[Occlusion of patent ductus arteriosus with a Gianturco-Grifka device. First case at the Instituo Mexicano del Seguro Social (IMSS)]. / Oclusión de conducto arterioso permeable con dispositivo de Gianturco-Grifka. Primer caso en el IMSS.

We present the initial experience of closing of patent ductus arteriosus (PDA) with a new device; Gianturco-Grifka, at the General Hospital of The Medical Center "La Raza". The patient was a 4 year's old girl, in whom we detected continuous murmur in the second intercostal space, echocardiography showed a long conical patent ductus arteriosus 4.9 mm of diameter, systolic pressure of the pulmonary artery was 35 mm Hg with QP/QS 1.6:1. Hemodynamic study revealed a long conical ductus arteriosus 5 mm of diameter, type A1 from Krichenko classification. We proceeded to occlude the PDA with a Gianturco-Grifka device of 7 mm. Immediately after the PDA occlusion the shunt disappeared, there were no complications during the procedure. More cases are needed to determine long term benefits and limitations, of this procedure. However we conclude that technically it is easy to use. There is greater decrease of residual shunt that the one reported with other devices.

[A comparative study of Rashkind, Grifka and coil devices in percutaneous closing of patent ductus arteriosus]. / Estudio comparativo entre dispositivos de Rashkind, Grifka y Coil para el cierre percutáneo del conducto arterioso.

This study was performed to evaluate the efficacy of transcatheter Coil and Grifka closure of the patent ductus arteriosus in comparison to our experience with the Rashkind umbrella device. Ninety seven patients (36 male and 61 females) underwent occlusion of the PDA. The following variables were compared: age, sex, ductus diameter, morphology, device, occlusion time, residual shunt, multiple device and complications. Data obtained were compared using the Student's test and Chi 2. Median patient age was 7.82 +/- 6.89, forty five patients underwent transcatheter Rashkind-17 closure, 19 patients with Rashkind-12, 18 patients with Coil and 13 patients with Grifka device, in two patients the closure could not be performed. There were differences between the morphology and device used (p = 0.008), between the ductus diameter and device used (p < 0.001). There was immediate closure in 26.7% in the Rashkind-17 group compared with, 57.9% for the Rashkind-12 group, 83.3% for Coil group and of 91.7% for Grifka group. The occlusion within 24 hrs of implantation was 60% with Rashkind-17, 78.9% with Rashkind-12, 94.4% with Coil and 100% with Grifka. Residual shunt persisted for more than a year in 7 patients with Rashkind-17 and 1 with Rashkind 12, (p = 0.001), in 4 patients two devices wore placed. The complications were, 15.5% for Rashkind-17, 26.3% for Rashkind-12, 5.2% for Coil and 30% for Grifka, (p = 0.004), one coil and one Grifka embolized. Transcatheter Coil and Grifka occlusion are more effective in achieving immediate closure than the Rashkind device. The indication to use each device is made according to the morphology and size of the ductus.

[Percutaneous occlusion of patent ductus arteriosus with Rashkind device. 4-year follow-up]. / Oclusión percutánea de conducto arterioso permeable con dispositivo de Rashkind. Seguimiento a 4 años.

We present the results and follow up of ductus arteriosus closure with the Rashkind device. Sixty-six devices were implanted in 63 patients, 41 women and 22 men, with a mean age of 8.2 years. We determined the diameter of the duct, the presence or absence of immediate residual leak at 3 months, 6 months, 1 year, and every year of follow-up by ecocardiography. The hemodynamic determinations showed: type A morphology in 49, type C in 7 and type E in 7; with a mean diameter of 4.2 +/- 1.4 mm (range of 2.3 to 8.7 mm) and a Qp/Qs 2.2 +/- 1.5 (range 0.7 to 8.6). Forty-five 17 mm devices and 18 of 12 mm were used. The incidence of immediate residual leak was 65% (n-41); at 24 hrs. Post-procedure was 31.7% (n-20) and at one year 7.9% (n-5). Three patients with persistent leak had implantation of a second Rashkind device and one more patient an endovascular coil, the other patient is waiting for a second occlusor. Minor complications occurred in 15.8% (n-10). Results show an occlusion rate at 24 hrs of 68% and at one year of 92%; no patient presented migration of the device, hemolysis or obstruction of the pulmonary artery branches. We consider that occlusion of the ductus arteriosus with the Rashkind device is a safe and effective option for the treatment of this pathology.

