Técnica minimalista para valvuloplastía aórtica percutánea / Minimally invasive balloon aortic valve valvuloplastyBackground

RESUMEN: ANTECEDENTES: La valvuloplastía aórtica es un procedimiento paliativo o como puente al reemplazo aórtico percutáneo o quirúrgico. Nuestro abordaje incluye una técnica minimalista y la utilización de balones de mayor tamaño que lo estándar. OBJETIVO: Evaluar los resultados clínicos inmediatos y alejados de pacientes tratados mediante esta técnica modificada. MÉTODOS: Se incluyó a todos los pacientes sometidos a balonplastía aórtica entre Julio del 2012 y Agosto del 2019 en nuestro centro. El procedimiento se realizó bajo sedación consciente mediante un único acceso femoral y sin instalación de un marcapasos transitorio. El éxito de la intervención se definió como caída de gradiente basal en 50% o más en ausencia de complicación mayor. RESULTADOS: Se realizaron un total de 52 procedimientos en 49 pacientes. La edad promedio fue 76 ± 9,9 años. Un tercio de los pacientes tenía una fracción de eyección del ventrículo izquierdo ≤35% y similar proporción tenía un perfil de riesgo STS score > 10 puntos. La duración total promedio fue de 31,1 + 10,0 min. Se utilizó un balón #28 en el 84.6% de los casos. El éxito del procedimiento se alcanzó en 94,2% de los casos. Ocurrieron 2 muertes intraoperatorias (3,9%), ambas en pacientes de muy alto riesgo y 2 (3,9%) complicaciones vasculares mayores. La sobreviva en el seguimiento alejado fue 32,7%. CONCLUSIÓN: La valvuloplastia aórtica percutánea con técnica modificada, utilizando balones de mayor tamaño que lo habitual, es una técnica segura que logra óptimos resultados hemodinámicos.

ABSTRACT: Aortic balloon valvuloplasty (ABV) is a palliative procedure or a bridge to percutaneous or surgical aortic valve replacement. Our group proposes a minimalist approach that reduces the use of resources and also stands out for using larger balloons. AIM: To assess the safety and the immediate results of patients undergoing aortic balloon valvuloplasty using a minimally invasive procedure. METHODS: All patients who underwent ballon aortic valvuloplasty (BAV) between July 2012 and Au- gust 2019 were included. The procedure was performed under conscious sedation using a single femoral access and without the installation of a temporary pacemaker. Success was defined as a 50% drop in the mean aortic gradient plus the absence of major complications. RESULTS: 52 procedures in 49 patients were performed; the average age was 76 ± 9,9 years. A third of patients included had a left ventricular ejection fraction ≤35% and a similar proportion had a high risk profile with an STS score> 10 points. A 28 mm balloon was used in 84.6% of cases. The procedure was successful in 94,2% of cases. There were 2 (3,85%) intraoperative deaths in very high-risk patients and 2 (3,85%) major vascular complications. The survival rate at late follow up was 32,7%. CONCLUSION: Aortic balloon valvuloplasty with a minimally invasive technique using larger than usual balloons is a safe technique that achieves optimal hemodynamic results.

Comparison of early and long-term follow-up results of percutaneous mitral balloon valvuloplasty and mitral valve replacement

SUMMARY BACKGROUND: Percutaneous mitral balloon valvuloplasty and mitral valve replacement have been the treatment options for mitral stenosis for several years, however, studies that compare these two modalities are very rare in the literature. ObjectIve: In this article, we aim to investigate the comparison of clinical results of percutaneous mitral balloon valvuloplasty and mitral valve replacement. Methods: 527 patients with rheumatic mitral stenosis, treated with percutaneous mitral balloon valvuloplasty or mitral valve replacement (276 patients with percutaneous mitral balloon valvuloplasty and 251 patients with mitral valve replacement) from 1991 to 2012 were evaluated. The demographic characteristics, clinical, echocardiographic and catheterization data of patients were evaluated retrospectively. The results of early and late clinical follow-up of patients after percutaneous mitral balloon valvuloplasty and mitral valve replacement were also evaluated. Results: The mean follow-up time of the percutaneous mitral balloon valvuloplasty group was 4.7 years and, for the mitral valve replacement-group, it was 5.45 years. The hospital stay of the percutaneous mitral balloon valvuloplasty group was shorter than that of the mitral valve replacement group (2.02 days vs 10.62 days, p<0.001). The hospital mortality rate of percutaneous mitral balloon valvuloplasty and mitral valve replacement were 0% and 2% respectively (p=0.024). In the percutaneous mitral balloon valvuloplasty group, early postprocedural success rate was 92.1%. The event-free survival of percutaneous mitral balloon valvuloplasty and mitral valve replacement was found to be similar. While reintervention was higher in percutaneous mitral balloon valvuloplasty-group (p<0.001), mortality rate was higher in mitral valve replacement-group (p<0.001). Conclusion: Percutaneous mitral balloon valvuloplasty seems to be more advantageous than mitral valve replacement due to low mortality rates, easy application of the procedure and no need for general anesthesia.

