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Purpose: To evaluate the results of percutaneous balloon valvuloplasty (PBV) for membranous subaortic stenosis (MSAS)., Methods: Seven patients with MSAS were submitted to PBV using the retrograde approach. Hemodynamic and angiographic studies were performed before and after the procedure. The balloon/annulus ratio varied between 0.9 to 1.05., Results: The systolic gradient (SG) between the left ventricle (LV) and aorta was reduced from 57.8 +/- 11.6 to 22.0 +/- 8.6 mmHg (p < 0.001) and the LV systolic pressure from 154.5 +/- 30.3 to 118.7 +/- 18.4 mmHg (p < 0.001). One patient had arterial occlusion and was submitted to surgical embolectomy and another one showed severe mitral regurgitation combined with aortic insufficiency (AI) and required surgical valvuloplasty. There was no mortality. Four patients had a 11 +/- 10 month follow up: the SG measured by echocardiogram was 34 +/- 7 mmHg and no patient showed worsening of the AI., Conclusion: PBV is an effective procedure to reduce the subaortic SG, with an acceptable morbidity and persistence of the results in the short term follow up. PBV is a valid alternative as an initial mode of therapy in the management of patients with MSAS.

Plant aspartic proteinases characterised at the molecular level contain one or more consensus N-glycosylation sites [Runeberg-Roos, P., Tŏrmäkangas, K. & Ostman, A. (1991) Eur. J. Biochem. 202, 1021-1027; Asakura, T., Watanabe, H., Abe, K. & Arai, S. (1995) Eur. J. Biochem, 232, 77-83; Veríssimo, P., Faro, C., Moir, A. J. G., Lin, Y., Tang, J. & Pires, E. (1996) Eur. J. Biochem. 235, 762-768]. We found that the glycosylation sites are occupied for the barley (Hordeum vulgare L.) aspartic proteinase (Asn333) and the cardoon (Cynara cardunculus L.) aspartic proteinase, cardosin A (Asn70 and Asn363). The oligosaccharides from each site were released from peptide pools by enzymatic hydrolysis with peptide-N-glycanase A or by hydrazinolysis and their structures were determined by exoglycosidase sequencing combined with matrix-assisted laser desorption/ionization time of flight mass spectrometry. It was observed that 6% of the oligosaccharides from the first glycosylation site of cardosin A are of the oligomannose type. Modified type glycans with proximal Fuc and without Xyl account for about 82%, 14% and 3% of the total oligosaccharides from the first and the second glycosylation sites of cardosin A and from H. vulgare aspartic proteinase, respectively. Oligosaccharides with Xyl but without proximal Fuc were only detected in the latter proteinase (4%). Glycans with proximal Fuc and Xyl account for 6%, 86% and 92% of total oligosaccharides from the first and second glycosylation sites of cardosin A and from H. vulgare aspartic proteinase, respectively.

The authors report their experience with the percutaneous closure of the patent ductus arteriosus with the Rashkind technique. They performed 42 procedures with a success of 97.6% and one embolization episode. The mean age was 8.7 +/- 6.7 years, the mean weight was 25.0 +/- 15.8 Kg and the minimum diameter of the ductus was 4.0 +/- 1.3 mm. The immediate overall prevalence of residual shunt was 48.8% falling to 21% in a mean follow-up of 17 +/- 13 months in 29 cases. Two patients underwent late reocclusion: one with a new umbrella and the other with a coil. Another patient had an immediate severe residual shunt and it was reoccluded in the same procedure with a coil. The anatomical type and minimum internal diameter of the ductus, age and weight, size of the umbrella and the rotation of the umbrella were not predictors of residual shunt. There were no deaths, hemolysis, endarteritis or fracture of the umbrella's arms. One patient remained with a slight gradient in the left pulmonary artery. The authors conclude that the Rashkind technique is safe and efficient and has good long term results. It should be considered as the first line therapeutic modality in the treatment of selected patients with persistent ductus arteriosus.

Six days old neonate with pulmonary atresia and intact ventricular septum is reported in which a communication was established between the right ventricle and the pulmonary artery. The membraneous atresia was perforated with a special radiofrequency catheter 2F connected to a Hat 200S radiofrequency generator (Osypka). The energy necessary to perforation was 15W. After perforation of the atresia, balloon dilation was performed (balloon diameter: 2, 3, 4mm of coronary angioplasty and 5, 8mm Penta Medi-tech). The valve was completely opened giving the continuity between right ventricle and pulmonary artery.

A 64-year-old woman is reported with Stage I (Rai) chronic lymphocytic leukaemia (CLL), in whom hypercalcemia developed when an increased proportion of prolymphocytic cells characterized a transformation of CLL in prolymphocytoid leukaemia (CLL/PL). Although hypercalcemia is more frequently found in T-cell leukaemia associated with human T lymphotropic lymphocyte type I, scattered reports indicate that patients with B-CLL can also be affected with this metabolic disturbance. The case described here, progressed with an indolent course of CLL for 26 months, when she was admitted with a very aggressive disease characterized by a high WBC count, splenomegaly and hypercalcemia. Despite an effort to achieve a clinical remission, she failed treatment and death was attributed to unresponsive hypercalcemia. The mechanism of hypercalcemia in such cases is unclear as no parathyroid adenoma or second malignant tumor was found ante mortem. This electrolytic disturbance would appear to be a direct consequence of the transforming leukaemia and a possible mechanism involving a secreted humoral factor that could lead to altered calcium metabolism.

