Safety of catheter ablation of AF without pre- or periprocedural imaging for the detection of LA thrombus

Funding Acknowledgements

Type of funding sources: None.

Background

The need for pre- or peri-procedural imaging to rule out the presence of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation (AF) is unclear in the era of uninterrupted direct oral anticoagulant (DOAC) regimen. We sought to examine the safety of catheter ablation in appropriately selected patients with paroxysmal AF without performing screening for left atrial thrombus.

Methods

Consecutive patients planned for radiofrequency AF catheter ablation between January 2016 and June 2020 were enrolled, and prospectively studied. All subjects were receiving uninterrupted anticoagulation with DOACs for at least 4 weeks before the procedure. All subjects were in sinus rhythm the day of the procedure. The primary outcome of the study was ischemic stroke or transient ischemic attack (TIA) during at 30 days.

Results

A total of 451 patients (age 59.7 ± 10.2 years, 289 males) with paroxysmal AF were included in the study. The mean CHA2DS2-VASc score was 1.4 ± 1.2. The mean left ventricular ejection fraction and left atrial diameter were 60 ± 5% and 39.3 ± 4 mm, respectively. Regarding the anticoagulation regimen, apixaban was used in 197 (43.6%) patients, rivaroxaban in 148 (32.8%) patients, and dabigatran in 106 (23.5%) patients. None of the patients developed clinical ischemic stroke or TIA during the 30-day post-discharged period.

Conclusions

Catheter ablation can be safely performed in low-risk patients with paroxysmal AF without imaging for the detection of left atrial thrombus in the era of uninterrupted DOAC anticoagulation.

414 Ventricular-arterial interaction predicts response to cardiac resynchronization therapy: a link with improvement of endothelial function and arterial elastic properties

Background

Endothelial dysfunction (ED) is a hall mark of chronic heart failure and has been linked to disease progression, hospitalizations and mortality.

Purpose

to evaluate the impact of cardiac resynchronization therapy (CRT) in ED and to determine predictors of response to CRT

Methods

CRT recipients from 19/07/2016 until 19/10/2018 were studied at baseline and 3 months after. In each visit we evaluated a 12 lead ECG, carotid to femoral pulse wave velocity (cfPWV), flow-mediated dilatation of the brachial artery (FMD), left ventricle ejection fraction (LVEF) and left ventricle (LV) global longitudinal strain (GLS). We evaluated arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography and the ratio of cfPWV to GLS, as valid markers of ventricular-arterial interaction. We also assessed the layer of endothelial glycocalyx by measurement of Perfused Boundary Region (PBR) of the sublingual microvessel range:5-25 microns.

Results

32 patients with a mean age 65.5 (±10.9) years and severe LV systolic dysfunction were enrolled. During follow-up, LVEF, GLS, LVESV and all ED markers exhibited significant improvement (table 1). 23 patients were responders. Among the baseline vascular function markers, only the ratio cfPWV/GLS predicted response to CRT (OR: 0.245, 95%CI: 0.042-0.759, p = 0.044).Threshold analysis showed that the best threshold of cfPWV/GLS for response to CRT was 2.75 (specificity: 0.67%, sensitivity: 0.94%).

Conclusions

After 3 months of CRT, endothelial function, arterial elasticity and ventricular arterial interaction are improved. The baseline ratio cfPWV/GLS, a novel marker of ventricular arterial interaction, can be applied to predict response to CRT.

table 1 Baseline Follow-up Change Measurement mean (sd) mean (sd) mean (sd) p-value SBP (mmHg) 126 (19) 128 (16) 2.18 (11.98) 0,465 DBP (mmHg) 79 (9) 80 (9) 1.06 (8.58) 0,618 LVEF (%) 27 (7) 35 (9) 7.50 (4.77) <0.001 LVESV (mL) 151 (42) 120 (46) -26.91 (17.20) <0.001 GLS (%) 6.47 (2.89) 9.33 (4.18) 2.85 (2.28) <0.001 FMD (%) 5.88 (2.79) 10.25 (3.67) 4.37 (3.34) <0.001 Ea/Ees 2.81 (1.10) 2.04 (0.99) -0.77 (0.47) <0.001 cfPWV 11.11 (2.61) 10.01 (2.45) -1.10 (1.56) 0,003 PBR 5-25(microns) 2.26 (0.20) 2.14 (0.24) -0.13 (0.25) 0,028 cfPWV/GLS 2.18 (1.46) 1.45 (1.11) -0.73 (0.55) <0.001 Measurements at baseline, follow-up and their change during study

Abstract 414 Figure. picture 1

P709Improvement in endothelial function and arterial elastic properties facilitates response to cardiac resynchronization therapy

Background

Cardiac resynchronization therapy (CRT) is a well-established therapy in heart failure (HF) patients with prolonged QRS. In HF patients, reduced nitric oxide availability and increased oxidative stress promote endothelial dysfunction (ED) and arterial stiffness.

