Angiographic demonstration of spontaneous occlusion of systemic arterial supply in pulmonary sequestration.

We describe the first angiographic demonstration of spontaneous occlusion of the arterial supply of a right lower lobe pulmonary sequestration. Intralobar pulmonary sequestration was first diagnosed by cardiac catheterization and aortography in a 1-year-old female. Systemic arterial supply was from a branch of the infra-diaphragmatic aorta and venous drainage was to the left atrium. Conservative management was elected, and the patient was followed up with annual exams. Repeat catheterization and aortography, performed to evaluate complaints of chest pain at age 13 years, showed no flow through the previously demonstrated systemic arterial supply from the aorta.

Recurrent pulmonary embolism originating from right atrial myxoma.

The use of transesophageal echocardiography is a useful adjunct to transthoracic echocardiography in the diagnosis and management of right atrial tumors in patients who are thought to have idiopathic recurrent pulmonary embolism, especially with suboptimal transthoracic echocardiography studies. We describe a 30-year-old woman with a history of recurrent pulmonary embolism who was admitted for investigation of pleuritic chest pain in whom transesophageal echocardiography played a critical role in the diagnosis and management.

Successful balloon angioplasty of a coarctation in an infant <500 g.

We describe the first successful balloon angioplasty of a coarctation in a 460-g newborn infant with coarctation of the aorta and heart failure. A coronary angioplasty catheter was positioned across the coarctation via a transumbilical approach. The waist of the balloon disappeared on maximal inflation and there was an increase in blood pressure distal to the coarctation and the clinical status improved. A ductus arteriosus was ligated 4 days after angioplasty.

Aortic atherosclerosis and stroke.

METHODS: Studies using transesophageal echocardiography (TEE) suggest aortic atherosclerosis may be a risk factor for stroke, particularly stroke of undetermined mechanism, but controls in prior studies were not balanced for vascular risk factors. We used TEE to evaluate aortic atherosclerosis in 60 patients with stroke compared with a high-risk control population of 46 subjects. We also examined the possible association of plasma viscosity and fibrinogen levels to aortic atherosclerosis. RESULTS: The mean maximal plaque thickness (MMPT) was similar for the control (2.8 +/- 3.6 mm) and the stroke group (3.3 +/- 3.5 mm), but varied with stroke mechanism. The MMPT was similar in stroke of undetermined and atherosclerotic mechanism [3.5 +/- 4 mm (n = 25) and 4.2 +/- 4.3 mm (n = 16), respectively], significantly greater than in stroke of other mechanisms (1.7 +/- 1.2 mm, P < .05, n = 19). Patients with stroke of undetermined mechanism were four times more likely (95% confidence interval [CI] 1.2-12) to have plaques >/=5 mm compared with controls. Ulcerated plaque was associated with plaque thickness (P < .001) and plasma viscosity (P < .001). CONCLUSIONS: Aortic atherosclerosis is associated with stroke of undetermined cause suggesting atherosclerosis is a cause of stroke of undetermined etiology. Plaque ulceration was associated with the thickness of aortic plaque and plasma viscosity.

Percutaneous balloon coarctation angioplasty: long-term results.

One hundred and ten patients, age 2 days to 35 years (mean 7.0 +/- 7.0 years), have undergone 118 percutaneous balloon angioplasty procedures for discrete coarctation of the aorta since April 1982. The mean systolic gradient was significantly decreased from 48 +/- 22 to 8 +/- 7 mmHg after angioplasty (P less than 0.0001). Long-term results were evaluated in 95 patients, by follow-up catheterization in 30 and Doppler echocardiography in 65 patients. The follow-up period was 1-9 years (4.2 +/- 2.1). At follow-up the mean residual gradient was 9 +/- 8 mmHg. On the basis of follow-up data, four groups of patients were identified: group I consisted of 53 patients over 3 months of age with native coarctation of the aorta; group II consisted of 13 patients with postoperative coarctation restenosis; group III consisted of 21 infants 3 months of age or younger with native coarctation of the aorta; and group IV consisted of eight infants who developed postdilatation restenosis. Patients in groups I and II had good results and required no redilatation or surgical repair. In group III successful redilatation in eight and surgical repair in seven infants were performed 1 month to 5 years after the initial dilatation. There were no mortalities related to the 118 dilatation procedures. Of the seven patients who had surgical repair of the coarctation and the associated cardiac anomalies, four expired in the immediate postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon pulmonary valvuloplasty: results of the Valvuloplasty and Angioplasty of Congenital Anomalies Registry.

