Successful Valvuloplasty Research Articles

Left atrial structural and functional remodeling following balloon mitral valvuloplasty.

Mitral stenosis (MS) is associated with left atrial (LA) functional and morphological changes as a result of chronic increase in LA pressure. Relieving the mitral obstruction via balloon mitral valvuloplasty (BMV) might be associated with LA structural and functional remodeling. To study alterations of LA volume and functions 1 year following successful BMV in patients with isolated rheumatic severe mitral stenosis. Thirty patients (median age 33 years, 22 women) with severe rheumatic MS were included in the study. Using biplane method, trans-thoracic 2D echocardiography was used to estimate LA volume indexed to body surface area (BSA). Maximal, minimal and pre-A left atrial volumes were measured and indexed to BSA. LA volumetric functions were then assessed and the measurements were repeated 6 months and 1 year after successful valvuloplasty. At baseline, median mitral valve area (MVA) was 0.9 (0.6-1.3)cm2 measured by planimetry with a mean pressure gradient of 12.5 (8-24)mmHg. Following BMV, a significant regression of left atrial volume index was noticed at 6 months compared to baseline (51 vs. 60ml/m2, p = 0.001) with a further decrease at 1 year (48 vs. 51ml/m2, p = 0.03). At 6 months, volumetric assessment of left atrial functions showed a significant improvement in LA total emptying fraction (42% vs 30%, p = 0.001) as well as in LA passive emptying fraction (26% vs 14%, p = 0.033) and LA active emptying fraction (20% vs. 18%, p = 0.016). All these indices showed further improvement at 1 year [47% (P = 0.02), 29% (p = 0.03) and 31% (p = 0.001) respectively]. In patients with isolated rheumatic MS, mitral valvuloplasty was associated with a significant decline of LA volume accompanied by a significant improvement of its volumetric functions.

Penetration cardiac wound associated with anterior mitral leaflet perforation: a case report and review of the literature

The paper presents a rare case of successful correction of an anterior mitral leaflet perforation. A 28-years old patient was referred with progressive heart failure symptoms at 18 weeks after he had a penetrating stab wound of the right ventricle. Massive pericardial effusion with cardiac tamponade risk and severe mitral valve insufficiency were found at examination. By the time of referral, spontaneous closure of the ventricular septal defect, which is an inevitable component of the “unhappy triad”, had happened. Accurate topical ultrasound diagnosis of the intracardial lesion that resulted from the penetrating wound of the left ventricular outflow allowed for a successful urgent mitral valve reconstruction with a xenopericardial patch and the insertion of a 28 mm MedEng annuloplasty band. To prevent any future pericardial constriction, subtotal pericardectomy by Cooley was performed.Conclusion: Perioperative echocardiography and subsequent follow up by cardiologist are obligatory in all cases of precordial wounds after discharge from hospital. Timely surgery for traumatic mitral leaflet perforation allows for a successful valvuloplasty.

Transcatheter pulmonary valvuloplasty in neonates with pulmonary atresia and intact ventricular septum

Transcatheter pulmonary valvuloplasty in neonates with pulmonary atresia and intact ventricular septum (PA-IVS) or duct-dependent pulmonary valve stenosis (DD-PVS) has become a reasonable alternative to surgical right ventricle decompression. To investigate mid-term outcomes following pulmonary valvuloplasty. Sixty-five neonates with PA-IVS (n=29) or DD-PVS (n=36) (median age 4 days; mean weight 3.0kg) undergoing pulmonary valvuloplasty were reviewed retrospectively. Procedural data and clinical outcomes were assessed. Pulmonary valvuloplasty was successful in 59 patients (90.8%). Preterm birth, larger tricuspid valve annulus diameter and PA-IVS correlated with procedural failure. Eleven patients (18.6%) required a Blalock-Taussig shunt during early follow-up, despite valvuloplasty. These neonates had smaller tricuspid and pulmonary valve annulus Z-scores (-1.9 vs. -0.8 [p=0.04] and -2.5 vs. -0.9 [P=0.005], respectively) and a higher incidence of "bipartite" right ventricle (P=0.02). Mean follow-up was 5.4±3.3 years. Mortality after successful valvuloplasty was 8.5% (n=5). Among the 54 survivors, biventricular repair was achieved in 52 patients (96.3%), including nine with a previous Blalock-Taussig shunt. The cumulative rate of subsequent surgery (excluding Blalock-Taussig shunt) was 13.7% (95% confidence interval 6.8-26.7%) and 16.4% (95% confidence interval 8.5-30.4%) at 2 and 4 years, respectively. Secondary surgery was significantly more frequent in PA-IVS compared with DD-PVS, and in neonates with a Blalock-Taussig shunt (P=0.003 and 0.01, respectively). Selected neonates with DD-PVS or PA-IVS managed by transcatheter pulmonary valvuloplasty had a good mid-term outcome. In neonates with a borderline small right ventricle, a hybrid strategy with a supplementary source of pulmonary blood flow can be efficient to achieve biventricular repair.

