[Long-term follow-up after percutaneous septal ablation in hypertrophic obstructive cardiomyopathy ]. / Langzeitverlauf nach perkutaner Septumablation bei hypertropher obstruktiver Kardiomyopathie.

BACKGROUND AND OBJECTIVE: Persisting disabling symptoms despite optimal medical treatment in patients with hypertrophic cardiomyopathy and significant outflow tract obstruction prompt surgical or interventional therapy targeted at relief of obstruction. While surgical treatment was introduced more than 40 years ago, there are only a few data on the long-term results of percutaneous septal ablation. This study gives the results of a large number of patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent septal ablation in our institution. PATIENTS AND METHODS: 347 patients (156 females, 191 males, 54 +/- 15 years) in NYHA functional class III or IV, or in class II but with evidence of more severe limitation on exercise testing, underwent percutaneous transluminal septal myocardial ablation (PTSMA). Mortality and morbidity, as well as clinical and echocardiographic parameters were assessed during follow-up, either at our institution, or by the referring cardiologist. RESULTS: During an average follow-up of 58 +/- 35 months the overall mortality was about 1,8 % per year, with a cardiovascular-related mortality of about 1 % per year. 8 % of patients needed a second procedure. A significant and sustained improvement of symptoms (89 % patients were in NYHA class I or II a follow-up) and obstruction were demonstrated (74 % of patients were free from obstruction at rest, 60 % did not exhibit provokable gradients). Supraventricular arrhythmias, especially atrial fibrillation, were observed in 12 % of patients. CONCLUSION: Percutaneous septal ablation provides significant and sustained beneficial effects on symptoms and echocardiographic variables, without evidence of an excess mortality. But independently of the clinical success of the procedure persistence of the underlying structural heart disease should be kept in mind. Periodic re-evaluation is mandatory to identify and treat high-risk patients.

Echo-guided percutaneous coil embolization of a symptomatic massive metastasis of a renal cell carcinoma in the right ventricular outflow tract.

We present the case of a 41-year-old woman who was admitted to our centre with progressive symptoms of congestive heart failure (NYHA class III) 5 years after a radical nephrectomy for renal cell carcinoma. Magnetic resonance imaging demonstrated a 5 x 3 cm homogeneous intracardial mass causing right ventricular outflow tract obstruction, not accessible to surgical resection. Serial echo-guided, percutaneous coil embolization of the cardial metastasis was performed with Contour SE Microparticles (150-250 or 300-500 microm) after identification of the target region of the metastasis by contrast injection (Levovist) through the balloon catheter into the coronary artery under transoesophageal echocardiographic control prior to induction of the necrosis, corresponding to the technique which has been described for septal ablation in hypertrophic obstructive cardiomyopathy. Follow-up after serial embolization showed a good haemodynamic and a marked clinical response (dyspnoea NYHA I-II) which lasted during the 19 month of survival after the index procedure.

One-year follow-up of percutaneous septal ablation for symptomatic hypertrophic obstructive cardiomyopathy in 312 patients: predictors of hemodynamic and clinical response.

AIM: The aim of this study was to analyze hemodynamic and clinical outcome in a cohort of 312 patients who were followed up over a period of 12 months after alcohol septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). METHODS AND RESULTS: PTSMA was intended in 337 patients with HOCM (mean age: 54+/-15 years), with 312 procedures completed by injection of 2.8+/-1.2 ml of alcohol. In 25 patients (8%) the intervention was aborted, mostly because of contrast echocardiographic findings. In the 312 patients who received alcohol, permanent pacing was necessary in 22 cases (7%); and in-hospital mortality was 1.3% (four patients). During follow-up, contact to six patients (2%) was lost, and three additional patients (1%) died. The 299 patients who either underwent non-invasive reassessment in our institution or transmitted followup data from their local physician formed the study population. Improvement in symptoms was reported by 272 patients (91%). Mean NYHA functional class was reduced from 2.9+/-0.4 to 1.5+/-0.7 (p<0.0001) along with a gradient reduction (echo-Doppler) from 59+/-32 to 8+/-15 mmHg at rest, and from 120+/-42 to 28+/-32 mmHg with provocation (p<0.0001 each). Exercise capacity improved from 94+/-51 to 119+/-40 watts (p=0.001), and peak oxygen consumption from 18+/-4 to 21+/-6 ml/ kg/min (p=0.01). Younger age and higher outflow gradients at baseline and immediately after intervention were associated with a less favorable hemodynamic outcome. The degree of limitation of exercise capacity at baseline was the only predictor of symptomatic improvement. CONCLUSIONS: Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. In contrast to a previous study, in this cohort of 312 patients there was no association between post-interventional enzyme release and hemodynamic success. Younger patients with high baseline gradients, however, tended to have a less favorable hemodynamic outcome with higher residual gradients.

