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Background: Intravascular ultrasound is a sensitive tool to study transplant vasculopathy. However, there is no consensus regarding the methodology for imaging protocol. The impact of single versus multiple epicardial vessel imaging in determining the prevalence of transplant vasculopathy has not been determined. This study examines the benefit of three-vessel imaging versus one-vessel imaging in detecting transplant vasculopathy., Methods and Results: One hundred eleven transplant recipients with intravascular ultrasound imaging at baseline (within 2 months of transplantation) were studied: 107 at 1-year, 53 at 2-year and 41 at 3-year follow-up. A total of 222 arteries, 519 segments and 772 sites were analyzed (94 LAD, 65 LCX and 65 RCA). The prevalence of transplant vasculopathy lesions was 27%, 41% and 58% at 1 year, 39%, 55% and 71% at 2 years and 39%, 55% and 74% at 3 years for patients with one-, two- and three-vessel imaging, respectively. Single- or two-vessel disease was present in 23% (7) and 32% (10) patients with three-vessel imaging, leading to the potential mislabeling of these 17 (55%) patients as "disease free" if they underwent only single-vessel imaging., Conclusions: Multivessel imaging is more sensitive in detecting the transplant vasculopathy lesions compared to single-vessel imaging. This important variable should be considered when designing and interpreting trials utilizing intravascular imaging derived end-point.

Intravascular ultrasound imaging is a relatively new imaging modality that uses miniaturized ultrasound transducers, which are mounted on catheter tips and introduced into the vessel lumen to provide cross-sectional images of the vascular structure in real time. It has gained popularity rapidly among interventional cardiologists because of its ability to overcome many limitations of angiography, especially when dealing with complex anatomy and new devices for coronary revascularization. The tomographic perspective and the ability to elicit the detailed structure of the arterial wall have allowed the use of intravascular ultrasound to better understand the coronary atherosclerotic and allograft vasculopathy disease processes. The response of lesions to various interventional procedures also has been studied in detail. This review discusses the rationale, technique, methods of interpretation, and the current knowledge in the field of intravascular ultrasound imaging.

Intravascular ultrasound imaging has been recognized as a sensitive tool to study early transplant vasculopathy lesions. An early examination performed soon after transplantation allows one to study donor atherosclerosis. Further, serial follow-up imaging with meticulous site matching provides important information regarding the progression of donor atherosclerosis and the development of transplant vasculopathy lesions. This review highlights the contribution of intravascular imaging in understanding the transplant coronary artery disease. This review also outlines various methodologies employed by different investigators, and stresses the strengths and weaknesses of these methodologies for correct interpretation as well as comparison of data from different studies.

Background: Transplant coronary artery disease is a combination of atherosclerosis transmitted from the donor and new lesions of allograft vasculopathy. We sought to determine the morphological characteristics of allograft vasculopathy and differentiate it from donor-transmitted atherosclerosis with serial intravascular ultrasound., Methods and Results: Intravascular ultrasound examination was performed in 93 patients at 27.2+/-15.0 and 369. 7+/-23.9 days after transplantation. The maximally and minimally diseased sites were selected in each segment as defined by Coronary Artery Surgery Study classification. For each matched site, maximal plaque thickness was measured. Lesions (maximum plaque thickness >/=0.5 mm) present at baseline examination were defined as donor lesions. On follow-up, lesions that developed at previously normal sites were defined as de novo lesions. The distribution and severity of donor and de novo lesions were similar in proximal, mid, and distal segments. The de novo lesions were less focal (43% vs 74%) and more circumferential (69% vs 45%) compared with the donor lesions, but there was significant morphological heterogeneity. Similar numbers of patients with and those without donor lesions developed de novo lesions. Moreover, progression of donor lesions was not associated with the presence or absence of de novo lesions., Conclusions: Differentiation between early allograft vasculopathy from conventional atherosclerosis by distribution and morphology of lesions alone is difficult. Serial intravascular ultrasound imaging with early baseline examination is necessary to make this distinction. This distinction is important because the progression of donor lesions and the development of de novo lesions are independent of each other.

Background: Recent studies have documented the utility of intravascular ultrasonography in quantifying coronary morphologic characteristics and determining an appropriate intervention. Unfortunately, its potential for quantifying lesion calcification is limited by subjective evaluation and manual tracing. The aim of this study was to develop an objective automated method for quantifying calcification in intracoronary images with digital image analysis., Methods: Images of human coronary arteries acquired with a 30 MHz intracoronary ultrasound catheter were evaluated with digital image analysis and compared with manual tracings. Calcifications were automatically identified as highly echogenic regions detected by global thresholding within sectors of acoustic shadowing defined as regions devoid of texture., Results: The mean percentage agreement, sensitivity, and specificity of detecting calcification in 1-degree sectors of calcified vessels were 82%, 73%, and 87%, respectively. Similar results were obtained in noncalcified images., Conclusion: The accuracy of this automated technique was comparable to interoperator and intraoperator variability in manually tracing calcification.

