Increase In Valve Area Research Articles

Objective Assessment of Postoperative Outcomes in Endonasal Spreader Grafts

Objectives: Use acoustic rhinometry to objectively measure the functional outcomes of endonasal spreader grafts in patients undergoing surgical correction of internal nasal valve collapse. Methods: Eighteen adult patients undergoing open septoplasty with unilateral or bilateral endonasal spreader graft placement were recruited. Patients were asked to undergo preoperative and postoperative acoustic rhinometry to measure changes in cross-sectional area of the internal nasal valve. Postoperative subjective nasal symptoms as measured by SNOT-22 and NOSE scores were also compared to preoperative values. Results: Patients undergoing septoplasty with endonasal spreader graft placement had a statistically significant increase in the cross-sectional area of the internal nasal valve ( P < .05). This was concomitant with mild improvement in SNOT-22 and NOSE scores postoperatively ( P < .05). Conclusions: This study provides objective evidence of an increase in internal nasal valve area after placement of endonasal cartilage spreader grafts in combination with septoplasty.

92 The Importance of Auditing Procedural Outcomes from Percutaneous Balloon Mitral Valvuloplasty

IntroductionMitral stenosis (MS), as a consequence of rheumatic fever (RF), carries a substantial worldwide morbidity and mortality. Despite the decrease in RF in industrialised countries due to improved antibiotic control,...

Anesthetic and Perioperative Considerations for Transapical Transcatheter Aortic Valve Replacement

AORTIC VALVE REPLACEMENT (AVR) continues to be the standard for treatment of aortic stenosis. The overall operative mortality for patients undergoing a surgical AVR (SAVR) ranges from 2.5%-4%.1–4 With increasing age, the risk for octogenarians and nonagenarians ranges between (4.9% and 9.6%), and this can be as high as 25% in patients with significant co-morbidities.1,5–7 As such, up to 30% of these patients are not considered candidates for traditional open surgical intervention.8,9 Balloon aortic valvuloplasty results in only temporary relief of symptoms by a small increase in valve area.

Balloon aortic valvuloplasty (BAV) as a bridge to aortic valve replacement in cancer patients who require urgent non-cardiac surgery.

BackgroundBalloon aortic valvuloplasty (BAV) is a percutaneous treatment option for severe, symptomatic aortic stenosis. Due to early restenosis and failure to improve long term survival, BAV is considered a palliative measure in patients who are not suitable for open heart surgery due to increased perioperative risk. BAV can be used also as a bridge to surgical or transcatheter aortic valve implantation (TAVI) in haemodinamically unstable patients or in patients who require urgent major non-cardiac surgery.Patients and methods.We reported on 6 oncologic patients with severe aortic stenosis that required a major abdominal and gynaecological surgery. In 5 cases we performed BAV procedure alone; in one patient with concomitant coronary artery disease we combined BAV and percutaneous coronary intervention (PCI).ResultsWith angioplasty and BAV we achieved a good coronary artery flow and an increase in aortic valve area without any periprocedural complications. After the successful procedure, we observed a hemodynamic and symptomatic improvement. As a consequence the operative risk for non-cardiac surgery decreased and the surgical treatment of cancer was done without complications in all the 6 cases.ConclusionsBAV can be utilized as a part of a complex therapy in severe aortic stenosis aimed to improve the quality of life, decrease the surgical risk for major non-cardiac surgery or as a bridge to surgical or transcatheter aortic valve implantation.

