Role of transesophageal echocardiography during balloon mitral valvuloplasty.

Transoesophageal echocardiography (TEE) was performed during balloon mitral valvuloplasty (BMV) in 40 patients of rheumatic mitral stenosis, to assess its feasibility and additional benefits. The age range was 12-35 (mean 20 +/- 6) years. Patients were in an unsedated state and the procedure was tolerated by all without any complication. High resolution images of the interatrial septum and the puncture assembly were obtained which guided the septal puncture. In eight (20%) patients, puncture assembly had to be readvanced into superior vena cava and withdrawn down to obtain a satisfactory position for puncture. In 2 additional cases, the puncture assembly was redirected towards the fossa ovalis region under TEE guidance alone to obtain a successful septal puncture. TEE was not found useful in either negotiating the mitral valve or positioning the balloon catheter across it.

Verapamil responsive ventricular tachycardia: clinical and electrophysiologic characteristics.

Ventricular tachycardia is a rare arrhythmia in young patients without associated heart disease. Electrophysiologic studies were performed in thirteen young patients (mean age 26.4 +/- 7 years) with recurrent sustained ventricular tachycardia (VT) responsive to intravenous verapamil. The QRS duration during VT was less than 0.14 sec in all patients. The VT showed a right bundle branch block (RBBB) morphology in all cases, with left axis deviation in 12 and right axis deviation in one. Eleven patients were free of organic heart disease. VT could be induced in the laboratory in 10 patients, out of whom the electrophysiologic mechanism of VT could be assessed in 9 cases. The data were consistent with reentry in 8 patients and suggested triggered activity in one patient. Atrial pacing induced the VT in two cases. Nine patients were restudied 48 to 72 hours after oral verapamil (240 to 320 mg/day). VT was not inducible in 8 patients and was markedly slowed in one. VT of RBBB morphology occurring in young patients has distinct electrocardiographic and electropharmacologic properties. Reentry is the usual underlying mechanism. Verapamil is highly effective in terminating and preventing the VT.

Clinical utility of transoesophageal echocardiography--preliminary experience of 100 cases.

We performed transoesophageal echocardiography (TEE) and compared its results with transthoracic echocardiographic (TTE) studies in a consecutive series of 100 cases. TEE was performed with a 5 MHz transducer with pulsed wave, continuous wave and colour Doppler facilities. All the patients were in unsedated state; the initial 50 were, in addition, monitored noninvasively for any change in heart rate, blood pressure or arterial oxygen saturation. The procedure was well tolerated by all; one patient had transient ventricular bigeminy. Except increase in heart rate and systolic blood pressure at the time of insertion of probe, there was no change in any of the clinical parameters studied. In patients of mitral stenosis, a thrombus in left atrium (LA) or left atrial appendage (LAA) was seen in 7/52 TEE studies, as compared to 4/52 TTE studies. LAA thrombi (2 cases) were detected only on TEE. Following balloon mitral valvuloplasty, a small atrial septal defect was seen in 6/8 TEE, but only 2/8 TTE studies. In 20 cases with doubtful atrial septal defects on TTE, TEE revealed an intact septum in 6 and delineated the anatomy of the defect in the remaining 14. TEE facilitated detection and better visualisation of paravalvular regurgitation in 4 cases with mitral and 3 cases with aortic valve prosthesis. In addition, TEE helped in excluding vegetations in 3 suspected cases of infective endocarditis and in studying details of 2 intracardiac masses. We conclude, TEE can be safely performed in conscious unsedated patients and provides valuable information in addition to transthoracic echocardiography.

Totally occluded coronary arteries with normal LV function: clinical and angiographic profile.

The clinical and coronary angiographic profile of 50 patients (Group I) with total occlusion of one or more major coronary arteries in the absence of electrocardiographic findings of myocardial infarction and normal segmental and global left ventricular (LV) functions were analysed to identify any variables responsible for this observation. Twenty five age and sex matched patients (Group II), who had 100% occlusion of at least one major coronary artery with significant wall motion abnormalities on LV angiograms, served as controls. The mean duration of angina before angiography or the occurrence of acute coronary event was significantly longer in Group I (2.8 +/- 2.2 yrs) compared to Group II (1.2 +/- 1.2 yrs; p less than .05) patients. RCA was found totally occluded more often in Group I as compared to Group II (60% vs 32%; p less than .05) patients, whereas complete occlusion of LAD occurred more frequently in Group II than in Group I (70% vs 32%; p less than .05). Significant stenoses in other arteries was found in 88% of Group I, compared to 48% of Group II patients (p less than .001). Although there was no significant difference in the frequency of collaterals feeding the totally occluded arteries in the two groups, 80% of patients in Group I had grade 3 collaterals compared to only 30% in Group II patients (p less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

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.