Multiple mitral valve repairs ­ in relapsing endocarditis

Mitral valve repair 6 months after a successful valvuloplasty for Staph. aureus endocarditis.

Tissue Doppler imaging in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome before and after fetal aortic valvuloplasty.

Fetal aortic valvuloplasty can improve filling and reduce afterload of the left ventricle in critical aortic stenosis. Success of an intrauterine intervention is currently measured by technical success, clinical survival and eventual postnatal biventricular physiology. In the present study we investigated the use of tissue Doppler imaging (TDI) to evaluate changes in ventricular function assessed before and after prenatal aortic valvuloplasty. Between October 2008 and December 2012, cardiac function was assessed by TDI before and after intervention in 23 fetuses that underwent technically successful valvuloplasty for critical aortic stenosis and in which postnatal outcome was known. The measurements were transformed into gestational age-independent Z-scores where appropriate. Mean ± SD gestational age at intervention was 27.5 ± 3.1 weeks. Of the 23 fetuses, 14 had biventricular outcome. Before intervention all left ventricular (LV) TDI-derived parameters and mitral annular plane systolic excursion (MAPSE) were severely abnormal. It was possible to demonstrate considerably improved cardiac function after technically successful valvuloplasty. Among fetuses with postnatal biventricular outcome, TDI-derived LV myocardial peak velocity during early diastole (E') and myocardial peak velocity during systole in the ejection phase (S') significantly increased, E'/myocardial peak velocity during late diastole with atrial contraction (A') increased towards normal values, and LV transmitral-to-mitral-annular diastolic velocity ratio (E/E') and myocardial performance index (MPI') decreased but remained abnormally elevated. In addition, right ventricular A', S' and MPI' significantly improved after intervention. Technically successful fetal aortic valvuloplasty led to significantly improved myocardial performance. It was possible to use TDI to detect distinct changes in ventricular function and TDI-derived parameters correlated with a biventricular outcome after birth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Echocardiographic parameters for assessing successful balloon mitral valvuloplasty in juvenile age groups.

Different echocardiographic parameters have been studied and validated for assessing the severity of mitral stenosis; however, scant data are available for these markers in the context of balloon mitral valvuloplasty in juvenile age groups (ages ⩽20 years). The aim of the present study was to find out the utility of echocardiographic parameters such as mitral valve separation index, left atrial volume, right ventricular systolic pressure, tricuspid annular plane systolic excursion, tricuspid annular systolic velocity, and right ventricular Tei index in predicting success of balloon mitral valvuloplasty and their relation to mitral valve area in juvenile mitral stenosis. We carried out a prospective single-centre study involving 52 juvenile mitral stenosis patients undergoing elective valvuloplasty. Success was defined as an increase in mitral valve area ⩾50% or ⩾1.5 cm2. Echocardiographic measurements were taken before and 24 hours after the procedure and statistical analyses were carried out. The mean age of the study population was 14.3 years (SD ±4.55), ranging from 7 to 20 years. Valvuloplasty was successful in 49 out of 52 patients. The mean valve area improved from 0.89 (SD ±0.16) to 1.73 (SD ±0.22) cm2/m2 (p<0.01), and the mean mitral valve gradient decreased from 19.87 (SD ±7.89) to 7.45 (SD ±2.07) (p=0.021). All the surrogate parameters improved favourably after valvuloplasty (p<0.01). The decrease in right ventricular systolic pressure was a better indicator of the success followed by the increase in valve separation index (area under the curve 0.81 and 0.76, respectively). All the surrogate markers studied showed favourable improvement, and right ventricular systolic pressure reduction and improved mitral valve separation index were better indicators of successful valvuloplasty.