Background: A high plasma homocysteine concentration is a risk factor for atherosclerosis and thrombosis, which are major causes of morbidity and mortality in heart transplant patients. High homocysteine concentrations may be caused by lower folate and vitamin B6 levels. We hypothesized that these patients might have high homocysteine concentrations and low levels of folate and vitamin B6, which could contribute to the development of vascular complications., Methods: Total fasting plasma homocysteine was measured in 189 cardiac transplant recipients and in healthy controls, as were concentrations of folate, vitamin B12, vitamin B6, and creatinine., Results: Homocysteine concentrations were higher in recipients than controls (19.1+/-13.0 vs. 11.0+/-3.0 micromol/L, P<0.01), and hyperhomocysteinemia (>90th percentile for controls, 14.6 micromol/L) was seen in 68% of recipients (P<0.01). Folate and vitamin B6 concentrations were lower (5.9+/-4.2 vs. 7.9+/-4.2 pmol/L and 40+/-25 vs. 84+/-77 nmol/L, respectively; P<0.01 for both). Folate and vitamin B6 deficiencies were seen in 10.8% and 17.91% of recipients, respectively (P<0.01). Hyperhomocysteinemia was more frequent in patients with vascular complications after transplantation than in those without (79.2% vs. 63.8%, P<0.05)., Conclusions: Elevated plasma homocysteine and deficiencies of folate and vitamin B6 are common in transplant recipients. A high homocysteine concentration was more common in patients with vascular complications. Prospective studies are now required to evaluate the role of these abnormalities as risk factors for the atherothrombotic complications of transplantation.

Haziness at sites of balloon angioplasty is believed to represent plaque fractures or platelet deposition. The etiology of haziness adjacent to coronary stents remains uncertain. This study examines the prevalence and etiology of "peri-stent" haziness following high-pressure deployment. Consecutive patients undergoing coronary stenting and intravascular ultrasound imaging were included. Haziness was defined as nonhomogeneous contrast density and/or indistinct vessel borders by consensus of 2 observers. Patients were excluded if angiography revealed an obvious cause of haziness (thrombus, dissection). Matched control segments without haziness were selected for comparison. The most diseased site within the reference segment was identified by ultrasound. Lumen and plaque areas, percent plaque area, and plaque echo density were assessed. Haziness was identified within 31 segments in 30 patients (15% of 201 angiograms examined). At hazy sites, ultrasound revealed a large percent plaque area in 15, dissections in 14, and near-normal findings in 2 segments. In the absence of dissection, percent plaque area and lumen area step-down from the stent to the diseased reference were greater than controls (percent plaque area 64 +/- 12% vs 56 +/- 10%, p = 0.04 and lumen step-down 35 +/- 20% vs 13 +/- 25%, p = 0.006). With dissections, percent plaque area and lumen step-down were not different from controls (p = 0.13 and 0.30, respectively), but underlying plaques were more frequently echolucent (64% vs 23%, p = 0.02). Thus, in this study, peri-stent haziness was evident in 15% of patients after high-pressure coronary stent deployment. Etiologies identified by intravascular ultrasound included unrecognized reference plaque and angiographically occult dissections.

Patients undergoing percutaneous coronary revascularization (PCR) for narrowed saphenous vein grafts (SVGs) have a high incidence of subsequent cardiac events, but the relative contribution of treated and untreated SVGs, and of native coronary narrowings to late events is uncertain. This study evaluated the role of progression of SVG disease at untreated sites to cardiac events in these patients. All patients with successful PCR of SVG lesions who were enrolled in clinical trials with mandated repeat angiography from 1990 to 1994 were studied. One hundred three patients (age 63 +/- 8 years, 82% men, ejection fraction 54 +/- 12%, graft age 8 +/- 4 years), contributing 1,095 analyzable 15- to 25-mm SVG segments were followed 29 +/- 13 months (4 patients were lost to follow-up). Actuarial event-free (death, myocardial infarction, bypass surgery, or PCR) and overall survival at 12 months were 47 +/- 5% and 94 +/- 2%, respectively. Fifty-six percent of all early (< or = 12 months) events resulted from ischemia from recurrence at initially treated SVG sites, 26% at nontreated SVG sites, and 14% at nontreated native coronary sites. By 36 months, event-free and overall survival were 25 +/- 6% and 86 +/- 4%, respectively. Events occurring > 12 months after initial treatment resulted most frequently from ischemia from progression of narrowing at untreated SVG sites (46%). Ischemic events from initially untreated SVG sites were correlated with initial percent stenosis (initial, 41% to 50%; 45% events, 31% to 40%; 18% events, < or = 30%; 2% events, p <0.001) and reference SVG diameter (p = 0.003). Recurrent ischemic events from initially treated SVG sites were independently correlated with initial percent stenosis (initial > 75%; 43% events, 50% to 75%; 27% events, < 50%; 18% events, p = 0.01), but not with final percent stenosis. The frequent occurrence of events from nontreated 41% to 50% stenoses suggests a need for increased surveillance in patients with these lesions. The low incidence of events from initially treated lesions < 50% suggests that the hypothesis that "nonsignificant" 41% to 50% lesions might best be treated at the time other more severe narrowings are treated should be examined.

Percutaneous balloon mitral valvuloplasty (PBMV) is an effective means of palliating mitral stenosis, but it sometimes leads to adverse clinical outcomes and exorbitant in-hospital costs. Because echocardiographic score is known to be predictive of clinical outcome in patients undergoing PBMV, we examined whether it could also be used to predict in-hospital cost. Preprocedure echocardiographic scores, baseline clinical characteristics, and total in-hospital costs were examined among 45 patients who underwent PBMV between January 1, 1992, and January 1, 1994. Patients ranged in age from 18 to 71 years and had preprocedure echocardiographic scores that ranged from 4 to 12. Following PBMV, mean mitral valve area increased from 1.1 +/- 0.3 to 2.4 +/- 0.6 cm2 (p = 0.0001), and mean pressure gradient decreased from 18.3 +/- 5.9 to 6.7 +/- 2.7 mm Hg (p = 0.0001). In-hospital cost for the 45 patients ranged from $3,591 to $70,975 (mean $9,417; median $5,311). Univariate and multiple linear regression analyses demonstrated that among the variables examined, echocardiographic score (p = 0.0007), age (p = 0.01), and preprocedure mitral valve gradient (p = 0.03) were associated with in-hospital cost. Regression modeling suggested that every increase in preprocedure echocardiographic score of one grade was associated with an increase in in-hospital cost of $2,663. Because echocardiographic score is predictive of both clinical outcome and in-hospital cost, we conclude that patients with elevated scores should be considered for alternative therapy.

