Valvulopathies (XIV). The role of percutaneous valvuloplasty in congenital valvular diseases

The present article describes the cooperative experience Córdoba-Las Palmas since 1983 in 123 patients with congenital right or left ventricular outflow obstructions who were treated by percutaneous balloon dilatation. Seventy of them had pulmonary stenosis (63 valvular and seven supravalvular types); two had pulmonary atresia, 25 valvular aortic stenosis and 27 discrete subaortic stenosis. In patients with valvular pulmonic stenosis the gradient and the right ventricular pressure decreased significantly. No significant changes were observed in the degree of pulmonary regurgitation. One neonate died. No other major complications occurred. After a mean follow up of 3 +/- 2 years, we did not observe significant changes in the degree of pressure relief. The mean residual gradient is 26 +/- 19 mmHg. In our 21 patients out of the neonatal period with valvular aortic stenosis the gradient and the left ventricular pressure dropped significantly. Progression of aortic regurgitation in more than I grade was observed in 4 patients (19%), although only one (5%) progressed to grade III. There were no major complications in this group. After a mean follow up period of 24 +/- 17 months they persist with the obtained pressure relief and same degree of valvular competence. All 4 neonates with critical aortic stenosis had unsuccessful dilations and they died, wether after ulterior surgery or without it. In 27 patients with discrete subaortic stenosis the gradient and the left ventricular pressure decreased markedly, without significant changes in valve competence. There were no related major complications. After dilation, a broken and mobile membrane was frequently seen. At follow up (24 +/- 18 months), 6 patients (22%) had restenosis; five of them were successfully redilated. The remaining 21 patients persist with a reduced residual gradient (24 +/- 7 mmHg) and without significant changes in valve competence.     

经皮球囊扩张术治疗儿童先天性主动脉瓣狭窄

目的探讨儿童先天性主动脉瓣狭窄（aortic stenosis,AS）球囊扩张的治疗效果。方法选择21例单纯性AS患儿,其中1例合并动脉导管未闭（PDA）,3例因导管难以进入左室,2例左心导管测跨主动脉瓣压力阶差（AP）小于50mmHg（1mmHg=0．133kPa）而未扩张,其余16例采用与瓣环直径之比为0．98±0．04（0．92～1．10）的球囊扩张治疗,合并的PDA予Amplatzer伞片封堵治疗。结果即刻AP下降至原AP50％以上者13例,占81．25％;下降至原AP40％～50％者2例。随访6个月～5年,3例患儿AP回复至50mmHg以上,分别予第二次扩张或外科手术后好转。无一例轻度以上的主动脉瓣反流。结论AS经皮球囊扩张术结果表明,球囊扩张对单纯性AS具有一定疗效,由于其非开胸、方便且较安全地缓解左心室流出道梗阻,从而可替代或延缓外科开胸瓣膜切开术,为AS的治疗提供了另外一种选择。     

Long-term results of balloon aortic valvulotomy for congenital aortic stenosis in children and adolescents

BACKGROUND AND AIM OF THE STUDY: The aim of the study was to report on the long-term results of aortic valve balloon dilatation (AVBD) for congenital valvular aortic stenosis in children and young adults. METHODS: The records of 74 patients (age range: 1-20 years) who underwent AVBD at a single center were analyzed retrospectively. Special attention was paid to factors that might influence long-term outcome. RESULTS: The procedure was successful in 71 patients (96%). The mean (+/- SD) reduction in peak-to-peak systolic gradient (PSG) was 68.7 +/- 13.5%. No patient required immediate surgical intervention. Survival after dilatation was 100% at 12 years. At follow up (mean 5.5 +/- 2.9 years; range: 2-12 years), 20% of patients had restenosis and 21% had significant aortic regurgitation (AR) (grade > or = 3). Reintervention was performed in 14% of patients. Severity of AR and high residual stenosis immediately after AVBD were associated with the late event rates. The actuarial intervention-free rates at five, seven and 12 years were 92.9%, 84.4% and 60%, respectively. CONCLUSION: AVBD is a useful, albeit palliative, procedure for children and young adults with significant congenital valvular aortic stenosis.     

