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Background Percutaneous balloon aortic valvuloplasty (PBAV) is an alternative to surgical valvulotomy for the treatment of congenital aortic stenosis (AS). This article aims to summarize our preliminary experience on feasibility and safety of PBAV under only echocardiographic guidance in patients with congenital AS. Methods Clinical data from 20 consecutive patients with aortic valve stenosis who underwent PBAV under only echocardiographic guidance at Fuwai Hospital from January 2016 to January 2019 were analyzed retrospectively. Median age of patients was 18.38±15.88 years and 65% of the patients were male. Aortic annulus diameter was 18.40±3.25 mm and balloon diameter was 17.38±3.89 mm, with B/A ratio of 0.93±0.06. Results All the patients successfully underwent PBAV. The peak transaortic gradient (TG) significantly decreased from 81.59±24.91 (range, 58-112) mmHg preoperatively to 36.32±12.83 (range, 16-51) mmHg (P=0.000) immediately post operation, without significant difference in aortic regurgitation (AR). At mean 24.31±17.35 months follow-up, peak TG was 37.06±13.52 (range, 21-58) mmHg which was not significantly different from the immediate postoperative value (P=0.65). Conclusions In this retrospective, single center study, systematic use of Doppler echocardiography as only guidance modality for PBAV was feasible and associated with a high success rate and a very low complication rate.

A 2-year, 4-month-old neutered female Labrador retriever was brought for evaluation of right-sided congestive heart failure. Echocardiographic examination revealed tricuspid valve dysplasia with only two small orifices in the valve resulting in severe tricuspid stenosis. The dog underwent a right fifth lateral intercostal thoracotomy and surgical tricuspid valvulotomy, under cardiopulmonary bypass. The stenosis was relieved by dividing the valve leaflets between the two orifices with continuation to the commissures, creating a ‘bileaflet’ valve. The dog made a good recovery initially, with echocardiography at 48 h after surgery showing a reduction in tricuspid valve E and A wave velocities and pressure half-time (from 230 ms to 65 ms). She was discharged five days after surgery, and spironolactone, benazepril, pimobendan, and clopidogrel were prescribed. The dog was re-presented two days later having collapsed, with pyrexia, facial swelling, and pitting edema on the ventral neck and intermandibular region. Investigations did not reveal an underlying cause, and the clinical signs resolved with supportive therapy. Two years after surgery, the dog was free of clinical signs with normal exercise tolerance and only mild tricuspid regurgitation on echocardiography, with discontinuation of all medications.

Herein we present the first case report of laparoscopic exploration, endovascular valvulotomy, and open side-to-side bypass of a gonadal vein into the ipsilateral external iliac vein for Nutcracker syndrome in an adolescent patient with solitary kidney without pelvic congestion. Though prior management has included various large open surgeries or endovascular or extravascular approaches with the use of stents and shields, this case offers an expanded novel approach to weigh the unique challenges of the patient's age and solitary renal status. If reproducible, this technique may gain value in the management of patients with this rare, incapacitating condition.

V dospěle populaci stoupa pocet jedinců, kteři maji vrozenou srdecni vadu (VSV). Nyni je takových pacientů v absolutnim cisle dva- až třikrat vice než děti s VSV. Je tedy důležite zvysovat povědomi o nejcastějsich VSV v dospělosti - defekty siňoveho septa (ASD), defekty komoroveho septa, koarktace aorty, Fallotova tetralogie (TOF) a pulmonalni stenoza (PS). Jedna se o pacienty, kteři jsou v dětstvi po jedne nebo vice operacich pro VSV, maji neoperovanou vadu (vada byla nevýznamna nebo inoperabilni) anebo vada nebyla dosud diagnostikovana (nejcastěji ASD). Někteři pacienti se po dosaženi dospělosti ztrati na různě dlouhou dobu z dispenzarizace. Diky caste absenci symptomů i při hemodynamicky významných vadach lekařskou peci dlouho nevyhledavaji. My uvadime připad 46leteho muže s postupně progredujici pulmonalni regurgitaci (PR) po chirurgicke valvulotomii pro PS v deseti letech. Tento pacient i přes sledovani kardiologem nebyl odeslan do specializovaneho centra k referencnimu vysetřeni a po fyzicke zatěži u něj doslo k oběhove zastavě na podkladě fibrilace komor (FK).

Objectives Congenital aortic valvular stenosis in neonates is a life-threatening condition requiring urgent management. Therapeutic strategy remains controversial between balloon valvuloplasty (BV) and surgical valvulotomy (SV). We reviewed our long-term single-center experience of neonatal aortic stenosis management and compared aortic valve outcomes regarding BV versus SV. Methods Between 1990 and 2020, 137 patients underwent aortic stenosis treatment (SV [n = 83] and BV [n = 54]) with a median age of 5.5 days (range: 0 to 30 days) and a median weight of 3 kg (range: 1.8 to 4.8 kg). Procedure strategy was decided according to the surgeon availability especially at the beginning of the study. Additionally, there was a traditional local protocol favoring balloon in case of left ventricular dysfunction like in many centers. Results The median follow-up was 6.7 years (up to 28y, 88% complete). We did not report any operative death but the intra-hospital mortality was notably greater for patients after balloon procedure (20.3%) versus SV group (8.4%). The one-year and ten-year patient survival was respectively 90 and 89% in SV group versus 75 and 69% in BV group (P Fig. 1 ). Conclusion Long-term survival and freedom from reintervention are excellent after surgical valvotomy. However, poor results are obtained when patients had initial left ventricular dysfunction or multiple left ventricular outflow lesions.

Presented herein is an original method of preparing a bypass graft (a non-reversed autovein for femoropopliteal and femorotibial bypass grafting) and assessment of quality of valvulotomy using a thermal imager. The study included a total of 31 patients. All patients subdivided into 2 groups were subjected to bypass grafting operations with the use of a non-reversed autovein. In group 1 (n=16) prior to applying a bypass graft we assessed its patency with the use of an original method by means of a thermal imaging camera. In group 2 (n=15) assessment of graft patency after destruction of valves was not performed. In group 1 there were no bypass graft thromboses in the postoperative period, whereas three (20%) patients in group 2 developed bypass graft thrombosis within the first 24 postoperative hours, requiring repeat operation. Bypass graft thrombosis was caused in all cases by insufficiently destroyed valves of the venous transplant. There were no lethal outcomes within 1 year postoperatively. Control ultrasonographic examination after 1 year revealed bypass graft thrombosis in two (13.3%) patients in group 2, leading to the development of critical ischaemia and gangrene in one (6.6%) of these patients and later on requiring limb amputation at the level of the femur. A conclusion drawn is that thermal imaging makes it possible to intraoperatively assess quality of valvulotomy in using a non-reversed autovein as a bypass graft and to improve the results of surgical treatment.Представлен оригинальный способ подготовки шунта (нереверсированной аутовены для операции бедренно-подколенного и бедренно-берцового шунтирования) и оценки качества вальвулотомии с использованием тепловизора. В исследование включен 31 больной. Всем больным, разделенным на 2 группы, проводились шунтирующие операции с использованием нереверсированной аутовены. В 1 группе (n=16) перед наложением шунта оценивалась его проходимость с использованием оригинального способа с помощью тепловизора. Во 2 группе (n=15) оценка проходимости шунта после разрушения клапанов не проводилась. В послеоперационном периоде в 1 группе тромбозов шунта отмечено не было, тогда как во 2 группе тромбоз шунта в первые сутки после операции возник у 3 (20%) больных, что потребовало выполнения повторной операции. Причиной тромбоза шунта во всех случаях были недоразрушенные клапаны венозного трансплантата. В сроки до 1 года после операции летальных исходов не было. При проведении контрольного ультразвукового исследования через 1 год у 2 (13,3%) больных во 2 группе выявлен тромбоз шунта, что привело к развитию критической ишемии и гангрены у 1 (6,6%) из этих пациентов и в дальнейшем потребовало выполнения ампутации конечности на уровне бедра. Сделан вывод, что тепловизионное исследование позволяет интраоперационно оценить качество вальвулотомии при использовании в качестве шунта нереверсированной аутовены и улучшить результаты хирургического лечения.

