Mohamed Eid Fawzy

One- to Ten-Year Follow-Up Results of Balloon Angioplasty of Native Coarctation of the Aorta in Adolescents and Adults

OBJECTIVES We attempted to evaluate the role of balloon angioplasty in the treatment of discrete coarctation of the aorta in adolescents and adults, with special emphasis on long-term results. BACKGROUND Controversy persists over the use of balloon dilation for the treatment of native coarctation of the aorta. METHODS Between July 1986 and January 1997, 43 consecutive adolescent and adult patients with discrete coarctation of the aorta underwent balloon angioplasty. One- to 10-year follow-up data of 37 patients, including results of cardiac catheterization and magnetic resonance imaging (MRI), form the basis of this study. RESULTS No early or late deaths occurred. Balloon angioplasty produced a reduction in the peak to peak coarctation gradient from a mean +/- SD of 69 +/- 24 mm Hg (95% confidence interval [CI] 61 to 76) to 12 +/- 8 mm Hg (95% CI 10 to 14.8) (p < 0.001). Follow-up catheterization 12 months later (37 patients) revealed a residual gradient of 6.7 +/- 6 mm Hg (95% CI 4.6 to 8.9); 3 (7%) of 43 patients had suboptimal results with development of recoarctation, defined as peak gradient >20 mm Hg, with successful repeat angioplasty. A small aneurysm developed at the site of dilation in 3 (7%) of the 43 patients. MRI follow-up data 1 to 10.8 years (mean 5.2 +/- 2.7) after angioplasty (37 patients) revealed no new aneurysm or appreciable change in the size of the preexisting aneurysm in the three patients. The blood pressure had normalized without medication in 27 (73%) of 37 patients at follow-up examination. CONCLUSIONS Balloon angioplasty is safe and effective and should be considered a viable alternative to operation for treatment of discrete coarctation of the aorta in adolescents and adults.

Immediate and long-term effect of mitral balloon valvotomy on severe pulmonary hypertension in patients with mitral stenosis

The pulmonary vascular hemodynamics were studied in 21 patients with severe mitral stenosis and severe pulmonary hypertension. Hemodynamic data were obtained before and immediately after mitral balloon valvotomy (MBV) and at follow-up 7 to 14 months (mean 12 months) later by repeat catheterization. The mean pulmonary capillary wedge pressure (PCW) decreased from 27 +/- 5 to 15 +/- 4 mm Hg (p < 0.001). The mean mitral valve gradient (MVG) decreased from 18 +/- 4 to 6 +/- 2 mm Hg (p < 0.001). Mitral valve area (MVA) increased from 0.6 +/- 0.1 to 1.5 +/- 0.3 cm2 (p < 0.02). Cardiac index increased from 2.2 +/- 0.3 to 2.6 to 0.5 L/min/m2 (p < 0.02). The pulmonary artery systolic pressure decreased from 65 +/- 13 to 50 +/- 13 mm Hg (p < 0.001), and no significant change was seen in pulmonary vascular resistance (PVR) immediately after MBV from 461 +/- 149 to 401 +/- 227 dynes/sec/cm(-5) (p = 0.02). At follow-up the MVA increased from 1.5 +/- 0.3 to 1.7 +/- 0.3 cm2 (p < 0.02). Cardiac index increased further to 3 +/- 0.4 L/min/m2 (p < 0.02). MVG and PCW pressure remained the same. The pulmonary artery systolic pressure decreased further to 38 +/- 9 mm Hg (p < 0.02). PVR decreased significantly to 212 +/- 99 dynes/sec/cm(-5) (p < 0.02). We concluded that the pulmonary artery pressure decreased without normalizing immediately after MBV and normalized in patients with optimal results from mitral balloon valvotomy 7 to 14 months later. Insignificant change in PVR was seen immediately after MBV and markedly decreased or normalized at late follow-up in patients with optimal result from MBV.

