RESUMO
BACKGROUND: Although refinements have occurred in coronary angioplasty over the past decade, little is known about whether these changes have affected outcomes. METHODS AND RESULTS: Baseline features and in-hospital and 1-year outcomes of 1559 consecutive patients in the 1997-1998 Dynamic Registry who were having first coronary intervention were compared with 2431 patients in the 1985-1986 National Heart, Lung, and Blood Institute Registry. Compared with patients in the 1985-1986 Registry, Dynamic Registry patients were older (mean age, 62 versus 58 years; P:<0.001) and more often female (32.1% versus 25.5%; P:<0.001). In the Dynamic Registry, procedures were more often performed for acute myocardial infarction (22.9% versus 9.9%; P:<0.001) and treated lesions were more severe (84.5% versus 82.5% diameter reduction; P:<0.001), thrombotic (22.1% versus 11.3%; P:<0.001) or calcified (29.5% versus 10.8%; P:<0.001). Stents were used in 70.5% of Dynamic Registry patients, whereas 1985-1986 patients received balloon angioplasty alone. Procedural success was higher in the Dynamic Registry (92.0% versus 81.8%; P:<0.001) and the rate of in-hospital death, myocardial infarction, and emergency coronary bypass surgery combined was lower (4.9% versus 7.9%; P:=0.001) than in the 1985-1986 Registry. The 1-year rate for CABG was lower in the Dynamic Registry (6.9% versus 12.6%; P:<0.001). CONCLUSIONS: Although Dynamic Registry patients had more unstable and complex coronary disease than those in the 1985-1986 Registry, their rate of procedural success was higher whereas rates of complications and subsequent CABG were lower. Results of percutaneous coronary intervention have improved substantially over the past decade.
Assuntos
Angioplastia Coronária com Balão , Doença das Coronárias/terapia , Doença das Coronárias/etnologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Sistema de Registros , Resultado do TratamentoRESUMO
Mitral balloon valvuloplasty was performed in 14 patients with recurrent mitral stenosis 16.9 +/- 1.8 years (range 6 to 30) after surgical commissurotomy. There were 13 women and 1 man with a mean age of 55 +/- 4 years (range 23 to 73). Mitral balloon valvuloplasty resulted in an increase in mitral valve area from 0.8 +/- 0.1 to 1.7 +/- 0.2 cm2 (p = 0.001), a decrease in mean mitral diastolic pressure gradient from 15 +/- 2 to 7 +/- 1 mm Hg (p = 0.001) and an increase in cardiac output from 3.4 +/- 0.3 to 3.9 +/- 0.3 liters/min (p = 0.03). No deaths, strokes, vascular complications or conduction abnormalities were observed. Mitral regurgitation developed or increased in severity in seven patients (50%). There was no evidence of significant left to right shunt through the atrial septal puncture site after mitral balloon valvuloplasty. A good result (defined as a mitral valve area greater than 1.0 cm2, an increase in mitral valve area greater than 25% and a mean gradient less than 10 mm Hg) was achieved in 9 (64%) of the 14 patients. A subgroup of four patients who had a superior result (increase in mitral valve area of 1.7 +/- 0.2 versus 0.5 +/- 0.1 cm2 in the other 10 patients, p = 0.004) was identified. These patients had less echocardiographic evidence of rheumatic mitral valve damage and were the only patients who had sinus rhythm. They were also younger, less debilitated and had a lower grade of fluoroscopic valve calcification compared with the other patients. Thus, mitral balloon valvuloplasty is a safe and effective procedure for patients with recurrent mitral stenosis after surgical commissurotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Cateterismo , Estenose da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Adulto , Idoso , Cateterismo/efeitos adversos , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/fisiopatologia , RecidivaRESUMO
Light and electron microscopic examinations were performed on 20 coronary artery sites from nine patients who had undergone percutaneous transluminal coronary angioplasty. Twelve successfully dilated sites without prior thrombosis showed evidence of a tear in the luminal surface (with or without fracture of an atheroma) even at 140 days after angioplasty. The tear split through a relatively undistensible intima in 9 (75%) of the 12 sites. Two successfully dilated sites with prior thrombosis showed an intraintimal tear with a widely lacerated fibrous cap and thin mural thrombus. After dilation, the occluded prior nonthrombosed site showed marked protrusion of a separated plaque. An occluded prior thrombosed site after dilation revealed intraintimal canal-like hematoma. Four sites that occluded after balloon passage revealed a dissecting hematoma in three and plaque disruption in the other.