Balloon aortic valvuloplasty of severe aortic stenosis in the era of TAVR

Introduction. Balloon aortic valvuloplasty (BAV) is a percutaneous treatment option for aortic stenosis (AS). Because of early restenosis and poor long-term survival, it is used as a bridge to surgery (SAVR) or transcatheter aortic valve replacement (TAVR), in hemodinamically unstable patients or patients that require urgent non-cardiac surgery. Aim. The aim of this study was to evaluate all the BAV procedures performed in our centre in 2010 and to report our experience with BAV as a potential bridge to definitive therapy or as a palliative treatment. Methods. We retrospectively analyzed all the patients who underwent percutaneous treatment of aortic stenosis in our institution between January and December 2010. We stratified our cohort into 3 groups: BAV as a bridge to TAVR or SAVR, BAV as a final therapy and TAVR without prior BAV. We evaluated patient characteristics, echocardiographic data and peri-procedural complications in each cohort. Survival was evaluated using Kaplan-Meier analysis. Results. We included 86 high risk symptomatic patients with mean age of 82.2 ± 5.0 years and mean logistic EuroSCORE of 19.2 ± 11.8 %. After BAV we observed a significant decrease in mean transvalvular gradient (from 43.8 ± 14.4 to 33.5 ± 12.3 mmHg; p < 0.01) and a significant increase in aortic valve area after BAV (from 0.6 ± 0.2 to 0.8 ± 0.3 cm2; p < 0.01). Systolic pulmonary artery pressure, left ventricular ejection fraction and mitral regurgitation did not change significantly. Major intrahospital complications occurred in 5 patients (6.5 %), without any death related to the procedure. BAV as a bridge to TAVR had a better outcome compared with BAV alone. Conclusion. BAV is a feasible and reasonably safe approach for temporary relief of symptoms, improvement of quality of life, decrease of surgical risk prior major non-cardiac surgery or as a bridge to surgical or transcatheter aortic valve implantation in severe aortic stenosis.

Very early complication of rheumatic heart disease (valvuloplasty for severe mitral valve stenosis for 6 year old male patient)

Rheumatic heart disease continues to contribute greatly to the burden of cardiovascular disease in Yemen, It’s usual to see a lot of advance RHD cases in adult in Yemen but in pediatric it is rare to see such advance case specially under the age of eight. Case report A.M, a 6 year old Yemeni male child was seen in September 2012 with history of recurrent breathlessness which started about 4 years earlier. His symptoms worsened in the previous three weeks when he became breathless at rest, had paroxysmal nocturnal dyspnea, huge abdominal distention, bilateral leg swelling and cough productive of whitish sputum. Past history was not significant for recurrent sore throat but he was diagnosed to have RHD at age of 3 year old without any farther follow up and irregular using to long acting penicillin. He was the second child in his family; both parents are in a very low income group. There was no family history of the disease in any of his siblings. Examination revealed that the child looked marasmic, pale, was chronically ill, and had a tinge of jaundice with bilateral pitting pedal edema. A cardiovascular system examination revealed a pulse rate of 101 per minute, regular and small volume, blood pressure of 90/60 m mmHg, elevated jugular venous pressure, displaced apex beat which was located at 5th intercostal space anterior axillary line, loud first and second heart sounds opening snap and mid diastolic rumbling murmur with systolic murmur at left parasternal border. The respiratory rate was 26 cycles per minute and bilateral crepitations. Other examination findings were visible dilated abdominal vein, a tender, pulsatile hepatomegaly of 3 cm below the right coastal margin and massive ascites. An echocardiography showed densely thickened mitral valves with severe commissural fusion leading to doming of the mitral valve in diastole, markedly dilated left atrium, normal left ventricular eject ion fraction, markedly dilated right atrium and right ventricle. Colour flow showed severe tricuspid regurgitation and severe pulmonary hypertension. The calculated mitral valve area is 0.6 cm square and pressure gradient max/mean (14/6 mmHg) respectively. ECG sinus rhythm normal axis and dilated LA with RBBB Complete blood count showed low HB 9 mg/dl with normal a white cell count. The chest X-ray revealed cardiomegaly with a double cardiac shadow positive mitralization sign. He was placed on diuretics (furosemide and low-dose spironolactone) Angiotensin Converting Enzyme inhibitor (Lisinopril), intranasal oxygen, intravenous heparin and antibiotics. And was prepared for percutaneous mitral valvuloplasty On the third day of admission, The PMVP was done with good out come the mitral valve area increase from 0.6 to 1.8 cm 2 and decrease in the pressure gradient to 6/4 mmHg and the pulmonary hypertension to mild. After that patient condition get better with improving to the dyspnea, the child become more active start to eat and play more frequent than before with decrease to the abdominal distension and the patient discharge to home in good condition and advice to follow up the hospital after six month. Discussion Rheumatic heart disease, no doubt remains a disease with great morbidity and mortality in most low and middle income countries specially in Yemen despite been having almost eradicated in high income countries, it affects the young population of our community whom presented late most of the time with complication due to the shortage of the medical service in the most of the regain of Yemen specially the remote areas. The case being presented typifies the cost of late presentation in patients with rheumatic heart disease. its usual in our country to see such cases in late stage and complicated but it’s rare to see a 6 year old child presented with severe mitral stenosis and he needed PMVB even it is successful procedure that saved his live but all that could be prevented from happening in the first place by a simple preventive program which we do not have in our country.

