Tracheobronchial Wallstents for degenerated saphenous vein bypass grafts.

The tracheobronchial Wallstent was employed as an endoluminal prosthesis in degenerated saphenous vein bypass grafts in three patients. This Wallstent has unique characteristics that make it potentially useful in patients with vein graft disease.

Myocardial perforation in the cardiac catheterization laboratory: incidence, presentation, diagnosis, and management.

The introduction of balloon valvuloplasty and new devices for coronary intervention has increased the incidence and changed the site and clinical presentation of cardiac perforation. We reviewed all cases of cardiac perforation that occurred during 11,845 consecutive catheterization procedures during a 6-yr period (1986-91). Fourteen cardiac perforations (overall incidence 0.12%) occurred as a result of the following procedures: mitral valvuloplasty 7 of 150 (4.7%), aortic valvuloplasty 4 of 260 (1.5%), pericardiocentesis 1 of 90 (1.1%), temporary pacer 1 of 1,660 (0.06%), and diagnostic left heart catheterization 1 of 6,965 (0.01%). Perforation was recognized in the catheterization laboratory in 11 patients, within 1 hr of leaving the laboratory in two patients, and 15 hr later in one patient. Hemodynamic evidence of tamponade developed in 13 patients and was confirmed by fluoroscopy (immobile heart borders) or echocardiography. Pericardiocentesis is definitive therapy in nearly half of the cases; the remaining patients require pericardiocentesis plus surgical repair of the perforation.

Immediate results and long-term follow-up after repeat balloon aortic valvuloplasty.

Balloon aortic valvuloplasty (BAV) was performed in 219 elderly patients with aortic stenosis between December 1985 and April 1990. Forty-three patients underwent repeat BAV for symptomatic restenosis of the aortic valve 13 +/- 8 mo following initial BAV. To evaluate the outcome following initial and repeat BAV, hemodynamic results were analyzed according to the following subgroups: BAV 1--initial BAV for all patients (n = 219); BAV 1/1--initial BAV in those who had only one BAV (n = 176); BAV 1/2--the initial BAV in those who had repeat BAV (n = 43); and BAV 2--repeat BAV (n = 43). The mean age of patients undergoing BAV 2 was 82 +/- 6 yr compared to 78 +/- 10 yr for all patients undergoing BAV 1 (p = .01). At the time of BAV 1 there was no difference in baseline or post-valvuloplasty aortic valve area (AVA) or peak aortic valve gradient (AVG) for patients having BAV 1/1 compared to those having BAV 1/2. However, for patients having repeat BAV, although the magnitude of the hemodynamic improvement of BAV 1/2 (AVA increased from 0.6 to 0.9 cm2, AVG decreased from 68 to 34 mm Hg, p less than .001) was similar to the magnitude of the hemodynamic improvement of BAV 2 (AVA increased from 0.5 to 0.8 cm2, AVG decreased from 65 to 34 mm Hg, p less than .001), the baseline AVA (0.5 cm2 at BAV 2 vs. 0.6 at BAV 1/2) and the post-valvuloplasty AVA (0.8 cm2 at BAV 2 vs. 0.9 at BAV 1/2) were significantly smaller (p less than .004).(ABSTRACT TRUNCATED AT 250 WORDS)

PTCA in the elderly: the "young-old" versus the "old-old".

OBJECTIVE: To evaluate the use of percutaneous transluminal coronary angioplasty (PTCA) in elderly coronary artery disease (CAD) patients. DESIGN: A prospective study of patients 60 years and older undergoing de novo PTCA. We analyze patient risk factors, underlying disease, and clinical outcomes, with at least 3-year follow-up. Comparisons between different age strata among these patients are made to clarify differences between the young old (60 to 69 years), the middle old (70 to 79 years), and the very old (80 years and older). SETTING: Beth Israel Hospital, Boston, both a primary care and tertiary care teaching hospital. PATIENTS: 907 consecutive elderly cardiac patients referred for PTCA are studied. INTERVENTIONS: PTCA's were completed using the newest catheter technologies as they became available. All patients were premedicated with aspirin and dipyridamole, and all were anticoagulated with heparin. RESULTS: Subdivision by age demonstrates that the majority (67%) of patients aged 60 to 69 were males, but females were preponderant (61%) in those aged 80 and older. Octogenarians also had lower incidence of hypercholesterolemia, tobacco use, and family history of CAD, and a higher frequency of CHF, angina, and previous MI. Although total procedure-complications increased with age, critical complications (MI, reocclusion, CABG, death) did not. Primary procedural success was similar in all age strata, but older patients had a higher prevalence of multi-vessel disease and longer hospital stay. Follow-up shows that most patients did well after PTCA; there was no increase in repeat PTCA, CABG, and MI with age. CONCLUSIONS: While advanced age is associated with changes in risk and clinical parameters for CAD patients, age alone is not a reasonable criterion to limit the use of PTCA.

