Residual atrial septal perforation after percutaneous transvenous mitral commissurotomy with lnoue balloon catheter To estimate the incidence of residual atrial septal perforation (ASP) following percutaneous transvenous mitral commissurotomy (PTMC) with the moue balloon catheter and to examine the factors contributing to ASP, we studied 46 patients with mitral stenosis undergoing PTMC. Residual ASP was evaluated by Doppler color flow imaging 1 day after PTMC, and was detected in 7 out of 46 patients (15.2%). We examined the relationship between the development of ASP (ASP+) and the age of the patient, the left atrial dimension before PTMC, the mean pressure difference between left and right atrium after PTMC, and the duration of the procedure from atrial septal puncture by the Brockenbrough method to balloon inflation. There was a good correlation between the development of residual ASP and the duration of the procedure (ASP+, 51.0 -t 34.0 minutes; without ASP, 24.6 ? 16.2 minutes; p < 0.01). However, there was no significant correlation between the development of ASP and other factors. In the follow-up study, ASP disappeared in four patients within 3 months. ASP persisted in two patients for 1 year after PTMC. However, the shunt in these two patients was clinically insignificant. These data suggest that residual ASP may depend on the duration of the procedure, and that most cases of ASP disappear within 1 year after PTMC. (AM HEART J 1990;120:873.)
Fuminobu Nobushige
Ishikura, MD, Seiki Nagata, MD, Satoshi Yasuda, MD, Yamashita, MD, and Kunio Miyatake, MD. Osaka Japan
Atrial septal perforation (ASP) is one of the most common complications of percutaneous mitral valvuloplasty. The double balloon method is common in the United States and in Europe,lp 2 and it carries a higher risk to produce ASP than does the single balloon method.3 The Inoue balloon catheter has a unique structure designed to prevent the production of ASP,4 because the clinician can stretch the Inoue balloon by the stretching metal tube after deflation of the balloon. Thus the risk of producing ASP by the Inoue balloon catheter may be less than the risk encountered with the angioplastic balloon. As there were few reports on residual ASP51 6 and no report so far on ASP following percutaneous transvenous mitral commissurotomy (PTMC) with the Inoue balloon catheter, this study was conducted to assess the incidence of ASP following PTMC with the Inoue From the Division diovascular Center.
of Cardiology,
Supported in part from The Ministry
by a research Grant for Cardiovascular Disease (63X5) of Health and Welfare of Japan, Tokyo, Japan, 1988.
Received
for publication
Jan.
Department
16, 1990;
accepted
Reprint requests: Seiki Nagata, MD, Division Medicine, National Cardiovascular Center, Osaka 565, Japan. 411122615
of Medicine,
April
National
Car-
1, 1990.
of Cardiology, Department of 5-7-l Fujishiro-dai, Suita,
balloon catheter and to determine contributing to it.
the risk factors
METHODS Patients.
We studied 46 patients with symptomatic mitral stenosisundergoingPTMC. There were 14men and 32 women, and a mean age of 51 f 7 years (range, 31 to 70 years). Twenty-four patients were in sinusrhythm and 22 patients had atria1 fibrillation. Percutaneous
transvenous
mitral
commissurotomy.
Before PTMC, anticoagulant (warfarin potassium)wasnot administered to patients in sinusrhythm but wasgiven to or dosagewasmaintained for at least 3 months in patients with atria1 fibrillation or sinus rhythm with episodesof systemic embolism. However, at 48 to 72 hours before PTMC, anticoagulant therapy wasstopped.Before PTMC, premeditation, suchashydroxyzine (Atarax-P, 25 mg,J.B. Roerig, New York, N.Y.), was usually administered. Both right- and left-sided catheterization were performed from the left femoral artery and vein, The Inoue balloon catheter was inserted from the right femoral vein after transseptal catheterization with a Brockenbrough needle. Before transseptal catheterization, heparin wasadministered (100 IU/kg). The prototyped Inoue balloon catheter (14F) was used on all patients. When the Inoue balloon passed through the stenotic mitral orifice into the left ventricle, the distal half (the tip side half) of the balloon wasslightly inflated. It wasthen pulled back until someresistancewas 873
874
Ishikura
et al.
Fig. 1. Structural characteristic of the Inoue balloon catheter. Upper panel showsthat the Inoue balloon is not stretched by the stretching metal tube. Lower panel showsthat the Inoue balloon is stretched by the stretching metal tube.
felt. The proximal half and center portion were then inflated. The duration of inflation waslessthan 5 seconds. After balloon inflation, a pressurestudy and left ventriculography were performed. When the Inoue balloon catheter waswithdrawn from the left atrium after all examinations, the balloon could be stretched by the stretching metal tube (Fig. 1). At 24hours after PTMC, anticoagulant wasreadministered, if needed. Hemodynamic
and echocardiographic
measurements.