[Pulmonary valvuloplasty. Long term results at the Centro Medico la Raza]. / Valvuloplastía pulmonar: resultados a largo plazo. Experiencia en el Centro Médico La raza.

The purpose of this study was to evaluate the immediate and long term results of pulmonary valve ballon dilation, and to determine the prognostic factors of failure in 109 patients (60 female and 49 male), aged 7.04 +/- 8.4 years. Seventy two patients (66.1%) had isolated valvular stenosis and 33.9% presented associated lesions. Peak systolic pressure gradient across the pulmonary valve decreased from 89.53 +/- 37.23 to 20.8 +/- 19.41 mmHg (p < 0.0001) after valvuloplasty. Forty three patients developed reactive infundibular stenosis after valvuloplasty with a systolic gradient of 19.65 +/- 35.64 mmHg. At a mean period of 8 years of follow-up the pressure gradient was 20.75 +/- 14.32 (p < 0.001). Valvuloplasty was successful in 86.2% of the cases with a global mortality of 1.9%, minor complications in 15.2%, and a failure rate of 13.8%. At follow-up restenosis developed in 6.7%. The comparative analysis between the groups of success and failure yield as significant risk factors for failure an age younger than 3.5 years and a pulmonary valve with displastic (p < 0.05) or combined morphology (p < 0.05). This group had also more complications and higher systolic gradients and right ventricular pressures post-dilation (p < 0.05). Pulmonary valvuloplasty is a safe and effective procedure for the treatment of pulmonary valve stenosis with a good immediate and long-term results, and is now considered the treatment of choice.

[Gianturco-Grifka device in the percutaneous closure of patent ductus arteriosus]. / Dispositivo de Gianturco-Grifka en el cierre percutáneo del conducto arterioso permeable. Experiencia en 13 casos.

We present our early experience with the Gianturco-Grifka device for transcatheter closure of patent ductus arteriosus. Grifka occlusion was attempted in 13 patients (7 female, 6 male), median patient age was 6.5 years. Echocardiographic evaluation showed a mean ductal diameter of 5.47 +/- 1.09 mm, and the morphology was type C in 7 patients, type A in 5 and type E in 1 patient. The angiographic ductal morphology was 6 type A, 5 type C and 2 type E. Mean PDA diameter was 5.69 +/- 1.15 mm. Three patients had pulmonary hypertension. They were given supplemental oxygen (100%), decreasing their pulmonary pressures. A total of 13 devices were implanted, 5 of 7 mm and 8 of 9 mm. Twelve patients had complete ductal occlusion documented by aortic angiography (92%), one patient presented residual shunt (8%). Color echocardiography at 24 hrs documented complete occlusion in 12 cases. One device embolized to the descending aorta 2 hours after closure, and it was successfully retrieved in the catheterization lab. We conclude that the Gianturco-Grifka device is an appropriate alternative for transcatheter closure of the PDA. This technique can be performed in ductus arteriosus type C, D and E, with diameter < 9 mm. More clinical trials are needed to establish the long-term results of this technique.

Hemodynamic indexes in newborns using the arteriovenous oxygen content difference.