Assuntos
Angioplastia com Balão , Doença das Coronárias/terapia , Vasos Coronários/patologia , Idoso , Angiografia , Angioplastia com Balão/efeitos adversos , Artérias , Doença das Coronárias/complicações , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/patologia , Trombose Coronária/complicações , Vasos Coronários/lesões , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The immediate outcome of the first 150 patients (Group 1) and the last 161 patients (Group 2) who underwent percutaneous mitral balloon valvuloplasty was compared. There was no difference between the two groups in age, gender, New York Heart Association functional class, presence of calcification, atrial fibrillation, degree of mitral regurgitation, mean pulmonary artery pressure, left atrial pressure, cardiac output, pulmonary vascular resistance, mitral valve gradient and mitral valve area. Fewer patients in Group 1 than Group 2 had an echocardiographic score less than or equal to 8 (62% versus 69%, respectively, p = 0.02). The atrial septum was dilated with an 8 mm balloon in 74% of patients in Group 1 and with a 5 mm balloon in all patients in Group 2. Ratio of effective balloon dilating area to body surface area was larger in Group 1 than in Group 2 (4.05 +/- 0.07 versus 3.7 +/- 0.03 cm2/m2, p = 0.0001). A good result (mitral valve area greater than or equal to 1.5 cm2) was obtained in 77% and 75% in Groups 1 and 2, respectively (p = NS). After percutaneous mitral valvuloplasty, a greater than or equal to 2 grade increase in mitral regurgitation was noted in 12% of Group 1 and 6% of Group 2 (p = 0.02) and a left to right shunt was detected in 22% of Group 1 and 11% of Group 2 (p = 0.0001). There were three procedure-related deaths in Group 1, but none in Group 2.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Cateterismo/métodos , Estenose da Valva Mitral/terapia , Ecocardiografia , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/mortalidade , Estenose da Valva Mitral/fisiopatologia , Oximetria , Prognóstico , Taxa de SobrevidaRESUMO
Percutaneous mitral balloon valvuloplasty was performed in 150 patients. There were 124 women and 26 men (mean age 53 +/- 1 years). A left to right shunt through the created atrial communication was present in 28 patients (19%) after valvuloplasty. The pulmonary to systemic flow ratio was greater than or equal to 2:1 in 4 patients and less than 2:1 in 24. Univariate predictors of left to right shunting after valvuloplasty included older age (p less than 0.01), lower cardiac output before mitral valvuloplasty (p less than 0.01), higher New York Heart Association functional class before valvuloplasty (p less than 0.05), presence of mitral valve calcification under fluoroscopy (p less than 0.01) and higher echocardiographic score (p less than 0.05). Multiple stepwise logistic regression analysis identified the presence of mitral valve calcification (p less than 0.02) and lower cardiac output (p less than 0.02) as the independent predictors of a left to right shunt through the atrial communication after balloon valvuloplasty. Follow-up (10 +/- 1 months) of patients with an atrial septal defect after valvuloplasty showed that 1) 6 patients died (3 in the hospital and 3 at 2, 16 and 18 months, respectively, after valvuloplasty); 2) an atrial septal defect was demonstrated in 3 of 6 patients who underwent mitral valve replacement (6 +/- 0.8 months after valvuloplasty); and 3) 13 patients were in functional class I, 2 patients were in class II and 1 patient was in class III at 13 +/- 1 months after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Cateterismo/efeitos adversos , Traumatismos Cardíacos/etiologia , Septos Cardíacos/lesões , Estenose da Valva Mitral/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Ecocardiografia , Ecocardiografia Doppler , Feminino , Seguimentos , Átrios do Coração/lesões , Insuficiência Cardíaca/mortalidade , Traumatismos Cardíacos/fisiopatologia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de SobrevidaRESUMO
Seven patients with severe aortic stenosis underwent percutaneous aortic balloon valvuloplasty in preparation for major noncardiac surgery. There were four men and three women (mean age 82 +/- 1.3 years, range 78 to 88). A significant reduction in the transaortic pressure gradient from 77 +/- 7.8 to 31 +/- 6.2 mm Hg (p = 0.002) and increase in calculated aortic valve area from 0.5 +/- 0.1 to 1.0 +/- 0.3 cm2 (p = 0.05) was noted. Three of the seven procedures were performed anterograde with use of transseptal puncture: two of the three because of abdominal aortic aneurysm and one because of peripheral vascular disease. All seven patients underwent uncomplicated noncardiac surgery under general anesthesia 10 +/- 4.3 days (range 0 to 29) after aortic valvuloplasty. One patient had exploratory laparotomy, one underwent stabilization of a hip fracture and two underwent resection of an abdominal aortic aneurysm. Of the three other patients who underwent colectomy, one had repeat aortic valvuloplasty and repair of a hip fracture 7 months later and one required exploratory laparotomy without repeat valvuloplasty 7 weeks later. Percutaneous aortic balloon valvuloplasty is an effective and safe procedure that may reduce the risk of general anesthesia and major noncardiac surgery in elderly patients with aortic stenosis.