Balloon valvotomy for pregnant patients with severe pliable mitral stenosis using the Inoue technique with total abdominal and pelvic shielding

Balloon valvotomy by means of the Inoue technique was attempted in seven pregnant (5 to 9 months) patients with severe mitral stenosis; the mean age of the patients was 32 +/- 8 years, and all had a two-dimensional echocardiographic mitral valve score of < 8. Indications for Inoue balloon valvotomy included severe symptomatic mitral stenosis with a Doppler mitral valve area < or = 1 cm2 and heart failure refractory to medical therapy, or absolute contraindications for the use of beta-blockade; Inoue valvotomy was also indicated for patients who lived a long distance from the hospital. Inoue balloon valvotomy was performed with no angiography and total pelvic and abdominal shielding; the balloon catheter was introduced into the right atrium without the aid of fluoroscopy, which was used for the transseptal puncture. Stepwise two-dimensional echocardiographic Doppler mitral valve dilatation was done. After Inoue balloon valvotomy the mean Doppler mitral valve area increased from 0.8 +/- 0.1 to 2.0 +/- 0.3 cm2 (p < 0.01) and by two-dimensional echocardiography from 0.8 +/- 0.2 to 1.9 +/- 0.3 cm2 (p < 0.01), with no significant Doppler residual stenosis (defined as mitral valve area < or = 1.5 cm2). The mean total fluoroscopy time was 16 +/- 7 minutes. The degree of mitral regurgitation increased in two patients from grade 1+/4+ to grade 2+/4+ and from grade 0+/4+ to grade 2+/4+, respectively. There was no mortality or significant morbidity. Pregnancy was uneventful in all patients, and all were delivered of normal babies without complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-two years of follow-up results of balloon angioplasty for discreet native coarctation of the aorta in adolescents and adults

BACKGROUND AND AIMS Although the immediate and intermediate-term results of balloon angioplasty (BA) for patients with aortic coarctation (AC) have been encouraging, there is paucity of data on long-term follow-up results. This study evaluated the long-term (up to 22 years) follow-up results of BA in adolescent and adult patients with discrete (shelf-like) coarctation of the aorta. METHODS Follow-up data of 58 patients (mean age 24+/-9 years) undergoing BA for discrete AC at median interval of 13.4 years including cardiac catheterization, magnetic resonance imaging, and Doppler echocardiography form the basis of this study. RESULTS No early deaths occurred. Balloon angioplasty produced immediate reduction in peak AC gradient from 60+/-22 mm Hg to 8.5+/-8 mm Hg (P<.0001). Follow-up catheterization 12 months later revealed a residual gradient of 5+/-6.4 mm Hg (P=.01). Five patients (8%) with suboptimal initial outcome (peak gradient>20 mm Hg) developed restenosis, and 4 of these had successful repeat angioplasty. Aneurysm developed at the site of dilatation in 4 patients (7%). Magnetic resonance imaging follow-up results revealed no new aneurysm. In one patient, the aneurysm increased in size, but no recoarctation or appreciable changes in the Doppler gradient across the AC site was noted. The blood pressure had normalized without medical treatment in 29 (50%) of the 58 patients. CONCLUSION Long-term results of BA for discrete AC are excellent and should be considered as first option for treatment of this disease.

Percutaneous mitral valvotomy with the Inoue balloon catheter in children and adults: immediate results and early follow-up.