Primary tumors of the heart are uncommon; even rarer are primary cardiac neuroendocrine tumors. To our knowledge, only two cases have been described to date, both being high-grade tumors. We report a solitary low-grade neuroendocrine tumor of the heart, unexpectedly discovered during aortic valve repair for infectious bacterial endocarditis on the wall of the right ventricle in a 44-year-old man with a history of balloon valvulotomy as a child. Frozen section was sent intraoperatively and demonstrated a plasmacytoid neoplasm. Final pathology of the biopsies showed a tumor composed of both cohesive and discohesive plasmacytoid cells separated by a vascular network and strands of fibrosis. The tumor showed strong reactivity for AE1/3, synaptophysin, and CDX2 with focal reactivity for chromogranin-A and CD56. Neither necrosis nor a mitotic rate of greater than 2 mitoses per 2 mm2 was seen. A colonoscopy was performed and demonstrated only a tubular adenoma. An esophagogastroduodenoscopy was unremarkable. PET-CT DOTATATE, performed after complete resection of the tumor, demonstrated no abnormal radiotracer uptake. The patient continues to do well at present, 1 year later, and reports no symptoms attributable to carcinoid syndrome or disease progression. The patient was assigned by medical oncology to yearly follow-up and imaging, and is considered to have no evidence of disease.

Purpose To evaluate the safety and efficacy of arteriovenous fistula (AVF) creation with a thermal resistance anastomosis device (TRAD). Materials and Methods From January 2014 to March 2015, 26 patients underwent ultrasound (US)-guided percutaneous creation of proximal radial artery–to–perforating vein AVFs with a TRAD that uses heat and pressure to create a fused anastomosis. Primary endpoints were fistula creation, patent fistula by Doppler US, two-needle dialysis at the prescribed rate, and device-related complications. Results Technical success rate of fistula creation was 88% (23 of 26). Procedure time averaged 18.4 minutes (range, 5–34 min), and 96% of anastomoses (22 of 23) were fused. At 6 weeks, 87% of AVFs (20 of 23) were patent, 61% (14 of 23) had 400-mL/min brachial artery flow, 1 patient was receiving dialysis, 2 fistulae had thrombosed, and 1 patient had died unrelated to the procedure. Eighty percent (16 of 20), 70% (14 of 20), and 60% (12 of 20) of patients were receiving dialysis at 3, 6, and 12 months; 4 patients died, 3 fistulae failed, and one patient was lost to follow-up. Overall, 87% of AVFs (20 of 23) had an additional procedure at a mean of 56 days (range, 0–239 d), including balloon dilation in 43% (n = 10), brachial vein embolization in 26% (n = 6), basilic vein ligation in 17% (n = 4), venous transposition in 30% (n = 7), and valvulotomy in 4% (n = 1). There were no major complications related to the device. Conclusions Percutaneous AVFs created with a TRAD met the safety endpoints of this study. Midterm follow-up demonstrated intact anastomoses and fistulae suitable for dialysis.

Background: We aimed to determine the overall prevalence of coronary artery disease (CAD), atherosclerotic risk factors and clinical profile of patients with rheumatic heart disease (RHD) undergoing valvular interventions in Asian Indians. Method: This was an all comers, observational, prospective study of 757 rheumatic patients, who underwent coronary angiography (CAG) prior to percutaneous balloon valvulotomy, surgical valvular repair or replacement from July 2011 to December 2013. Among them who had significant CAD (stenosis ≥50%) (Group A), were compared with similar number of age and sex matched patients of RHD without CAD (Group B). Result: The overall prevalence of CAD in the patients undergoing valvular intervention was 9.1% (66.7% males, 33.3% female; mean age 55.20±8.6). The CAD incidence in patients with mitral, aortic and both valve replacement were 24.1%, 10.8% and 6.1% respectively. The prevalence of smoking habit (33.3% vs. 20.9%), diabetes (24.6% vs. 3.1%), hypertension (21.7% vs. 6.8%), postmenopausal status (65.2% vs. 18.4%), family history of CAD (17.4% vs. 8.3%) and aortic valve disease (10.1%) was significantly higher in group A as compared to group B except for obesity (11.5% vs. 18.7%). Conclusion: Prevalence of CAD in patients with valvular heart disease in western population of Asian Indians is 9.1%. Coronary angiography should be performed in patients having CAD risk factors, irrespective of the valvular lesion involved.

Introduction Different interventional procedures like annuloplasty, valvulotomy/valvuloplasty, repair and replacement of the mitral valve of heart for regurgitation or prolapse are increasing day by day. This emphasizes the need for clear understanding of the mitral valve anatomy. The present study is an endeavor to find out the real anatomy of mitral valve in Eastern Indian population. Material and methods The present study was conducted on 52 adult formalin fixed heart specimens. Morphometric parameters of mitral valves like number and location of leaflets, annular circumference and diameter, length of annular attachment of each leaflet and their height were observed and analyzed statistically. Results Among the samples 40% are having three cusps and 6% are with single cusp. Mean annular diameter and circumference were found to be 2.6 ± 0.495 cm and 9.27 ± 1.017 cm respectively. Mean length of attachment of anterior and posterior cusps along the annulus is nearly same. Mean height of anterior and posterior cusps was noted 1.87 ± 0.399 cm and 1.46 ± 0.418 cm respectively. Discussion This study will improve our understanding for structural and functional value of mitral valve complex which will enrich the existing data and help the cardiothoracic surgeons and prosthetic manufacturers during valve operations.

Isolated post-capillary pulmonary hypertension (Ipc-PH) is characterized by elevated left atrial pressures that are passively transmitted upstream, whereas combined pre- and post-capillary PH (Cpc-PH) demonstrates additional reactive changes in pulmonary vasculature. The increased load imposed on the right ventricle (RV) influences left ventricular (LV) mechanics by means of interventricular interaction. However, there is lack of evidence to substantiate the effect of possible additional alterations in the arterio-ventricular (AV) coupling and their effect on LV function. Considering the discrepant RV load in Cpc-PH and Ipc-PH, we sought to investigate whether these two conditions are also characterized by differential alterations in AV coupling. Invasive hemodynamic and echocardiographic data of 120 patients with PH due to severe rheumatic mitral stenosis before and immediately after percutaneous valvulotomy, along with 40 age-matched healthy controls, were analyzed. Effective arterial (E a) and ventricular elastance (E es) were measured. PH patients demonstrated elevated LV afterload (E a) along with AV uncoupling, and these derangements were more evident in the Cpc-PH group [E a: 3.3 (2.3–5.4) vs 2.6 (2.1–3.5) mmHg/mL, E a/E es: 0.73 (0.6–0.9) vs 0.88 (0.7–1.2), p

Mitral valve disease in the elderly differs from that in the younger patients in several ways. Since rheumatic fever is now uncommon in North America and Western Europe, most rheumatic heart disease is seen in younger patients not born in the United States or in older patients. In patients born in North America or Western Europe, mitral stenosis (MS) is predominantly seen in patients over the age of 50–60 years, many of whom have had one or more surgical or balloon valvuloplasties. At present, balloon valvuloplasty is the procedure of choice, even in the elderly and even in patients who have had previously valvulotomy and are who now have mitral restenosis. Mitral regurgitation (MR) has many etiologies, the most common of which are degenerative or mitral valve prolapse, functional MR due to ischemia, or cardiomyopathy. In patients with grade I or II ischemic MR, revascularization alone can reduce or eliminate the MR. With grade III or IV ischemic MR, revascularization and concomitant annuloplasty or valve replacement can markedly reduce the degree of MR and result in better outcomes. With mitral valve disease, atrial fibrillation (AF) is a common complication and if valve surgery is indicated, consideration should be given to a concomitant Maze procedure or ablation for AF. Mitral annular calcification (MAC) is most frequently seen in the elderly patient and is probably a marker for vascular atherosclerosis and an independent predictor of adverse cardiovascular events such as myocardial infarction and stroke. The American Heart Association recommendations for antibiotic prophylaxis for valvular disease has been markedly altered so that now prophylaxis is no longer recommended for valvular regurgitation. However, many physicians still prescribe antibiotic prophylaxis for their patients with valve disease.

