Transesophageal echocardiography during percutaneous mitral commissurotomy in patients with left atrial thrombus.

BACKGROUND: Transesophageal echocardiography (TEE) is used routinely before percutaneous transvenous mitral commissurotomy (PTMC) to detect left atrial appendage thrombus (LAAT) to avoid the risk of embolic complications. The issue of whether patients with small and fixed LAAT should be denied the potential benefit of PTMC is worth examining. OBJECTIVE: To evaluate the safety and efficacy of PTMC with Inoue balloon catheter in mitral stenosis patients with LAAT using TEE continuous monitoring during the procedure. Material and Method: All TEE studies performed during PTMC and transthoracic echo-cardiography (TTE) performed the same day and repeated on the day after the procedure between March 1995 and January 2000 were reviewed. RESULTS: A total of 1,238 consecutive TEE during PTMC were reviewed. LAAT was detected in 111 patients (mean age 43.7 +/- 10.1 years, male:female = 1:2, atrial fibrillation : sinus rhythm 2.47:1). LAAT were grossly oval with the largest measuring 3.5 x 2.8 centimeters. Mobile LAAT was detected in 3 patients (2.7%), one of whom developed a transient ischemic attack and another had an episode of stroke after PTMC. Mitral valve area (by 2D Echocardiography) pre PTMC was 0.8 +/- 0.2 cm2 and post-PTMC was 1.5 +/- 0.3 cm2. Most of our patients became fully ambulatory and could be discharged from the hospital the day after the procedure, except for two patients who developed severe mitral regurgitation and needed elective mitral valve surgery thereafter. CONCLUSION: PTMC with the Inoue-balloon catheter can be carefully and safely performed in patients with small, fixed LAAT under continuous TEE guidance with acceptable risk.

Percutaneous balloon mitral valvulotomy with transesophageal echocardiographic monitoring: experience in Khon Kaen University.

To study the results and complications of Percutaneous Balloon Mitral Valvulotomy with Transesophageal Echocardiographic monitoring in patients with symptomatic mitral stenosis. From November 1996 to November 1998, PBMV with TEE monitoring was performed in 107 patients with symptomatic mitral stenosis. There were 72 females and 35 males, aged 19 to 65 years (mean 37.63). The mitral valve was successfully dilated in 104 patients. Immediately after PBMV, there was significant reduction of mean mitral valve gradient (17.89 +/- 6.7 mm Hg to 6.21 +/- 3.02 mm Hg), mean left atrial pressure (26.67 +/- 6.61 mm Hg to 13.97 +/- 4.7 mm Hg), mean pulmonary artery pressure (35.21 +/- 13.03 mm Hg to 27.71 +/- 10.31 mm Hg). Mitral valve area was increased from 0.80 +/- 0.24 cm2 to 1.75 +/- 0.42 cm2 and cardiac output was increased from 3.84 +/- 0.97 L/min to 4.74 +/- 1.09 L/min. Mitral regurgitation was detected in 20 patients, severe mitral regurgitaion appeared in one patient. None of these patients required emergency surgery. Cardiac tamponade was detected in one case and resolved by pericardiocentesis. TEE was well tolerated and no complications of TEE were detected. PBMV aided by TEE is safe and well tolerated.

Frequency of angina pectoris and coronary artery disease in severe isolated valvular aortic stenosis.

Angina pectoris is a frequent symptom of severe valvular aortic stenosis (AS), even in the presence of normal coronary arteries. To determine the prevalence of angiographically significant coronary artery disease (CAD) and its relation to angina pectoris and coronary risk factors in severe isolated valvular AS patients. All cases of symptomatic AS patients who underwent aortic valve replacement and preoperative cardiac catheterization at the Central Chest Hospital between January 1, 1986 and December 31, 1996 were retrospectively analyzed. Excluded were those with multiple valvular disease, aortic regurgitation of grade 2 or more, and prior coronary or valve surgery. A total of ninety consecutive patients with severe AS (64 men and 26 women, mean age 58.94 years, range 38 to 71) were studied. Significant CAD (coronary diameter stenoses > or = 50%) was found in 15 patients (16.7%). Typical angina was present in 66.7 per cent of them but it was also found in 46.7 per cent of the non-CAD patients. This symptom had low positive predictive value (22%). Of the patients without angina (n = 45) 11.1 per cent had significant CAD, The negative predictive value of angina alone was thus 89 per cent. By univariate logistic regression, the statistically significant variables to discriminate those with or without significant CAD were age, history of hypertension, positive familial history of premature CAD, and cholesterol level. However, only age and hypertension were statistically significant by multivariate logistic regression analysis. Coronary arteriography can probably be omitted in severe valvular AS, especially those without a history of hypertension and < 40 years of age in men and < 50 years in women. For all other cases, coronary arteriography is recommended. In our study, angina pectoris is not a significant predictor for associated CAD.

Atrial myxoma: a review of clinical experience at Srinagarind Hospital.

Thirty-two intracardiac myxoma patients who underwent tumor excision in Srinagarind Hospital between January 1, 1983 and January 30, 1997 were retrospectively reviewed. Clinical presentations, diagnostic method, operative findings, and postoperative course were also analysed. There were 20 female and 12 male patients, age range 10 to 60 years (mean 37.9). Clinical presentations included congestive heart failure (56.2%), atypical chest pain (25.0%), syncope (18.9), and constitutional symptoms (9.3%). In six patients, there was clinical evidence of systemic embolism. One patient was essentially asymptomatic and incidentally detected during clinical check-up. Diagnosis was all made by two dimensional (2-D) echocardiographic study. There were 29 left atrial, 2 right atrial and 1 combined right atrial and right ventricular myxomas. There were 3 postoperative deaths, two due to septicemia and the other due to cerebral embolism. One patient developed postoperative severe mitral regurgitation and complete heart block needed mitral valve replacement and permanent pacemaker insertion. One patient developed localized seizure 6 years after resection and was suspected of brain metastasis. The other was found to have two high echogenic liver masses, 2 years after resection, suggestive of hepatic metastasis. Unfortunately, we could not obtain the histologic confirmation from any of those suspected lesions. Because of the non-specific and various manifestations of atrial myxoma, a high index of suspicion is needed. The diagnostic method of choice is 2D-echocardiography. Clinical follow-up for at least 10 years may be needed to rule out recurrence or metastasis.