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon catheter was attempted in 60 consecutive patients with severe symptomatic mitral stenosis. There were 10 children (mean age 13 years) and 50 adults (mean age 31 years). Forty patients were females and 20 were males; 53 were in sinus rhythm. The procedure was technically successfully performed in 57 (95%) patients. There were no deaths or thromboembolic complications. Balloon valvotomy was done using a 22 to 30 mm diameter catheter with the echo/Doppler guided stepwise mitral dilatation technique. After PMV the mean left atrial pressure decreased from 23.0 +/- 5.0 to 14.0 +/- 4.0 mm Hg (p less than 0.001). The mean mitral valve gradient (MVG) decreased from 15.0 +/- 4.0 to 6.0 +/- 2.0 mm Hg (p less than 0.001). The mitral valve area (Gorlin formula) increased from 0.7 +/- 0.2 to 1.6 +/- 0.4 cm2 (p less than 0.001). The mitral valve area as determined by echocardiography increased from 0.8 +/- 0.1 to 1.9 +/- 0.3 cm2 (p less than 0.001). Mild mitral regurgitation (MR) developed in six patients (11%) and increased by one grade in another five patients (9%). No patient developed severe mitral regurgitation. Mitral valve area at mean follow-up of 4.8 months remained unchanged at 1.9 +/- 0.3 cm2. We conclude that PMV, using the Inoue balloon catheter, is safe and effective in the treatment of severe mitral stenosis in children and adults, without inducing significant mitral regurgitation.

Long-term effects of balloon angioplasty on left ventricular hypertrophy in adolescent and adult patients with native coarctation of the aorta. Up to 18 years follow-up results.

Little is known regarding the long‐term follow‐up results of balloon angioplasty (BA) for patients with native aortic coarctation (AC) on left ventricular hypertrophy (LVH) regression.

Percutaneous mitral balloon valvotomy

Percutaneous mitral balloon valvotomy (PMBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, PMBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of PMBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0–0.5%), cerebral accident (0.5–1%), mitral regurgitation (MR) requiring surgery (1.6–3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with PMBV and surgical commissurotomy. Restenosis after PMBV ranges from 4 to 70% depending on the patient selection, valve morphology, and duration of follow up. Restenosis was encountered in 21% of the authors series at mean follow‐up 6 ± 4.5 years and the 10 and 15 years restenosis‐free survival rates were (70 ± 3)% and (44 ± 5)%, respectively, and were significantly higher for patients with favorable mitral morphology (85 ± 3% and 65 ± 6%), respectively (P < 0.0001). The 10 and 15 years event‐free survival rates were (79 ± 2)% and (43 ± 9)% and were significantly higher for patients with favorable mitral morphology (88 ± 2)% and (66 ± 6)%, respectively (P < 0.0001). The effect of PMBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of PMBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.

Magnetic resonance imaging compared with angiography in the evaluation of intermediate-term result of coarctation balloon angioplasty

Between July 1986 and December 1990, 24 consecutive adult patients with native coarctation of the aorta underwent balloon dilatation. Their ages ranged from 15 to 55 (mean 25) years. Dissection of the aorta developed in one patient. The remaining 23 patients were restudied by catheterization and magnetic resonance imaging (MRI) 8 to 60 (mean 21) months after dilatation. Both studies were performed between 1 and 180 (mean 40) days of each other. The diameter of the aorta at the site of previous coarctation was measured on angiogram and MRI by two independent observers. The data were compared by means of linear regression analysis. The gradient across the previous coarctation site ranged from 0 to 20 (mean 7 +/- 7.3) mm Hg. The diameter of the aorta at the site of previous coarctation measured on angiogram was 13.7 +/- 3.7 mm and on MRI it measured 13.5 +/- 3.7 mm, with excellent correlation (r = 0.96, SEE = 0.92, p < 0.001). Two patients had small aneurysms 2 cm in diameter demonstrated by angiography and MRI, and two patients developed restenosis, diagnosed correctly by both cardiac catheterization and MRI. This study demonstrates that MRI provides excellent visualization of the anatomy of the aorta and is a good noninvasive method for follow-up of patients undergoing balloon coarctation angioplasty.

The impact of mitral valve morphology on the long-term outcome of mitral balloon valvuloplasty.