Valvuloplastia mitral percutánea con balón: experiencia en el Cardiocentro de Santiago de Cuba / Percutaneous balloon mitral valvuloplasty: experiences at the Cardiocentro in Santiago de Cuba

RESUMEN Introducción: La valvuloplastia mitral percutánea con balón actualmente es el primer procedimiento terapéutico que se contempla en el mundo desarrollado para los pacientes con estenosis mitral reumática e indicación para ello, y se realiza en el Cardiocentro de Santiago de Cuba desde julio de 2008. Objetivos: Describir los resultados de la valvuloplastia mitral percutánea con balón en los pacientes estudiados. Método: Se realizó un estudio observacional y descriptivo, unicéntrico, que incluyó a 91 pacientes tratados mediante este procedimiento en el Cardiocentro de Santiago de Cuba, desde julio de 2008 hasta junio de 2019. Se evaluaron variables clínico-epidemiológicas, ecocardiográficas y hemodinámicas, así como el resultado inmediato del procedimiento. Resultados: Predominaron los pacientes jóvenes (60,4% entre 15-44 años), del sexo femenino (86,8%), con antecedentes de fiebre reumática (48,4%), en clase funcional III (64,8%) de la NYHA (New York Heart Association) y en ritmo sinusal (86,8%). Se logró un aumento promedio del área valvular de más del doble (0,99 vs. 2,12 cm2) del valor inicial y una reducción de la presión auricular mayor de 50% (25,0 vs.11, 76 mmHg), lo que permitió evaluar de satisfactorio el tratamiento en el 95,6% de los pacientes. Se identificó una asociación significativa (Prueba de Fisher ≤ 0,05) entre la puntuación de Wilkins ≤ 8 y el resultado satisfactorio del procedimiento. Conclusiones: Los resultados de la aplicación de la valvuloplastia mitral percutánea con balón en el centro fueron satisfactorios y congruentes con los referidos nacional e internacionalmente.

ABSTRACT Introduction: Percutaneous balloon mitral valvuloplasty has flourished as a mainstream therapy (mostly in developed countries) for treating patients with medical indication and those suffering from rheumatic mitral stenosis. This procedure is performed at the Cardiocentro in Santiago de Cuba since July 2008. Objectives: To describe the results of percutaneous balloon mitral valvuloplasty in the study participants. Methods: A descriptive, single-centered and observational study including 91 patients treated by this procedure was conducted at the Cardiocentro in Santiago de Cuba from July 2008 to June 2019. Clinical/epidemiological, echocardiographic and hemodynamic variables were assessed, as well as immediate procedure outcomes. Results: Young individuals (60.4% between 15-44 years), female (86.8%), with a history of rheumatic fever (48.4%), NYHA (New York Heart Association) functional class III (64.8%) and sinus rhythm (86.8%) predominated. An average increase in valve area of over double (0.99 vs. 2.12 cm2) the initial value and a reduction in atrial pressure of more than 50% (25 vs. 11.76 mmHg) was achieved; thus evidencing that the treatment was effective in 95.6% of the patients. A significant association (Fisher Test ≤ 0.05) was identified between Wilkins score ≤ 8 and satisfactory outcome of the procedure. Conclusions: The results of percutaneous balloon mitral valvuloplasty in the medical center were successful and consistent with those achieved nationally and internationally.

Estenosis valvular aórtica congénita. ¿Qué debemos esperar? ¿Cómo actuar? / Congenital aortic valve stenosis. What can we expect? How should we act? / O que esperar e como agir nos casos de estenose valvar aórtica congênita?

Resumen: La estenosis valvular aórtica congénita en edad pediátrica es una cardiopatía que debe ser valorada adecuadamente considerando en especial su potencial grado de severidad, a los efectos de realizar el tratamiento de forma adecuada y oportuna, evitando una complicación mayor: la muerte súbita. Se analizan los lineamientos generales para el diagnóstico y reconocimiento de su severidad así como el accionar terapéutico indicado. Por último se ejemplifica mediante cuatro casos clínicos diferentes situaciones evolutivas, mostrando los procedimientos diagnósticos y tratamientos realizados.

Summary: Congenital aortic valve stenosis in children is a heart disease that must be adequately evaluated. The potential degree of severity should be especially considered for a timely treatment in order to prevent sudden death. Guidelines for the diagnosis, recognition of severity and therapeutic action are suggested. Finally, the study presents four clinical cases, with the applied treatment and follow up.

Resumo: A estenose valvar aórtica congênita em pacientes pediátricos é uma doença cardíaca que deve ser avaliada adequadamente, considerando, em particular, seu potencial grau de severidade, a fim de realizar o tratamento adequado e oportuno, evitando a grave complicação da morte súbita. Analisamos as diretrizes gerais para o diagnóstico e reconhecimento de sua gravidade, bem como a ação terapêutica indicada. Finalmente, diferentes situações evolutivas são exemplificadas por quatro casos clínicos, mostrando os procedimentos diagnósticos e os tratamentos realizados.

Uso de la valvuloplastia mitral percutánea con balón en un hospital provincial / Use of the mitral percutaneous balloon valvuloplasty in a provincial hospital

Se realizó un estudio observacional y descriptivo, que incluyó a 46 pacientes tratados con valvuloplastia mitral percutánea con balón, en el Hospital Provincial Saturnino Lora Torres de Santiago de Cuba, desde julio de 2008 hasta diciembre de 2015, a fin de evaluar el resultado inmediato del proceder empleado. Se analizaron variables clinicoepidemiológicas, ecocardiográficas y hemodinámicas. Predominaron los pacientes jóvenes de 15-44 años (63,0 por ciento), las mujeres con antecedentes de fiebre reumática (87,0 por ciento), la clase III, según la clasificación funcional de la insuficiencia cardiaca (76,1 por ciento) y el ritmo sinusal (84,8 por ciento). Se logró un aumento del área valvular superior a 100,0 por ciento y una reducción de la presión auricular de aproximadamente 50,0 por ciento. El tratamiento fue satisfactorio en 93,5 por ciento de los afectados. Hubo asociación significativa entre los pacientes con una escala de Wilkins de 8 o menos y el sexo femenino, con un resultado favorable de dicho proceder