Purpose

To investigate the pathophysiologic changes in endothelium and arterial elastic properties in CRT patients and their correlation to therapy.

Methods

We studied 32 HF patients before and 3 months after CRT implantation. In each visit we performed a 12-lead ECG and assessed markers of endothelial function. Specifically, we examined flow-mediated dilatation of the brachial artery (FMD), carotid to femoral pulse wave velocity (cfPWV), as well as the layer of endothelial glycocalyx using the Perfused Boundary Region (PBR) of the sublingual microvessel range: 5–25 microns. We also evaluated left ventricle ejection fraction (LVEF), left ventricle (LV) global longitudinal strain (GLS) and arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography.

Results

32 HF CRT patients, at age 65.5 (±10.9) years, with reduced LVEF (baseline LVEF: 27±7%, LVESV: 151±42 ml, GLS: 6.47±2.89%) were followed-up for a median of 115 days (IQR: 36). During follow up, all markers of ED demonstrated significant change: FMD was increased by 4.37±3.34% (p<0.001), cfPWV and PBR 5–25 were reduced by 1.10±1.56 (p=0.003) and 0.13±0.25 microns (p=0.028) respectively. LVEF was significantly increased (mean change: 7.50±4.77%) and LVESV was significantly reduced (mean change: −26.91±17.20 ml). 16 of 32 patients were responders (LVESV change ≥15% compared to baseline). Among the changes of the examined markers during follow-up, response to CRT correlated with the change of FMD (OR: 3.10, 95% CI: 1.47–15.51, p=0.039) and change of Ea/Ees (OR: 0.000, 95% CI: 0.000–0.061, p=0,0239).

Effect of change in measurements during follow-up on response to CRT Measurement OR (95% CI) Main effect p-value FMD change 3.100 (1.470–15.513) 0.0397 cfPWV change 0.669 (0.295–1.354) 0.0622 PBR 5–25 change 1.773 (0.008–455.458) 0.828 Ea/Ees change 0.000 (0.000–0.061) 0.0239

Conclusion

Improvement in endothelial function and arterial elastic properties evaluated by FMD and Ea/Ees respectively are related with effective CRT.

The association of hematological indices with the response to cardiac resynchronization therapy: a single-center study

BACKGROUND

Cardiac resynchronization therapy (CRT) is an established therapeutic option for patients with heart failure (HF) and left ventricular ejection fraction (LVEF) ≤35 % who meet specific criteria according to current guidelines. However, up to 40 % of patients have no response to CRT. Our study aimed to investigate the association between different hematological and biochemical indices and response to CRT.

METHODS

Patients with HF due to ischemic or dilated cardiomyopathy referred to our hospital for CRT implantation from January 2013 to November 2017 were included in the study. Response to CRT was defined as an increase in LVEF ≥10 % or a decrease in left ventricular end-systolic volume (LVESV) ≥15 % at six months of follow-up.

RESULTS

A total of 48 patients (mean age: 66.2 ± 9.5 years, 81.3 % males) were included in the study. Of these HF patients, 29 (60.4 %) had ischemic cardiomyopathy, and 19 (39.6 %) had dilated cardiomyopathy. At six months of follow-up, 37 patients (77.1 %) had responded to CRT. Ten patients (20.8 %) had ventricular tachycardia (VT), 24 (50 %) patients were hospitalized, and two patients (4.2 %) died during the follow-up period. Multivariate analysis demonstrated that age (p =0.03) and creatinine levels (p =0.02) were independent predictors of the response to CRT. No significant associations between hematological markers (white blood cells, neutrophils, lymphocytes, platelets, neutrophil to lymphocyte ratio, red blood cells distribution width) and CRT response were observed.

CONCLUSIONS

A smaller increase in LVEF and a smaller decrease in LVESV were predictive for VT occurrence and hospitalizations in patients receiving CRT. No significant association between hematological markers and response to CRT was found. HIPPOKRATIA 2019, 23(3): 118-125.

