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In 2002 the first transcatheter aortic valve implantation (TAVI) was performed in Europe. Since this time, TAVI has become increasingly utilised both across Europe and worldwide. With the early trials now reporting encouraging mid- to late-term results, TAVI has become a cost-effective alternative in high-risk patients not amenable to open surgery. Indeed, these indications look likely to become further expanded into a wider range of patient groups as we gain further technical familiarity alongside the development of novel generations of valve and advances in transcatheter technology. This chapter discusses the evolution of TAVI in Europe, summarising the route leading up to its incorporation into routine clinical practice and the potential for future development.

Since the description by Lababidi in 1983 of balloon aortic valvuloplasty, it has been used extensively by several groups of workers for relief of valvar aortic stenosis of moderate to severe degree. The indications for the procedure are peak-to-peak gradients ≥ 50 mmHg with symptoms or ECG changes or a gradient of ≥ 70 mmHg irrespective of the symptoms and ECG changes. One or more balloon catheters are placed across the aortic valve, over an extra-stiff guidewire and balloon inflated, producing aortic valvuloplasty. The recommended balloon: annulus ratio is 0.8:1.0. Immediate reduction of peak-to-peak gradient along with a fall of left ventricular peak systolic and end-diastolic pressures occurs. Rarely, significant aortic insufficiency, particularly in the neonate, may develop. At intermediate-term follow-up, catheter-measured peak-to-peak gradients and Doppler-measured peak instantaneous gradients remain low for the group as a whole. However, nearly one-quarter of the patients may develop restenosis, defined as peak-to-peak gradient ≥ 50 mmHg. The restenosis is successfully treated with surgical or repeat balloon valvotomy. Predictors of restenosis were age ≤ 3 years and an immediate postvalvuloplasty aortic valve gradient ≥ 30 mmHg. Comparison with surgical results is difficult, but overall, the balloon therapy appears to carry less morbidity. Long-term follow-up data are scanty. The limited data suggest low Doppler peak instantaneous gradients, minimal additional restenosis beyond what was observed at intermediate-term follow-up, and progression of aortic insufficiency in nearly one-quarter of patients. Event-free rates are 76% and 60%, respectively, at 5 and 10 years following initial balloon valvuloplasty. Based on immediate and intermediate-term follow-up data, balloon aortic valvuloplasty appears to produce reasonably good results, avoiding/postponing the need for surgical intervention. The late follow-up data are of some concern in that significant aortic insufficiency with left ventricular dilatation may develop, and some require surgical intervention. Prospective studies on larger groups of children and careful comparison with long-term follow-up surgical data may be necessary to make a definitive recommendation that balloon aortic valvuloplasty is the therapeutic procedure of choice.

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

Antibiotic prophylaxis in congenital cardiac disease has long been a topic of debate. Although there is little dispute around antibiotic cover for surgical procedures and catheter interventions where foreign material is being inserted, there are little data specific to non-device-placement procedures such as atrial septostomy or balloon valvotomy. We sought to assess the effect of routine prophylaxis on post-interventional infections via a retrospective pseudo-randomised analysis, and an online survey on paediatric interventional cardiologists in the United Kingdom and United States.

ObjectiveThere are conflicting data on choosing balloon aortic valvoplasty (BAV) or surgical aortic valvotomy (SAV) in neonates and infants requiring intervention for aortic valve stenosis. We aim to report the outcome of both techniques based on results from the UK national registry.MethodsThis is a retrospective study, including all patients under 1 year undergoing BAV/SAV between 2000 and 2012. A modulated renewal approach was used to examine the effect of reinterventions on outcomes.ResultsA total of 647 patients (488 BAV, 159 SAV, 292 neonates) undergoing 888 aortic valve procedures were included, with a median age of 40 days. Unadjusted survival at 10 years was 90.6% after initial BAV and 84.9% after initial SAV. Unadjusted aortic valve replacement (AVR) rate at 10 years was 78% after initial BAV and 80.3% after initial SAV. Initial BAV and SAV had comparable outcomes at 10 years when adjusted by covariates (p>0.4). AVR rates were higher after BAV and SAV reinterventions compared with initial valvoplasty without reinterventions (reference BAV, HR=3 and 3.8, respectively, pConclusionsIn a group of consecutive neonates and infants, BAV and SAV had comparable survival and freedom from reintervention as initial procedures and when performed as reinterventions. These findings support a treatment choice based on patient characteristics and centre expertise, and further research into the best patient profile for each choice.

