Complications of cardiac catheterization in the current era: a single-center experience.

Consecutive cardiac catheterization procedures done over a 2-yr period (April 1996 to March 1998) were prospectively analyzed to determine and characterize procedure-related complications (in-hospital and 1-mo follow-up), as they occur at present. During the study period, 11,821 procedures (7,953 diagnostic and 3,868 therapeutic) were performed. The majority of procedures (> 60%) were done in high-risk patients. Stents were implanted in 33% of patients, and adjunctive abciximab was used in 6.6% of therapeutic procedures. The overall complication rate was 8% (3.6% of diagnostic procedures and 15.1% of therapeutic procedures). The procedure-related mortality rates were 0.2%, 0.1%, and 0.5% for total, diagnostic, and therapeutic procedures, respectively. Cardiac complications were seen in 3.9% (1.5% of diagnostic and 9% of therapeutic procedures). Emergency cardiac surgery was required in 0.05% of the diagnostic procedure group and 0.3% of the therapeutic procedure group (total, 0.1%). Despite marked changes in patient population and practice, the complication rates of cardiac catheterization remain very low.

Left main stenting-as a bridge to surgery-for acute type A aortic dissection and anterior myocardial infarction.

Acute anterior wall myocardial infarction is a rare but often catastrophic presentation of ascending aortic dissection. We report the case of a patient who was successfully treated by direct stenting of the left main coronary artery, allowing for definitive surgical correction.

Double vessel occlusions after balloon angioplasty treated by stenting and subsequently by abciximab infusion.

Stent thrombosis is a serious complication after percutaneous coronary intervention. A patient is presented with a double vessel occlusion after balloon angioplasty and subsequent stenting. He was then managed by abciximab therapy alone. Control angiography showed complete resolution of the thrombotic occlusions. His subsequent clinical course was uneventful.

Effects of probucol on vascular remodeling after coronary angioplasty. Multivitamins and Protocol Study Group.

BACKGROUND: We have shown that probucol reduces restenosis after balloon angioplasty. Whether probucol acted via prevention of neointimal formation or improvement in vascular remodeling could not be addressed by angiography and required the use of intravascular ultrasound (IVUS). METHODS AND RESULTS: Beginning 30 days before angioplasty, 317 patients were randomly assigned to receive probucol, multivitamins, combined treatment, or placebo. Patients were then treated for 6 months after angioplasty. IVUS examination was performed immediately after angioplasty and at follow-up in 94 patients (111 segments). The cross section selected for serial analysis was the one at the angioplasty site with the smallest lumen area at follow-up. In the placebo group, lumen area decreased by -1. 21+/-1.88 mm2 at follow-up, and wall area and external elastic membrane (EEM) area increased by 1.50+/-2.50 and 0.29+/-2.93 mm2, respectively. Change in lumen area, however, correlated more strongly with the change in EEM area (r=0.53, P=0.002) than with the change in wall area (r=-0.13, P=0.49). Lumen loss was -1.21+/-1.88 mm2 for placebo, -0.83+/-1.22 mm2 for vitamins, -0.25+/-1.17 mm2 for combined treatment, and -0.15+/-1.70 mm2 for probucol alone (P=0.002 for probucol, P=0.84 for vitamins). Change in wall area was similar for all groups. EEM area increased by 0.29+/-2.93 mm2 for placebo, 0. 09+/-2.33 mm2 for vitamins only, 1.17+/-1.61 mm2 for combined treatment, and 1.74+/-1.80 mm2 for probucol only (P=0.005 for probucol). CONCLUSIONS: Lumen loss after balloon angioplasty is due to inadequate vessel remodeling in response to neointimal formation. Probucol exerts its antirestenotic effects by improving vascular remodeling after angioplasty.

Development of coronary aneurysm after cutting balloon angioplasty: assessment by intracoronary ultrasound.

We report the case of a coronary aneurysm observed 6 mo after cutting balloon angioplasty complicated by a mild perforation. Intravascular ultrasound allowed characterization of the malformation as a true aneurysm. The clinical course was uneventful.

