Percutaneous aortic valve in severe valvular regurgitation caused by infective endocarditis.

Recently, the feasibility and safety of percutaneous aortic valve replacement (PAVR) have been reported in the treatment of degenerative aortic valve stenosis in patients at high-risk for surgical aortic valve replacement (AVR). However, so far this therapy has been limited to patients with severe stenosis of the native valve. We report the case of an 84 year old patient with severe aortic regurgitation caused by infective endocarditis who was successfully treated by implantation of a CoreValve (CoreValve Inc, Irvine. Calif) prosthesis with a totally percutaneous approach.

Coronary flow reserve by contrast-enhanced echocardiography: a new noninvasive diagnostic tool for cardiac allograft vasculopathy.

Noninvasive tests have proven unsatisfactory in cardiac allograft vasculopathy (CAV) diagnosis. We assessed coronary flow reserve (CFR) by contrast-enhanced transthoracic echocardiography (CE-TTE) in heart transplantation (HT). CFR was assessed in the left anterior descending coronary artery in 73 HT recipients (59 male, aged 50+/-12 years at HT), at 8+/-4.5 years post-HT. CFR measurements were taken blindly from coronary angiographies. CFR cut points were the standard value of

Aborted myocardial infarction: a clinical-magnetic resonance correlation.

This report illustrates a magnetic resonance image of aborted myocardial infarction after primary angioplasty. Myocardial oedema in the absence of late enhancement seems to be the magnetic resonance marker of the myocardium at risk of infarction that has been reperfused within 30 minutes and aborted in the clinic.

Imaging for the diagnosis of an unusual case of left ventricular aneurysm.

An isolated ventricular diverticulum in an adult patient investigated for chest pain is reported. An exhaustive diagnosis was obtained by different means and complementary imaging techniques such as echocardiography, cardiovascular magnetic resonance imaging and cineangiography.

[Simultaneous coronary angioplasty and percutaneous mitral valvuloplasty: a case report]. / Angioplastica coronarica e valvuloplastica mitralica percutanea simultanee: presentazione di un caso.

A patient with symptomatic pliable mitral stenosis and a significant lesion of the left coronary artery underwent combined interventional procedures during a single session. From the femoral approach a percutaneous transluminal coronary angioplasty was performed, with unsatisfactory results and necessitating stent implantation. Thereafter, mitral valve stenosis was relieved by percutaneous balloon valvotomy.

Analytical expression of effective afterload in aortic and mitral regurgitation.

Effective arterial elastance (Ea) is the coupling parameter between the left ventricle and peripheral circulation in normal subjects. If left ventricular end systolic pressure (Pes), contractility (Es) and Ea are known, left ventricular end diastolic volume (LVEDV) and ejection fraction of the ventricle are completely determined. The aim of this study was to give an analytical expression for Ea in patients with mitral and aortic regurgitation, and predict both LVEDV and the effect of vasodilator therapy on LVEDV. Twenty-three subjects with atypical chest pain, 15 patients with mitral insufficiency and 11 with aortic insufficiency underwent diagnostic cardiac catheterization, coronary angiography, and left ventricular cineangiography, which was analyzed quantitatively. Ea was 2.05 +/- 0.63 in normal subjects, while it was 1.28 +/- 0.71 and 1.57 +/- 0.87 in patients with mitral and aortic insufficiency, respectively. All these groups differed with ANOVA test (p = 0.0031). We tested the ability of the analytical expressions for Ea in normal subjects, and patients with mitral insufficiency or aortic insufficiency to predict measured Ea and LVEDV. Ea and LVEDV were predicted rather accurately in every case (p < 0.0001). We used published data to test the effect of resistance modulation on LVEDV. Predicted and measured LVEDV were linearly correlated both in aortic (p < 0.0001) and mitral insufficiency (p = 0.027). Moreover, in some cases a left ventricular enlargement after vasodilator therapy could be anticipated because of an unbalanced decrease in resistance and heart rate. Ea seems to be the coupling parameter between the left ventricle and the peripheral circulation not only in normal subjects, but also in patients with mitral or aortic regurgitation; its measurement before administering vasodilating drugs may be useful in order to predict the effects on LVEDV, and achieve an optimal ventriculoarterial coupling.