Eight hundred twenty-two balloon pulmonary valvuloplasties were reported to the Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Before and after systolic outflow gradients were recorded in 784 valvuloplasties, and the gradient decreased from 71 +/- 33 to 28 +/- 21 mm Hg. The sites of residual obstructions could be ascertained in 196 patients. In these, the total systolic outflow gradients decreased from 85 +/- 41 mm Hg to 33 +/- 27 mm Hg. Of this total residual gradient, 16 +/- 15 mm Hg was transvalvar and 18 +/- 24 mm Hg was infundibular. The degree to which infundibular obstruction subsequently resolved was not determined in this study. The procedure was less effective in reducing outflow gradients in patients with dysplastic valves with or without Noonan's syndrome. There were 5 major complications (0.6%), including 2 deaths (0.2%), a cardiac perforation with tamponade (0.1%) and 2 tricuspid insufficiencies (0.2%). There were 11 minor complications (1.3%) and 21 incidents (2.6%). The incidence of major complications, minor complications and incidents was inversely related to age; it was substantially higher in infants and, in particular, neonates. Balloon pulmonary valvuloplasty is a safe and effective method of lowering pulmonary outflow gradients in infants, children and adults. Small transvalvar and varied infundibular gradients commonly are present at the end of the procedure. Assessing the full effect of the procedure requires intermediate-term follow-up and assessing the duration of relief requires long-term follow-up.

Bronchopulmonary sequestration.

Bronchopulmonary sequestration is an area of lung parenchyma that is devoid of normal connection to the trachebronchial tree. Arterial supply is from an aberrant systemic artery, usually a branch of the aorta. There are two broad types of bronchopulmonary sequestration: intralobar and extralobar. The former shares a common pleura with the lung while the latter is separated by its own pleura. Definitive therapy requires pulmonary resection.

[Percutaneous transluminal balloon dilatation of discrete membranous subvalvular aortic stenosis]. / Perkutane transluminale Ballondilatation der rein membranösen subvalvulären Aortenstenose (DMSS).

Discrete membranous subaortic stenosis (DMSS) which is localized immediately subvalvular and can be differentiated from fibromuscular stenosis of the left ventricular outflow tract, represents theoretically a well-suited lesion for uncomplicated balloon dilatation. The practical use of balloon dilatation for treatment of DMSS has been reported by two groups [6, 10]. In this overview, we will report our experience with balloon dilatation of DMSS in six children. Between June, 1986 and June, 1987, balloon dilatation of DMSS was carried out in six male children ranging in age from four to ten years (Table 2). In one child, coarctation of the aorta had been present and was previously treated successfully with balloon dilatation. In two children, the aortic valve was thickened with or without stenosis. All children had mild aortic regurgitation. After transvenous right heart catheterization and transarterial left heart catheterization including levocardiography and supraaortic angiography, 50 units of heparin per kilogram of body weight were administered and a guidewire advanced to the left ventricle for positioning of the balloon catheter in the left ventricular outflow tract. The choice of balloon diameter was based on measurement of the angiographically-determined aortic ring diameter (Table 1). Pressure measurements were obtained by means of a diagnostic catheter after the dilatation. No complications were observed either during or immediately after the intervention. After the dilatation, all children were discharged from the hospital to go home. Pressure in the left ventricle was reduced from 225 +/- 55 to 116 +/- 29 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous transvenous antegrade balloon angioplasty in aortic isthmus stenosis]. / Perkutane transvenöse antegrade Ballonangioplastie bei Aortenisthmusstenose.

Balloon angioplasty of native or postoperative coarctation of the aorta has been recommended as an alternative method to surgical treatment. On use of the retrograde approach via the femoral artery, after introduction of the catheter into a vessel of narrow lumen, not infrequently, injury or obstruction was observed. This overview summarizes our experience primarily on use of antegrade balloon angioplasty for coarctation of the aorta, the first description of which was published as a case report in 1986. Between December, 1985, and September, 1987, balloon angioplasty was carried out for native coarctation of the aorta in seven neonates, age two to 30 days. Concomitant cardiovascular anomalies included ventricular septal defect in five, patent ductus arteriosus in five, mitral valve atresia in two and transposition of the great arteries with and without double outlet right ventricle in two (Table 1). Prior to balloon angioplasty for coarctation, in four neonates therapeutic balloon atrial septostomy had been performed. For balloon angioplasty, via the right femoral vein, an end-hole catheter was advanced into the right ventricle. In five neonates, the catheter could be advanced into the ascending aorta directly from the right ventricle or through a ventricular septal defect. In the two other neonates, the catheter was advanced via the foramen ovale and the mitral valve into the left ventricle and the ascending aorta. Pressure was measured by the end-hole catheter as well as in the femoral artery after direct puncture.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative balloon pulmonary valvuloplasty.

Closed operative pulmonary valvulotomy for relief of critical pulmonary valve stenosis can be performed effectively by intraoperative use of a balloon catheter without inflow occlusion or hemodynamic instability and with minimal blood loss. Follow-up evaluation indicates adequate growth of the valve.

Morphologic effects of percutaneous balloon pulmonary valvuloplasty.

