Comparison of results of percutaneous balloon mitral commissurotomy in patients aged > or = 65 years with those in patients aged < 65 years.

Percutaneous balloon mitral commissurotomy (PBMC) is now first-line therapy in patients with symptomatic mitral stenosis (MS) and favorable valve morphology. Unfortunately, the outcome of Medicare-aged patients undergoing this procedure has not previously been defined. The results of PBMC in 55 patients > or = 65 years old (71 +/- 6 years) with moderate or severe MS were compared with 268 younger patients (47 +/- 10). Preprocedural New York Heart Association functional class and pulmonary pressures did not differ. The older patients had higher blood pressure, were more likely to be in atrial fibrillation and had higher valve scores (9.9 +/- 2.5 vs 8.6 +/- 2.2, p = 0.001). Procedural success was higher in the younger group (71% vs 55%, p = 0.013), with a greater increase in mitral valve area. Complications were similar in both groups and there were no periprocedural deaths. At 6 months a significant improvement in function class was seen in both groups. Restenosis, as assessed by serial echocardiography, occurred at a rate of 0.06 cm(2)/year in both groups, and functional class remained unchanged over 3 years. Event-free survival was similar at 48 months: 76% in the younger group and 69% in the older group. Our data thus demonstrates that PBMC can be safely performed in the Medicare-aged population. Despite less acute success in the older population, complication rates do not differ and decrement in valve area over time occurs at a similar rate. Functional class remains improved and event-free survival over 4 years appears similar in both groups. PBMC should thus be offered to patients with MS and suitable anatomy regardless of their age.

Inhaled nitric oxide selectively dilates pulmonary vasculature in adult patients with pulmonary hypertension, irrespective of etiology.

OBJECTIVES: We sought to compare the responses of patients with pulmonary hypertension from primary and secondary causes (PPH and SPH, respectively) to inhaled nitric oxide (iNO) in the cardiac catheterization laboratory. BACKGROUND: Pulmonary hypertension can lead to right ventricular pressure overload and failure. Although vasodilators are effective as therapy in patients with PPH, less is known about their role in adults with SPH. Inhaled nitric oxide can accurately predict the response to other vasodilators in PPH and could be similarly utilized in SPH. METHODS: Forty-two patients (26 to 77 years old) with pulmonary hypertension during cardiac catheterization received iNO. Demographic and hemodynamic data were collected. Their response to iNO was defined by a decrease of > or =20% in mean pulmonary artery (PA) pressure or pulmonary vascular resistance (PVR). RESULTS: Mean PA pressures and PVR were lower during nitric oxide (NO) inhalation in all patients with pulmonary hypertension. Seventy-eight percent of patients with PPH and 83% of patients with SPH were responders to iNO. A trend was seen toward a greater response with larger doses of NO in patients with SPH. Nitric oxide was a more sensitive predictor of response (79%), compared with inhaled oxygen (64%), and was well tolerated, with no evidence of systemic effects. Elevation in right ventricular end-diastolic pressure appeared to predict poor vasodilatory response to iNO. CONCLUSIONS: Nitric oxide is a safe and effective screening agent for pulmonary vasoreactivity. Regardless of etiology of pulmonary hypertension, pulmonary vasoreactivity is frequently demonstrated with the use of NO. Right ventricular diastolic dysfunction may predict a poor vasodilator response.

Contrast Agents for Cardiac Angiography: Osmolality and Contrast Complications.

Radiographic contrast agents have undergone a tremendous evolution over the past several decades. The creation of contrast agents with greater iodine carrying capacity and lower osmolality has improved imaging quality and reduced complications, including nausea, vomiting, congestive heart failure, and cardiac rhythm abnormalities. Whether differences exist among agents in terms of thrombotic complications remains controversial. Several characteristics including potential complications, toxicity, and cost must factor into the decision to use a particular contrast agent in cardiac procedures.

Cardiac rhabdomyoma in an adult patient presenting with ventricular arrhythmia.

Cardiac rhabdomyomas are extremely uncommon in the adult patient. We describe a previously healthy man who presented with ventricular arrhythmias resulting from a right ventricular, cardiac rhabdomyoma. Echocardiography, CT scanning, and MRI are recognized as useful diagnostic modalities for intracardiac lesions. Cardiac catheterization in our patient demonstrated the presence of a tumor blush. This has not previously been reported with cardiac rhabdomyomas. Although lesions may spontaneously regress, surgery is often necessary and frequently resolves the underlying arrhythmia.

Weekend and holiday exercise testing in patients with chest pain.

OBJECTIVE: To determine the outcome, safety, and possible cost savings of patients undergoing weekend or holiday exercise treadmill testing. DESIGN: Medical records of all 195 patients scheduled for weekend and holiday exercise testing were reviewed, and 77.9% of patients were contacted by telephone to ascertain medical outcomes and need for further emergency department or inpatient care. Costs were calculated from estimates of days of hospitalization saved and incremental costs incurred in conjunction with weekend or holiday testing. SETTING: Urban tertiary care academic medical center. PATIENTS: A total of 195 patients were scheduled for testing, and 181 tests were performed. Over three quarters (75.1%) of patients underwent testing for assessment of chest pain. Other indications included risk stratification after myocardial infarction or coronary angioplasty or prior to noncardiac surgery, or evaluation for arrhythmias, dyspnea, or syncope. MEASUREMENTS AND MAIN RESULTS: Outcomes included results and complications of testing, hospital course after testing, subsequent emergency department visits and readmissions, myocardial infarction, need for cardiac catheterization or revascularization, and mortality. No complications were noted during testing. In 136 patients tested for the indication of chest pain, 90 (66.2%) had negative tests, 39 (28. 7%) were intermediate, and 6 (4.4%) were positive for ischemia. Same day discharge occurred in 115 (84.6%) of the patients, saving an estimated 185 days of hospitalization ($316.83 per patient tested). Event rates over the 6 months following discharge were low. CONCLUSIONS: Weekend and holiday exercise testing is a safe and effective means of risk stratification prior to hospital discharge for patients with chest pain. It also reduces length of stay and is cost saving.