Intermuscular implantation technique for subcutaneous cardioverter-defibrillators

BACKGROUND

The conventional technique for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation has been associated with pocket complications. The aim of this study was to evaluate the efficacy and safety of an alternative intermuscular technique for S‑ICD implantation.

METHODS

S-ICDs were implanted in ten consecutive patients (ten males, mean age: 46.8 ± 14.7 years). The pocket for the pulse generator was made above the serratus anterior muscular fascia and beneath the latissimus dorsi muscle by detaching the fibrous tissue between the muscles. Electrode implantation was performed using the three- (n = 4) or the two-incision technique (n = 6).

RESULTS

All S‑ICDs were successfully implanted in the absence of any procedure-related complications with a successful 65-J standard polarity defibrillation threshold testing, apart from one patient with Brugada syndrome who needed device repositioning more dorsally. During a mean follow-up of 16.5 ± 7.3 months, no major complications requiring surgical repair were encountered, while patients demonstrated high levels of comfort and satisfaction with the cosmetic result. One patient experienced an inappropriate shock due to noise detection, which was resolved after reprogramming to a different sensing vector.

CONCLUSION

The intermuscular technique is a safe and efficacious approach for S‑ICD implantation. This technique could lead to fewer pocket-related complications and better cosmetic results.

Management of atrial fibrillation in patients with heart failure

BACKGROUND

There is a well-documented relationship and a complex interaction between atrial fibrillation (AF) and heart failure. The coexistence of these 2 clinical entities renders their management even more challenging.

METHODS AND RESULTS

We searched current literature to review the management of AF in patients with heart failure. The cornerstones of AF treatment are rate control, cardioversion, and maintenance of sinus rhythm (SR), and prevention of thromboembolism. The issue of rhythm versus rate control remains unresolved. Nonpharmacologic therapies such as radiofrequency catheter ablation of the atrioventricular node with permanent pacemaker implantation, curative catheter ablation of AF, and cardiac resynchronization therapy are emerging and may alter the management of these patients.

CONCLUSION

Treatment of atrial fibrillation in the setting of heart failure encompasses a variety of approaches including drugs, devices, and ablation. Larger randomized trials are required to clarify the management of such patients.

Studies on apoptosis and fibrosis in skeletal musculature: a comparison of heart failure patients with and without cardiac cachexia

Apoptosis has been found in skeletal muscles of patients with chronic heart failure (CHF) and has been associated with exercise intolerance. In CHF, cachexia is characterized by neurohormonal activation and muscle wasting. Neurohormonal activation can lead to cell death and fibrosis. The purpose of the study was to determine the severity of apoptosis and fibrosis in skeletal muscles of patients with CHF and cachexia and its relationship to exercise intolerance in these patients. Skeletal muscle biopsies of 21 patients with CHF (eight with cachexia) and four healthy controls of similar age have been studied by in situ end labeling (ISEL) for apoptosis and by the Picrosirius Red technique for collagen. Apoptosis in skeletal muscles was detected by ISEL in 52% of the patients with CHF (11 out of 21) and in none of the controls. CHF patients with apoptosis-positive skeletal muscles had impaired exercise tolerance (peak oxygen consumption 11.4+/-5.7 vs. 16.91+/-6.6, P=0.029). Increased collagen was detected by Picrosirius Red in eight out of 21 patients with CHF and in none of the controls. Increased collagen (fibrosis) was detected in six out of eight patients with cachexia and in two out of 13 patients without cachexia (P=0.01). Peak oxygen consumption and apoptosis were similar in cachectic and non-cachectic patients. Thus, the skeletal musculature of patients with cardiac cachexia is characterised by the presence of fibrosis. Apoptosis was not found to be more frequent in cachectic CHF patients. Our data support the hypothesis that cachexia contributes by a different mechanism to skeletal muscle myopathy of CHF patients and different mechanisms are implicated in deterioration of exercise tolerance and progression to cardiac cachexia.

Effect of atrial pressure increase on effective refractory period and vulnerability to atrial fibrillation in patients with lone atrial fibrillation

BACKGROUND

There is evidence suggesting that atrial fibrillation (AF) may be induced by acute increase of atrial pressure. The aim of the present study was to investigate the effect of alterations in atrial pressure, induced by varying the atrioventricular (AV) interval, on atrial refractoriness, and on the frequency of induction of (AF), in patients with a history of lone atrial fibrillation (LAF).