Background: The effect of mitral valve morphology (MVM) on the long‐term results of mitral balloon valvuloplasty (MBV) is not well established. The aim of the study was to evaluate the impact of MVM on long‐term outcome of MBV. Methods : Five hundred and eighteen consecutive patients (mean age, 31 ± 11 years) who underwent successful MBV were followed up for 0.5–16.5 (mean, 6 ± 4.5) years. Patients were divided into two groups according to their mitral echo score (MES) before MBV: group A (n = 340; MES ≤ 8) and group B (n = 178; MES > 8). Results: We report the immediate and long‐term clinical and echocardiographic results of the above‐mentioned 518 consecutive patients. The mitral valve area was significantly larger in group A than in group B, both immediately after MBV (2.0 ± 0.3 vs. 1.82 ± 0.3 cm2, respectively; P < 0.0001) and also at the last follow‐up (1.8 ± 0.33 vs. 1.5 ± 0.33 cm2, respectively; P < 0.0001). Restenosis occurred in 38/340 (11%) in group A vs. 73/178 (41%) in group B (P < 0.0001). Actuarial freedom from restenosis at 5, 10, 15 years were 92 ± 2%, 85 ± 3%, 65 ± 6% for group A vs. 72 ± 4%, 44 ± 5%, 9 ± 6% for group B (P < 0.001). Event‐free survival rates at 5, 10, 15 years for group A were 93 ± 1%, 88 ± 2%, 66 ± 6% vs. 82 ± 3%, 59± 6%, 8 ± 7% for group B (P < 0.0001). Stepwise Cox multivariate regression analysis identified MES, preprocedure functional class, and postprocedure mitral valve area ≤ 1.8 cm2, as predictors of restenosis (P < 0.0001, P = 0.014, P = 0.0015, respectively); MES and age as predictors of event‐free survival (P < 0.0001, P < 0.0001, respectively). Conclusion: MBV has excellent long‐term results in patients with favorable MVM. Favourable MVM is a strong predictor of good long‐term outcome.

Immediate and long-term effect of mitral balloon valvotomy on left ventricular volume and systolic function in severe mitral stenosis

To determine the immediate and long-term effect of mitral balloon valvotomy (MBV) on left ventricular (LV) volume and function, we studied 17 patients (mean age 27 +/- 9 years) with severe mitral stenosis undergoing MBV by cardiac catheterization and angiography before and immediately after MBV and at mean 12 months later. At baseline, LV end-diastolic volume index (EDVI) was reduced. Ten patients had EDVI < or = 55 ml/m2, and four patients (23.5%) had LV ejection fraction < 50%. EDVI increased from 60 +/- 17 ml/m2 to 66 +/- 17 ml/m2 (p < 0.05) immediately after MBV and increased further to 72 +/- 16 ml/m2 (p < 0.05) later. Stroke volume index increased from 34 +/- 10 ml/m2 to 41 +/- 12 ml/m2 (p < 0.05) immediately after MBV and increased further to 50 +/- 11 ml/m2 (p < 0.001) later. LV end diastolic pressure increased from 12 +/- 5 mm HG to 16 +/- 4 mm HG (p < 0.05) immediately after MBV and fell to 13 +/- Hg at follow-up. LV ejection fraction increased from 57 +/- 7% to 62 +/- 6% (p < 0.05) immediately after MBV and 71 +/- 8% later (p < 0.001). Mean systolic ejection rate increased from 82 +/- 35 ml/sec to 101 +/- 48 ml/sec (p < 0.05) immediately after and 165 +/- 81 ml/sec later (p < 0.05). Systemic vascular resistance fell from 1887 +/- 525 dyne/sec/cm-5 to 1280 +/- 231 dyne/sec/cm-5 (p < 0.001) at follow-up. We conclude that the LV end-diastolic volume and systolic function are reduced in patients with mitral stenosis, and the LV end-diastolic volume is increased immediately after MBV and continues to increase at follow-up 12 months later; the LV ejection performance improves after successful MBV because of an increase in end-diastolic LV volume (preload) and reduction of SVR.