An observational and descriptive study that included 46 patients treated with mitral percutaneous balloon valvuloplasty, was carried out in Saturnino Lora Torres Provincial Hospital in Santiago de Cuba, from July, 2008 to December, 2015, in order to evaluate the immediate result of the procedure that was used. Clinical epidemiological, echocardiographic and hemodynamic variables were analyzed. There was a prevalence of the young patients aged 15-44 (63.0 percent), women with history of rheumatic fever (87.0 percent), the class III, according to the functional classification of heart failure (76.1 percent) and the sinus rhythm (84.8 percent). A 100.0 percent increase from the upper valvular area and an approximately 50.0 percent reduction of the atrial pressure were achieved. The treatment was satisfactory in 93.5 percent of the affected patients. There was a significant association between the patients with an 8 or less Wilkins scale and the female sex, with a favorable result of the procedure

Valvuloplastia mitral percutánea de emergencia en un paciente con edema pulmonar refractario / Emergency percutaneous mitral valvuloplasty in a patient with refractory pulmonary oedema

Resumen La estenosis mitral usualmente es causada por fiebre reumática. A pesar de ser una patología poco frecuente en los países desarrollados, es prevalente en los países en vía de desarrollo, donde aproximadamente dos tercios de la población mundial vive, haciendo de esta condición, una enfermedad valvular común. Es importante considerar la estenosis mitral en el diagnóstico diferencial de los pacientes con edema agudo de pulmón cardiogénico refractario y la valvuloplastia mitral percutánea de emergencia como el tratamiento definitivo. Se presenta el caso de un paciente femenino de 21 años, con edema agudo de pulmón cardiogénico refractario, secundario a estenosis mitral muy severa de origen reumático, tratado con valvuloplastia percutánea con balón de urgencia. Se realiza una revisión sobre la estenosis mitral y se examina el tratamiento con especial énfasis en los casos publicados en la literatura de valvuloplastia mitral percutánea de emergencia.

Abstract Mitral valve stenosis is usually caused by rheumatic fever. Although it is an uncommon disease in developed countries, it is prevalent in developing countries where approximately two-thirds of the world population lives, making this condition a common valve disease. It is important to consider mitral stenosis in the differential diagnosis of patients with acute refractory cardiogenic pulmonary oedema, and emergency percutaneous mitral valvuloplasty as the definitive treatment. The case is presented of a 21 year-old female with acute refractory cardiogenic pulmonary oedema, secondary to a very severe mitral stenosis of rheumatic origin, and who was treated with an urgent percutaneous balloon valvuloplasty. A review of mitral stenosis is presented, and the treatment is examined, with special emphasis on cases of emergency percutaneous mitral valvuloplasty published in the literature.

Resultados clínicos y ecocardiográficos a largo plazo de pacientes sometidos a valvuloplastia mitral percutanea / Long-term clinical and echocardiographic results of patients undergoing percutaneous mitral valvuloplasty

Resumen Antecedentes: la valvuloplastia mitral percutánea con balón (VMPB) es un tratamiento efectivo y recomendado para pacientes con estenosis mitral (EM) moderada o severa. Objetivos: describir las características epidemiológicas, clínicas y ecocardiográficas de pacientes con estenosis mitral sometidos a VMPB en el momento del procedimiento y hacerles seguimiento a 5, 10 y 15 años. Diseño: retrospectiva de una cohorte de pacientes con EM intervenidos con VMPB en la Clínica CardioVID; se analizan las características epidemiológicas, clínicas y ecocardiográficas antes, después del procedimiento y a largo plazo. Se define supervivencia libre de reintervención si durante el tiempo de seguimiento los pacientes no presentan nueva VMPB o cirugía de reemplazo valvular. Los procedimientos fallidos se definen como un área valvular mitral (AVM) pos VMPB<1.5cm2 o insuficiencia mitral>2+. Se define restenosis al tener AVM <1.5 cm2 con pérdida de 50% o más del área ganada con la VMPB. Resultados: se analizaron 162 VMPB realizadas desde enero de 1993 hasta diciembre de 2011. La ecocardiografía pos VMPB mostró que el AVM aumentó de 0.95±0.24cm2 a 1.56±0.33cm2 (p<0.001) medida por planimetría y 0.96±0.24 cm2 a 1.69±0.41 cm2 (p <0.0001) calculada por tiempo de hemipresión. El gradiente medio transvalvular disminuyó desde 14.1±5.7 mmHg a 6.9±3.4 mmHg (p <0.001). La supervivencia libre de reintervención fue 74% a cinco años, 53% a 10 años y 42% a 15 años. El tiempo mediano de supervivencia fue 128.8±26.4 meses (IC 95% 76.8-180.7); en pacientes con procedimiento fallido fue 57.2±6.1 meses y en el grupo de procedimiento exitoso fue 185.4±25.9 meses (p<0.001). Conclusiones: la VMPB es un procedimiento efectivo que produce un aumento significativo del área valvular mitral y retrasa de forma significativa la necesidad de cirugía de reemplazo valvular. EL AVM pos VMPB<1.5 cm2 fue el principal determinante negativo en el pronóstico a largo plazo.