Objectives: We sought to determine whether careful examination of angiograms in conjunction with other clinical information could reliably detect, quantitate and localize target lesion calcification before a coronary intervention., Background: The presence, extent and location of calcium in coronary artery lesions are important determinants of outcome after coronary intervention. Intravascular ultrasound is proposed as a superior technique for identifying patients with coronary artery calcification. However, the precise role of this costly and invasive method has not yet been established., Methods: Target lesion calcification was assessed in 183 patients (155 men; mean [+/-SD] age 58 +/- 10 years) by angiography and intravascular ultrasound before a planned percutaneous coronary intervention., Results: Ultrasound detected calcium in 138 patients (>90 degrees in 56, 91 degrees to 180 degrees in 52, 181 degrees to 270 degrees in 22 and > 270 degrees in 8), whereas angiography showed calcification in 63 (1+ in 32, 2+ in 27 and 3+ in 4). The two techniques agreed in 92 patients and disagreed in 91. Sensitivity and specificity of angiography were 40% and 82%, respectively. The arc of calcium by ultrasound was greater in patients with angiographically visible calcification (175 degrees +/- 85 degrees vs. 108 degrees +/- 71 degrees, p=0.0001). The depth of calcification by ultrasound was superficial in 61 patients (44%), deep in 68 (49%) and mixed in 8 (7%). The sensitivity of angiography in identifying superficial calcium was 35%. Of 120 patients without angiographically visible calcium at the target lesion site, 83 showed calcium by ultrasound. The only predictor of ultrasound calcium in these 120 patients was angiographic calcification elsewhere in the coronary tree (p=0.0001). The probability of any calcium and superficial >90 degrees calcium were 60% and 12%, respectively, in the 90 patients without angiographic calcifications anywhere in the coronary tree., Conclusions: Despite poor sensitivity, angiography may help identify patients requiring intravascular ultrasound. When it is angiographically visible, the arc of calcium is likely to be large and superficial. Angiographic calcification at a remote site is a predictor of angiographically undetected target lesion calcium. Patients without angiographic calcification in the coronary tree may not need routine ultrasound examination, as the likelihood of >90 degrees superficial calcium is low.

Objective: The aim of this study was to evaluate the extent and distribution of coronary atherosclerosis after transplantation., Background: Transplant coronary artery disease is an important cause of death after cardiac transplantation. Unlike coronary angiography, intravascular ultrasound is a sensitive tool for detection and quantitation of this disease., Methods: We performed intravascular ultrasound imaging in 132 (106 men, 50 +/- 10 years) patients, 1 to 9 years after transplantation using a 30-MHz ultrasound catheter., Results: All three coronary arteries were visualized in 49, two in 62 and one in 21 patients. Of the 1,188 coronary artery segments, 706 were imaged (74% proximal, 64% mid- and 40% distal). At least one site with atherosclerosis (intimal thickness > or = to 0.5 mm) was found in 83% of patients. Atherosclerosis was noted in 64% of proximal, 43% of mid- and 26% of distal segments. Disease was diffuse in 48% and focal in 52%, circumferential in 66% and noncircumferential in 34%. Focal atherosclerosis was more common in proximal (59%) than mid- (48%) and distal segments (27%) (p=0.001). Noncircumferential plaques were more common in the proximal (42%) than mid- (28%) and distal segments (12%) (p=0.001). This pattern of focal and noncircumferential disease proximally, diffuse and circumferential disease distally, was observed irrespective of the time from transplantation., Conclusion: Atherosclerosis was detected in more than 80% of patients, with proximal segments most frequently involved. Diffuse and circumferential atherosclerosis was more common in mid- and distal segments. However, focal and noncircumferential involvement was more frequent proximally, a similar pattern to native atherosclerosis. These findings suggest that transplant coronary artery disease has a dual etiology based on the dichotomous pattern of atherosclerosis seen by intravascular ultrasound.

During the last several years, major improvements in intravascular ultrasound image quality have led to new and important information about the clinical application of rotational atherectomy. Ultrasound is providing data on the mechanism of luman enlargement, burr sizing, and the effects of the procedure on different plaque morphologies. This information is often important for optimizing device selection and procedural success, as well as for minimizing complications. In this review we first discuss the currently available data regarding the mechanisms of lumen enlargement following rotational ablation and the implications of these findings for lesion and patient selection. We review how this data is modifying several of the technical aspects of the rotational ablation procedure in the interventional laboratory. We than assess the available data that suggest that preprocedural ultrasound examination may eventually help to identify lesions at high risk for adverse outcome with stand-alone balloon angioplasty or stent placement. These ultrasound data may help triage many of these targets to initial debulking with rotational ablation. Finally, we review data that suggest that ultrasound analysis has important implications for comparative trials of new devices, particularly trials of the Rotabalator.