Purpose: To evaluate the late hemodynamic and angiographic results of 52 patients who underwent mitral valvoplasty by the double balloon technique in the treatment of the rheumatic mitral stenosis., Methods: The mean follow-up was of 18 months and the patients had a Doppler-echocardiogram and cardiac catheterization one year after dilatation. Of the 52 patients 84.6% were female and the mean age was 21.9% years. Eighty one percent were in NYHA class I whereas 5.7% had atrial fibrillation at the end of 18 months., Results: Immediately after valvoplasty 46 patients (88.5%) had a valvar area larger, and 6 (11.5%) smaller than 1.5 cm2. The first group had a good clinical outcome with maintenance of the clinical, echocardiographic and angiographic results in the late follow-up, including the diastolic gradient and the valvar area. Of the 6 cases with mitral area smaller than 1.5 cm2, 2 had a good clinical evolution, 2 were re-dilated, 1 was scheduled for surgery and the last one is under clinical management but with poor hemodynamic results. Three (5.7%) cases developed an atrial septal defect after the procedure, with hemodynamic repercussion in 1. Mitral regurgitation developed in 16 cases (+ in 8, +/++ in 8) without changes during the follow-up period., Conclusion: Double balloon mitral valvoplasty is a safe effective method in the treatment of the rheumatic mitral stenosis, and offers a better evolution in patients with a valvar area larger than 1.5 cm2 after the dilatation.

White male patient, 14 years old, who developed a severe subaortic stenosis in the late postoperative period of a total correction of atrioventricular septal defect. Clinical diagnosis was confirmed by echocardiography and cardiac catheterization. The patient underwent reoperation for treatment of the new condition, with resection of subaortic stenosis. Atrioventricular septal defects show a narrow and deformed left ventricle outflow tract, susceptible to obstruction before or after operation. It is, therefore, advisable to investigate a possible obstruction before the operation at the operation room and in the late postoperative period.

Purpose: To identify patients suitable for outpatient cardiac catheterization strategy, based on social aspects, risks and complications, for a 24 hour period., Methods: In a series of 2.126 cases submitted to cardiac catheterization at the Instituto Dante Pazzanese de Cardiologia, between September 1990 and June 1991, were excluded: a) those over 75 years of age; b) the acute ischemic syndromes; c) those in NYHA functional class IV; d) patients who used 7 or 8 French femoral angiographic catheters; e) patients who had undergone general anesthesia, electrophysiological study or endomyocardial biopsy. After the procedure, the patients were observed for a 3 hour period and in the absence of any complication, they were discharged from the hospital, returning the next day for clinical evaluation. If any complication occurred it was registered., Results: In a cohort of 719 eligible patients, 68% were male, with a mean age of 55.3 years. Sixty one per cent were in NYHA functional class I and most of them (80.8%) were studied by the brachial approach. Eighty-three per cent of the patients were submitted to coronary angiography, with 52% of them having coronary artery disease. Four hundred and fourteen patients were not discharged on the same day: 217 did not have their procedures finish after 6 p.m., 111 for social-economical reasons, 23 because of their physician's refuse, 8 because of left main coronary disease, 55 because of any kind of complication. All the 305 patients who were discharged on the same day, did not have shown any complication in the next day evaluation., Conclusion: Outpatient cardiac catheterization is a safe technique in selected patients, making possible the accomplishment of a greater number of procedures improving bed utilization and decreasing hospital costs.

Since the first pulmonary valvuloplasty report, the procedure has been used frequently, becoming the best option in isolated valvar pulmonary stenosis. Pulmonary valvuloplasty in adults with calcified valvar pulmonary stenosis, however, has been minimal. We have reported the case of a 62-year-old female patient, with calcified valvar pulmonary stenosis, who underwent valvuloplasty with balloon catheter and showed a decrease in the transvalvular systolic gradient, thus proving the success of post procedure.