Balloon valvotomy recommended for asymptomatic patients with domed pulmonary valve and peak instantaneous Doppler gradient >60 mmHg or mean Doppler gradient >40 mmHg (in association with less than moderate PV regurgitation)

Introduction: The optimal treatment for congenital aortic stenosis (AS) is debated despite decades of experience with both balloon aortic valvuloplasty (BAV) and surgical aortic valve repair (SAV). While BAV has been the mainstay of therapy for AS, recent single-center reports suggest optimal results following SAV. Hypothesis: We propose that reintervention rates following SAV and BAV are equivalent. Methods: We queried Medline, EMBASE and Web of Science for eligible studies using the keywords: “congenital aortic stenosis”, “balloon valvotomy”, “aortic valve stenosis surgery” and “treatment outcome or reintervention”. Studies were excluded when cohort size was Results: A total of 20 studies were included in our meta-analysis: SAV alone (n=3), BAV alone (n=12), and both (n=5). The mean age at BAV was 3.1 years (range, 4 days - 7 years) with a mean follow-up duration of 6.8 years, while mean age at SAV was 2.8 years (range, 14.2 days - 7.1 years) with a mean follow-up duration of 9.1 years. Mortality rates following BAV and SAV were 12.3% (95% CI: 7.7 - 19.1) and 10.2% (95% CI: 7.0 - 14.5), respectively (p=0.27). Reintervention following initial procedure for treatment of AS was higher following BAV (35.7% [95% CI: 29 - 43.1]) compared to SAV (25.2% [95% CI: 19.9 - 31.3])(p=0.012). Long-term and mid-term follow-up in these studies showed moderate to severe AR was present in 24.1% and 28.1% of BAV and SAV patients, respectively. Conclusions: Notwithstanding publication bias, both survival rates and development of late AR following BAV and SAV are similar. However, reintervention rates are significantly higher following BAV compared to SAV.

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

AIMS: Left atrial (LA) stretch-associated electrophysiological changes in patients with mitral stenosis (MS) predispose to atrial fibrillation. We hypothesized that the normalization of the pressure gradient by percutaneous transvenous mitral balloon valvotomy (PTMV) affects LA but not right atrial (RA) conduction, depending on the site of stimulation. Because direction-dependent (asymmetric) changes of conduction may contribute to arrhythmogenesis, we assessed conduction symmetry in MS patients and tested whether it is restored by PTMV. METHODS AND RESULTS: In nine patients with MS, atrial effective refractory period and local activation times (ATs) were determined during stimulation before and after PTMV, with up to four decapolar catheters (LA and RA). Eight patients with ventricular pre-excitation served as controls. ATs at basic cycle length were similar before and after PTMV. With stimulation from either atrium, they were about 45 ms in the ipsilateral atrium and about 115 ms in the contralateral atrium. With premature stimulation, ATs increased dramatically. The shortest ATs were found in the RA with RA stimulation (78 +/- 9 and 80 +/- 6 ns, before and after PTMV). PTMV caused a shortening in LA-ATs (following LA stimulation) from 118 +/- 14 to 82 +/- 5 ms (before and after; P

Background: Dyspnea is a common symptom in a patient with valvular heart disease. The mechanism underlying this is still uncertain.Methods: We prospectively studied 20 patients with rheumatic mitral valve stenosis who were candidates for percutaneous balloon mitral valvotomy. Assessment of airway hyper-reactivity by histamine challenge test was done on all patients at baseline and at 1 week after the procedure. The provocative concentration of histamine solution required producing a 20% fall in forced expiratory volume in 1 second (FEV1) (PC20) was recorded as a measure of airway hyper-reactivity. The severity of dyspnea in study subjects was also studied by the 6-minute-walk test and visual analog scale.Results: After balloon valvotomy, a significant improvement was seen in the six minute walking distance (219±30.15 to 237.55±32.25; p < 0.001), visual analog scale as a measure of dyspnea (60.95±12.16 to 44.4±13.71; p < 0.001) and airway hyper-reactivity (PC20; 5.69±6.01 mg/ml to 10.16±7.93; p < 0.001).Conclusions: Improvement in dyspnea in mitral stenosis after balloon valvotomy is associated with significant improvement in airway hyper-reactivity.