[Clinical and haemodynamic results after repeat valvotomy of the mitral valve using the Inoue balloon. A comparison with the results after primary valvotomy]. / Klinische und hämodynamische Ergebnisse nach Re-Valvotomie der Mitralklappe mittels Inoue-Ballon. Ein Vergleich zu Ergebnissen nach primärer Valvotomie.

BACKGROUND AND OBJECTIVE: Percutaneous mitral valvotomy (MVT) with the Inoue balloon is the most frequently performed therapeutic alternative to surgical commissurotomy in patients with symptomatic mitral valve stenosis. Few data are available on the results of repeat MVT. PATIENTS AND METHODS: We compared the immediate and 3-month results of all patients who had a repeat MVT (n = 39) with those who had a primary intervention (n = 1,117) in our institution between February 1989 and January 2001. Mean age of the 31 women and 8 men with repeat MVT was 53 +/- 14 years at the first and 57 +/- 14 years at the second intervention performed 3 - 10 years later. RESULTS: Following primary intervention the invasively assessed mitral valve are (MVA) had increased from an average of 1.0 +/- 0.2 cm(2) to 1.7 +/- 0.4 cm(2). Echocardiography three months after the intervention revealed a MVA of 1.7 +/- 0.3 cm(2). Repeat MVT resulted in an immediate increase of MVA from 1.0 +/- 0.2 cm(2) to 1.6 +/- 0.4 cm(2), after 3 months the average MVA was 1.6 +/- 0.3 cm(2). According to the NYHA classification clinical symptoms had improved on average from 2.6 to 1.6 three months after primay intervention and from 2.8 to 2.1 three months following the repeat procedure. The incidence of significant procedure-related complications was less than 3 % for both primary and repeat MVT. CONCLUSION: The clinical and hemodynamic results demonstrated in our patients suggests repeat MVT as the treatment option of choice in mitral restenosis after previous balloon intervention, if mitral valve morphology is still suitable.

[Predicting the risk of atrioventricular conduction lesions after percutaneous septal ablation for obstructive hypertrophic cardiomyopathy]. / Vorhersage des Risikos permanenter atrioventrikulärer Uberleitungsstörungen nach perkutaner Septumablation bei Patienten mit hypertropher obstruktiver Kardiomyopathie.

BACKGROUND AND INTRODUCTION: Damage to the AV conduction system is a frequent complication of percutaneous septal ablation (PTSMA) that needs early and reliable identification of those patients (pts.) at risk for complete heart block (CHB) and subsequent pacemaker implantation. METHODS AND RESULTS: In the first 39 pts. who underwent PTSMA in 1996, AV conduction recovery needed up to 11 days. One pt. suffered from unexpected CHB after 9 days. Seven pts. who needed a DDD pacemaker (DDD-PM) were compared to those without conduction disturbances. A score was established which identified all DDD-PM candidates retrospectively if they presented with >12 score points. In the following 137 consecutive pts. treated in 1997 and 1998, this score was applied prospectively, and again correctly identified all candidates for a DDD-PM. In addition, a low risk group was identified with <8 score points. From 1999 on, the score was applied in routine clinical decision-making in 120 consecutive pts. with respect to DDD-PM implantation. All low risk pts. (<8 points) remained free from bradycardias, while 2/54 pts. (4%) of the intermediate risk group, and 20/23 pts. (87%) of the high risk group had to undergo DDD-PM implantation. Pts. with a first-degree AV block or those with a right bundle branch block at baseline had no excess risk, while 50% of the pts. with a left bundle branch block (LBBB) needed a DDD-PM. CONCLUSIONS: Based on pre-interventional data and careful monitoring of the first 48 hours after PTSMA, identification of pts. at risk for CHB and subsequent DDD-PM implantation seems to be possible. Pts. with a score <8 seem to be at low, those with >12 points at high risk. In the remaining cases watchful waiting with prolonged monitoring may allow AV conduction to recover, thus, reducing the number of unnecessary DDD-PM implantations. In cases with LBBB at baseline, however, implantation of a DDD-PM should be considered first-line therapy.

