Infective endocarditis following balloon dilatation of mitral valve.

Three cases of infective endocarditis were encountered following balloon dilatation of the mitral valve. The diagnosis was difficult due to negative blood cultures and nondiagnostic transthoracic echocardiogram, the latter the consequence of the preexisting severe rheumatic valvar disease. Transoesophageal echocardiography proved superior in diagnosis. The possible causes and means of preventing this potentially lethal complication are discussed.

"Anatomically corrected malposition": a rare case with bilateral absence of a complete subarterial muscular infundibulum.

A unique case of anatomically corrected malposition of great arteries with a bilateral absence of a complete subarterial muscular infundibulum is presented. The other unusual feature of the case was absence of any complex associations and interestingly an intact ventricular septum. The presenting lesion was valvar pulmonary stenosis and balloon valvotomy could not be achieved because of abnormal relationship of the great vessels.

Coarctation of aorta with unusual association of diverticulum of the left ventricle and double orifice mitral valve.

We describe a case of coarctation of aorta with two unusual associated anomalies, namely, a diverticulum of the left ventricle and double orifice of the mitral valve. Echocardiography and colour flow mapping precisely diagnosed the bridging tongue of leaflet tissue responsible for the double orifice of the mitral valve. Balloon angioplasty for coarctation produced dramatic benefits which are sustained at follow-up. The other two lesions caused no haemodynamic abnormality.

Balloon valvotomy for mitral restenosis after open or closed surgical commissurotomy.

Balloon mitral valvotomy was performed in 48 patients (Group I) with mitral restenosis following prior surgical commissurotomy 3-21 years previously. Their results were compared with those of balloon valvotomy in 302 patients without prior commissurotomy (Group II). The procedure was successful in 91.7% of Group I. The mitral valve area, cardiac output, mitral valve gradient, mean left atrial and pulmonary arterial pressures significantly improved following valvotomy (all P < 0.001) in Group I and similar results were obtained in Group II. A comparison of the absolute and percentage change in the mitral valve area following valvotomy amongst the two groups revealed no significant difference (P = N.S.). The baseline clinical characteristics in both the groups were similar except for a higher echocardiographic score (8.64 +/- 1.5 vs. 7 +/- 1.7; P < 0.005) in Group I. Despite the high echo score, achievement of an 'optimal' result and occurrence of postprocedural mitral regurgitation were similar in both groups. The complications included systemic embolus in one patient and increase in mitral regurgitation to > or = 2+ in 2. There were no deaths. Balloon valvotomy for mitral restenosis following surgical commissurotomy is safe, effective and produces clinical and hemodynamic results comparable to those in unoperated cases.

Discrete subaortic stenosis: a study of 20 cases.

Twenty patients with discrete subaortic stenosis were studied during last 11 years. Cross sectional echocardiography and angiography demonstrated a membrane in 17 (85%), fibromuscullar collar in 2 (10%), and diffuse tunnel type of obstruction in 1 (5%) patient. Eighty five percent of patients had severe obstruction with average peak systolic gradients being 96.5 +/- 36.3 mm of Hg. Eight patients with membranous obstruction seen during the last 5 years underwent successful balloon dilatation with decrease in peak systolic gradient from 107.1 +/- 24.2 to 32.3 +/- 14.2. The haemodynamic benefits were sustained during 4 to 24 (mean 9.6) months followup. The results indicate that balloon dilatation can be a safe and effective treatment for thin subaortic membrane. Surgical resection is needed in patients with collar or tunnel type of obstruction.

Profile of submitral left ventricular aneurysms in Indian patients.

Annular subvalvar aneurysms of the left ventricle initially described from Nigeria are considered to be rare in India. We report 6 such cases studied clinically and by noninvasive and invasive investigations during the last 8 years. In 4 cases morphologic documentation was available at surgery or autopsy. The clinical picture was dominated by congestive cardiac failure and mitral regurgitation and most of the patients were young. Echocardiographic studies provided the precise noninvasive diagnosis by demonstrating large aneurysms arising below the posterior mitral leaflet. In one case the submitral left ventricular aneurysm extended into the left atrium. The mortality was high in unoperated cases and operative repair under cardiopulmonary bypass is the most appropriate management.

Mitral and pulmonary balloon valvotomy in pregnant patients.