Abstract Background: percutaneous mitral balloon valvuloplasty (PMBV) is an effective and recommended treatment for patients with moderate or severe mitral stenosis (MS). Objectives: to describe the epidemiological, clinical and echocardiographic characteristics of patients with mitral stenosis undergoing PMBV at the time of the procedure and to follow up at 5, 10 and 15 years. Design: retrospective review of a cohort of MS patients treated with PMBV at the CardioVID Clinic. The epidemiological, clinical and echocardiographic characteristics are analyzed before, after the procedure and in the long term. Reintervention-free survival is defined if during the follow-up period the patients do not undergo new PMBV or valve replacement surgery. Failed procedures are defined as a mitral valve area (MVA) pos PMBV <1.5cm2 or mitral insufficiency> 2+. Restenosis is defined as having MVA <1.5 cm2 with loss of 50% or more of the area gained with PMBV. Results: 162 PMBV realized from January 1993 to December 2011 were analized. Pos-PMBV echocardiography showed that MVA increased from 0.95 ± 0.24cm2 to 1.56 ± 0.33cm2 (p <0.001) as measured by planimetry and 0.96 ± 0.24 cm2 at 1.69 ± 0.41 cm 2 (p <0.0001) calculated by time of hemi pressure. The mean transvalvular gradient decreased from 14.1 ± 5.7 mmHg to 6.9 ± 3.4 mmHg (p <0.001). Survival free of reintervention was 74% at 5 years, 53% at 10 years and 42% at 15 years. Median survival time was 128.8 ± 26.4 months (95% CI 76.8-180.7); in patients with failed procedure was 57.2 ± 6.1 months and in the successful procedure group it was 185.4 ± 25.9 months (p <0.001). Conclusions: PMBV is an effective procedure that produces a significant increase in the mitral valve area and significantly delays the need for valve replacement surgery. The MVA pos PMBV <1.5 cm2 was the main negative determinant in the long-term prognosis.

Valvuloplastia pulmonar en menores de 21 años / Pulmonary valvuloplasty in patients under the age of 21

Resumen Objetivo: Determinar la asociación entre la proporción de las reintervenciones en los pacientes con la estenosis valvular pulmonar y la presencia de un gradiente transvalvular pulmonar final ≥25 mm Hg en pacientes menores de 21 años. Metodología: Estudio unicéntrico observacional, tipo corte transversal de período. Población: Pacientes entre 0 meses y 21 años en quienes se realizó valvuloplastia pulmonar con balón. Análisis: Descripción del grupo y análisis en los subgrupos dados por el gradiente final transvalvular ≥25 mm Hg y la reintervención. Se realizaron pruebas chi2 de Pearson, para las variables categóricas. Para las variables continuas se realizaron pruebas U de Mann-Whitney. Se realizó una regresión logística para definir la asociación entre las variables y el desenlace a la reintervención. Resultados: En el grupo con el gradiente final ≥25 mm Hg, el 86,67% eran lactantes. Se encontró que en el grupo con el gradiente final < 25 mm Hg la mediana del gradiente inicial fue de 42 mm Hg IQ 25-75%: (34-59) en comparación con el grupo con el gradiente final ≥25 mm Hg, la mediana del gradiente inicial fue 70 mm Hg IQ 25-75%: (41-86). Al analizar los grupos por la variable reintervención, se observó que el cambio en la relación de las presiones entre el ventrículo derecho y el ventrículo izquierdo se asoció con menor necesidad de reintervención. OR 0,04; IC 95% (0,002-0,7). El tener un gradiente final después de la intervención ≥25 mm Hg se asoció a reintervención. OR 14,5; IC 95% (2,8-75). Conclusiones: Un gradiente final transvalvular pulmonar ≥25 mm Hg se asoció a mayor probabilidad de reintervención.

Abstract Motivation: To determine the association between the proportion of reoperations in patients with pulmonary valvular stenosis and the presence of a final pulmonary transvalvular gradient of ≥25 mm Hg in patients under the age of 21. Methods: Observational single-centre study, cross-sectional period type. Population: Patients between 0 months and 21 years of age who underwent balloon pulmonary valvuloplasty. Analysis: Description of the group and analysis in the subgroups given by the final transvalvular gradient of ≥25 mm Hg and reoperation. Pearson's chi-squared test was conducted for categorical variables. For the continuous variables, the Mann-Whitney U test was conducted. Logistic regression was used to define the association between variables and reoperation outcome. Results: In the group with the final gradient of ≥25 mm Hg, 86.67% were infants. The group with the final gradient of < 25 mm Hg the median of the initial gradient was 42 mm Hg IQ 25-75%: (34-59) in comparison to the group with the final gradient ≥25 mm Hg, the median of the initial gradient was 70 mm Hg IQ 25-75%: (41-86). By analysing both groups with the reoperation variable, it was observed that the change in the relationship of the pressured between the right ventricle and the left ventricle was associated with a lower need for reoperation. OR 0.04; CI 95% (0.002-0.7). Having a final gradient of ≥25 mm Hg after the surgery was associated to reoperation. OR 14.5; CI 95% (2.8-75). Conclusion: Having a final pulmonary transvalvular gradient of ≥25 mm Hg was associated to a higher probability of reoperation.

Balloon dilation of congenital supravalvular pulmonic stenosis in a dog

Percutaneous balloon valvuloplasty is considered the standard of care for treatment of valvular pulmonic stenosis, a common congenital defect in dogs. Supravalvular pulmonic stenosis is a rare form of pulmonic stenosis in dogs and standard treatment has not been established. Although, there have been reports of successful treatment of supravalvular pulmonic stenosis with surgical and stenting techniques, there have been no reports of balloon dilation to treat dogs with this condition. Here, a case of supravalvular pulmonic stenosis diagnosed echocardiographically and angiographically in which a significant reduction in pressure gradient was achieved with balloon dilation alone is presented.

First reported case of fetal aortic valvuloplasty in Asia

Prenatal intervention of severe fetal aortic valve stenosis by ultrasound-guided percutaneous balloon valvuloplasty has been performed to prevent the progression to hypoplastic left heart syndrome, and achieve biventricular circulation in neonates. Here we report a case of fetal aortic valvuloplasty prenatally diagnosed with aortic stenosis at 24 weeks of gestation and showed worsening features on a follow-up echocardiography. Prenatal aortic valvuloplasty was performed at 29 weeks of gestation, and was a technical success. However, fetal bradycardia sustained, and an emergency cesarean delivery was performed. To the best of our knowledge, this is the first reported case of fetal aortic valvuloplasty which was performed in Asia.

