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Balloon mitral valvotomy (BMV) is safe and effective in patients with mitral stenosis (MS) and coexisting mild mitral regurgitation (MR). Influence of preexisting MR on late outcome of BMV is under evaluation. We included 77 patients without MR and 72 with MR in this study, and compared their immediate and late results in a mean follow-up of 33 ± 24 months after BMV. Patients with coexisting MR were older and more frequently had significant valvular calcium and atrial fibrillation than patients without MR. After BMV, mitral valve gradient decreased, and cardiac output and mitral valve area by planimetry increased significantly (all p = 0.0001) in both groups. There was no difference in values of mitral valve gradient and cardiac output after BMV between the groups. Mitral valve area was significantly smaller in patients with preexisting MR. During follow-up, there were 11 patients (14%) in the group without MR and 24 (33%) in the group with MR developed cardiac events (p = 0.006). Cumulative event-free survival was 90% at the second year, 87% at the fourth year, and 69% at the sixth year, respectively, in the group without MR versus 78%, 62%, and 37%, respectively, in the group with MR (p = 0.0014). Cox regression showed that preexisting MR was a significant predictor for late cardiac events with a threefold increased hazard risk (p = 0.0025), but age, valvular calcium, echocardiographic score, and cardiac rhythm also played a culpable role. We conclude that preexisting MR is an important risk factor for poor, late outcome of BMV.

We developed a prognostic scoring system to predict the outcome of follow-up after balloon mitral valvotomy. The system incorporates seven variables before valvotomy: age, New York Heart Association class, fluoroscopic calcification, echocardiographic score, cardiac rhythm, mitral regurgitation, and mitral valve area. Each variable was coded with either 0 or 1 and a total score was between 0 and 7. The study included 150 patients with a mean follow-up of 33 ± 24 months. In patients with scores of 0-1, 2-3, 4-5, and 6-7, the estimated cardiac event-free survival rate was 97%, 94%, 86%, and 68%, respectively, at 1 year; 95%, 88%, 74%, and 47%, respectively, at 3 years; and 92%, 82%, 61%, and 30%, respectively, 5 years after valvotomy ( p = 0.0001). The hazard risk ratio for cardiac events was 1.7 times greater for every step up of the score ( p = 0.0001). Our scoring system provides a simple but effective method to predict late outcome of balloon mitral valvotomy. (Am Heart J 1997;134:772-8.)

The follow-up results between Inoue balloon (n = 43, group 1) and double-balloon (n = 43, group 2) mitral valvotomies were compared in a patient-to-patient matched study. Matching was based on patients' age, mitral valve echo score, fluoroscopic calcification, mitral valve area before valvotomy, and follow-up period. The mean follow-up period was 13 +/- 9 months for both groups. At follow-up, 72% of patients were symptom free in each group; 2 (4.7%) patients in group 1 and 1 (2.3%) patient in group 2 underwent mitral valve replacement surgery. Of these 3 patients, 2 died after surgery, 1 from each group. The mitral valve area by Doppler was 1.8 +/- 0.3 cm2 in group 1 and 1.8 +/- 0.4 cm2 in group 2 (p = 0.7); the area by echo planimetry was 1.7 +/- 0.3 cm2 in group 1 and 1.8 +/- 0.3 cm2 in group 2 (p = 0.3) at follow-up. Restenosis occurred in 5 (12%) patients from each group. The cumulative restenosis-free rate was 96% at 1 years, 78% at 2 years, and 58% at 3 years in group 1 and 98%, 76%, and 51%, respectively, in group 2 (p = 0.8). Balloon selection did not appear to influence the clinical outcome at follow-up. We conclude that both the inoue balloon and the double-balloon valvotomies are effective therapies with comparable follow-up results for patients with mitral stenosis.

Resurgence of the transseptal procedure in the last decade has occurred coincident with the advent of therapeutic catheterizations and in particular mitral balloon valvuloplasty. As larger numbers of these procedures have been performed, experience shows that the position of intended septal puncture varies for each anticipated procedure and need not lie at the fossa ovalis, which is frequently displaced or inaccessible. Recognizing the dynamic alterations in septal and atrial anatomy that accompany the various combinations of valvular heart disease, the experienced interventionalist will use precatheterization echo and radiological techniques to enable precise and localized transseptal puncture. Using these techniques in 597 patients for valvular heart disease, we have had no deaths and a morbidity of 1.8% with the transseptal puncture. © 1992 Wiley-Liss, Inc.

We present a patient with a left atrial hemangioma associated with shortness of breath and irregular heart-beats. Imaging modalities used to evaluate this rare tumor demonstrated characteristic features of its vascular nature. After successful surgical excision of the tumor under cardiopulmonary bypass, there were no clinical or echocardiographic evidence of recurrence at 18 months.

