Percutaneous aortic balloon dilatation for calcific aortic stenosis in elderly patients: immediate haemodynamic results and short-term follow up.

Eight elderly patients (mean (SD) age 72.6 (8.5) years) with severe calcified stenosis of the aortic valve were considered for transluminal balloon dilatation in the Thoraxcenter between March and November 1986. In one patient the procedure could not be performed because of technical difficulties. Balloons of increasing diameter (13-25 mm) were successively passed retrogradely from the femoral artery and manually inflated with pressures of 400-600 kPa (4-6 atmospheres). Post-dilatation, there were significant changes in left ventricular pressures (from 237/21 to 204/13 mm Hg), mean systolic gradient (from 66 to 41 mm Hg, systolic aortic flow (from 172 to 202 ml/s, and aortic valve area (from 0.47 to 0.74 cm2); the cardiac index did not increase significantly (from 2.4 to 2.5 l/min/m2). One patient developed a pseudoaneurysm at the site of the femoral artery puncture that required surgical repair two months after the procedure; one patient experienced an acute left hemianopia during the procedure but had almost completely recovered at discharge. Five patients maintained a clinical improvement at a mean follow up time of 4.5 months after the procedure; two patients underwent aortic valve replacement, one because of minimal haemodynamic improvement after aortic balloon dilatation and persistence of severe dyspnoea and the other because of late recurrence of symptoms caused by restenosis after a successful procedure. Aortic balloon dilatation provides an alternative treatment for patients who are poor surgical candidates for cardiac or extracardiac reasons. At this stage the limited haemodynamic improvements suggest that the treatment can only be regarded as palliative, although proposed technical advances may achieve better immediate results in the future. Long term follow up is needed to evaluate the usefulness of this technique.     

Percutaneous aortic balloon dilatation for calcific aortic stenosis in elderly patients: immediate haemodynamic results and short-term follow up

Eight elderly patients (mean (SD) age 72.6 (8.5) years) with severe calcified stenosis of the aortic valve were considered for transluminal balloon dilatation in the Thoraxcenter between March and November 1986. In one patient the procedure could not be performed because of technical difficulties. Balloons of increasing diameter (13-25 mm) were successively passed retrogradely from the femoral artery and manually inflated with pressures of 400-600 kPa (4-6 atmospheres). Post-dilatation, there were significant changes in left ventricular pressures (from 237/21 to 204/13 mm Hg), mean systolic gradient (from 66 to 41 mm Hg, systolic aortic flow (from 172 to 202 ml/s, and aortic valve area (from 0.47 to 0.74 cm2); the cardiac index did not increase significantly (from 2.4 to 2.5 l/min/m2). One patient developed a pseudoaneurysm at the site of the femoral artery puncture that required surgical repair two months after the procedure; one patient experienced an acute left hemianopia during the procedure but had almost completely recovered at discharge. Five patients maintained a clinical improvement at a mean follow up time of 4.5 months after the procedure; two patients underwent aortic valve replacement, one because of minimal haemodynamic improvement after aortic balloon dilatation and persistence of severe dyspnoea and the other because of late recurrence of symptoms caused by restenosis after a successful procedure. Aortic balloon dilatation provides an alternative treatment for patients who are poor surgical candidates for cardiac or extracardiac reasons. At this stage the limited haemodynamic improvements suggest that the treatment can only be regarded as palliative, although proposed technical advances may achieve better immediate results in the future. Long term follow up is needed to evaluate the usefulness of this technique.     

Percutaneous balloon dilatation of mitral valve stenosis and aortic coarctation

We describe the percutaneous management of a 19-year-old woman with juvenile rheumatic mitral stenosis, associated with aortic coarctation. The dilemmas were both diagnostic and therapeutic, i.e., the association of juvenile rheumatic mitral stenosis with aortic coarctation and the difficult surgical approach of managing both lesions in the same intervention. We performed the balloon dilatation of these lesions during the same procedure, with good short- and long-term results.     

Percutaneous balloon dilatation of aortic valve stenosis in neonates and infants.

Percutaneous balloon dilatation of severe aortic valve stenosis was attempted in thirteen patients (seven neonates and six infants). In two the valve could not be crossed and both died during subsequent operation. Two patients died during manipulation of the balloon catheter. No significant benefit was obtained in another patient who later died during operation. Balloon dilatation was successful in the remaining eight patients, reducing the aortic valve pressure gradient from a mean of 63 mmHg (95% confidence interval 38 to 88 mmHg) to a mean of 23 mmHg (95% confidence interval 7 to 39 mmHg). Two of these patients subsequently died from heart failure related to other cardiac lesions. The six survivors have done well. At follow up the maximum Doppler velocities in the ascending aorta ranged from 1.9 to 4.0 m/s after 2-23 months, but despite this evidence of an increasing valve gradient there has been lasting clinical improvement.     