Tratamiento percutáneo de estenosis múltiple de arteria pulmonar por vena yugular / Percutaneous treatment of multiple stenosis of pulmonary artery by jugular vein

El acceso venoso femoral es el abordaje de elección para realizar valvuloplastia y angioplastia en el árbol arterial pulmonar. Objetivo: Comunicar el tratamiento percutáneo de estenosis múltiple de la arteria pulmonar a través de un acceso venoso inusual en un lactante. Método: Estudio descriptivo. Historia clínica y base de datos del laboratorio de cateterismo. Resultados: paciente con trombosis de venas femorales a quien se le realizó valvuloplastia pulmonar, angioplastia de tronco arterial y origen de ambas ramas arteriales pulmonares de forma efectiva con catéteres balón de tamaño progresivo a través de la vena yugular interna derecha en un solo tiempo. Conclusión: El acceso venoso yugular para intervenciones percutáneas en el árbol arterial pulmonar es factible y seguro aún en lactantes.

The femoral venous access is the approach of choice for valvuloplasty and angioplasty in the pulmonary arteries. Objective: we report the percutaneous treatment for multiple pulmonary artery stenosis through an unusual venous approach in an infant. Method: descritve study. Medical records and catheterization laboratory database. Results: patient with femoral veins thrombosis in whom we performed effectively pulmonary valvuloplasty and angioplasty of pulmonary trunk and both branches of the pulmonary artery with progressive size balloon catheters, through the right internal jugular vein during the same procedure. Conclusion: The approach from internal jugular vein for percutaneous interventions in pulmonary trunk and its branches is feasible and safe even in infants.

Importância do comprometimento subvalvar nos resultados da valvoplastia mitral com cateter de inoue / Severity of subvalvular impairment in the results of mitral valvuloplasty with inoue catheter

Fundamentos: A valvoplastia mitral por cateter-balão foi introduzida em 1984 por Inoue e colaboradores, e atualmente é considerada o método de eleição no tratamento da estenose mitral. Objetivo: Comparar resultados de valvoplastia mitral em pacientes com estenose mitral com comprometimento subvalvar ≥3 e <3. Métodos: Estudo retrospectivo com 104 pacientes submetidos à valvoplastia mitral com balão de Inoue. Os pacientes foram estratificados em dois grupos: com comprometimento subvalvar (ASV) ≥3 e ASV <3. Realizada a comparação dos resultados imediatos, aos 12 meses e aos 24 ou mais meses entre os grupos com os dados obtidos por estudo ecocardiográfico e hemodinâmico. Resultados: Os resultados imediatos mostraram sucesso nos dois grupos, com significância estatística pré/pós procedimento, quanto aos parâmetros ecocardiográficos e hemodinâmicos, e ausência de diferenças significativas entre os grupos. Os resultados ecocardiográficos aos 12 meses evidenciaram que o gradiente médio e a área valvar foram semelhantes e sem significância estatística entre os grupos, o mesmo a correndo na comparação dos resultados ecocardiográficos aos 24 ou mais meses. Conclusão: Os resultados obtidos com a valvoplastia mitral com o balão de Inoue não diferiram tanto nos pacientes com comprometimento do aparelho subvalvar ≥3 quanto <3.

Background: Balloon mitral valvuloplasty was introduced in 1984 by Inoue et al and is currently considered the method of choice in the treatment of mitral stenosis. Objective: To compare results of mitral valvuloplasty in patients with mitral stenosis with subvalvular impairment ≥3 and <3. Methods: Retrospective study with 104 patients undergoing mitral valvuloplasty with Inoue balloon. Patients were stratified into two groups: subvalvular impairment (SVI) ≥3 and SVI <3. The immediate results were compared at 12 months and 24 months or more between the groups with data obtained by echocardiography and hemodynamic study. Results: The immediate results revealed success in both groups, with statistical significance pre/post-procedure regarding the echocardiographic and hemodynamic parameters and no significant differences between groups. Echocardiographic results at 12 months showed that the mean gradient and the valve area were similar and not statistically significant between the groups, the same occurring in the comparison of echocardiographic results at 24 or more months. Conclusion: The results obtained with mitral valvuloplasty with Inoue balloon did not differ both in patients with subvalvular impairment ≥3 and <3.

Valvuloplastia percutánea con balón de válvula mitral durante la gestación. Reporte de dos casos en un hospital de cuarto nivel de atención en Cali, Colombia y revisión de la literatura / Percutaneous balloon mitral valvuloplasty during pregnancy. Report of two cases in a level IV hospital in Cali, Colombia, and review of the literature

Objetivo: Describir la experiencia de dos casos de gestantes con estenosis mitral valvular, llevadas a valvuloplastia percutánea con balón y dilatación como alternativa terapéutica para contrarrestar los riesgos de colapso y deterioro materno-fetal y permitir la progresión del embarazo sin complicaciones cardiovasculares o el deterioro funcional, y realizar una revisión de la literatura publicada sobre la realización del procedimiento en gestantes. Materiales y métodos: Se presentan dos casos de estenosis mitral severa y compromiso funcional asociado, de aparición en el segundo trimestre del embarazo, atendidos en una institución de cuarto nivel de complejidad, centro de referencia regional. Se manejaron por medio de valvuloplastia mitral con balón, con desenlaces clínicos maternos perinatales favorables. La revisión de la literatura se hizo a partir de los términos: "valvuloplastia", "estenosis mitral" y "embarazo". Se realizó una búsqueda en la base de datos Medline vía PubMed, Medes y Scopus. Se excluyeron los procedimientos descritos que estaban dirigidos al reparo valvular del feto. Los estudios se centraron en los cambios en las mediciones de la válvula, los resultados obstétricos y la seguridad. Resultados: Se identificaron doce títulos. Los resultados obtenidos son comparables a los reportes de casos de estenosis de válvula mitral con procedimiento asistido por balón para dilatación de la válvula. En general, el procedimiento es exitoso, incrementa el área de la válvula mitral y reduce el gradiente de presión en la válvula. No obstante, existe el riesgo de desarrollar insuficiencia de válvula mitral tras la conducta, trombosis y muerte. Conclusión: La valvuloplastia percutánea con balón y dilatación como alternativa terapéutica es una opción por considerar en el manejo de la estenosis mitral en la gestante con deterioro de la clase funcional y el aumento durante el seguimiento de la presión en cuña pulmonar. Se requieren estudios controlados que validen los resultados de los estudios observacionales.