Predictors of event-free survival after balloon aortic valvuloplasty.

BACKGROUND: Balloon aortic valvuloplasty was developed as an alternative to aortic-valve replacement in selected elderly patients with aortic stenosis. The use of this procedure is limited, however, by a high incidence of restenosis. METHODS: Between December 1985 and April 1989, valvuloplasty was performed in 205 patients. We evaluated 40 demographic and hemodynamic variables as univariate predictors of event-free survival by Cox regression analysis and identified independent predictors of event-free survival by stepwise multivariate analysis. RESULTS: Early hemodynamic results indicated a decrease in the peak transaortic-valve pressure gradient from 67 +/- 28 to 33 +/- 15 mm Hg after valvuloplasty and an increase in aortic-valve area from 0.6 +/- 0.2 to 0.9 +/- 0.3 cm2 (P less than 0.001 for both comparisons). The rate of event-free survival (defined as survival without recurrent symptoms, repeated valvuloplasty, or aortic-valve replacement) was 18 percent over the mean (+/- SD) follow-up period of 24 +/- 12 months (range, 1 to 47). Significant predictors of event-free survival included the left ventricular ejection fraction and the left ventricular and aortic systolic pressure before valvuloplasty, and the percent reduction in the aortic-valve pressure gradient; the pulmonary-capillary wedge pressure was inversely associated with event-free survival. Although the predicted event-free survival rate for the entire patient group was 50 percent at one year (95 percent confidence interval, 43 to 57 percent) and 25 percent at two years (95 percent confidence interval, 19 to 31 percent), the probability of event-free survival at one year varied between 23 and 65 percent when patients were stratified according to three independent predictors: the aortic systolic pressure, the pulmonary-capillary wedge pressure, and the percent reduction in the peak aortic-valve gradient. CONCLUSIONS: The most important predictors of event-free survival after balloon aortic valvuloplasty were related to base-line left ventricular performance. The best long-term results after valvuloplasty were observed among patients who would also have been expected to have excellent long-term results after aortic-valve replacement.

Aortic valvuloplasty.

Balloon aortic valvuloplasty is a palliative treatment for adult patients with aortic stenosis who are not candidates for AVR. BAV can be performed using a single balloon (one balloon, one shaft), multiple balloons (multiple balloons, multiple shafts), or complex balloon configurations (bifoil or trefoil balloons on a single shaft) by the retrograde (femoral or brachial) or antegrade (transseptal) approach. The mechanisms of successful BAV are fracture of calcified nodules, separation of fused commissures, and simple stretching of valve leaflets, leading to increased leaflet mobility and larger orifice dimensions. Clinically, these changes lead to a 50% to 70% decrease in transaortic valve gradient and a 50% to 70% increase in aortic valve area, resulting in immediate improvement in symptoms in most patients. Despite the fact that these beneficial hemodynamic results are achieved with a low incidence of life-threatening complications, the major limitation of BAV is the high incidence of restenosis. About 80% of patients have recurrent symptoms within 2 years of BAV, leading to death of the patient or requiring late AVR or repeat BAV. As a result of the high incidence of restenosis after BAV, elderly patients with aortic stenosis should not be denied the opportunity for AVR solely on the basis of age. BAV may have a role, however, in the following situations: (1) to treat patients in whom AVR is contraindicated for clinical or technical reasons; (2) to treat patients who require urgent noncardiac operations; (3) to clarify the extent of surgery required in patients with aortic stenosis, severe mitral regurgitation, and poor LV function; and (4) to predict the likelihood of successful outcome after AVR in patients with aortic stenosis, low gradients, low cardiac output, and poor LV function.