[Aortic isthmus stenosis with open ductus Botalli as etiology of severe heart failure in a 36-year-old patient--case report of successful surgical treatment]. / Aortenisthmusstenose mit offenem Ductus Botalli als Ursache einer schweren Herzinsuffizienz bei einer 36-jährigen Patientin--Fallbericht über eine erfolgreiche operative Behandlung.

We report on the history of a 36-year-old woman with untreated coarctation of the aorta and patent ductus arteriosus who developed refractory heart failure due to severely impaired left ventricular function. After coarctation repair and duct resection, left ventricular function improved to normal. Even in the presence of longstanding left ventricular pressure and volume overload, subsequent severe myocardial failure may be reversible by surgical repair.

[Congenital tubular supravalvular aortic stenosis with massive coronary artery dilatation in a 35-year-old man]. / Kongenitale, tubuläre supravalvuläre Aortenstenose mit massiver Koronararteriendilatation bei einem 35-jährigen Mann.

Supravalvular aortic stenosis is a rare cause of left ventricular outflow obstruction in adults. It occurs as an isolated defect sporadically or on a hereditary basis with an autosomal dominant trait without further phenotypical anomalies, or as part of the Williams syndrome with mental retardation and multiple other anomalies. This lesion was proved to result from a defect of the elastin coding gene. Supravalvular aortic stenosis is frequently associated with cardiovascular defects, particularly of the peripheral pulmonary arteries, thoracic aorta, carotid, subclavian, and coronary arteries and the aortic valve. The coronary arteries are subject to an increased perfusion pressure leading to dilatation, tortuosity and accelerated arteriosclerosis. We give details of a 35-year-old patient in whom a previously asymptomatic supravalvular aortic stenosis is associated with an excessive dilatation of the right coronary artery and the left anterior descending coronary artery as well as an ostium stenosis of the left common carotid artery. The patient did not present any phenotypical anomalies of the Williams syndrome.

Transvenous closure of patent ductus arteriosus with Ivalon plugs. Multicenter experience with a new technique.

RATIONALE AND OBJECTIVE: The authors assess the clinical efficacy of transvenous closure of patent ductus arteriosus (PDA) with a new plug consisting of Ivalon foam and a platinum/iridium frame with four aortic and two pulmonary nitinol struts. The most widely used devices for transcatheter treatment of PDA (Porstmann plug, Rashkind umbrella, Botallo occluder, coils) have specific limitations inherent to their design (e.g., transarterial approach, residual shunts, limited retrieval). METHODS: Between 1994 and 1997, PDA closure was attempted in 33 children and 67 adolescents and adults in 7 clinical centers; PDA diameter was 2 to 11 mm. Plug diameter was 6 to 20 mm, and 8 to 16 F venous sheaths were used for insertion. RESULTS: Placement was successful in 98% (with a single plug in 88%, and a second or third plug in 10%) and unsuccessful in 2%. Plugs were retrieved after malpositioning in 12 of 12 patients and after pulmonary embolization in 2 of 3 patients. One patient underwent surgery for removal of an embolized plug. Complete PDA closure was proved by aortography and color Doppler echocardiography in 85% (40 of 43 patients with a PDA 2-3.9 mm, 30 of 36 patients with a PDA 4-5.9 mm, and 15 of 21 patients with a PDA 6-11 mm). During a median follow-up interval of 16 months, there were no complications (infection, hemolysis, fracture, embolization). CONCLUSION: The new plug device can be used successfully in patients with a PDA diameter up to 11 mm. Further investigations are underway to determine the definite clinical value of this technique.