Recent advances in microelectronic and piezoelectric technology have permitted development of miniaturized ultrasound devices capable of real-time tomographic intravascular imaging. Initial studies have successfully employed intravascular ultrasound to augment angiography in both diagnostic and therapeutic catheterization. The cross-sectional perspective of intravascular ultrasound appears to be ideally suited for precision measurements of luminal diameter and cross-sectional area. In addition, ultrasound improves assessment of problem lesions such as ostial stenoses or disease at bifurcations. Intravascular imaging provides unique, detailed cross-sectional images of the arterial wall not previously obtainable in vivo by any other technique and is more sensitive than angiography in detecting atherosclerosis. Intravascular ultrasound images of atherosclerotic wall abnormalities have the potential to augment greatly the understanding of the anatomy and pathophysiology of coronary disease. For interventional applications, ultrasound analysis of lesion characteristics offers many potential advantages. Evaluation of the normal reference segment used for device sizing constitutes an important emerging application for intravascular imaging. After the procedure, intravascular ultrasound often yields smaller luminal size measurements than angiography and greater of stenosis. These differences probably reflect augmentation of the apparent angiographic diameter by extraluminal contrast within cracks, fissures or dissection planes. New ultrasound instruments under development combine an imaging transducer with an interventional device, permitting on-line guidance during the procedure. Although the clinical value of routine ultrasound imaging before or after mechanical revascularization has not been tested by randomized trials, it seems likely that this new imaging modality will provide valuable insights into diverse phenomena such as abrupt occlusion and restenosis. Accordingly, we anticipate a continuing role for this modality in cardiovascular interventional therapy.

Background: Transplant coronary artery disease is a major cause of morbidity and mortality after cardiac transplantation. However, limited data exist regarding the potential contribution of coronary atherosclerosis in the donor heart to cardiac-allograft vasculopathy., Methods and Results: We performed quantitative coronary angiography and intravascular ultrasound imaging in 50 of 62 consecutive heart-transplant recipients (40 men, 10 women, mean age, 53 +/- 9 years) 4.6 +/- 2.6 weeks after transplantation. The donor population consisted of 30 men and 20 women (mean age, 32 +/- 12 years). Ultrasound imaging visualized all three coronary arteries in 22 patients, two coronary arteries in 23, and one coronary artery in 5. Ultrasound imaging detected coronary atherosclerosis (intimal thickness > or = 0.5 mm) in 28 patients (56%). However, the angiography was abnormal in only 13 patients (26%). The sensitivity and specificity of coronary angiography were 43% and 95%, respectively. With ultrasound, the average atherosclerotic plaque thickness was 1.3 +/- 0.6 mm and the cross-sectional area narrowing was 34 +/- 16%. Atherosclerotic involvement frequently was focal (85%), eccentric (mean eccentricity index, 87 +/- 8), and near arterial bifurcations. Donors of the transplant recipients with coronary atherosclerosis were older than those without atherosclerosis (37 +/- 12 versus 25 +/- 10 years, P = .001). Maximal intimal thickness correlated with donor age (r = .54, P = .0001). Multivariate analysis demonstrated that donor age (P = .0001), male sex of donor (P = .0006), and recipient age (P = .03) were independent predictors of atherosclerosis., Conclusions: Coronary atherosclerosis is frequently but inadvertently transmitted by means of cardiac transplantation from the donor to the recipient. Long-term outcomes of donor-transmitted coronary artery disease will require further evaluation.

Immediate outcome and 4-year follow-up results of percutaneous mitral balloon valvotomy (PMV) in patients with previous surgical mitral commissurotomy are studied. Repeat surgical mitral commissurotomy in patients with previous surgical commissurotomy is associated with higher mortality and morbidity. PMV has been proven to be safe and could be an ideal alternative in this patient group. The results of 68 patients with previous surgical commissurotomy were compared with those of 261 patients without prior surgical intervention. A good outcome, defined as the final mitral valve area > 1.5 cm2, was obtained in 51% of the patients with prior surgical commissurotomy compared with 71% in the control group (p = 0.002). During the 4-year follow-up period, there were more patients who required mitral valve replacement (19% vs 7%; p = 0.004) and who were in New York Heart Association functional class III and IV (85% vs 71%; p = 0.02) among those with prior surgical commissurotomy. However, when these patients were divided according to echocardiographic score, those with a score < or = 8 had immediate outcome and long-term results similar to those without prior commissurotomy. PMV can be performed safely in patients with prior surgical commissurotomy. Although results of long-term follow-up in these patients is not as good as those in patients without prior surgical commissurotomy, those with a low echocardiographic score had similar excellent long-term results.

The long-term outcome after mitral valvuloplasty is excellent and compares well with surgical treatment of mitral stenosis. Compared with the double balloon technique, the Inoue method is technically easier and may reduce acute complications without any adverse effect on long-term outcomes. Excellent long-term outcome is also seen after balloon valvuloplasty of aortic stenosis in the young and in pulmonary stenosis at all ages. Finally, although balloon aortic valvuloplasty in the elderly may not change the terrible prognosis of such patients, it does improve functional status and is a useful bridge to surgery in selected patients.

In this report, we describe two cases of attempted mitral valvuloplasty using an Inoue balloon in which left atrial thrombus was not present before transseptal puncture but developed within minutes of the puncture in one, and within 1 mo in the other, despite systemic anticoagulation.