"Woven" right coronary artery: case report and therapeutic implications.

We report an unusual anomaly of the right coronary artery consisting of proximal branching of the artery and subsequent interweaving of the branches, referred to as a "woven" coronary artery. Implications and differential diagnosis are discussed.

Serial assessment of mitral regurgitation by pulsed Doppler echocardiography in patients undergoing balloon aortic valvuloplasty.

Mitral regurgitation was serially assessed by pulsed Doppler echocardiography in 144 patients undergoing balloon aortic valvuloplasty for symptomatic aortic stenosis. Regurgitant scores of 0, 1, 2 and 3 were assigned to pulsed Doppler patterns corresponding to no, mild, moderate and severe mitral regurgitation, respectively. Before balloon aortic valvuloplasty, mitral regurgitant score correlated significantly (p less than 0.005) but weakly with aortic valve area (r = -0.24), left ventricular ejection fraction (r = -0.34) and left ventricular systolic pressure (r = 0.23). There was no significant correlation between mitral regurgitation and either mean catheterization or mean Doppler aortic valve gradient. Balloon aortic valvuloplasty produced significant decreases in both catheterization and Doppler mean transvalvular aortic valve gradients (56 +/- 19 to 31 +/- 12 and 60 +/- 19 to 48 +/- 16 mm Hg, respectively; both p less than 0.0001) and a significant increase (p less than 0.0001) in aortic valve area assessed by catheterization (0.6 +/- 0.2 to 0.9 +/- 0.3 cm2). Left ventricular ejection fraction did not change, but cardiac output increased (p less than 0.001) and pulmonary capillary wedge pressure decreased (p less than 0.0001). Pulsed Doppler findings of mitral regurgitation were present in 102 of the 144 patients. Eighty-eight patients had a score compatible with mild or more severe degrees of mitral regurgitation, and 49 had a score indicative of moderate or severe valvular insufficiency. In the entire group of 144 patients, mitral regurgitant score decreased significantly from 1.1 +/- 1.0 to 1.0 +/- 1.0 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Progressive improvement in pulmonary vascular resistance after percutaneous mitral valvuloplasty.

Percutaneous mitral valvuloplasty has been proposed as a nonsurgical technique for treating high-risk patients with mitral stenosis who are deferred from mitral valve replacement. The effect of this technique on patients with pulmonary hypertension, however, has not been fully evaluated. Accordingly, serial assessment of pulmonary vascular resistance was made in 14 patients with critical mitral stenosis and pulmonary hypertension (pulmonary vascular resistance greater than 250 dynes.sec/cm5 or mean pulmonary artery pressure greater than 40 mm Hg or both) who underwent percutaneous balloon dilatation of the mitral valve. Balloon valvuloplasty was performed with either one (n = 10) or two (n = 4) balloons through the transseptal approach, and it resulted in significant improvement in mean mitral gradient (from 18 +/- 4 to 9 +/- 4 mm Hg, p less than 0.001), systemic blood flow (from 3.7 +/- 1.2 to 5.0 +/- 2.2 l/min, p less than 0.001), and calculated mitral valve area (from 0.7 +/- 0.2 to 1.6 +/- 0.7 cm2, p less than 0.001). Immediately after balloon mitral valvuloplasty, pulmonary vascular resistance fell from 630 +/- 570 to 447 +/- 324 dynes.sec/cm5. Repeat catheterization 7 +/- 4 months after valvuloplasty showed further improvement of pulmonary hypertension in 12 of the 14 patients, with a mean pulmonary vascular resistance for the group as a whole of 280 +/- 183 dynes.sec/cm5, p less than 0.005. In two patients, mitral valve restenosis to a mitral valve area less than 1.0 cm2 was associated with a return of pulmonary hypertension to predilatation values.(ABSTRACT TRUNCATED AT 250 WORDS)

Improvement in symptoms and left ventricular performance after balloon aortic valvuloplasty in patients with aortic stenosis and depressed left ventricular ejection fraction.