Balloon mitral valvotomy (BMV) provides improvement in pulmonary vascular resistance (PVR) in patients with severe mitral stenosis. Its normalization, however, remains questionable. We evaluated PVR before, after BMV, and at follow-up in 37 patients who had a previous successful BMV. Patients were divided into 2 groups: group 1 had 21 patients with normalized PVR (125 dynes/s/cm5) either after BMV or at follow-up, and group 2 had 16 patients with persistently abnormal PVR. Patients in group 2 were older than patients in group 1 (55+/-13 vs 43+/-14 years, p = 0.01) and had atrial fibrillation more frequently (10 [63%] vs 6 [29%], p = 0.04). Age, cardiac rhythm, mitral valve area, pulmonary bed gradient, pulmonary artery pressure, and PVR before the procedure were significant univariate predictors for normalization of PVR. Age, echocardiographic score, systolic pulmonary artery pressure, and mitral regurgitation were all independent determinants of normalization of PVR in a multivariate logistic regression model. We conclude that PVR failed to return to normal in 16 patients (43%) after successful BMV; this can be predicted by baseline clinical and hemodynamic parameters.

In summary, the possibility of developing moderate to severe (3+) MR after balloon dilatation was greater in patients with preexisting moderate MR. Nevertheless, improvements in hemodynamics and increases in mitral valve area can be equally achieved using balloon mitral valvotomy for treatment of mitral stenosis in patients with or without moderate MR.

We assessed immediate and late outcome in 55 patients with significantly calcified valves (group 1) after balloon mitral valvotomy and compared the results with those from 60 patients with noncalcified or minimally calcified valves (group 2). After valvotomy, mitral valve area increased from 1.03 +/- 0.30 cm2 to 1.64 +/- 0.35 cm2 (p = 0.0001) by echo planimetry in group 1 but was significantly smaller than the mitral valve area in group 2 after valvotomy (1.94 +/- 0.38 cm2; p = 0.0001). At a mean follow-up period of 30 months (range 2 to 81 months), 51% of patients in group 1 and 83% in group 2 were symptom free (p = 0.0002). In group 2, 15 (27%) patients and in group 2, 4 (7%) patients had cardiac events (p = 0.003). The risk ratio for cardiac events was 4.3 times greater in group 1 than in group 2. In group 1, the risk ratio for cardiac events was 3.2 times higher in patients age > or = 65 years and in patients with atrial fibrillation. The 6-year cumulative cardiac event-free survival rate was 64% in group 1 and 90% in group 2 (p = 0.005). In 75 (65%) patients who had follow-up echocardiographic study (35 in group 1 and 40 in group 2), mitral valve area decreased to 1.48 +/- 0.42 cm2 at follow-up in group 1 (p < 0.01) and to 1.77 +/- 0.50 cm2 in group 2 (p = 0.3). Restenosis occurred in 16 (46%) of 35 patients in group 1 and 10 (25%) of 40 in group 2 (p = 0.06).(ABSTRACT TRUNCATED AT 250 WORDS)

This is a 43-yr-old female presenting with recurrent atrial septal defect, closed surgically, 10 years prior, severe aortic and mitral stenosis, and severe tricuspid regurgitation. She was considered inoperable because of the severe pulmonary hypertension and the complexity of the disease. A percutaneous umbrella closure of the atrial septal defect in conjunction with mitral and aortic balloon valvotomies could be safely and successfully performed. After significant clinical and hemodynamic improvement, surgery was judged feasible, but was refused by the patient who suddenly expired 8 weeks later. The usefulness of percutaneous therapy as a rescue procedure and the management of patients with Eisenmenger's physiology are discussed.

A patient with progressive disabling angina was found to have a single right coronary artery with atresia of the left main coronary artery, and absence of any obstructive coronary disease. The patient required aortocoronary by-pass surgical reconstruction of a left main coronary artery to control her angina. Possible mechanisms for the development of her anginal pain are briefly discussed.

