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Aortic valve disruption after percutaneous aortic balloon valvoplasty
Aortic Valve Disruption After Percutaneous Aortic Balloon Valvoplasty Otto Brdlik, DO, Glenn W. Laub, MD, Javier Fernandez, MD, Dryden Morse, MD, Francis P. Sutter, DO, and Lynn B. McGrath, MD Department of Thoracic and Cardiovascular Surgery, Deborah Heart and Lung Center, Browns Mills, New Jersey
Severe disruption of the aortic valve cusps in patients with aortic valve stenosis can occur during percutaneous aortic balloon valvoplasty. We report such a case treated successfully by aortic valve replacement. (Ann Thorac Surg 1990;49:822-3)
and mortality. We report the case of a patient who had severe disruption of the aortic valve cusps during balloon valvoplasty requiring valve replacement.
ercutaneous aortic balloon valvoplasty is used as an alternative to open heart operation for the treatment of patients with aortic stenosis. Initially introduced as a technique for treating patients who have been labeled as inoperable, the indications are being expanded to a wider population. Several groups are now advocating balloon valvoplasty as an alternative to operation in select patients with calcific aortic stenosis [14]. Evaluation of a new technique requires reporting of the procedure’s morbidity
A 75-year-old man was admitted to a hospital in Florida in December 1987 with an episode of syncope and a history of calcific valvular aortic stenosis. Cardiac catheterization showed an aortic valve gradient of 50 mm Hg, calculated aortic valve area of 0.53 cm’, no aortic valve regurgitation, normal myocardial function, and single-vessel coronary artery disease. During that hospitalization, the patient underwent an aortic balloon valvoplasty complicated by transiently slurred speech. After valvoplasty, the aortic valve gradient decreased to 12 mm Hg, and the calculated aortic valve area increased to 1.0 cm2. Ascending aortic angiography revealed 3+ aortic regurgitation.
A
B
P
Fig I . lntraoperative photos of aortic valve showing ( A ) cusp disruption and ( B ) extent of disruption between right and left leaflets. Accepted for publication Oct 27, 1989. Address reprint requests to Dr Laub, Department of Surgery, Deborah Heart and Lung Center, 200 Trenton Rd, Browns Mills, NJ 08015.
0 1990 by The Society of Thoracic Surgeons
0003-4975/90/$3.50
CASE REPORT BRDLIK ET AL VALVE DISRUPTION AFTER VALVOPLASTY
A n n Thorac Surg 1990;49:822-3
Over the ensuing 6 months, progressive shortness of breath and intractable congestive heart failure developed. The patient was referred to Deborah Heart and Lung Center, and he underwent repeat cardiac catheterization that showed an aortic valve gradient of 44 mm Hg, an aortic valve area of 0.6 cm’, 4+ aortic regurgitation, and a severe left anterior descending coronary artery stenosis. On May 23,1988, the patient was taken to the operating room and the aortic valve was found to be heavily calcified with a complete tear of the right coronary cusp (Fig 1). The patient underwent aortic valve replacement with a 23-mm Carpentier-Edwards tissue valve and a bypass graft to the left anterior descending coronary artery. The patient had a normal convalescence with an uneventful postoperative course.
Comment Currently revived as a nonsurgical procedure, percutaneous aortic balloon valvoplasty is gaining increased acceptance. Conceptually, there is no reason to expect the results obtained with percutaneous valvoplasty to be superior to those obtained with closed surgical techniques. Initial reports confirm that the results obtained with percutaneous valvoplasty are generally far from satisfactory, and many complications including aortic valve injury have been documented [4-71. Percutaneous valvoplasty may be indicated in a select group of moribund patients, but currently, it should not be considered an alternative to operation. This patient was a low surgical risk, but was assigned by his cardiologist to undergo percutaneous balloon valvoplasty because of the prevailing attitude that percutaneous valvoplasty procedures are simple to perform, carry a low risk, and are as effective as established surgical procedures. The procedure was performed at considerable expense and resulted in morbidity and an unsatisfactory result.
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The complications associated with this attempt to avoid operative intervention should prompt physicians to question the merit of this new procedure. Despite encouraging preliminary results, percutaneous balloon valvoplasty has inherent risk and should be used only in select patients. We report, however, the successful surgical management of cusp disruption secondary to percutaneous balloon valvoplasty.
We gratefully acknowledge Alison Perritt, RN, BSN, Donna Mull, and Michelle Pallante for their help in preparation of the manuscript.
References 1. Isner JM, Salem DN, Desnoyers MR, et al. Treatment of calcified aortic stenosis by balloon valvuloplasty. Am J Cardiol 1987;59:31>7. 2. Cribier A, Savin T, Saoudi N, Behar P, Rocha P, Letac B. Percutaneous balloon valvuloplasty (PBV) in adult aortic stenosis: an alternative to surgery for valve replacement. Circulation 1986;74(Suppl 2):365. 3. Vahanian A, Guerinon J, Michael PL, Slama M, Grivaux M, Acar J. Experimental balloon valvuloplasty of calcified aortic stenosis in the elderly. Circulation 1986;74(Suppl 2):365. 4. Robicsek F, Harbold NB Jr, Daugherty HK, et al. Balloon valvuloplasty in calcified aortic stenosis: a cause for caution and alarm. Ann Thorac Surg 1988;45:515-25. 5. Phillips PR, Gerlis LM, Wilson N, Walker DR. Aortic valve damage caused by operative balloon dilatation of critical aortic valve stenosis. Br Heart J 1987;57:16&70. 6. Waller BF, Girod DA, Dillon JC. Transverse aortic wall tears in infants after balloon angioplasty for aortic valve stenosis. J Am Coll Cardiol 1984;4:123541. 7. Seifert PE, Auer JE. Surgical repair of annular disruption following percutaneous balloon aortic valvuloplasty. Ann Thorac Surg 1988;46:242-3.