The application of balloon aortic valvuloplasty to elderly patients with severe aortic stenosis and a low ventricular ejection fraction is undefined. Balloon aortic valvuloplasty was performed in a subset of 28 patients with low left ventricular ejection fraction (37 +/- 11%), severe aortic stenosis, and a mean age of 79 +/- 5 years. After valvuloplasty, significant increases were seen in aortic valve area (from 0.5 +/- 0.1 to 0.9 +/- 0.2 cm2), aortic systolic pressure (from 120 +/- 12 to 135 +/- 22 mm Hg), and cardiac output (from 4.2 +/- 1.1 to 4.8 +/- 1.6 l/min) (p less than 0.01), and significant decreases were seen in transaortic pressure gradient (from 69 +/- 25 to 35 +/- 15 mm Hg) and pulmonary capillary wedge pressure (from 24 +/- 9 to 20 +/- 7 mm Hg) (p less than 0.01). All patients had symptomatically improved at the time of discharge. Serial radionuclide ventriculography showed an increase in left ventricular ejection fraction from 37 +/- 11% before valvuloplasty to 44 +/- 14% within 48 hours after dilatation and to 49 +/- 13% at 3 months after dilatation. However, there was substantial heterogeneity of response. Thirteen patients (group A) showed progressive increases in left ventricular ejection fraction (from 34 +/- 11% to 49 +/- 15% to 58 +/- 11%, p less than 0.0001), whereas 15 patients (group B) showed no significant change in ejection fraction (from 41 +/- 10% to 40 +/- 13% to 41 +/- 10%, p = NS) over 3 months. There was no difference between these groups with respect to age, extent of coronary artery disease, history of myocardial infarction, and aortic valve area before and after valvuloplasty. However, peak systolic wall stress and left ventricular dimensions were higher in group B compared with group A. In conclusion, balloon aortic valvuloplasty may result in symptomatic improvement in patients with aortic stenosis and depressed left ventricular ejection fraction; some patients develop progressive increases in ejection fraction, whereas others fail to show improvement.

Balloon aortic valvuloplasty in 170 consecutive patients.

Between October 1, 1985, and April 1, 1988, we performed balloon aortic valvuloplasty in 170 patients (mean age [+/- SD], 77 +/- 5 years) who had symptomatic aortic stenosis. The procedure was completed successfully in 168 patients and resulted in significant increases in the mean (+/- SD) aortic-valve area (from 0.6 +/- 0.2 to 0.9 +/- 0.3 cm2) and cardiac output (from 4.6 +/- 3.4 to 4.8 +/- 1.4 liters per minute) and decreases in the peak aortic-valve pressure gradient (from 71 +/- 20 to 36 +/- 14 mm Hg) (P less than 0.01 for all three comparisons). There were six in-hospital deaths, and five patients required early aortic-valve replacement. Follow-up data were available for all patients, for a period averaging 9.1 months. In addition to the 6 patients who died in the hospital, 25 patients died an average of 6.4 +/- 5.3 months after discharge. Symptoms recurred in 44 patients; they were managed by repeat valvuloplasty in 16 patients, by aortic-valve replacement in 17, and by medical therapy in 11. At the most recent follow-up examination, the symptoms of 103 patients had improved after valvuloplasty; this number includes 15 patients with restenosis who successfully underwent redilation. Life-table analysis indicates that the probability of survival 12 months after the procedure was 74 percent. We conclude that balloon aortic valvuloplasty is an effective palliative therapy for some elderly patients with symptomatic aortic stenosis. Symptoms improve in the majority of patients; although restenosis is common, it can be managed in some patients by repeat balloon dilation.

Combined aortic and mitral balloon valvuloplasty in patients with critical aortic and mitral valve stenosis: results in six cases.