Utility of Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Assessment and Percutaneous Intervention of Bioprosthetic Pulmonary Valve Stenosis

Accurate echocardiographic evaluation of the pulmonary valve is technically difficult because of its close proximity to the left lung, which often limits decision making. Pulmonary valvotomy is the intervention of choice for symptomatic pulmonary valve stenosis, but fluoroscopy lacks appropriate real time anatomic detail. In this report, we present a case where direct imaging of the pulmonary valve with live/real time three-dimensional transesophageal echocardiography (3DTEE) aided in accurate evaluation and was then used to help guide and monitor successful valvuloplasty of a stenotic pulmonary valve bioprosthesis. We demonstrate that even in cases where two-dimensional (2D) evaluation of the pulmonary valve is difficult, the use of live/real time 3DTEE allows for accurate evaluation of bioprosthetic pulmonary valve structure and function, and enhances the precision and monitoring of percutaneous valvuloplasty.

Outcomes and Predictors of Reintervention in Patients With Pulmonary Atresia and Intact Ventricular Septum Treated With Radiofrequency Perforation and Balloon Pulmonary Valvuloplasty

Radiofrequency perforation and valvuloplasty (RFV) is an effective initial treatment in patients with pulmonary atresia and intact ventricular septum (PA-IVS) and mild to moderate right ventricle and tricuspid valve hypoplasia. Outcomes and risk factors for the need for additional interventions in these patients are poorly defined. All patients with PA-IVS who underwent RFV at our center between January 2000 and July 2011 were reviewed. Twenty-three patients met the inclusion criteria. All patients underwent successful valvuloplasty with no procedural deaths and one major complication. Excluding two patients with limited follow-up, 6 (29%) patients underwent no subsequent interventions, whereas 9 (42%) patients underwent surgical right-ventricular outflow tract augmentation. All except one patient with adequate follow-up have a biventricular circulation with saturation >92%. Patients who did not undergo any right-ventricular outflow tract intervention after valvuloplasty had a significantly lower gradient across the pulmonary valve after valvuloplasty (9.9mmHg±8.4 vs. 19.1mmHg±10.4, p=0.05). Significantly more patients who received a supplemental source of pulmonary blood flow had a tricuspid valve z-score <-0.7 compared with patients who did not receive supplemental blood flow [2 (15%) vs. 7 (70%), p=0.008]. In our cohort of patients with PA-IVS, radiofrequency perforation with valvuloplasty was an effective and safe first step in establishing a biventricular circulation. Postvalvuloplasty pulmonary valve gradient may be predictive of subsequent outflow tract intervention, and tricuspid hypoplasia may be predictive of the need for a supplemental source of pulmonary blood flow.

An Adolescent With Aortic Regurgitation Caused by Behçet's Disease Mimicking Endocarditis

Aortic regurgitation is a serious complication of Behçet's disease. We report a 17-year-old male with severe aortic regurgitation caused by Behçet's disease. An early diagnosis led to the immediate start of immunosuppressants followed by successful valvuloplasty with autologous pericardium.

Deep venous external valvuloplasty using a rigid angioscope

The aim of this study was to evaluate the long-term results of deep venous valvuloplasty using a rigid metal angioscope. Forty patients who underwent deep venous external valvuloplasty using a rigid metal angioscope for primary deep venous insufficiency were enrolled. The preoperative CEAP (Clinical/Etiology/Anatomy/Pathophysiology) classifications were class 2 in 13 patients, class 3 in 8 patients, class 4 in 12 patients, class 5 in 1 patient, and class 6 in 6 patients. In 9 legs in 6 patients, the valves were either destroyed or congenitally absent, and deep venous plication was applied instead. The long-term operative results were evaluated from clinical charts and direct telephone interviews. During a mean follow-up period of 5.0 years, we experienced no deep vein thromboses or other complications. In 39 of the 40 patients, the subjective symptoms improved. The improvement after successful valvuloplasty was 82% with respect to the CEAP classification. Among the 9 legs treated by deep venous plication alone, 5 had improved CEAP classifications, while 4 showed no change. Deep venous external valvuloplasty assisted by a rigid angioscope is a safe and effective method for severe valve insufficiency. Furthermore, the long-term results are positive. Deep venous plication may therefore represent an effective alternative for patients who cannot undergo valvuloplasty.