Balloon aortic valvuloplasty for severe aortic stenosis as a bridge to transcatheter/surgical aortic valve replacement

This study aimed to determine success- and complication rates after balloon aortic valvuloplasty (BAV) and the outcome of BAV as a standalone therapy versus BAV as a bridge to transcatheter/surgical aortic valve replacement (T/SAVR). The introduction of transcatheter aortic valve replacement (TAVR) has led to a revival in BAV as treatment for patients with severe aortic stenosis. A cohort of 472 patients underwent 538 BAV procedures. The cohort was divided into two groups: BAV alone 387 (81.9%) and BAV as a bridge 85 (18.1%) to (n = 65, TAVR; n = 20, surgery). Clinical, hemodynamic, and follow-up mortality data were collected. There was no significant difference between the two groups in mean age (81.7 ± 8.3 vs. 83.2 ± 10.9 years, P = 0.18), society of thoracic surgeons score (13.1 ± 6.2 and 12.4 ± 6.4, P = 0.4), logistic EuroSCORE (45.4 ± 22.3 vs. 46.9 ± 21.8, P = 0.43), and other comorbidities. The mean increase in aortic valve area was 0.39 ± 0.25 in the BAV alone group and 0.42 ± 0.26 in the BAV as a bridge group, P = 0.33. The decrease in mean gradient was 24.1 ± 13.1 in the BAV alone group vs. 27.1 ± 13.8 in the BAV as a bridge group, P = 0.06. During a median follow up of 183 days [54-409], the mortality rate was 55.2% (n = 214) in the BAV alone group vs. 22.3% (n = 19) in the BAV as a bridge group during a median follow-up of 378 days [177-690], P < 0.001. In high-risk patients with aortic stenosis and temporary contraindications to SAVR/TAVR, BAV may be used as a bridge to intervention with good mid-term outcomes.

Impact of Pulmonary Artery Stiffness on Right Ventricular Function and Tricuspid Regurgitation after Successful Percutaneous Balloon Mitral Valvuloplasty: The Importance of Early Intervention

We assessed impact of pulmonary artery stiffness (PAS) on the long-term right ventricular (RV) function and tricuspid regurgitation (TR) changes after percutaneous balloon mitral valvuloplasty (PBMV). Using Doppler echocardiography, PAS was calculated by dividing maximal frequency shift of pulmonary flow by the acceleration time, and mitral area, RV function, and degree of TR severity were evaluated before, immediately after, 6 months, and 12 months after successful PBMV in 81 consecutive patients. Compared with control subjects patients with mitral stenosis (MS) had significant higher PAS (P < 0.001). The PAS was significantly lower in patients with progressive RV function improvement and regression of TR (P < 0.001). PAS was significantly correlated with the degree of pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), and E/E'm ratio (P < 0.0001, <0.0001, and < 0.001, respectively). Multivariate regression analysis showed that the PAS is an independent predictor of TR regression and sustained RV functional improvement after successful PBMV (P < 0.0001). The changes in RV function and TR after successful PBMV were significantly correlated with the degree of PAS. Despite a sustained increase in mitral valve area, some patients showed no regression of TR, and progressive RV dysfunction suggests a significant role of PAS on RV function and the degree of TR regression in patients with MS suggests that PBMV must be performed early, utilizing PAS as a noninvasive parameter for proper timing for PBMV.

Transapical aortic valve implantation: The Vancouver experience.