[Diagnosis and differential therapy of mitral stenosis]. / Diagnose und Differentialtherapie der Mitralstenose.

Clinical symptoms and diagnostic findings in patients with mitral stenosis are usually determined by the extent of the stenosis. Compared to a normal mitral valve area (MVA) of > 4 cm2, MVA in patients with severe mitral stenosis is usually reduced to < 1.5 cm2. In older patients symptoms are frequently influenced by concomitant diseases (e.g. atrial fibrillation, arterial hypertension or lung disease). An important diagnostic element besides anamnesis, auscultation, ECG and chest X-ray is echocardiography, which is required in order to measure non-invasively and reliably the mitral valve gradient (MVG), the MVA and morphologic changes to the valves, as well as concomitant valvular disease, ventricular functions and, where appropriate, left-atrial thrombi. In addition to the surgical treatment of patients with severe mitral stenosis, which has been an established procedure for 50 years, percutaneous balloon mitral valvuloplasty (MVP) has recently established itself as an alternative option. At the current time, the Inoue technique seems to display the most advantages. Following transseptal puncture, the Inoue balloon is guided transvenously into the left atrium and then into the left ventricle using a special support wire. The balloon is short and soft. Its special unfolding character enables it to be placed securely in the mitral valve without any risk of ventricular perforation (Figure 1). As with surgical commissurotomy, balloon valvuloplasty leads to a separation of fused commissures. This results in a significant reduction of MVG, accompanied by an increase in the MVA (Figure 2). The results and success of MVP are influenced by the morphology of the valves and the changes to the subvalvular apparatus. In randomized studies, the results of surgical commissurotomy were comparable with those of balloon mitral valvulotomy. In our hospital, an increase in MVA from 1.0 to 1.8 cm2 could be achieved in 899 patients (mean age 56 +/- 3 years). In younger patients with less significantly changed valves, the results were correspondingly more favorable than in older patients (Figure 3). Provided valve morphology is suitable, a relapse following previous surgical commissurotomy is not a contraindication for MVP. The MVP complication rate is very low in skilled hands: mortality is below 1%; mitral insufficiency occurs in 3 to 10% of interventions; we observed a severe mitral insufficiency in 5% of our patient group. Thromboembolic complications may be prevented after exclusion of atrial thrombi by transesophageal echocardiography. The occurrence of a hemodynamically significant atrial septum defect is a very rare event. The mid-term results (5 to 10 years) and the low restenosis rate following MVP in patients with suitable valves are comparable with those of surgical commissurotomy. In older patients with considerably changed, calcified and fibrotic valves, restenosis may be expected within 1 to 5 years. In these patients MVP represents no more than a palliative intervention in order to prolong the point of surgery, for example in patients where a concomitant aortic valve disease in itself is not yet an indication for surgery. Special indications are to be found in young patients with severe mitral stenosis yet few symptoms, in pregnant females and in emergency situations, as well as in patients with Grade II mitral stenosis with intermittent atrial fibrillation. Catheter therapy is much less invasive than surgery. In case of failure the patient still has the option of surgical therapy. Patients with morphologically significantly altered valves usually receive a valve replacement since an unsuccessful reconstruction would lead to a second operation within a very short time interval. Contraindications for MVP are thrombi in the left atrium, a previously existing > Grade II mitral regurgitation and marked, degenerative destruction of the subvalvular apparatus or extensive calcification of the valves. MVP thus represents a significant addi

[Emergency percutaneous valvulotomy with the Inoue balloon in high grade mitral valve stenosis in pregnancy]. / Notfallmässige perkutane Valvulotomie mit dem Inoue-Ballon bei hochgradiger Mitralstenose in der Schwangerschaft.