Objective: To describe the experience of two cases of pregnant women with mitral stenosis taken to percutaneous balloon valvuloplasty and dilatation as a therapeutic option to counteract the risk of collapse and maternal and foetal deterioration, and to allow progression of the gestation without cardiovascular complications or functional impairment; and to conduct a review of the published literature regarding this procedure in pregnant women. Materials and methods: Two cases of severe mitral stenosis and associated functional involvement of early onset during the second trimester of pregnancy, seen in a level IV regional referral centre. The two cases were managed with balloon mitral valvuloplasty, with favourable perinatal maternal outcomes. The review of the literature was done using the terms Valvulopasty, Mitral Stenosis and Pregnancy. A search was conducted in Medline via Pubmed and in the MEDES and SCOPUS databases. Procedures described for the performance of foetal valve repair were excluded. Studies were focused on the diagnostic findings and the course of the surgical procedure. Results: Overall, 12 titles were identified. The results obtained are comparable with the case reports found in the literature on mitral valve stenosis using balloon-assisted procedures for valve dilatation. In general terms, the procedure is successful, increasing the area of the mitral valve and reducing the pressure gradient across the valve. However, there is a risk of mitral regurgitation, thrombosis and death following the procedure. Conclusion: Percutaneous mitral valvuloplasty with balloon dilatation is a therapeutic option that may be considered for the management of mitral stenosis in pregnant women with functional class deterioration and increasing pulmonary wedge pressure during follow-up. Controlled studies are required in order to validate the results of observational studies.

Infective Endocarditis in a Patient after Percutaneous Mitral Balloon Valvuloplasty / 대한내과학회지

Percutaneous mitral balloon valvuloplasty (PMBV) is the treatment of choice for mitral stenosis. Only a few reported cases have been reported in PMBV patients worldwide. In this study, a case of a 34 year-old female with infective endocarditis a year after PMBV is presented. The patient presented with fever, and peripheral vascular symptoms. Transthoracic echocardiography showed vegetation on the anterior mitral leaflets and Staphylococcus Viridans was isolated from blood cultures. The patient was successfully treated with Amoxicillin + Clavulate and Gentamicin. Further studies on the correlation between PMBV and infective endocarditis are needed.

Transcatheter aortic valve implantation with balloonexpandable valve: early experience from China / Implantação da válvula aórtica transcateter com válvula balão-expansível: experiência inicial da China

AbstractObjective:The aim of the current study was to evaluate the early experience of the application of transcatheter aortic valve implantation with the balloon-expandable system in China. The transcatheter aortic valve implantation technology has been widely used for patients with inoperable severe aortic stenosis in the developed world. The application of transcatheter aortic valve implantation is still in the early stages of testing in China, particularly for the balloon-expandable valve procedure.Methods:This was a retrospective study. All patients undergoing transcatheter aortic valve implantation with balloon-expandable system in our hospital between 2011 and 2014 were included. Edwards SAPIEN XT Transcatheter Heart Valve was used. The improvement of valve and heart function was evaluated as well as 30-day mortality and major complications according to the VARC-2 definition.Results:A total of 10 transcatheter aortic valve implantation procedures with the balloon-expandable system were performed in our hospital, of which 9 were transfemoral and 1 was transapical. The median age was 76 years, and the median STS score and Logistic EuroSCORE (%) were 8.9 and 16.2. The implantation was successfully conducted in all patients, only 2 patients had mild paravalvular leak. There was no second valve implantation. Moreover, no 30-day mortality or complications was reported. Following the transcatheter aortic valve implantation procedure, the heart and valve functions had improved significantly. During the follow-up period of 3-34 months, one patient died of lung cancer 13 months after the operation.Conclusion:This early experience has provided preliminary evidence for the safety and efficacy of transcatheter aortic valve implantation procedure with the balloon-expandable system in the developing world with an increasing aging population.

ResumoObjetivo:O objetivo do presente estudo foi avaliar a experiência inicial da aplicação do implante percutâneo da válvula aórtica com o sistema balão-expansível na China. A tecnologia TAVI tem sido amplamente utilizada para pacientes com estenose aórtica grave inoperável no mundo desenvolvido. A aplicação de implante percutâneo da válvula aórtica está ainda nas etapas iniciais de teste na China, em particular o procedimento de válvula balão-expansível.Métodos:O estudo foi retrospectivo e todos os pacientes submetidos a implante percutâneo da válvula aórtica com sistema balão-expansível em nosso hospital entre 2011 e 2014 foram incluídos. Edwards SAPIEN XT Válvula Cardíaca Transcatheter foi usado. A melhoria do funcionamento da válvula e do coração foi avaliada, bem como mortalidade em 30 dias e as principais complicações de acordo com a definição VARC-2.Resultados:Um total de 10 procedimentos Tavi com o sistema balão-expansível foram realizados em nosso hospital, dos quais 9 foram transfemorais e 1 foi transapical. A idade média foi de 76 anos, e os STS mediana marcar e Logistic EuroSCORE (%) foram de 8,9 e 16,2. A implantação foi realizada com sucesso em todos os pacientes, apenas 2 pacientes tiveram vazamento paravalvar leve. Não houve um futuro implante valvar. Além disso, mortalidade em 30 dias ou complicações não foram relatadas. Seguindo o procedimento de implante percutâneo da válvula aórtica, as válvulas cardíacas e funções melhoraram significativamente. Durante o período de acompanhamento de 3-34 meses, um paciente morreu de câncer de pulmão 13 meses após a operação.Conclusão:Esta experiência inicial apresentou elementos de prova preliminar para a segurança e eficácia do procedimento implante percutâneo da válvula aórtica com o sistema balão-expansível no mundo em desenvolvimento com crescente envelhecimento da população.