Off-pump transapical aortic valve implantation (TA-TAVI) through mini-thoracotomy was first performed in Vancouver, Canada in October 2005. The objective of this manuscript is to describe the Vancouver experience with 178 TA-TAVI cases in symptomatic severe aortic stenosis (AS) since 2005. Baseline characteristics and in-hospital outcomes were calculated for the overall cohort. To compare pre-procedure and post-procedure echocardiographic measurements, one way analysis of variance was utilized, followed by Tukey's HSD. In-hospital outcomes were compared between early and late cohorts using Z-test and chi-squared test as appropriate. Kaplan-Meier analysis was used to generate 3-year survival curves. The Log-rank test was used to compare survival between low-risk and high-risk groups, based on STS score. Between October 2005-March 2012, TA-TAVI was performed in 178 patients. Mean age was 80.5±8.6 years. Congestive heart failure and renal failure were more common in the late cohort, while previous myocardial infarction was more common in the early cohort (P<0.05). Eleven patients (6.2%) had significant intra-operative complications, including death (1.7%), conversion to CPB (3.9%), and valve embolization (1.1%). In-hospital survival was 87.9%. Mean length of hospital stay was 12.2±17.1 days. In-hospital incidence of stroke was 3.4%. Bleeding (20.2% vs. 4.7%) and vascular (14.6% vs. 3.5%) complications were more common in the early cohort. Echocardiography demonstrated a significant increase in aortic valve area and decrease in mean transvalvular gradient post-procedure. These improvements were maintained throughout the 3-year follow-up period. Overall survival was 72.1% at 6 months, 67.7% at 12 months, 55.5% at 24 months, and 47.3% at 36 months. Repeated Kaplan-Meier analysis for the 2 groups stratified by STS score, demonstrated improved survival in the low-risk group (Log-rank P=0.039). Among patients with symptomatic severe AS at high risk for conventional AVR, TA-TAVI is a reasonable therapeutic option with acceptable risk. Long-term survival appears to be superior in lower-risk patients.

Percutaneous Transluminal Mitral Commissurotomy for Rheumatic Mitral Stenosis in a 5-Year-Old Child

We report a 5-year-old boy weighing 11 kg, with severe mitral valve stenosis of rheumatic aetiology, who underwent successful percutaneous transluminal mitral commissurotomy (PTMC) with valvuloplasty balloon. Postprocedural mean pressure gradient across the mitral valve decreased to 6 mmHg from an initially recorded value of 22 mmHg. In addition to symptomatic improvement, the mitral valvular area increased from 0.4 to 0.8 cm(2) without significant change in mitral regurgitation. At 1- and 3-month follow up, transthoracic echocardiography revealed further improvement with an increase in mitral valve area to 1.0 cm(2), a decrease in pulmonary arterial pressure, and a mean mitral valve pressure gradient of 8 mmHg with trivial mitral regurgitation. To best of our knowledge, this is the first successful PTMC procedure performed in the youngest and smallest ever reported child with rheumatic mitral stenosis (MS). We conclude that PTMC with valvuloplasty balloon could be a logical alternative to surgery in young patients with rheumatic MS.

Copeptin Level and Copeptin Response to Percutaneous Balloon Mitral Valvuloplasty in Mitral Stenosis

We aimed to investigate copeptin levels in mitral stenosis (MS) patients and the behavior of copeptin after hemodynamic improvement achieved by percutaneous balloon mitral valvuloplasty (PBMV). The study involved 29 consecutive symptomatic patients with moderate to severe rheumatic MS who underwent PBMV. Twenty-eight age- and gender-matched healthy volunteers composed the control group. Blood samples for copeptin were obtained immediately before and 24 h after PBMV, centrifuged, then stored at -70°C until assayed. The copeptin level of the patient group was statistically different from that of the control group (61.8 ± 34.4 and 36.8 ± 15.2 pg/ml, respectively; p = 0.001). PBMV resulted in a significant increase in mitral valve area and a significant decrease in transmitral gradient as well as systolic pulmonary artery pressure. While hemodynamic relief was obtained, we detected a statistically significant decline in copeptin levels 24 h after PBMV compared to the baseline levels (from 61.8 ± 34.4 to 44.1 ± 18.2 pg/ml; p = 0.004).

The Incremental Value of Valvuloarterial Impedance in Evaluating the Results of Transcatheter Aortic Valve Implantation in Symptomatic Aortic Stenosis

