Percutaneous transarterial balloon dilatation of the mitral valve: five year experience.

OBJECTIVE: To examine the value of transarterial balloon dilatation of the mitral valve for treatment of patients with mitral stenosis over a period of five years. DESIGN: Analysis of patients' functional state, and haemodynamic and echocardiographic variables, before and immediately after the procedure and during a follow up of up to five years. SETTING: A cardiovascular centre in Belgrade, Yugoslavia. PATIENTS: Two hundred and ninety four patients who underwent percutaneous transarterial dilatation of the mitral valve between February 1985 and February 1990. RESULTS: Mean mitral valve area was enlarged by 109%. Complications included death (0.7%), severe mitral insufficiency (2.3%), mild mitral insufficiency (9.9%), cerebral embolism (2%), and injury to the femoral artery (2%). Two more patients died at two and 11 months after the procedure. Late cardiac surgery was needed in eight patients (mitral insufficiency in three, restenosis in three, thrombus in one, and endocarditis in one. Restenosis occurred in seven patients. Four of these underwent repeat dilatation and three had surgery. Improvement of symptoms was seen in 94% of patients during the follow up. CONCLUSION: Transarterial balloon dilatation of the mitral valve gave good results with acceptable morbidity and mortality and had some advantages over the anterograde approach.

Selective coronary angiography versus two-dimensional echocardiography for diagnosis of left atrial thrombi.

Coronary angiographic findings indicative for left atrial thrombi (neovascularization in the region of the left atrium) were compared with echocardiographic ones. Of 214 patients who had mitral surgery, the authors had all the available data for 161 (31 of whom had left atrial thrombi). The presence of a neovascularization had a sensitivity of 61%, a specificity of 100%, predictive accuracy of 100%, and predictive value of 92%, while echocardiography had a sensitivity of 52%, specificity of 96%, predictive accuracy of 76%, and predictive value of 89%. There was no difference in the sensitivity of both methods for the detection of thrombi located in the left atrium as a whole cavity (p less than 0.05). However, coronary angiography was superior to echocardiography in the diagnosis of thrombi located in the left atrial appendage (p less than 0.05). The diagnosis of left thrombi could be improved by using both methods (specificity 77%, predictive value 95%). Thus, selective coronary angiography is a useful diagnostic method, in addition to echocardiography, in the diagnosis of left atrial thrombi.

[Coronary surgery in patients with severely impaired left ventricular function]. / Koronárni chirurgie u nemocných s tezce omezenou funkcí levé komory.

Views on surgical treatment of patients with coronary disease and severely restricted left ventricular function are still controversial. In the present work the authors compare the results of direct reconstruction of the coronary arteries in 184 patients with satisfactory or medium restricted left ventricular function (SLV) with a group of 77 patients with severely restricted left ventricular function (RLV). Twenty-three clinical, angiographic, peroperative and postoperative indicators were compared. Patients with RLV had more frequently a myocardial infarction before operation, on average a more restricted functional capacity and lower ejection fraction of the left ventricle than patients with SLV. The mortality during hospitalization was 1.1% in patients with SLV and 5.2% in patients with RLV. These results confirm that reconstruction of the coronary arteries is safe also in patients with a significantly restricted left ventricular function. An essential prerequisite of successful operation is perfect peroperative protection of the heart muscle by the method of continuous local cooling.

Systemic and pulmonary flow in mitral stenosis: evidence for a bronchial vein shunt.

We measured pulmonary and systemic flows in 22 patients with mitral stenosis and in 7 controls. In patients with mitral stenosis, pulmonary flow index averaged 2.33 +/- 0.41 l/min/m2 and systemic flow index averaged 2.15 +/- 0.60 l/min/m2, p = 0.045. There was a strong correlation between the difference in pulmonary and systemic flow indexes and the difference in mean left and right atrial pressure (r = 0.749, p = 0.00008). After a successful dilatation in 17 patients, there was a significant drop in the difference between pulmonary and systemic flow indexes (0.26 +/- 0.41 vs. 0.07 +/- 0.37 l/min/m2, p = 0.048). We conclude that chronic elevation of left atrial pressure leads to a left to right shunt probably through bronchial veins.

Double-umbrella device for transvenous closure of patent ductus arteriosus and atrial septal defect: first experience.

A new device for transcatheter closure of heart defects was constructed and used to close a patent ductus arteriosus (PDA) in seven adult patients and an atrial septal defect (ASD) in six adult patients. The device consisted of two self-opening umbrellas and a piece of Ivalon. A Dacron patch was sewn on the "male" umbrella for the ASD closure. The device required a 9 Fr introducing venous sheath for PDA and a 14 Fr sheath for the ASD. The venoarterial (right femoral vein-PDA or ASD-left femoral artery) long wire track was arranged. The "male" umbrella and the Ivalon were inserted transvenously one after another, advanced over the long wire across the PDA or ASD and extruded into the aorta or left atrium, respectively. The "female" umbrella was advanced transvenously over the long wire into the pulmonary artery (for PDA) or into the right atrium (for ASD). The metal conus on the long wire was used to pull the "male" umbrella while a special stiff pusher was used to bring the "female" umbrella to the "male" umbrella along the long wire. By these means the umbrellas interlocked at the defect level and closed it. The long wire was then removed through the left femoral artery. Protrusion of the interlocked device through the PDA occurred in one patient and through the ASD in two patients. In all three patients the device was kept on the wire until surgery and an early postrelease device embolization was avoided. In all other patients the defects were successfully closed. The follow-up of 3-27 months was uneventful in all patients. These results indicate that the described procedure is effective and safe, and warrants further clinical trial.

Percutaneous transarterial balloon mitral valvuloplasty: 30 months experience.