Desfechos hospitalares e tardios de pacientes submetidos à valvoplastia mitral percutânea em centro com volume intermediário de procedimentos estruturais / In-hospital and late outcomes of patients undergoing percutaneous mitral valvuloplasty in a center with intermediate volume of structural procedures

A valvoplastia mitral percutânea é o tratamento de escolha da estenose mitral reumática comanatomia favorável, por sua capacidade de prevenir complicações inerentes ao tratamento cirúrgico e com manutenção da eficácia. Faz-se necessário promover comparações entre os resultados obtidos com o procedimento por centros de referência e alta drenagem de pacientes e por instituições de menor volume e casuística, sendo este o objetivo principal deste estudo. Métodos: Foram analisados 31 pacientes consecutivos submetidos à valvoplastia mitral percutânea no período de setembro de 2006 a janeiro de 2015. Avaliaram-se o sucesso imediato do procedimento e a sobrevida livre de eventos tardios, definidos como morte cardiovascular ou necessidade de novaintervenção valvar mitral. Resultados: A média de idade foi de 40,9 ± 14,2 anos, com predomínio do sexo feminino (96,8%). O escore médio de Wilkins e Block foi de 8,1 ± 1,2. A totalidade dos procedimentos foi efetivada pela técnica de Inoue, com taxa de sucesso imediato de 90,3%. Em acompanhamento médio de 6,8 ± 2,5 anos, foram constatadossete eventos (22,6%), sendo dois óbitos de etiologia cardiovascular, quatro cirurgias de troca valvar mitral e uma comissurotomia mitral. Conclusões: Em um hospital com volume intermediário de procedimentos, os resultados da valvoplastia mitral percutânea no tratamento da estenose mitral reumática com anatomia favorável foram comparáveis àqueles alcançados por centros de alto referenciamento...

Background: Percutaneous mitral valvuloplasty is the treatment of choice for rheumatic mitral stenosis with favorable anatomy, for its ability to prevent complications inherent to a surgical procedure, while maintaining effectiveness. It is necessary to promote comparisons between the results obtained by the procedure performed at referral centers with high patient inflow and at institutions with lower volume and fewer patients, which represents the main objective of this study. Methods: Thirty-one consecutive patients undergoing percutaneous mitral valvuloplasty were analyzed from September 2006 to January 2015. Immediate procedural success and late event-free survival rates were evaluated, defined as cardiovascular death or need for a new mitral valve intervention. Results: The mean age was 40.9 ± 14.2 years, with a predominance of females (96.8%). The mean Wilkinsand Block score was 8.1 ± 1.2. All procedures were performed using the Inoue technique, with na immediate success rate of 90.3%. At mean follow-up of 6.8 ± 2.5 years, seven events (22.6%) were observed: two cardiovascular deaths, four surgeries for mitral valve replacement, and one mitral commissurotomy Conclusions: In a hospital with intermediate procedure volume, the results of percutaneous mitral valvuloplasty in the treatment of rheumatic mitral stenosis with favorable anatomy were comparable to those achieved by high-volume centers...

Balloon valvuloplasty in dysplastic pulmonary valve stenosis: immediate and intermediate outcomes

To determine the immediate and intermediate outcome in dysplastic and doming pulmonary valve stenosis in children and to determine various factors associated with unsuccessful outcome. An interventional study. The Children's Hospital, Lahore, Pakistan, from June 2006 to December 2012. All patients presenting with severe pulmonary valve stenosis were enrolled in the study. Balloon valvuloplasty was performed on all patients. Successful outcome [residual gradient < 36 mmHg] was compared with matched doming pulmonary valve stenosis control group valvuloplasty. Difference in various quantitative variables was calculated using independent t-test and Mann Whitney U test. Categorical variables were compared using Chi square and Kruskal-Wallis test. Multivariate analysis was performed to determine various factors associated with outcome. Kaplan- Meier survival table was used to determine freedom from re-intervention proportions. One hundred and fifty two patients [Dysplastic group A, n=73; Doming group B, n=79] with median age of 24 months [range 3 - 192 months] and M:F; 2:1 were included in the study. Mean gradient decreased from 96 +/- 33 mmHg to 29 +/- 20 mmHg. Group A had significantly higher number of patients with unsuccessful outcome [9.6%, p=0.02]. Preprocedure gradient > 75 mmHg was the most significant factor associated with unsuccessful outcome [p < 0.001]. Median follow-up duration was 3 years [range 1 - 6 years]. Freedom from re-intervention proportion at 1, 3 and 6 years was 91.3%, 86.7% and 78.9% respectively in group A compared to 100%, 96.5% and 96.5% respectively in group B. Immediate postprocedure gradient > 60 mmHg was the only significant factor associated with re-intervention in group A [p=0.001]. The results from balloon valvuloplasty in dysplastic pulmonary valve were suboptimal when compared to doming valves. However, it provides a high freedom from re-intervention rate in intermediate follow-up. Intervention at moderate severity can result in better outcome

Postoperative Outcomes of Mitral Valve Repair for Mitral Restenosis after Percutaneous Balloon Mitral Valvotomy