Aortic valve balloon dilatation in infants with critical aortic stenosis

Twenty-six infants aged 10 days-11 months (mean 3.5 +/- 2.4 months), with critical aortic stenosis underwent aortic valve balloon dilatation in last six years. In 19 (73%) infants, aortic valve balloon dilatation had to be performed as an emergency procedure. The systolic gradients decreased from 71.7 +/- 11.8 mm Hg to 21.0 +/- 8.1 mm Hg. There was no procedural death. Severe aortic regurgitation developed in two (7.7%) which was medically managed. Four (15.4%) infants had femoral artery thrombosis following aortic valve balloon dilatation and all responded to intravenous streptokinase. Congestive heart failure resolved in all (100%). Two infants developed endocarditis during follow-up after aortic valve balloon dilation and one of them died, another patient died of severe pulmonary artery hypertension. In the surviving 24 infants, left ventricular function improved markedly. On follow-up of 18 +/- 5 months, restenosis developed in two (7.7%) patients. We conclude that aortic valve balloon dilatation is safe and effective treatment for infants with critical aortic stenosis and severe left ventricular dysfunction.     

Results of percutaneous catheter valvuloplasty for calcified aortic stenosis in the elderly

Percutaneous catheter valvuloplasty was performed in 37 patients between 60-88 years of age (mean age 74.5 years): 16 of these patients were in functional class IV, with pulmonary oedema at the time of the procedure. A good haemodynamic result was obtained in 32 patients, but 3 of them had to be operated upon subsequently, because of persistence of their symptoms. Two successfully dilated patients died in the hospital, one of cardiac failure following myocardial dysfunction caused by multiple infarcts which had no relation to the aortic dilatation, the other of neurological complications after dilatation. Thus, the primary success rate was 27/37 (73%). The first 10 patients with good initial results have been followed up for more than 6 months. The functional result has been maintained in 8 cases with moderate myocardial dysfunction (left ventricular ejection fraction 0.41 to 0.7), one with restenosis at Doppler assessment. Two patients with severe myocardial dysfunction (left ventricular ejection fraction 0.22 and 0.25) had recurrent cardiac failure, with valvular restenosis in one case. One of them died at home. Percutaneous aortic valvuloplasty is therefore an effective means of treating calcified aortic stenosis in elderly patients. The benefits of this procedure have been maintained for as long as 6 months provided myocardial dysfunction was moderate. At its present stage of development, the technique allows only partial reduction of the aortic stenosis, which may explain the absence of long-term improvement in patients with severe myocardial disease.     

Percutaneous aortic valvuloplasty. Long-term outcome apropos of 85 patients with successful dilatation]

The outcome at 2, 6, 12, 18 and 24 months in terms of clinical status and Doppler echocardiographic parameters of 85 patients successfully dilated out of 116 patients undergoing percutaneous aortic valvuloplasty is reported. The objectives were to determine the survival rate, degree of clinical remission, the restenosis rate and its predictive factors. The 31 patients considered to be primary failures were excluded from the study. The global survival rates were 90 +/- 2% at 2 months, 84 +/- 4% at 6 months, 78 +/- 5% at 12 months, 69 +/- 6% at 18 months and 60 +/- 8% at 2 years. Patients in clinical remission and with clinical relapse were compared at the 6th month: relapse was significantly, related to prevalvuloplathy, low cardiac output (p = 0.05), low ejection fraction (p less than 0.03) and low fractional shortening (p less than 0.01), but the clinical relapse was independent of aortic valve surface area before and dilatation. In the relapse group, 14 patients (12%) were operated without complications in the first month of follow up, 6 patients underwent repeat valvuloplasty with 4 immediate failures and 2 improvements. The other patients were treated medically. The restenosis rate (loss of greater than 50% of initial gain in surface area or return of pre-valvuloplasty maximal pressure gradient +/- 25%) increased up to the 12th month in both groups (remission and relapse) and reached 78% at 12 +/- 3 months and seemed more pronounced in the less severe aortic stenosis. The incidence of restenosis was independent of gain in surface area after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon dilatation of the aortic valve after previous surgical valvotomy: immediate and follow up results.