Valvuloarterial impedance (Z(va)) can estimate the global hemodynamic load on the left ventricle in patients with severe aortic stenosis better than the standard indexes, as shown in previous studies. In fact, Z(va) can estimate global left ventricular hemodynamic load as the sum of valvular and vascular loads. The aim of this study was to evaluate the acute improvement of left ventricular performance in patients with symptomatic aortic stenosis after transcatheter aortic valve implantation (TAVI) using Z(va). One hundred two consecutive patients who underwent TAVI were submitted to transthoracic echocardiography immediately before and after aortic valve implantation, together with invasive hemodynamic measurements. After TAVI, immediate reductions in the transaortic peak pressure gradient (P < .0001) and mean pressure gradient (P < .0001) and a concomitant increase in aortic valve area (P < .0001) were seen on echocardiography. Left ventricular ejection fraction significantly increased immediately after TAVI in all patients (from 48.9 ± 10.3% to 52.1 ± 11.1%, P < .0001). Regarding global left ventricular hemodynamic load, acute and significant reductions in end-systolic meridional wall stress (from 82.7 ± 42.6 to 57.8 ± 30.1 kdyne · cm(-2), P < .0001) and in Z(va) (from 6.81 ± 2.51 to 5.38 ± 2.13 mm Hg · mL(-1) · m(-2), P < .0001) were observed. Furthermore, patients who died at 6-month follow-up had higher baseline Z(va) values compared with those who were alive at 6-month follow-up (8.13 ± 3.08 vs 6.41 ± 2.12 mm Hg · mL(-1) · m(-2), P < .004). TAVI is characterized by an immediate enhancement of global left ventricular hemodynamic performance, as demonstrated by an acute Z(va) improvement, even in patients with low baseline ejection fractions.

Implante valvular aórtico percutâneo (IVAP): análise de uma série de casos realizados com o dispositivo autoexpansível CoreValveTM sem uso de pré-dilatação

INTRODUCAO: O implante valvular aortico percutâneo (IVAP) vem se desenvolvendo rapidamente nos ultimos anos. A manipulacao da valva aortica degenerada pode acarretar complicacoes. O IVAP direto, sem pre-dilatacao com balao e com menor manipulacao, seria uma alternativa. O objetivo deste estudo e apresentar uma serie de 8 casos de IVAP direto com seguimento a medio prazo realizado no Instituto de Cardiologia do Rio Grande do Sul. METODOS: Serie de 8 casos com descricao da tecnica e resultados imediatos e a medio prazo do implante do dispositivo CoreValveTM sem valvuloplastia com balao. RESULTADOS: No total, 7 pacientes do sexo masculino e 1 do sexo feminino, com media de idade de 76 anos e EuroSCORE logistico variando de 6% a 62%, foram submetidos ao implante do dispositivo CoreValveTM. Houve significativa queda dos gradientes entre o ventriculo esquerdo e a aorta. Foram registrados tres casos de insucesso do implante, um obito no periodo pos-implante imediato e um obito aos 6 meses, sem relacao com o procedimento. No seguimento de um ano, nao houve novos casos de implante de marca-passo e eventos embolicos. CONCLUSOES: O IVAP direto sem pre-dilatacao com balao mostrou-se uma alternativa potencialmente eficaz. Quando realizado com sucesso, determina melhora dos sintomas, diminuicao sustentavel do gradiente transvalvar aortico e aumento da area valvar aortica. Nao esta claro, contudo, qual o paciente e qual a condicao anatomica ideal para essa abordagem. Estudos adicionais e seguimento mais prolongado ainda sao necessarios para definir o exato papel e as precisas indicacoes dessa variacao da tecnica.

Acute improvement in arterial-ventricular coupling after transcatheter aortic valve implantation (CoreValve) in patients with symptomatic aortic stenosis

The recent development of transcatheter aortic valve implantation (TAVI) to treat severe aortic stenosis (AS) offers a viable option for high-risk patients categories. Our aim is to evaluate the early effects of implantation of CoreValve aortic valve prosthesis on arterial-ventricular coupling by two dimensional echocardiography. Sixty five patients with severe AS performed 2D conventional echocardiography before, immediately after TAVI, at discharge (mean age: 82.6 ± 5.9 years; female: 60%). The current third generation (18-F) CoreValve Revalving system (Medtronic, Minneapolis, MN) was used in all cases. Vascular access was obtained by percutaneous approach through the common femoral artery; the procedure was performed with the patient under local anesthesia. We calculated, apart the conventional parameters regarding left ventricular geometry and the Doppler parameters of aortic flow (valvular load), the vascular load and the global left ventricular hemodynamic load. After TAVI we showed, by echocardiography, an improvement of valvular load. In particular we observed an immediate reduction of transaortic peak pressure gradient (P < 0.0001), of mean pressure gradient (P < 0.0001) and a concomitant increase in aortic valve area (AVA) (0.97 ± 0.3 cm(2)). Left ventricular ejection fraction improved early after TAVI (before: 47 ± 11, after: 54 ± 11; P < .0001). Vascular load, expressed by systemic arterial compliance, showed a low but significant improvement after procedure (P < 0.01), while systemic vascular resistances showed a significant reduction after procedure (P < 0.001). As a global effect of the integrated changes of these hemodynamic parameters, we observed a significant improvement of global left ventricular hemodynamic load, in particular through a significant reduction of end-systolic meridional stress (before: 80 ± 34 and after: 55 ± 29, P < 0.0001). The arterial-valvular impedance showed a significant reduction (before: 7.6 ± 2 vs after: 5.8 ± 2; P < 0.0001. Furthermore we observed a significant reduction with a normalization of arterial-ventricular coupling (P < 0.005). With regard to left ventricular (LV) efficiency, we observed, after the procedure, a significant reduction of stroke work (P < 0.001) and potential energy (P < 0.001), with a significant increase of work efficiency early after the procedure (P < 0.001). Our results showed that the TAVI procedure was able to determine an early improvement of the global left ventricular hemodynamic load, allowing a better global LV performance. Further follow-up investigations are needed to evaluate these results in a more prolonged time observation.