Assuntos
Estenose da Valva Aórtica/terapia , Cateterismo , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/fisiopatologia , Feminino , Hemodinâmica , Humanos , Masculino , Período Pós-Operatório , Procedimentos Cirúrgicos OperatóriosRESUMO
Percutaneous transvenous balloon mitral valvotomy was performed successfully in a 57 year old man with refractory congestive heart failure due to calcific mitral stenosis. Cardiac surgery was not an option because of other major medical problems. Balloon mitral valvotomy was performed using the transseptal technique. The interatrial septum was dilated with the use of an 8 mm balloon catheter to allow passage of larger balloon valvotomy catheters to the mitral anulus. The procedure resulted in a marked decrease in the diastolic transmitral gradient from 20 to 4 mm Hg. This decrease was associated with an increase in cardiac output from 3.4 to 5.7 liters/min. Mitral valve area increased from 0.7 to 2.5 cm2. Balloon valvotomy did not result in significant mitral regurgitation. This case indicates that further trials are warranted to evaluate percutaneous transseptal mitral valvotomy for the treatment of patients with mitral stenosis.
Assuntos
Calcinose/terapia , Estenose da Valva Mitral/terapia , Dilatação/métodos , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: The goal of this study was to evaluate the role of percutaneous aortic valvuloplasty in patients with cardiogenic shock due to severe aortic stenosis and associated major comorbid conditions and to establish predictors of survival. BACKGROUND: The prognosis for patients in cardiogenic shock with severe aortic stenosis is poor. Aortic valve replacement can be lifesaving, but the presence of multiorgan failure precludes these patients from operation. Percutaneous aortic balloon valvuloplasty has been used in these patients with short-term improvement and could be an alternative therapeutic option. METHODS: Of 310 patients undergoing percutaneous aortic balloon valvuloplasty, 21 were in cardiogenic shock and were included in this study. All 21 patients had associated major comorbid conditions at the time of presentation. RESULTS: After percutaneous aortic balloon valvuloplasty, systolic aortic pressure increased from 77 +/- 3 (mean +/- SEM) to 116 +/- 8 mm Hg (p = 0.0001); aortic valve area increased from 0.48 +/- 0.04 to 0.84 +/- 0.06 cm2 (p = 0.0001); and cardiac index increased from 1.84 +/- 0.13 to 2.24 +/- 0.15 liters/min per m2 (p = 0.06). Nine patients died in the hospital, two during the procedure and seven after successful percutaneous aortic balloon valvuloplasty (five from multiorgan failure). Five patients had vascular complications. Stroke, cholesterol emboli and aortic regurgitation requiring aortic valve replacement occurred in one patient each. Twelve patients (57%) survived and were followed up for 15 +/- 6 months; five patients subsequently died. The Kaplan-Meier survival curve showed a 38 +/- 11% survival rate at 27 months. The only predictor for longer survival rate was the postprocedure cardiac index. CONCLUSIONS: 1) Emergency percutaneous aortic balloon valvuloplasty can be performed successfully as a lifesaving procedure. 2) Morbidity and mortality remain high despite successful percutaneous aortic balloon valvuloplasty. 3) For nonsurgical candidates, percutaneous aortic balloon valvuloplasty may be the only therapeutic alternative.