Maternal cardiac disease is a major cause of non-obstetric morbidity and accounts for 10–25% of maternal mortality (Pessel and Bonanno 2014). In emerging countries, rheumatic valve disease is the m...

Aim. To specify the indications for in situ femoropopliteal (tibial) bypass, to study complications rate immediately after, within 1 and 2 years of the surgery. Methods. The study group included 33 patients with symptoms of critical lower limb ischemia, who underwent femoral-popliteal or femoral-tibial bypass. 4 (12.1%) cases of type C and 29 (87.9%) cases of type D arterial bed lesions according to TASC II classification were revealed after investigation. Patients were followed up for 2 years period. Shunt thrombosis rate, condition of the trophic ulcers, chronic arterial ischemia stage before and after the surgery, mortality, lower limb amputation were measured outcomes. Results. Repeated reconstructions rate for primary shunt thrombosis immediately after surgery was 30.3±8.0%. Shunt thrombosis (secondary) occurred in only three (9.1±5.0%) patients. The main causes which led to the shunt thrombosis during or at the 1st day after the surgery, were absence of intraoperative valvulotomy quality control and presence of unligated great saphenous vein tributaries. Trophic defects healing was observed in 3 (30.0±14.5%) of 10 patients with ulcers immediately after surgery and in all cases (100.0%) by the end of 1 year follow-up. The total number of high-level amputations within 2 years was 25.8±7.9%, the overall mortality rate within 2 years was 6.1±4.2%. Femoral-popliteal or femoral-tibial bypass surgery allowed to preserve the limb in 74.2% of patients within 2 years of follow-up. Bypass patency was preserved in 41.7% of patients out of 24 in situ bypass surgeries for the follow-up time. In our opinion critical limb ischemia with significant and extended arterial bed lesions of D and C types (according to TASC II score) is one of the indications for in situ femoropopliteal (tibial) bypass as for the surgery of the first choice. Endovascular treatment is also impossible for this type of lesion, as alternative surgeries using reversed autovein and synthetic explant do not meet all the requirements for an extended bypass. Conclusion. The lack of adequate intraoperative valvulotomy quality control and presence of unligated great saphenous vein tributaries may be the causes of early postoperative shunt thrombosis; despite the low femoropopliteal (tibial) bypass patency rate in patients with critical ischemia, the surgery was recognized as efficient as it allowed to preserve the limbs in 74.2% of patients.

Background Inferior vein graft patency after coronary artery bypass grafting (CABG) is attributed to various factors. Venous valves may limit flow, cause thrombus formation, and diminish diastolic backflow. The aim of our study was to compare clinical outcome and midterm patency rate of valvulotomized vein grafts and arterial grafts in patients undergoing CABG. Methods Between 2007 and 2010, valvulotomized saphenous vein segments were used to graft the right coronary artery (RCA) in 147 patients undergoing CABG with mean 2.8 ± 1 arterial and 1.5 ± 0.6 venous anastomoses. Outcome, reintervention, and reoperation were assessed after 4 ± 1.6 years. Intraoperative bypass flow rate was measured before and after valvulotomy of venous bypass grafts in 12 patients. Patency of the grafts was assessed by means of multislice computed tomography (MSCT) in 45 patients. Results A total of 102 patients underwent isolated CABG and 45 had combined procedures. In-hospital mortality was 2%. At 4 years' clinical follow-up, 95% of the patients were asymptomatic. Five patients underwent recoronary angiography because of angina pectoris. The MSCT and reangiography patency rate of all valvulotomized saphenous vein grafts was 97.1 versus 95.8% of arterial grafts 18 ± 6 months postoperatively. Intraoperative measurements showed a significant increase (+20.2 mL/min; p = 0.01) of flow in the venous bypass grafts to the RCA after valvulotomy. There were no reoperations at the latest follow-up. Conclusion Patients with valvulotomized venous grafts had good clinical outcome. The one-year patency rate of those grafts is comparable to that of arterial grafts. However, long-term results and angiography studies will be needed to strengthen these findings.

Objective We aimed to assess the feasibility of using a percutaneous transhepatic cardiac catheterization technique to perform fetal pulmonary valvuloplasty and valvulotomy under ultrasound guidance at mid-gestation. Method In 13 mid-gestation fetal lambs without cardiac pathology, percutaneous transhepatic cardiac catheterization was used to position a coronary angioplasty catheter within the pulmonary valve. The balloon was inflated/deflated several times, simulating pulmonary valvuloplasty. In another two fetal lambs, a guidewire tip was positioned against the pulmonary valve, and unipolar diathermy was applied to simulate perforation of an atretic valve. Results Percutaneous access followed by right heart catheterization was successful in all cases. One fetus died following right ventricle perforation. Simulated pulmonary valvuloplasty was successful in nine cases using catheters with 6-mm-long balloons but unsuccessful in two cases (both survived) using 12-mm-long balloons. In one case, the catheter could not be inserted as the cannula became dislodged. Diathermy of the pulmonary valve was successful in both attempts. Conclusion We successfully simulated in utero perforation and dilation of the pulmonary valve using percutaneous transhepatic access in fetal lambs. The technique has potential for clinical translation into treatment for human fetuses with critical pulmonary stenosis or pulmonary atresia with intact ventricular septum. © 2014 John Wiley & Sons, Ltd.

More than half of patients with carcinoid syndrome develop carcinoid valve disease. Both the tricuspid and pulmonary valve are often involved. Symptoms of carcinoid syndrome with flushing, diarrhea, and bronchospasm often precedes cardiac symptoms. We report a case of carcinoid initially presenting with rapid development of right heart failure due to severe pulmonary valve stenosis. In untreated carcinoid, there is a risk of carcinoid crisis with anesthesia and surgery. In local anesthesia, we performed a sub-acute balloon pulmonary valvuloplasty. The procedure was successful without any residual pulmonary valve stenosis and with immediately relief of dyspnea. The final diagnostic workup for the underlying malignancy continued the day after valvuloplasty. © 2015 Wiley Periodicals, Inc.

"Partial forms of Shone complex are rare. Surgical outcomes of the complete forms have generally been poor, whereas there is a lack of data on long-term follow-up of surgically treated adult partial complex. Between 2001 and 2011, nine patients (age: 38 ± 8 years; six males, 67%) were referred for valvular heart disease. Transthoracic and transoesophageal echocardiography was performed. Data were confirmed by intra-operative findings and reports. Patients were diagnosed as partial Shone complex and presented with mitral stenosis (MS) (45%) or mitral regurgitation (22%) or aortic regurgitation (22%). All but one patient (89%) reported previous surgery: coarctation of the aorta repair (87.5%) and aortic valvulotomy (12.5%). Redo intervention included: mitral valve replacement (25%), mitral repair (25%), aortic valve replacement (37.5%) and subvalvular aortic ridge resection (25%). One patient refused surgery. Patients surgically treated before the age of 5 (87.5%) showed favourable outcome (survival rate: 100%) and a 23.6 (± 4.6)-year follow-up free from events. The patient who underwent first intervention at the age of 50 and the patient with MS who refused surgery showed a 45 (± 7)-year follow-up free from major morbidity. Patients with partial Shone complex, properly diagnosed and treated, show favourable surgical outcome free from major clinical events.. . "