OBJECTIVE--To evaluate the immediate and long-term results of transcatheter balloon dilatation of the aortic valve for restenosis after previous surgical valvotomy. DESIGN--Prospective follow up by clinical examination and cross sectional Doppler echocardiography of all patients fulfilling the above criteria. SETTING--Tertiary paediatric cardiology referral centre. PATIENTS AND METHODS--22 patients (18 male, 4 female)--median (range) age 157.5 (12-254) months--underwent 25 balloon dilatation procedures at a median of 72 (8-155) months after surgery. The median age at surgical valvotomy was 82.5 (0.5-230) months and the systolic gradient across the aortic valve immediately after surgery was 31 (0-49) mm Hg. The indication for dilatation was a Doppler derived peak instantaneous gradient of > 60 mm Hg with grade 2 or less aortic regurgitation. A single balloon was used, and the median balloon to annulus ratio was 1 (0.9-1). RESULTS--After dilatation the catheter pullback gradient decreased acutely from 55 (35-75) to 30 (0-75) mm Hg (p < 0.01) and the Doppler gradient from 74 (52-92) to 40.5 (30-96) mm Hg (p < 0.01). In three patients who underwent a second dilatation of the aortic valve eight months after the first procedure, the pullback gradient decreased from 50 (50-60) to 15 (15-16) mm Hg. Aortic regurgitation grade increased from 1 (0-2) to 2 (1-3); only one patient had grade 3 regurgitation. Over a median follow up of 33 (2-67) months seven patients had aortic valve replacement for recurrent stenosis (six patients) or severe regurgitation (one patient with grade 3 regurgitation after dilatation, who had partial detachment of one of the valve leaflets). There was no significant difference for the pullback gradient (median of 19 v 32.5 mm Hg), Doppler gradient 24 hours after dilatation (33.5 v 50.5 mm Hg; p = 0.03), or the duration of follow up (27.5 v 18 months) between the 12 patients who did not require further dilatation or surgery and the 10 patients who did. CONCLUSIONS--Balloon dilatation of the aortic valve is a safe and feasible option for palliation of restenosis after surgical valvotomy for congenital aortic valve stenosis. In many patients, however, stenosis progressed and a further intervention was required.     

Percutaneous balloon valvuloplasty in patients with severe aortic stenosis and low ejection fraction. Immediate results and 1-year follow-up

The efficacy, morbidity, and 1-year follow-up of balloon aortic valvuloplasty in patients with low ejection fraction (less than 40%) were studied on a consecutive series of 55 patients (mean age, 77 years) treated from September 1985 to February 1987. Because of their age (20 patients greater than 80 years old), poor left ventricular function, and associated diseases, 45 patients were definitely not surgical candidates. Balloon dilatation with 15-23-mm diameter balloon catheters decreased the transvalvular gradient from 66 +/- 24 to 28 +/- 14 mm Hg (p less than 0.001) and increased the valve area from 0.47 +/- 0.15 to 0.83 +/- 0.27 cm2 (p less than 0.001). Immediately after dilatation, ejection fraction mildly increased from 29 +/- 7% to 34 +/- 9% (p less than 0.001) in 38 patients who had undergone a second left ventricular angiogram after dilatation. No significant change in the degree of aortic regurgitation was found after the procedure. Three patients died in hospital (femoral arterial complications in two, septicemia in one). Immediate clinical improvement was noted in 80% of the patients. During the follow-up (mean, 11 months), 22 patients died (heart failure in 15 patients, sudden death in five patients, myocardial infarction in one patient, cancer in one patient). Thirty patients survived, 21 with persistent clinical improvement. Repeat cardiac catheterization was performed at 6 months in 20 patients, of whom eight had recurrence of symptoms. Nine patients had restenosis: their hemodynamic indexes had returned to prevalvuloplasty values.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term follow-up of elderly patients with severe aortic stenosis treated by balloon aortic valvuloplasty. Importance of haemodynamic parameters before and after dilatation

