0.2 to 0.4 +/- 0.1 (p less than 0.001). Pulmonary valvuloplasty is well tolerated, safe and may reduce the number of patients requiring surgical valvotomy.     

Angioplasty and percutaneous valvuloplasty in congenital and acquired cardiopathies. Short- and long-term results

Percutaneous transluminal balloon catheterization was performed in 38 patients, age 2 to 38 years (mean 13) between October, 1985 and May, 1987. Nineteen with pulmonary valve stenosis (PVS), three with small atrial septal defect (ASD) and one with ventricular septal defect (VSD); six with aortic valve stenosis (AVS); eight with Coarctation of the aorta (CoAo), in two with VSD and one with small ductus arteriosus; and four with rheumatic mitral stenosis (RMS). In PVS the peak systolic gradient (PSG) decreased significantly immediately after the procedure (92 +/- 40 vs 20 +/- 19 mmHg P less than 0.01). Nine patients were evaluated three months and seven one year later and no significant change occurred (19 +/- 11 and 20 +/- 19 mm Hg). The right ventricular systolic pressure (RVSP) and the ratio RVSP/left ventricular systolic pressure (LVSP) decreased immediately after the procedure (114 +/- 37 vs 69 +/- 36 mmHg P less than 0.15, and 0.98 +/- 0.29 vs 0.62 +/- 0.36, P less than 0.15). Three months later the RVSP and ratio RVSP/LVSP decreased more (57 +/- 16 mmHg, P less than 0.05, and 0.47 +/- 0.18, P less than 0.05) and one year later (54 +/- 27 mm Hg, P less than 0.05 and 0.46 +/- 0.24, P less than 0.05). In one case we repeated de dilatation one year later for restenosis. In CoAo PSG decreased immediately after dilation (59 +/- 21 vs 26 +/- 18 mmHg, P less than 0.1). Three months later the gradient was 38 +/- 20 mmHg. One patient was sent to surgery for significant residual gradient and one was dilated again 4 months after the first dilatation. One case was evaluated at cardiac catheterization one year later with gradient of 28 mmHg and blood pressure and femoral pulses were normal. In AVS PSG decrease immediately in all (91 +/- 25 vs 37 +/- 22 mmHg, P less than 0.02). Recatheterization in 4 patients three months later showed improvement in two. Two cases were sent to surgery for significant residual gradient. In these two patients we did not performed a dilatation because one had thrombosis in the puncture site and in the other we suspect subvalvular obstruction. The other two patients have shown clinical, echocardiographic and radiographic improvement.(ABSTRACT TRUNCATED AT 400 WORDS)     

Doppler echocardiographic assessment of transmitral gradients and mitral valve area before and after mitral valve balloon dilatation

This is a comparative study of 60 sets of observations of mitral valve end-diastolic gradient, mean diastolic gradient, and mitral valve area obtained by Doppler echocardiography and cardiac catheterization. The studies were performed in 28 patients, 16 of whom underwent mitral valve balloon valvuloplasty. These 16 patients had studies performed before, immediately after valvuloplasty, and one week later. Thus 28 studies were performed before or without valvuloplasty (Group I) and 32 after valvuloplasty (Group II). The time interval between Doppler echocardiography and cardiac catheterization was less than 24 hours in 44 studies and 24 to 72 hours in 16 studies. In Doppler echocardiography the gradients were obtained by simplified Bernoulli's equation and the mitral valve area by pressure half-time method. There was excellent correlation between end-diastolic gradients (r = 0.96, p less than 0.001) and mean diastolic gradients (r = 0.92, p less than 0.001) measured by the two techniques. A statistically significant correlation also existed in the mitral valve area values (r = 0.53, p less than 0.005). On separate analysis Group I showed excellent correlation for all three variables (r values of 0.90, 0.87, and 0.82 for end-diastolic gradients, mean-diastolic gradients, and mitral valve area, respectively). Group II also showed excellent correlation of end-diastolic gradients (r = 0.80) and mean diastolic gradients (r = 0.87), but poor correlation of the mitral valve areas (r = 0.17; p = NS) by the two techniques. Doppler echocardiography can accurately measure transmitral gradients both before and after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hemodynamic evaluation before and after balloon atrial septostomy in patients with transposition of the great arteries using pulsed Doppler echocardiography

In nine patients with transposition of the great arteries, hemodynamic changes after the initial balloon atrial septostomy (BAS) were investigated using pulsed Doppler echocardiography and cardiac catheterization. Patients consisted of five males and four females, who ranged in age from zero to 82 days (median, one day). All but one who had ventricular septal defect had no associated cardiac anomalies other than patent ductus arteriosus. Prostaglandin E1 was administered before and after BAS to four patients who had hypoxemia. At cardiac catheterization, right and left atrial pressures and arterial oxygen partial pressure were measured. Using pulsed Doppler echocardiography, the time-velocity curve was recorded at the tricuspid and mitral valves, pulmonary artery, ascending aorta and interatrial septum. The maximum diastolic velocity was measured from the tricuspid and mitral valve time-velocity curves. The product of the time-velocity integral and heart rate was measured from the time-velocity recordings at the pulmonary artery and ascending aorta. The duration of the left-to-right shunt at the foramen ovale was measured and was normalized by corresponding R-R intervals on the electrocardiogram. After BAS, left atrial pressures and pressure gradients between both atria decreased significantly (p less than 0.01). Arterial oxygen partial pressure increased from 24.4 +/- 7.2 to 40.4 +/- 6.0 mmHg (p less than 0.01). The maximum flow velocity at the tricuspid valve increased significantly (p less than 0.01), but that at the mitral valve showed no significant change after BAS. The velocity time integral of the aorta increased significantly (p less than 0.01), but that of the pulmonary artery did not.(ABSTRACT TRUNCATED AT 250 WORDS)