Objectives Our objective was to determine the feasibility and early to medium-term outcome of stenting the patent ductus arteriosus at the time of radiofrequency valvotomy in the subgroup of patients with pulmonary atresia with intact ventricular septum and intermediate right ventricle. Background Stenting of the patent ductus arteriosus and radiofrequency valvotomy have been proposed as the initial intervention for patients with intermediate right ventricle inasmuch as the sustainability for biventricular circulation or 1½-ventricle repair is unclear in the early period. Methods Between January 2001 and April 2009, of 143 patients with pulmonary atresia and intact ventricular septum, 37 who had bipartite right ventricle underwent radiofrequency valvotomy and stenting of the patent ductus arteriosus as the initial procedure. The mean tricuspid valve z-score was −3.8 ± 2.2 and the mean tricuspid valve/mitral valve ratio was 0.62 ± 0.16. Results Median age was 10 days (3–65 days) and median weight 3.1 kg (2.4–4.9 kg). There was no procedural mortality. Acute stent thrombosis developed in 1 patient and necessitated emergency systemic–pulmonary shunt. There were 2 early in-hospital deaths owing to low cardiac output syndrome. One late death occurred owing to right ventricular failure after the operation. Survival after the initial procedure was 94% at 6 months and 91% at 5 years. At a median follow-up of 4 years (6 months to 8 years), 17 (48%) attained biventricular circulation with or without other interventions and 9 (26%) achieved 1½-ventricle repair. The freedom from reintervention was 80%, 68%, 58%, and 40% at 1, 2, 3, and 4 years, respectively. Conclusions Concomitant stenting of the patent ductus arteriosus at the time of radiofrequency valvotomy in patients with pulmonary atresia with intact ventricular septum and intermediate right ventricle is feasible and safe with encouraging medium-term outcome.

Background: Symptomatic mitral restenosis develops in up to 21% of patients after percutaneous balloon mitral valvotomy (PBMV), and most of these patients undergo mitral valve replacement (MVR). Hypothesis: Repeating PBMV (re-PBMV) might be an effective and less-invasive treatment for these patients. Methods: Forty-seven patients with post-PBMV mitral restenosis and unfavorable valve characteristics were assigned either to re-PBMV (25 cases; mean age 40.7 ± 11 y, 76% female) or MVR (22 cases; mean age 47 ± 10 y, 69% female) at 51 ± 33 months after the prior PBMV. The mean follow-up was 41 ± 32 months and 63 ± 30 months for the re-PBMV and MVR groups, respectively. Results: The 2 groups were homogenous in preoperative variables such as gender, echocardiographic findings, and valve characteristics. Patients in the MVR group were older, with a higher mean New York Heart Association functional class, mean mitral valve area, mitral regurgitation grade, and right ventricular systolic pressure (P = 0.03), and more commonly were in AF. There were 3 in-hospital deaths (all in the MVR group) and 4 during follow-up (3 in the MVR group and 1 in the re-PBMV group). Ten-year survival was significantly higher in re-PBMV vs MVR (96% vs 72.7%, P

Respiratory sensations of eight patients with mitral stenosis in response to i.v. lobeline and 6-min walk before percutaneous mitral valvulotomy (PMV) were 'being short of breath', pressure in chest, tracheo-bronchial irritation, a desire to cough, persistent dry cough, chest pain and were qualitatively similar amongst 75% (P=0.005) of the patients. A week after PMV lobeline evoked similar sensations but the threshold dose decreased from 32.4+/-3.8 to 24.1+/-3.2 microg/kg (P=0.001) and pulmonary artery wedge pressure (PAwP), signifying reduction in pulmonary congestion, from 23.1+/-1.4 to 14.3+/-3.4 mm Hg (P0.001). Distance walked in 6 min increased from 217+/-58 to 319+/-51.6m; and mitral valve area from 0.63+/-0.01 to 1.43+/-0.26 cm(2) (P0.001). A fall in lobeline-sensation threshold dose indicated reduction in pulmonary congestion and stimulus to juxtapulmonary/J (or pulmonary C fibre) receptors which suggests that they had contributed to the respiratory and viscerosomatic symptoms seen before PMV.

Objective: Percutaneous balloon valvulotomy (PBV) is the procedure of choice for the treatment of valvular pulmonary stenosis (PS) with similar results comparable to surgical valvotomy but less invasive. . Methods and Results: Twenty-seven consecutive patients with PS being evaluated for PBV were enrolled in the study. Peak instantaneous transvalvular gradient, right ventricle (RV) diameter, mean atrial pressures, RV systolic pressure (RVSP), pro-brain natriuretic peptide (proBNP) levels significantly decreased immediately after PBV. Regarding heart rate variability (HRV) parameters, mean HR (heart rate), LF (low frequency) day and night, LF/HF day and night significantly decreased and standard deviation of all NN intervals (SDNN), root mean square of successive differences (RMSSD), P number of NN intervals that differed by more than 50 ms from adjacent interval divided by the total number of all NN intervals (PNN50), HF (High frequency) day and night significantly increased 1 day after PBV and these changes were shown to be preserved at the first month. The increase in SDNN was correlated with the decrease in right atrial pressure (RAP) (r =−0.5, P = 0.04); the increase in standard deviation of the 5-minute mean RR intervals (SDANN) was correlated with the decrease in proBNP (r =−0.4, P = 0.03). Conclusions: Sympathetic overactivity and increased proBNP levels were associated with the symptomatic status of patients with PS. Associated with a decrease in atrial pressures and proBNP levels, PBV yielded a decrease in adrenergic overactivity in the patients with PS.

Objective This study was conducted to determine whether it was feasible to increase the diameter of smaller great saphenous veins (GSVs) in preparation for possible bypass and whether such a conditioned conduit could be used with reasonable patency. Methods Twenty-five patients (26 cases: 24 peripheral arterial occlusive disease, 2 popliteal aneurysms) with GSV diameters between 2 and 3 mm underwent in situ GSV valvulotomy and were observed for 3 months. After GSV dilation to >3 mm for below-knee revascularization and >3.5 mm for above-knee revascularization, arterial bypass surgery was performed with the valvulotomized GSV. Results Adequate GSV diameter was reached in 20 cases (77%). Arterial bypass surgery using valvulotomized GSV was performed an average 131 days (range, 64-373 days) after valvulotomy in 16 patients (61.5%). No deaths, amputations, or aneurysms occurred 2 years after surgery. At 1 and 2 years, primary patency was 81% ± 9.8% and 69% ± 11.8%, respectively, and secondary patency was 87% ± 8.3% and 75% ± 11%, respectively. Conclusions Valvulotomy can be used to expand small-diameter GSV for lower extremity arterial bypass.

Due to the relative rarity of the lesion and the complexity of patient selection and the intervention itself, current numbers of reported cases are limited to approximately two dozens. The first publication worldwide was issued in 2002 by Tulzer et al. [1] from Children’s Heart Center Linz, describing a successful valvulotomy of the pulmonary valve, performed in a fetus with heart failure at 28 weeks of gestation. Following the procedure significant growth of the tricuspid valve and the right ventricle was observed. The neonate was delivered at 38 weeks with a RV suitable for biventricular repair leading the authors to the conclusion that in utero pulmonary valvulotomy is feasible and may change the natural history of the condition in affected fetuses with PA/IVS [1]. In 2006 another successful intervention was reported by Galindo et al. [2] performed in a fetus with critical PS-IVS and heart failure at 25 weeks of gestation. After the procedure a significant improvement in fetal hemodynamics was seen up to 34 weeks, when a significant restenosis with signs of circulatory failure leads to premature delivery of the baby and an immediate postnatal valvuloplasty provided a biventricular repair for the baby [2].

Rheumatic mitral stenosis remains a common mitral valve disorder in the developing world. Percutaneous Mitral Valvotomy is an important therapy for rheumatic mitral stenosis. This chapter will review the critical role that echocardiography plays in the diagnosis, assessment of suitability and guidance of percutaneous mitral valvotomy.