Early and late prognosis after percutaneous balloon aortic valvuloplasty (PBAV) was assessed in 38 consecutive elderly patients (mean age, 78.5 +/- 6.1 years). Significant valve opening was achieved in 35 patients. The hospital mortality was 8% (three patients); two other patients died within the first month and three underwent aortic valve replacement. At 2 years follow-up, there were 10 additional deaths (seven cardiac deaths) and five patients had symptom recurrence managed by aortic valve replacement (3) or repeat PBAV (2). Overall, six patients underwent surgery without untoward events and six had repeat PBAV. Only two out of six patients with repeat PBAV had sustained improvement; one was referred to surgery and the remaining three died soon after the second PBAV. One- and 2-year survival were respectively 72 and 62% and percentage of survivors with persistent improvement 68 and 41%. Although aortic valve area after PBAV was associated with outcome, predictors of poor long-term prognosis were primarily related to the pre-operative haemodynamic status. Patients with pulmonary resistances greater than 400 dynes cm-1 s-5 had the poorest outcome (chi 2 = 18.4-P less than 0.0001). Overall, signs of heart failure were predictors of poor long term follow-up. These data indicate that long-term success of PBAV is mainly related to the left ventricular dysfunction noted prior to intervention.     

Hemodynamic and clinical results following percutaneous aortic valve valvuloplasty in adults

We analyzed the results and the follow-up in our first 80 patients after percutaneous balloon aortic valvuloplasty (BAV) since November 1986. Mean age was 74 +/- 10 years, 78 patients were in the NYHA functional classes III or IV. Initially we used relatively small balloons (15-18 mm), later balloons of 20 mm and, with increasing frequency, of 23 mm diameter were utilized, providing very strong inflations at the end of the procedure. The average valve area after BAV increased from initially 0.75 +/- 0.18 to 0.87 +/- 0.28 cm2 after July 1987. Using the 23-mm balloon a mean valve area of 1.05 +/- 0.19 cm2 was obtained. The procedure-related mortality was 2.5%, the total early mortality (30 days) was 6.25%. Other non-fatal complications included two cases of severe valve incompetence requiring valve replacement, one dissection in the aortic root, one cerebrovascular accident, and eight cases of arterial damage (surgical repair). Twenty-six patients with initially successful dilation were restudied hemodynamically, 12 of whom had a restenosis (46%) after 5 months; 13 patients had a second dilatation. The clinical improvement was remarkable (at least 1 NYHA functional class) in 79% of the patients. 33% were improved 1 year and 20% 18 months after the first or eventually the second BAV. Eighteen of the discharged patients died in the follow-up period (two after valve replacement); 20 patients had aortic valve replacement due to restenosis. Our results show a correlation of the maximal balloon size to the valve area after BAV. However, even a perfect technique cannot prevent the restenosis that occurs mostly during the first year. Therefore, BAV may be useful and appropriate for selected patients with inoperable aortic stenosis, but it is no alternative to valve replacement.     

Balloon dilatation of critical stenosis of the pulmonary valve in neonates.