Assuntos
Angioplastia Coronária com Balão , Estenose da Valva Aórtica/terapia , Choque Cardiogênico/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão/efeitos adversos , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Comorbidade , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Taxa de SobrevidaRESUMO
OBJECTIVES: This study analyzed the immediate and long-term outcome of percutaneous balloon mitral valvotomy in patients with and without fluoroscopically visible mitral valve calcification. BACKGROUND: Mitral valve calcification has been shown to be an important factor in determining immediate and long-term outcome of patients undergoing surgical mitral commissurotomy. Patient selection has an important impact on the outcome of percutaneous balloon mitral valvotomy. METHODS: The immediate and long-term results of percutaneous balloon mitral valvotomy were compared in 155 patients with and 173 patients without mitral valve calcification. The patients with calcified valves were assigned to four groups according to severity of calcification. RESULTS: Patients with calcified mitral stenosis more frequently were in New York Heart Association functional class III or IV and more frequently had atrial fibrillation, previous surgical commissurotomy, echocardiographic score > 8, higher pulmonary artery and left atrial pressures, higher pulmonary vascular resistance and mean mitral valve gradient and lower cardiac output and smaller mitral valve area. Mitral valve area after valvotomy was significantly smaller in patients with calcified valves (1.8 +/- 0.06 vs. 2.1 +/- 0.06 cm2) and was > or = 1.5 cm2 in 65% of patients with and 83% of patients without calcified valves (p = 0.004). A successful outcome, defined as mitral valve area > 1.5 cm2 without significant mitral regurgitation and left to right shunting, was achieved in 52% of patients with and 69% of patients without uncalcified valves (p = 0.001). The success rate was 59%, 48%, 35% and 33% in subgroups with 1+, 2+, 3+ and 4+ calcification, respectively. The rates of significant left to right shunting and mitral regurgitation after valvuloplasty were similar in the two groups. Estimated survival rate (80% vs. 99%, respectively, p = 0.0001), survival rate without mitral valve replacement (67% vs. 93%, respectively, p < 0.00005) and event-free survival rate (63% vs. 88%, respectively, p < 0.00005) at 2 years were significantly better in the patients with uncalcified valves. Survival rate curves became progressively worse as the severity of calcification increased. CONCLUSIONS: These findings indicate that immediate and long-term results of mitral valvuloplasty are not as successful in patients with fluoroscopically visible mitral valve calcification as in those without calcification.
Assuntos
Calcinose/complicações , Cateterismo , Estenose da Valva Mitral/terapia , Cateterismo/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/mortalidade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
In patients with symptoms of heart failure after mitral valve replacement, identification of a stenosed prosthesis may be difficult. Twelve such patients were evaluated, presenting at a mean of 8.4 years after mitral valve replacement (four mechanical, eight porcine). Transvalvular pressure gradients were obtained using both indirect (pulmonary capillary wedge) and direct (transseptal catheterization) measurements of left atrial pressure. In all 12 patients, the diastolic gradient across the prosthetic valve was overestimated when pulmonary wedge rather than transseptal measurements were used. Calculated mitral valve prosthetic area was underestimated by the pulmonary wedge determinations. These findings may be caused by either the phase delay of the pulmonary wedge V wave relative to the transseptal V wave, resulting in a higher diastolic mean left atrial pressure, or the faulty wedge determinations in the setting of pulmonary hypertension, or both. In patients being considered for repeat mitral valve replacement because of prosthetic valve stenosis, transseptal catheterization allows for more accurate determination of prosthetic valve area and more accurately defines the need for repeat mitral valve surgery.
Assuntos
Cateterismo Cardíaco/métodos , Septos Cardíacos , Próteses Valvulares Cardíacas/efeitos adversos , Estenose da Valva Mitral/diagnóstico , Valva Mitral/cirurgia , Pressão Propulsora Pulmonar , Idoso , Feminino , Átrios do Coração/fisiopatologia , Insuficiência Cardíaca/fisiopatologia , Próteses Valvulares Cardíacas/normas , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/etiologia , Estenose da Valva Mitral/fisiopatologia , ReoperaçãoRESUMO
To develop an approach to predicting adverse events after percutaneous transluminal coronary angioplasty (PTCA), 50 patients had thallium-201 exercise testing within 1 month after successful single vessel coronary angioplasty and were followed up for a mean of 18 months. Adverse events were: 1) clinical events consisting of recurrent angina (17 patients) and myocardial infarction (1 patient); 2) treatment events consisting of repeat coronary angioplasty (10 patients) and coronary bypass surgery (1 patient); and 3) restenosis, defined as a greater than 30% increase in luminal stenosis (15 of 38 recatheterized patients). There were no deaths. Of the clinical, exercise, angiographic and thallium scan variables analyzed by stepwise logistic regression, postangioplasty gradient greater than 20 mm Hg predicted clinical events and treatment events, and the number of segments with slower thallium clearance predicted clinical events, treatment events and restenosis. Using Cox Hazards model regression of survival without events, the number of transient qualitative thallium defects also predicted clinical events and restenosis. At 1 year after angioplasty, 24% of patients with these variables had restenosis compared with only 6% of those without these variables and 36% of patients with these variables had a clinical or treatment event compared with 8% of patients without these variables. Three measures of the adequacy of myocardial perfusion (post-angioplasty gradient, reduced thallium clearance and transient thallium defects) were additive predictors of adverse events after coronary angioplasty with the relative risk being approximately four times greater in patients with these variables than in those without. Such adverse events, therefore, are usually a consequence of inadequate revascularization.