Previous studies have demonstrated that mitral regurgitation (MR) greatly influenced long-term outcome after surgical mitral commissurotomy in pts with mitral stenosis. However, this issue has not been addressed after balloon mitral valvotomy (BMV). We therefore examined 6 year follow-up (FU) data in 69 pts who presented MR assessed by angiography before BMV (group 1), and compared the results with 75 pts who had no MR (group 2). Mean FU period was 27 ± 20 mo in group 1 and 33 ± 23 mo in group 2 (p = NS). Comparison of pts baseline characteristics, mitral valve area (MVA) before and after BMV and FU results between the groups were: Clinical Profile Group 1 Group 2 p-value Age (yr) 57 ± 13 45 ± 16 0.0001 Sex: M/F 80%/20% 17%/83% NS NYHA-FC: III-IV 90% 81% NS Echo score g8 22% 12% NS Fluoroscopic Ca 2+ 87% 60% 0.001 A.F 56% 19% 0.0001 Pre 2D MVA (cm 2 ) 1.06 ± 0.30 100 ± 027 NS Post 2D MVA (cm 2 ) 1.71 ± 0.35 1.88±0.41 0.01 FU NYHA class I 51% 88% 0.0001 Cardiac events (CE) 28% 9% l 0.01 CE = stroke, repeat BMV, mitral valve replacement (MVR), and death Comparison of 6 year CE-free and MVR-free actuarial survival rates were: Gr 1/Gr 2 1-yr 2-yr 3-yr 4-yr 5-yr 6-yr p-value CE-free (%) 87/94 79/92 73/90 65/90 59/90 49/79 0.002 MVR-free (%) 93/96 89/96 82/96 78/96 78/96 65/84 0.01 Hazard risk ratio by Cox regression analysis was 3.7 (95% CI: 1.5-8.9) times greater for CE (p l 0.01), and 4.0 (1.2–12.7) times greater for MVR (p l 0.05) at FU in group 1 than in group 2. Conclusions (1) MR before BMV increases risk for late CE, particularly requiring MVR in the early FU. (2) Pts with MR appears to be older with calcified valves and AF, and to obtain smaller MVA post BMV, all of which may exacerbate the poor later outcome. (3) Half of such pts may still derive long-term benefits from BMV.

A low incidence rate of thromboembolism has been reported in mitral porcine valve recipients. In contrast, 5 of 22 single mitral porcine valve recipients (23 percent) followed up in our clinic for a mean of 16 months had thromboembolic events. All patients but one were receiving long-term anticoagulant therapy. One thromboembolic event resulted in death, three in permanent neurologic deficits and one in a peripheral arterial occlusion. All five patients with emboli had atrial fibrillation and left atrial enlargement. Three had thromboembolic events before porcine heart valve implantation. In addition, five mitral porcine valve recipients who were not receiving anticoagulant therapy were examined at autopsy. Thrombus was identified in the left atrium in three patients, at the tissue-valve interface (sewing ring) in two, on the porcine valve cusps in one and in the right atrium in one. Factors influencing thrombus formation such as left atrial enlargement, atrial fibrillation and a prosthetic device are present after mitral porcine valve implantation and are indications for long-term anticoagulation therapy.

Summary The clinical diagnostic features of right ventricular myxoma are described in a recent patient and related to the 15 cases previously reported. The presence of a pulmonic systolic ejection murmur with a delayed (120 to 140 msec.) and accentuated pulmonic second sound, or calcification in the region of the right ventricular outflow tract should suggest this lesion. Cardiac catheterization with angiocardiography is diagnostic. 67 Ga scanning may assist in the diagnosis and follow-up after surgical removal of the myxoma. Early surgical removal will avoid the possibility of sudden death.

Eighty of 98 patients with acquired complete heart block are presented and discussed with respect to the effect on prognosis of age, etiology, presence of cardiac and extracardiac complications and electrocardiographic data. In this series of 48 control and 32 paced patients, mortality was adversely affected by myocardial infarction, uremia, shock, diabetes, a ventricular rate below 30/min., and Stokes-Adams attacks. Mortality was not affected by changing block, duration of the QRS interval, or the presence of cardiac failure. The prognosis in complete heart block was improved by pacing except in the presence of severe renal or metabolic complications.

Quantitative preoperative evaluation of potential postoperative myocardial performance after resection of an akinetic area has been difficult because the usual indices of myocardial performance provide no directly applicable information or cannot be applied because of disorders of isovolumetric contraction. Critical factors in postoperative performance are residual ventricular size and the capacity to increase fiber shortening. We have assumed that postoperative incremental fiber shortening is determined primarily by reduction in afterload secondary to reduction in ventricular volume. Using this assumption, a preoperative late systolic force-length curve can be extrapolated to form a boundary for postoperative fiber shortening after surgical unloading. Preliminary preoperative studies in human beings have adequately estimated postoperative performance and are compatible with these assumptions. Mathematical considerations developed for these purposes suggest that the relatively simple spherical model is adequate for most ventricles.

A patient with constrictive pericarditis was studied 5 days before and 50 days and 13 months after extensive pericardiectomy. Functional data were derived from measurement of intracardiac pressure and left ventricular volume. Before operation the left ventricle was characterized by both systolic and diastolic unloading due to volume restriction. Complete anterior and lateral decortication was accompanied by minimal early clinical improvement. Catheterization studies reflected persistent severe biventricular restriction. A year after operation, marked clinical improvement was accompanied by studies revealing resolution of the restrictive elements.

