Are patients with renal failure good candidates for percutaneous coronary revascularization in the new device era?

BACKGROUND: Patients with end-stage renal disease undergoing conventional balloon angioplasty have reduced procedural success and increased complication rates. This study was designed to determine the immediate and long-term outcomes of patients with varying degrees of renal failure undergoing percutaneous coronary intervention in the current device era. METHODS AND RESULTS: We compared the immediate and long-term outcomes of 362 renal failure patients (creatinine >1.5 mg/dL) with those of 2972 patients with normal renal function who underwent percutaneous coronary intervention between 1994 and 1997. Patients with renal failure were older and had more associated comorbidities. They had reduced procedural success (89.5% versus 92.9%, P:=0.007) and greater in-hospital combined major event (death, Q-wave myocardial infarction, emergent CABG; 10.8% versus 1.8%; P:<0.0001) rates. Renal failure was an independent predictor of major adverse cardiac events (MACEs) (OR, 3.41; 95% CI, 1.84 to 6.22; P:<0.00001). Logistic regression analysis identified shock, peripheral vascular disease, balloon angioplasty strategy, and unstable angina as independent predictors of in-hospital MACEs in the renal group. Compared with 362 age- and sex-matched patients selected from the control group, patients with renal failure had a lower survival rate (27.7% versus 6.1%, P:<0.0001) and a greater MACE rate (51% versus 33%, P:<0.001) at long-term follow-up. Cox regression analysis identified age and PTCA strategy as independent predictors of long-term MACEs in the renal group. Finally, within the renal failure population, the dialysis and nondialysis patients experienced remarkably similar immediate and long-term outcomes. CONCLUSIONS: Although patients with renal failure can be treated with a high procedural success rate in the new device era, they have an increased rate of major events both in hospital and at long-term follow-up. Nevertheless, utilization of stenting and debulking techniques improves immediate and long-term outcomes.

Coronary composition and macrophage infiltration in atherectomy specimens from patients with diabetes mellitus.

BACKGROUND: Lipid-rich, inflamed atherosclerotic lesions are associated with plaque rupture and thrombosis, which are the most important causes of death in patients with diabetes mellitus. This study was designed to quantify lipid composition and macrophage infiltration in the coronary lesions of patients with diabetes mellitus. METHODS AND RESULTS: A total of 47 coronary atherectomy specimens from patients with diabetes mellitus were examined and compared with 48 atherectomy specimens from patients without diabetes. Plaque composition was characterized by trichrome staining. Macrophage infiltration was characterized by immunostaining. Clinical and demographic data were similar in both groups. The percentage of total area occupied by lipid-rich atheroma was larger in specimens from patients with diabetes (7+/-2%) than in specimens from patients without diabetes (2+/-1%; P:=0.01), and the percentage of total area occupied by macrophages was larger in specimens from patients with diabetes (22+/-3%) than in specimens from patients without diabetes (12+/-1%; P:=0.003). The incidence of thrombus was also higher in specimens from patients with diabetes than in specimens from patients without diabetes (62% versus 40%; P:=0.04). Plaque composition, macrophage infiltration, and thrombus were similar in lesions from diabetic patients treated with insulin compared with lesions from patients treated with sulfonylureas or diet. CONCLUSIONS: Coronary tissue from patients with diabetes exhibits a larger content of lipid-rich atheroma, macrophage infiltration, and subsequent thrombosis than tissue from patients without diabetes. These differences suggest an increased vulnerability for coronary thrombosis in patients with diabetes mellitus.

Implications of small reference vessel diameter in patients undergoing percutaneous coronary revascularization.