Cerebral Blood Flow Characteristics and Biometry in Fetuses Undergoing Prenatal Intervention for Aortic Stenosis with Evolving Hypoplastic Left Heart Syndrome

Children with hypoplastic left heart syndrome (HLHS) are at risk for neurodevelopmental dysfunction; prenatal factors may play a role in this predilection. Cerebral blood flow profiles are abnormal in fetuses with HLHS, raising the possibility that cerebral hemodynamics in utero may be related to neurodevelopmental abnormalities. Prenatal aortic valvuloplasty for fetal aortic stenosis with evolving HLHS is technically feasible and improves left heart hemodynamics. This study aimed to assess the effects of prenatal intervention on cerebral blood flow profiles and head circumference in fetuses with evolving HLHS. Seventy fetuses underwent prenatal aortic valvuloplasty for evolving HLHS (median 23 weeks gestation). Among 46 fetuses that had successful valvuloplasty and available data, middle cerebral artery (MCA) pulsatility (PI) and resistive (RI) indices were abnormal (Z-scores –1.7 ± 1.1 and –2.2 ± 1.4, p < 0.001). Early post-valvuloplasty ( n = 33) and at late gestation follow-up ( n = 28), MCA PI and RI Z-scores remained low with no difference from pre- or early postintervention. Fetal head circumference was normal, as were umbilical artery PI and RI Z-scores. Cerebral blood flow characteristics are abnormal in mid-gestation fetuses with evolving HLHS, suggesting low cerebral vascular impedance. The mechanisms and significance of these abnormalities are unknown. Prenatal aortic valvuloplasty did not have a major impact on these indices. (E-mail: doff.mcelhinney@cardio.chboston.org)

Percutaneous Intervention for Severe Aortic Stenosis and Left Main Artery Disease in a Morbidly Obese Patient

Obesity increases significantly the rate of postsurgical complications and mortality in patients undergoing major surgery. We present the case of a morbidly obese 65-year-old female with severe aortic stenosis and left main coronary artery disease who underwent successful aortic valvuloplasty and angioplasty, with placement of a stent in the left main coronary artery. After undergoing bariatric surgery and losing 30% of her body weight, the patient was accepted for cardiac surgery to replace the aortic valve and to bypass the left anterior descending coronary artery using the mammary artery. There were no surgical complications.

Excimer Laser Guidewire Penetration of the Imperforate Valve and Balloon Valvuloplasty for Pulmonary Atresia With Intact Ventricular Septum

Objective To evaluate the initial experience of using Excimer laser guidewire penetration of the imperforate valve and balloon valvuloplasty for infants with pulmonary atresia and intact ventricular septum.Methods Seven consecutive babies with pulmonary atresia and intact ventricular septum referred between January 1996 to October 1997 were catheterized. The imperforate pulmonary valve was penetrated using a 0.018inch (0.46 mm) guidewire attached to an Excimer laser. The guidewire was introduced through a catheter previously lodged in the infundibular cavity and abutting on the atretic pulmonary valve. After penetration, the valve was dilated with progressively larger balloons.Results Excimer laser energy was applied in 7 babies and 6 (86%) had successful penetration of the imperforate pulmonary valve. The 6 babies with successful penetration of the imperforate valve all had successful valvuloplasty. On followup, 2 babies required a modified BlalockTaussig shunt to maintain the arterial saturation above 80%. The growth of the right ventricular cavity after balloon valvuloplasty was documented in 5 patients with significantly larger diameters of the tricuspid valvar annulus (P0.005) and infundibular cavity (P0.0005).Conclusion Excimer laser guidewire penetration of the imperforate pulmonary valve followed by balloon valvuloplasty is an acceptable nonsurgical alternative treatment for babies suffering from pulmonary atresia and intact ventricular septum.

Noninvasive assessment of mitral stenosis before and after percutaneous balloon mitral valvuloplasty

