F1r.u~F. I. CT of the chest. (upper) hefnr chemothrapy (lower) four months aftr the initiation of chemotherapy.
hilateral hilar adenopathy, diffuse hilateral intrstitial infiltratt>s, pleural effusions, and mediastinal adenopathy (Fig 1). consistent with interstitial tumor soread in the lunl!s. Chemotherapy was then instihtted with cycles of cisplatin 20 mw' m' for three days, and a single dose of cyclophosphamide (600 mw m'). After the second course of chemotherapy. there was progressive improvement ofhmg compliance from initial values of 4 mVcm H,O to final values of 15 mVcm H,O. The patient was removed from mechanical ventilation, and the tracheostomy was dosed on the 72nd postoperative day. Suhsequent to diSd fever. chills, and lethargy. Two days later, he was found unrPsponsive and was hospitalized. Physical findings included a largP (95.4 kg) obtunded male with a temperahtre of 40.3°C (104.6°F), left-sided weakness, a grade 316 harsh systolic murmur, and discrete areas of ecchymosis on the soles ofhoth feet. The patiPnt required t>nclotracheal intuhation for pulmonary edema. A dopamint> infitsion was instihtted for systemic hypotension (R2 mm Hg). An electrocardiogram showed an acute anterior infarction which was confirmed by cardiac enzymt> levels. An echocarcliogram revealed moderately reducPd IPft ventricular limelion and lar~l' mitral valve ve~etations (Fi~ 1). A peak aortic valve gradient of 71 mm H~ . mild aortic insuffidency, and mild mitral re~urgitation were found by Doppler ultrasound. Blood cultures ~rew ~roup G Strrptococcus. Penicillin was administered intravenously. Diagnostic cardiac cathett>rization performt>cl on the third hospital clay revealed a mean pulmonary capillary wedge pressure of24 mm Hg and a thermodilution cardiat· index of 3.36 Umin/m'. Left ventriculo~raphy mnfirmecl the echd using a protoc•>l approved by the Institutional Review Board and \\;th written informed mnsent from the next of kin. The curved tip of the guidewire over which the balloon catheter was placed was advanced well into the cardiac apex, as far away from the mitral annulus as possible. After inflations with a 20 mm J,alloon, the pressure gradient across the valve decrea~ed to 35 mm Hg and aortic valve area increased to 1.7 em' (O.R cm'/m'. Cardiac index was 3.44 Umin/m'. Postprocedural mean pulmonary capillary wedge was unchanged at 24 mm Hg. It decreased to as low as 17 mm Hg on the following day.
FIC:l'RE 2. Apical four-chamher view obtained 18 days after valvuloplasty, demonstrating resolution of vegetations. Subsequent physical examinations, including neurolo~c examinations, showed no new evidence of emholization. Echocardiography performed shortly after the procedure showed no change in vegetation size. Subsequent cardiac enzyme levels were normal. Postprocedural head computerized tomography wa' unchanged from the admission scan. Dramatic recovery followed with extubation , defervescence, blood culture sterility, and a return to normal mental stah1s. Echocardiography performed 18 days after the procedure showed no mitral valve vegetations (Fig 2). Four weeks after dilatation, the patient was discharged to a rehabilitation facility, where he showed continued improvement with no evidence of recurrent endocarditis. Seven weeks after the procedure, the patient again suffered an acute myocardial infarction and died in the tenth postprocedural week of respiratory failure . An autopsy was requested hut refttsed by the family. DISCUSSION
This isolated case demonstrates that balloon aortic valvuloplasty can be performed in the presence of mitral valve endocarditis without embolic complications. Our patient's condition was particularly precarious because of his recent anterior myocardial infarction. The potential for embolic complications was certainly present, especially in view of the limited control of guidewires and catheters in the left ventricle after they have traversed the stenotic aortic valve . In this case, there was no evidence of bacterial seedin~ of the aortic valve, a recognized but rare complication of valvuloplasty.' This illustrates that whereas bacterial endocarditis involvin~ the nondilated valve may increase the risk of valvuloplasty, it should not be considered an absolute contraindication to the procedure. ACKNOWLEDGMENTS: The author thanks Drs. Garv Ansel , Theodore Fraker, Jr.. and Thomas Walsh for their help in 'the care of this patient. REFERENCES
Fir.I'RF I. Apic·al four-ehamber vif'w demonstrating prominent mitral valve vegetations ( arrotd.
