Stenotic aortic and mitral valves treated with catheter balloon valvuloplasty in a patient with small valve anuli

Concurrent aortic and mitral balloon valvuloplasty by the retrograde non-transseptal technique

Balloon valvuloplasty for combined aortic and mitral stenosis is now being increasingly practised. Transseptal catheterisation forms an integral part of this procedure. We describe a case where the retrograde non-transseptal approach was used for dilating both valves in a single intervention.

Multicenter experience with balloon mitral commissurotomy. NHLBI Balloon Valvuloplasty Registry Report on immediate and 30-day follow-up results. The National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry Participants

BACKGROUND

Balloon mitral commissurotomy can increase mitral valve areas and reduce symptoms in selected patients with mitral stenosis. The National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry was organized to address concerns regarding differences in patient selection and technique and to report the current clinical outcome.

METHODS AND RESULTS

In 24 cooperating centers, 738 patients had balloon mitral commissurotomy. Baseline clinical, echo Doppler, and cardiac catheterization data, procedure details, and hemodynamic and 30-day clinical outcome were reported. Overall, 81% of the patients were women (mean age, 54 +/- 15 years), and 24% had moderate or severe other valvular lesions. When single- and double-balloon procedures were compared, the final mitral valve area was larger (1.7 +/- 0.7 versus 2.0 +/- 0.8 cm2, p = 0.0009), increase in mitral regurgitation was similar (4% versus 12%, p = 0.08), and interatrial shunts occurred more frequently (2% versus 12%, p = 0.04) after double-balloon procedures. Increase in mitral valve area was weakly related to mitral valve morphology as assessed by an echo score (r = -0.15). Multivariate predictors of improved clinical status at 30 days were cases performed in larger-volume centers, baseline mitral valve area greater than 0.5 cm2, and age less than 70 years. At 30-day follow-up, 4% of the patients with completed procedures had mitral valve surgery, 3% had died, and 83% had their overall condition improved. Patients with mixed mitral stenosis or regurgitation and isolated mitral stenosis had a similar course, but fewer patients with multivalve disease became asymptomatic.

CONCLUSIONS

Balloon mitral commissurotomy, as practiced in a broad range of experienced centers, produced significant short-term hemodynamic and clinical improvements. Balloon mitral commissurotomy can be considered an effective treatment option in patients with symptomatic mitral stenosis.

Follow-up recatheterization after balloon aortic valvuloplasty. Mansfield Scientific Aortic Valvuloplasty Registry Investigators

The results of recatheterization were assessed in a select group of 95 patients enrolled in the Mansfield Scientific Aortic Valvuloplasty Registry to determine whether any procedural or patient-related variables at baseline predicted either initial immediate or follow-up (6.2 +/- 3.3 months) results. At the follow-up catheterization, 39 (41%) of the patients were in improved condition and 56 patients (59%) had recurrence of symptoms, allowing for analysis of the effect of the procedure in two symptomatic patient subsets. In the total group the aortic valve area increased initially from 0.56 +/- 0.16 to 0.87 +/- 0.27 cm2 but partial return to the baseline valve area was evident at follow-up (0.63 +/- 0.25 cm2). Similarly, the mean aortic gradient initially decreased from 72 +/- 30 to 35 +/- 16 mm Hg but then increased to 55 +/- 25 mm Hg at follow-up. Neither the initial nor the late hemodynamic results appeared affected by any definable procedural variable at the time of valvuloplasty, including the maximal diameter of balloons, number of balloons simultaneously used, mean inflation time or total number of inflations. Such technical concerns also did not seem to affect short- or long-term outcome. Similarly, no baseline hemodynamic variable clearly separated those who became increasingly symptomatic from those whose condition was improved at the 6 month interval. At recatheterization, a reduction in the aortic valve area toward baseline was observed in 24 (62%) of the 39 improved patients and in 45 (80%) of the 56 who were symptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

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.