Combined aortic and mitral balloon valvuloplasty in patients with critical aortic and mitral valve stenosis: results in six cases

Combined mitral and aortic stenosis of rheumatic origin with double-valve replacement in an octogenarian

We describe double valve replacement for rheumatic mitral and aortic stenosis in an 83-year-old woman, a very uncommon event in an octogenarian.

Transjugular approach to concurrent mitral-aortic and mitral-tricuspid balloon valvuloplasty

A transjugular approach was successfully used for concurrent mitral-aortic and mitral-tricuspid valvuloplasty in one patient each. This approach simplifies antegrade transvenous aortic valve dilatation in rheumatic aortic stenosis. Advantages obtained by transjugular tricuspid valvuloplasty are easy crossing of the tricuspid valve and stable balloon position, co-axial with the tricuspid orifice.

Combined mitral and aortic valvuloplasty by antegrade transseptal approach using Inoue balloon catheter

OBJECTIVE

The purpose of this paper is firstly to highlight the ease with which the antegrade balloon aortic valvuloplasty can be performed with the Inoue balloon and secondly, the utility of the Inoue rubber nylon self-positioning balloon catheter used for twin valve dilatation.

STUDY DESIGN

Percutaneous balloon valvuloplasty is being increasingly practised for treatment of multivalvular stenoses. We describe the case of a young (21 years), male who successfully underwent combined dilation of rheumatic mitral and aortic stenosis via the transseptal antegrade approach using Inoue balloon catheters for both valves.

RESULT

Following the procedure, the mitral valve area increased from 0.6 cm2 to 1.7 cm2 and the peak systolic gradient across the aortic valve decreased from 100 mm Hg to 8 mm Hg without causing significant regurgitation at either.

CONCLUSIONS

This report highlights the ease of performing balloon aortic valvuloplasty via the antegrade transvenous route and utilizing the advantages of Inoue balloon catheter.

Percutaneous balloon mitral valvuloplasty

Percutaneous balloon mitral valvuloplasty, first performed by Inoue in 1982, was a rational progression from 4 decades of experience with the blunt surgical dilatation technique of closed mitral commissurotomy. As with surgical commissurotomy, balloon valvuloplasty relieves mitral stenosis by the splitting of fused commissures. A series of studies have shown that balloon valvuloplasty achieves excellent acute hemodynamic results in close to 90% of patients, with a typical 100% increase in mitral valve area. Over the past 15 years since Inoue's first patient, a number of other techniques have been introduced and largely discarded in favor of the original approach. Advances have occurred along the lines of improved noninvasive assessment of mitral valve disease, which have allowed better case selection and prediction of outcome. Follow-up series have shown sustained improvement, with modest rates of complications and restenosis. Comparative studies have shown that balloon valvuloplasty is as effective and safe as surgical commissurotomy, and is a cost-effective procedure of first choice in ideal patients.

Percutaneous double-valve balloon valvotomy for multivalve stenosis: immediate results and intermediate-term follow-up

Ten patients each with combined mitral and tricuspid stenosis (group 1) and with combined mitral and aortic stenosis (group 2) underwent double-valve balloon valvotomy as a single staged procedure. The aortic valve was dilated by the Mansfield balloon technique, whereas the mitral and tricuspid valves were dilated with either the Mansfield or Inoue balloon. The mitral valve area increased from 0.78 +/- 0.21 cm2 to 2.05 +/- 0.56 cm2 (p < 0.0005) in group 1 and from 0.75 +/- 0.20 cm2 to 2.1 +/- 0.59 cm2 (p < 0.05) in group 2. The tricuspid valve area increased from 1.11 +/- 0.41 cm2 to 2.52 +/- 0.69 cm2 (p < 0.0005). In group 2, the transaortic gradient decreased from 93.56 +/- 17.7 mm Hg to 28.56 +/- 7.8 mm Hg (p < 0.0005) and the valve area increased from 0.37 +/- 0.05 cm2 to 1.03 +/- 0.25 cm2 (p < 0.005). The excellent symptomatic and hemodynamic results were sustained at 30.3 +/- 9.8 months of follow-up in group 1 and at 23.5 +/- 9.1 months in group 2. Double-valve balloon valvotomy is feasible and safe and provides excellent immediate and intermediate-term follow-up results in selected patients with multivalve disease. A longer follow-up in a larger number of cases is needed to define further the role of this therapy.

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.