Percutaneous balloon dilatation of aortic valve stenosis in neonates and infants

Percutaneous balloon dilatation of severe aortic valve stenosis was attempted in thirteen patients (seven neonates and six infants). In two the valve could not be crossed and both died during subsequent operation. Two patients died during manipulation of the balloon catheter. No significant benefit was obtained in another patient who later died during operation. Balloon dilatation was successful in the remaining eight patients, reducing the aortic valve pressure gradient from a mean of 63 mmHg (95% confidence interval 38 to 88 mmHg) to a mean of 23 mmHg (95% confidence interval 7 to 39 mmHg). Two of these patients subsequently died from heart failure related to other cardiac lesions. The six survivors have done well. At follow up the maximum Doppler velocities in the ascending aorta ranged from 1.9 to 4.0 m/s after 2-23 months, but despite this evidence of an increasing valve gradient there has been lasting clinical improvement.     

Percutaneous balloon aortic valvuloplasty in adults with calcific aortic stenosis

After 5 years' experience with percutaneous balloon aortic valvuloplasty and more than 550 patients dilated for calcific aortic stenosis in our series, the limits of the method are well recognized, and the indications have been reviewed. To date, the two main indications are very old patients with increased surgical risks and critically ill patients in whom the procedure is most often used as a bridge to surgery. From our series of 180 octogenarians and nonagenarians with several factors increasing the predicted perioperative mortality, we showed that the technique is able to efficiently palliate the symptoms and improve survival. Valve replacement remains, however, recommended in otherwise healthy and active elderly patients. Balloon aortic valvuloplasty is also clearly useful in critically ill patients with major left ventricular dysfunction and severe heart failure, especially in patients with cardiogenic shock in whom it may be life saving. A dramatic improvement of left ventricular function is most generally obtained, allowing valve replacement to be performed later with an acceptable lowered risk. Balloon aortic valvuloplasty, a low-cost and low-risk procedure in experienced hands, requiring only local anesthesia and a short hospitalization stay, partially reduces aortic stenosis but may in many cases be the only valuable therapeutic option for patient improvement.     

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

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

Percutaneous double balloon aortic valvuloplasty in an adult patient with calcific aortic stenosis and a Bjork-Shiley prosthetic mitral valve

Percutaneous transluminal balloon valvuloplasty is a new technique in interventional cardiology which to date has been applied successfully in the dilatation of all four cardiac valves. Although the different techniques appear to be quite effective, the safety of these procedures has not been fully explored. In particular, because of the close anatomic relationship of the aortic and mitral annuli, the safety of aortic valvuloplasty in patients with mitral valve prosthesis is unknown. Therefore, we report the applicability of a percutaneous double balloon valvuloplasty in an elderly patient with calcific aortic stenosis and a Bjork-Shiley mitral valve prosthesis.     

Percutaneous transluminal balloon dilatation of discrete membranous subvalvular aortic stenosis

Discrete membranous subaortic stenosis (DMSS) which is localized immediately subvalvular and can be differentiated from fibromuscular stenosis of the left ventricular outflow tract, represents theoretically a well-suited lesion for uncomplicated balloon dilatation. The practical use of balloon dilatation for treatment of DMSS has been reported by two groups [6, 10]. In this overview, we will report our experience with balloon dilatation of DMSS in six children. Between June, 1986 and June, 1987, balloon dilatation of DMSS was carried out in six male children ranging in age from four to ten years (Table 2). In one child, coarctation of the aorta had been present and was previously treated successfully with balloon dilatation. In two children, the aortic valve was thickened with or without stenosis. All children had mild aortic regurgitation. After transvenous right heart catheterization and transarterial left heart catheterization including levocardiography and supraaortic angiography, 50 units of heparin per kilogram of body weight were administered and a guidewire advanced to the left ventricle for positioning of the balloon catheter in the left ventricular outflow tract. The choice of balloon diameter was based on measurement of the angiographically-determined aortic ring diameter (Table 1). Pressure measurements were obtained by means of a diagnostic catheter after the dilatation. No complications were observed either during or immediately after the intervention. After the dilatation, all children were discharged from the hospital to go home. Pressure in the left ventricle was reduced from 225 +/- 55 to 116 +/- 29 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nanobacteria-associated calcific aortic valve stenosis

Calcific aortic valve stenosis is the most common valvular disease in developed countries, and the major reason for operative valve replacement. In the US, the current annual cost of this surgery is approximately 1 billion dollars. Despite increasing morbidity and mortality, little is known of the cellular basis of the calcifications, which occur in high-perfusion zones of the heart. The case is presented of a patient with calcific aortic valve stenosis and colonies of progressively mineralized nanobacteria in the fibrocalcific nodules of the aortic cusps, as revealed by transmission electron microscopy. Consistent with their outstanding bioadhesivity, nanobacteria might serve as causative agents in the development of calcific aortic valve stenosis.     

Aortic valve damage caused by operative balloon dilatation of critical aortic valve stenosis.