Right and left heart pressuresand meantransmitral pressure gradient weremeasuredbefore and after PTMC in all 46 patients. Left ventriculography wasalso performed before and after PTMC in 43 of 46 patients. Severity of mitral regurgitation from left ventriculography was graded semiquantitatively from l+ to 4+. Mitral regurgitation in three patients without left ventriculography wasevaluated by two-dimensionalDoppler color flow imaging.Oximetric study wasperformed to detect any left-to-right shunt at the atria1 level in 16 of 46 patients. Doppler and echocardiographic examination were performed within 7 days before PTMC and 1 day after PTMC. The existenceof residual ASP wasrecognizedby two-di-
mensionalDoppler color flow imagingfrom the parasternal short-axis view or the subcostalview (Fig. 2). In the cases with residual ASP, Doppler and echocardiographicexaminations were performed 3 months and 1 year after PTMC. Factors contributing to residual atrial septal perforation. We examined the relationship betweenresidual ASP
and the following factors: (1) age of the patient; (2) left atria1 dimension before PTMC evaluated by two-dimensional echocardiography; (3) meanpressuredifference between the left and right atrium after PTMC; (4) duration of the procedure from atria1 septal puncture by the Brockenbrough method to balloon inflation. Statistical analysis. Data are expressed as mean k standard deviation of the mean. Comparisonsof meanfor continuous variables were made using the unpaired Student’s t test. A probability (p) value =40 mm Hg at follow-up underwent repeat balloon valvuloplasty. For the inltlal balloon pulmonary valvuloplasty, the mean ratio of the balloon dlameter to pulmonary valve annulus diameter was 0.98 f 0.2; at repeat valvuloplasty the mean was 1.19 2 0.12. The Immediate post-repeat balloon valvuloplasty results showed a reduction in the peak systolic gradient from a mean of 70.2 + 17.8 to 29.1 + 19.0 mm Hg (p < 0.001). This reduction In the gradient was maintained at a mean of 14.3 f 5.0 mm Hg in 8 of the 10 patients who underwent further follow-up studies. We conclude that successful repeat balloon pulmonary valvuloplasty with the use of larger sized balloons is feasible In patients who have restenosis after the Initial percutaneous balloon valvuloplasty-lncludlng partial but not complete dysplasia of the pulmonary valve. (AM HEART J 1990;120:878.)
M. A. Ali Khan, MD, Saad Al-Yousef, MD, John W. Moore, MD, and William Sawyer, MB, ChB. Riyadh, Saudi Arabia
Results of follow-up studies after percutaneous balloon valvulopasty for pulmonary stenosis have shown rates of significant valvar restenosis between 14% and 33 % L 2; inadequate balloon size334 and pulmonary valve dysplasia13 5-7 are factors that have been From Reprint Hospital, Received 4/l/22824
878
the Riyadh
Cardiac
Center,
Armed
Forces
Hospital.
requests: M. A. Ali Khan, MD, Pediatric Cardiology, PO Box ‘789’7, Riyadh 11159, Saudi Arabia. for publication
May
17, 1989;
accepted
May
Armed
21, 1990.
Forces
related to restenosis. Significant valvar restenosis after balloon pulmonary valvuloplasty may be managed by either repeat balloon valvuloplasty or surgery. Although immediate results of repeat balloon pulmonary valvuloplasty have been recorded,8-10 late results have not been fully described in the literature. This retrospective study reviews our results of repeat balloon pulmonary valvuloplasty in patients with significant pulmonary valvar restenosis, immediately after the procedure and at follow-up studies.
Fuminobu Nobushige
Ishikura, MD, Seiki Nagata, MD, Satoshi Yasuda, MD, Yamashita, MD, and Kunio Miyatake, MD. Osaka Japan
Atrial septal perforation (ASP) is one of the most common complications of percutaneous mitral valvuloplasty. The double balloon method is common in the United States and in Europe,lp 2 and it carries a higher risk to produce ASP than does the single balloon method.3 The Inoue balloon catheter has a unique structure designed to prevent the production of ASP,4 because the clinician can stretch the Inoue balloon by the stretching metal tube after deflation of the balloon. Thus the risk of producing ASP by the Inoue balloon catheter may be less than the risk encountered with the angioplastic balloon. As there were few reports on residual ASP51 6 and no report so far on ASP following percutaneous transvenous mitral commissurotomy (PTMC) with the Inoue balloon catheter, this study was conducted to assess the incidence of ASP following PTMC with the Inoue From the Division diovascular Center.
of Cardiology,
Supported in part from The Ministry
by a research Grant for Cardiovascular Disease (63X5) of Health and Welfare of Japan, Tokyo, Japan, 1988.
Received
for publication
Jan.
Department
16, 1990;
accepted
Reprint requests: Seiki Nagata, MD, Division Medicine, National Cardiovascular Center, Osaka 565, Japan. 411122615
of Medicine,
April
National
Car-
1, 1990.
of Cardiology, Department of 5-7-l Fujishiro-dai, Suita,
balloon catheter and to determine contributing to it.
the risk factors
METHODS Patients.
We studied 46 patients with symptomatic mitral stenosisundergoingPTMC. There were 14men and 32 women, and a mean age of 51 f 7 years (range, 31 to 70 years). Twenty-four patients were in sinusrhythm and 22 patients had atria1 fibrillation. Percutaneous
transvenous
mitral
commissurotomy.