CASE REPORT: A 26-year-old pregnant woman (18th week of pregnancy) was admitted to a hospital with right heart failure and pulmonary congestion. After establishing the diagnosis of mitral stenosis, a first stabilization could be achieved by medical therapy with digitalis, diuretics, and beta-blockers. Readmission was necessary in the 23rd week. After failure of medical treatment the patient was transferred to our center. We decided to perform an emergency mitral valvulotomy with the Inoue balloon. Taking care of maximal radiation protection for mother and fetus doubling of the mitral valve opening are (from 0.6 cm2 to 1.3 cm2) could be achieved. The pleural effusions and tricuspid regurgitation disappeared. The patient was symptom-free and could be delivered from a male infant on schedule.

[Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: acute results in 66 patients with reference to myocardial contrast echocardiography]. / Perkutane transluminale septale Myokardablation bei hypertroph-obstruktiver Kardiomyopathie: Akutergebnisse bei 66 Patienten unter Berücksichtigung der Myokard-Kontrastechokardiographie.

BACKGROUND: In hypertrophic obstructive cardiomyopathy (HOCM) therapy, surgical myectomy and DDD pacemaker implantation are considered to be established extensions to medical treatment. As an alternative procedure for reducing the left ventricular outflow tract gradient (LVOTG), percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced septal branch occlusion has been introduced. We report on the acute results and the short-term clinical course following 66 PTSMA interventions in symptomatic patients (pts.) with HOCM. METHODS: In pts. who were symptomatic despite adequate drug therapy (31 women, 35 men; mean age 52.9 +/- 15.0 years, range: 16-86) 66 PTSMA interventions were performed (4 pts. with a re-intervention). Septal branches were occluded by injection of 3.5 +/- 1.8 (1.5-11.0) ml ethanol (96%). In the first 30 pts. the target vessel was determined by probatory balloon occlusion (PBO) alone, in the following 36 by additional myocardial contrast echocardiography (MCE). In-hospital follow-up of LVOTG and clinical course were determined. RESULTS: The invasively determined LVOTG could be reduced by > 50% or eliminated in 54 interventions (82%) with a mean reduction from 71.2 +/- 34.4 (4-174) to 18.0 +/- 21.5 (0-105) mmHg at rest and from 145.7 < or = 42.3 (68-257) to 63.7 +/- 49.3 (0-185) mmHg post extrasystole (p < 0.0001). All pts. experienced angina pectoris within the first 24 hours. The creatine kinase peak was 690 +/- 364 (201-1810) U/l after 11.0 +/- 5.4 (4-24) hours. 45 pts. (68%) developed trifascicular block, requiring temporary, or in 9 cases (14%) permanent, (DDD) pacemaker implantation. Two pts. (3%) died 9 and 2 days after successful intervention, due to uncontrollable ventricular fibrillation associated with betasympathomimetic and theophylline treatment for chronic obstructive pulmonary disease in one case, and fulminant pulmonary embolism in the other. The remaining pts. were discharged after 11.1 +/- 4.6 (5-24) days following an uncomplicated hospital course. The introduction of MCE was associated with a higher percentage of short-term success (92% vs. 70%, p < 0.015). CONCLUSIONS: PTSMA in HOCM is a promising non-surgical technique for septal myocardial reduction with a consecutive reduction of the LVOTG. MCE has shown to be a useful addition to PBO for selection of the target vessel. Possible complications are trifascicular blocks requiring permanent pacemaker implantation and tachycardiac rhythm disturbances. Prospective, long-term observations of larger populations and a comparison with the established forms of therapy are necessary in order to determine the definitive significance of PTSMA.

Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: acute results and 3-month follow-up in 25 patients.