[Percutaneous mitral and aortic valve dilatation in the same session]. / Dilatazione percutanea valvolare mitralica ed aortica nella stessa seduta.

Percutaneous balloon valvuloplasty is used successfully for mitral and aortic rheumatic stenosis. Its application is limited in elderly degenerative aortic stenosis because of its poor long-term results. It is thus indicated only in selected groups of patients at high surgical risk. We describe three cases affected with mitral and aortic stenosis who underwent simultaneous mitral and aortic percutaneous balloon valvuloplasty. Etiology was rheumatic in the first two cases, while it was rheumatic and degenerative in the third case. Immediately after the procedure, mitral and aortic gradients decreased, with a simultaneous increment in aortic and mitral areas and cardiac index. There were no major complications. The follow-up after seven years revealed the persistence of relatively good results in the first two cases affected with rheumatic valvulopathies. In the last case, restenosis recurred a few years after the procedure.

[Mitral valvuloplasty in pregnancy: a report of 4 cases]. / La valvuloplastica mitralica in gravidanza: descrizione di quattro casi.

Normal gestation is associated with adaptative cardiovascular changes. Pregnant women with mitral stenosis may be unable to tolerate these changes despite optimal medical therapy, and life-threatening complications can occur. Commissurotomy or valve replacement during gestation are very high-risk procedures both for mother and fetus. Percutaneous valvuloplasty is a valid alternative to cardiac surgery. In this study, we describe four pregnant women with mild or severe mitral stenosis who underwent percutaneous valvuloplasty after the first trimester of gestation. Despite tailored medical therapy with diuretics and beta blockers, all patients were symptomatic: NYHA class II in two cases, and class III in the last two. In order to protect the fetus from radiation, the patient's pelvic-abdominal area was shielded and left ventriculography was not performed. Fluoroscopy time was 7 +/- 3 min. No major immediate complications were observed after the procedure. Mitral valve area (sec. Gorlin) increased from 1.05 +/- 0.08 cm2 to 2.52 +/- 0.26 cm2 and mitral gradient decreased from 26.7 +/- 5.7 mmHg to 8.5 +/- 3 mmHg. The four women delivered healthy full-term babies. At a mean follow-up of 22 +/- 8 months, all patients are free of symptoms, two patients with diuretics and two without therapy. Percutaneous valvuloplasty can be considered the treatment of choice for pregnant women with symptomatic mitral stenosis refractory to medical therapy.

Intracoronary stenting for thrombus-containing lesions in the setting of acute ischemic syndromes.

AIM: The presence of intracoronary thrombus was considered a contraindication for stent deployment. Recently, many investigators have demonstrated that the use of stents for thrombus-laden lesions under both elective and bail-out conditions is effective and safe, even in the setting of acute myocardial infarction (AMI). METHODS AND RESULTS: In this study Palmaz-Schatz stents were implanted to treat suboptimal results and complications of percutaneous transluminal coronary angioplasty (PTCA) in 41 thrombus-containing lesions. Clinical presentation was unstable angina in 24 and AMI in 17 patients. Stents were deployed because of suboptimal result (n = 27), coronary dissection with threatening occlusion (n = 13) or abrupt closure (n = 1). An angiographic successful deployment was obtained in all but one lesions (98%). Four patients (9.8%) suffered from in-hospital complications: three developed a non fatal non-Q wave AMI and one died. There was no need for emergency coronary artery bypass graft surgery, repeat PTCA or blood transfusion for vascular complications. At six-months follow-up one patient (2.6%) developed a non-Q wave AMI and two (5.1%) underwent a repeat coronary angioplasty. CONCLUSIONS: Our experience confirms that adequately dilated Palmaz-Schatz stent might be safe and effective for thrombus-containing lesions in the setting of acute ischemic syndromes.

[Coronary angioplasty in acute myocardial infarction]. / Angioplastica coronarica primaria nell'infarto miocardico acuto.

Primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) allows to obtain a higher reperfusion rate in the culprit vessel than thrombolytic therapy, reducing the incidence of death, non fatal reinfarction and recurrent ischemia. The aim of this study was to test the in-hospital and mid-term results of an early invasive strategy with PTCA in patients with AMI. Thirty-four patients with AMI underwent coronary angiography within 3 hours from the onset of symptoms. Twenty-four patients had anterior AMI and 3 were in cardiogenic shock. Three patients, 1 without significant lesions and 2 with multivessel diffuse coronary disease, were left out of the procedure, and 31 patients underwent PTCA. Twenty-six lesions were total occlusions with TIMI flow 0.A TIMI flow 1 was present in the other 5 vessels. Stent deployment was decided for 16 lesions (52%). Primary success (TIMI flow 3 with mean residual stenosis of 15 +/- 20%) was obtained in 30 patients (97%). In 1 patient recanalization of the anterior descending coronary artery was not possible due to tortuosity of the abdominal and thoracic aorta. At pre-discharge angiography a good result was confirmed in 24/25 patients. After 6 months only 1 patient (3%) underwent a new PTCA for recurrent angina. In conclusion, primary PTCA for AMI within 3 hours of symptom onset allows good in-hospital and mid-term results with a low rate of complications.

Troponin T, creatine kinase MB mass, and creatine kinase MB isoform ratio in the detection of myocardial damage during non-surgical coronary revascularization.

The presence of myocardial injury during non-surgical coronary revascularization has been evaluated by means of highly specific and sensitive biochemical markers. Troponin T, creatine kinase-MB isoenzyme mass concentration, and creatine kinase MB2/MB1 isoform ratio have been determined in 80 patients who underwent coronary revascularization with percutaneous transluminal coronary angioplasty (PTCA). Forty-five patients underwent balloon angioplasty, 15 rotational atherectomy, 10 directional atherectomy, and 10 elective coronary stenting. Serum concentration of the evaluated markers did not increase significantly after 57 uncomplicated revascularization procedures, including 15 rotablation procedures, nor after 8 PTCAs complicated by localized coronary type B and C dissections. Significant elevation of all markers above the upper limits of the reference interval (P < 0.05) was detected after occlusion of small side branches (< 0.5 mm diameter) in 5 patients. Creatine kinase MB2/MB1 isoform ratio was the earliest marker to increase. After recanalization of occluded vessels in 8/10 patients with 6-60 days old myocardial infarction only troponin T concentrations increased from a baseline of 0.28 microgram/l to a median peak of 0.80 microgram/l. This increase was statistically not significant (P = 0.12). In conclusion, myocardial damage was not detected following uncomplicated non-surgical revascularization obtained with different techniques. Markers of myocardial injury provide high sensitivity after small side branch occlusion.

[Percutaneous mitral valvuloplasty in mitral restinosis after surgical commissurotomy]. / Valvuloplastica mitralica percutanea nella restenosi mitralica dopo commissurotomia chirurgica.

UNLABELLED: The frequency of mitral restenosis after surgical commissurotomy has been estimated between 10 and 30% up to 10 years and 85% up to 28 years. Aim of this study was to analyze the results of balloon mitral valvuloplasty (BMV) in a series of patients with previous surgical commissurotomy. METHODS: Between December 1988 and December 1995 432 patients underwent BMV. Of these patients, 30 (6.9%; 10 men, 20 women, aged 53 +/- 12 years) had recurrent mitral stenosis after surgical commissurotomy. Contraindications to BMV were the evidence of left atrial thrombi at transesophageal echocardiography and/or of mitral insufficiency > 2+/4+. The Inoue's single balloon catheter was used for all the procedures. RESULTS: BMV resulted in a decrease in mean mitral gradient from 12.6 +/- 3.8 to 6.1 +/- 2.9 mmHg, and an increase in mitral valve area from 1.03 +/- 0.19 cm2 to 1.95 +/- 0.40 cm2. A mitral insufficiency > or = 3+/4+ occurred in 4/30 BMV (13%). At follow-up (mean 27 +/- 18 months) 20/26 patients (77%) remained clinically improved: 54% were in NYHA class I and 23% in class II. CONCLUSIONS: BMV is an effective short- and long-term procedure for patients with previous surgical commissurotomy, with a low additional risk of complications. Thus, BMV can be considered the treatment of choice in these patients.