Objectives: This study analyzed the immediate and long-term outcome of percutaneous balloon mitral valvotomy in patients with and without fluoroscopically visible mitral valve calcification., Background: Mitral valve calcification has been shown to be an important factor in determining immediate and long-term outcome of patients undergoing surgical mitral commissurotomy. Patient selection has an important impact on the outcome of percutaneous balloon mitral valvotomy., Methods: The immediate and long-term results of percutaneous balloon mitral valvotomy were compared in 155 patients with and 173 patients without mitral valve calcification. The patients with calcified valves were assigned to four groups according to severity of calcification., Results: Patients with calcified mitral stenosis more frequently were in New York Heart Association functional class III or IV and more frequently had atrial fibrillation, previous surgical commissurotomy, echocardiographic score > 8, higher pulmonary artery and left atrial pressures, higher pulmonary vascular resistance and mean mitral valve gradient and lower cardiac output and smaller mitral valve area. Mitral valve area after valvotomy was significantly smaller in patients with calcified valves (1.8 +/- 0.06 vs. 2.1 +/- 0.06 cm2) and was > or = 1.5 cm2 in 65% of patients with and 83% of patients without calcified valves (p = 0.004). A successful outcome, defined as mitral valve area > 1.5 cm2 without significant mitral regurgitation and left to right shunting, was achieved in 52% of patients with and 69% of patients without uncalcified valves (p = 0.001). The success rate was 59%, 48%, 35% and 33% in subgroups with 1+, 2+, 3+ and 4+ calcification, respectively. The rates of significant left to right shunting and mitral regurgitation after valvuloplasty were similar in the two groups. Estimated survival rate (80% vs. 99%, respectively, p = 0.0001), survival rate without mitral valve replacement (67% vs. 93%, respectively, p < 0.00005) and event-free survival rate (63% vs. 88%, respectively, p < 0.00005) at 2 years were significantly better in the patients with uncalcified valves. Survival rate curves became progressively worse as the severity of calcification increased., Conclusions: These findings indicate that immediate and long-term results of mitral valvuloplasty are not as successful in patients with fluoroscopically visible mitral valve calcification as in those without calcification.

Coronary intravascular ultrasound imaging has been found to be the most sensitive method for detecting postcardiac transplantation coronary vasculopathy. Techniques for this type of imaging have been well established for adult patients, but coronary intravascular ultrasound imaging in young children has not been previously reported. We describe the cases of 2 children, ages 8.5 years and 9 months, respectively, who had confusing clinical pictures after cardiac transplantation. Currently available imaging equipment and techniques were used in these children to visualize the coronary arteries. The results of ultrasound imaging were considered helpful in determining future treatment for these 2 pediatric patients.

Background: We analyzed the immediate and long-term outcome of percutaneous balloon mitral valvotomy (PMV) in 99 patients who were greater than or equal to 65 years of age (81 women and 18 men; mean +/- SEM age, 72 +/- 0.5 years)., Methods and Results: There were 84 patients in New York Heart Association (NYHA) class III or IV; 26 patients had previous surgical commissurotomy; 64 had one or more comorbidities; 73 had fluoroscopically visible mitral valve (MV) calcification; and 63 had echocardiographic score greater than 8 (mean +/- SEM score, 9.2 +/- 0.2). There were three procedural deaths, all occurring in our early experience. Pericardial tamponade occurred in five patients, thromboembolism in three, and transient atrioventricular block in one. After PMV, MV area was greater than or equal to 1 cm2 in 86 patients and greater than or equal to 1.5 cm2 in 56. A successful outcome (defined as MV area greater than or equal to 1.5 cm2 without a greater than or equal to 2-grade increase in mitral regurgitation and without left-to-right shunt with a pulmonary-to-systemic flow ratio of greater than or equal to 1.5:1) was achieved in 46 patients. The best multivariate predictor of success was the combination of echocardiographic score, NYHA functional class, and inverse of MV area. Mean follow-up was 16 +/- 1 months. Actuarial survival (79 +/- 7% versus 62 +/- 10%, p = 0.04), survival without MV replacement (71 +/- 8% versus 41 +/- 8%, p = 0.002), and survival without MV replacement and NYHA class III or IV (54 +/- 12% versus 38 +/- 8%, p = 0.01) at 3 years were significantly better in the successful group of 46 patients than in the unsuccessful group of 53 patients. Low echocardiographic score was the only independent predictor of survival. Lack of MV calcification and low NYHA class, low mean left atrial pressure, and low pulmonary artery pressure were the independent predictors of event-free survival., Conclusions: PMV can be performed safely in selected patients greater than or equal to 65 years old with good immediate and long-term results. In addition to clinical examination, echocardiographic evaluation of the mitral valve and fluoroscopic screening for valvular calcification are the most important steps in patient selection for successful outcome.

Percutaneous balloon mitral valvotomy (PBMV) compares well with surgical commissurotomy, showing comparable improvement in symptoms and catheterization-proven valve area early after the procedure. This study reports the New York Heart Association class, mitral valve area calculated by echocardiography, and the results of transseptal cardiac catheterization 2 years after PBMV. The data are compared with the status immediately before and after PBMV. Forty-one patients returned to enter the study (mean follow-up time 24 +/- 3 months). All patients were evaluated clinically by the same investigator who had seen them at the time of PBMV. Transseptal cardiac catheterization and echocardiographic analysis (2-dimensional and Doppler echocardiography) were performed on the same day. At follow-up, 17 patients were class I, 20 were class II, and 4 were class III. Although the mitral valve area calculated by cardiac catheterization increased significantly from immediately before to immediately after PBMV there was a decrease in the calculated mitral valve area at 2-year follow-up. Echocardiographic analysis did not show as large an increase in mitral area, immediately after PBMV, and no significant decrease in mitral valve area at 2 years (before PBMV planimetry 1.1 +/- 0.1 cm2; immediately after 1.8 +/- 0.1 [p less than 0.05]; follow-up 1.6 +/- 0.1 [p = not significant compared with immediately after PBMV]). Doppler halftime measurements were similar. PBMV is effective therapy with good midterm results for selected patients with mitral stenosis.