Before PTMC, anticoagulant (warfarin potassium)wasnot administered to patients in sinusrhythm but wasgiven to or dosagewasmaintained for at least 3 months in patients with atria1 fibrillation or sinus rhythm with episodesof systemic embolism. However, at 48 to 72 hours before PTMC, anticoagulant therapy wasstopped.Before PTMC, premeditation, suchashydroxyzine (Atarax-P, 25 mg,J.B. Roerig, New York, N.Y.), was usually administered. Both right- and left-sided catheterization were performed from the left femoral artery and vein, The Inoue balloon catheter was inserted from the right femoral vein after transseptal catheterization with a Brockenbrough needle. Before transseptal catheterization, heparin wasadministered (100 IU/kg). The prototyped Inoue balloon catheter (14F) was used on all patients. When the Inoue balloon passed through the stenotic mitral orifice into the left ventricle, the distal half (the tip side half) of the balloon wasslightly inflated. It wasthen pulled back until someresistancewas 873
874
Ishikura
et al.
Fig. 1. Structural characteristic of the Inoue balloon catheter. Upper panel showsthat the Inoue balloon is not stretched by the stretching metal tube. Lower panel showsthat the Inoue balloon is stretched by the stretching metal tube.
felt. The proximal half and center portion were then inflated. The duration of inflation waslessthan 5 seconds. After balloon inflation, a pressurestudy and left ventriculography were performed. When the Inoue balloon catheter waswithdrawn from the left atrium after all examinations, the balloon could be stretched by the stretching metal tube (Fig. 1). At 24hours after PTMC, anticoagulant wasreadministered, if needed. Hemodynamic
and echocardiographic
measurements.
Right and left heart pressuresand meantransmitral pressure gradient weremeasuredbefore and after PTMC in all 46 patients. Left ventriculography wasalso performed before and after PTMC in 43 of 46 patients. Severity of mitral regurgitation from left ventriculography was graded semiquantitatively from l+ to 4+. Mitral regurgitation in three patients without left ventriculography wasevaluated by two-dimensionalDoppler color flow imaging.Oximetric study wasperformed to detect any left-to-right shunt at the atria1 level in 16 of 46 patients. Doppler and echocardiographic examination were performed within 7 days before PTMC and 1 day after PTMC. The existenceof residual ASP wasrecognizedby two-di-
mensionalDoppler color flow imagingfrom the parasternal short-axis view or the subcostalview (Fig. 2). In the cases with residual ASP, Doppler and echocardiographicexaminations were performed 3 months and 1 year after PTMC. Factors contributing to residual atrial septal perforation. We examined the relationship betweenresidual ASP
and the following factors: (1) age of the patient; (2) left atria1 dimension before PTMC evaluated by two-dimensional echocardiography; (3) meanpressuredifference between the left and right atrium after PTMC; (4) duration of the procedure from atria1 septal puncture by the Brockenbrough method to balloon inflation. Statistical analysis. Data are expressed as mean k standard deviation of the mean. Comparisonsof meanfor continuous variables were made using the unpaired Student’s t test. A probability (p) value =40 mm Hg at follow-up underwent repeat balloon valvuloplasty. For the inltlal balloon pulmonary valvuloplasty, the mean ratio of the balloon dlameter to pulmonary valve annulus diameter was 0.98 f 0.2; at repeat valvuloplasty the mean was 1.19 2 0.12. The Immediate post-repeat balloon valvuloplasty results showed a reduction in the peak systolic gradient from a mean of 70.2 + 17.8 to 29.1 + 19.0 mm Hg (p < 0.001). This reduction In the gradient was maintained at a mean of 14.3 f 5.0 mm Hg in 8 of the 10 patients who underwent further follow-up studies. We conclude that successful repeat balloon pulmonary valvuloplasty with the use of larger sized balloons is feasible In patients who have restenosis after the Initial percutaneous balloon valvuloplasty-lncludlng partial but not complete dysplasia of the pulmonary valve. (AM HEART J 1990;120:878.)
M. A. Ali Khan, MD, Saad Al-Yousef, MD, John W. Moore, MD, and William Sawyer, MB, ChB. Riyadh, Saudi Arabia
Results of follow-up studies after percutaneous balloon valvulopasty for pulmonary stenosis have shown rates of significant valvar restenosis between 14% and 33 % L 2; inadequate balloon size334 and pulmonary valve dysplasia13 5-7 are factors that have been From Reprint Hospital, Received 4/l/22824
878
the Riyadh
Cardiac
Center,
Armed
Forces
Hospital.
requests: M. A. Ali Khan, MD, Pediatric Cardiology, PO Box ‘789’7, Riyadh 11159, Saudi Arabia. for publication
May
17, 1989;
accepted
May
Armed
21, 1990.
Forces
related to restenosis. Significant valvar restenosis after balloon pulmonary valvuloplasty may be managed by either repeat balloon valvuloplasty or surgery. Although immediate results of repeat balloon pulmonary valvuloplasty have been recorded,8-10 late results have not been fully described in the literature. This retrospective study reviews our results of repeat balloon pulmonary valvuloplasty in patients with significant pulmonary valvar restenosis, immediately after the procedure and at follow-up studies.