Pulmonic stenosis is a right sided valvular lesion that is usually asymptomatic. It is often a congenital lesion and is associated with Noonan Syndrome, Leopard Syndrome, and Tetralogy of Fallot. On auscultation, the patient may present with a systolic murmur loudest at the left sternal border. The murmur is louder upon standing and with inspiration. An ejection click may be present. Patients rarely require treatment unless severe. If severe, treatment options include balloon valvotomy and cardiac catheterization with dilation.

Percutaneous endovascular therapy has now become a reality. From early balloon valvotomy for valvular stenosis, technologies have been developed that allow percutaneous replacement of pulmonic and aortic valves and repair of regurgitant mitral valves in selected patients. Following extensive investigations in animals, early clinical reports have shown successes in selected patients. As criteria for patient selection and clinical safety and efficacy trials progress, the role of these new technologies in patient care strategy will become better understood.

Background— Pulmonary atresia with intact ventricular septum (PA-IVS) is a rare congenital lesion with high mortality. Therapy was exclusively surgical until recently, when the use of radiofrequency-assisted perforation of the atretic valve was introduced as a treatment option. This study analyzes the outcomes and morphological changes to right heart structures after percutaneous perforation and balloon dilation of the atretic valve. Methods and Results— Between April 1992 and August 2000, 30 patients with PA-IVS underwent attempted percutaneous valve perforation and balloon dilation of the pulmonary valve. Longitudinal echocardiographic measurements of the tricuspid valve diameter, right ventricular length and area were recorded. Z scores were calculated according to published formulas. Perforation was achieved in 27 patients. In 14 patients a modified Blalock-Taussig shunt was performed between 2 and 24 days after valve dilation. There were 3 early and 2 late deaths. Among the survivors (follow-up time of 1 to 87 months), 16 patients had a biventricular circulation, 3 a 1 ½-ventricle circulation, and 1 a Fontan operation. Four patients are awaiting further palliation. There was no significant change of the tricuspid valve Z score or right ventricular length Z score with time. Conclusions— Percutaneous balloon valvotomy is an effective treatment strategy for patients with PA-IVS provided that there is a patent infundibulum and a lack of a right ventricle–dependent coronary circulation. Despite the observation that right heart growth does not increase with body growth in early follow-up, it appears adequate to maintain a biventricular circulation in many patients.

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

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

The Ross-Konno procedure is an excellent technique for the treatment of complex multilevel left ventricular outflow tract obstruction with severe annular hypoplasia and a dysplastic aortic valve. The operation can be performed earlier in life, thus avoiding repeated surgical reinterventions, which may provide only short-term palliation and potentially exacerbate ventricular function. The Ross-Konno procedure increases our therapeutic choices for neonates or infants with critical aortic stenosis, who show unacceptable results following open valvotomy or balloon valvotomy. The pulmonary autograft demonstrates durability without the likelihood of developing aortic stenosis or progressive dilatation and a low incidence of developing aortic insufficiency. Despite the technically demanding nature of the operation, the Ross-Konno procedure is the method of choice for the multilevel type of left ventricle outflow tract obstruction, especially in newborns and infants.