Reduced pulmonary clearance of endothelin-1 in pulmonary hypertension.

OBJECTIVE: Pulmonary hypertension (PHT) is associated with increased endothelin-1 (ET-1) levels that correlate with the severity of the disease. The pulmonary circulation is an important site for ET-1 metabolism and may modulate plasma ET-1 through an increase in production, a reduction in removal, or a combination of both. We measured and compared pulmonary metabolism of circulating ET-1 in controls and in patients with PHT. METHODS AND RESULTS: The indicator-dilution technique was combined with measurements of ET-1 levels to quantify pulmonary metabolism of ET-1 in controls (n = 13) and in patients with PHT (n = 17). ET-1 levels doubled in PHT (p < 0.05) and, although there was no difference between aortic and pulmonary artery levels in controls (0.68+/-0.09 and 0.61+/-0.08 pg/ml, respectively, p = 0.22), they tended to be higher in PHT (1.23+/-0.26 vs 1.07+/-0.19 pg/ml, p = 0.08). Pulmonary extraction of tracer iodine-125-ET-1 was reduced from 47%+/-2.0% in the controls to 34%+/-3.6% in PHT (p = 0.005) and inversely correlated with the severity of pulmonary hypertension (r = -0.524, p = 0.03). Consequently, circulating ET-1 clearance was reduced by PHT from 1424+/-77 ml/min to 892+/-119 ml/min (p < 0.001). Pulmonary production of circulating ET-1 (in picograms per minute) was not different but the quantity of ET-1 that survives passage through the lungs was increased by PHT (1860+/-359 pg/min vs 992+/-152 pg/min, p = 0.037). CONCLUSION: PHT is associated with a reduced pulmonary clearance of ET-1 that contributes to the increase in circulating levels.

Management of resistant coronary lesions by the cutting balloon catheter: initial experience.

Resistant coronary lesions remain a challenge for modern angioplasty. Classical approaches include high-pressure inflations, prolonged inflations, or balloon oversizing. More recently, new technologies like rotablator, atherectomy, or laser have been proposed as adjunct to balloon angioplasty for the treatment of these specific lesions. However, all these technologies remain more difficult to handle, costly, and they do not offer long-term benefit over conventional methods. Therefore, a simple device such as the cutting balloon catheter which has been developed from a standard over the wire balloon catheter, may prove to be useful in resistant coronary lesions. We present our single center experience using the new cutting balloon catheter in six resistant lesions.

Predictive factors of restenosis after multivessel percutaneous transluminal coronary angioplasty.

To evaluate the rate and predictive factors of restenosis after multivessel percutaneous transluminal coronary angioplasty (PTCA), 122 consecutive patients with multivessel PTCA performed in the same setting were included in a prospective study. Systematic angiographic control at 6 months was performed in 112 patients (92%). Restenosis (increase > 20% and stenosis > 50%) was found in 62 patients (55%) and 82 of 254 segments (32%) were dilated. Statistical analysis identified the number of successfully dilated segments as the only predictor of restenosis by patient (2.4 +/- 0.7 vs 2.0 +/- 0.7; p < 0.03), and the greater degree of residual stenosis as the only predictor of restenosis by lesion (30 +/- 14% vs 23 +/- 12%; p < 0.005). Twenty-two of 62 restenosed patients (35%) were asymptomatic (group 1). Baseline clinical and angiographic characteristics of these patients were similar to those with symptomatic restenosis (n = 40; group 2) and without restenosis (n = 50; group 3). Repeat revascularization for restenosis was used only in symptomatic patients (re-PTCA in 36; bypass surgery in 4). After a mean follow-up of 75 +/- 24 months, clinical status, and rates of cardiac death and myocardial infarction were similar in the 3 groups. Medical care was similar in groups 1 and 3, and higher in group 2. However, the rate of repeat revascularization for progression of disease was similar in the 3 groups (29%). In conclusion, restenosis is a frequent event after multivessel PTCA and is strongly related to the number of successfully dilated segments.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical relevance of the low correlations between Doppler and hemodynamic measurements before and after balloon mitral commissurotomy.

