Improvement in aortic valve area using a new "hour glass" shaped valvuloplasty balloon compared with standard cylindrical balloons in severe aortic stenosis patients.

AIM: Balloon aortic valvuloplasty (BAV) has reemerged with transcatheter valve therapy. Cylindrical balloons have been the device of choice despite limitations. An hour glass shaped balloon may permit enhanced fixation and broader leaflet opening without annular compromise. METHODS: We report our initial BAV experience using the V8 balloon (InterValve Inc.) in 20 consecutive patients compared to 20 patients from a 403-patient BAV database using cylindrical balloons. Patients were propensity matched on a 1:1 basis by age, gender, left ventricular ejection fraction (LVEF), baseline aortic valve area (AVA) and Society of Thoracic Surgery (STS) mortality risk score. End points included change in AVA and aortic insufficiency (AI) by echocardiography. New atrioventricular conduction defects (AVCD), need for post procedure pacemaker were documented. Major adverse events (MAE) included procedure related death, emergency surgery or stroke. RESULTS: V8 and cylindrical balloon groups were similar across age, gender, LVEF, AVA and STS score. The change in AVA from baseline to post-procedure strongly trended towards being larger in the V8 group than cylindrical balloon group (mean [SD]; 0.30±0.23 cm2 vs. 0.17±0.21 cm2; P=0.063). There were no differences in outcomes for degree of AI, AVCD, need for pacemaker or MAE. CONCLUSION: Preliminary findings in this small experience suggest an advantage for enhancing AVA when using the V8 compared with cylindrical balloons. Additionally, there was no evidence of increased AI, AVCD or MAE.

Differentiation of tricuspid regurgitation from constrictive pericarditis: novel criteria for diagnosis in the cardiac catheterisation laboratory.

BACKGROUND: Severe tricuspid regurgitation, constrictive pericarditis and restrictive cardiomyopathy can all present with signs and symptoms of right heart failure and similar haemodynamic findings of elevation and equalisation of diastolic pressures at catheterisation. Although catheterisation findings of enhancement of ventricular interaction are a reliable parameter to distinguish constrictive pericarditis from restrictive cardiomyopathy, this also may be present in severe tricuspid regurgitation. OBJECTIVE: To identify unique haemodynamic parameters that differentiate severe tricuspid regurgitation from constrictive pericarditis. METHODS: Haemodynamic findings from simultaneous right and left heart catheterisation of 14 patients (age 59 years; men 71%) with documented severe tricuspid regurgitation (group I) were compared with those of 14 patients with surgically proven constrictive pericarditis (group II). RESULTS: Findings of elevated right atrial pressure, early rapid ventricular filling and expiratory equalisation of ventricular diastolic pressures were similar in both groups. Ventricular interdependence, assessed by interaction of left ventricular (LV) and right ventricular (RV) systolic pressures, was also present in both groups. Relative changes in LV and RV diastolic pressures during respiration reliably distinguished group I from group II. During inspiration, the difference between the LV and RV diastolic pressures widened in group I but narrowed in group II. The height and slope of the early rapid filling wave in RV pressure trace was accentuated during inspiration in group I but did not change in group II. CONCLUSIONS: The haemodynamic findings at cardiac catheterisation in patients with severe, symptomatic tricuspid regurgitation are similar to those of constrictive pericarditis. Careful analysis of the relationship of the LV and RV diastolic pressures during respiration can help differentiate the two entities.

Immediate improvement in coronary flow reserve after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: To examine whether percutaneous alcohol septal ablation affects coronary flow reserve (CFR) in patients with hypertrophic cardiomyopathy (HCM). METHODS: CFR was measured immediately before and after septal ablation in patients with symptomatic obstructive HCM. CFR was also obtained in normal subjects (NL) for comparison. RESULTS: Patients with HCM (n = 11), compared with NL (n = 22), had a lower mean (SD) baseline CFR (1.96 (0.5) vs 3.0 (0.7), p<0.001), a lower coronary resistance (1.04 (0.45) vs 3.0 (2.6), p = 0.002), a higher coronary diastolic/systolic velocity ratio (DSVR; 5.1 (3.0) vs 1.8 (0.5), p = 0.04) and a lower hyperaemic coronary flow per left ventricular (LV) mass (0.73 (0.4) vs 1.1 (0.6) ml/min/g, p = 0.007). Septal ablation in the HCM group (n = 7) reduced the outflow tract gradient but not the left atrial or LV diastolic pressures. Ablation resulted in immediate normalisation of CFR (to 3.1 (1), p = 0.01) and DSVR (to 1.9 (0.8), p = 0.09) and an increase in coronary resistance (to 1.91 (0.6), p = 0.02). This was probably related to an improvement in the systolic coronary flow. CONCLUSIONS: This study demonstrates that successful septal ablation in patients with symptomatic HCM results in immediate improvement in CFR, which is reduced in HCM partly because of the increased systolic contraction load.

Left ventricular diastolic function assessed using Doppler tissue imaging in patients with hypertrophic cardiomyopathy: relation to symptoms and exercise capacity.