Results of balloon aortic valvuloplasty in patients with aortic stenosis associated with significant aortic regurgitation

The influence of balloon aortic valvuloplasty (BAV) on aortic regurgitation (AR) in patients with severe aortic stenosis associated with greater than or equal to grade II AR was studied by supraaortic angiogram before and after BAV. The results of 50 patients aged 72 +/- 12 years with significant AR before BAV (group A) were compared to 297 patients (mean age 76 +/- 10 years) with no or mild AR (group B). In group A, the patients had a higher left ventricular end diastolic volume (96 +/- 19 mL/m 2 vs 81 +/- 32 mL/m 2, P less than 0.01) and left ventricular end diastolic pressure (23 +/- 9 mmHg vs 19 +/- 9 mmHg, P less than 0.01). The aortic valve area was similar in both groups. Following BAV, the improvement in aortic valve area and hemodynamics were similar in both groups. In group A, AR remained unchanged in 31 patients (62%), increased by 1 grade in 13 patients (26%), and decreased by 1 grade in 6 patients (12%). In group B, AR increased by greater than 1 grade in 34 patients (11%) and greater than 2 grades in 4 patients (1.3%) post-BAV. Two patients in group B underwent emergency aortic valve replacement following BAV because of severe acute AR. In conclusion, when it is indicated, BAV can be performed with similar risk in patients with significant AR.

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.

Predictors of event-free survival after balloon aortic valvuloplasty

BACKGROUND

Balloon aortic valvuloplasty was developed as an alternative to aortic-valve replacement in selected elderly patients with aortic stenosis. The use of this procedure is limited, however, by a high incidence of restenosis.

METHODS

Between December 1985 and April 1989, valvuloplasty was performed in 205 patients. We evaluated 40 demographic and hemodynamic variables as univariate predictors of event-free survival by Cox regression analysis and identified independent predictors of event-free survival by stepwise multivariate analysis.

RESULTS

Early hemodynamic results indicated a decrease in the peak transaortic-valve pressure gradient from 67 +/- 28 to 33 +/- 15 mm Hg after valvuloplasty and an increase in aortic-valve area from 0.6 +/- 0.2 to 0.9 +/- 0.3 cm2 (P less than 0.001 for both comparisons). The rate of event-free survival (defined as survival without recurrent symptoms, repeated valvuloplasty, or aortic-valve replacement) was 18 percent over the mean (+/- SD) follow-up period of 24 +/- 12 months (range, 1 to 47). Significant predictors of event-free survival included the left ventricular ejection fraction and the left ventricular and aortic systolic pressure before valvuloplasty, and the percent reduction in the aortic-valve pressure gradient; the pulmonary-capillary wedge pressure was inversely associated with event-free survival. Although the predicted event-free survival rate for the entire patient group was 50 percent at one year (95 percent confidence interval, 43 to 57 percent) and 25 percent at two years (95 percent confidence interval, 19 to 31 percent), the probability of event-free survival at one year varied between 23 and 65 percent when patients were stratified according to three independent predictors: the aortic systolic pressure, the pulmonary-capillary wedge pressure, and the percent reduction in the peak aortic-valve gradient.

CONCLUSIONS

The most important predictors of event-free survival after balloon aortic valvuloplasty were related to base-line left ventricular performance. The best long-term results after valvuloplasty were observed among patients who would also have been expected to have excellent long-term results after aortic-valve replacement.

Concurrent double balloon valvotomy for combined rheumatic mitral and tricuspid stenosis

We expanded the application of percutaneous balloon valvotomy (PBV) to 4 adults (age 14 to 30 years, average 22.2 years) with combined rheumatic mitral and tricuspid stenosis. Double balloon dilatation reduced the transmitral gradient from 17.36 +/- 3.54 to 5.52 +/- 0.89 (P less than 0.025) and transtricuspid gradient from 12.65 +/- 2.67 to 3.67 +/- 0.95 (P less than 0.025). Mitral and tricuspid valve area increased from 0.73 +/- 0.20 to 2.57 +/- 0.67 (P less than 0.005) and from 0.77 +/- 0.24 to 2.67 +/- 0.24 cm2 (P less than 0.005), respectively. The procedures were well tolerated, with no significant increase in valvular regurgitation or left to right shunt across the atrial septum. The excellent symptomatic and haemodynamic benefits are sustained at 3-24 months follow-up. It is concluded that combined dilatation of stenotic valves by double balloon technique can emerge as an alternative to surgery in selected patients with polyvalvar rheumatic heart disease.

Acute reduction of mitral valve area after percutaneous balloon mitral valvuloplasty: assessment with Doppler continuity equation method

Mitral valve areas before and after balloon mitral valvuloplasty were serially determined by the Doppler continuity equation method in 16 patients. Ultrasound examinations were performed before and immediately after balloon inflation and 24 hours, 1 week, and 1 month after valvuloplasty. Mitral valve area determined by the Doppler continuity equation method correlated well with that determined at catheterization by the Gorlin formula, not only before but also immediately after balloon inflation (y = 0.87 x + 0.05, standard error of estimate = 0.22 cm2, r = 0.90). Serial calculation of mitral valve area by the Doppler continuity equation method showed a slight but significant decrease in the valve area at 24 hours after balloon mitral valvuloplasty but no change after that. We conclude that the Doppler continuity equation method provides an accurate estimation of mitral valve area before and even after balloon valvuloplasty. Mitral valve area dilated by balloon inflation is decreased slightly within 24 hours after the procedure, which corroborates valve stretch as one mechanism for increasing mitral valve area with balloon valvuloplasty. Estimation of mitral valve area immediately after balloon mitral valvuloplasty may overestimate the long-term efficacy of the procedure.

