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Background Balloon mitral valvotomy (BMV) is a well-established therapeutic modality for rheumatic mitral stenosis (RMS). However, there are chances of procedural failure and the more ominous post-procedural severe mitral regurgitation. There are only a few prospective studies, which have evaluated the pathogenic mechanisms for these major complications of BMV, especially in relation to the subvalvular apparatus (SVA) pathology. Methods All symptomatic patients of RMS suitable for BMV by echocardiographic criteria in a span of 1 year were selected. In addition to the standard echocardiographic assessment of RMS (Wilkins score and score by Padial et al.), a separate grading and scoring system was assigned to evaluate the severity of the SVA pathology. The SVA score was ‘I’, when none of the two SVAs had severe disease, ‘II’ when one of the two SVAs has severe disease, and ‘III’ when both SVAs had severe disease. With these scoring systems, the outcomes of BMV (successful procedure, failure, and post-procedural mitral regurgitation) were analyzed. Emergency valve replacement was performed depending on clinical situation, and in cases of replacement, the pathology of the excised mitral valves were compared with echocardiographic findings. Results Of the 356 BMVs performed in a year, 43 patients had adverse outcomes in the form of failed procedure (14 patients) and mitral regurgitation (29 patients). Forty-one among these had a SVA score of III. The sensitivity and specificity of the MR score was lesser than the SVA score (sensitivity 0.34 vs. 1.00, specificity 0.92 vs. 0.99, respectively). The mitral valvular morphology in 39 patients who underwent post-procedural valve replacements correlated well with echocardiography findings. Conclusion It is important to assess the degree of SVA pathology in the conventional echocardiographic assessment for RMS, as BMV would have adverse events when both SVAs were severely diseased.

Severe pulmonary valve (PV) regurgitation can result from surgical or balloon valvotomy. If left untreated PV regurgitation in the setting of right ventricular non-compliance may lead to progressive cyanosis, increased morbidity and mortality. A 60-year-old white male with history of hypoxia

The management of uncomplicated aortic valve stenosis presenting with critical obstruction in infants continues to be associated with significant morbidity and mortality. However, not all infants have critical obstruction, and outcomes spanning the broader spectrum of disease severity are less well defined.In a 12-year period, 55 infants (3 months of age) were seen with aortic valve stenosis and with anatomy suitable for biventricular repair. Clinical, echocardiographic, angiographic, management, and outcome data were reviewed.Status at presentation (median age 6 days) included signs of congestive heart failure in 20 patients, cardiovascular collapse in 5 patients, and an asymptomatic heart murmur in 30 patients. The initial echocardiogram showed reduced left ventricular function in 26% of patients, with a mean peak instantaneous gradient of 69 +/- 30 mm Hg in patients with normal function. There were 5 deaths (9%), all in patients with poor ventricular function. The initial intervention was balloon valvotomy in 24 patients and surgical valvotomy in 20 patients, with 11 patients having no intervention to date. The freedom-from-intervention rate was 69% at age 1 week, 58% at 1 month, 36% at 3 months, and 28% at 1 year. Patients without cardiovascular collapse, normal left ventricular function, and gradients60 mm Hg at presentation (n =1 9) had better survival and longer freedom from intervention than patients with poor ventricular function or gradientsor=60 mm Hg (n = 36, P =.0001).Most infants with aortic valve stenosis receive intervention, although this may be safely delayed in selected patients with lower initial gradients and good left ventricular function.

Permanent pacemaker lead-induced tricuspid regurgitation is extremely uncommon. We report a patient with severe tricuspid stenosis detected 10 years after permanent single chamber pacemaker implantation in surgically corrected congenital heart disease. The loop at the level of the tricuspid valve may have caused endothelial injury and eventually led to stenosis. Percutaneous balloon valvotomy for such stenosis has not been reported from India.

There has been an explosion in the field of interventional cardiology since Andreas Gruentzig performed the first percutaneous transluminal coronary angioplasty more than 30 years ago. With the development of a multitude of steering wires, balloons, rotablators, and stents, percutaneous coronary

A woman presented at 24 weeks gestation with previously undiagnosed mitral stenosis. She did not respond to conservative management and underwent successful percutaneous balloon mitral valvotomy for refractory congestive cardiac failure, with complete resolution of her symptoms. The remainder of her pregnancy was uncomplicated and she delivered a healthy infant at 39 weeks gestation. An epidural block provided analgesia/anesthesia for vaginal delivery and repair of the perineal tear.