Percutaneous balloon dilatation was attempted in 15 consecutive neonates (mean age 7.3 (range 1-27) days and weight 3.2 (range 2.5-4.1) kg) with critical stenosis of the pulmonary valve. Dilatation was successful in 11 (73%) patients. The mean balloon to annulus ratio was 1.1 (range 0.6-1.77). The ratio of right ventricle to femoral artery systolic pressure decreased from a mean (1 SD) of 1.4 (0.32) before to 0.8 (0.24) after dilatation and the transvalvar gradient decreased from 81 (29.7) mm Hg before to 33 (27.7) mm Hg after dilatation. All four (27%) patients in whom dilatation was unsuccessful underwent surgical valvotomy. Complications of balloon dilatation occurred in three (20%) patients; these included retroperitoneal haematoma (one) and iliofemoral venous occlusion (two). In one (7%) patient severe hypoxia and hypotension developed when the valve was crossed with a guide wire and balloon catheter. Despite successful dilatation he died 7 days after the procedure. During a mean (1 SD) follow up of 2 (1.7) years, seven (64%) of the 11 patients remained free of important restenosis. One patient required repeat dilatation three weeks after the initial procedure. In three (27%) patients restenosis developed 4-9 months after dilatation and all three had surgical valvotomy. Of the four patients initially referred for surgery three required a second operation and one required balloon dilatation. Percutaneous balloon dilatation gave effective relief of critical pulmonary stenosis in most neonates but complications and restenosis requiring surgery were common.     

Valvotomy and congenital aortic valve stenosis. Long-term results

Twenty nine patients (average age 11 years) underwent valvotomy for congenital valvular aortic stenosis from 1967 to 1983. The medium and long-term results were analysed retrospectively: 14 children have been reoperated; 11 for restenosis and 3 for aortic regurgitation after an average period of 11 years. Thirteen of the other 15 patients have been regularly followed-up for about 10 years: there are 7 good results, 3 average results and 3 restenoses. One patient was lost to follow-up after 9 years and the other patient died secondarily of a non-cardiac cause. This series was compared to a previous one of 35 cases of valvular aortic stenosis who underwent valvotomy between 1954 and 1964. There were 6 deaths in the perioperative period and 6 during follow-up (on average 11 years after surgery), including 3 sudden deaths. Eleven patients were reoperated: 2 for endocarditis, 5 for restenosis and 4 for aortic regurgitation (on average after 13 years). Three patients were lost to follow-up and there are 9 survivors who have not been reoperated (average follow-up 27 years): 5 of these patients were reexamined; there were 2 excellent results, 2 average results and 1 restenosis. These results show that conservative surgery of congenital valvular aortic stenosis is now a low risk procedure in children, but it is a palliative solution. The main problem is that of follow-up to detect restenosis because of the risk of sudden death. This follow-up is much easier since the introduction of Doppler echocardiography, eventually associated with exercise stress testing in doubtful cases.(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.     

Open valvotomy for critical aortic stenosis in infancy.

Over a 5 year period open valvotomy was performed on 13 patients under the age of one year with critical aortic stenosis. All 13 survived operation. There were two late deaths--one 38 days after operation, associated with an unrelated neurosurgical procedure and the other 2 years 6 months after when aortic root enlargement and replacement of the aortic valve were performed. During this period two other infants presented with aortic stenosis. One, who was very ill before transfer, died before operation could be performed. The second patient had a hypoplastic left ventricle with a small mitral valve ring and was, therefore, considered to be part of a different subgroup. All the surviving children have been followed up (median length of follow up 2 years and 11 months, range 7 months-5 years). Left ventricular function, in terms of percentage systolic wall thickening, was shown to be significantly impaired in all age groups. Peak diastolic thinning was abnormal in those children aged from 3 to 5. The aortic valve gradient, as assessed by peak instantaneous continuous wave Doppler, was less than 40 mm Hg in five patients and between 40 and 70 mm Hg in seven patients. One patient, with appreciable restenosis, has undergone successful percutaneous balloon dilatation of the aortic valve.     

