Mitha As

Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: A prospective hemodynamic study

Closed surgical mitral valvotomy is the procedure of choice in most patients with symptomatic pliable mitral stenosis in developing countries. The procedure is efficacious and safe. Mitral valvotomy performed with a balloon has shown similar good results, with infrequent complications in selected subjects. Because there is a paucity of studies comparing the two techniques, this study was undertaken to compare the results of percutaneous balloon mitral valvuloplasty with those of closed commissurotomy as determined by catheterization studies. Forty-five patients with tight pliable mitral stenosis were randomly assigned to one of two groups: 23 patients had balloon valvuloplasty by the single catheter technique (group I) and 22 underwent closed surgical valvotomy (group II). The two groups were similar with regard to clinical and hemodynamic findings before intervention. Mitral valve area increased from 0.8 +/- 0.3 to 2.1 +/- 0.7 cm2 in group I (p less than 0.001) and from 0.7 +/- 0.2 to 1.3 +/- 0.3 cm2 in group II (p less than 0.001). Pulmonary artery pressure and pulmonary vascular resistance decreased in both groups, but these changes did not reach statistical significance in group II. Treadmill exercise time increased from 3.8 +/- 2.3 to 7.3 +/- 2.6 min in group I (p less than 0.001) and from 4 +/- 2.6 to 5.6 +/- 2.6 min in group II (p less than 0.001). There were no deaths. One patient in each group developed moderate (3+) mitral regurgitation. A small interatrial shunt (less than 1.5:1) was detected in three patients in group I immediately after the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe calcification of glutaraldehyde-preserved porcine xenografts in children

Despite the widespread use of glutaraldehyde-preserved porcine xenografts, severe short-term calcification of these valves has been infrequently reported. This report describes four cases of glutaraldehyde-preserved porcine xenografts in the mitral valve position in which severe calcification occurred within 17 to 25 months of implantation. All four patients were children, aged 13 to 15 years. The clinical presentation in all four cases occurred at a late stage when there was severe xenograft obstruction, with acute symptoms of cardiac decompensation in the presence of pulmonary hypertension and right heart failure. There was rapid cardiac deterioration resulting in a low output state and episodic pulmonary edema necessitating urgent mitral valve replacement. In only one case was there clear auscultatory evidence of severe mitral stenosis. Calcification of these xenografts occurred in the presence of normal serum calcium levels and was not related to infective endocarditis. Histologic examination of the calcified xenografts strongly suggested dystrophic calcification resulting from primary collagen degeneration. The exact cause is unclear, but it appears that glutaraldehyde-preserved porcine xenografts may produce severe short-term calcification with acute hemodynamic deterioration necessitating urgent valve replacement and that this accelerated calcification may be a complication in young persons,

Immediate Haemodynamic Effects of Verapamil in Man

The effect of the antiarrhythmic drug verapamil (Isoptin) on circulatory dynamics and myocardial contractility was studied in six patients in sinus rhythm: three patients were control subjects and three had underlying rheumatic valvular disease. The drug was given as an intravenous bolus (10 mg) and measurements made in the control state and repeated 1, 3, 5 and 10 min after administration of verapamil. Left ventricular (LV) systolic pressure fell by 18% 1 min after intravenous verapamil (p less than 0.01) and returned twoards the range of normal after 10 min. Heart rate increased and cardiac and stroke index were not altered 5 and 10 min after administration of the drug. Peak LVdp/dt and Vmax were reduced while LV end-diastolic pressure increased reflecting a decrease in LV contractility. The hemodynamic effects were similar in digitalised and nondigitalised patients.

The ECG of constrictive pericarditis—Pattern resembling right ventricular hypertrophy

The ECG changes in 122 cases of constrictive pericarditis have been reviewed. Ninety-five per cent of tracings were typical and showed a normal QRS axis, low voltage, and generalized T wave flattening or inversion. The remaining six tracings showed evidence of right ventricular hypertrophy and half of these showed right axis deviation in addition. In only one could these findings be readily accounted for by the presence of severe fibrotic annular subpulmonic constriction; the remainder are unexplained and it is postulated that cardiac rotation and distrotion is causative since none of the other mechanisms of right axis deviation or right ventricular hypertrophy were operative.

Percutaneous balloon dilatation of the mitral valve in critically ill young patients with intractable heart failure.

OBJECTIVE--To assess the outcome of percutaneous balloon dilatation of the mitral valve in critically ill young patients with intractable heart failure. DESIGN--Retrospective analysis of all such patients presenting over a period of 4 years. PATIENTS--Of 432 consecutive patients undergoing percutaneous balloon dilatation of the mitral valve, 12 (mean age 29 years) with intractable heart failure were identified. Nine had severe pulmonary oedema and three had pulmonary oedema with severe right heart failure and hypotension. Three patients were pregnant and three required mechanical; ventilatory support. PROCEDURE--Percutaneous balloon dilatation of the mitral valve was performed using the Inoue balloon technique. The procedure was shortened by excluding full right study, cardiac output measurement, and left ventriculography. The mitral valve morphology and mitral valve area were determined before and after percutaneous balloon dilatation using cross sectional Doppler echocardiography. RESULTS--The procedure was technically successful in all patients. The mean (SD) echocardiographic value of the mitral valve area increased from 0.7 (0.1) to 1.4 (0.2) cm2 with a concomitant reduction in pulmonary artery systolic pressure (Doppler) from 81 (17) to 50 (7) mm Hg. There was a significant clinical improvement in all patients. The mean (range) fluoroscopy time for the procedure was 6.9 (1.7-14.1) min. During follow up (mean 10 months) nine patients were in New York Heart Association (NYHA) functional class I, one was in class II, one under NYHA elective mitral valve replacement, and one, who refused elective surgery, died suddenly at home. CONCLUSION--Percutaneous balloon dilatation of the mitral valve can be performed as a life saving procedure in critically ill patients with mitral stenosis, as even a modest increase in valve area in these patients produces gratifying clinical improvement.