The aim of this study was to evaluate the clinical consequences of the poor correlations between Doppler and hemodynamic measurements before and after balloon mitral commissurotomy (BMC). From March 1987 to December 1991, 317 patients with symptomatic mitral stenosis were selected for BMC at the Montreal Heart Institute. Despite the low correlation coefficients between Doppler and hemodynamic measurements before BMC (transmitral gradient: r = 0.57, mitral valve area: r = 0.35, mitral regurgitation: r = 0.33), the positive predictive value of Doppler echocardiography to select patients for BMC was 96%. Hemodynamic success, defined as a final mitral valve area greater than 1.5 cm2 and an increase in mitral valve area of more than 25% was obtained in 204 (80%) of the 253 patients who completed the procedure without complications. Doppler and hemodynamic mitral valve area increase were poorly correlated (r = 0.2) but the sensitivity and specificity of Doppler in the diagnosis of hemodynamic success were 86% and 63% respectively. A prospective six month echocardiography and hemodynamic re-examination was performed in our 50 patients first treated by BMC. Hemodynamic restenosis, defined as a loss of more than 50% of the gain achieved in mitral valve area and a mitral valve area of less than 1.5cm2 were diagnosed in 12 (26%) of the 46 patients with initially successful BMC. Despite a low correlation between Doppler and hemodynamic mitral valve area measurements (r = 0.28), the sensitivity and specificity of echocardiography in the diagnosis of hemodynamic restenosis were 66% and 88% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon mitral commissurotomy for mitral restenosis after surgical commissurotomy.

Balloon mitral commissurotomy (BMC) was performed in 113 patients. Of these patients, 27 (24%) (25 women and 2 men, aged 49 +/- 13 years) had recurrent mitral stenosis 13 +/- 6 years (range 5 to 29) after surgical commissurotomy. Eleven patients (41%) were considered at high risk for surgery. BMC resulted in an increase in mitral valve area from 1.1 +/- 0.3 to 1.9 +/- 0.7 cm2 (p < 0.0001), and a decrease in mean mitral gradient from 16 +/- 7 to 6 +/- 3 mm Hg (p < 0.0001). An optimal result of BMC (increase in valve area > or = 25% with a post-BMC valve area > or = 1.5 cm2) was obtained in 18 patients (67%). The results did not differ from those observed in the 86 patients of our entire series without prior surgical commissurotomy. Patients with an optimal result of BMC had a more recent surgical commissurotomy and lesser morphologic alterations of the mitral valve than did those with a nonoptimal result. Patients with echocardiographic scores < 10 had an 80% success rate of BMC; however, this rate decreased to 29% for those with scores > or = 10. One patient (4%) died from a cerebrovascular accident. Clinical follow-up at 1 year showed persistent clinical improvement in 89% of patients with an optimal result of BMC; 72% were in New York Heart Association class I and 17% in class II.(ABSTRACT TRUNCATED AT 250 WORDS)

Five- to ten-year outcome after multivessel percutaneous transluminal coronary angioplasty.