Open valvotomy for critical aortic stenosis in infancy

Over a 5 year period open valvotomy was performed on 13 patients under the age of one year with critical aortic stenosis. All 13 survived operation. There were two late deaths--one 38 days after operation, associated with an unrelated neurosurgical procedure and the other 2 years 6 months after when aortic root enlargement and replacement of the aortic valve were performed. During this period two other infants presented with aortic stenosis. One, who was very ill before transfer, died before operation could be performed. The second patient had a hypoplastic left ventricle with a small mitral valve ring and was, therefore, considered to be part of a different subgroup. All the surviving children have been followed up (median length of follow up 2 years and 11 months, range 7 months-5 years). Left ventricular function, in terms of percentage systolic wall thickening, was shown to be significantly impaired in all age groups. Peak diastolic thinning was abnormal in those children aged from 3 to 5. The aortic valve gradient, as assessed by peak instantaneous continuous wave Doppler, was less than 40 mm Hg in five patients and between 40 and 70 mm Hg in seven patients. One patient, with appreciable restenosis, has undergone successful percutaneous balloon dilatation of the aortic valve.     

Balloon dilatation of critical stenosis of the pulmonary valve in neonates

Percutaneous balloon dilatation was attempted in 15 consecutive neonates (mean age 7.3 (range 1-27) days and weight 3.2 (range 2.5-4.1) kg) with critical stenosis of the pulmonary valve. Dilatation was successful in 11 (73%) patients. The mean balloon to annulus ratio was 1.1 (range 0.6-1.77). The ratio of right ventricle to femoral artery systolic pressure decreased from a mean (1 SD) of 1.4 (0.32) before to 0.8 (0.24) after dilatation and the transvalvar gradient decreased from 81 (29.7) mm Hg before to 33 (27.7) mm Hg after dilatation. All four (27%) patients in whom dilatation was unsuccessful underwent surgical valvotomy. Complications of balloon dilatation occurred in three (20%) patients; these included retroperitoneal haematoma (one) and iliofemoral venous occlusion (two). In one (7%) patient severe hypoxia and hypotension developed when the valve was crossed with a guide wire and balloon catheter. Despite successful dilatation he died 7 days after the procedure. During a mean (1 SD) follow up of 2 (1.7) years, seven (64%) of the 11 patients remained free of important restenosis. One patient required repeat dilatation three weeks after the initial procedure. In three (27%) patients restenosis developed 4-9 months after dilatation and all three had surgical valvotomy. Of the four patients initially referred for surgery three required a second operation and one required balloon dilatation. Percutaneous balloon dilatation gave effective relief of critical pulmonary stenosis in most neonates but complications and restenosis requiring surgery were common.     

The long-term evolution of patients with senile aortic stenosis undergoing percutaneous valve dilatation]

The long-term follow-up of 35 patients with mean age of 74.3 +/- 8 years (64-86) who underwent percutaneous aortic valvuloplasty (PAV) is presented. The mean duration of the follow-up study was 33 months (range 1-48). Global mortality was 42% (14 patients) and was related to post-PAV aortic valvular area (47% mortality in less than 0.7 cm2 area group vs 28% in greater than or equal to 0.7 cm2 group) and left ventricular ejection fraction (67% in EF less than 35% group vs 35% in EF greater than or equal to 35% group). The actuarial probability of remaining alive and free of symptoms and of cardiac surgery or new PAV was 57, 41, 33, and 20% at 1, 2, 3 and 4 years. After PAV clinical improvement was obtained in most of the patients (68%), but only 42% of those with successful dilatation remain asymptomatic after a 24 months period (85 +/- 28 mmHg, p = NS). Transvalvular gradient studied by Doppler decreased immediately after PAV (92.8 +/- 26 mmHg vs 51 +/- 16 mmHg, p less than 0.001), but returned to baseline values after 12 months. These results show that PAV yields a clinical improvement in most of the patients, but this improvement is transitory, does not modify the natural history of the disease and has a high degree of restenosis. Thus, its use must be limited to a reduced group of patients who are not candidates for cardiac surgery.     