Percutaneous balloon mitral valvotomy is a technique that allows relief of mitral stenosis without thoracotomy. Commissurotomy of the mitral valve with proper sized balloons that are placed antegrade by means of a transseptal catheterization results in good immediate and midterm results in most patients. Younger patients with echocardiographic scores of 8 or lower and who are without atrial fibrillation, mitral regurgitation or valvular calcification, and histories of surgical commissurotomy are the best candidates for PMV. Nevertheless, many patients who are not ideal candidates for PMV also derive substantial relief from this procedure. Mortality and morbidity related to the procedure are low in most experienced centers. Complications include pericardial tamponade, thromboembolism, rhythm abnormalities, left to right shunting, and mitral regurgitation. The survival with freedom from mitral valve replacement at 2 years after PMV is 84%. In addition to history and physical examination, echocardiography has a central role in the selection of patients for PMV.

The immediate outcome of the first 150 patients (Group 1) and the last 161 patients (Group 2) who underwent percutaneous mitral balloon valvuloplasty was compared. There was no difference between the two groups in age, gender, New York Heart Association functional class, presence of calcification, atrial fibrillation, degree of mitral regurgitation, mean pulmonary artery pressure, left atrial pressure, cardiac output, pulmonary vascular resistance, mitral valve gradient and mitral valve area. Fewer patients in Group 1 than Group 2 had an echocardiographic score less than or equal to 8 (62% versus 69%, respectively, p = 0.02). The atrial septum was dilated with an 8 mm balloon in 74% of patients in Group 1 and with a 5 mm balloon in all patients in Group 2. Ratio of effective balloon dilating area to body surface area was larger in Group 1 than in Group 2 (4.05 +/- 0.07 versus 3.7 +/- 0.03 cm2/m2, p = 0.0001). A good result (mitral valve area greater than or equal to 1.5 cm2) was obtained in 77% and 75% in Groups 1 and 2, respectively (p = NS). After percutaneous mitral valvuloplasty, a greater than or equal to 2 grade increase in mitral regurgitation was noted in 12% of Group 1 and 6% of Group 2 (p = 0.02) and a left to right shunt was detected in 22% of Group 1 and 11% of Group 2 (p = 0.0001). There were three procedure-related deaths in Group 1, but none in Group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

We performed percutaneous balloon pericardial window (PBPW) in 8 patients (age 40 to 70 yrs; 4 men, 4 women) with malignant pericardial effusion and tamponade. Pericardial window was indicated because they continued to drain greater than 100 ml/day of pericardial fluid through the pigtail catheter for greater than or equal to 3 days. A 0.038 inch guidewire was advanced through the pigtail catheter into the pericardial space and then the catheter was removed. A 20 mm diameter, 3 cm long balloon dilating catheter was advanced to straddle the parietal pericardium. Manual inflations were performed until the waist produced by the pericardium disappeared. All patients tolerated the procedure well with minimal discomfort and with no complications. A left or bilateral pleural effusion occurred in all patients after PBPW. No patient developed recurrent pericardial tamponade at a mean follow-up of 6 +/- 2 months. Thus, PBPW is a useful and safe technique to avoid surgery in patients with malignant pericardial effusion and tamponade.

We analyzed the immediate and long-term outcome of percutaneous transluminal angioplasty (PTCA) of native coronary arteries via saphenous vein grafts (SVG) in 30 patients. The mean age of the grafts was 69 months. Angioplasty was successful in 27 (90%) patients. One patient died following emergency bypass surgery. There were no distal embolizations and one non-Q myocardial infarction. Follow-up angiography was performed in 12 patients, which revealed restenosis in three patients. At a mean follow-up of 20 months, cumulative survival was 93%. Freedom from myocardial infarction, repeat bypass surgery, and death was 80%. We conclude that PTCA of native coronary arteries via SVG is a safe alternative to repeat CABG in selected patients.

We investigated the impact of the atrial communication on the mitral valve area calculation after percutaneous mitral balloon valvotomy in 17 patients (15 women, 2 men; mean age 56 +/- 4 years). The hemodynamic measurements and mitral valve area calculations were performed with and without balloon occlusion of the atrial septal puncture site. The mitral valve area determined with balloon occlusion was significantly smaller than the mitral valve area determined without occlusion (1.6 +/- 0.1 vs. 1.9 +/- 0.1 cm2, P less than 0.01), and was similar to the echocardiographically determined valve area (1.6 +/- 0.1 cm2). This decrease in the calculated mitral valve area with occlusion was associated with a decrease in the measured cardiac output, without a change in the mitral valve gradient or the diastolic filling period. Occlusion of the atrial septal puncture site may permit more accurate determination of the mitral valve area and thus provide a better reference point for future comparison should the question or restenosis arise.

To determine the incidence and prognostic significance of new postoperative conduction disturbances, 2,000 consecutive patients who underwent primary elective coronary bypass surgery were evaluated. One hundred eleven (5.5%) of the 2,000 patients developed a new intraventricular conduction defect that persisted to hospital discharge. Right bundle branch block occurred in 86 (85%), left bundle branch block in 5 (4%) and nonspecific intraventricular conduction defect in 9 (11%). One hundred of these 111 patients were successfully matched with others in the study population who had maintained normal intraventricular conduction during the operative period. Patients were matched on the basis of age, gender, absence of preoperative conduction disturbances, left ventricular function and bypass grafts to the same vessels. Follow-up of the two groups for a period of 1 to 76 months (mean 60 months) failed to show any difference in survival or cardiac events such as myocardial infarction, repeat coronary bypass surgery, coronary angioplasty and permanent pacemaker implantation. The appearance of right or left bundle branch block or a nonspecific intraventricular conduction defect after coronary bypass surgery does not appear to have an unfavorable impact on the long-term prognosis of these patients.