METHODS AND RESULTS

Twenty-five patients were included in this study. The patients were divided in two groups: the LAF group, and the control group. None of the patients in either group had organic heart disease. Effective refractory period (ERP) and duration of atrial extrastimulus electrogram (A(2)) were measured at two right atrial sites (high lateral wall, atrial appendage) during AV pacing (cycle length: 500 msec) with different AV intervals. Peak, minimal and mean atrial pressure increased from 8.57 +/- 2.37 to 18.14 +/- 4.74 mm Hg, 2 +/- 2.23 to 5.14 +/- 2.60 mm Hg (p = 0.0001) and from 4.28 +/- 1.6 mm Hg to 9.77 +/- 2.9 mm Hg (p = 0.001), respectively during AV interval modification. During lateral and atrial appendage pacing, with a progressive decrease of AV interval to 160, 100, 80, 40, 0 msec, the ERP, the dispersion of ERP, functional refractory period (FRP), A2 and latency period (LP) did not change significantly, in both groups. The frequency of induction of AF was not statistically different in both lateral atrial wall and appendage, during pacing in different AV intervals.

CONCLUSIONS

This study demonstrates that alterations in the intraatrial pressure does not have important effects on atrial refractoriness and does not increase vulnerability to AF in patients with a history of LAF.

Excessive sinus pauses and their elimination in a patient with sleep apnea syndrome

A 40-year-old man with severe sleep apnoea syndrome presented significant sinus pauses during a 48 h electrocardiogram Holter recording. Holter analysis showed one sinus pause of 6.4 s duration, and many pauses greater than 3 s. The 48 h Holter reevaluation, after a continuous positive air pressure device was applied, showed no pauses. The electrophysiological study was negative for sick sinus syndrome.

Carotid sinus hypersensitivity in patients undergoing coronary arteriography: relation with the severity of carotid atherosclerosis and the extent of coronary artery disease

INTRODUCTION

The purpose of the present investigation was to study the precise relationship between carotid sinus hypersensitivity (CSH) and both the severity of carotid atherosclerosis and the extent of coronary artery disease in patients who were referred for evaluation for suspected ischemic heart disease.

METHODS AND RESULTS

Duplex echocardiography and coronary angiography were used to assess carotid and coronary artery atherosclerosis in 130 consecutive patients. Carotid sinus stimulation was performed before coronary arteriography with simultaneous recordings of the ECG and aortic pressure. Coronary artery disease was present in 103 patients (79%). Thirty patients (23.08%) had one-vessel disease (1-VD), 31 (23.85%) had 2-VD, 29 (22.31%) had 3-VD, and 13 patients (10%) had left main coronary artery disease. Carotid artery atherosclerosis was present in 100 patients (76.92%) and carotid disease (diameter stenosis > 50%) was present in 24 patients (18.46%). CSH was found in 33 patients (25%). The incidence of CSH was 9% in patients with carotid stenosis 1%-15%, 17% in patients with stenosis 16%-49%, 85% in patients with stenosis 50%-79%, and 100% in patients with stenosis > or = 80%. The incidence of CSH was 11%, 17%, 23%, 34%, and 62% in patients with no VD, 1-VD, 2-VD, 3-VD, and left main coronary artery disease, respectively. Stepwise multiple logistic regression analysis revealed that carotid disease and left main coronary artery disease were the most significant determinants of CSH (P < 0.001 and P = 0.013, respectively).

CONCLUSION

The incidence of CSH increased in proportion to the severity of carotid and coronary atherosclerosis. These data provide evidence that CSH is closely related to severe carotid atherosclerosis or left main coronary artery disease in patients being evaluated for suspected ischemic heart disease.

Stress echocardiography using adenosine combined with nitroglycerin-dobutamine in the detection of viable myocardium in patients with previous myocardial infarction