Assuntos
Angioplastia com Balão , Doença das Coronárias/diagnóstico por imagem , Adulto , Angioplastia com Balão/efeitos adversos , Angiografia Coronária , Doença das Coronárias/terapia , Teste de Esforço , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Prognóstico , Radioisótopos , Cintilografia , Recidiva , Tálio , Fatores de TempoRESUMO
Exercise-induced increases in pulmonary blood volume ratio have been shown to be a sensitive marker of coronary artery disease, and correlate well with exercise-induced increases in left ventricular filling pressure. To compare the impact of single vessel coronary disease on left ventricular systolic function (ejection fraction) versus diastolic filling pressure (pulmonary blood volume) before and after intervention, serial supine exercise gated blood pool scans were performed before and after coronary angioplasty in 32 patients with isolated left anterior descending coronary artery disease. By applying previously established criteria of abnormal ejection fraction (rest less than 50% or failure to rise by 5% with exercise) and pulmonary blood volume ratio (greater than 1.06), 66% of the patients were found to have abnormal responses before angioplasty by ejection fraction compared with 81% abnormal responses by pulmonary blood volume ratio (p = 0.15). After angioplasty, the proportion of patients with abnormal ejection fraction (59%) was essentially unchanged, whereas only 38% continued to have an abnormal pulmonary blood volume ratio (p less than 0.01 compared with before angioplasty). The mean pulmonary blood volume ratio also decreased significantly from 1.15 +/- 0.10 before angioplasty to 1.02 +/- 0.15 after angioplasty (p less than 0.001). It is concluded that in single vessel coronary artery disease: 1) pulmonary blood volume ratio is abnormal at least as frequently as is ejection fraction; 2) in contrast to ejection fraction, pulmonary blood volume ratio improves significantly after successful angioplasty; and 3) pulmonary blood volume ratio may be a more sensitive indicator of changes in ventricular function after an intervention in single vessel coronary disease.
Assuntos
Angioplastia com Balão , Doença das Coronárias/fisiopatologia , Circulação Pulmonar , Volume Sistólico , Adulto , Volume Sanguíneo , Doença das Coronárias/terapia , Feminino , Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Esforço FísicoRESUMO
Although beneficial results have been reported immediately after percutaneous mitral balloon valvuloplasty, little information is available concerning the longer-term outcome of this procedure. The anatomic and functional results of percutaneous mitral valvuloplasty were assessed in 20 patients, in whom two-dimensional and Doppler echocardiographic examination could be obtained both immediately and 6 to 11 months (mean 7.5 +/- 2.0) after balloon dilation. Mean valve area measured by planimetry decreased slightly but significantly from 1.90 +/- 0.59 cm2 immediately after valvuloplasty to 1.62 +/- 0.55 cm2 (p less than 0.001) at follow-up. Individual changes in valve area were variable, and in four patients valve area decreased by greater than 25%. Echocardiographic scores of valvular morphology were obtained by assigning scores of 0 to 4 (with increasing abnormality) to each of four morphologic characteristics of the valve, namely, leaflet mobility, thickening, calcification and subvalvular thickening. This score was higher in the four patients with a decrease in valve area greater than 25% at follow-up than in the other patients (11 +/- 2 versus 7 +/- 2, p less than 0.002). Multiple regression analysis of several hemodynamic and echocardiographic factors identify first the echocardiographic score and second the valve area postvalvuloplasty as the only significant predictors of the percent decrease in valve area (r = 0.70, p less than 0.006). Mitral regurgitation graded by pulsed Doppler ultrasound decreased from 1.9 +/- 1.2 immediately after valvuloplasty to 1.0 +/- 0.9 (p less than 0.003) at follow-up, whereas there was no change in mean transmitral pressure gradient by Doppler echocardiography (5 +/- 2 versus 6 +/- 3 mm Hg, p = NS) and left atrial volume (74 +/- 34 versus 72 +/- 27 cm3, p = NS). Thus, 6 to 11 months after balloon mitral valvuloplasty, mean mitral valve area decreases slightly. Individual changes in valve area, however, are variable. Valvular morphology assessed by two-dimensional echocardiography may be useful for identifying those patients who have an increased likelihood of developing valvular restenosis.