[Immediate and long-term results of treatment of focal lesions with aortocoronary venous bypass with a stent implant]. / Risultati immediati e a distanza del trattamento di lesioni focali di bypass venosi aortocoronarici mediante l'impianto di stent.

Patients with recurrent angina after coronary artery bypass graft surgery pose a problem. Stent implantation has been advocated in an effort to avoid repeat operation and to address the limitations of balloon angioplasty. Aim of the present study was to determine the in-hospital and long-term results of stent deployment in focal, de novo lesions of vein grafts. Thirty-five focal, de novo lesions of vein grafts in 31 patients were treated with stent deployment. Twenty-four patients (77%) had three vessels, 6 (20%) two vessels and 1 (3%) single vessel disease. Saphenous vein grafts aged 9.7 +/- 4.2 years (range 1-19 years). Twenty-two lesions (63%) were located within the body of the saphenous graft, 8 (23%) at the graft/coronary artery anastomosis and 5 (14%) at the aorta/graft anastomosis. The indications for stent deployment included: suboptimal result from balloon angioplasty (defined as > or = 50% post-angioplasty residual stenosis) in 29/35 lesions (83%); post-angioplasty coronary dissection with threatening occlusion in 4/35 (11%); abrupt closure in 2/35 (6%). Patients were screened for death, myocardial infarction, bypass surgery and repeat angioplasty during in-hospital stay and after a follow-up of 12 +/- 8 months. Even-free survival curve was constructed by the Kaplan-Meier method. Stent deployment was successful in all patients. One stent was deployed in 24/35 lesions (69%), half Palmaz-Schatz stent in 6/35 (17%) and 2 or more stents in 5/35 (14%). The balloon/vessel ratio resulted of 1.0 +/- 0.1 Minimal lumen diameter increased from 0.8 +/- 0.4 to 3.8 +/- 0.6 mm, with a mean gain of 1.8 +/- 0.6 mm (range 1.8-4.0 mm). During the in-hospital period 1 patient (3.2%) died and 1 (3.2%) had a non Q wave myocardial infarction. Therefore, the clinical success rate, was 94%. During the follow-up period, 2 patients died (6.9%), 2 (6.9%) developed a non Q wave myocardial infarction, 1 (3.4%) underwent bypass surgery and 3 (10.3%) underwent repeat angioplasty. The estimated 2-year event-free survival rate (free from myocardial infarction, repeat surgery and repeat angioplasty) was 62%. In conclusion, Palmaz-Schatz stent deployment in focal, de novo vein grafts presents a high rate of procedural success, a low rate of acute complications and good long-term results.

Percutaneous transluminal coronary angioplasty in refractory unstable angina pectoris: are new devices useful?

This study was undertaken to assess if the introduction of new angioplasty devices (autoperfusion balloon catheters, stent and atherectomy) could ameliorate early and late results of prompt percutaneous transluminal coronary angioplasty (PTCA) in patients with refractory unstable angina. From January 1993 to June 1995, 59 of 278 patients (14 female, 45 male; mean age: 61 +/- 10 years; range: 38-78) admitted to our Coronary Care Unit with the diagnosis of unstable angina had more than one episode of chest pain at rest with dynamic electrocardiographic ST-T changes and without signs of cardiac necrosis while on medical therapy including oxygen, aspirin, heparin, nitroglycerin and either a beta-blocker or a calcium-antagonist. Coronary angiography was performed within 48 h from the last ischemic attack and a culprilesion technically suitable for PTCA was identified. PTCA was performed in 73 lesions. Elective stent implantation was considered for 16 type B or C lesions in 14 patients. The procedure was initially successful in 52/59 patients (88%), uncomplicated unsuccessful in 4/59 (7%) and complicated in 3/59 (5%). Elective stent insertions were all successful (16/16, 100%). All successfully treated patients were followed up for a mean of 12 +/- 7 months (range: 6-27): 2/52 patients (3.8%) suffered from non-transmural myocardial infarction, 14/52 (26.9%) had a recurrence of angina and 2/52 (3.8%), asymptomatic, had a positive stress test. We conclude that prompt PTCA in refractory unstable angina using 1990s 'state of the art' equipment compares favorably to previous study and that stent delivery might become the elective treatment of complex lesions in this subset of patients.

