Balloon dilatation of the stenosed aortic valve: how does it work? Why does it fail?

The hemodynamic changes that may occur in patients undergoing aortic balloon valvuloplasty were examined in the circulatory model. Four conclusions were reached. (1) Significant transvalvular pressure gradients appear only if the orifice is severely narrowed. (2) The magnitude of this gradient is highly flow dependent. (3) At critical narrowings, minute alterations in orifice size may induce most significant changes in the transvalvular gradient. (4) In low flow states significant gradients appear only if the stenosis is extreme. In patients with aortic stenosis, especially those with failing hearts and low cardiac output, the pressure gradient may be effectively decreased by minimal dilatation of the aortic orifice. These patients, however, remain in jeopardy because recurrent narrowing may cause a gradient incompatible with life.

Balloon valvuloplasty in calcified aortic stenosis: a cause for caution and alarm.

Balloon dilation by the percutaneous route has recently been recommended as an alternative to surgical intervention in the management of calcified aortic valvular stenosis. To investigate the validity of balloon valvuloplasty, this procedure was carried out in the operating room under direct vision in 30 patients just prior to excision and replacement of the ossified aortic valve. Changes induced by balloon dilation were evaluated by visual inspection as well as by geometric measurements. By visual observation, balloon valvuloplasty did not have a detectable impact on the valvular anatomy in about 19 of the patients and induced enlargement of the functional aortic orifice judged as "minimal" or "moderate" in only 11. In no patient was there a substantial increase in the functional orifice size. These findings were supported by geometrical measurements. Therefore, we believe that the virtues of this procedure have been grossly overstated by its proponents and that it should be offered only to patients who present a truly forbidding risk by standards of modern surgery.

Limited value of balloon dilatation in calcified aortic stenosis in adults: direct observations during open heart surgery.

Percutaneous balloon dilatation was recently recommended as a treatment for management of calcified aortic valvular stenosis. This procedure was initially reserved for patients who were not considered surgical candidates; it is now regarded by some as an acceptable alternative for valve replacement. To investigate the validity of this postulate, balloon valvuloplasty was performed under direct vision in the operating room in 16 patients just before excision and replacement of their ossified aortic valve. Changes after valvuloplasty were evaluated by inspection as well as by geometric measurements. The authors found that balloon valvuloplasty did not make a detectable impact on valvular anatomy in about two-thirds of the patients and induced enlargement of the functional aortic orifice judged as "minimal" or "moderate" in one-third of the cases. In no patient was there significant increase in the functional orifice size. Other investigators have shown that hemodynamic and clinical improvement may be induced in some patients by small increases in the aortic orifice; based on the observations herein, such an improvement, if it occurs at all, would be short-lasting; the procedure should be offered only to those who present truly prohibitive risk by standards of modern surgery.

Management of the patient with a prosthetic heart valve.

Approximately 20,000 heart valve prostheses are inserted yearly in the United States. Even after successful heart operations, the patients who receive them cannot be regarded as healthy individuals but are a special group with special problems who need close medical attention for the rest of their lives. They are susceptible to many unusual complications because of their implanted foreign body, and it is a challenge to all physicians in contact with them to be aware of their peculiar problems in order to prevent complications if possible and to treat them immediately if they occur. General therapy, surgical complications, infection, and mechanical problems are reviewed, with means for management outlined. These difficulties can be dealt with only by careful follow-up and well-coordinated teamwork between the family physician and the institution where the operation was performed.

Long-range observations with external aortic grafts.

The late results of aortic aneurysms treated by external grafting are presented. This procedure consists of completely dissecting the involved aortic segment and suturing it in a well-fitted tubular Dacron prosthesis. The operation was carried out under the following circumstances: (a) Small fusiform aneurysm of the abdominal aorta. (b) Small and medium-sized aneurysms of the thoracic aorta. (c) Aneurysms unfavorably located in the very old and very debilitated. (d) Aneurysms involving the origin of the renal arteries. (e) Aneurysmatic dilatation of the aortic arch. Sixty-two patients were operated upon with this method with the follow-up period ranging from three months to seven years. There were no deaths during this period which could be directly related to either the aneurysm or the procedure itself.

Beneficial metabolic effects of methylprednisolone sodium succinate in acute myocardial ischemia.

The metabolic and hemodynamic effects of methylprednisolone sodium succinate (40 mg/kg body weight) after acute myocardial ischemia were determined in 24 heparinized mongrel dogs. Myocardial ischemia was produced by ligation of the left anterior descending coronary artery. Catheters in the coronary sinus and the vein draining the left anterior descending coronary arterial area were used to collect blood samples from nonischemic and ischemic myocardium. Lactate, pyruvate, glucose, free fatty acids and oxygen were measured in arterial and venous blood from ischemic and nonischemic areas before and 3, 30 and 60 minutes after myocardial ischemia in animals with (Group II) and without (Group I) steroid treatment. In both Groups I and II glucose, lactate, free fatty acids, oxygen and coronary blood flow in nonischemic areas were not significantly changed, whereas glucose uptake in ischemic areas was significantly increased with myocardial ischemia and remained elevated. In Group I lactate uptake in ischemic areas became negative after coronary arterial ligation and remained so; in Group II, it increased after 30 (70%) and 60 (111%) minutes. Free fatty acid uptake in ischemic areas was reduced after myocardial ischemia in Group I, but in Group II it increased after 30 (224%) and 60 minutes (173%), and there was a concomitant increase in oxygen uptake. Pyruvate uptake in nonischemic areas decreased after 60 minutes in Group I, whereas it was reduced after 30 (68%) and 60 minutes (513%) in Group II. The changes were similar in ischemic myocardium. There were no significant changes in hemodynamic indexes. Coronary blood flow in ischemic areas decreased in Group I after myocardial ischemia and further after 30 and 60 minutes, but in Group II it increased after 30 (82%) and 60 minutes (53%). The data indicate that administration of methylprednisolone results in improved collateral blood flow into the infarcted area and a significantly improved metabolic response of ischemic myocardium. The glucocorticoid may also have a direct benefical effect on carbohydrate metabolism and cause the increased pyruvate neccesary to maintain the generation of energy-producing substrates. The results also suggest that methylprednisolone increases cell survival time and results in greater salvage of ischemic myocardium.