Immediate and long-term results of mitral balloon valvuloplasty in patients with severe pulmonary hypertension.

BACKGROUND AND AIM OF THE STUDY: Mitral stenosis (MS) with severe pulmonary hypertension (PHT) constitutes a high-risk subset for surgical commissurotomy or valve replacement. Mitral balloon valvuloplasty (MBV) has emerged as the treatment of choice for patients with severe pliable MS. The efficacy of this procedure in patients with severe PHT has not been fully elucidated, notably with regards to the long-term outcome. METHODS: MBV was successfully performed in 531 consecutive patients. Of these patients, 82 (15%) had severe PHT at baseline (group A), defined as pulmonary artery systolic pressure (PASP) at rest > 60 mmHg, compared to the remaining 449 patients, who served as controls (group B). RESULTS: Patients with PHT had a higher echo score and were more symptomatic, the majority (52.4%) having moderate to severe tricuspid regurgitation (TR). When comparing PHT with controls, the left atrial pressure was higher (28 +/- 4.9 versus 25.6 +/- 4.6 mmHg; p < 0.0001), the mean mitral gradient was similar (14.6 +/- 3.8 versus 14.4 +/- 2.1 mmHg; p = 0.30), the baseline mitral valve area (MVA) was smaller (0.72 +/- 0.17 versus 0.86 +/- 0.19 cm2; p < 0.0001), pulmonary vascular resistance was higher (612 +/- 343 versus 211 +/- 183 dyne/s/cm(-5); p < 0.0001), and post-procedure MVA was smaller (1.7 +/- 0.44 versus 1.85 +/- 0.54 cm2; p = 0.007). The PASP decreased significantly over 12 months after MBV, from 79 +/- 14 to 36.7 +/- 7.53 mmHg (p < 0.0001). Freedom from restenosis in PHT patients at 10 and 15 years, respectively, was 66 +/- 6% and 45 +/- 8% versus 78 +/- 2% and 47 +/- 3% in controls (p = 0.0066). Event-free survival at 10 and 15 years, respectively, was 77 +/- 6% and 41 +/- 11% in PHT patients versus 89 +/- 1% and 54 +/- 4% for controls (p = 0.0169). In total, 33 patients (40%) had moderate TR and 10 (12%) had severe TR at baseline. At follow up, only 12 patients had moderate TR and none had severe TR. CONCLUSION: MBV is a safe and effective technique for treating patients with MS and severe PHT. Although the immediate results were comparable with those in controls, the long-term results proved to be slightly inferior, with a regression of PHT and concomitant severe TR.

Aortic pseudoaneurysm with fistulization into the pulmonary artery: a cause of refractory heart failure after bentall procedure.

We present the case of a patient who developed left-sided congestive heart failure several years after undergoing composite graft surgery for annuloaortic ectasia and aortic regurgitation. Transthoracic echocardiography showed markedly elevated left ventricular filling pressures and severe pulmonary hypertension. However, no underlying pathology or anatomic abnormality to explain the high filling pressures could be identified. On transesophageal echocardiography, a large aortic pseudoaneurysm was demonstrated arising from dehiscence of the distal graft anastomosis to the native aorta. A fistulous communication was noted between the pseudoaneurysm and the right pulmonary artery resulting in a large aortopulmonary shunt. This case illustrates the inherent limitations of transthoracic echocardiography in the detection of complications after composite graft surgery of the aorta.

Dual thrombosis of the pulmonary arterial and venous anastomotic sites after single lung transplantation: role of transesophageal echocardiography in diagnosis and management.

We present the case of a patient who developed severe respiratory and hemodynamic compromise shortly after single right lung transplantation. Transesophageal echocardiography showed a large intraluminal thrombus at the right pulmonary artery anastomosis resulting in severe obstruction to flow together with thrombosis of the right pulmonary veins extending into the left atrium. After thrombectomy and surgical revision of the vascular anastomoses, the patient made an uneventful recovery. This case illustrates the usefulness of transesophageal echocardiography in the diagnosis and treatment of patients who are hemodynamically unstable after lung transplantation.

The impact of mitral valve morphology on the long-term outcome of mitral balloon valvuloplasty.

BACKGROUND: The effect of mitral valve morphology (MVM) on the long-term results of mitral balloon valvuloplasty (MBV) is not well established. The aim of the study was to evaluate the impact of MVM on long-term outcome of MBV. METHODS: Five hundred and eighteen consecutive patients (mean age, 31+/-11 years) who underwent successful MBV were followed up for 0.5-16.5 (mean, 6+/-4.5) years. Patients were divided into two groups according to their mitral echo score (MES) before MBV: group A (n=340; MES8). RESULTS: We report the immediate and long-term clinical and echocardiographic results of the above-mentioned 518 consecutive patients. The mitral valve area was significantly larger in group A than in group B, both immediately after MBV (2.0+/-0.3 vs. 1.82+/-0.3 cm2, respectively; P<0.0001) and also at the last follow-up (1.8+/-0.33 vs. 1.5+/-0.33 cm2, respectively; P<0.0001). Restenosis occurred in 38/340 (11%) in group A vs. 73/178 (41%) in group B (P<0.0001). Actuarial freedom from restenosis at 5, 10, 15 years were 92+/-2%, 85+/-3%, 65+/-6% for group A vs. 72+/-4%, 44+/-5%, 9+/-6% for group B (P<0.001). Event-free survival rates at 5, 10, 15 years for group A were 93+/-1%, 88+/-2%, 66+/-6% vs. 82+/-3%, 59+/-6%, 8+/-7% for group B (P<0.0001). Stepwise Cox multivariate regression analysis identified MES, preprocedure functional class, and postprocedure mitral valve area

Rescue in situ thrombolysis for acute coronary thromboembolism in an angiographically normal coronary artery.

Coronary thromboembolism in an angiographically normal coronary artery is extremely uncommon. There are few instances where normal coronary arteries have been documented just prior to an episode of acute thromboembolic insult. We now report such a case of acute coronary thromboembolism in a patient with widely patent coronary vessels documented just prior to the event during preoperative screening angiogram with successful in situ revascularization.