Acute changes in left ventricular function after percutaneous transluminal mitral valvuloplasty.

Percutaneous balloon mitral valvuloplasty (PBMV) has been shown to induce an immediate increase in the left ventricular end-diastolic volume, which increase, in turn, has been attributed to an increase in left ventricular compliance. We studied 51 patients, 41 women and 10 men, who underwent PBMV, and were in sinus rhythm before and after the procedure. Heart rate did not vary significantly. There were increases in left ventricular end-diastolic volume (97.5 +/- 25.6 vs 112.7 +/- 25.7 ml/m2, P < 0.001), left ventricular end-diastolic pressure (8.7 +/- 3.0 vs 9.7 +/- 4.3 mmHg, P = 0.04), and both left ventricular systolic pressure and stress (118 +/- 20.5 vs 123 +/- 23.2 mmHg and 468 +/- 129 vs 580 +/- 164 mmHg; P = 0.04 and P < 0.001, respectively). The elastic stiffness constant did not vary (16.2 +/- 1.9 vs 15.7 +/- 1.9 (dimensionless units), P = 0.2). The increase in volume seemed to be particularly important when the ventricle appeared to be "shrunken" before PBMV. This increase was still present after a 1 year follow up. Thus, PBMV determines an increase in both end-diastolic volume and pressure, so that the left ventricle appears to move along a single pressure-volume curve. This enlargement evokes the Frank Starling mechanism, and improves systolic performance. Since it is still evident after a 1 year follow up, some concern may arise when a simultaneous volume overload is present, as in aortic insufficiency.

[Rotational atherectomy and PTCA in complex coronary lesions (B2 and C): the immediate and long-term results]. / Aterectomia rotazionale e PTCA in lesioni coronariche complesse (B2 e C): risultati immediati e a distanza.

BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) in complex coronary lesions (type B2 and C of the modified AHA/ACC classification) presents a lower primary success rate and higher risk of dissection than type A and B1 lesions. An alternative approach to this lesions is coronary rotational ablation (Rotablator, Heart Technology) with complementary PTCA using low inflation pressures ("facilitated angioplasty"). MATERIALS AND METHODS: Twenty-six type B2 and C lesions in 24 patients (pts) (8 female, 16 male, age 37-80 years) were treated with coronary rotational ablation and complementary PTCA between January 1993 and December 1994 (4.7% of all interventional coronary procedures performed in this period in our laboratory). Eleven pts had stable effort angina and 13 pts had unstable, class IB, IIB, and IIC, angina. The treated vessel was the LAD in 15 cases, CX in 5, RCA in 5, and an intermediate branch in one case. Coronary rotational ablation was proposed because of the presence of two or more risk factors for uneffective or complicated PTCA: eccentricity, calcified lesions, bifurcation stenosis, lesion length > 10 mm, severe stenosis (90-99%), ostial location and bend location (45-60 degrees). No lesion showed coronary thrombus, considered as absolute contraindication to coronary rotational ablation. We used small burrs (burr/artery ratio < 0.75), and complementary PTCA was performed using low inflation pressure (< 8 atm) and long balloons for long lesions (> 10 mm) in order to minimize the risk of dissection. RESULTS: Coronary rotational ablation was successfully performed in all but two cases (24/26; 92.3%), with a reduction of the stenosis from 88 +/- 9% to 45 +/- 10% (range 30-60%). In two pts (7.7%) the procedure was complicated by acute occlusion: both pts underwent effective salvage PTCA with 30% residual stenosis. Small type A and B dissections occurred in 4/26 cases (15.4%). All but one lesions complicated by acute occlusion or dissection following coronary rotational ablation were not or only slightly calcified. Complementary PTCA was performed in all but two pts who already presented 30% residual stenosis after rotational ablation. A further reduction of stenosis to 20 +/- 9% (range 5-30%) was achieved. After complementary PTCA four pts (15.4%) developed type A and B dissections; in one of these a Palmaz-Schatz stent was implanted, whereas the remaining three pts presented a residual stenosis below 30% and no further procedures were undertaken. Overall success rate of rotational atherectomy plus salvage or complementary PTCA or stenting was 100%, and no major complications (Q-wave myocardial infarction, emergency bypass surgery or death) occurred. Three pts showed delayed coronary run-off (slow reflow) after rotational ablation, and two of these released a small amount of cardiac specific enzymes (CK MB) without ECG changes and wall motion alteration on echocardiographic examination. Clinical restenosis, defined as recurrent angina and/or positive exercise stress test, developed in 45.8% (11 pts); in all these pts restenosis was angiographically evidenced (75-99%). CONCLUSIONS: Our experience suggests that coronary rotational ablation along with complementary PTCA using low inflation pressure and long balloons is safe and effective in type B2 and C lesions if calcifications are present; however, restenosis rate remains high.