Operative balloon dilatation of the aortic valve was performed in seven neonates with critical stenosis of the aortic valve. The procedure was followed by the development of severe aortic regurgitation in four patients. Necropsy was performed in three and revealed partial detachment of the right coronary cusp of the aortic valve. Damage to the valve leaflet caused by balloon dilatation was probably the result of using a balloon with a diameter that was too large in relation to the aortic valve ring diameter and of shearing forces created in the aortic wall by the contracting ventricle. The diameter of the inflated balloon should not be larger than the diameter of the aortic valve ring.     

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.     

Percutaneous balloon valvuloplasty for congenital aortic valve stenosis]

We performed percutaneous balloon aortic valvuloplasty for 10 patients with congenital aortic valve stenosis aged from 2 to 17 years and a 54-day-old infant with critical stenosis. The retrograde single balloon technique was used for 6 patients including the infant; the retrograde double balloon technique was used for 3 patients; and both techniques for 2 patients. The valvuloplasty was effective for 10 patients except for the infant in terms of the peak systolic pressure gradient between the left ventricle and aorta (from 80.6 +/- 21.9 to 29.4 +/- 17.0 mmHg). Follow-up cardiac catheterizations one year after valvuloplasty in 3 patients and 3 years after valvuloplasty in one patient disclosed no re-stenosis. Aortic regurgitation newly developed in one patient and advanced Sellers' classification I in 3 patients, however, all of them were asymptomatic and did not progress further. In the infant with critical stenosis, sufficient dilatation could not be achieved and acute myocardial infarction mainly at the lateral wall of the left ventricle developed during the valvuloplasty. He died 3 days after the valvuloplasty. The double balloon technique was found to be superior to the single balloon technique with the latter being ineffective in 2 cases, because the fixation of the balloon at the annulus was very difficult. Double balloon technique has low risk of vascular trauma and is applicable to a large sized annulus, because it enables blood supply between the 2 balloons during the inflation period.     

Histopathology of calcific aortic valve stenosis

Calcific aortic valve stenosis is the most common and increasing heart valve disease in the western world. In the last 30 years, diagnosis and management were revolutionized by the development of cardiac catheterisation, echocardiography, cardiac surgery, and medication. Recently, new strategies were introduced for aortic valve replacement using more sophisticated bioprosthetic heart valves. Moreover, tissue-engineered heart valves are under development to improve management strategies. In this article we review the current morphological and histopathological findings in the progression of calcific aortic valve stenosis.This is, to our understanding, important to contribute to the knowledge of fundamental management strategies of this disease.     

Doppler evaluation of results of percutaneous aortic balloon valvuloplasty in calcific aortic stenosis

To evaluate the short-term results of percutaneous aortic balloon valvuloplasty, 55 consecutive elderly patients with symptomatic, severe aortic stenosis who were at high risk for surgical intervention underwent the procedure, with follow-up by clinical evaluation and Doppler echocardiography. Over a mean follow-up of 6.2 months, there were three early deaths (less than 30 days) and eight late deaths. Nine patients underwent subsequent aortic valve surgery, and four had repeat balloon valvuloplasty. Doppler echocardiography revealed a reduction in aortic valve mean gradient from 48 +/- 18 to 33 +/- 12 mm Hg after the procedure (p less than 0.0001) but a return to 46 +/- 16 mm Hg at follow-up (p less than 0.05). The aortic valve area increased from 0.54 +/- 0.15 to 0.85 +/- 0.23 cm2 after the procedure (p less than 0.0001), but there was a significant decrease to 0.67 +/- 0.19 cm2 at follow-up (p less than 0.05). Of patients free of aortic valve operation or death after 30 days after the procedure, 76% were severely symptomatic before the procedure as compared with 38% at follow-up. In patients undergoing percutaneous aortic balloon valvuloplasty, there is a continued high short-term mortality and a significant incidence of restenosis over short-term follow-up. Nonetheless, a subset of patients do experience sustained clinical improvement from this procedure.     

Aortic valve damage caused by operative balloon dilatation of critical aortic valve stenosis

Operative balloon dilatation of the aortic valve was performed in seven neonates with critical stenosis of the aortic valve. The procedure was followed by the development of severe aortic regurgitation in four patients. Necropsy was performed in three and revealed partial detachment of the right coronary cusp of the aortic valve. Damage to the valve leaflet caused by balloon dilatation was probably the result of using a balloon with a diameter that was too large in relation to the aortic valve ring diameter and of shearing forces created in the aortic wall by the contracting ventricle. The diameter of the inflated balloon should not be larger than the diameter of the aortic valve ring.     

Percutaneous balloon dilatation in congenital mitral stenosis.

A three year old girl with severe congenital mitral stenosis was successfully treated by percutaneous balloon dilatation of the mitral valve. Cardiac catheterisation and cross sectional and Doppler echocardiography indicated that the orifice of the mitral valve had doubled in area. A small atrial septal defect was found at follow up cardiac catheterisation and angiography. Balloon dilatation of the mitral valve is a reasonable alternative to surgical treatment for typical congenital mitral stenosis even in young children.