The early and late outcome of patients who underwent multivessel percutaneous transluminal coronary angioplasty (PTCA) in a 1-stage procedure are described, and the predictors for clinical event and new revascularization procedure are identified. Of 1,937 patients treated by PTCA between 1981 and 1986, 203 (10.4%) had multivessel PTCA in a 1-step procedure. A follow-up extending to 71 +/- 23 months was obtained in 195 patients (96%). Primary success was achieved in 91% of 494 attempted sites, and complete revascularization in 65% of 203 patients. There were no in-hospital deaths. Acute complications occurred in 13 patients (6.4%), including non-Q-wave (n = 8) and Q-wave (n = 5) infarction, and urgent coronary artery bypass surgery (n = 3). Before PTCA, 126 patients (62%) were in class III or IV of the Canadian Cardiovascular Society classification; at follow-up, 84% were angina-free or in class I. Death occurred in 14 patients and nonfatal myocardial infarction in 18. Angiographic restenosis was diagnosed in 37.2% of dilated lesions in 96 patients (60% of 159 restudied). A repeat revascularization procedure for restenosis or progression of disease, or both, was needed in 92 symptomatic patients (47%). The survival rate at 7 years without the need for surgery or PTCA was 53%, and cardiac survival without myocardial infarction was 85.5%. The only independent predictor of cardiac death was ejection fraction (p < 0.001). The rate of restenosis per patient was primarily determined by the number of segments dilated, whereas progression of disease was related to the number of nonsignificant coronary artery stenoses (< 50%) at baseline (p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[Short- and mid-term results of percutaneous mitral valve commissurotomy for restenosis after surgical commissurotomy]. / Résultats à court et moyen terme de la commissurotomie mitrale percutanée pour resténose après commissurotomie chirurgicale.

Fifty nine of the 280 percutaneous mitral valvuloplasties (21%) performed between March 1987 and December 1991 at the Montreal Heart Institute were carried out for symptomatic mitral restenosis 15 +/- 6 years after surgical commissurotomy. The patients were selected according to echocardiographic criteria. The mitral valve disease was comparable to that of patients without previous surgical commissurotomy. Patients with good hemodynamic result had undergone surgical commissurotomy more recently and had less severe valvular damage than patients with an incomplete (n = 10) or poor result (n = 7). One patient died of a cerebral embolism during the procedure, two patients underwent emergency surgery for a mitral valve rupture and 4 patients had an atrial septal defect with Qp/Qs ratio greater than 1.5 by oximetry. The numbers of successes and complications were comparable to those observed in patients without previous surgical commissurotomy. The patients who had undergone previous surgical commissurotomy were followed up for 1 year. At 12 months, 4 remained in Class II of the NYHA classification, 44 (74%) were improved by at least 1 functional class and 10 (17%) had required a mitral valve replacement. Percutaneous mitral valvuloplasty is therefore a useful procedure in patients with moderate degrees of valvular disease who develop restenosis after surgical commissurotomy. A functional improvement can be expected in 3/4 of patients Complications related to the procedure are rare and acceptable compared with the risks of a second thoracotomy. Failure of percutaneous mitral valvuloplasty is generally due to the degree of valvular disease which contraindicated surgical commissurotomy and required mitral valve replacement.

Balloon mitral commissurotomy in patients aged > or = 70 years.

Of 280 patients treated by balloon mitral commissurotomy (BMC) between 1987 and 1991, 28 (10%) were > or = 70 years old. Two patients with associated significant aortic stenosis were excluded from the study. Older patients more often were in New York Heart Association class III or IV (84 vs 67%; p < 0.007) and atrial fibrillation (61 vs 36%; p < 0.0001), and had a higher echocardiographic score (9.3 +/- 2 vs 8 +/- 1.6; p < 0.0004) and a lower baseline cardiac index (2.1 +/- 0.6 vs 2.4 +/- 0.6 liters/min/m2; p < 0.03) than younger ones. Baseline mean pulmonary pressure (37 +/- 11 vs 34 +/- 12 mm Hg), transmitral gradient (14 +/- 4 vs 14 +/- 5 mm Hg) and valve area (1.0 +/- 0.4 vs 1.1 +/- 0.3 cm2) were not different between older and younger patients (p = NS). Acute complications during the procedure (including cardiac perforation, embolism, severe mitral regurgitation and surgical atrial shunt), and 30-day mortality after BMC were more frequent in older than younger patients (27 vs 9% [p < 0.01], and 12 vs 0.8% [p < 0.005], respectively). A complete success, defined as a mitral valve area increase > 25% and postmitral valve area > 1.5 cm2 was obtained in 16 of the 22 older patients (72%) with the completed procedure (compared with 81% of younger ones; p = 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term (9 to 33 months) echocardiographic follow-up after successful percutaneous mitral commissurotomy.