[Percutaneous mitral valvuloplasty: the immediate and long-term results]. / Valvuloplastica mitralica percutanea: risultati immediati e a lungo termine.

BACKGROUND: Between December 1988 and December 1992, 235 patients (pts) underwent percutaneous balloon mitral valvuloplasty (PBMV). METHODS AND RESULTS: There were 55 men (23%) aged 49 +/- 13 years and 180 women (77%) aged 51 +/- 13 years. Previous surgical commissurotomy (PSC) had been performed in 22 pts. Procedure was successful (area > 1.5 cm2 or area increase > or = 50% without mitral regurgitation > 2+) in 91.9% of pts, with increase in mitral valve area from 1.05 +/- 0.2 to 2.26 +/- 0.6 cm2, decrease of transvalvular mean pressure gradient from 14.4 +/- 5.5 to 6.05 +/- 4.91 mm Hg and increase of cardiac index from 2.79 +/- 0.75 to 3.17 +/- 0.9 l/m'/m2 (p < 0.001). Insufficient increase in valve area occurred in 3.8% of pts. Major complications included 5 pts with 3+ mitral regulation (MR) requiring mitral valve replacement (MVR), 2 TIA's (0.85%) and 1 pericardiocentesis (0.42%). At follow-up (mean 18.9 months) clinical improvement was achieved in 93.8% of pts (NYHA class from 2.4 to 1.3); mitral valve area was 1.9 +/- 0.4 cm2 and mean mitral valve gradient 5.3 +/- 2.3 mm Hg. Restenosis (area < 1.5 cm2 or > or = 50% loss of initial gain) occurred in 24 pts (10.16%). Six pts required MVR; 1 pt underwent a second successful PBMV. Multivariate study (logistic regression) identified as independent factors of severe MR NYHA class and PSC; echo score, age and basal mean mitral valve gradient were independent factors for restenosis. CONCLUSIONS: In conclusion, PBMV is a safe technique and stable clinical improvement can be obtained in the majority of pts.

Measurement of systemic resistances in aortic regurgitation.

Peripheral resistance is usually measured by dividing mean aortic pressure by mean aortic flow. This statement holds true as long as resistance is constant throughout the heart cycle. This is not the case in aortic regurgitation, because during diastole, but not in systole, a conduit is opened to blood flow through the regurgitating valve. Peripheral resistance was measured in 11 patients with aortic regurgitation and in 23 normal subjects by solving for Ri in the "windkessel" equation. We compared this resistance (R1) with that measured by standard methods (RES). In normal subjects, R1 and RES are almost identical [R1 = 0.96 (RES) +/- 0.12, r = .95], while in aortic regurgitation there is no correlation [R1 = 0.64 (RES) +/- 1.4, r = 0.2]. RES in normal subjects is increased with respect to RES in aortic regurgitation (32 vs 22, p = 0.0019), while R1 in aortic regurgitation is decreased compared to both R1 and RES in normal subjects (13.5 vs 21 and 22, p = 0.0063). The difference between R1 and RES in aortic regurgitation is related to the regurgitating volume. Compliance, calculated by assuming a monoexponential diastolic aortic pressure decay, is markedly decreased in aortic insufficiency, while it is increased if it is calculated by dividing the time constant of aortic pressure decay by R1. Thus, in severe aortic regurgitation peripheral resistance is usually less than normal, and standard methods of measurement fail to detect this fact. Correct evaluation of resistance and compliance may be useful to evaluate ventriculoarterial coupling and to titrate vasodilator therapy in this disease.