OBJECTIVES: The purpose of this study was to determine whether small reference diameter of the culprit coronary artery influences the outcome of an attempted percutaneous revascularization procedure in the current era of interventional cardiology. BACKGROUND: Although the interventional strategy is largely determined by the size of the culprit coronary artery, earlier quantitative studies have not shown a worse acute outcome for small reference vessel diameter (< or =2.5 mm). METHODS: A total of 2,306 patients undergoing percutaneous coronary revascularization was divided in groups with reference diameters < or =2.5 mm (n = 813) or >2.5 mm (n = 1,493). Success and in-hospital major adverse cardiac event (death, Q-wave myocardial infarction and emergency coronary artery bypass graft) rates between both groups were compared. RESULTS: Patients with lesions in small vessels were older and presented more frequently with female gender, diabetes mellitus, heart failure, peripheral vascular, multivessel coronary disease and American Heart Association/American College of Cardiology (AHA/ACC) lesion type C (p < or = 0.01, each). Further, utilization of interventional devices differed markedly. In contrast to stents (18.5% vs. 41.9%) and directional atherectomy (3.7% vs. 13.5%), conventional balloon angioplasty (73% vs. 50%) and rotational atherectomy (16.1% vs. 8.3%) were used more often in smaller vessels (p < or = 0.0001, each). Success rate was lower in the small vessel group (92% vs. 95%; p = 0.006). Major adverse cardiac events occurred more frequently in small than large vessels (univariate 3.4% vs. 2.0%, p = 0.03; multivariate odds ratio 2.1, p = 0.02), particularly when proximal coronary segments were compared. CONCLUSIONS: Lesions in vessels with small reference diameter represent a distinct group with respect to clinical and morphologic characteristics as well as device utilization. These lesions have lower chances of successful percutaneous intervention and carry relatively higher risks, specifically when located in proximal coronary segments.

Comparison of early versus late experience with percutaneous mitral balloon valvuloplasty.

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)

Mitral balloon valvuloplasty for mitral restenosis after surgical commissurotomy.

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)

Percutaneous transvenous balloon valvotomy in a patient with severe calcific mitral stenosis.

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.

Atrial septal defect after percutaneous mitral balloon valvuloplasty: immediate results and follow-up.

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)

Percutaneous aortic balloon valvuloplasty: its role in the management of patients with aortic stenosis requiring major noncardiac surgery.

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.

Three-year follow-up of the Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease (ERACI).

OBJECTIVES: The purpose of this study was to report the 3-year follow-up results of the ERACI trial (Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease). BACKGROUND: Although coronary angioplasty has been used with increased frequency in patients with multivessel coronary artery disease, its value, compared with bypass graft surgery, has not been established. Thus, controlled, randomized clinical trials such as the ERACI are needed. METHODS: In this trial 127 patients who had multivessel coronary artery disease and clinical indication of myocardial revascularization were randomized to undergo coronary angioplasty (n = 63) or bypass surgery (n = 64). The primary end point of this study was event-free survival (survival with freedom from myocardial infarction, angina and new revascularization procedures) for both groups of patients at 1, 3 and 5 years of follow-up. RESULTS: Freedom from combined cardiac events (death, Q-wave myocardial infarction, angina and repeat revascularization procedures) was significantly greater for the bypass surgery group than the coronary angioplasty group (77% vs. 47%; p < 0.001). There were no differences in overall (4.7% vs. 9.5%; p = 0.5) and cardiac (4.7% vs. 4.7%; p = 1) mortality or in the frequency of myocardial infarction (7.8% vs. 7.8%; p = 0.8) between the two groups. However, patients who had bypass surgery were more frequently free of angina (79% vs. 57%; p < 0.001) and required fewer additional reinterventions (6.3% vs. 37%; p < 0.001) than patients who had coronary angioplasty. CONCLUSIONS: 1) Freedom from combined cardiac events at 3-year follow-up was greater in patients who had bypass surgery than in those who had coronary angioplasty. 2) The coronary angioplasty group had a higher incidence of recurrence of angina and the need for repeat revascularization procedures. 3) Cumulative cost at 3-year follow-up was greater for the bypass surgery group than for the coronary angioplasty group.

Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease (ERACI): in-hospital results and 1-year follow-up. ERACI Group.