In order to analyze the impact of different polarity and electrode designs on the acute pacing and sensing characteristics of pacemaker leads, 80 patients with complete heart block or sinus node dysfunction undergoing pacemaker implantation received eight different leads from five manufacturers. Once the leads were positioned, volt and current thresholds, P wave, peak-to-peak, and slew rate were assessed prospectively. There was no statistically significant difference between acute pacing thresholds, sensing characteristics, or unipolar and bipolar pacing thresholds. Active fixation leads allow atrial mapping and lead placement in areas generally inaccessible to tined tip leads. This is an advantage, especially for patients with a history of open heart surgery.

The short- and long-term outcome of percutaneous transluminal coronary angioplasty were analyzed in 34 patients who had documented coronary artery disease without symptoms. Of the 34 patients, 33 had abnormal stress tests before angioplasty. Angioplasty was successful in 31 patients (91%). Follow-up was 100% for a mean period of 36 +/- 15 months. Follow-up exercise test was normal or improved in 29 of the 31 patients who had successful angioplasty. Follow-up catheterization was performed in 24 of the 31 patients (77%). Restenosis of the previously dilated segment was found in seven patients. Actuarial cardiac survival at 3 years was 100%. Freedom from myocardial infarction, bypass surgery, angioplasty for a new lesion, and death was 87%. We conclude that although the most effective treatment for silent ischemia remains to be determined, our data suggest that coronary angioplasty is a therapeutic option in these patients.

Coronary artery anomalies are commonly associated with congenital heart disease. It is important to recognize these anomalies to avoid errors in diagnosis, decrease technical difficulties in angiography, and prevent inadvertent injury in surgery. We found that of 66,884 patients who underwent coronary arteriography between 1972 and 1982 at the Cleveland Clinic Foundation, 1,000 had coronary anomalies. Of these, 101 had associated congenital anomalies: 29 had mitral valve prolapse, 18 had bicuspid aortic valves, 16 had tetralogy of Fallot, 11 had corrected transposition, 10 had a univentricular heart, 6 had coarctation of the aorta, 3 had ventricular septal defects, and 8 had miscellaneous congenital heart defects. The most common coronary anomaly was ectopic origin of a coronary artery: 30 from the sinus of Valsalva, 12 from the ascending aorta, 11 from the pulmonary artery. Nineteen patients had no left main trunk. Thirteen patients had coronary artery fistulas and 21 had miscellaneous coronary anomalies.

The authors evaluated the long-term outcome of percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery in patients with shepherd's crook morphology (51 patients) compared to a control group (53 patients) matched for lesion location, date of procedure, age, and gender. The primary success rate was lower (86% v 98%; P = .03) in the shepherd's crook group than in the control group. At a mean follow-up of 29 months, there was one death in each group. The restenosis rate was 18% in the shepherd's crook group and 21% in the control group; repeat PTCA (14% v 15%) and bypass surgery (2% v 6%) rates were also similar in both groups. The data suggest that PTCA of right coronary arteries with shepherd's crook morphology has a significantly lower primary success rate but similar long-term outcome when compared to PTCA of right coronary arteries without this anatomic variation.

The authors report a case of intra-aortic balloon rupture and entrapment in a patient with extensive vascular disease. The balloon was subsequently removed percutaneously. A review of the diagnosis and management of this unusual complication is presented.

Clinical and angiographic characteristics, procedural details and outcome were analyzed in 2,677 consecutive patients who underwent elective single-artery, single-lesion percutaneous transluminal coronary angioplasty (PTCA) between December 1980 and May 1987. Primary success was achieved in 2,479 (93%) patients. The primary success rate was significantly lower during the first period, when nonsteerable systems were used (73%), than in later periods (94%) (p less than 0.0001), when steerable and low-profile systems became available. Univariate analysis revealed the following variables as predictors of lower primary success: totally obstructed arteries (p less than 0.0001), presence of calcium in the narrowing (p = 0.002), prior myocardial infarction (p = 0.005), stenoses located in the right coronary artery (p = 0.02), narrowings between 90 and 99% in diameter (p = 0.02) and patients older than 60 years of age (p = 0.07). Multivariate analysis revealed the following 4 independent predictors of lower primary success: 100% obstruction (p less than 0.0001), calcium (p = 0.005), previous myocardial infarction (p = 0.029) and patients older than 60 years of age (p = 0.036). With present technology, single-narrowing elective PTCA can be performed with a high success rate in most patients. Although total occlusion, presence of calcium, older age and history of myocardial infarction influence the outcome unfavorably, PTCA can still be performed with acceptable primary success rates.

Angiograms from 1,043 consecutive patients undergoing right coronary artery angioplasty were reviewed to determine the incidence of "shepherd's crook" origin of the right coronary artery. Primary results, complications, and technical difficulties were compared with a control group. Fifty-one patients (4.9%) were found to have this anatomic variation. Compared with a control group, the primary success rate was lower (86% vs. 98%) and the incidence of procedural difficulties was higher (33% vs. 13%). Technical problems led to the use of more guiding catheters and more guidewires per patient than in the control group. Thus, coronary angioplasty of shepherd's crook right coronary artery imposes technical problems and is associated with less than an optimal primary success rate.