To compare characteristics of aortic regurgitation (AR), the results of 213 procedures (110 balloon aortic valvotomies [BAV] and 103 surgical aortic valvotomies [SAV]) for treatment of congenital aortic valve stenosis were reviewed. These procedures were performed in 187 patients from June 1981 to September 1993. Echocardiograms recorded immediately before, within 6 months afterward, and at latest follow-up were compared. Color Doppler was used to assess the degree of AR and was quantified as the ratio of the regurgitant jet width to valve annulus, the jet width ratio. Whereas BAV patients were older (median age 5.7 years vs 3 months; p = 0.0001), there was no significant difference in median follow-up interval (3.1 years [range 0.5 to 7.2] for BAV vs 3.6 years [range 0.6 to 10.4] for SAV; p = 0.44). The mean balloon-to-annulus ratio for BAV was 0.99 ± 0.09. An open valvotomy was performed in 83% of surgical cases. Acute systolic gradient reduction and subsequent increase at late follow-up was similar for both groups. Acutely, the mean jet width ratio increased similarly (p = 0.84) for BAV (+9 ± 15%; p = 0.0001) and SAV (+9 ± 12%; p = 0.0003) and was not related to age at procedure. At late follow-up, mean jet width ratio further increased significantly in both groups, although there was no difference (p = 0.17) in amount of progression (BAV +10 ± 12%; p = 0.0001, SAV +15 ± 13%; p = 0.0002). Thus, BAV and SAV produce AR of similar severity with similar rates of progression.

Pulmonary atresia with an intact ventricular septum is characterized by varying degrees of right ventricular cavity hypoplasia. This factor is critical in determining the most appropriate surgical approach for each patient. We describe a patient who underwent definitive biventricular surgical repair in early infancy. We used an atrial septal defect patch with a one-way valve and performed a right ventricular overhaul after a balloon valvotomy.

Percutaneous double balloon valvotomy for severe rheumatic mitral stenosis was successfully performed in 281 of 285 consecutive patients. The changes evoked were a decrease of the mean transvalvular gradient from 16 +/- 7 to 5 +/- 3 mm Hg, an increase in cardiac output from 3.8 +/- 1.0 liters/min to 5.4 +/- 1.5 liters/min and an increase in mitral valve area from 0.86 +/- 0.24 cm2 to 2.41 +/- 0.54 cm2. The mean pulmonary artery pressure decreased from 37 +/- 13 mm Hg to 27 +/- 12 mm Hg and the pulmonary vascular resistance decreased from 307 +/- 181 to 238 +/- 122 dynes/s/cm-5. Symptomatic improvement occurred in 272 of the 285 (95%) patients. There were 3 procedure-related deaths (1%). Postdilatation mitral regurgitation was not significant in most patients. Therefore, this procedure can be performed at a low risk with effective results and a fast recovery.

(RBCI) includes two articles that portray the results of well-established techniques as well as innovations in the percutaneous treatment of valvular heart disease in Brazuk. Aguiar Filho et al., from the Instituto de Cardiologia Dante Pazzanese (Sao Paulo, SP, Brazil), show the evolution of the first 200 patients with mitral stenosis treated by balloon valvotomy from 1987 to 1990, their management over time, the probability of being free of restenosis after 20 years of evolution, and predictors of lesion recurrence. In a corresponding editorial, Palacios and Silva, from the Massachusetts General Hospital (Boston, USA), draw attention to the importance of the accurate analysis of valve morphology and function to obtain the best procedural results, the differences in clinical profile and outcome in different published series, and the different techniques available. At the end of their article, they reaffirm its role as a first-line treatment for rheumatic mitral stenosis.Additionally, Brito Jr., from Hospital Albert Einstein (Sao Paulo, SP, Brazil), and other physicians from the Brazilian Registry of Transcatheter Aortic Valve Im-plantation share their experience with an alternative route for CoreValve

Results for balloon mitral valvotomy (BMV) are usually reported for large heterogenous groups. Different outcomes are expected for good commissurotomy candidates (Ideal) compared to patients with significant valve deformity who might otherwise be good MVR candidates (Non-Ideal). We defined Ideal as echo score ≤ 6 and Non-Ideal as score ≥ 9/age ≤ 72. Ideal Patients Non-Ideal Patients n 344 154 Age (years) 47 ± 12 54 ± 11 * NYHA 2.8 ± 0.7 2.9 ± 1.6 * Echo Score 4.8 ± 1.4 10.1 ± 1.3 * MVA pre→post 1 ± 0.3→1.8 ± 0.6 1 ± 0.3→1.7 ± 0.6 * MVR 30 days 5.2% 8.1% 3 Yr. Event Free 82% 62% * * = p l 0.01 vs Ideal Conclusions Immediate BMV results for ideal patients with pliable valves and non-ideal patients who would otherwise be MVR candidates are good. Three year event free survival is excellent in ideal patients. Non-ideal patients with significant valve deformity have freedom from death, MVR or repeat PTMC after three years in 62% of cases.

The current status of percutaneous balloon valvotomy for aortic, subaortic, and mitral stenosis and angioplasty of aortic arch obstructions are reviewed. Results from the authors and other laboratories are discussed in relation to technique and other factors such as patient age and underlying pathology. Current indications for these procedures are reviewed.