OBJECTIVES: This study was designed to compare freedom from combined cardiac events (death, angina, myocardial infarction) at 1-, 3- and 5-year follow-up in patients with multivessel disease randomized to either percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery. BACKGROUND: Percutaneous transluminal coronary angioplasty has been an effective approach in patients with coronary artery disease, but its role in patients with multivessel coronary artery disease is still controversial. METHODS: One-hundred twenty-seven patients with multivessel disease and lesions suitable for either form of therapy were randomized to either coronary artery bypass grafting (n = 64) or coronary angioplasty (n = 63). In this study we report the immediate results and freedom from combined cardiac events at 1-year follow-up. RESULTS: Demographic, clinical and angiographic characteristics were similar in both groups. There were no differences in in-hospital deaths, frequency of periprocedure myocardial infarction or need for emergency revascularization procedures between the two groups. At 1-year follow-up, there were no differences in mortality or in the incidence of myocardial infarction between the groups. However, patients treated with coronary artery bypass grafting were more frequently free of angina, reinterventions and combined cardiac events than were patients treated with coronary angioplasty (83.5% vs. 63.7%, p < 0.005). In-hospital cost and cumulative cost at 1-year follow-up were greater for the coronary artery bypass grafting than for the coronary angioplasty group. CONCLUSIONS: No significant differences were found in major in-hospital complications between patients treated with coronary artery bypass grafting or coronary angioplasty. Although at 1-year follow-up there were no differences in survival and freedom from myocardial infarction, patients in the coronary artery bypass grafting group were more frequently free from angina, reinterventions and combined events than were patients in the coronary angioplasty group.

Prevalence and timing of regional myocardial dysfunction after rotational coronary atherectomy.

OBJECTIVES: This study aimed to evaluate the prevalence and time course of wall motion abnormalities associated with rotational coronary atherectomy. BACKGROUND: Although initial clinical studies found evidence of transient wall motion abnormalities after rotational coronary atherectomy, the prevalence and duration of these wall motion abnormalities are unknown. METHODS: Using simultaneous echocardiography, we prospectively evaluated 22 patients undergoing rotational atherectomy and compared their wall motion abnormalities with those of 10 patients undergoing coronary angioplasty alone. The extent of wall motion abnormality was quantified and plotted against time to produce curves of abnormal wall motion development and recovery for the two groups. RESULTS: The cumulative ischemic time was similar for the two groups ([mean +/- SD] 10.3 +/- 6 min for rotational atherectomy vs. 9.6 +/- 4.2 min for coronary angioplasty, p = 0.73). The rate of return to baseline function was significantly lower in the rotational atherectomy group than in the coronary angioplasty group (rotational atherectomy rate constant 0.069 +/- 0.079/min vs. coronary angioplasty rate constant 1.250 +/- 0.47/min, p = 0.0001). The mean time to recovery of baseline wall motion in the rotational atherectomy group (153 min, 95% confidence interval [CI] 6.5 to 3,600) was significantly longer than in the coronary angioplasty group (2.6 min, 95% CI 1.3 to 5.5, p = 0.0001). Rotational atherectomy burr time was longer in the patients who developed myocardial infarction than in those without myocardial infarction (4.7 +/- 2.4 vs. 3 +/- 1.4 min, p = 0.045). CONCLUSIONS: Transient wall motion abnormalities are common after rotational coronary atherectomy and have a longer duration than those observed after coronary angioplasty. This disparity may be a consequence of differences in the mechanisms by which rotational coronary atherectomy and coronary angioplasty produce their effect.

Differentiation of restrictive cardiomyopathy from pericardial constriction: assessment of diastolic function by radionuclide angiography.

