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Growing evidence have shown cardiac extracorporeal shock wave therapy (ESWT) improve clinical symptoms and left ventricular ejection fraction (LVEF) for patients with end-stage diffuse coronary artery disease (EnD-CAD) unsuitable for coronary interventions. However, little is known whether cardiac ESWT remains effective on symptomatic relief and improvement of LVEF for the EnD-CAD patients with end-stage renal disease (ESRD).

Percutaneous transvenous mitral commissurotomy (PTMC) was performed in 219 patients with symptomatic, severe rheumatic mitral stenosis. There were 59 men and 160 women, aged 19 to 76 years (mean 43). Pliable, noncalcified valves were present in 139 (group 1), and calcified valves or severe mitral subvalvular lesions, or both, in 80 patients (group 2). Atrial fibrillation was present in 133 patients (61%) and 1+ or 2+ mitral regurgitation in 59 (27%). Technical failure occurred with 3 patients in our early experience. There was no cardiac tamponade or emergency surgery. The only in-hospital death occurred 3 days after the procedure in a group 2 premoribund patient in whom last-resort PTMC created 3+ mitral regurgitation. Mitral regurgitation appeared or increased in 72 patients (33%); 3+ mitral regurgitation resulted in 12 patients (60%). There were 3 systemic embolisms. Atrial left-to-right shunts measured by oximetry developed in 33 patients (15%). immediately after PTMC, there were significantly reduced (p = 0.0001) left atrial pressure (24.2 [+ or -] 5.6 to 15.1 [+ or -] 5.1 mm Hg), mean pulmonary artery pressure (39.7 [+ or -] 13.0 to 30.6 [+ or -] 10.9 mm Hg) and mitral valve gradient (13.0 [+ or -] 5.1 to 5.7 [+ or -] 2.6 mm Hg). Mitral valve area increased from 1.0 [+ or -] 0.3 to 2.0 [+ or -] 0.7 cm[sup.2] (p = 0.0001) and cardiac output from 4.4 [+ or -] 1.4 to 4.7 [+ or -] 1.2 liters/min (p [is not greater than] 0.01). The results mirrored clinical improvements in 209 patients (97%). Multivariate analysis showed an echo score [is greater than]>8, and valvular calcification and severe subvalvular lesions as independent predicters for suboptimal hemodynamic results. The cardiovascular event-free survival rate for group 1 was 100% up to 42 months; that for group 2 was 91% at 12 months, and held at 76% from 24 to 31 months. PTMC is safe, achieves good immediate and long-term results and is the procedure of choice in selected patients with mitral stenosis. (Am J Cardiol 1991;67:854-862), Mitral valve stenosis is a pathologic narrowing of the mitral valve, which directs blood flow between the left atrium and ventricle in the heart. It has traditionally required surgery in serious cases, but an alternative treatment known as percutaneous transvenous mitral commissurotomy (PTMC) has recently been developed. In this procedure, a balloon is inserted into the mitral valve and inflated to open the valve. It has been shown to be safe and initially effective in selected patients. Less is known about its long-term effectiveness. This study examined the short- and long-term results of PTMC in 219 patients with mitral stenosis, with patients divided into two groups: group I (139 patients) having noncalcified, pliable valves, while group II (80 patients) had calcified valves or other valve lesions. All PTMC procedures were performed by the same person in the same facility. Results showed that the valve was initially dilated successfully in 216 (99 percent) of the patients. Immediate improvements as measured by hemodynamic (blood flow) evaluation were seen in 204 patients and at the end of two weeks, 209 (97 percent) had noticeable improvement of symptoms. Complications were minimal. Long-term results were obtained for 215 of the patients at the end of six months, and up to 42 months in 136 group I patients and up to 31 months in 79 group II patients. Cardiovascular event-free rates for group I were 100 percent the entire time, and 92, 91 and 86 percent in group II at 6, 12 and 18 months, respectively. These results indicate that PTMC is not only safe and effective in the short-term treatment of mitral valve stenosis in selected patients, it also appears to be highly effective in the long run. (Consumer Summary produced by Reliance Medical Information, Inc.)

To study the relation between Plasma atrial natriuretic peptide (ANP) and cardiac pressure, and to assess the pathophysiologic significance of ANP in water and electrolyte metabolism, the changes in plasma levels of ANP and arginine vasopressin (AVP) were examined in 11 pattern with mitral stenosis who underwent permbneous transvenous mitrald valvuplasty and compared with the changes in the renin-angiotensin-aldosterone system and renal function. immediately after valvuloplasty, plasma ANP levels decreased significantly with a concomitant decrease in mean pressures in the left atrium, the pulmonary artery and the right atrium. plasma ANP levels decreased tO the normal range in 4 of the 6 patients with normal sinus rhythm, while all 5 patients with atrial fibrillation had higher levels despite a similar degree of decrease in atrial pressure. There were significant positive correlations between plasma ANP levels and the mean left atrial pressure (r = 0.61, p, Atrial natriuretic peptide (ANP) is a substance originally isolated from the human atrium (either of the chambers of the heart that receive blood from the body and lungs prior to delivering it to the ventricles), that has now been purified and synthesized. ANP has effects on sodium and water retention, as well as on blood vessels, and it is possible that it is released in response to increased pressure in the atria, such as could occur during heart failure, when blood is not pumped efficiently. If atrial stretch is significantly involved in increasing ANP levels, then reduction of atrial pressure should decrease them, and this was assessed in 11 patients with faulty mitral valves (the valve between the left atrium and left ventricle) who underwent a corrective procedure. Blood was taken before the procedure known as percutaneous transvenous mitral valvuloplasty (valve surgery or restoration), and at intervals afterward until 24 hours had passed. Blood was assayed for its levels of ANP, AVP (arginine vasopressin, a hormone apparently detected by cells in the atrium), renin, and aldosterone. These latter substances are known to control sodium and water retention, and to reflect renal (kidney) function. Results showed a decrease in the average left atrial pressure, but not the right, after valvuloplasty. ANP levels were elevated in nine patients before the procedure, and dropped to lower than control levels immediately afterward. Although lower, ANP levels remained above normal for the five patients who experienced atrial fibrillation (random, irregular contractions of the atria). Levels of ANP were correlated with left atrial pressure, right atrial pressure, and pulmonary arterial pressure (the artery through which blood flows from the right ventricle to the lungs). AVP levels increased temporarily after valvuloplasty, then returned to the same level as before surgery. Renin and aldosterone levels increased 30 minutes after valvuloplasty, as did measures of renal function. Overall, the results indicate that the heart's atrium responds to a reduction in pressure by reducing ANP secretion, which, in turn, alters water and sodium metabolism. It also appears that atrial fibrillation, or abnormal atrial contraction in itself, can stimulate ANP secretion. (Consumer Summary produced by Reliance Medical Information, Inc.)