Late results after successful percutaneous mitral commissurotomy were assessed by prospective clinical and echocardiographic follow-up. Fifty-seven patients were followed for a mean of 19 +/- 6 months (range 9 to 33) after the procedure. Mitral valve area (measured by Doppler half-time method) increased from 1.0 +/- 0.2 to 2.2 +/- 0.5 cm2 immediately after commissurotomy, and then decreased to 1.9 +/- 0.5 cm2 at follow-up (p less than 0.05), whereas gradient did not change after its immediate postcommissurotomy reduction. Echocardiographic restenosis (mitral valve area less than or equal to 1.5 cm2 with greater than 50% reduction of initial gain) was seen in 12 of 57 patients (21%). Atrial shunting, detected by transthoracic color Doppler in 61% of patients immediately after the procedure (color flow jet through atrial septum), persisted in 30% at follow-up. Restenosis by univariate analysis correlated with age, smaller valve area after the procedure, and higher echocardiographic score. Multivariate analysis identified leaflet mobility and calcifications as the components of a score that was predictive for restenosis. Magnitude of shunt (pulmonary-to-systemic flow ratio greater than 1.5), use of a Bifoil balloon (2 balloons on 1 shaft), and smaller valve area after the procedure were predictors by multivariate analysis of the persistence of atrial shunting. Clinical improvement persisted at long-term follow-up (mean New York Heart Association class 1.6 +/- 0.6 vs 2.6 +/- 0.6 before commissurotomy). Improvement of greater than or equal to 1 functional class was seen in 75% of patients (80% of those without and 58% of those with restenosis); patients with a shunt did not differ from the entire group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of subvalvular disease on results of percutaneous mitral valvotomy]. / Influence de l'atteinte de l'appareil sous-valvulaire sur les résultats de la valvulotomie mitrale percutanée.

In order to study the results of percutaneous mitral valvuloplasty (PMV), subvalvular mitral disease was classified using: 1) the transthoracic echo score (0-4), 2) an index derived from left ventricular angiography defined as the ratio of the distance from the extremity of the papillary muscle and the mitral valve in systole and the distance between the beginning of the aortic root and the apex of the left ventricle in diastole. This index of subvalvular fibrosis could be measured in 80 out of our first 103 PMV performed without complication; the mitral surface are a increased from 1.1 +/- 0.4 to 2.2 +/- 0.8 cm2 (p less than 0.0001). After PMV, mitral regurgitation was observed or was aggravated in 28 patients (35%), by one grade in 25 and by more than one grade in 3. The overall echo score was 8.3 +/- 1.5 and that of subvalvular fibrosis was 2 +/- 0.6. The angiographic index of subvalvular fibrosis was 0.18 +/- 0.04. No correlation was observed between echo and angiographic appreciation of subvalvular fibrosis. Multivariate analyses were selected: 1) the overall echocardiographic score (r = -0.45, p less than 0.0001), but not the angiographic index of subvalvular fibrosis or echocardiographic score of subvalvular fibrosis, was predictive of increase of valve surface area; 2) the absence of mitral regurgitation before PMV (p less than 0.01) and an angiographic index of subvalvular fibrosis less than or equal to 0.15 (p less than 0.03) were predictive of increased mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term angiographic follow-up after angioplasty of venous coronary bypass grafts.