Grossman W Complications of cardiac catheterization: incidence, causes, and prevention. In : Grossman W. ed. Cardiac catheteri7.ation and angiography, 3rd ed . Philadelphia: Lea and Fehiger, 1986:39 2 Cujec B, McMeekin J, Lopez J. Bacterial endocarditis after percutaneous aortic valvuloplasty. Am Heart J 1988; 115:178-79 CHEST I 99 I 6 I JUNE. 1991
1535
hilateral hilar adenopathy, diffuse hilateral intrstitial infiltratt>s, pleural effusions, and mediastinal adenopathy (Fig 1). consistent with interstitial tumor soread in the lunl!s. Chemotherapy was then instihtted with cycles of cisplatin 20 mw' m' for three days, and a single dose of cyclophosphamide (600 mw m'). After the second course of chemotherapy. there was progressive improvement ofhmg compliance from initial values of 4 mVcm H,O to final values of 15 mVcm H,O. The patient was removed from mechanical ventilation, and the tracheostomy was dosed on the 72nd postoperative day. Suhsequent to diSd fever. chills, and lethargy. Two days later, he was found unrPsponsive and was hospitalized. Physical findings included a largP (95.4 kg) obtunded male with a temperahtre of 40.3°C (104.6°F), left-sided weakness, a grade 316 harsh systolic murmur, and discrete areas of ecchymosis on the soles ofhoth feet. The patiPnt required t>nclotracheal intuhation for pulmonary edema. A dopamint> infitsion was instihtted for systemic hypotension (R2 mm Hg). An electrocardiogram showed an acute anterior infarction which was confirmed by cardiac enzymt> levels. An echocarcliogram revealed moderately reducPd IPft ventricular limelion and lar~l' mitral valve ve~etations (Fi~ 1). A peak aortic valve gradient of 71 mm H~ . mild aortic insuffidency, and mild mitral re~urgitation were found by Doppler ultrasound. Blood cultures ~rew ~roup G Strrptococcus. Penicillin was administered intravenously. Diagnostic cardiac cathett>rization performt>cl on the third hospital clay revealed a mean pulmonary capillary wedge pressure of24 mm Hg and a thermodilution cardiat· index of 3.36 Umin/m'. Left ventriculo~raphy mnfirmecl the echd using a protoc•>l approved by the Institutional Review Board and \\;th written informed mnsent from the next of kin. The curved tip of the guidewire over which the balloon catheter was placed was advanced well into the cardiac apex, as far away from the mitral annulus as possible. After inflations with a 20 mm J,alloon, the pressure gradient across the valve decrea~ed to 35 mm Hg and aortic valve area increased to 1.7 em' (O.R cm'/m'. Cardiac index was 3.44 Umin/m'. Postprocedural mean pulmonary capillary wedge was unchanged at 24 mm Hg. It decreased to as low as 17 mm Hg on the following day.
FIC:l'RE 2. Apical four-chamher view obtained 18 days after valvuloplasty, demonstrating resolution of vegetations. Subsequent physical examinations, including neurolo~c examinations, showed no new evidence of emholization. Echocardiography performed shortly after the procedure showed no change in vegetation size. Subsequent cardiac enzyme levels were normal. Postprocedural head computerized tomography wa' unchanged from the admission scan. Dramatic recovery followed with extubation , defervescence, blood culture sterility, and a return to normal mental stah1s. Echocardiography performed 18 days after the procedure showed no mitral valve vegetations (Fig 2). Four weeks after dilatation, the patient was discharged to a rehabilitation facility, where he showed continued improvement with no evidence of recurrent endocarditis. Seven weeks after the procedure, the patient again suffered an acute myocardial infarction and died in the tenth postprocedural week of respiratory failure . An autopsy was requested hut refttsed by the family. DISCUSSION
This isolated case demonstrates that balloon aortic valvuloplasty can be performed in the presence of mitral valve endocarditis without embolic complications. Our patient's condition was particularly precarious because of his recent anterior myocardial infarction. The potential for embolic complications was certainly present, especially in view of the limited control of guidewires and catheters in the left ventricle after they have traversed the stenotic aortic valve . In this case, there was no evidence of bacterial seedin~ of the aortic valve, a recognized but rare complication of valvuloplasty.' This illustrates that whereas bacterial endocarditis involvin~ the nondilated valve may increase the risk of valvuloplasty, it should not be considered an absolute contraindication to the procedure. ACKNOWLEDGMENTS: The author thanks Drs. Garv Ansel , Theodore Fraker, Jr.. and Thomas Walsh for their help in 'the care of this patient. REFERENCES
Fir.I'RF I. Apic·al four-ehamber vif'w demonstrating prominent mitral valve vegetations ( arrotd.
Grossman W Complications of cardiac catheterization: incidence, causes, and prevention. In : Grossman W. ed. Cardiac catheteri7.ation and angiography, 3rd ed . Philadelphia: Lea and Fehiger, 1986:39 2 Cujec B, McMeekin J, Lopez J. Bacterial endocarditis after percutaneous aortic valvuloplasty. Am Heart J 1988; 115:178-79 CHEST I 99 I 6 I JUNE. 1991
1535
