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To determine the utility of transesophageal echocardiographic monitoring during percutaneous balloon mitral valvotomy, we analyzed data from 40 consecutive patients who had been randomly assigned to undergo balloon mitral valvotomy under transesophageal echocardiographic guidance or without echo. All procedures were carried out under general anaesthesia. The completion rate (100% vs 73%), the procedure time (108 +/- 28 min vs 65 +/- 18 min), the X-ray exposure time (62 +/- 13 vs 33 +/- 12 min), resulted significantly (P less than 0.001) more favorable in the echo-monitored patients. Moreover, a lower rate of major complications (cardiac tamponade, large residual atrial shunting, and severe mitral regurgitation) was noted in the echo-monitored patients. The achieved final area of the mitral valve did not differ significantly between the two groups. From an evaluation of results as a whole, 96% of the echo-monitored procedures were successful, whereas only 40% of the procedures conducted without echocardiographic control achieved a satisfactory final result in absence of major complications. We conclude that transesophageal echocardiography is a safe, effective, and valuable tool to monitor each step of balloon mitral valvotomy in order to shorten the time of the procedure, and to improve the results of this complex interventional catheterization technique.

In order to evaluate the short and mid-term results of percutaneous aortic balloon valvuloplasty, 40 consecutive elderly patients with symptomatic severe calcific aortic stenosis, underwent the procedure consecutively, with follow-up by clinical evaluation and Doppler echocardiography. Over a mean follow-up period of 11.2 months there were 5 deaths, and 12 patients underwent subsequent aortic valve replacement. Doppler echocardiography revealed an increase in aortic valve area from 0.62 +/- 0.20 cm2 to 0.91 +/- 0.23 cm2 after the procedure, but there was a significant trend toward restenosis by 12 months follow-up in 23 of 32 patients (72%). Restenosis was accompanied by symptomatic deterioration in 18 of 23 patients (78%). Although balloon valvuloplasty may often improve haemodynamics and relieve symptoms, these benefits seem to be short-lived in most cases. Restenosis has a high rate of occurrence. Aortic balloon valvuloplasty should be reserved for truly inoperable cases and for haemodynamically-unstable patients, who may later undergo surgery.

Two cases of massive mitral regurgitation due to mitral valve disruption following percutaneous balloon valvuloplasty are reported. This severe complication occurred in two elderly women with recurrent mitral stenosis after previous surgical commissurotomy. Due to their unstable hemodynamic and clinical condition, both patients underwent emergency valve replacement. At surgery, the commissures appeared fused and heavily calcified; the chordae tendineae thickened, shortened, and fused; and the leaflets presented a large tear with sheared edges. Because the technical aspects of both procedures were unremarkable, the anatomic features of the mitral valve seemed to affect the occurrence of severe mitral regurgitation. Percutaneous balloon valvuloplasty should be therefore applied carefully to patients with prior surgical valvotomy, in whom the structural alterations of the mitral apparatus may predispose to severe valvular damage.

In order to evaluate the short- and mid-term results of percutaneous aortic balloon valvuloplasty, 40 consecutive elderly patients, who had undergone balloon valvuloplasty for calcific aortic stenosis, were prospectively followed up by means of clinical and echo-Doppler examinations. Although valvuloplasty often dramatically improves hemodynamics and relieves symptoms, these benefits seem to be short-lived in most cases. Restenosis, defined as a loss of 50% or more of the increase in aortic valve area obtained by the dilatation, has a very high rate of occurrence. Aortic balloon valvuloplasty should therefore be reserved for truly inoperable cases and can be performed in hemodynamically unstable patients, who may later undergo surgery.

The authors report the case of a 57 year-old man with severe calcific aortic stenosis and single vessel coronary artery disease, symptomatic of angina pectoris, who refused surgical therapy and was treated with combined percutaneous aortic valvuloplasty and coronary angioplasty as a single procedure. Valvuloplasty was performed initially, and the calculated aortic valve area increased from 0.75 to 1.27 cm2. Subsequently, a 75% proximal right coronary artery stenosis was dilated to 20%. Two months later, at follow-up the patient was asymptomatic and the Doppler-determined aortic valve area was 1.01 cm2.

Objective -- To investigate transthoracic Doppler echocardiography in the identification coronary artery bypass graft (CABG) flow for assessing graft patency. Design -- The initial study group comprised 45 consecutive patients with previous CABG undergoing elective cardiac catheterisation for recurrent ischaemia. The Doppler variables best correlated with angiographic graft patency were then tested prospectively in a further 84 patients (test group). Setting -- Three tertiary referral centres. Interventions -- Flow velocities in grafts were recorded at rest and during hyperaemia induced by dipyridamole (0.56 mg/kg/4 min), under the guidance of transthoracic colour Doppler flow mapping. Findings on transthoracic Doppler were compared with angiography. Main outcome measures -- Feasibility of identifying open grafts by Doppler and diagnostic accuracy for Doppler detection of significant (&ges; 70%) graft stenosis. Results -- In the test group the identification rate for mammary artery grafts was 100%, for saphenous vein grafts to left anterior descending coronary artery 91%, for vein grafts to right coronary artery 96%, and for vein grafts to circumflex artery 90%. Coronary flow reserve (the ratio between peak diastolic velocity under hyperaemia and at baseline) of < 1.9 (95% confidence interval 1.83 to 2.08) had 100% sensitivity, 98% specificity, 87.5% positive predictive value, and 100% negative predictive value for mammary artery graft stenosis. Coronary flow reserve of < 1.6 (95% CI 1.51 to 1.73) had 91% sensitivity, 87% specificity, 85.4% positive predictive value, and 92.3% negative predictive value for significant vein graft stenosis. Conclusions -- Transthoracic Doppler can provide non-invasive assessment of CABG patency. [ABSTRACT FROM AUTHOR]