From April 1981 to June 1987, 57 patients underwent venous coronary bypass graft percutaneous angioplasty and had a minimal follow-up of 18 months. The procedure was elective for 28 patients, urgent for 19, and was considered as an emergency for 10. A total of 64 grafts were dilated that had been bypassed 58 +/- 48 months previously (range 2 to 184 months); lesions were located on the aortic anastomosis in 12 grafts, on the body in 38, and on the coronary anastomosis in 14. Technical success was 95.3% (61 of 64) per lesion; clinical success was 84.4% (54 of 64) per lesion and 82.5% (47 of 57) per patient. Thrombotic complications with images of a lacunar defect occurred in 11 grafts (17.2%). Predictive factors for these complications were: age of grafts 38.5% for greater than 60 month grafts versus 2.6% for less than 60 month grafts (p less than 0.01); site of lesion, body lesion 28.9% versus anastomosis none (p less than 0.01); type of lesion, concentric and short 6% versus other 29% (p less than 0.05); and recent fibrinolysis in 66% versus 10.6% (p less than 0.05). Long-term follow-up is available in the 47 successful patients and the three limited non-Q wave myocardial infarction patients. Two patients died at 13 and 17 months. Long-term angiographic follow-up is available in 45 of 48 patients or 94%. At the end of the study, 35 of 57 (61.4%) venous bypass grafts in 32 patients (64%) were patent after one or more percutaneous transluminal angioplasties.(ABSTRACT TRUNCATED AT 250 WORDS)

[Immediate results and mid-term follow-up after percutaneous mitral valve replacement]. / Résultats immédiats et suivi à moyen terme après valvuloplastie mitrale percutanée.

Percutaneous mitral valvuloplasty (PMV) was performed by the anterograde transseptal approach (double balloon technique) in 154 patients with symptomatic mitral stenosis. The mean age of the patients was high (53 +/- 14 years), 87% were women, 68% were in functional Classes III or IV of the NYHA and 37 (24%) had previously undergone surgical commissurotomy. The echocardiographic score was 8.5 +/- 1.6. PMV could not be completed because of a technical failure or a complication in 14 cases (9%). In the other patients, PMV increased mitral surface area from 1.0 +/- 0.3 to 2.0 +/- 0.8 cm2 (p less than 0.0001). A haemodynamic success (greater than or equal to 25% increase in mitral surface area and final area greater than or equal to 1.5 cm2) was obtained in 104 patients (75%). The predicting factors of success were echocardiographic score (8.1 +/- 1.4 versus 9.4 +/- 1.7; p less than 0.0001) and cardiac output (4.0 +/- 1.1 versus 3.0 +/- 1.0/l/min; p less than 0.0001). The duration of the procedure, the technical failure rate and the frequency of cardiac perforation were influenced by the learning curve. The degree of mitral regurgitation increased after PMV in 34% of cases, usually by one grade and without clinical or haemodynamic consequences. Acute mitral regurgitation was a rare (3%) and impredictable complication. An interatrial shunt was demonstrated in 80% of cases after PMV but the Qp/Qs ratio rarely exceeded 1.5 (11%). This shunt disappeared or decreased in the majority of cases during follow-up. The clinical result was an improvement of at least one functional Class in 83% of cases at 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous mitral valvuloplasty. An analysis of the immediate results]. / Valvuloplastia mitral percutánea. Análisis de los resultados inmediatos.

Percutaneous mitral valvuloplasty (PMV) was performed by the anterograde transseptal approach in 113 patients with symptomatic mitral stenosis. Mean age was 53 +/- 14 years and 89% were female. PMV resulted in a marked decrease in mitral gradient from 16 +/- 5 to 6 +/- 3 mmHg (p less than 0.0001) and a significant increase in mitral valve area from 1.09 +/- 0.36 to 2.12 +/- 0.83 cm2 (p less than 0.0001). An optimal hemodynamic result (gain in valve area greater than or equal to 25% and post-PMV valve area greater than or equal to 1.5 cm2) was obtained in 82 patients (73%). Multivariate statistical analysis selected as independent predictors of an optimal result: normal cardiac index (p = 0.0001), NYHA functional class less than 3 (p = 0.002), smaller left atrial diameter (p = 0.005), and echocardiographic score less than or equal to 8 (p = 0.01). The lowest frequency of optimal results was observed in patients with echocardiographic scores greater than or equal to 11 (20%). Three patients died (2.6%). All deaths occurred among the first 34 patients and none in the last 79 (p less than 0.05). Morbidity was also influenced by a learning curve effect. Mitral regurgitation developed or increased in severity in 38% of patients. This increase was mild (1 degree) in 85% of cases. Although the incidence of atrial shunting was high (76% by indicator dilution curve and 33% by oximetry), their magnitude was usually small (mean Qp/Qs 1.23 +/- 0.23) and lacked clinical significance. In conclusion, PMV provides excellent immediate hemodynamic results with low mortality and morbidity risks, specially once experience has been gained with this technique. Patients with echocardiographic scores less than or equal to 8 and smaller left atrial diameters, usually younger and less symptomatic, are the best candidates for PMV.