Thirty-seven patients with symptomatic mitral stenosis underwent balloon dilatation of the mitral valve. Significant increases (p < 0.001) were noted in both catheterization- and Doppler-determined valve area (0.9 ± 0.3 to 1.8 ± 0.8 and 0.9 ± 0.2 to 1.7 ± 0.5 cm 2). However, catheterization and Doppler areas before and after valvuloplasty correlated less well (r = 0.51, p < 0.002 and r = 0.47, p < 0.005, respectively) than the catheterization-Doppler area correlation in a previous study of 59 consecutive patients with varying degrees of mitral stenosis (r = 0.84, p < 0.001). Mitral valve area increases were independent of valve thickness estimated using 2-dimensional echocardiography. Flail mitral leaflet movement was not observed and the degree of mitral regurgitation qualitatively assessed using pulsed Doppler mapping techniques increased by >1 of 4 grades in only 1 patient. The lateral mitral valve orifice diameter increased more than the anteroposterior diameter, suggesting commissural splitting as the mechanism of successful valvuloplasty. Increases (all p < 0.0001) were noted in mitral valve EF slope (7 ± 5 to 18 ± 10 mm/s), excursion (11 ± 5 to 13 ± 4 mm), S20S interval (0.07 ± 0.02 to 0.08 ± 0.02 s) and cardiac output (4.2 ± 1.3 to 5.3 ± 2.0 liters/min). There were significant decreases (all p < 0.001) in left atrial diameter (5.4 ± 1.0 to 5.1 ± 1.0 cm), mean catheterization gradient (15 ± 5 to 8 ± 4 mm Hg) and mean Doppler gradient (10 ± 4 to 6 ± 3 mm Hg). Thus, while Doppler study can accurately predict catheterization mitral valve area in patients referred for assessment of mitral stenosis, the correlation coefficients are lower in balloon valvuloplasty patients preselected for severe mitral stenosis and in patients after balloon valvuloplasty. Other noninvasive parameters, previously shown to be inaccurate predictors of baseline valve area, do reflect increases after valvuloplasty. Valvuloplasty can successfully increase valve area even in patients with severe mitral valve thickening and causes little change in the degree of mitral regurgitation.

Changes in myocardial repolarization in patients undergoing balloon valvuloplasty for congenital pulmonary stenosis: evidence for contraction-excitation feedback in humans.

Alterations in ventricular loading conditions lead to changes in action potential duration and arrhythmias via contraction-excitation feedback; a decrease in load leads to prolongation of repolarization. To determine whether changes in right ventricular load alter ventricular repolarization in man, the corrected QT interval, a measure of overall ventricular repolarization, was measured in 32 patients before and after valvuloplasty for pulmonary stenosis. Right ventricular systolic pressure decreased (82.5 +/- 30.7 to 40.5 +/- 9.5 mm Hg, p less than .001) and the QTc increased concurrently (409.1 +/- 24.3 to 440.7 +/- 28.0 msec, p less than .001) after successful valvuloplasty. The increase in QTc was most marked for those patients with a greater than 30 mm Hg decrease in right ventricular pressure (40.0 +/- 23.3 vs 16.3 +/- 21.3 msec, p = .006). In a subset of seven patients in whom monophasic action potentials were recorded, monophasic action potential duration, a measure of local repolarization, was prolonged (230.0 +/- 24.3 vs 216.9 +/- 21.9, p less than .001) after successful valvuloplasty, confirming that the QTc prolongation reflected changes in local ventricular repolarization. In addition, during nine acute right ventricular outflow tract occlusions in a subset of six patients, monophasic action potential duration shortened (206.6 +/- 17.6 vs 221.7 +/- 20.9 msec, p less than .01) and early afterdepolarizations developed consistent with contraction-excitation feedback. These data suggest that, in humans, changes in mechanical load are associated with changes in ventricular repolarization consistent with contraction-excitation feedback.

Percutaneous transluminal valvuloplasty in calcific aortic stenosis: the double balloon technique.

The double balloon technique for aortic valvuloplasty using a combined brachial and femoral artery approach with readily available angioplasty equipment is described. Online hemodynamic assessment of the patient during the procedure was provided by continuous, reflective spectorphotometric monitoring of the pulmonary artery mixed venous oxygen saturation and the arterial pressure in the femoral sheath. Successful valvuloplasty was achieved in 10 patients with the transaortic peak-to-peak systolic gradient reduced from 77.6 +/- 28 to 27.8 +/- 15 mmHg (P less than 0.001), the mean gradient from 62.0 +/- 24 to 26.0 +/- 15 mmHg (P less than 0.0007), and the aortic valve area increased from 0.56 +/- 0.3 to 1.03 +/- 0.6 cm2 (P less than 0.05). No significant complications were encountered. The double balloon technique for aortic valvuloplasty is an acceptable alternative method to the single balloon technique.

Mitral valvuloplasty and repair for infective endocarditis

The traditional therapy for acute bacterial endocarditis of the mitral valve refractory to medical treatment is valve replacement. Successful valvuloplasty may be feasible in selected cases, in which the infection is limited to a small portion of the mitral valve anulus. The following report describes a case in which valvuloplasty with excision of the affected valve was performed successfully with no recurrence of infection over a 3-year follow-up period.