Assuntos
Cateterismo , Ecocardiografia , Estenose da Valva Mitral/patologia , Valva Mitral/patologia , Adulto , Idoso , Ecocardiografia/métodos , Feminino , Seguimentos , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/fisiopatologia , Estenose da Valva Mitral/fisiopatologia , Valor Preditivo dos TestesRESUMO
Percutaneous balloon mitral valvuloplasty is a new technique used in the treatment of adult patients with mitral stenosis. To evaluate the occurrence and severity of mitral regurgitation after balloon valvuloplasty, 24 patients (20 women and 4 men, mean age 57 years) were studied using two-dimensional and Doppler echocardiography before and less than 24 h after this procedure. Mitral valve area increased after valvuloplasty in all patients, from 0.89 +/- 0.07 to 1.61 +/- 0.09 cm2 (p less than 0.001). Before valvuloplasty, 10 patients had no mitral regurgitation, 4 had 1+, 4 had 2+ and 6 had 3+ mitral regurgitation. After valvuloplasty, new mitral regurgitation occurred in six patients. Regurgitation grade did not change in 13 patients (54%), increased by one grade in 8 patients (33%) and by two grades in 3 patients (13%). Left atrial volume decreased in all except one patient from 100 +/- 12 to 83 +/- 12 cm3 (p less than 0.001). Neither age, sex, cardiac rhythm, initial mitral valve area, increase in mitral valve area, morphologic characteristics of the valvular and subvalvular apparatus, previous mitral commissurotomy nor effective balloon dilating area discriminated between those patients with and without an increase in mitral regurgitation after valvuloplasty. Thus, mitral balloon valvuloplasty is frequently associated with an increase in mitral regurgitation. However, in this series, no patient developed severe mitral regurgitation, and left atrial volume decreased in nearly all patients. An increase in mitral regurgitation could not be predicted from any features of the valve or subvalvular apparatus, clinical characteristics of the patients or technical aspects of the procedure.
Assuntos
Cateterismo/efeitos adversos , Ecocardiografia , Insuficiência da Valva Mitral/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/patologia , Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/patologia , Estenose da Valva Mitral/fisiopatologia , Estenose da Valva Mitral/terapiaRESUMO
To assess the effect of short-term alteration of left atrial pressure and volume on the circulating plasma level of atrial natriuretic factor, 11 patients with left atrial hypertension due to mitral stenosis were studied at the time of percutaneous balloon mitral valvuloplasty. Hemodynamic measurements and plasma atrial natriuretic factor levels were obtained before, immediately (5 to 10 min) after and 24 h after valvuloplasty, and echocardiographic left atrial size was determined before and 24 h after valvuloplasty. Immediately after valvuloplasty, left atrial pressure decreased from 28 +/- 2 to 10 +/- 1 mm Hg (p less than 0.0005), mitral pressure gradient decreased from 20 +/- 2 to 7 +/- 1 mm Hg (p less than 0.0005), mitral valve area increased from 0.8 +/- 0.1 to 1.9 +/- 0.2 cm2 (p less than 0.0005) and plasma atrial natriuretic factor level rose from 249 +/- 42 to 348 +/- 50 pg/ml (p less than 0.01). This short-term rise in atrial natriuretic factor level may reflect a transient increase in left atrial pressure associated with balloon occlusion of the mitral valve.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Fator Natriurético Atrial/sangue , Cateterismo , Coração/fisiopatologia , Hemodinâmica , Estenose da Valva Mitral/fisiopatologia , Adulto , Idoso , Aldosterona/sangue , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/sangue , Estenose da Valva Mitral/terapia , Renina/sangueRESUMO