OBJECTIVE: To determine in peripheral blood samples of newborns (NB) cardiac output (Q), cardiac index (CI), systemic vascular resistance index (SVRI), and effective oxygen transport (EO2T), through arteriovenous oxygen content difference ([C(a-v) O2]). DESIGN: Comparative survey. SETTING: Healthy NBs and NBs in intermediate care in third level medical attention units. MATERIAL AND METHODS: Forty-seven NB (17 pre-term) were prospectively studied in August and September/1995. A blood sample of 0.4 mL was taken from the umbilical or femoral vein and from the umbilical, radial or femoral artery. The inferencial statistics were done with a t test and Pearson's correlation coefficient. Significance was considered if p < 0.05. RESULTS: Cardiac output ranged from 0.3 to 1.4, mean = 0.6 L/min +/- 0.24 (+/- SD); CI ranged from 1.8 to 6.4 L/min/m2 body surface area (mean = 3.3 +/- 1.2); SVRI ranged from 533 to 2,391 dyne/sec/cm-5/m2 BSA (mean = 1,317 +/- 494); EO2T ranged from 307 to 1,017 mL/min/m2 BSA (mean = 549 +/- 186); the [C(a-v) O2] ranged from 3.1 to 10.7% in volume (mean = 6.8 +/- 2.1). No significant differences were found in Q between pre-term and full-term NB nor was there any correlation between Q and gestational age. CONCLUSIONS: The [C (a-v)O2] is a good alternative to obtain indexes in peripheral blood of NB without cardiopathy, whenever other less invasive and more sophisticated methods are unavailable. In order to calculate the indexes in critically-ill patients, it is necessary to measure O2 consumption prior to applying this method.

[National registry of percutaneous mitral commissurotomy. 8-year's experience]. / Registro nacional de comisurotomía mitral percutánea. Experiencia de 8 años.

From April 1986 to June 1994 we performed percutaneous transvenous mitral commissurotomy in 689 patients with rheumatic mitral stenosis in a multicenter study. Mean age was 40 +/- 11 years, of then 84.9% female, 2.7% to had previous surgical treatment and in 1.4% the procedure was performed during pregnancy. Inoue balloon was used in 89.4%, double balloon 9.7% and monoballoon 0.9%. Mitral valve area (MVA) increased from 0.93 +/- 0.20 to 1.85 +/- 0.37 cm2 (p < 0.001) and mean pulmonary artery pressure from 31.5 +/- 15.8 to 22.4 +/- 11.5 mmHg (p < 0.001), mean left atrial pressure decreased from 20.9 +/- 8.1 to 10.0 +/- 5.9 mmHg (p < 0.001), transvalvular gradient (TVG) from 15.4 +/- 6.4 to 3.4 +/- 3.1 mmHg (p < 0.001) and mean pulmonary artery pressure from 31.5 +/- 15.8 to 22.4 +/- 11.5 mmHg (p < 0.001). Complete procedure without mayor complications was achieved in 93.1%. Severe mitral regurgitation (MR) was present in 3.9%. Optimal result in 82.1%, suboptimal in 8.2% and failure in 9.7%. Major complications 4.7%. Mortality was 0.9%. Six months follow-up MVA decreased to 1.77 +/- 0.38 (p < 0.001) and no changes to 24 months (1.78 +/- 0.37 p ns). Twenty four months follow-up 93.3% are in NYHA class I. Only MVA (> 1 cm2) and good predilatation NYHA class were predictors of optimal results. Severe MR were more frecuently in patients with atrial fibrillation and with high score (> 8). Our results were similar the international experience. We conclude that the technique of PTMC is a safe and effective technique.

[Percutaneous transluminal angioplasty in aortic coarctation in adolescents and adults. Mid-term results]. / Angioplastía transluminal percutánea de coartación aórtica en adolescentes y adultos. Resultados a mediano plazo.

From October 1985 to February 1992 we performed 80 percutaneous transluminal angioplasty (PTA) in 76 patients with coarctation of the aorta (CoAo). Sixteen of them with ages ranging from 12 to 62 years (mean = 21.1). We describe the experience in these cases. Fifteen with native and one with post-surgical coarctation. The gradient decreased from 72 +/- 33 to 18 +/- 17 mmHg immediately after dilation, in the follow-up (1 to 69 months m = 25) was 23 +/- 20 mmHg. In one patient we performed simultaneously angioplasty of CoAo and mitral valvuloplasty with excellent results in both lesions. We redilated two cases for residual gradient successfully. We had one failure in a patient with long coarctation. He needed surgery. In the initial experience we had one severe complication (cerebral stroke). No deaths or aneurysms. In conclusion we believe that PTA is an adequate alternative in adolescents and adults with native or post-surgical coarctation of the aorta with minimum incidence of complications.

[Hemodynamic and angiocardiographic assessment of thoracopagus twins for surgical separation purposes]. / Evaluación hemodinámica y angiocardiográfica de gemelos toracópagos con finalidad de separación quirúrgica.