Six patients with severe combined aortic and mitral valve stenosis underwent double valve balloon dilation as an alternative to surgical valve replacement. Cardiac catheterization in all patients before valve dilation revealed heavily calcified aortic and mitral valves with severe stenosis and minimal regurgitation. Balloon aortic valvuloplasty was performed in each patient with a 20 mm balloon dilation catheter passed retrograde through the aortic valve whereas mitral valvuloplasty was performed transseptally with either a single or double balloon technique. After dilation, the mean aortic and mitral gradients decreased in all patients, with the area of the aortic and the mitral valve increasing from 0.5 +/- 0.3 to 0.9 +/- 0.3 cm2 and from 0.7 +/- 0.1 to 1.5 +/- 0.7 cm2, respectively. The procedures were well tolerated, with no embolic events and no significant increase in valvular regurgitation, and resulted in a reduction in symptoms of dyspnea on exertion and weakness in all patients that has persisted for an average of 5.7 months of follow-up in five of the six patients. It is concluded that combined dilation of stenotic aortic and mitral valves can be accomplished percutaneously and may be considered for patients with combined valvular stenosis who refuse or are deferred from surgical intervention.

Percutaneous balloon mitral valvuloplasty in a pregnant woman with mitral stenosis.

A 39-year-old woman with symptomatic mitral stenosis underwent percutaneous mitral valvuloplasty at the end of her first trimester of pregnancy. Balloon dilatation utilizing a double 18-20 mm balloon technique resulted in improvement in mean mitral gradient (16 to 7 mmHg) and in calculated mitral valve area (1.4 to 2.4 cm2), without significant complications and with an estimated radiation exposure to the fetus of less than 0.2 rads. The procedure resulted in disappearance of symptoms of congestive heart failure and allowed for discontinuation of diuretics. The subsequent course of gestation was uncomplicated and a normal baby boy was delivered in the 36th wk. We conclude that percutaneous mitral valvuloplasty may produce successful palliation of symptoms in patients with mitral stenosis during pregnancy.

Combined percutaneous aortic valvuloplasty and transluminal coronary angioplasty in adult patients with calcific aortic stenosis and coronary artery disease.

Of 120 consecutive balloon aortic valvuloplasty procedures for critical aortic stenosis, valvuloplasty was performed in combination with coronary angioplasty in nine patients (average age 76 years). All nine patients were symptomatic with angina and congestive heart failure before combined procedures. Aortic valvuloplasty was performed with 20 to 23 mm balloon catheter advanced retrogradely from the femoral artery and resulted in an improvement in peak aortic valve gradient (60 +/- 19 to 33 +/- 13 mm Hg; p less than or equal to .01) and calculated aortic valve area (0.7 +/- 0.1 to 1.1 +/- 0.3 cm2; p less than or equal to .01). Single-vessel coronary angioplasty was performed via the femoral approach, with 2.0 to 3.5 mm balloon catheters, and resulted in a mean reduction of a critical coronary stenosis in each patient from 91 +/- 4% to 29 +/- 8%. The site of coronary angioplasty was the left anterior descending artery in three patients, the circumflex artery in three patients, the right coronary artery in two patients, and a bypass graft to the right coronary artery in one patient. Combined procedures were performed with a mean arterial time of 108 min. Complications included groin hematomas (n = 2), transient left bundle branch block (n = 1), and transient atrial fibrillation (n = 1). No patient experienced prolonged chest pain, myocardial infarction, major increase in aortic insufficiency, or embolic phenomena. Eight of the nine patients treated with combined procedures noted significant improvement in symptoms of angina and congestive heart failure and were discharged.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon dilation of mitral stenosis in adult patients: postmortem and percutaneous mitral valvuloplasty studies.