The aim of this study was to assess the value of adenosine (A) and the combination of nitroglycerin (N) with dobutamine (D) stress echocardiography (SE) in the identification of viable myocardium. The clinical and electrocardiographic (ECG) effects of both tests were also evaluated. Fifty-two coronary artery disease patients, aged 56.4 +/- 8 years, with left ventricular dysfunction due to a previous myocardial infarction (mean ejection fraction: 49 +/- 8%) were included in the study. Cardiac catheterization was performed in all patients before A (140 micrograms/kg/minute for five minutes) and the combination of N with D (5-10 micrograms/kg/minute) stress echocardiography. On the echocardiogram, the left ventricle was divided into 16 segments and wall motion was graded semiquantitatively from 1 (normal) to 4 (dyskinesia). The echocardiographic index was also estimated. A segment was considered viable during A infusion when resting asynergy showed deterioration of one grade or more. In contrast, segmental viability was considered to be present during the combination of N with D infusion when resting asynergy showed improvement of one grade or more. A thallium 201 single photon emission computed tomography (SPECT) with reinjection was performed as reference standard for the identification of viable myocardium. Stress echocardiography during infusion of A was associated with short-duration angina attacks in 3 (5.8%) patients and transient complete atrioventricular (AV) block in 1 (1.9%), whereas during the combination of N with D infusion, 6 (11.5%) patients experienced ventricular bigeminy lasting for a short period. ST segment elevation greater than 1 mm was recorded in those leads having a Q wave, in 19 (36.5%) patients. In 10 of these 19 (52.6%), viable myocardium was present in SPECT, as it was in 33 patients (63.5%) having no ST segment elevation (P = NS). Of a total of 832 segments that were graded during A-SE, 276 exhibited resting asynergy and the remaining 556 had normal motion and thickening at rest. The echocardiographic index during A infusion increased from 1.52 +/- 0.22 to 1.71 +/- 0.24 (P < 0.001), whereas during D and N infusion it decreased from 1.53 +/- 0.31 to 1.30 +/- 0.42 (P < 0.001). With SPECT considered as the gold standard for the identification of viable myocardium, sensitivity, specificity, and positive and negative predictive values of A-SE in detecting viable myocardium were 54%, 86%, 65% and 80%, respectively. The respective values for the combination of nitroglycerin with D-SE were 91%, 89%, 78%, and 96%, respectively. Stress echocardiography during A, and the combination of N with D, constitute safe methods in the identification of viable myocardium. The detection of ST segment elevation in the ECG leads with a Q wave during the combined infusion of nitroglycerin and dobutamine is not related to the presence of viable myocardial tissue. The A-SE provide moderate diagnostic accuracy, while the combination of N with D during SE is much superior in detecting viable myocardium.

The Contribution of the Left Atrioventricular Plane Displacement During Low Dose Dobutamine Stress Echocardiography in Predicting Recovery of Left Ventricular Dyssynergies

The aim of this study was to assess the significance of the left systolic atrioventricular (AV) plane displacement during low dose dobutamine stress echocardiography (DSE), in predicting the recovery of left ventricular dyssynergies after revascularization. In 30 infarctiers with left ventricular dysfunction scheduled for RE (14 percutaneous transluminal coronary angioplasty and 16 coronary artery bypass graft) and in 25 age- and sex-matched healthy subjects, a DSE, using a 16 ventricular segment model and a four-grade scoring system for the assessment of regional wall motion of the left ventricle was performed. Prior and during DSE, the left systolic AV plane displacement was recorded from the apical four- and two-chamber views, by M-mode echo, at four left ventricular sites, corresponding to the septal, lateral, anterior, and inferior walls, both in patients and controls. The study was repeated in all patients 101 +/- 14 days after successful revascularization. Healthy subjects showed a significant increase of left systolic AV plane displacement at all left ventricular sites during dobutamine infusion (DI) (P < 0.001). Patients also exhibited a significant maximum increase of left systolic AV plane displacement during DSE only in the dyssynergic sites with functional improvement in the postrevascularization echocardiogram (P < 0.001). In the remaining dyssynergic sites, without functional improvement after revascularization, the left systolic AV plane displacement did not change (P > 0.05). Selecting a maximum LAVPD increase of >2 mm at any site of the left ventricule to predict recovery of the regional ventricular dyssynergies, results in a sensitivity of 91%, specificity of 83%, positive predictive value of 88%, and negative predictive value of 87%. When two-dimensional DSE was used for the detection of reversible dysfunction, sensitivity and specificity were found to be 81.5% and 87.5%, respectively, while the positive and negative predictive values were 90% and 78%, respectively. When the two methods were in agreement the sensitivity was 90%, the specificity 100%, and the positive and negative predictive values were 100% and 84.2%, respectively. The assessment of left systolic AV plane displacement during DI constitutes a new, simple, and accurate method in the prediction of left ventricular dyssynergy recovery after revascularization. The combination of this method and two-dimensional DSE are basic predictor markers of viability of dysfunctional myocardium. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Analysis of left atrioventricular plane movement during diastole in ischemic heart disease