肾动脉粥样硬化性狭窄介入治疗的长期效果

目的观察动脉粥样硬化性肾动脉狭窄（ARAS）行肾动脉介入治疗的安全性、近期及远期效果。方法冠状动脉造影发现动脉粥样硬化的患者同时行肾动脉造影,肾动脉狭窄〉70％的150例患者行肾动脉介入治疗。长期随诊观察血压及肾功能变化。结果150例患者中96％合并冠心病,54％为3支病变患者,共植入170枚支架,成功率99．3％。住院期间死亡3例,随访期间死亡2例。临床随访7个月至5年,随访率为98．6％（145例）。166支血管再狭窄10支,占6．0％。肾动脉造影复查30例,肾血管再狭窄5例,其中3例行再次介入治疗。结论冠心病合并肾动脉狭窄行介入治疗是安全有效的,术后大部分患者血压可以得到改善,肾功能基本保持稳定。     

Intraoperative valvuloplasty in calcific aortic stenosis: a study comparing the mechanism of a novel expandable device with conventional balloon dilatation

In selected patients with calcific aortic stenosis, balloon valvuloplasty is an intermediate alternative to surgery. The effect of balloon valvuloplasty to increase valve area, however, is limited and the restenosis rate is high during follow-up. To improve the results and reduce the complication rate, a new device for valvuloplasty of calcific aortic stenosis was developed. This system consists of three expandable prongs mounted on a freely movable catheter tip. To evaluate the efficacy of this new device, valvuloplasty was performed in 10 patients with severe aortic stenosis intraoperatively just prior to valve replacement. Comparison was made with the results of conventional balloon dilatation performed in an additional 20 patients during surgery. Using the new device, the relative orifice area increased from 10 +/- 3% before to 20 +/- 6% following intervention. However, in only one patient was a considerable increase of static valve area (greater than 15%) found. The results were comparable to the effect of conventional balloon dilatation, which led to an increase of orifice area from 12 +/- 7% to 24 +/- 10%. With both systems, the best results were achieved in patients with aortic stenosis and significant commissural fusion. In contrast, in bicuspid or tricuspid valves without fused commissures the effect of the intervention was limited. Because complete obstruction of the aortic valve does not occur during dilatation, this new device might be superior to conventional balloon dilatation. Preselection of patients according to the morphology of the valve seems mandatory to improve the success and reduce the complication rate of valvuloplasty in aortic stenosis.     

Results of percutaneous valvuloplasty in calcified aortic stenosis in the adult

Aortic valvuloplasty by percutaneous valve dilatation was attempted in 52 patients aged from 60 to 88 years, 20 of whom were in functional stage IV with pulmonary oedema at the time of the procedure. Forty-seven stenoses could be dilated, with haemodynamic success (50 p. 100 increase of aortic valve area) in 44 patients. Among these 44 patients, 3 had to be operated upon because of persistent functional symptoms and 3 died during their stay in hospital (2 as a result of the procedure or the cardiopathy, 1 of heart failure unrelated to the aortic stenosis or the dilatation). The primary success rate therefore was 38/52 attempts, or 72.9 p. 100. The first 11 patients regarded as initial success could be followed up for at least 6 months: functional improvement with moderate myocardial alteration persisted in 9 of them, but Doppler examination in one showed restenosis. Two patients with severe myocardial dysfunction relapsed into cardiac failure; restenosis could be dilated in one of them. Percutaneous aortic valvuloplasty is an effective treatment of calcified aortic stenosis in elderly people who remain improved for at least 6 months when myocardial lesions are mild or moderate. The procedure incompletely reduces the aortic stenosis, which may account for the left of improvement in left ventricular function in patients with severe myocardial damage prior to dilatation. For this subgroup of patients, the choice lies between percutaneous valvuloplasty, which avoids surgery, and surgery which ensures a more complete haemodynamic result in the valve.