The rate of conjoined twins is 1 in 50,000 births. These patients usually have a common pericardial sac (90%) and conjoined hearts (75%). In case of shared heart there is a communication by a vascular channel between both atria and ventricles. If there is not ventricular communication, surgical separation is possible. We describe such a case in whom in spite that interventricular connections were present; surgical separation was decided because of the critical conditions of twin A in an effort to preserve the survival of twin B.

[Percutaneous transluminal angioplasty in aortic coarctation. The short- and median-term results]. / Angioplastía transluminal percutánea en coartación aórtica. Resultados a corto y mediano plazo.

Percutaneous transluminal angioplasty (PTA) was performed in 34 patients with aortic coarctation (Ao Co). One of them with coarctation after surgical correction, the rest were native Ao Co. We used one balloon in 28 patients and two balloons simultaneously in 6. They were separated in three groups according to the degree of aortic arc hypoplasia. Group I (mild to moderate hypoplasia N = 9) the gradient dropped 39% with angiographic improvement of 48% during the follow-up (m = 13.1 months). Three cases with restenosis, 2 were satisfactory dilated and one was sent to surgery. In Group II (severe hypoplasia N = 4) the gradient dropped 31% with angiographic improvement of 30% (follow-up 16.3 months). Two cases with recoarctation were sent to surgery. In Group III (without hypoplasia N = 21) we obtained dropped of gradient of 71% with angiographic improvement of 60% (follow-up 18.5 months). Two cases were redilated successfully. The complications were: cerebral hemorrhage with death due to hypertensive crisis, (1) cerebral embolism, (1) thrombosis in the puncture site 1 and small aneurysm in dilated zone. (1) We think PTA is a good choice to conventional surgery with low rate of morbidity-mortality. The results depend basically on the anatomic type of coarctation and degree of aortic arch hypoplasia.

[Percutaneous transluminal angioplasty using balloon catheter in a Blalock-Taussig pulmonary-systemic fistula]. / Angioplastia transluminal percutánea con catéter de globo en una fístula sistémico-pulmonar de Blalock-Taussig.

Percutaneous transluminal balloon angioplasty has been used successfully in the treatment of valvular and vascular stenosis. This article describes our experience with this technique to improve pulmonary blood flow in a patient with a severely stenotic Blalock-Taussig (B-T) systemic-to-right pulmonary artery anastomosis, with improvement in oxygen peripheric saturation from 33 to 78% immediately postdilatation and 69% three months later. Hemoglobin decreased from 20.4 to 18.9 gm/dl and hematocrit from 64% to 58.5%. In conclusion we think that this technique is an alternative instead of cardiac surgery, in these cases the procedure is only palliative.

[Valvuloplasty with balloon catheter in biologic prosthesis. Reality or illusion]. / Valvuloplastía con cáteter de globo en prótesis biológicas. Realidad o ilusión.

We performed catheter balloon valvuloplasty (CBV) on 8 stenotic operatively-excised bioprosthetic valves (2 Hancock and 6 Ionescu Shiley). Pathology of valves before CBV included degenerative changes: commissural fusion by mounds of calcific deposits (2 valves), fibrotic and focally calcified leaflets (7 valves) and stiff and thick valves (1 valve). Inflation of the balloon resulted in commissural splitting (2 valves), leaflet cracks and fractures (3 valves). Removal of the deflated balloon catheter was associated with debris dislodgement (3 valves). In one case the valve was unable to close with potential for acute regurgitation. Thus, CBV of bioprosthetic valves can split fused commissures by similar mechanisms as in native valves. CBV may fracture calcific deposits causing acute emboli. It can also disrupt the leaflets causing acute insufficiency. The findings suggest a limited role of CBV in the treatment of stenotic bioprosthetic valves in mitral and aortic position.

[Percutaneous pulmonary valvuloplasty. Short-term and long-term results]. / Valvuloplastía pulmonar percutánea. Resultados a corto y largo plazo.