Symptomatic mitral stenosis (MS) develops in 7% to 21% of patients after percutaneous mitral balloon valvotomy (PMV). Treatment options for these patients are surgical mitral valve replacement (MVR) or repeated PMV. However, no comparisons were made between these 2 procedures regarding long-term outcome. This retrospective study compares the long-term outcome of 888 patients with symptomatic MS after MVR or repeated PMV who underwent PMV from April 1988 to December 2003. Thirty-two patients subsequently underwent repeated PMV, and 59 patients underwent MVR for symptomatic MS. Mean follow-up was 85 +/- 43 months with a maximum follow-up of 15 years. Patients with MVR have more unfavorable clinical characteristics, including a higher incidence of atrial fibrillation and severe mitral regurgitation. Event-free survival was similar between the 2 groups up to 40 months after the procedure; 3-year event-free survival rates were 96.6% for MVR patients and 90.0% for repeated PMV patients (p = 0.215). However, after 40 months, the outcome was more favorable for MVR. Comparing MVR versus PMV, 6-year event-free survival rates were 93.0% versus 75.9% (p = 0.036), and 9-year event-free survival rates were 90.4% versus 36.0% (p0.001). In conclusion, the long-term outcome of patients with symptomatic MS after previous PMV was more favorable after MVR than after repeated PMV. These data suggest that MVR may be the preferred mode of therapy in patients with unfavorable valve morphologic characteristics and no co-morbid disease.

Despite being one of the most common congenital cardiac abnormalities, the treatment of critical left ventricular outflow tract obstruction (LVOTO) in the neonate and infant remains a significant challenge. Critical LVOTO in the neonate and infant includes continuous and diverse spectrum of anatomic diagnoses ranging from hypoplastic left heart complex to isolated aortic valvular stenosis with otherwise normally formed left heart structures. Depending on related anatomic features, there are multiple single ventricle and biventricular management strategies available for patients with critical LVOTO; all of which carry significant risk of death and requirement for future interventions. Because of the wide array of morphologic lesions and physiologic manifestations, application of the currently available published data to guide decision making in the individual patients can be challenging. Therefore, the aim of this review is to describe the different therapeutic strategies that can be applied to neonates presenting with critical LVOTO taking into consideration each patient's unique physiologic and anatomic findings.

To investigate the value of transoesophageal echocardiography in the assessment of commissural morphology and prediction of outcome after balloon mitral valvotomy (BMV).Prospective study.Tertiary cardiac referral centre.72 consecutive patients (mean age 61.3 years, range 38-89 years) referred for BMV.Transoesophageal echocardiography was performed immediately before BMV and the mitral commissures were scanned systematically. Anterolateral and posteromedial commissures were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2). Calcified commissures usually resist splitting and scored 0. Scores for each commissure were combined giving an overall commissure score for each valve of 0-4, higher scores reflecting increased likelihood of commissural splitting. Valve anatomy was also graded by the method of Wilkins et al, which does not include commissural assessment.Patients were divided into outcome groups: A (good) and B (suboptimal). "Good" was defined as final valve area1.5 cm2 with a25% increase in area and absence of severe mitral regurgitation judged by echocardiography.Valve area increased from a mean (SD) of 1.1 (0.28) cm2 to 1.8 (0.46) cm2. Commissure scores were higher in group A than in group B (p0.01), scoresor = 2 predicting a good outcome with positive and negative accuracy of 67% and 82%, respectively (p0.001). Commissure score was the strongest independent predictor of outcome.Transoesophageal echocardiographic assessment of commissural morphology predicts outcome after BMV, adding significantly to the Wilkins score.

This study compared immediate with long-term results of mitral balloon valvotomy (MBV) in patients who underwent MBV as an initial procedure versus those who underwent repeat MBV. Fifty-six patients who were a mean age of 28 +/- 8.8 years (group A) and had mitral restenosis after surgical or balloon commissurotomy underwent MBV and were compared with 524 patients who were a mean age of 31 +/- 11 years (group B) and underwent MBV as an initial procedure. Prospective data obtained included demographic, hemodynamic, echocardiographic, and clinical follow-up for 0.5 to 15 years after MBV. No deaths or technical failure were encountered after MBV. Mitral regurgitation2/4 occurred in 1 patient (2%) in group A and in 9 patients (2%) in group B (p = 0.24). Fifty-two of 56 patients (93%) in group A had good immediate results (mitral valve areaor=1.5 cm(2), mitral regurgitation2/4), as did 504 of 524 patients (96%) in group B (p = 0.4). Actuarial values for freedom from restenosis at 10 years were 58 +/- 7% for group A versus 69 +/- 3% for group B (p = 0.18). Ten-year event-free survival rate was 54 +/- 7% for group A versus 80 +/- 3% for group B (p0.005). The predictors of event-free survival were age (p = 0.003), echocardiographic score (p0.0001), and baseline atrial fibrillation (p = 0.01). In conclusion, MBV is safe and provides good immediate results in patients who have restenosis. Long-term results are inferior compared with de novo mitral stenosis but is still satisfactory. More than 50% of patients remained improved at 10 years, thus enabling the operation or reoperation to be deferred.

To assess the safety, efficacy, and long term results of mitral balloon valvotomy (MBV) for rheumatic mitral stenosis in children and adolescents in comparison to adults.The results of 468 patients with mitral stenosis who underwent successful MBV and were followed up for 0.5-13 years were analysed. Patients were divided according to age at the time of MBV into group 1 consisting of 84 patientsor = 20 years of age (children and adolescents) and group 2 that included 384 patients, age20 (adults).Patients in group 1 had a lower mitral echo score (mean (SD) 7.5 (1.3) v 8 (1.1), p0.001), smaller Doppler mitral valve area (MVA) (0.84 (0.17) v 0.92 (0.18) cm2, p0.001), and higher Doppler mitral valve gradient (15.0 (5.3) v 12.7 (4.5) mm Hg, p0.001) than group 2. Immediately after MBV group 1 had larger MVA, whether measured by Doppler (2.0 (0.30) v 1.96 (0.28) cm2, p0.05) or by catheter (2.0 (0.59) v 1.8 (0.52) cm2, p0.001), and similar complication rates, compared to group 2. After a mean follow up of 5 (3.5) years there was no significant difference between groups 1 and 2 in the incidence of restenosis (14.3% v 16.1%, NS). Event-free survival rates at 5, 10, and 12.5 years were 93%, 79%, and 79% for group 1 and 94%, 90%, and 84% for group 2 (p = 0.18).MBV is safe and effective in children and adolescents with rheumatic mitral stenosis. It provides better immediate results than in adults and excellent long term results that are comparable to those seen in adults.

Aims We assessed early and long-term pulmonary function changes after percutaneous balloon mitral valvotomy (PBMV). Methods and results Mitral area, lung function, and exercise capacity were evaluated before, immediately after, and 3 months, 6 months, and 12 months after successful PBMV in 24 patients. PBMV resulted in a significant and sustained increase in mitral area, from 1.0 ± 0.1 to 1.9 ± 0.1 cm 2 (p = 0.001) [mean ± SD], with a progressive increase in exercise tolerance at 6-month follow-up (from 22.6 ± 1.4 to 28.2 ± 1.2 mL/kg, p = 0.0001). An immediate drop in the diffusing capacity of the lung for carbon monoxide (D lco ) was observed (from 26.7 ± 1.5 to 22.3 ± 1.1 mL/min/mm Hg, p = 0.0002) after PBMV, followed by a gradual regression to baseline values at 3 months; at 1 year, the D lco remained elevated (27.3 ± 6.3 mL/min/mm Hg). The flow in the small airways was reduced at baseline, and there was no significant change during follow-up. Conclusions PBMV produces an initial decrease in D lco , suggesting a reduction of pulmonary congestion. During follow-up, the regression to the initial lung diffusion values despite a sustained hemodynamic improvement suggests that some irreversible interstitial changes were present. In patients with mitral stenosis, an impairment of lung function parameters suggests that PBMV must be performed early, even if patients have few symptoms.