Severe disruption of the aortic valve cusps in patients with aortic valve stenosis can occur during percutaneous aortic balloon valvoplasty. We report such a case treated successfully by aortic valve replacement. (Ann Thorac Surg 1990;49:822-3)
and mortality. We report the case of a patient who had severe disruption of the aortic valve cusps during balloon valvoplasty requiring valve replacement.
ercutaneous aortic balloon valvoplasty is used as an alternative to open heart operation for the treatment of patients with aortic stenosis. Initially introduced as a technique for treating patients who have been labeled as inoperable, the indications are being expanded to a wider population. Several groups are now advocating balloon valvoplasty as an alternative to operation in select patients with calcific aortic stenosis [14]. Evaluation of a new technique requires reporting of the procedure’s morbidity
A 75-year-old man was admitted to a hospital in Florida in December 1987 with an episode of syncope and a history of calcific valvular aortic stenosis. Cardiac catheterization showed an aortic valve gradient of 50 mm Hg, calculated aortic valve area of 0.53 cm’, no aortic valve regurgitation, normal myocardial function, and single-vessel coronary artery disease. During that hospitalization, the patient underwent an aortic balloon valvoplasty complicated by transiently slurred speech. After valvoplasty, the aortic valve gradient decreased to 12 mm Hg, and the calculated aortic valve area increased to 1.0 cm2. Ascending aortic angiography revealed 3+ aortic regurgitation.
A
B
P
Fig I . lntraoperative photos of aortic valve showing ( A ) cusp disruption and ( B ) extent of disruption between right and left leaflets. Accepted for publication Oct 27, 1989. Address reprint requests to Dr Laub, Department of Surgery, Deborah Heart and Lung Center, 200 Trenton Rd, Browns Mills, NJ 08015.
0 1990 by The Society of Thoracic Surgeons
0003-4975/90/$3.50
CASE REPORT BRDLIK ET AL VALVE DISRUPTION AFTER VALVOPLASTY
A n n Thorac Surg 1990;49:822-3
Over the ensuing 6 months, progressive shortness of breath and intractable congestive heart failure developed. The patient was referred to Deborah Heart and Lung Center, and he underwent repeat cardiac catheterization that showed an aortic valve gradient of 44 mm Hg, an aortic valve area of 0.6 cm’, 4+ aortic regurgitation, and a severe left anterior descending coronary artery stenosis. On May 23,1988, the patient was taken to the operating room and the aortic valve was found to be heavily calcified with a complete tear of the right coronary cusp (Fig 1). The patient underwent aortic valve replacement with a 23-mm Carpentier-Edwards tissue valve and a bypass graft to the left anterior descending coronary artery. The patient had a normal convalescence with an uneventful postoperative course.
Comment Currently revived as a nonsurgical procedure, percutaneous aortic balloon valvoplasty is gaining increased acceptance. Conceptually, there is no reason to expect the results obtained with percutaneous valvoplasty to be superior to those obtained with closed surgical techniques. Initial reports confirm that the results obtained with percutaneous valvoplasty are generally far from satisfactory, and many complications including aortic valve injury have been documented [4-71. Percutaneous valvoplasty may be indicated in a select group of moribund patients, but currently, it should not be considered an alternative to operation. This patient was a low surgical risk, but was assigned by his cardiologist to undergo percutaneous balloon valvoplasty because of the prevailing attitude that percutaneous valvoplasty procedures are simple to perform, carry a low risk, and are as effective as established surgical procedures. The procedure was performed at considerable expense and resulted in morbidity and an unsatisfactory result.
823
The complications associated with this attempt to avoid operative intervention should prompt physicians to question the merit of this new procedure. Despite encouraging preliminary results, percutaneous balloon valvoplasty has inherent risk and should be used only in select patients. We report, however, the successful surgical management of cusp disruption secondary to percutaneous balloon valvoplasty.
We gratefully acknowledge Alison Perritt, RN, BSN, Donna Mull, and Michelle Pallante for their help in preparation of the manuscript.
References 1. Isner JM, Salem DN, Desnoyers MR, et al. Treatment of calcified aortic stenosis by balloon valvuloplasty. Am J Cardiol 1987;59:31>7. 2. Cribier A, Savin T, Saoudi N, Behar P, Rocha P, Letac B. Percutaneous balloon valvuloplasty (PBV) in adult aortic stenosis: an alternative to surgery for valve replacement. Circulation 1986;74(Suppl 2):365. 3. Vahanian A, Guerinon J, Michael PL, Slama M, Grivaux M, Acar J. Experimental balloon valvuloplasty of calcified aortic stenosis in the elderly. Circulation 1986;74(Suppl 2):365. 4. Robicsek F, Harbold NB Jr, Daugherty HK, et al. Balloon valvuloplasty in calcified aortic stenosis: a cause for caution and alarm. Ann Thorac Surg 1988;45:515-25. 5. Phillips PR, Gerlis LM, Wilson N, Walker DR. Aortic valve damage caused by operative balloon dilatation of critical aortic valve stenosis. Br Heart J 1987;57:16&70. 6. Waller BF, Girod DA, Dillon JC. Transverse aortic wall tears in infants after balloon angioplasty for aortic valve stenosis. J Am Coll Cardiol 1984;4:123541. 7. Seifert PE, Auer JE. Surgical repair of annular disruption following percutaneous balloon aortic valvuloplasty. Ann Thorac Surg 1988;46:242-3.