OBJECTIVES: We report the acute results and midterm clinical course after percutaneous transluminal septal myocardial ablation (PTSMA) in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: In the treatment of HOCM, surgical myectomy and DDD pacemaker therapy are considered the standard procedural extensions to drug therapy with negatively inotropic drugs. As an alternative nonsurgical procedure for reducing the left ventricular outflow tract (LVOT) gradient, PTSMA by alcohol-induced septal branch occlusion was introduced. However, clinical follow-up has not been sufficiently described. METHODS: In 25 patients (13 women, 12 men; mean [+/- SD] age 54.7 +/- 15.0 years) who were symptomatic despite sufficient drug therapy, 1.4 +/- 0.6 septal branches were occluded with an injection of 4.1 +/- 2.6 ml of alcohol (96%) to ablate the hypertrophied interventricular septum. After 3-months, follow-up results of LVOT gradients and clinical course were determined. RESULTS: The invasively determined LVOT gradients could be reduced in 22 patients (88%), with a mean reduction from 61.8 +/- 29.8 mm Hg (range 4 to 152) to 19.4 +/- 20.8 mm Hg (range 0 to 74) at rest (p < 0.0001) and from 141.4 +/- 45.3 mm Hg (range 76 to 240) to 61.1 +/- 40.1 mm Hg (range 0 to 135) after extrasystole. All patients had angina pectoris for 24 h. The maximal creatine kinase increase was 780 +/- 436 U/liter (range 305 to 1,810) after 11.1 +/- 6.0 h (range 4 to 24). Thirteen patients (52%) developed a trifascicular block for 5 min to 8 days requiring temporary (n = 8 [32%]) or permanent (DDD) pacemaker implantation (n = 5 [20%]). An 86-year old woman died 8 days after successful intervention of uncontrollable ventricular fibrillation in conjunction with beta-sympathomimetics in chronically obstructive pulmonary disease. The remaining patients were discharged after 11.3 +/- 5.4 days (range 5 to 24), after an uncomplicated hospital course. Clinical and echocardiographic follow-up was achieved in all 24 surviving patients after 3 months. No cardiac complications occurred. Twenty-one patients (88%) showed clinical improvement, with a New York Heart Association functional class of 1.4 +/- 1.1. A further reduction in LVOT gradient was shown in 14 patients (58%). CONCLUSIONS: PTSMA of HOCM is a promising nonsurgical technique for septal myocardial reduction, with a consecutive reduction in LVOT gradient. Possible complications are trifascicular blocks, requiring permanent pacemaker implantation, and tachycardiac rhythm disturbances. Clinical long-term observations of larger patient series and a comparison with conventional forms of therapy are necessary to determine the conclusive therapeutic significance.

Nonsurgical septal reduction for hypertrophic obstructive cardiomyopathy: outcome in the first series of patients.

BACKGROUND: Some patients with hypertrophic obstructive cardiomyopathy may gain symptomatic relief from a reduction in the extent of obstruction to left ventricular outflow. We present the outcome of the first series of patients treated with an alternative method of gradient reduction using catheter techniques. METHODS AND RESULTS: Eighteen patients were treated with selective intracoronary alcohol injection to induce localized septal infarction. Patients underwent echocardiographic measurement of left ventricular dimensions and Doppler echocardiographic evaluation of left ventricular outflow tract gradients before the procedure, on the first postoperative day, and at a median follow-up of 3 months after the procedure. In addition, patients underwent exercise testing and symptom evaluation before and 3 months after nonsurgical septal reduction. There was a significant reduction in left ventricular outflow tract obstruction after the procedure (preprocedure, 67 mm Hg [95% CI, 48 to 87 mm Hg]; postprocedure, 25 mm Hg [95% CI, 16 to 34 mm Hg]; P=.0006), which persisted at 3-month follow-up (22 mm Hg [95% CI, 12 to 32 mm Hg]; P=.001). This was associated with a significant improvement in symptoms. There was a small but not significant increase in exercise capacity (n=10; preprocedure, 418 seconds [95% CI, 273 to 563 seconds]; postprocedure, 452 seconds [95% CI, 283 to 621 seconds). Left ventricular dimensions were not significantly altered by nonsurgical septal reduction. CONCLUSIONS: Nonsurgical septal reduction significantly reduces left ventricular outflow tract obstruction and improves symptoms in some patients with hypertrophic obstructive cardiomyopathy. The technique may provide an alternative to surgical myomectomy in selected patients.