Between February, 1985, and August, 1987, 76 patients with mitral stenosis underwent percutaneous transarterial mitral balloon valvuloplasty (MVP). There were 58 females and 18 males aged from 15 to 69 years (mean 39 +/- 11). In 31 patients the mitral valve was pliable (40%) and in 45 patients (60%) the valve was nonpliable. Calcified mitral stenosis was found in 24 patients (31%). Transseptal catheterization was used to place one or two 0.035" (350 cm long) exchange wires into the ascending aorta in order to be snared, retrieved and exteriorized, each one through a femoral artery. Over these wires, the balloon dilation catheters were advanced through the femoral artery, retrogradely, across the mitral valve, for mitral dilation. Single (25 mm in diameter, trefoil 3 x 12 mm, bifoil 2 x 19 mm) and double (18 and 15 mm, 18 and 18 mm, 18 and 20 mm) balloons were used in 24 and 52 patients respectively. Transarterial mitral valvuloplasty produced immediate improvement of mitral valve area (MVA = 1.1 +/- 0.3 to 2.4 +/- 0.4 cm2, p less than 0.001), mitral valve gradient (19 +/- 4 to 8 +/- 6 mmHg, p less than 0.001), echocardiographic left atrial diameter (LAD = 58 +/- 6 to 54 +/- 5 mm, p greater than 0.05) and echo-MVA (0.9 +/- 0.4 to 2.1 +/- 0.7, p less than 0.001). In three patients no MVA enlargement was achieved. A significant mitral regurgitation was produced in two patients. A stroke occurred in three patients (3.9%), one of these patients subsequently died (1.3%), one recovered and one remained hemiplegic. No atrial septal defect was found after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous mitral valvuloplasty: retrograde, transarterial double-balloon technique utilizing the transseptal approach.

Between February 1985 and May 1987, 72 patients with mitral stenosis (MS) underwent percutaneous transluminal mitral valvuloplasty (PTMV). The retrograde transarterial double-balloon technique was used on 54/72 patients (75%); 16 males, 38 females; mean age: 39 +/- 11 years. Transseptal catheterization was used to place two 0.035", 350-cm exchange wires into the ascending aorta in order to be snared, retrieved, and exteriorized, each through a femoral artery. Over these wires, the balloon dilation catheters were advanced through the femoral artery, retrogradely, across the mitral valve, for PTMV. The transmitral mean gradient fell [18 +/- 4 to 9 +/- 5 mmHg (P less than 0.001)]; the cardiac output increased [5.1 +/- 0.8 6.1 +/- 0.8 L/min (P less than 0.001)]; the hemodynamically calculated valve area increased [1.2 +/- 0.2 to 2.3 +/- 0.6 cm2 (P less than 0.001)]; and the short axis two-dimensional echocardiographic valve area increased [1.1 +/- 0.3 to 2.2 +/- 0.7 (P less than 0.001)]. PTMV was unsuccessful in two patients (4%), due to the inability to maintain the inflated balloons in the mitral position. Significant complications were encountered in two patients: two strokes (3.7%) and one mortality from the stroke (1.4%). Significant mitral regurgitation occurred in two patients (3.7%); no post-PTMV hemodynamically significant atrial septal defects were detected. Follow-up (mean time: 11 +/- 6 months) of 43 patients showed a persistent improvement in echocardiographic findings in 27 (63%) and hemodynamically measured mitral valve area in the 16 patients in which cardiac catheterization was repeated. The retrograde, transarterial double-balloon technique can successfully accomplish PTMV with good results and an acceptable low morbidity and mortality.

Transarterial balloon mitral valvuloplasty.

Between February 1985 and November 1986, 36 patients, aged between 15 and 67 years (mean 39 years), with moderate (27 patients) and severe (9) mitral valvular stenosis (MS) underwent percutaneous transarterial balloon mitral valvuloplasty (PTBMV). Originally, a right femoral vein-LA-LV-aorta-left femoral artery track had been formed with a long guide wire, which had been advanced transseptally through the Brockenbrough catheter to the LV, where its distal end was caught by means of a retriever set and exteriorized through the femoral artery. Introduction of the transseptal sheath through the LA-LV to the aorta with the Swan-Ganz catheter as a guidance, made the formation of two long guide tracks much easier and enabled the application of the double balloon technique. PTBMV was performed in 15 patients using the single balloon technique with a balloon of 25 mm in diameter and in 19 patients using double-balloon technique (18 + 15 mm in one patient, 20 + 18 mm in two patients and 18 + 18 mm in 16 patients). The mitral valve gradient decreased from 18 +/- 4.3 to 8.4 +/- 4.4 mm Hg (p less than 0.001) and the mitral valve area (MVA) enlarged from 1.26 +/- 0.025 to 2.3 +/- 0.66 cm2 (p less than 0.001) (87%) immediately after valvuloplasty. PTBMV produced significant mitral regurgitation in two patients (grade IV and II). Enlargement of the MVA by 127% was achieved in patients with type A MS and only by 53% in patients with type B MS.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transarterial balloon valvuloplasty for mitral valve stenosis.

A new technique was developed that allows mitral commissurotomy without surgery. A balloon catheter was inserted percutaneously from the left femoral artery over a long guidewire introduced into the right femoral vein and advanced transseptally through the Brockenbrough catheter to the left ventricle and drawn out of the body through the left femoral artery using an intravascular retriever set. This procedure was performed in 3 patients with moderate mitral stenosis. After the procedure, the mean diastolic pressure gradient across the mitral valve was reduced and left ventriculography revealed no resultant mitral regurgitation in any of the patients. The procedure was easy to perform and caused no complications.