Preliminary reports have documented the utility of percutaneous balloon valvuloplasty of the mitral valve in adult patients with mitral stenosis, but the mechanism of successful valve dilation and the effect of mitral valvuloplasty on cardiac performance have not been studied in detail. Accordingly, mitral valvuloplasty was performed in five postmortem specimens and in 18 adult patients with rheumatic mitral stenosis, using either one (25 mm) or two (18 and 20 mm) dilation balloons. Postmortem balloon dilation resulted in increased valve orifice area in all five postmortem specimens, secondary to separation of fused commissures and fracture of nodular calcium within the mitral leaflets. In no case did balloon dilation result in tearing of valve leaflets, disruption of the mitral ring or liberation of potentially embolic debris. Percutaneous mitral valvuloplasty in 18 patients with severe mitral stenosis (including 9 with a heavily calcified valve) resulted in an increase in cardiac output (4.3 +/- 1.1 to 5.1 +/- 1.5 liters/min, p less than 0.01) and mitral valve area (0.9 +/- 0.2 to 1.6 +/- 0.4 cm2, p less than 0.0001), and a decrease in mean mitral pressure gradient (15 +/- 5 to 9 +/- 4 mm Hg, p less than 0.0001), pulmonary capillary wedge pressure (23 +/- 7 to 18 +/- 7 mm Hg, p less than 0.0001) and mean pulmonary artery pressure (36 +/- 12 to 33 +/- 12 mm Hg, p less than 0.01). Left ventriculography before and after valvuloplasty in 14 of the 18 patients showed a mild (less than or equal to 1+) increase in mitral regurgitation in five patients and no change in the remainder.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional and Doppler echocardiographic diagnosis of an aortic to right atrial fistula complicating aortic dissection.

A 60 year old woman presented with massive aortic root dilation and sudden cardiovascular collapse 10 years after aortic valve replacement. An aortic to right atrial fistula was diagnosed by echocardiographic imaging and Doppler ultrasound. At operation, the patient was found to have chronic aortic dissection with aneurysm formation. Rupture of the aneurysm into the right atrium was confirmed.

Assessment of left ventricular and aortic valve function after aortic balloon valvuloplasty in adult patients with critical aortic stenosis.

Preliminary reports have documented the utility of balloon aortic valvuloplasty as a palliative treatment for high-risk patients with critical aortic stenosis, but the effect of this procedure on cardiac performance has not been studied in detail. Accordingly, 32 patients (mean age 79 years) with long-standing, calcific aortic stenosis were treated at the time of cardiac catheterization with balloon dilatation of the aortic valve, and serial changes in left ventricular and valvular function were followed before and after valvuloplasty by radionuclide ventriculography, determination of systolic time intervals, and Doppler echocardiography. Prevalvuloplasty examination revealed heavily calcified aortic valves in all patients, a mean peak-to-peak aortic valve gradient of 77 +/- 27 mm Hg, a mean Fick cardiac output of 4.6 +/- 1.4 liters/min, and a mean calculated aortic valve area of 0.6 +/- 0.2 cm2. Subsequent balloon dilatation with 12 to 23 mm valvuloplasty balloons resulted in a fall in aortic valve gradient to 39 +/- 15 mm Hg, an increase in cardiac output to 5.2 +/- 1.8 liters/min, and an increase in calculated aortic valve area to 0.9 +/- 0.3 cm2. Individual hemodynamic responses varied considerably, with some patients showing major increases in valve area, while others demonstrated only small increases. In no case was balloon dilatation accompanied by evidence of embolic phenomena. Supravalvular aortography obtained in 13 patients demonstrated no or a mild (less than or equal to 1+) increase in aortic insufficiency. Serial radionuclide ventriculography in patients with a depressed left ventricular ejection fraction (i.e., that less than or equal to 55%) revealed a small increase in ejection fraction from 40 +/- 13% to 46 +/- 12% (p less than .03). In addition, for the study group as a whole there was a decrease in left ventricular end-diastolic volume index (113 +/- 38 to 101 +/- 37 ml/m2, p less than .003), a fall in stroke-volume ratio (1.49 +/- 0.44 to 1.35 +/- 0.33, p less than .04), and no immediate change in left ventricular peak filling rate (2.05 +/- 0.77 to 2.21 +/- 0.65 end-diastolic counts/sec, p = NS). Serial M mode echocardiography and phonocardiography showed an increase in aortic valve excursion (0.5 +/- 0.2 to 0.8 +/- 0.2 cm, p less than .001), a decrease in time to one-half carotid upstroke (80 +/- 30 to 60 +/- 10 msec, p less than .001), and a small decrease in left ventricular ejection time (0.44 +/- 0.03 to 0.42 +/- 0.02 sec, p less than .001).(ABSTRACT TRUNCATED AT 400 WORDS)