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

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

A 32-year-old woman was diagnosed at the age of 8 years with a third degree atrioventricular block for which a DDD pacemaker was implanted. She now presented with exertional fatigue and dyspnoea because of a pacemaker lead-induced isolated tricuspid valve stenosis (mean gradient was 4 mm Hg at rest and 19 mm Hg during exercise, measured valve area using planimetry was 1.2 cm2) (Figure 1A). She was successfully treated with balloon valvotomy of the tricuspid valve using a 30 mm Inoue balloon (Toray industries Inc.) (Figure 1B) after which the tricuspid valve area augmented from 1.2 to 2.4 cm2 (mean resting transvalvular gradient of 2 mm Hg at rest and 6 mm Hg during exercise) with only a mild tricuspid regurgitation (Figure 1C). The patient mentioned a dramatic symptomatic improvement during the weeks after the procedure. The most probable pathophysiological mechanism of this pacemaker lead-induced tricuspid stenosis is repeated whiplash injury by the lead leading to severe scarring of the valve with subsequent stenosis. To our knowledge, this is only the third case described of successful percutaneous balloon valvotomy for pacemaker lead-induced tricuspid stenosis.1 ,2 Most reported cases are treated surgically or conservatively.

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

Background. Pulmonary valve (PV) balloon valvotomy (BV) is considered the treatment of choice for isolated pulmonary valve stenosis (IPVS). While immediate and long-term results of PVBV are usually excellent, the reported results in dysplastic valves are variable. High-pressure (HP) PVBV in dysplastic valves that fail low-pressure (LP) PVBV may increase success rate, reducing the need for surgical interventions. Methods. We reviewed all cases of IPVS in patients

Aim The significance of passive stretching of the mitral valve as a contributor to valve opening, after percutaneous transvenous mitral commissurotomy (PTMC), is not known. Our objective was to determine whether any acute reduction in valve area occurs due to recoil of stretched valve structures. Methods and Results In a prospective observational study, we evaluated nine patients (age 30.1±8.0 years; median valve score 7) who underwent PTMC. We calculated mitral valve area (MVA) before, immediately after, and at 10 and 30 min after valvotomy. There was no acute reduction in MVA after successful PTMC. But there was a significant increase in MVA at 30 min, from that measured immediately after the procedure (1.8±0.4 to 2.0±0.4 cm 2 ; P =.048). This was attributable to the continuing fall in pulmonary artery wedge (PAW) pressures (17±3 to 15±3 mmHg; P =.003) and transmitral gradients (8±3 to 7±2 mmHg; P =.037). Conclusion Passive stretching of the valve apparatus does not play an important role in valve opening after PTMC in young patients with favorable valve morphology.

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

Aims Pulmonary atresia with intact ventricular septum (PA–IVS) is a complex congenital heart malformation with multitude therapeutic approaches. Recently, balloon valvotomy has been used as an alternative to primary surgery. This study aimed to identify echocardiographic markers of balloon dilation success in PA–IVS. Methods and results The echocardiograms of 26 patients diagnosed with PA–IVS who underwent primary pulmonary balloon valvotomy were reviewed. Tricuspid annulus Z -score, pulmonary annulus Z -score, right ventricular (RV) to left ventricular (LV) length ratio, RV to LV transverse diameter ratio, and tricuspid valve (TV) to mitral valve (MV) annulus diameter ratio were measured. The tricuspid Z -score, pulmonary Z -score, RV/LV length ratio, RV/LV diameter ratio, and the TV/MV ratio were significantly different in the group which had successful balloon dilation compared with that failed. Based on decision trees using the Weka classifier package, only RV/LV diameter ratio >0.76 predicts a 92.3% success rate. In contrast, an RV/LV diameter ratio ≤0.76 associated with RV/LV length ratio ≤0.70 predicts 100% failure. Conclusion Successful balloon dilation in membranous type PA–IVS can be predicted by a scoring system using RV/LV diameter ratio and RV/LV length ratio.