Pathomorphological characteristics of resected mitral valves after unsuccessful valvuloplasty.

OBJECTIVE: Percutaneous mitral valvuloplasty has been shown to be an acceptable alternative to surgery as treatment for selected patients with severe mitral stenosis. We examined hemodynamic, echocardiographic, and pathomorphologic findings in a series of 308 patients undergoing balloon valvuloplasty, 41 of whom underwent subsequent surgery, in search of possible predictors of an unsuccessful outcome. INTERVENTION AND RESULTS: Patients with severe mitral stenosis underwent Inoue single ballon valvuloplasty over a 48-month period and had follow-up for a mean of 14.5+/-16.8 months (range 1 to 64 months). Of the 308 patients, 267 (Group I) were clinically improved and stable throughout follow-up, while subsequent surgery was required in 41 (Group II) after 38.2+/-143.5 days (range 1 to 1212). Significant differences between the groups were observed for NYHA class (2.7+/-0.6 vs 2.9+/-0.6, p<0.05), mitral valve area (1.0+/-0.3 vs 0.9+/-0.2 cm2, p<0.01) and left atrial endsystolic dimension by echo (51.3+/-8.0 vs 55.4+/-10.2 mm, p<0.01). Two of the 41 Group II patients underwent surgery for left to right shunting, 1 for tamponade and 2 were lost to follow-up. The excised mitral valves of the remaining 36 patients all showed calcification and/or fibrosis: 9 homogenous, 5 non-homogenous; 19 were classified as having a funnel-shaped deformity, and 3 did not fit into a discrete category. Among the funnel-shaped valves, 13 had a tear versus 6 where dilation was primarily accomplished by stretching. Only one of 9 valves with homogenous calcification was torn, whereas a tear was noted in 3 of the 5 with non-homogenous calcification. CONCLUSION: Funnel-shaped valves and those with non-homogenous distribution of calcification and/or fibrosis appear to be least suitable for balloon valvuloplasty.

Predictors of unsuccessful outcome after percutaneous mitral valvulotomy including a new echocardiographic scoring system.

BACKGROUND AND AIMS OF THE STUDY: Percutaneous mitral valvulotomy has been shown to be an accept able alternative to surgery as treatment for selected patients with severe mitral stenosis. Uncertainty still exists regarding predictors of unsuccessful outcome. MATERIALS AND METHODS: 308 patients with severe mitral stenosis underwent Inoue single balloon valvulotomy over a 48-month period and were followed up for a mean of 14.5 +/- 16.8 months (range one to 64 months). Two hundred and sixty-seven (Group I) improved clinically and remained stable throughout the follow up, while subsequent surgery was required in 41 (Group II) after 38.2 +/- 143.5 days (range one to 1,212). Clinical and echocardiographic parameters of the two groups were compared to find significant predictors of an unsuccessful outcome. RESULTS: Significant differences between the groups were observed for NYHA class (2.7 +/- 0.6 vs. 2.9 +/- 0.6, p < 0.05), mitral valve area (1.0 +/- 0.3 vs. 0.9 +/- 0.2 cm2, p < 0.01), left atrial end-systolic dimension by echo (51.3 +/- 8.0 vs. 55.4 +/- 10.2 mm, p < 0.01) and an echocardiographic scoring system including grading for eccentricity of the mitral orifice and distribution of commissural calcification (7.5 +/- 2.0 for Group I and 8.7 +/- 2.0 for Group II, p < 0.001). CONCLUSIONS: Mitral valves that are more likely to have an unsuccessful outcome can be identified by hemodynamic, clinical and echocardiographic criteria, including grading for eccentricity of the mitral orifice and distribution of commissural calcification.