The results of this investigation reveal that 39 per cent of patients in a study group of 46 patients with heart valve prostheses had gallstones if they survived 18 months or longer following valve replacement. In contrast, the prevalence of gallstones in a general population of autopsied rheumatic heart disease patients, including those who had been operated for severe valvular heart disease and had not survived for more than one month, was only 12 per cent. These findings suggest that gallstones are a frequent late complication of heart valve replacement.

Pulmonary embolism and infarction are often associated phenomena, but the terms should not be used synonymously. Although pulmonary infarction may follow embolism, many emboli are not followed by infarction. The probability of infarction is increased in the presence of elevated pressures in the pulmonary circulation, such as is seen with left ventricular failure or mitral stenosis. Thrombi may originate in the venous channels of the lower extremities, pelvis, right atrial appendage, or a malignant organ. The venous disease and/or stasis as seen with congestive failure, infectious diseases, malignancies, blood dyscrasias, toxic agents, and convalescent periods for surgical procedures, childbirth, or fracture, may predispose to venous thrombi and potential pulmonary emboli.

A patient with a continuous murmur due to flow through an internal mammary-to-pulmonary artery fistula is described. Previously reported cases have been thought to be congenital in origin. A history of an anteriorly placed chest tube suggests an acquired etiology for this malfor mation.

Echocardiography is an established method for the diagnosis of pericardial effusion. Echographic findings in fibroadhesive disease have also been described. The interpretation of a changing serial echogram during the clinical course of pericardial disease has not been established. Sixteen patients with echographic evidence of pericardial effusion were followed with serial echographic studies. In seven, surgical or autopsy correlation was obtained. Because of the serial changes noted we undertook a study in dogs to clarify the problem of variability in intensity of sound reflected from the pericardial space. Three open-chested dogs were studied with rapid sequence surface echograms as blood introduced into the pericardial space was converted from the unclotted to the clotted state. In all three dogs blood clooting increased the intensity or sound reflected from the pericardial space. Our study of two patients with fibroadhesive pericardial disease documents serial changes in echoes from the pericardium and pericardial space accompanying the clinical evolution of the disease process, and suggests a method for avoiding the commonly encountered difficulty in proper identification of the pericardial and epicardial echoes. Our preliminary studies suggest that serial echograms should play an important role in the management of patients with pericardial effusion; further surgical/pathological correlations are required.

The protein selectivity index was measured in 68 patients (53 males, 15 females) with proteinuria due to IgA nephropathy to determine whether it bore any relationship to other clinical and pathological features of known prognostic significance. The mean age of the patients was 25 +/- 8 years with a follow-up period of 42 +/- 35 months. Forty-six presented with asymptomatic haematuria and proteinuria, 17 with macroscopic haematuria and 5 with the nephrotic syndrome. Twenty-three (34%) patients had selective proteinuria and 45 (66%) had non-selective proteinuria. Patients with non-selective proteinuria had more glomerulosclerosis (29% +/- 20 vs. 16% +/- 20, p less than 0.02), higher serum creatinine (1.47 mg/dl +/- 0.70 vs. 1.17 mg/dl +/- 0.33, p less than 0.02), lower creatinine clearance (79 ml/min +/- 28 vs. 95 ml/min +/- 25, p less than 0.02), and higher incidence of hypertension (chi 2 = 3.84, p less than 0.05) when compared to those with selective proteinuria. The protein selectivity was measured at the end of the study. Of the 5 patients with the nephrotic syndrome, 1 had poorly selective proteinuria and failed to remit and 4 had highly selective proteinuria who either remitted spontaneously (1 patient) or with treatment (3 patients). The results suggest that patients with IgA nephropathy and poorly selective proteinuria are more likely to have other features indicating a poor prognosis such as glomerulosclerosis, renal impairment and hypertension.

A total of 63 patients, who survived mitral valve replacement with the Kay--Shiley caged disc mitral valve prosthesis, were followed for 11 years by single clinic group to assess long-term results post valve replacement. Sixty-one patients (97%) received a muscle guard type Kay--Shiley prosthesis. All patients received oral anticoagulation therapy. The valvular damage was caused by rheumatic disease in 51 patients, infectious endocarditis in six patients, myxomatous degeneration in two patients, coronary artery disease in two patients, and idiopathic ruptured chordae tendineae in two patients. Late death occurred in 21 patients (33%); the 10-year actuarial survival was 65%. Twenty-six patients had at least one thromboembolic event, and the total number of thromboembolic events was 10.3 per 1000 patient months. Two patients developed prosthetic valve endocarditis. Both patients were heroin addicts and died of valve ring abscess. Long-term periods of clinical observation are necessary to assess the effects and benefits of prosthetic valve implantation. These data are important for comparison with other "10-years" valves.