Percutaneous balloon valvuloplasty

In the technique of percutaneous balloon valvuloplasty, one or more large balloons are inserted percutaneously and then inflated across a stenotic valve to decrease the degree of obstruction. Currently, the procedure is being performed for patients with pulmonic, mitral, or aortic stenosis. The results vary according to the type of valve and the age of the patient. In patients with pulmonic stenosis, balloon valvuloplasty can be performed safely and the results are excellent. Therefore, at many institutions it is the procedure of choice for the treatment of isolated pulmonic stenosis. In patients with mitral stenosis, the results depend on the morphologic features of the stenotic valve. In patients with highly calcified and fibrotic mitral valve leaflets, the risks of the procedure are increased and the results are suboptimal. In experienced hands, however, balloon valvuloplasty is excellent for patients with a pliable, noncalcified mitral valve or those for whom operation imposes an extremely high risk. The use of balloon valvuloplasty for aortic stenosis has been limited to the frail, elderly patient who either is not a surgical candidate or is at high risk for operation. Although mortality and restenosis rates are high on short-term follow-up, aortic balloon valvuloplasty provides palliation of symptoms in many patients who otherwise would have been unable to undergo any intervention. Long-term follow-up is necessary for determining the ultimate role of balloon valvuloplasty in cardiology.

Combined percutaneous mitral and aortic balloon valvuloplasty

Between August 1987 and November 1988, combined mitral and aortic balloon valvuloplasty was performed in 10 patients (mean age 42 +/- 9 years), all of whom had symptomatic mitral and aortic stenosis. The procedure was performed using a transarterial approach with a multiballoon catheter and an exteriorized intracardiac long guidewire circuit. The procedure could be considered successful in 9 patients where significant increases in the mean mitral (0.97 +/- 0.19 to 1.80 +/- 0.26 cm2) and aortic (0.63 +/- 0.18 to 1.15 +/- 0.32 cm2) areas were achieved. Severe mitral regurgitation that required surgery developed in 1 patient in the following 24 hours. Femoral vascular surgery was necessary in 1 patient. Mid-term follow-up was available in 8 patients for a period averaging 8 +/- 3 months. The 9 patients in whom the procedure was successful showed persistent clinical improvement in functional class, Doppler echocardiography showed 2 cases of aortic restenosis and none of mitral restenosis. Combined mitral and aortic balloon valvuloplasty could be a valid alternative treatment in selected patients with both mitral and aortic rheumatic stenosis. Further experience and long-term hemodynamic follow-up are necessary to define the role of this mode of treatment.

Transient acute severe aortic regurgitation complicating balloon aortic valvuloplasty

Transient, acute severe aortic regurgitation documented by hemodynamic and Doppler-echocardiographic assessment was observed in an elderly woman immediately following balloon aortic valvuloplasty for critical aortic stenosis. Aortic regurgitation responded to medical therapy and resolved within 24 hr. Potential mechanisms are discussed. We suspect that an oversized balloon to aortic ring area stretched the annulus, separating the valve cusps and resulting in severe regurgitation, which rapidly normalized.

Restenosis is a common feature of the angiographic follow-up after balloon valvoplasty of calcified aortic stenoses

Balloon dilatation of calcified aortic stenosis was attempted in 12 patients, 6 men and 6 women, aged 38-82 years. Two patients underwent emergency surgery because of myocardial injury or pericardial tamponade. One patient with severe depressed left ventricular function in whom the procedure was attempted in cardiogenic shock died during the procedure. One patient experienced severe aortic insufficiency after dilatation. The remaining pressure gradient was higher than 50 mm Hg in another patient. Seven dilatations were considered to be successful with a remaining pressure gradient below 50 mm Hg and a mean gradient reduction of 53 mm Hg. In one of these 7 patients, who suffered from severe heart failure, valvoplasty had been carried out to make aortic valve replacement possible. The operation was performed 2 weeks later without complications. Five of 6 patients treated medically after successful valvoplasty had restenosis within 3 to 12 months. One of them exhibited a good result at 3 months but severe restenosis after one year. It is concluded that balloon valvoplasty of calcified aortic stenosis cannot be considered an alternative to surgery. If, however, left ventricular function improves after successful valvoplasty, valve replacement will then carry less risk.