The aim of the present study was to investigate the properties of diastolic left atrioventricular plane displacement (AVPD) in coronary artery disease (CAD) patients. In 125 patients (mean age 58.7 +/- 13.7) with CAD and in 51 age-matched healthy subjects, a complete transthoracic echocardiographic study was performed. The AVPD was recorded by M-mode echocardiography, from apical four and two chamber views at four sites corresponding to the septal, lateral, anterior and inferior walls of the left ventricle. Mean AVPD in early diastole (E-AVPD), mean AVPD from atrial systole (A-AVPD) and the ratio A-AVPD/E-AVPD were determined. In normal subjects, such as in 35 patients without left ventricular segmental wall motion abnormalities (SWMA), stepwise multiple regression analysis showed none of these factors to be significantly related to E-AVPD or A-AVPD. Aging was correlated negatively to the E-AVPD/A-AVPD ratio (p < 0.05). In 90 patients with left ventricular SWMA, stepwise multiple regression analysis showed that indices of left ventricular systolic function correlated positively to E-AVPD (p < 0.001) and A-AVPD (p < 0.001). The E-AVPD/A-AVPD ratio was correlated to left ventricular ejection fraction and heart rate (p < 0.005). Mean E-AVPD was significantly lower in CAD patients than in normal subjects (p 0.001), while A-AVPD was higher in patients without left ventricular SWMA in comparison to normal subjects (p = 0.02). Also, mean A-AVPD/E-AVPD was higher in CAD patients than in the control group (p < 0.001). Mean E-AVPD/A-AVPD was correlated to the E/A ratio of transmitral flow in CAD patients with (r = 0.669) and without (r = 0.771) SWMA. The E-AVPD and A-AVPD in CAD patients with SWMA is reduced according to the deterioration of left ventricular systolic function. The atrial contribution to the longitudinal distension of the left ventricle is increased in CAD patients. In CAD patients, especially those without left ventricular SWMA, the E-AVPD/A-AVPD ratio has a good correlation to left ventricular filling behavior.

Retrograde nontransseptal balloon mitral valvuloplasty using a modified Inoue balloon catheter

Retrograde nontransseptal balloon mitral valvuloplasty, a method developed in our institution for the treatment of symptomatic mitral stenosis, avoids transseptal catheterization. Until recently, the self-positioning Inoue balloon catheter, unlike all other commercially available balloon catheters, had not been employed in this nontransseptal technique due to the short length of its catheter shaft. To employ a self-positioning balloon in retrograde nontransseptal balloon mitral valvuloplasty, we modified the Inoue device by extension of the catheter shaft. After retrograde nontransseptal left atrial catheterization using a steerable cardiac catheter, the modified Inoue balloon catheter was inserted through the femoral artery and advanced to the mitral valve retrogradely. Valvuloplasty was performed in 20 patients, with a successful result achieved in all. The modified Inoue balloon catheter was easy to use in retrograde nontransseptal balloon mitral valvuloplasty and showed excellent stability during inflation. Mean mitral valve area increased from 1.0 +/- 0.29 to 2.23 +/- 0.64 cm2 (P < 0.001) and mean transmitral gradient decreased from 11.4 +/- 6 to 4.3 +/- 2.1 mm Hg (P < 0.001). No major or minor complications were observed. Retrograde nontransseptal balloon mitral valvuloplasty using a modified Inoue balloon catheter is a feasible and effective technique for the treatment of symptomatic mitral stenosis. It appears to combine the advantages of avoiding transseptal catheterization with the advantages of this balloon's special configuration.

Mitral regurgitation from papillary muscle rupture: role of transesophageal echocardiography

A case of a 61 year old male with lateral myocardial infarction, congestive heart failure and fever of days is presented. The exact etiology of this patient's heart failure was established with the application of transesophageal echocardiography. The transthoracic two-dimensional and Doppler echo showed a mobile echogenic density attached to the tip of the anterior mitral leaflet accompanied by moderate mitral regurgitation. Transesophageal echocardiography attributed this echogenic density to a ruptured head of the anterolateral papillary muscle, resulting in severe mitral regurgitation. Cardiac catheterization confirmed the severe mitral regurgitation and uncovered significant stenotic lesions of the coronary arteries. The resultant surgical treatment for the replacement of the mitral valve and coronary artery by-pass confirmed the rupture of the head of the anterolateral papillary muscle. It is suggested that transesophageal echocardiography is particularly capable of providing a definitive and prompt diagnosis of papillary muscle rupture.