Two pregnant patients, one each with mitral and pulmonary valvar stenosis, underwent successful balloon valvotomy during their third trimester. Single balloon technique was utilised in both and this resulted in a short procedure and fluoroscopy time (9 minutes in patient with mitral stenosis and 3.5 minutes in pulmonary stenosis). The procedure produced satisfactory hemodynamic and symptomatic benefits in both cases with no complications. The patient remained asymptomatic without medications and delivered healthy full term babies at term. Balloon valvotomy is feasible, effective, and safe during pregnancy and should be considered as an alternative to surgery in symptomatic patients refractory to medical therapy.

Balloon mitral valvotomy in a patient with Ebstein's anomaly of tricuspid valve and rheumatic mitral stenosis.

We report a young woman with Ebstein's anomaly of tricuspid valve and rheumatic mitral stenosis who successfully underwent mitral valvotomy using double balloon technique. The clinical and haemodynamic benefits are sustained at 1 year followup.

Percutaneous mitral valvotomy in 200 patients using Inoue balloon-immediate and early haemodynamic results.

We report our experience with percutaneous balloon valvotomy using the Inoue technique in 200 cases with rheumatic mitral stenosis. The procedure was successful in 195 (97.5%) cases with a fluoroscopy time of 9 +/- 2.7 and procedure time of 60 +/- 19 minutes. Mitral valve area as estimated by Gorlin's equation and pressure half time increased from 0.86 +/- 0.17 to 2.21 +/- 0.41 and from 0.94 +/- 0.14 to 1.90 +/- 0.26 (p < 0.001) respectively. Other hemodynamic variables including mitral valve gradient, cardiac output, left atrial mean and pulmonary artery pressure improved significantly. There were no deaths and the incidence of major complications was small. Increase in mitral regurgitation was observed in 35 (17.9%) with grade 2+ increase in 7 (3.6%). Inoue balloon technique is safe, easy to perform and provides excellent clinical and hemodynamic benefits in majority of cases.

Coronary artery disease in premenopausal Indian women: risk factors and angiographic profile.

Coronary angiographic and clinical profile of 47 premenopausal women presenting with myocardial infarction (MI) or angina is presented. Seventeen patients (36%) had significant obstructive coronary artery disease (CAD) (Group I), while 30 (64%) had normal coronaries (Group II). The latter group included 4 who had MI and 26 who presented with angina. Risk factors in Group I included hypertension (53%), diabetes mellitus (24%), hypercholesterolemia (29%), oral contraceptives and a positive family history (11.8%). Frequency of one, two and three vessel disease was 47%, 18% and 35% respectively. The left anterior descending artery was most commonly affected (82%). In Group II the risk factors included hypertension (17%) and diabetes (7%). No patient in either group was a smoker. This analysis shows that significant obstructive CAD in premenopausal Indian females is more commonly associated with hypertension, diabetes and hypercholesterolemia. Smoking was not encountered and ingestion of contraceptive pills is uncommon.

Prevalence of significant coronary heart disease in valvular heart disease in Indian patients.

Records of 326 patients were analysed to determine the prevalence of coronary heart disease (CHD) in patients with valvular heart disease (VHD) and to identify the group in whom coronary arteriography is essential. Significant CHD (60% or more luminal narrowing) was found in 7 per cent of cases, and its prevalence was 3 per cent in mitral, 10 per cent in aortic, and 6 per cent in combined mitral and aortic valve disease. Angina was present in 14 per cent of patients with mitral, 39 per cent with aortic, and 21 per cent with combined mitral and aortic valve disease. Seventy-three per cent of patients with CHD had angina whereas only 19 per cent with angina had CHD. The prevalence of CHD was higher in patients above 50 years (13%) and in males (98%) as compared to those below 50 years (3%) and females (none). We conclude that the prevalence of CHD is low in our patients with VHD. Routine coronary arteriography is recommended only in males over the age of 50 years.

Clinical and hemodynamic profile of patients with calcific mitral valve disease.

Clinical, hemodynamic and fluoroscopic findings were analysed in 1123 patients with rheumatic mitral valve disease. The incidence of mitral valve calcification was 15 percent (mild 3 percent, moderate 9 percent, and severe 3 percent). There was a male preponderance (male 17 percent, female 5 percent). The presence of moderate to severe degree of calcification of mitral valve correlated with age, rhythm, transmitral gradient, associated mild mitral regurgitation, pulmonary artery pressure, systemic embolisation and previous commissurotomy. No correlation was found between the degree of calcification and presence or absence of other valve lesions.

Acute effect of balloon mitral valvotomy on serial electrocardiographic changes and their haemodynamic correlation.