Percutaneous mitral valvuloplasty is a promising new technique for the treatment of mitral stenosis, with a relatively low complication rate reported to date. To assess the sequelae of this procedure, Doppler echocardiographic studies were prospectively performed before and after percutaneous mitral valvuloplasty in a series of 172 patients (mean age 53 +/- 17 years). After balloon dilation, mitral valve area increased from 0.9 +/- 0.3 to 2 +/- 0.8 cm2 (p less than 0.0001), mean gradient decreased from 16 +/- 6 to 6 +/- 3 mm Hg (p less than 0.0001) and mean left atrial pressure decreased from 24 +/- 7 to 14 +/- 6 mm Hg (p less than 0.0001). Although most patients were symptomatically improved, six (4%) were identified who had unusual sequelae evident on Doppler echocardiographic examination immediately after percutaneous mitral valvuloplasty. These included rupture of a posterior mitral valve leaflet, producing a flail distal leaflet portion with severe mitral regurgitation detected on Doppler color flow mapping (n = 1); asymptomatic rupture of the chordae tendineae attached to the anterior mitral valve leaflet with systolic anterior motion of the ruptured chordae into the left ventricular outflow tract (n = 1); a double-orifice mitral valve (n = 1); and evidence of a tear in the anterior mitral valve leaflet (n = 3), producing on both pulsed Doppler ultrasound and color flow mapping a second discrete jet of mitral regurgitation in addition to regurgitation through the main mitral valve orifice. All six patients made a satisfactory recovery and none has required mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Cateterismo/efeitos adversos , Ecocardiografia Doppler , Estenose da Valva Mitral/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo/métodos , Cateterismo/estatística & dados numéricos , Cordas Tendinosas/diagnóstico por imagem , Cordas Tendinosas/lesões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/lesões , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/epidemiologia , Insuficiência da Valva Mitral/etiologia , Estenose da Valva Mitral/diagnóstico por imagem , Estenose da Valva Mitral/terapia , Estudos Prospectivos , RupturaRESUMO
OBJECTIVES: This study describes the technique, clinical characteristics and results of the first 50 patients undergoing percutaneous balloon pericardiotomy as part of a multicenter registry. BACKGROUND: Percutaneous balloon pericardiotomy involves the use of a percutaneous balloon dilating catheter to create a nonsurgical pericardial window. METHODS: Patients eligible for percutaneous balloon pericardiotomy had either cardiac tamponade (n = 36) or a moderate to large pericardial effusion (n = 14). In addition to clinical follow-up, serial echocardiograms and chest X-ray films were obtained. RESULTS: The procedure was considered successful in 46 patients after a mean follow-up period of 3.6 +/- 3.3 months. Two patients required an early operation, one for bleeding from a pericardial vessel and one for persistent pericardial catheter drainage. Two patients required a late operation for recurrent tamponade. Minor complications of the procedure included fever in 6 of the first 37 patients (studied before the prophylactic use of antibiotic agents), thoracentesis or chest tube placement in 8 and a small spontaneously resolving pneumothorax in 2. Despite the short-term success of this procedure, the long-term prognosis of the 44 patients with malignant pericardial disease remained poor (mean survival time 3.3 +/- 3.1 months). CONCLUSIONS: Percutaneous balloon pericardiotomy is successful in helping to manage large pericardial effusions, particularly in patients with a malignant condition. It may become the preferred treatment to avoid a more invasive procedure for patients with pericardial effusion and a limited life expectancy.