Zabiegi przezskórnej komisurotomii mitralnej u kobiet w ciąży – obserwacje odległe

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Dąbrowski M, Chmielak Z, Dąbrowski M, Rużyłło W. Original paperPercutaneous mitral commissurotomy in pregnant women – long-term observations. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2011;7(1):15-19. doi:10.5114/pwki.2011.21187. APA Dąbrowski, M., Chmielak, Z., Dąbrowski, M., & Rużyłło, W. (2011). Original paperPercutaneous mitral commissurotomy in pregnant women – long-term observations. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 7(1), 15-19. https://doi.org/10.5114/pwki.2011.21187 Chicago Dąbrowski, Maciej, Zbigniew Chmielak, Marek Dąbrowski, and Witold Rużyłło. 2011. "Original paperPercutaneous mitral commissurotomy in pregnant women – long-term observations". Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej 7 (1): 15-19. doi:10.5114/pwki.2011.21187. Harvard Dąbrowski, M., Chmielak, Z., Dąbrowski, M., and Rużyłło, W. (2011). Original paperPercutaneous mitral commissurotomy in pregnant women – long-term observations. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 7(1), pp.15-19. https://doi.org/10.5114/pwki.2011.21187 MLA Dąbrowski, Maciej et al. "Original paperPercutaneous mitral commissurotomy in pregnant women – long-term observations." Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, vol. 7, no. 1, 2011, pp. 15-19. doi:10.5114/pwki.2011.21187. Vancouver Dąbrowski M, Chmielak Z, Dąbrowski M, Rużyłło W. Original paperPercutaneous mitral commissurotomy in pregnant women – long-term observations. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2011;7(1):15-19. doi:10.5114/pwki.2011.21187.

144 Is redo percutaneous mitral balloon valvuloplasty indicated in patients with mitral restenosis?

It is unknown if patients who developed symptomatic mitral restenosis after PMV may benefit from repeat percutaneous mitral balloon valvuloplasty (PMV). Our purpose is to assess the immediate and long-term outcomes of repeat PMV for post-PMV mitral restenosis. We report the immediate outcomes and long-term clinical follow-up results of 73 patients (mean age 29,95 years, 80,6% women) with symptomatic mitral restenosis after prior PMV, who were treated with a repeat PMV at 51,73 ± 29,4 months after the initial PMV. The mean follow-up period was 58, 85 months. There was a significant increase in the mitral valve area (1,08 ± 0,21 to 1,76 ± 0,32; p < 0,001), and decrease in the mean transmitral gradient (15,28 ± 6,84 to 8,67 ± 4,07 mm Hg; p < 0.001) and the mean left atrial pressure (25,01 ± 7,33 to 14,75 ± 5,88 mm Hg; p < 0,001). Mean pulmonary artery pressure decreases significantly with redo PMV (47,5 ± 14,73 to 34,38 ± 9,57; p < 0,001). The onset of new mitral regurgitation had occurred in 15 patients (21, 7%) Successful procedural outcome was achieved in 79, 6% of patients. No patient developed severe mitral regurgitation after redo PMV. There were no in-hospital complications. Early symptomatic improvement after redo PMV of 1 NYHA functional class was obtained in 96.7% of the patients. During the follow-up period, there were no deaths, and 10 (13, 69%) patients required mitral valve replacement. Overall, 44 patients (60, 27%) were alive without further valvular intervention at follow up after redo PVM. All of these patients were in NYHA class I or II at follow-up. The probability of event-free survival (alive and free of mitral valve replacement and/or NYHA class >III) at follow up was 91.2%. By univariate analysis age, history of previous surgical commissurotomy, pre-PMV NYHA functional class, lower echocardiographic score, post-PMV pulmonary artery pressure and atrial fibrillation were identified as univariate predictors of long-term event-free survival in the redo PMV group. Repeat percutaneous mitral valvuloplasty in patients with restenosis after a prior percutaneous valvuloplasty is feasible and can be accomplished with acceptable morbidity and mortality.