Percutaneous mitral valvuloplasty in surgical high risk patients.

Among 126 consecutive patients undergoing percutaneous mitral valvuloplasty, 34 were judged to be at high risk for surgery on the basis of age greater than 70 years (n = 13), New York Heart Association functional class IV (n = 11), ejection fraction less than or equal to 35% (n = 3), severe pulmonary hypertension (n = 7), need for associated coronary bypass (n = 4) or additional valve surgery (n = 20) or severe pulmonary disease (n = 3). Baseline features of the high risk group were substantially worse than those of the other patients: age (65 +/- 11 versus 49 +/- 12 years; p = 0.0001) and echocardiographic score (9.4 +/- 1.8 versus 8.2 +/- 1.5; p = 0.005) were higher, whereas cardiac output (2.9 +/- 0.9 versus 4.1 +/- 1.2 liters/min; p = 0.0001) and mitral valve area (0.9 +/- 0.4 versus 1.1 +/- 0.3 mm2; p = 0.002) were lower. Three high risk patients experienced technical failures and three others had major complications. Among the remaining 28 patients, 18 (65%) had a complete hemodynamic success, 4 (14%) an incomplete success and 6 (21%) hemodynamic failure. Stepwise logistic regression analysis retained echocardiographic score as the only factor independently predictive of success. The percent increase in mitral valve area also correlated with echocardiographic score (r = 0.51, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Left-to-right atrial shunting after percutaneous mitral valvuloplasty. Incidence and long-term hemodynamic follow-up.

To assess the incidence and long-term evolution of left-to-right atrial shunting (AS) after the performance of percutaneous mitral valvuloplasty (PMV), venovenous indicator dilution curves and right heart oximetric measurements were obtained in 68 consecutive patients before and after successful PMV. The procedure increased the mitral valve area (p less than 0.0001) and decreased the mitral gradient (p less than 0.0001). No AS was detected before PMV, but it was detected immediately after PMV. Oximetry identified AS in 17 patients (25%), and dilution curves identified AS in an additional 25 (total, 62%). The ratio of mean pulmonary to systemic blood flow (Qp/Qs) was 1.31 +/- 0.2, and in six patients (9%), the ratio was 1.5 or greater. Among nine clinical, 20 hemodynamic, and six procedural variables, stepwise logistic regression analysis selected the following as independent predictors of AS: smaller increases in valve area (p = 0.01) after PMV, absence of previous surgical commissurotomy (p = 0.02), mitral valve calcification (p = 0.02), and smaller left atria (p = 0.06). Among the 33 patients recatheterized at 6 months, oximetry had detected AS in 10, and dilution curves detected AS in an additional nine (total, 58%) immediately after PMV. At 6 months, AS had decreased or disappeared in 14 of these patients (74%), had increased in three (16%), and was unchanged in two (10%). Overall, at 6 months, oximetry identified AS in three patients, and dilution curves identified AS in an additional 13 (total, 48%). AS was detected at 6 months in only three patients but was not detected immediately after PMV. Although AS is very frequent immediately after PMV, Qp/Qs is usually less than 1.5. The appearance of shunting correlates with patient characteristics and with less improvement in valve area after PMV. Atrial shunting usually persists at 6 months, but its severity almost always decreases.