The effect of acute haemodynamic changes that occur following balloon mitral valvotomy on the electrocardiogram were studied in 25 patients with isolated rheumatic mitral stenosis. Statistically significant changes were observed in the characteristics of P-wave and QRS axis. Patients who showed changes in P-wave had significantly greater fall in left atrial mean pressure (p < 0.025), lesser residual transmitral gradient (p < 0.025) and greater percentage change in mitral valve area (p < 0.01) following balloon mitral valvotomy. Good correlation was seen between the decrease in right axis deviation of QRS axis and fall in mean pulmonary artery pressure (r = +0.56, p < 0.001) and pulmonary vascular resistance (r = +0.48, p < 0.05). Transient arrhythmias were seen in six patients. All these changes occurred within 72 hours, and in the majority of patients within 24 hours. These results demonstrate that the acute haemodynamic changes following balloon mitral valvotomy produce corresponding changes on electrocardiogram and these changes indicate a significantly greater degree of haemodynamic benefit from the procedure than when these changes are not seen.

Thrombotic obstruction of inferior vena cava treated with streptokinase infusion and balloon dilatation.

A 35 year old male with thrombotic obstruction of the inferior vena cava superimposed on a membrane was treated by prolonged (48 hours) infusion of streptokinase followed by balloon membranotomy. The procedure produced excellent clinical, hemodynamic and angiographic results which are sustained at the end of six months.

Balloon mitral valvotomy. A new technique.

Balloon mitral valvotomy is a new technique for non-operative treatment of mitral stenosis and is performed by using single or double balloon. The technique is complex, involves transseptal puncture, however, can be safely performed in experienced catheterisation laboratory. The technique has been applied in calcific and noncalcific valves, mitral restenosis and also in presence of atrial fibrillation. The results with double balloon valvotomy at the present time is costlier than closed mitral valvotomy. The technique is promising and large trials are awaited to see its future status.

Percutaneous balloon angioplasty for native coarctation of the aorta. Early and intermediate term results.

We performed balloon angioplasty (BA) in 12 patients with native coarctation of the aorta (COA), aged 2-32 years (average 20.7). The peak systolic gradient across the COA segment decreased from 60.75 +/- 21.85 to 15.66 +/- 9.44 mmHg (p less than 0.001) after the procedure. Angiographically all had more than 50% increase in the diameter of the narrowed segment. During clinical follow up (2.42 months post procedure), all had marked symptomatic benefit. Follow up by haemodynamics and angiography in 4 cases (average 7.7 months post BA) and by echo-doppler in 2 cases (3.6 months post BA) revealed no evidence of aneurysm or restenosis. Our results indicate that BA is a simple, safe, nonoperative alternative to surgery in COA. The immediate and intermediate follow up results are encouraging; however, long term studies are needed to define the true incidence of restenosis and aneurysm.

Supravalvar aortic stenosis secondary to familial hypercholesterolaemia. Report of two cases.

Two cases of supravalvar aortic stenosis secondary to familial hypercholesterolaemia (type II A hyperlipoproteinaemia) are reported and the role of echocardiography in the diagnosis of this uncommon condition is discussed. The management of these patients is difficult and in one patient the serum cholesterol decreased substantially after treatment with gemfibrozil.

An unusual case of right atrial myxoma.

An unusual case of right atrial myxoma who had a ten year symptom free interval, following the initial manifestation is presented.

Total anomalous pulmonary venous connection: asymptomatic survival for 50 years without surgical intervention.

Total anomalous pulmonary venous connection (TAPVC) is an uncommon cyanotic heart disease and survival beyond infancy is rare. We report a patient of TAPVC of the supracardiac variety who has survived till the age of 50 years without surgery.

Percutaneous balloon valvotomy for aortic valve stenosis using single or double balloon technique.

Percutaneous balloon valvotomy was performed in 21 cases (aged 6 to 62 years) with moderate to severe aortic valve stenosis, using either single (16 cases) or double balloon (5 cases) technique. All patients had basal transaortic pressure gradient 50 mmHG or above. A majority of patients had significant haemodynamic improvement immediately following balloon dilatation. The mean systolic transaortic pressure gradient reduced from 94 mmHg (range 50 to 160) to 42 mmHg (range 14 to 82; P less than 0.05) immediately after the dilatation. The final gradient was less than 40 mmHg in 11 cases. The mean cardiac index improved from 3.86 L/min/M2 (range 2.8 to 5.2) to 4.14 L/min/M2 (range 3.4 to 5.6; P:NS) following the procedure. There was no death or major complication related to the intervention. There was a procedure-related mild aortic regurgitation in 4 cases. We conclude that percutaneous balloon dilatation is an effective, safe, low cost, nonsurgical method for treating patients with aortic valve stenosis.