Comparison Between Transcatheter and Surgical Prosthetic Valve Implantation in Patients With Severe Aortic Stenosis and Reduced Left Ventricular Ejection Fraction

Patients with severe aortic stenosis and reduced left ventricular ejection fraction (LVEF) have a poor prognosis with conservative therapy but a high operative mortality when treated surgically. Recently, transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement (SAVR) for patients considered at high or prohibitive operative risk. The objective of this study was to compare TAVI and SAVR with respect to postoperative recovery of LVEF in patients with severe aortic stenosis and reduced LV systolic function. Echocardiographic data were prospectively collected before and after the procedure in 200 patients undergoing SAVR and 83 patients undergoing TAVI for severe aortic stenosis (aortic valve area ≤1 cm(2)) with reduced LV systolic function (LVEF ≤50%). TAVI patients were significantly older (81±8 versus 70±10 years; P<0.0001) and had more comorbidities compared with SAVR patients. Despite similar baseline LVEF (34±11% versus 34±10%), TAVI patients had better recovery of LVEF compared with SAVR patients (ΔLVEF, 14±15% versus 7±11%; P=0.005). At the 1-year follow-up, 58% of TAVI patients had a normalization of LVEF (>50%) as opposed to 20% in the SAVR group. On multivariable analysis, female gender (P=0.004), lower LVEF at baseline (P=0.005), absence of atrial fibrillation (P=0.01), TAVI (P=0.007), and larger increase in aortic valve area after the procedure (P=0.01) were independently associated with better recovery of LVEF. In patients with severe aortic stenosis and depressed LV systolic function, TAVI is associated with better LVEF recovery compared with SAVR. TAVI may provide an interesting alternative to SAVR in patients with depressed LV systolic function considered at high surgical risk.

Comparison of Procedural and In-Hospital Outcomes of Percutaneous Balloon Aortic Valvuloplasty in Patients >80 Years Versus Patients ≤80 Years

Percutaneous balloon aortic valvuloplasty (PBAV) is a procedure used for palliation, bridging to surgery, and as an integral step in the procedure for percutaneous aortic valve replacement. Older patients with severe aortic stenosis are thought to have greater risk for adverse perioperative events than younger patients. The aim of this study was to evaluate the outcomes of patients aged >80 years and those aged < or =80 years who underwent PBAV to identify factors associated with adverse clinical outcomes. This was a retrospective study of 111 consecutive patients with severe symptomatic aortic stenosis who underwent retrograde PBAV at Massachusetts General Hospital from December 2004 to December 2008. Forty-nine patients (44%) were men, and the mean age for the whole group was 82 +/- 8 years. Patients were divided into 2 age groups: those aged >80 years (n = 73) and those aged < or =80 years (n = 38). Procedural outcomes, complications, and in-hospital adverse events were compared. Multivariate logistic regression was used for the adjusted analysis. Nearly 90% of patients were in New York Heart Association class III or IV. Patients aged >80 years had lower baseline ejection fractions (43.5% vs 56.1%, p <0.01) and smaller aortic valve areas (0.59 vs 0.73 cm(2), p <0.01). Although the 2 age groups had a similar percentage of aortic valve area increase (55.5% vs 45.2%, p = 0.28), those aged >80 years had smaller post-PBAV aortic valve areas (0.89 vs 1.02 cm(2), p <0.05). Overall, in-hospital mortality was 8.1%, with no significant differences between the groups. Advanced age was not an independent predictor of in-hospital death, myocardial infarction, stroke, cardiac arrest, or tamponade; however, patients aged >80 years had a significantly higher incidence of intraprocedural emergent intubation and cardiopulmonary resuscitation compared to the younger group. New York Heart Association class was the only independent predictor of worse in-hospital outcomes. In conclusion, compared to younger patients, those aged >80 years had less favorable preprocedural characteristics for PBAV but similar overall in-hospital clinical outcomes. Patients aged >80 years had significantly higher incidence of emergent intubation and cardiopulmonary resuscitation during PBAV.