The purpose of this study was to evaluate the possibility of using high-intensity focused ultrasound (US), or HIFU, to create lesions in cardiac valves in vitro. Calf mitral valves and aortic valves were examined. Focused US energy was applied with an operating frequency of 4.67 MHz at a nominal acoustic power of 58 W for 0.2, 0.3 and 0.4 s at 4-s intervals. Mitral valve perforation was achieved with 20.8 3.7 exposures of 0.2 s, 15.4 2.1 exposures of 0.3 s or 11.2 2.3 exposures of 0.4 s. Aortic valve perforation was achieved with 13.3 2.4 exposures of 0.2 s, 10.3 2.2 exposures of 0.3 s or 8.4 1.8 exposures of 0.4 s. The mean diameter of the perforated area was 1.09 0.11 mm. The lesions were slightly discolored and coagulation of tissue around the perforation was observed. HIFU was successful in perforating cardiac valves. With further refinement, HIFU may prove useful for valvulotomy or valvuloplasty. (E-mail: otsukaryo@aol.com) © 2005 World Federation for Ultrasound in Medicine & Biology.

Objective: The most appropriate management of aortic stenosis (AS) in children remains controversial. The purpose of this study was to determine the outcome following open valvotomy for AS in children. Methods: Ninety-seven consecutive, unselected, children (mean age 3.2 ^ 3.6 years, 1 day‐15 years) underwent an open valvotomy for criticalOna 36U or severeOna 61U AS between 1979 and 2000 in Southampton. Twenty-six were neonates (1‐31 days), 27 were infants (1‐12 months) and 44 were older children (1‐15 years). Mean followup was 10 ^ 5.4 years, 1 month‐21.9 years. Results: Two neonates died early giving an overall operative mortality of 2.1% (7.7% for the neonates and 0% for infants and older children). The mean aortic gradient was reduced from 76 to 24.5 mmHgOP , 0:0001U: Residual or recurrent AS occurred in 17 patients and severe aortic regurgitation in eight patients. Kaplan‐Meier 10-year freedom from residual or recurrent AS was 83.1 ^ 4.7% and from severe aortic regurgitation was 95.3 ^ 2.7%. Twenty-five patients required an aortic re-operation or re-intervention, 18 of whom had an aortic valve replacement (AVR) (mean valve size 21.8 ^ 0.9 mm, range 21‐25 mm). Ten-year freedom from any aortic re-operation or re-intervention was 78.4 ^ 5.2% and from AVR was 85.1 ^ 4.6%. There were ten late deaths. Overall 10year survival, including hospital mortality, was 90.2 ^ 3.1% (69.7 ^ 9.7% for the neonates, 92 ^ 5.4% for the infants and 100% for older children,OP , 0:0001U: Ten-year survival for children with isolated ASOna 69U was 100% and for those with associated cardiovascular problemsOna 28U was 67.3 ^ 8.9%OP , 0:0001U: All survivors are in New York Heart Association functional class I. Conclusions: Open valvotomy remains the gold standard in the management of AS in neonates, infants and older children. It is associated with low operative mortality and provides lengthy freedom from recurrent AS and regurgitation. Re-operations are common but if AVR is required, implantation of an adult-sized prosthesis is usually possible. There is a late death-hazard for those with severe associated lesions, but the survival prospects for the patients with isolated AS are excellent. q 2001 Elsevier Science B.V. All rights reserved.

Objective: Valvotomy and the autograft procedure are the most common surgical treatment options for children with valvular aortic stenosis. We evaluated the results of these surgical procedures in our institution. Methods: Retrospective analysis was done of all patients presenting with aortic stenosis and operated upon before the age of 18. In 11 patients a valvotomy was performed and in 36 an autograft procedure. Results: There was no hospital mortality. Mean follow-up in the valvotomy group was 4.8 years (SD 3.3), in the autograft group 4.5 years (SD 3.3). During follow-up one patient died suddenly 2 months after valvotomy. Two patients in the autograft group died (not valve-related). After valvotomy three patients underwent a balloon valvotomy, in one followed by an autograft procedure and one patient had a repeat valvotomy. In the autograft group one patient was reoperated for severe aortic regurgitation and moderate pulmonary stenosis. At last echocardiography after valvotomy (eight remaining patients) in only two patients (25%) no aortic stenosis or regurgitation was present. In the remaining six patients aortic stenosis is mild in two and moderate in three, including one with moderate aortic regurgitation. In one patient without stenosis, moderate aortic regurgitation was seen. No pulmonary stenosis or regurgitation is present. Echocardiography after autografting (33 remaining patients) showed no aortic stenosis. Aortic regurgitation was mild in seven patients, moderate in two, severe in one. Pulmonary stenosis was present in two patients (16%). Pulmonary regurgitation was mild in three patients and moderate in one. Conclusions: In selected patients with valvular aortic stenosis who are beyond infancy, valvotomy may be adequate and may postpone further surgery for a significant length of time. After valvotomy the main problem is residual aortic stenosis while after autografting a shift occurs to aortic regurgitation and problems related to the pulmonary valve. Careful clinical and echocardiographic follow-up is therefore warranted in young patients after the autograft procedure. q 2001 Elsevier Science B.V. All rights reserved.

OBJECTIVE—To evaluate the significance of commissural calcification, identified by transthoracic echocardiography, on the haemodynamic and symptomatic outcome of mitral balloon valvotomy. METHODS—Commissural calcification was graded from 0-4 using parasternal short axis transthoracic views. The morphology of the mitral valve was also assessed using the Massachusetts General Hospital echo score. SETTING—A tertiary cardiac centre in Scotland. PATIENTS—300 patients were studied, 85 retrospectively and 215 prospectively. Mean (SD) age was 59.8 (12.7) years, range 13 to 87; 30% had been judged unsuitable for surgery. Median echo score was 6.8 (3.0), range 2-16. MAIN OUTCOME MEASURES—Immediate increase in mitral valve area and in New York Heart Association functional class 1-3 months after balloon valvotomy. RESULTS—On univariate and multivariate analysis, commissural calcification grade was a significant predictor of achieving a mitral valve area of > 1.50 cm2 without severe mitral reflux. Its influence was greatest in patients with an echo score ⩽ 8: those with commissural calcification grade 0/1 had significantly greater improvement in valve area and symptom status than those with grade 2/3; the proportions of patients achieving a final valve area of > 1.50 cm2 were 67% and 46%, respectively (p 8, the influence of commissural calcification was smaller and not significant. CONCLUSIONS—Commissural calcification as assessed by transthoracic echocardiography is a useful predictor of outcome in patients with otherwise "good" valves (echo score ⩽ 8). Calcification of one commissure or more predicts a less than 50% probability of achieving a valve area above 1.50 cm2 and is an indication for valve replacement in those who are suitable for surgery. Keywords: mitral balloon valvotomy; commissure calcification

Purpose: To report the early results of endovascular in situ saphenous vein bypass (EISVB) using side branch coil occlusion. Methods: Between September 1997 and November 1998, 25 patients (15 men; mean age 70.9 years, range 53–85) with lower limb ischemia were treated with endovascular femorodistal bypass. The saphenous vein was prepared using retrograde valvulotomy and endoscopic cannulation with coil occlusion of the side branches. Duplex graft surveillance was performed at 1, 3, 6, and 12 months. Results: The 25 EISVB procedures consisted of 15 femorodistal popliteal, 7 femorotibial, 2 femoroperoneal, and 1 femorodorsalis pedis in situ saphenous vein reconstructions. Mean operative time was 202 ± 40 minutes, mean number of side branch coils per case was 5.1 ± 1.3, and mean number of incisions per case was 2.9 ± 0.6. Mean hospital length of stay (LOS) was 35 ± 13 hours (1.4 ± 0.6 days); 19 (76%) patients were discharged on the first postoperative day. Short-term follow-up (mean 6.2 months, range 2–15) was notable for 2 graft thromboses and 1 graft stenosis; primary and secondary patency rates were 88% and 92%, respectively. Three asymptomatic, persistent arteriovenous fistulas discovered on routine duplex were ligated in the outpatient setting. Only 1 (4%) minor wound complication was encountered. Conclusions: EISVB provides early patency comparable to conventional in situ infrainguinal bypass. Its distinct advantages, however, are the ability to minimize incision length with resultant reductions in wound-related complications, hospital LOS, and recovery time. EISVB promises to be a useful adjunct in the approach to peripheral vascular insufficiency.