BACKGROUND: Conventional Doppler indices of left ventricular diastolic function do not correlate with symptoms or exercise capacity in patients with hypertrophic cardiomyopathy, because of their dependence on loading conditions. Diastolic mitral annular velocity measured using Doppler tissue imaging has been reported to be a preload independent index of left ventricular diastolic function. OBJECTIVE: To determine the relation between diastolic annular velocities combined with conventional Doppler indices and symptoms or exercise capacity in hypertrophic cardiomyopathy. METHODS: 85 patients with hypertrophic cardiomyopathy and 60 normal controls were studied. Diastolic mitral annular velocities, transmitral left ventricular filling, and pulmonary venous velocities were measured. RESULTS: Early diastolic velocities at lateral and septal annulus were lower in patients with hypertrophic cardiomyopathy than in controls (lateral Ea: 10 (3) v 18 (4) cm/s, p < 0.0001; septal Ea: 7 (2) v 12 (3) cm/s, p < 0.0001). Unlike conventional Doppler indices alone, transmitral early left ventricular filling velocity (E) to lateral Ea ratio correlated inversely with peak oxygen consumption (r = -0.42, p < 0.0001). Patients in New York Heart Association (NYHA) class III had a higher transmitral E to lateral Ea ratio (12.0 (4.6)) than those in NYHA class II (7.6 (3.1), p < 0.005) or class I (6.6 (2.6), p < 0.0001). CONCLUSIONS: Early diastolic mitral annular velocities are reduced in patients with hypertrophic cardiomyopathy. Unlike conventional Doppler indices alone, the transmitral E to lateral Ea ratio correlates with NYHA functional class and exercise capacity.

Pacing in hypertrophic cardiomyopathy.

Dual chamber pacing has been proposed as an alternative to surgery in the management of hypertrophic cardiomyopathy. Reports have documented hemodynamic and symptomatic benefit from dual chamber pacing, raising the question of whether or not all patients with drug-refractory symptoms should undergo a trial of pacing before consideration of surgery. The enthusiasm for pacing in hypertrophic cardiomyopathy has generated a number of investigations addressing this issue, including several recently concluded clinical trials. This article reviews the recent experience with dual chamber pacing in hypertrophic cardiomyopathy.

Different effects of protamine on canine coronary microvessel and conductance arteries: evidence of hyperpolarizing factor release.

BACKGROUND: Protamine administration may lead to systemic hypotension, perhaps because of vasodilatation produced by endothelial nitric oxide. This study compared release of vasoactive substances from canine coronary microvessels with that from paired conductance arteries. METHODS: Microvessels were mounted in a videoscopic no-flow system, and circumflex arteries were studied in organ chambers; both were induced to contract by endothelin-1. RESULTS: Protamine (10 to 160 micrograms/mL) produced concentration-dependent relaxation in both microvessel and conductance arteries (46% +/- 14% maximal relaxations in microvessel and 82% +/- 15% in conductance arteries, n = 10 each). Removal of the endothelium abolished this relaxation (P < .05, n = 6). Indomethacin (10(-5) mol/L) did not alter the relaxation in either group (51% +/- 10% in microvessel and 103% +/- 7% in conductance arteries, n = 6 each). NG-monomethyl-L-arginine (L-NMMA, 10(-4) mol/L) attenuated relaxation in conductance arteries (38% +/- 12%, P = .04, n = 6) but had no effect on microvessel arteries (58% +/- 10%, n = 6). Tetraethylammonium chloride (10(-3) mol/L), an inhibitor of voltage-dependent potassium channels, had no effect on conductance arteries (103% +/- 9%, n = 6) but abolished relaxation in microvessels (-25% +/- 11%, P = .03, n = 6). CONCLUSIONS: Protamine sulfate causes endothelium-dependent relaxation in microvessel and conductance arteries in the heart by different mechanisms--that is, by nitric oxide release in conductance arteries and by endothelium-derived hyperpolarizing factor (EDHF) release in microvessels. This is the first description of the release of EDHF in response to protamine administration.

Autonomic failure and proximal skeletal myopathy in a patient with primary Sjögren syndrome.

Autonomic failure and proximal skeletal myopathy are rare features of the Sjögren syndrome (SS). We describe a 51-year-old woman with primary SS who had development of esophageal dysmotility, urinary retention, severe orthostatism, and skeletal myopathy during a 3-month period after the diagnosis of SS. Her symptoms and signs responded well to corticosteroid therapy. Although dysfunction of the peripheral nervous system has a prevalence rate of 20% in patients with SS, most commonly the nerve dysfunction is a sensory deficit, and autonomic neuropathy is less frequent. Autonomic neuropathy due to SS may be underreported. The cause of our patient's myopathy remains undetermined. We speculate that the myopathy was due to either a form of polymyositis or an immune-mediated neuropathy with muscle involvement.

Hypothermic storage with University of Wisconsin solution preserves endothelial and vascular smooth-muscle function.

BACKGROUND: The effect of University of Wisconsin (UW) solution on coronary endothelial function is debated. Although earlier studies demonstrated preservation of stimulated release of endothelial vasoactive factors, the effect of UW solution on basal nitric oxide release has not been investigated, and this was the purpose of the present study. METHODS AND RESULTS: Isolated canine coronary arteries were evaluated immediately after being harvested (group 1) and after 24-hour hypothermic (4 degrees C) storage in either buffered physiological saline solution (group 2) or UW solution (group 3). Smooth-muscle vascular response to sodium nitroprusside (10(-9) to 10(-6) mol/L), KCl (5 to 50 mmol/L), and prostaglandin F2alpha (10(-9) to 10(-6) mol/L) was comparable among the groups, as was the endothelial response to acetylcholine (10(-9) to 10(-6) mol/L) and calcium ionophore A23187 (10(-9) to 10(-6) mol/L). Vessels in group 3 exhibited better preservation of basal release of nitric oxide, as measured by contraction to either N(G)-monomethyl L-arginine (10(-4) mol/L) or methylene blue (10(-5) mol/L), in comparison with control arteries exposed to saline solution (group 2). There was no difference in the basal production of nitric oxide between group 1 and group 3 vessels. CONCLUSIONS: The present study demonstrated preservation of vascular smooth muscle and endothelium-dependent relaxations after prolonged hypothermic storage in UW solution. Furthermore, storage in this solution preserved basal release of nitric oxide.