Reverse Remodeling of the Atria After Treatment of Chronic Stretch in Humans: Implications for the Atrial Fibrillation Substrate

The aim of this report was to study the effect of chronic stretch reversal on the electrophysiological characteristics of the atria in humans. Atrial stretch is an important determinant for atrial fibrillation. Whether relief of stretch reverses the substrate predisposed to atrial fibrillation is unknown. Twenty-one patients with mitral stenosis undergoing mitral commissurotomy (MC) were studied before and after intervention. Catheters were placed at multiple sites in the right atrium (RA) and sequentially within the left atrium (LA) to determine: effective refractory period (ERP) at 10 sites (600 and 450 ms) and P-wave duration (PWD). Bi-atrial electroanatomic maps determined conduction velocity (CV) and voltage. In 14 patients, RA studies were repeated >or=6 months after MC. Immediately after MC, there was significant increase in mitral valve area (2.1 +/- 0.2 cm(2), p < 0.0001) with decrease in LA (23 +/- 7 mm Hg to 10 +/- 4 mm Hg, p < 0.0001) and pulmonary arterial pressures (38 +/- 16 mm Hg to 27 +/- 12 mm Hg, p < 0.0001) and LA volume (75 +/- 20 ml to 52 +/- 18 ml, p < 0.0001). This was associated with reduction in PWD (139 +/- 19 ms to 135 +/- 20 ms, p = 0.047), increase in CV (LA: 1.3 +/- 0.3 mm/ms to 1.7 +/- 0.2 mm/ms, p = 0.006; and RA: 1.0 +/- 0.1 mm/ms to 1.3 +/- 0.3 mm/ms, p = 0.002) and voltage (LA: 1.7 +/- 0.6 mV to 2.5 +/- 1.0 mV, p = 0.005; and RA: 1.8 +/- 0.6 mV to 2.2 +/- 0.7 mV, p = 0.09), and no change in ERP. Late after MC, mitral valve area remained at 2.1 +/- 0.3 cm(2) (p = 0.7) but with further decrease in PWD (113 +/- 19 ms, p = 0.04) and RA ERP (at 600 ms, p < 0.0001), with increase in CV (1.0 +/- 0.1 mm/ms to 1.3 +/- 0.2 mm/ms, p = 0.006) and voltage (1.8 +/- 0.7 mV to 2.8 +/- 0.6 mV, p = 0.002). The atrial electrophysiologic and electroanatomic abnormalities that result from chronic stretch due to MS reverses after MC. These observations suggest that the substrate predisposing to atrial arrhythmias might be reversed.

Immediate and Long‐Term Outcome of Redo Percutaneous Mitral Valvuloplasty: Comparison with Initial Procedure in Patients with Rheumatic Mitral Restenosis

We explored the immediate and long-term outcome of redo percutaneous mitral valvuloplasty (PMV) in a series of patients with mitral restenosis in comparison with initial PMV in the same series. We enrolled 40 consecutive patients presenting with mitral restenosis after successful initial PMV. Redo PMV was performed by the antegrade transseptal approach using either the Inoue technique or the multitrack technique. Reassessment by transthoracic echocardiography was repeated 48 hours later, and annually thereafter. Procedural success was defined as 50% or more increase of mitral valve area (MVA) with a final MVA >or=1.5 cm(2), without major complications. Restenosis was defined as loss of >50% of the initial gain of MVA by the preceding PMV with a final MVA <1.5 cm(2). Procedural success was achieved in 37 (92.5%) patients. Both the initial and redo procedures were similar concerning the final MVA and mean transmitral pressure gradient (P > 0.05 for all). The gain of MVA was higher in the initial as compared to the redo procedure (P < 0.001). The initial mitral valve score correlated negatively with the final MVA in both the initial and redo procedures, and was the only independent predictor of the time to redo procedure, by multivariate regression analysis. At long-term follow-up (61 +/- 2.8 months), the mean MVA was 1.6 +/- 0.3 cm(2). Three patients--out of 12 available for follow-up--developed restenosis. Redo PMV for mitral restenosis is feasible, safe, and achieves immediate and long-term outcome comparable to initial PMV.