Assuntos
Oclusão com Balão , Tamponamento Cardíaco/cirurgia , Cateterismo/métodos , Derrame Pericárdico/cirurgia , Pericardiectomia/métodos , Idoso , Anestesia Local , Tamponamento Cardíaco/epidemiologia , Cateterismo/efeitos adversos , Cateterismo/instrumentação , Cateterismo/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/epidemiologia , Pericardiectomia/efeitos adversos , Pericardiectomia/instrumentação , Pericardiectomia/estatística & dados numéricos , Prognóstico , Radiografia Intervencionista , Resultado do TratamentoRESUMO
OBJECTIVES: Our objectives were to identify and define a minimum set of variables for interventional cardiology that carried the most statistical weight for predicting adverse outcomes. Though "gaming" cannot be completely avoided, variables were to be as objective as possible and reproducible and had to be predictive of outcome in current databases. BACKGROUND: Outcomes of percutaneous coronary interventions depend on patient risk characteristics and disease severity and acuity. Comparing results of interventions has been difficult because definitions of similar variables differ in databases, and variables are not uniformly tracked. Identifying the best predictor variables and standardizing their definitions are a first step in developing a universal stratification instrument. METHODS: A list of empirically derived variables was first tested in eight cardiac databases (158,273 cases). Three end points (in-hospital death, in-hospital coronary artery bypass graft surgery, Q wave myocardial infarction) were chosen for analysis. Univariate and multivariate regression models were used to quantify the predictive value of the variable in each database. The variables were then defined by consensus by a panel of experts. RESULTS: In all databases patient demographics were similar, but disease severity varied greatly. The most powerful predictors of adverse outcome were measures of hemodynamic instability, disease severity, demographics and comorbid conditions in both univariate and multivariate analyses. CONCLUSIONS: Our analysis identified 29 variables that have the strongest statistical association with adverse outcomes after coronary interventions. These variables were also objectively defined. Incorporation of these variables into every cardiac dataset will provide uniform standards for data collected. Comparisons of outcomes among physicians, institutions and databases will therefore be more meaningful.
Assuntos
Angioplastia Coronária com Balão/estatística & dados numéricos , Doença das Coronárias/mortalidade , Coleta de Dados/estatística & dados numéricos , Medicina Baseada em Evidências , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Adulto , Idoso , Ponte de Artéria Coronária/estatística & dados numéricos , Doença das Coronárias/terapia , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Prognóstico , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: The purpose of this study was to assess the immediate and long-term outcome of repeat percutaneous mitral balloon valvuloplasty (PMV) for post-PMV mitral restenosis. BACKGROUND: Symptomatic mitral restenosis develop in 7% to 21% of patients after PMV. Currently, most of these patients are referred for mitral valve replacement. However, it is unknown if these patients may benefit from repeat PMV. METHODS: We report the immediate outcome and long-term clinical follow-up results of 36 patients (mean age 58+/-13 years, 75% women) with symptomatic mitral restenosis after prior PMV, who were treated with a repeat PMV at 34.6+/-28 months after the initial PMV. The mean follow-up period was 30+/-33 months with a maximal follow-up of 10 years. RESULTS: An immediate procedural success was obtained in 75% patients. The overall survival rate was 74%, 72% and 71% at one, two, and three years respectively. The event-free survival rate was 61%, 54% and 47% at one, two, and three years respectively. In the presence of comorbid diseases (cardiac and noncardiac) the two-year event-free survival was reduced to 29% as compared with 86% in patients without comorbid diseases. Cox regression analysis identified the echocardiographic score (p = 0.03), post-PMV mitral valve area (p = 0.003), post-PMV mitral regurgitation grade (p = 0.02) and post-PMV pulmonary artery pressure (p = 0.0001) as independent predictors of event-free survival after repeat PMV. CONCLUSIONS: Repeat PMV for post-PMV mitral restenosis results in good immediate and long-term outcome in patients with low echocardiographic scores and absence of comorbid diseases. Although the results are less favorable in patients with suboptimal characteristics, repeat PMV has a palliative role if the patients are not surgical candidates.
Assuntos
Cateterismo , Estenose da Valva Mitral/terapia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/mortalidade , Recidiva , Retratamento , Estudos Retrospectivos , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
We have constructed a bifocal diverging collimator (BDC), capable of simultaneously recording two views of the heart 50 degrees apart on each half of a standard imaging field. In this study, simultaneous two-view blood-pool scans using the BDC were compared with the same two separate views obtained using an all-purpose parallel-hole collimator (PHC), assessing left-ventricular ejection fraction and regional wall motion in 20 patients undergoing contrast left ventriculography (CV). Ejection fraction by BDC correlated closely with PHC (r = 0.94) and with CV (r = 0.88). Regional wall motion was scored qualitatively on a five-point scale from 3 (normal) to--1 (dyskinesis) with an 88% agreement between BDC and PHC and PHC for segment scores. The percentages for agreement between BDC and CV, and between PHC and CV, were identical, 79%. A single blood-pool scan acquisition using a new BDC provides information about global and regional left-ventricular function in two planes, comparable with that of a PHC.