BACKGROUND Dyspnea is a common symptom in a patient with valvular heart disease. The mechanism underlying this disease is still uncertain. Respiratory muscle weakness has been proposed to be one of the mechanisms underlying dyspnea in heart failure, but this has not been adequately studied in valvular heart disease. METHODS We prospectively studied 20 patients with rheumatic mitral valve stenosis who were candidates for percutaneous balloon mitral valvotomy. Respiratory muscle strength assessment by maximal static inspiratory mouth pressure and maximal static expiratory mouth pressure was done on all patients at baseline and at 1 week after the procedure. The severity of dyspnea in study participants was also studied by the 6-min walk test and visual analog scale. RESULTS Balloon valvotomy was followed by a significant improvement in the 6-min walking distance (from 219 +/- 30.15 to 237.55 +/- 32.25 m, P < 0.001), visual analog scale as a measure of dyspnea (from 60.95 +/- 12.16 to 44.4 +/- 13.71 mm, P < 0.001), inspiratory muscle strength (from 51.9 +/- 10.28 to 56.55 +/- 11.87 cmH2O, P < 0.001) and expiratory muscle strength (from 62.15 +/- 19.68 to 67.20 +/- 21.91 cmH2O, P < 0.001). CONCLUSION Improvement in dyspnea in mitral stenosis after balloon valvotomy is associated with significant improvement in respiratory muscle strength.

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

Percutaneous mitral balloon valvotomy (PMV) has evolved into an effective method for the treatment of patients with symptomatic mitral stenosis. An increase in mitral regurgitation can occur in ≈45% of patients undergoing PMV. Severe mitral regurgitation can be caused by rupture of chordae or of a papillary muscle. Noncommissural tearing of the mitral leaflet is also an important mechanism of severe regurgitation after PMV. A 35-year-old woman presented with exertional dyspnea that had been present for 3 months. Physical examination revealed a chronically …

AIMS Transesophageal Doppler echocardiography (TEE) is a useful tool to investigate pulmonary venous flow (PVF) velocity, which is altered in patients with mitral stenosis (MS). This study used TEE to analyze the variations in the PVF pattern after successful valvar dilatation in MS patients. METHODS/RESULTS A total of 15 MS patients, mean age 27.2 years, underwent effective percutaneous balloon valvotomy (PBV). All were submitted to TEE before and after PBV. TEE assessed systolic (SPFV) and diastolic (DPFV) peak flow velocities and their ratio (SPFV/DPFV), time-velocity integrals (STVI and DTVI) and their ratio, and diastolic flow deceleration (DFD). Valvotomy yielded statistically significant increases (P < or = 0.05) in the SPFV: increase on average by 67% and STVI by 120%, as well as in the diastolic component: increased on average by 35%, DTVI by 33%, and DFD by 75%. CONCLUSION TEE demonstrated that PBV induced a global increase in velocities of PVF, probably related to improvement of left atrial emptying.

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

La estenosis pulmonar valvular crítica en lactantes es una emergencia. El objetivo de este estudio es conocer nuestra casuística en dos centros ( Costa Rica y Guatemala). Método: se revisaron los expedientes de 24 lactantes menores de 4 meses, 12 de ellos menores de un mes, que se presentaron con estenosis pulmonar valvular crítica y que fueron sometidos a valvuloplastía. La edad varió de un día a tres meses y el peso de 2100 a 6000 gramos. La presiones ventriculares derechas variaron de 70 a 217 mmHg antes de la dilatación y de 20 a 90 mmHg postdilatación. El gradiente transvalvular varió de 35-203 mmHg pre dilatación y de 12 a 90 mmHg post dilatación. Hubo dos perforaciones cardíacas y una terminó en sala de operaciones. CONCLUSION: La valvuloplastía pulmonar es un procedimiento sencillo, barato para nuestro medio y con resultados muy alentadores hoy día. Critically pulmonary valve stenosis in infants is an emergency. The objective of this study is to know our cases in two centers ( Costa Rica and Guatemala). Methods: we review the records of 24 infants less than four months of age, twelve of them less than one month of age and all with critically pulmonary stenosis that suffered balloon valvotomy. The range of age was from one day to three months and the weight range was 2100-6000 grams. The right ventricle pressures range from 70-217 mmHg before dilatation and decrease to 20-90 mmHg after dilatation. The transpulmonary gradient range from 35-203 mmHg and decrease to 12-90 mmHg. Perforation of the right ventricular outflow tract occur in two cases and one was brought to operation room for exploration.One patient shows complete right bundle branch block for a short period of time. Conclusion: the pulmonary valvuloplasty is a simple procedure, cheap for our area and with good results today.