[Catheter treatment of hypertrophic obstructive cardiomyopathy]. / Kathetertherapie der hypertrophen obstruktiven Kardiomyopathie.

BASIC PROBLEMS AND OBJECTIVE: In addition to medication with negative inotropic drugs, surgical myectomy and DDD pacemaker implantation are standard procedures in the treatment of hypertrophic obstructive cardiomyopathy (HOCM). In a preliminary series the results obtained with a recently described method, consisting of transcatheter myocardial reduction, are evaluated. PATIENTS AND METHODS: Six patients (two women, four men; mean age 52.7 [44-68] years), who remained in moderate heart failure despite medical treatment, underwent the procedure. After atrial transseptal puncture (via a catheter introduced percutaneously into the femoral vein) the left ventricular outflow tract (LVOT) gradient was measured at rest and after 5-minute balloon occlusion of the first septal branch of the left coronary artery. After demonstration of significant reduction of the gradient by the occlusion, one (n = 3) or two (n = 3) septal branches were occluded by the injection of 2-5 ml of 96% alcohol. RESULTS: The LVOT gradient was reduced from 57.8 +/- 22.4 (38-97) mm Hg to 11.3 +/- 8.6 (0-21) mm Hg and postextrasystolic from 131.0 +/- 40.7 (78-198) mm Hg to 44.0 +/- 35.6 (19-69) mm Hg. All patients had angina for 24 hours after the procedure. Maximal rise in creatine kinase activity was 982 +/- 589 (392-1729) U/l after 8.0 +/- 3.9 (4-15) hours. In three patients transitory complete atrioventricular block developed 10 min to 5 days later, requiring temporary pacemaker implantation. The further course was without complication in all patients and they were discharged after 7.5 +/- 1.8 (6-11) days. CONCLUSION: The described catheter method provides a nonsurgical means of reducing the amount of septal myocardium with subsequent reduction of the LVOT gradient in HOCM. Long-term observation in a larger group of patients and comparison with conventional forms of treatment are required to determined the method's ultimate place in the treatment of HOCM.

[Transvenous closure of persistent ductus arteriosus with an Ivalon plug]. / Transvenöser Verschluss des persistierenden Ductus arteriosus mit einem Ivalon-Pfropf.

OBJECTIVE: To assess a new transvenous transcatheter method of closing a persistent ductus arteriosus, combining advantages of the Porstmann and Rashkind techniques. PATIENTS AND METHODS: Five patients (three men, two women, mean age 36.2 [19-56] years) underwent the procedure. The diameter of the duct was 3-6 mm. A compressed ivalon (poly-vinyl-alcohol) foam plug, introduced and held by a modified biopsy forceps, was placed into the duct via a percutaneously and transvenously placed catheter sheath. Small titanium legs attached to the plug at the aortic and pulmonary ends unfolded once the plug was correctly placed, ensuring safe fixation. RESULTS: Closure was achieved in all five patients and no shunt demonstrated immediately afterwards in four. In one patient a small shunt briefly persisted but was not longer present the day after. One patient had a fever of up to 39 degrees C for several weeks that required no treatment and was thought to have been a foreign body reaction. Follow-up examination after 5-19 months confirmed complete closure. CONCLUSION: The described method appears to be safe and superior to the Porstmann and Rashkind techniques, but the results must be tested on a larger number of patients with longer follow-up.

[Long-term follow-up after acute myocardial infarct cause by non-arteriosclerotic spontaneous coronary artery dissection]. / Langzeitverlauf nach akutem Myokardinfarkt infolge einer nicht arteriosklerotischen spontanen Koronararteriendissektion.

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction, primarily in young women. The etiology of dissections is still under discussion. Possible factors are inflammation, changes of flow dynamics, and preexisting intima lesions. We report on two young women, 49 and 30 years of age, who suffered and acute anterior wall infarction. Coronary angiography confirmed diagnosis of spontaneous coronary artery dissection of the LAD in the acute an subacute phase of acute myocardial infarction. The patients suffered no further cardiac events at long-term follow-up of up to 9 years.