Intravenous fenoldopam infusion in severe heart failure

SummaryFenoldopam, a selective DA1-receptor agonist, infused intravenously for 24 hours (0.6 ± 0.3 µg/kg/min, range 0.1–1.5) in 25 patients with NYHA functional class III or IV heart failure, produced a prompt and sustained hemodynamic response. Cardiac index rose from an average preinfusion baseline value of 1.8 to 2.6/l min. Stroke volume index increased from 19 to 26 ml/m2 and stroke work index increased from 18 to 25 g M/m2. These changes were accompanied by a reduction in systemic vascular resistance from an average of 2400 to 1500 dynes sec/cm.5 There was no change in the heart rate or right atrial pressure. There was a transient reduction in the left ventricular filling pressure from 25 to 20 mmHg. Urinary sodium excretion did not change significantly. Transient asymptomatic thrombocytopenia developed in four patients. The drug was well tolerated by all patients. These results suggest that continuous intravenous infusion of fenoldopam is safe and produces favorable hemodynamic responses in severe heart failure. However, unlike its effects in patients with hypertension, it failed to produce sustained natriuresis in these patients.

Haemolysis related to mitral valve replacement with the Beall valve prosthesis

Henderson, B. J., Mitha, A. S., le Roux, B. T., and Gotsman, M. S. (1973).Thorax, 28, 488-491. Haemolysis related to mitral valve replacement with the Beall valve prothesis. Experience of valve replacement with the Beall compressed Teflon disc valve in 59 patients confirms that the incidence of clinically significant late red cell destruction is high. An apparently previously unrecorded high incidence of early haemolysis, so severe in one patient as to be directly the cause of death, is reported. In 29 patients there was massive haemolysis in early convalescence, not recognized in urine from some hours after the end of bypass and never encountered with other designs of prosthetic valve or homograft valve.

Balloon dilatation of the mitral valve by a single bifoil (2 x 19 mm) or trefoil (3 x 15 mm) catheter.

The efficacy of balloon dilatation of the mitral valve by a bifoil (2 x 19 mm) or trefoil (3 x 15 mm) catheter (single catheter technique) was assessed in 53 patients (mean age 28) with mitral stenosis, most of whom were women. The procedure was unsuccessful in three patients. After balloon dilatation the left atrial pressure decreased from 22 mm Hg to 13 mm Hg and the mitral valve gradient from 12 mm Hg to 4 mm Hg. The mitral valve area increased from 0.7 cm2 to 2.1 cm2. Exercise time on the standard Bruce protocol increased from 3.9 minutes to 7.2 minutes. In 22 (44%) patients mitral regurgitation developed or the grade of regurgitation increased. Left to right shunts with pulmonary to systemic flow ratios greater than 1:5 were detected in four patients. Transient cerebrovascular episodes developed in two patients. One patient died after emergency valve replacement for severe mitral regurgitation. Balloon dilatation of the mitral valve by the single catheter technique with the bifoil or trefoil catheters is an effective treatment for patients with mitral stenosis. Mild mitral regurgitation is a frequent complication of the procedure.

Myocardial infarction in the black population of South Africa: Coronary arteriographic findings☆

Thirteen Black patients who had classic electrocardiographic evidence of myocardial infarction supported by changes in serum enzymes were investigated by coronary arteriography. Ten of these had occlusive atherosclerosis and in none of these did the associated risk factors such as hypertension or diabetes appear to be operative, and most were manual laborers. Their mean serum cholesterol measurement was found to be 222 mg. per cent, a value which is found in 25 per cent of the urban Black population. In the remaining three patients, the coronary arteries were found to be angiographically normal and two of these were associated with the billowing mitral leaflet syndrome; it is postulated that their myocardial infarction was a result of coronary spasm, or a consequence of fibrin emboli emanating from the redundant mitral leaflets. Based on statistics from our major referring hospital, it is estimated that the prevalence rate from myocardial infarction among general admissions to a medical ward is less than 0.05 per cent, a figure lower than previously reported by clinico-electrocardiographic studies. It would appear that the prevalence of this disease has not increased over the last two decades and the immunity of the Black population is unexplained.

Problems Encountered during Insertion of Permanent Endocardial Pacing Electrode

Case reports of two potential problems arising during permanent endocardial pacemaker electrode insertion are described. They are cannulation of a persistent left‐sided superior vena cava, and unsuspected subclavian vein thrombosis. A left‐sided superior vena cava may be recognized clinically and avoided; but, if necessary, it can be employed as a route to the right ventricular endocardium. Subclavian vein thrombosis appears to be a complication of previous cephalic vein pacemaker insertion and prohibits further access on the implanted side. It may present with a painful, swollen arm or with the symptoms of multiple pulmonary emboli; occasionally it is not clinically suspected unless abnormal venous distension is sought.