Diastolic filling variables were studied in 12 patients with the hemodynamic features of constriction, of whom 5 had restrictive cardiomyopathy, 5 had pericardial constriction and 2 had combined pericardial constriction and restrictive cardiomyopathy. The values were compared with those in 10 normal subjects of comparable age. The filling fractions between 10% and 70% of the diastolic time interval were greater in patients with pericardial constriction than in those with restrictive cardiomyopathy (p less than 0.01 between 20% and 50%, p less than 0.05 at 10%, 60% and 70%), with no overlap. The filling fractions in patients with pericardial constriction were also greater than those in normal subjects between 10% and 60% of the diastolic time interval. The filling fraction was lower in patients with restrictive cardiomyopathy than in normal subjects at 40% of the diastolic time interval (p less than 0.05). The time to peak filling rate in patients with pericardial constriction was shorter (110 +/- 14 ms) than in those with restrictive cardiomyopathy (195 +/- 45 ms, p less than 0.01) or in normal subjects (173 +/- 32 ms, p less than 0.01). The percent of atrial contribution to left ventricular filling was higher in those with restrictive cardiomyopathy (45 +/- 17%) than in those with pericardial constriction (21 +/- 6%, p less than 0.05) or in normal subjects (24 +/- 9%, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous mitral balloon valvotomy in patients with calcific mitral stenosis: immediate and long-term outcome.

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.

The role of percutaneous aortic balloon valvuloplasty in patients with cardiogenic shock and critical aortic stenosis.

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.

Underestimation of prosthetic mitral valve areas: role of transseptal catheterization in avoiding unnecessary repeat mitral valve surgery.

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.

Echocardiography can predict which patients will develop severe mitral regurgitation after percutaneous mitral valvulotomy.

OBJECTIVES: Using two-dimensional echocardiography, we sought to identify features that are associated with severe mitral regurgitation after percutaneous mitral valvulotomy and combine them into a predictive score. BACKGROUND: Severe mitral regurgitation after percutaneous mitral valvulotomy is a major complication carrying an adverse prognosis that, to date, has not been predictable in advance. METHODS: In a consecutive series of 566 patients who underwent percutaneous mitral valvulotomy, 37 (6.5%) developed severe mitral regurgitation (assessed by angiography) after the procedure, 31 of whom had an echocardiogram available before percutaneous mitral valvulotomy. These 31 patients were matched by age, gender, mitral valve area and degree of mitral regurgitation before valvulotomy with 31 randomly selected patients who did not develop severe mitral regurgitation after percutaneous mitral valvulotomy. An echocardiographic score was developed on the basis of the pathologic studies of valves of patients who developed severe regurgitation after percutaneous mitral valvulotomy (leaflet rupture of relatively thin portions of nonhomogeneously thickened leaflets in the presence of commissural and subvalvular calcification) and evaluated uneven distribution of thickness in the anterior and posterior mitral leaflets, degree of commissural disease and subvalvular disease involvement, with each component graded from 0 to 4 (total, 0 to 16). Intraobserver and interobserver variability for score assessment were 6% and 7%, respectively. RESULTS: The total mitral regurgitation echocardiographic score was significantly greater in the severe mitral regurgitation group (11.7 +/- 1.9 [mean +/- SD] vs. 8.0 +/- 1.2, p < 0.001). In addition, the component grades for the anterior leaflet (3.2 +/- 0.7 vs. 2.3 +/- 0.6, p < 0.001), commissures (2.6 +/- 0.7 vs. 1.6 +/- 0.6, p < 0.001) and subvalvular apparatus (3.2 +/- 0.6 vs. 2.3 +/- 0.7, p < 0.001) were also higher in the mitral regurgitation group. With a total score > or = 10 as a cutoff point for predicting severe mitral regurgitation after percutaneous mitral valvulotomy, a sensitivity of 90 +/- 5% and a specificity of 97 +/- 3% were obtained. Stepwise logistic regression analysis identified the mitral regurgitation echocardiographic score as the only independent predictor for developing severe mitral regurgitation after percutaneous mitral valvulotomy (p < 0.0001). CONCLUSIONS: This new mitral regurgitation echocardiographic score can predict the development of severe mitral regurgitation after percutaneous mitral valvulotomy and can be useful in the selection of patients for this technique.

Exercise capacity and systolic and diastolic ventricular function after recovery from acute dilated cardiomyopathy.