Purpose: To study the immediate clinical, echocardiographic and hemodynamic results of 200 patients who underwent percutaneous mitral balloon valvotomy (PMV) with double balloon technique., Methods: Two hundred patients were submitted to PVM for treatment of congestive heart failure secondary to severe mitral stenosis, between August 1987 to July 1991. Their mean age was 35.2 years, and 86.5% were female patients: 81% of them was in functional class, New York Heart Association (NYHA) III or IV; 4% was in atrial fibrilation and 4% had previous surgical commissurotomy., Results: PMV was successfully performed in 89% of the patients. The mitral valve area, by pressure half time method, increased from 0.91 +/- 0.27 to 2.10 +/- 0.47 cm2, p < 0.001; the mean mitral gradient decreased from 20.86 +/- 6.16 to 4.26 +/- 3.13 mmHg, p < 0.001; the left atrium and mean pulmonary artery pressure decreased from 22.3 +/- 7.1 to 11.9 +/- 8.3 and 36.47 +/- 12.93 to 24.56 +/- 9.98 mmHg, p < 0.001, respectively. Complications related to transeptal technique occurred in 12 patients, which resulted in cardiac tamponade in 5 and death in 1. In 19 patients the punction of the atrial septum could not be performed. Mitral regurgitation (MR) immediately after PMV appeared 1+ or more grade in 50 patients, increased in 8 patients and remained unchanged in 11 patients. Ten patients needed mitral valve replacement in the first 48h after PMV, for treatment of severe MR., Conclusions: PMV produces excellent immediate results and can be considered an alternative to surgery for the relief of mitral stenosis.

During pregnancy, medically refractory congestive heart failure due to mitral stenosis continues to present a clinical challenge and optimal management remains controversial. Thirteen women underwent balloon mitral valvotomy for control of functional class III or IV congestive heart failure due to mitral stenosis during pregnancy. The mean gestational age at the time of valvotomy was 25 +/- 6 weeks. Percutaneous balloon mitral valvotomy was performed successfully in all patients. No maternal or fetal mortality occurred. The mean mitral valve area assessed by Doppler echocardiography increased from 0.9 +/- 0.3 cm2 before to 2.1 +/- 0.3 cm2 after valvotomy. The mean mitral valve gradient decreased from 20 +/- 7 to 4 +/- 2 mm Hg. This was associated with a decrease in the pulmonary artery systolic pressure from 62 +/- 24 to 32 +/- 14 mm Hg. Currently, 12 of the 13 patients have delivered at an average gestational age of 38 +/- 0.5 weeks. Symptoms of congestive heart failure improved in all women and all were in New York Heart Association functional class I at the time of delivery. One patient is still pregnant and symptom free. Eleven singlet pregnancies resulted in the birth of full-term, healthy infants (mean birth weight 3.2 kg). The woman carrying a twin pregnancy improved from New York Heart Association class IV to class I after balloon mitral valvotomy but delivered prematurely at 32 weeks. The premature twin infants weighed 1.0 and 1.5 kg and died from respiratory failure at 48 hours. Percutaneous balloon mitral valvotomy can be performed safely during pregnancy and is effective in relieving symptoms of severe congestive heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Purpose: To analyse the impact of the new cardiac catheterization techniques on the complication profile of these procedures., Patients and Methods: One thousand consecutive patients who underwent cardiac catheterization from August through December, 1989 (739 diagnostic and 201 therapeutic procedures), who were followed up until hospital discharge. Complications were classified accordingly to their type and severity, and were related to the procedure employed and to the left ventricular ejection fraction., Results: There were no complications in 77.7% of the population studied. In the remaining 236 patients the incidence of mild, moderate and severe complications were, respectively: 11.2%, 7.3% and 3.8%. Severe vascular complications occurred in 0.5%, cardiac perforation requiring emergency surgical repair in 0.1%, severe arrhythmias in 1.4%, acute myocardial infarction in 0.4%, acute pulmonary edema in 0.3% and fatal events in 0.5% patients., Conclusion: Despite the increasing application of interventional techniques and the greater number of acutely ill patients referred to cardiac catheterization, these procedures have proved to be safe with a low complication rate.

We report our experience in 37 patients with aortic coarctation who underwent balloon aortoplasty. Of the 37, the lesion was native in 34 cases. Clinical re-evaluation was possible in 22 patients, with a mean follow-up period of 13 months and, of these, 21 patients were asymptomatic. Haemodynamic and angiographic studies were performed in 13 patients, with a mean period of follow-up of 12 months, showing excellent results in 11 patients. Aneurysmal formation had occurred in one and recoarctation in the other patient. Our experience has proved that balloon aortoplasty is an effective method for treating patients with aortic coarctation. Adequate selection in terms of the morphology of the coarctation and the size of the balloon catheter are crucial factors in the success of the procedure.

One-hundred patients with pulmonary valve stenosis underwent pulmonary valvoplasty, their ages ranging from 1 to 59 years. The systolic gradient across the valve ranged from 47 to 260 mm Hg (97.67 +/- 41.15) prior to the valvoplasty, and from 0 to 55 mm Hg (14.72 +/- 11.40) immediately after dilatation (P less than 0.0001). The clinical follow-up of 18.2 months of 56 patients showed a tendency for the systolic thrill to disappear, the systolic murmur became softer and there was a tendency to normalization of the electrocardiogram. A hemodynamic restudy was carried out in 54 patients and the systolic gradients across the valve ranged from 21.55 +/- 23.86. Seven patients required redilatation. In patients with hypertrophy of the infundibulum prior to valvoplasty this was observed to regress, indicating that infundibular hypertrophy is reversible.