Objective To evaluate prospectively mitral stenosis in pregnancy with emphasis on women with persistent symptoms. Setting King Edward VIII Hospital, a tertiary referral obstetric unit. Participants One hundred and twenty-eight consecutive women with mitral stenosis. Demographics The mean age was 27 years and 38 women (30%) were primigravidae. Seventy-eight (61%) women had their first cardiac evaluation in the third trimester. Fifty-four women (42%) of these women had mitral stenosis diagnosed for the first time in the index pregnancy. Twenty-nine (23%) had a previous mitral valvulotomy. Nineteen women (15%) developed hypertension during pregnancy, 10 of whom had pre-eclampsia. Sixty-three women (49%) had a mitral valve area of ≤ 1.2 cm2 with 11 having critical mitral stenosis (mitral valve area ≤ 0.8 cm2). Atrial fibrillation was present in 12 women. Most women (87%) required medical therapy to control the heart rate. Outcome in persistent symptomatic women Intervention was considered in 37 women (29%) who remained symptomatic, 11 (9%) of whom had a calcified mitral valve. The remaining 26 women were scheduled for balloon mitral valvulotomy during pregnancy, 20 of whom had balloon mitral valvulotomy with good effect (16 antepartum; 4 postpartum). In seven women, scheduled balloon mitral valvulotomy was not performed because of advanced preterm labour (n= 5), fetal distress (n= 1) and preterm labour with fetal distress (n= 1). These seven, together with the 11 with calcific mitral stenosis, were managed conservatively with good outcome. Maternal complications Fifty-one percent had maternal complications, the majority occurring at their initial admission to hospital. Pulmonary oedema was the most frequent. Multiple logistic regression analysis showed that the severity of stenosis assessed by measurement of the mitral valve area by echo-Doppler was the most powerful predictor of maternal pulmonary oedema. The other factors were late antenatal presentation, presence of symptoms prior to the index pregnancy and diagnosis of cardiac disease for the first time in the index pregnancy. Conclusion Despite serious disease, women with persistent symptoms treated either by balloon mitral valvulotomy where feasible, or conservatively with close noninvasive monitoring, had a satisfactory fetal and maternal outcome.

Objectives The present study was performed to determine the outcome of emergent balloon mitral valvotomy (BMV) in patients with refractory pulmonary edema. Methods Of 1776 patients undergoing BMV between 1986 and 2004, 17 patients presented with refractory pulmonary edema to medical treatment underwent emergent BMV. Results Age (mean+/−SD) 29+/−10.5 years, incidence of atrial fibrillation (30%), pulmonary artery systolic pressure (PAsP) (79+/−17 mm Hg), mitral valve (MV) score (8.6+/−2.9) and MV area (0.7+/−0.19 cm 2 ). After the procedure, minimal mitral regurgitation occurred in 20%, and mortality rate was 11%. Follow-up of 4.5+/−2 years was available in 14 of 15 survivors, of whom 11 were asymptomatic. The gain in MV area and the decrease in transmitral gradient (TMG) and PAsP persisted during the follow-up period. Conclusion Emergent BMV is safe and feasible in patients with symptomatic mitral stenosis and severe pulmonary edema refractory to medical therapy. Survivors have excellent clinical and hemodynamic status at follow-up.

Congenital ventricular aneurysm (CVA) is a rare, poorly understood and potentially lethal cardiac anomaly. We report a neonatal case, remitted to our hospital due to a cardiogenic shock. Echocardiographic study revealed a severe aortic stenosis and a giant left ventricular aneurysm. Surgical intervention was carried out with extracorporeal circulation support, but without cardiac arrest, achieving aortic valvulotomy and aneurismal resection. The postoperative course was uneventful during the first 24 h, but on the second day, the patient presented a sudden unexpected cardiac arrest, not responding to the resuscitation manoeuvres.

Mitral valve stenosis is the most frequently occurring acquired heart failure. In pregnancy it can result in severe problems to both mother and unborn infant. There are important changes in haemodynamics during pregnancy burdening maternal circulation. Normally, there is an evident increase of blood volume and cardiac output. Mitral valve stenosis prevents the left ventricle from filling with blood; this leads on the one hand to pulmonary congestion and on the other hand to reduced cardiac output. Therapeutic options like medical treatment and especially valvulotomy with the Inoue-balloon are described in two cases presented here. We performed emergency valvulotomy in the 23 rd or 33 rd week of pregnancy respectively. While ensuring maximal radiation protection for mother and fetus, valvulotomy of the mitral valve was achieved. Technically the intervention was successful in both cases, but for one woman intrauterine death occurred; she developed a lethal septic shock as a result of her previous poor haemodynamic condition. The other woman could be delivered from a healthy male infant on schedule.

We evaluated the influence of sub valvular pathology (SVP) on the immediate results and follow up events of Inoue Balloon Mitral Valvotomy (IBMY) in 206 patients with severe SVP (Group I) and compared their outcome with 206 age and sex matched patients selected from the rest of 619 patients having mild/moderate SVP (Group II). Pre-procedure echocardiographic recordings were reviewed and mitral valve morphology was evaluated using U.S. California Score. The severe SVP group had lower mitral valve areas (MVA) (0.7 cm2 vs. 0.8 cm2) and higher mean pulmonary artery pressure (MPAP) (46.3+/-16.9 mmHg vs. 40.7+/-16.25 mmHg) and mean pulmonary capillary wedge pressure (PCWP) (27.5+/-7.3 mmHg vs. 25.7+/-8.0 mmHg) (p0.001). IBMV was done using standard technique. The procedure was technically successful in 192/206 patients (93.2%) in group I and 187/206 (91%) in group II (p=ns). The mean transmitral gradient decreased from 24.8+/-7.6 mmHg to 7.46+/-3.4 mmHg while mean PCWP fell from 27.5+/-7.3 mmHg to 12.2+/-5.6 mmHg and MPAP fell from 46.3+/-16.9 mmHg to 23.6+/-12.2 mmHg (p=0.001). MVA increased from 0.7+/-0.2 cm2 to 1.7+/-0.4 cm2 (p=0.001). Severe mitral regurgitation (MR) occurred in 2 patients out of which one patient, who had associated coronary artery disease, died post operatively, and moderate MR occurred in 8 patients. The results achieved in patients with severe SVP were not statistically different from those with mild/moderate SVP. The benefits achieved immediate post IBMV were sustained in 184 patients with severe SVP who were available for follow up at a mean duration of 15.2 months (range 3 months to 51 months). Thus IBMV is safe and effective in patients with severe SVP. This group of patients with severe SVP are more hemodynamically deranged pre-BMV and also achieve better hemodynamic benefit compared to those with mild/moderate SVP. Severe SVP does not have any adverse effect either on immediate results (success/occurrence of MR) or on intermediate term follow up.

Background: Percutaneous transseptal mitral valvotomy (PTMV) has been established as an alternative to surgery in the treatment of mitral stenosis. Aim: To review our experience in the first 200 attempted PTMV procedures in patients with mitral stenosis, and the short and medium term follow-up. Methods: PTMV was attempted on 200 occasions in 189 patients with significant mitral stenosis between May 1988 and May 1994. There were 156 females and 33 males, mean age 53.5 years (range 14 to 83 years). Six patients were pregnant at the time of the procedure. Results: Valve split was achieved at the initial attempt in 183/189 procedures (97%). Clinical improvement of at least one New York Heart Association (NYHA) functional class was achieved in 172/189 patients (91%). The mean mitral valve gradient (mean±SD) decreased from 11.5±5.1 mmHg to 4.9±4. 1 mmHg, mean cardiac output rose from 3.9±1. 1 L/minute to 4.4±1.4 L/minute and mean calculated mitral valve area increased from 1.0±0.3 cm 2 to 2.1±0.9 cm 2 . Ten patients developed clinically significant mitral incompetence requiring surgical mitral valve replacement. There were two transient cerebral embolic events. Small atrial septal defects were detected echocardiographically in 42 patients, but none has been a clinical problem. There were no early deaths; there were 11 late deaths, four of which were non-cardiac. Twenty patients have had repeat PTMV for re-stenosis, four to 67 months after the first. Conclusions: PTMV provides significant haemodynamic and clinical improvement with low risk and should be considered the treatment of choice in patients with mitral stenosis.