OBJECTIVES: This study was undertaken to determine whether abnormalities in exercise capacity or ventricular function persist after recovery from acute dilated cardiomyopathy. BACKGROUND: Persistent ventricular structural abnormalities could cause abnormalities in exercise capacity or ventricular function. METHODS: The results of rest and exercise first-pass radionuclide ventriculography in 18 patients who were seen within 6 months of the onset of dilated cardiomyopathy and subsequently had a normal rest left ventricular ejection fraction were compared with those of age- and gender-matched control subjects. RESULTS: Patients were studied 144 +/- 34 (mean +/- SEM) days after the onset of left ventricular dysfunction at a time when heart failure symptoms had resolved. Patients with myocyte necrosis, as assessed by endomyocardial biopsy (n = 13) or antimyosin scintigraphy (n = 12), recovered more rapidly than did those without necrosis. Oxygen consumption both at peak exercise (17.7 +/- 1.2 vs. 26.1 +/- 1.5 ml/kg per min, p < 0.05) and at the anaerobic threshold (11.1 +/- 0.5 vs. 17.1 +/- 1.3 ml/kg per min, p < 0.05) was lower in the patients who had recovered from cardiomyopathy than in control subjects. Rest and exercise end-systolic and end-diastolic left ventricular volumes were greater in the patients than in the control subjects, although stroke volumes were similar. Left ventricular filling at rest was lower at diastolic filling intervals of 40% and 90%, and rest and exercise left ventricular early peak filling rate normalized for end-diastolic volume was slower in the patients than in the control subjects. At long-term follow-up of 1,082 +/- 206 days, two patients had a return of heart failure symptoms and a decrease in left ventricular ejection fraction. CONCLUSIONS: Despite the apparent normalization of rest left ventricular ejection fraction, patients who have recovered from dilated cardiomyopathy have abnormalities in aerobic exercise capacity and in left ventricular systolic and diastolic performance.

Significant tricuspid regurgitation is a marker for adverse outcome in patients undergoing percutaneous balloon mitral valvuloplasty.

OBJECTIVES: This study examined the association between the presence of tricuspid regurgitation and immediate and late adverse outcomes in patients undergoing balloon mitral valvuloplasty. BACKGROUND: Significant tricuspid regurgitation has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery for mitral stenosis. METHODS: We studied 318 consecutive patients (mean [+/- SD] age 54 +/- 15 years) who underwent balloon mitral valvuloplasty and had color Doppler echocardiographic studies before the procedure. Patients were classified into three groups: 221 with no or mild (69%), 60 with moderate (19%) and 37 with severe (12%) tricuspid regurgitation. Clinical follow-up ranged from 6 to 62 months. RESULTS: Before mitral valvuloplasty, increasing degrees of tricuspid regurgitation were associated with a smaller initial mitral valve area (p < 0.05), higher echocardiographic score (p < 0.05), lower cardiac output (p < 0.01) and higher pulmonary vascular resistance (p < 0.01). Although the initial success rate did not differ significantly between groups, patients with a higher degree of tricuspid regurgitation had less optimal results, as reflected by a smaller absolute increase in mitral valve area (1.02 vs. 0.9 vs. 0.7 cm2, p < 0.01). The estimated 4-year event-free survival rate (freedom from death, mitral valve surgery, repeat valvuloplasty and heart failure) was lower for the group with severe tricuspid regurgitation (68% vs. 58% vs. 35%, p < 0.0001). At 4 years, 94% of patients with mild tricuspid regurgitation were alive compared with 90% and 69%, respectively, of patients with moderate or severe tricuspid regurgitation (p < 0.0001). Cox proportional analysis identified tricuspid regurgitation as an independent predictor of late outcome (p < 0.001). CONCLUSIONS: Patients with mitral stenosis and severe tricuspid regurgitation undergoing mitral valvuloplasty have advanced mitral valve and pulmonary vascular disease, suboptimal immediate results and poor late outcome.

Echocardiographic evaluation of mitral valve structure and function in patients followed for at least 6 months after percutaneous balloon mitral valvuloplasty.

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.

Mitral regurgitation after percutaneous balloon mitral valvuloplasty in adults: evaluation by pulsed Doppler echocardiography.

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.