Five patients with pulmonary valve stenosis and other cardiac anomalies had elective operative repair after percutaneous balloon pulmonary valvuloplasty. Four had reduction in pulmonary valve gradients from 67 +/- 9 mm Hg to 39 +/- 9 mm Hg (P less than .01), whereas one patient with a dysplastic pulmonary valve did not. Operative evaluation of the pulmonary valves revealed the morphologic effects of the balloon forces on the stenotic valves to be commissure splitting in one patient, cusp tear in one patient, and a combination of commissure splitting and cusp avulsion in two patients. There were no deaths. Patients with combined infundibular and pulmonary valve stenosis have a high potential for cusp avulsion due to fixation of the balloon in the infundibulum and retraction of the balloon into the ventricle during systole. Echocardiography, cardiac catheterization pressure gradients, and cineangiography should be used to assess infundibular stenosis and avoid percutaneous balloon angioplasty in patients who have combined pulmonary valve stenosis and infundibular pulmonary stenosis.

Transluminal balloon dilatation for discrete subaortic stenosis.

Ten children, 10 weeks to 18 years old, with discrete subaortic stenosis (DSS) underwent transluminal balloon dilatation of the subaortic obstruction. The DSS was visualized by 2-dimensional echocardiography and cineangiography. Six patients had a thin discrete "membrane" immediately below the aortic valve (group I) and 4 patients had a thicker fibromuscular ring about 1 cm below the aortic valve (group II). In group I, the mean gradient decreased from 82 +/- 49 mm Hg (range 35 to 164) to 22 +/- 15 mm Hg (range 5 to 40); in group II, it decreased from 155 +/- 18 mm Hg (range 132 to 177) to 85 +/- 44 mm Hg (range 60 to 150). Three patients had follow-up cardiac catheterization 1 year later. Their mean gradient soon after the procedure was 37 +/- 23 mm Hg. On follow-up, it was still 37 +/- 19 mm Hg, indicating persistence of relief of the obstruction. Because of the high residual gradient in group II, 3 patients had surgical relief of the obstruction. The degree of aortic regurgitation present before the dilatation in all 10 patients did not change after the procedure. The mechanism of relief of the obstruction was by tearing of the subaortic membrane. Our data suggest that relief of subaortic obstruction is more favorable in the thin, membranous DSS.

Successful balloon valvuloplasty for neonatal critical aortic stenosis.

Transluminal balloon aortic valvuloplasty was performed in two term neonates, ages 6 and 7 days, with critical aortic stenosis. Transluminal balloon coarctation angioplasty was also performed in the second neonate. The neonates presented in congestive heart failure and underwent unsuccessful treatment with digoxin, furosemide, and careful fluid management before balloon dilatation. In the first patient, the gradient across the aortic valve was reduced from 75 mm Hg before balloon aortic valvuloplasty to 34 mm Hg after the procedure. The second neonate showed clinical improvement after both dilatation procedures. In both patients, follow-up clinical and Doppler echocardiography findings suggest persistent improvement 5 months after the procedure.

Transluminal balloon coarctation angioplasty: experience with 27 patients.

Transluminal balloon angioplasty (BA) was performed in 27 consecutive patients with coarctation of the aorta (COA), including 7 infants with preductal COA, 7 patients with restenosed COA after surgical repair, and 13 older children and 1 adult with unoperated COA. The patients were 4 days to 27 years old. The balloon was positioned across the COA and inflated sequentially to pressures of 100 and 120 psi, each inflation lasting for 5 to 10 seconds. Peak systolic pressure gradient (PSG) across the COA was recorded and an aortogram was performed before and immediately after BA. PSG also was recorded during follow-up studies performed in 13 patients 3 to 24 months after BA. BA was performed without complications in each patient. Immediately after BA, the mean PSG was reduced from 49 +/- 21 to 10 +/- 7 mm Hg (p less than 0.01), and the mean COA diameter increased from 3.9 +/- 1.4 to 9.6 +/- 3.6 mm (p less than 0.01). After a follow-up period of 3 to 24 months, the mean PSG remained low (15 +/- 11 mm Hg) and the mean COA diameter increased to 10.5 +/- 4.6 mm. BA can be performed safely. It can be a useful palliative treatment in seriously ill infants with COA.

Assessment of percutaneous balloon pulmonary and aortic valvuloplasty.

Percutaneous balloon pulmonary or aortic valvuloplasty was performed in 66 consecutive patients with no deaths. The transvalvular pressure gradient was reduced from 85 +/- 35 to 30 +/- 15 mm Hg (p less than 0.01) in 39 patients with congenital pulmonary valve stenosis and from 108 +/- 46 to 32 +/- 16 mm Hg (p less than 0.01) in 27 patients with congenital aortic valve stenosis. Subsequent mild aortic regurgitation occurred in seven patients and moderate regurgitation occurred in one patient. Operative evaluation of seven patients with pulmonary valve stenosis who had additional cardiac anomalies revealed the mechanisms of valve opening to be commissural splitting, cusp tear, or avulsion of the cusp from the anulus. Operative evaluation of two patients with residual high aortic valve gradients revealed minor degrees of commissural splitting. Although further evaluation is required to determine the long-term effects, early evaluation indicates that percutaneous balloon valvuloplasty may be useful in the definitive treatment of isolated pulmonary valve stenosis in some patients and of palliative value in others. The procedure is considered palliative in patients with aortic valve stenosis.