A critical step in the performance of in-situ bypass is to produce incompetence of the venous valves. Currently, there are several commercially available valvulotomes designed to fulfill this task. The purpose of the present work was to evaluate, in an ex-vivo system simulating an in-situ bypass, the efficiency of valve cutting and the degree of luminal damage produced by four of the most commonly used instruments (Reusable LeMaitre, Expandable LeMaitre, Gore Eze-Sit, and Mills). Cryopreserved cadaveric veins (2.5-6 mm diameter) were mounted in a perfusion chamber and submerged in Ringer's lactate. The same buffer containing 0.6% papaverine was infused at a pressure of 100 mm Hg through a catheter inserted into the proximal end of the vein. The valvulotome to be evaluated was introduced through the distal end of the vein, advanced beyond the most proximal valve and withdrawn at a rate similar to that used clinically through the full length of the vein. The vein was opened longitudinally and the efficacy of valve cutting (expressed as percent of individual valve cut) and presence of luminal damage were carefully evaluated by means of a dissecting microscope. Thirty-three valves in seven segments of veins (mean size 4.35 ± 0.86 mm) were tested with the Reusable LeMaitre valvulotome. The percent of valvular cutting was 29.9 ± 33.4. The Expandable LeMaitre valvulotome was tested in 22 valves contained in five segments (vein diameter 4.07 ± 1.04 mm) and the percent of valvular cutting was 89.2 ± 15.7. The Gore Eze-Sit valvulotome produced a 80.6 ± 25.5% of cutting in the 32 valves contained in the seven venous segments tested (vein diameter 3.67 ± 0.42 mm). The Mills valvulotome was tested in five segments of vein containing 20 valves and there was a 82.1 ± 24.0% of valve cutting after valvulotomy (diameter 3.67 ± 0.57 mm). Statistical analysis demonstrated a significant difference with less cutting (p < 0.0001) when the results of the Reusable LeMaitre valvulotome were compared against each of the other three valvulotomes. Luminal damage was detected in one instance after use of the Mills valvulotome. The Expandable LeMaitre, Gore Eze-Sit, and Mills valvulotomes demonstrated consistent efficacy in valve cutting, the Mills valvulotome producing injury to the wall in one occasion. The Reusable LeMaitre valvulotome gave significantly poorer results, most likely related to failure of engagement of the circular blade. Because of the presently demonstrated safety and efficacy, and avoidance of need for long skin incisions, the Expandable LeMaitre and Gore Eze-Sit are the most promising of the four tested valvulotomes.

Objectives. The present study was performed to determine the outcome of emergent balloon mitral valvotomy (BMV) in patients with cardiac arrest, pulmonary edema or cardiogenic shock.Background. In India, many patients with mitral stenosis present in critical condition. They have high mortality despite surgical relief. The role of BMV in such patients is ill-defined.Methods. Of 558 patients undergoing BMV between January 1993 and December 1994, 40 presented with cardiogenic shock, cardiac arrest or pulmonary edema refractory to medical treatment and underwent emergent BMV (group I). Elective BMV was performed in the remaining 518 patients (group II).Results. Age ([mean ± SD] 40 ± 13 vs. 31 ± 9 years, p < 0.05), incidence of atrial fibrillation (35% vs. 11%, p < 0.05), pulmonary artery systolic pressure (PAsP) (64 ± 14 vs. 51 ± 12 mm Hg, p < 0.001) and mitral valve (MV) score (7.4 ± 1.2 vs. 6.4 ± 1, p < 0.001) were higher and MV area lower (0.74 ± 0.17 vs. 0.86 ± 0.14 cm2, p < 0.001) in group I patients. After emergent BMV in group I, mitral regurgitation occurred in 15%, and the mortality rate was 35%. Stepwise logistic regression analysis identified MV score ≥8 (p = 0.008), PAsP ≥65 mm Hg (p = 0.023) and cardiac output ≤3.151 liters/min (p = 0.001) as significant predictors of a fatal outcome. Follow-up of 1 to 16 months (median 8) was available in 20 of 26 survivors in group I, of whom 15 were asymptomatic. The gain in MV area and the decrease in transmitral gradient and PAsP obtained immediately after BMV persisted during the follow-up period.Conclusions. Emergent BMV is feasible in critically ill patients. In-hospital survivors have excellent clinical and hemodynamic status at intermediate follow-up.

Objectives: Since 1990, transcatheter pulmonary valvotomy has become an alternative to surgical valvotomy in the management of neonates and infants with pulmonary atresia and intact ventricular septum. We sought to determine whether right ventricular growth after transcatheter pulmonary valvotomy is commensurate with body growth. Methods: Laser or radiofrequency-assisted balloon valvotomy was attempted in 12 neonates and infants with pulmonary atresia and intact ventricular septum. Tricuspid and mitral valve dimensions were measured retrospectively on the cross-sectional echocardiograms performed before the procedure and during follow-up. Z-values were used to standardize tricuspid valve dimensions with body size. Results: The atretic pulmonary valve was successfully perforated and dilated in nine of 12 patients. Five of these nine patients required additional transcatheter or surgical procedures to augment the pulmonary blood flow. Of six survivors, five are regularly followed up with a median follow-up of 60 months (range 37 to 68 months). All five have two-ventricle circulation, two of the five patients requiring surgical enlargement of the right ventricular outflow tract with or without closure of the atrial septal defect. Echocardiographic tricuspid valve dimensions and Z-values before transcatheter valvotomy tended to be smaller in the patients who died than in the survivors. In the survivors, the absolute tricuspid valve dimensions increased after valvotomy but the Z-values tended to decrease or stayed constant. Conclusions: Transcatheter valvotomy is a good alternative to surgical valvotomy in patients with pulmonary atresia and intact ventricular septum. Two-ventricle circulation can be achieved despite subnormal right ventricular growth. (J Thorac Cardiavasc Surg 1998;115:1055-62)

Background Thromboembolism after percutaneous balloon mitral valvotomy (PBMV) has been attributed to dislodement of preexisting thrombus during transseptal puncture and instrumentation of the left atrium. The occurrence of thromboembolic events after PBMV in the absence of demonstrable left atrial thrombus before PBMV suggests that thrombus might form during the procedure. Spontaneous echo contrast (SEC) is a swirling pattern of blood echogenicity that is a marker of blood stasis in the left atrium. Exacerbation of left atrial SEC during PBMV may be indicative of an increased thromboembolic risk. Methods Transesophageal echocardiography was performed during PBMV in 20 patients with mitral stenosis. Grades of severity of left atrial SEC [0 (nil) to 4+ (severe)] were allocated before and after each balloon inflation. Results Before PBMV, SEC was present in 17 patients. New SEC or increased severity of SEC was observed during 49 of 56 balloon inflations. SEC was unchanged after six deflations, decreased after 14 deflations, and disappeared after 36 deflations. The mean times to onset and dissipation of SEC after balloon inflation and deflation were 3.1 ± 1.5 and 3.9 ± 1.6 seconds, respectively. After successful PBMV, SEC was unchanged in three patients, decreased in one, and resolved in 13. Conclusions SEC is a dynamic and acutely reversible phenomenon that is highly sensitive to changes in left atrial hemodynamic conditions. Left atrial blood stasis induced by balloon inflation may promote thrombogenesis during PBMV. (Am Heart J 1998;135:609-13.)