Percutaneous angioplasty was performed in twenty consecutive patients, with congenital pulmonary valve stenosis. Ages ranged from eight months to thirty-two years (mean 9.5 years old). We achieved a valvular gradient dropping from 91 +/- 39 to 19 +/- 11 mm Hg (P less than 0.001) in early post angioplasty level and it was practically unchanged at three months and one year later. (19 +/- 12, 19 +/- 17 mm Hg) (P less than 0.001). Similar change was observed in the right ventricle systolic pressure which was diminished in a progressive way during the follow-up from 113 +/- 37 to 39 +/- 35 (P less than 0.001), 59 +/- 18 and 53 +/- 25 mm Hg (P less than 0.001) immediately, three months and one year later, respectively. The ratio right ventricle systolic pressure/left ventricle was diminished from 0.96 +/- 29 to 0.63 +/- 0.35 in the early post angioplasty period and later from 0.50 +/- 0.16 and 0.44 +/- 0.22 (P less than 0.001). Only one case had restenosis one year later and we repeated the angioplasty with good results. Most of the patients are asymptomatic, the pulmonary murmur features changed. We observed improvement in electrocardiographic and echocardiographic signs. One patient died of anesthetic complications. The remainder of patients did not have severe complications and they were discharged from 48 to 72 hours after angioplasty. In conclusion, valvuloplasty is an effective procedure in a short and long term basis. We considered valvuloplasty in congenital pulmonary valve stenosis the treatment of choice in this group of patients.

[Blade auricular septostomy]. / Septostomía auricular con navaja.

We describe the first case of BAS in our country in a three months old child with transposition of the great arteries, restrictive atrial septal defect (RASD) and intact interventricular septum. When he was 15 days old, we performed a balloon atrial septostomy. He had temporal improvement and six weeks later his cyanosis increased, and a new catheterization showed systemic arterial oxygen saturation of 30%, RASD and an interatrial pressure gradient of 2.1 mmHg (left atrium LA: 3.9 and right atrium RA: 1.8). We decided to perform a new septostomy with Park's blade atrial septostomy catheter. After the procedure the interatrial pressure gradient decreased to 0.2 mmHg (RA: 4.3 and LA: 4.5), the angiography shunt and atrial pressures increased. Five months later the child is alive and the systemic arterial oxygen saturation is 51.3%. The technique, advantages and complications are described.

[Transcatheter percutaneous commissurotomy in rheumatic mitral stenosis]. / Comisurotomía percutánea transcateterismo en la estenosis mitral reumática.

Percutaneous transcatheter balloon mitral commissurotomy was performed in an 11 year old girl. The atrial septum was perforated and an 8 mm angioplasty balloon was advanced the atrial septal perforation was then dilated to allow passage of 25 mm balloon valvuloplasty catheter across the mitral annulus. Transmitral balloon inflation acutely decreased the end diastolic transmitral gradient (23 mm Hg to 2 mm Hg). Immediate gradient reduction was associated with increases in cardiac output (3.4 to 5.3 L/min). Murmur intensity diminished immediately post-commissurotomy. Balloon commissurotomy did not produced mitral regurgitation. Five weeks later, follow-up catheterization was performed and did not show change in mitral valvular gradient (2 mmHg). Clinical improvement was evident.

[Percutaneous transluminal angioplasty in aortic coarctation. Report of a case]. / Angioplastía transluminal percutánea en coartación aórtica. Informe de un caso.

We describe the first case in our hospital of percutaneous transluminal angioplasty in a 16 years old boy with congenital coarctation of the aorta. The technique, hemodynamic findings, angiography before and after dilation and the advantages in comparison with the conventional cardiac surgery were analyzed. In our case the gradient decreased from 60 mmHg to 28 mmHg. We conclude that this procedure is an alternative treatment for patients with congenital coarctation of the aorta.

[Transcatheter pulmonary valvuloplasty]. / Valvuloplastía pulmonar transcateterismo.

We describe the first case of balloon pulmonary valvuloplasty performed in this country. This 12 year old girl had a transvalvular gradient of 94 mmHg and after the procedure it improved to 20 mmHg. Four months later, cardiac catheterization did not show any significative change in pulmonary valvular gradient (26 mmHg). We describe the technique, hemodynamic findings, complications, and advantages of this procedure. We also review the literature. We consider that balloon valvuloplasty should be the first choice procedure in the treatment of patients with congenital pulmonary valve stenosis.