A total of 33 patients age 35 years or younger underwent percutaneous transluminal coronary angioplasty (PTCA) at The Cleveland Clinic Foundation between January 1981 and October 1987. Arteriography showed one-, two-, and three-vessel disease in 16, 12, and 5 patients, respectively. Twenty-four patients (73%) had functional Class 3 or 4 angina and 17 (52%) had unstable angina. PTCA was performed in one vessel each in 22 patients and in multiple vessels in 11 patients. Of 47 vessels, 44 (94%) were successfully dilated. There were no deaths, emergency bypass procedures, or myocardial infarctions during hospitalization. At a mean follow-up of 30 months, there were two late deaths, nine repeat PTCA procedures, one coronary bypass, and one nonfatal myocardial infarction. Due to the progressive nature of coronary artery disease in the young adult, PTCA appears to be a good therapeutic modality for selected patients in this age group.

We analyzed the impact of evolving technology on percutaneous transluminal coronary angioplasty in 2677 patients. There were 168 patients in period 1 when fixed-wire catheters were used, 1117 patients in period 2 when steerable catheters were available, and 1392 patients in period 3 when low-profile systems were utilized. The age of patients (55 to 57 to 59 years) and the proportion of patients with severe angina increased over the three periods (25% to 36% to 54%). The percentage of high-grade stenosis and the proportion of distal lesions also increased. Primary success rate improved from 73% in period 1 to 94% in periods 2 and 3. Emergency bypass surgery decreased (8.3% to 4.2% to 2.5%), as did the incidence of myocardial infarction (7.1% to 3.3% to 2.4%). Mortality was 0% in period 1, 0.2% in period 2, and 0.4% in period 3. These results indicate that technological advancements and increased operator experience significantly improved the primary success rate and decreased the incidence of major complications.

Clinical features and natural history were analyzed in 30 patients with Ebstein's anomaly (mean age 26 years, range 1.5-58 years, 53% females). The main presenting symptoms were dyspnea and fatigue (83%). At presentation, there were six patients (20%) in New York Heart Association Functional Class (NYHAFC) I, nine (30%) in NYHA-FC II, and 15 (50%) in NYHA-FC III or IV; 12 patients (40%) were cyanotic. Common auscultatory findings were widely split second heart sound in 21 (70%), third heart sound in 14 (47%), fourth heart sound in 16 (53%), and a systolic murmur in 22 (73%). Right bundle branch block was present in 21 (70%), documented supraventricular tachycardia in seven (23%), and Wolff-Parkinson-White syndrome in three (10%). Catheterization was performed in 93% without complications. Fourteen patients were treated surgically (12 [86%] in NYHA-FC III or IV, 10 [71%] with associated anomalies); tricuspid valve replacement was performed in eight, atrial septal defect repair in two, accessory pathway ablation in two, right atrial plication in one, and automatic cardioverter defibrillator implantation in one. Surgical treatment improved 10 patients from NYHA-FC III or IV to NYHA-FC I or II. Death occurred in nine patients (five treated surgically and four medically); four of these deaths were sudden. In the eight patients who had tricuspid valve replacement, there were one operative and two late deaths. The authors conclude that surgical therapy with tricuspid valve replacement improves the clinical status of patients who are severely ill. Risk of sudden death remains an important problem in patients with Ebstein's anomaly regardless of severity of the disease and mode of treatment.

The efficacy of amiodarone was evaluated in 85 patients with supraventricular tachycardia (SVT) refractory to several antiarrhythmic agents (mean 3.8 +/- 1.0). All but six patients had organic heart disease. Patients were followed for 19 months (range 2-60 months). Response to amiodarone treatment was considered excellent (no recurrence of SVT) in 22 of 52 patients with paroxysmal atrial fibrillation (PAF), in four of 13 patients with chronic atrial fibrillation (CAF), and in three of 15 patients with Wolff-Parkinson-White syndrome-related circus movement tachycardia (WPW-CMT). Response was improved (marked improvement in symptoms with partial suppression of SVT) in 22 patients with PAF, in seven patients with CAF, in 10 patients with WPW-CMT, and in four patients with atrioventricular nodal reentry tachycardia. Response was considered poor (insignificant or no suppression of SVT) in three patients with PAF, in one patient with CAF, and in one patient with WPW-CMT. Seven patients required discontinuation of amiodarone due to adverse effects. We conclude that amiodarone is efficacious and relatively safe for control of SVT refractory to conventional antiarrhythmic agents irrespective of the underlying electrophysiologic mechanism.

Clinical, electrocardiographic and echocardiographic findings of 32 patients age 90 years or older were analyzed to assess the prevalence, characteristics and correlates of left ventricular (LV) hypertrophy. All patients (mean age 92 years, range 90 to 98; 21 women and 11 men) were referred to the echocardiography laboratory with a definite or suspected cardiovascular diagnosis. LV hypertrophy, echocardiographically diagnosed by high LV mass index, was present in 28 patients. The LV mass index ranged from 105 to 215 g/m2 in men and 140 to 262 g/m2 in women. Electrocardiographic evaluation showed LV hypertrophy in only 5 patients. Five patients had low voltage on the electrocardiogram. There was no correlation between the LV mass index and presence of electrocardiographic LV hypertrophy or presence of low voltage on the electrocardiogram. LV hypertrophy was concentric in 19 and eccentric in 9. There was no correlation between types of LV hypertrophy and underlying cardiovascular disease or presence of electrocardiographic LV hypertrophy. It is concluded that LV hypertrophy is frequently present and has a wide range and heterogeneous character in very elderly patients with cardiovascular disease. In the tenth decade of life, echocardiography is a sensitive method for detecting, characterizing and classifying LV hypertrophy, whereas electrocardiography lacks sensitivity in detecting it.