BACKGROUND: There have been a number of studies on mitral valve replacement and repeated percutaneous mitral balloon valvotomy for mitral valve restenosis after percutaneous mitral balloon valvotomy. However, studies on mitral valve repair for these patients are rare. In this study, we analyzed postoperative outcomes of mitral valve repair for mitral valve restenosis after percutaneous mitral balloon valvotomy. METHODS: In this study, we assessed 15 patients (mean age, 47.7+/-9.7 years; 11 female and 4 male) who underwent mitral valve repair between August 2008 and March 2013 for symptomatic mitral valve restenosis after percutaneous mitral balloon valvotomy. The mean interval between the initial percutaneous mitral balloon valvotomy and the mitral valve repair was 13.5+/-7 years. The mean preoperative Wilkins score was 9.4+/-2.6. RESULTS: The mean mitral valve area obtained using planimetry increased from 1.16+/-0.16 cm2 to 1.62+/-0.34 cm2 (p=0.0001). The mean pressure half time obtained using Doppler ultrasound decreased from 202.4+/-58.6 ms to 152+/-50.2 ms (p=0.0001). The mean pressure gradient obtained using Doppler ultrasound decreased from 9.4+/-4.0 mmHg to 5.8+/-1.5 mmHg (p=0.0021). There were no early or late deaths. Thromboembolic events or infective endocarditis did not occur. Reoperations such as mitral valve repair or mitral valve replacement were not performed during the follow-up period (39+/-16 months). The 5-year event-free survival was 56.16% (95% confidence interval, 47.467-64.866). CONCLUSION: On the basis of these results, we could not conclude that mitral valve repair could be an alternative for patients with mitral valve restenosis after percutaneous balloon mitral valvotomy. However, some patients presented with results similar to those of mitral valve replacement. Further studies including more patients with long-term follow-up are necessary to determine the possibility of this application of mitral valve repair.

Application of percutaneous balloon mitral valvuloplasty in patients of rheumatic heart disease mitral stenosis combined with tricuspid regurgitation / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Tricuspid regurgitation (TR) is frequently associated with severe mitral stenosis (MS), the importance of significant TR was often neglected. However, TR influences the outcome of patients. The aim of this study was to investigate the efficacy and safety of percutaneous balloon mitral valvuloplasty (PBMV) procedure in rheumatic heart disease patients with mitral valve (MV) stenosis and tricuspid valve regurgitation.</p><p><b>METHODS</b>Two hundred and twenty patients were enrolled in this study due to rheumatic heart disease with MS combined with TR. Mitral balloon catheter made in China was used to expand MV. The following parameters were measured before and after PBMV: MV area (MVA), TR area (TRA), atrial pressure and diameter, and pulmonary artery pressure (PAP). The patients were followed for 6 months to 9 years.</p><p><b>RESULTS</b>After PBMV, the MVAs increased significantly (1.7 ± 0.3 cm 2 vs. 0.9 ± 0.3 cm 2 , P < 0.01); TRA significantly decreased (6.3 ± 1.7 cm 2 vs. 14.2 ± 6.5 cm 2 , P < 0.01), right atrial area (RAA) decreased significantly (21.5 ± 4.5 cm 2 vs. 25.4 ± 4.3 cm 2 , P < 0.05), TRA/RAA (%) decreased significantly (29.3 ± 3.2% vs. 44.2 ± 3.6%, P < 0.01). TR velocity (TRV) and TR continue time (TRT) as well as TRV × TRT decreased significantly (183.4 ± 9.4 cm/s vs. 254.5 ± 10.7 cm/s, P < 0.01; 185.7 ± 13.6 ms vs. 238.6 ± 11.3 ms, P < 0.01; 34.2 ± 5.6 cm vs. 60.7 ± 8.5 cm, P < 0.01, respectively). The postoperative left atrial diameter (LAD) significantly reduced (41.3 ± 6.2 mm vs. 49.8 ± 6.8 mm, P < 0.01) and the postoperative right atrial diameter (RAD) significantly reduced (28.7 ± 5.6 mm vs. 46.5 ± 6.3 mm, P < 0.01); the postoperative left atrium pressure significantly reduced (15.6 ± 6.1 mmHg vs. 26.5 ± 6.6 mmHg, P < 0.01), the postoperative right atrial pressure decreased significantly (13.2 ± 2.4 mmHg vs. 18.5 ± 4.3 mmHg, P < 0.01). The pulmonary arterial pressure decreased significantly after PBMV (48.2 ± 10.3 mmHg vs. 60.6 ± 15.5 mmHg, P < 0.01). The symptom of chest tightness and short of breath obviously alleviated. All cases followed-up for 6 months to 9 years (average 75 ± 32 months), 2 patients with severe regurgitation died (1 case of massive cerebral infarction, and 1 case of heart failure after 6 years and 8 years, respectively), 2 cases lost access. At the end of follow-up, MVA has been reduced compared with the postoperative (1.4 ± 0.4 cm 2 vs. 1.7 ± 0.3 cm 2 , P < 0.05); LAD slightly increased compared with the postoperative (45.2 ± 5.7 mm vs. 41.4 ± 6.3 mm, P < 0.05), RAD slightly also increased compared with the postoperative (36.1 ± 6.3 mm vs. 28.6 ± 5.5 mm, P < 0.05), but did not recover to the preoperative level. TRA slightly increased compared with the postoperative, but the difference was not statistically significant (P > 0.05). The PAP and left ventricular ejection fraction appeared no statistical difference compared with the postoperative (P > 0.05), the remaining patients without serious complications.</p><p><b>CONCLUSIONS</b>PBMV is a safe and effective procedure for MS combined with TR in patients of rheumatic heart disease. It can alleviate the symptoms and reduce the size of TR. It can also improve the quality-of-life and prognosis. Its recent and mid-term efficacy is certain. While its long-term efficacy remains to be observed.</p>