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Comparison of three techniques for percutaneous balloon aortic valvuloplasty of aortic stenosis in adults
Volume
117
Number
1
Ds. Tc-99m MIBI (RP-30) and Tl-201 myocardial perfusion scintigraphy in patients with coronary artery disease: quantitative comparison of planar and tomographic techniques for uerfusion defect intensitv and defect reversibilitv _ IAbstractl. j Nd Med 1987;28:654: 51. Hakki A-H, Iskandrian AS, Kane SA, Amenta A. Thallium201 myocardial scintigraphy and left ventricular function at rest in patients with rest angina pectoris. AM HEART J 1984;108:326-32. J, Kiat H, Lew A, Shah P, Berman D. 52. Bellil D, Maddahi Significance of reversible rest-redistribution thallium-201 defects in patients with unstable angina: frequency and angiographic correlates [Abstract]. J Nucl Med 1988,29:768. 53. Kiat H, Maddahi J, Yang LD, et al. Late reversibility of tomographic myocardial thallium-201 defects: an accurate marker of myocardial viability. J Am Co11 Cardiol (in press).
Comparison
of
Tc-MIBI
and thallium 201
54. Brunken R, Schwaiger M, Grover-Mckay M, Phelps ME, Tillisch J, Schelhert HR. Positron emission tomography detects tissue metabolic activity in myocardial segments with persistent thallium perfusion defects. J Am Co11 Cardiol 1987;10:557-67. 55. Tamaki N, Yonekura Y, Senda M, et al. Value and limitations of stress thallium-201 single photon emission computed tomography: comparison with nitrogen-13 ammonia positron tomography. J Nucl Med 1988;29:1181-7. 56. Friedman J, Van Train K, Maddahi J, et al. “Upward creep” of the heart: a frequent source of false-positive reversible defects on Tl-201 stress-redistribution SPECT [Abstract]. J Nucl Med 1986;27:899-900. 57. Sporn V, Balini NP, Holman L, et al. Simultaneous measurement of ventricular function and myocardial perfusion using the technetium-99m isonitriles. Clin Nucl Med 1988;13:7781.
Comparison of three techniques for percutaneous balloon aortic valvuloplasty aortic stenosis in adults
of
Three different techniques for percutaneous balloon aortic vakuloplasty have been described: retrograde single balloon, retrograde double balloon,,and antegrade techniques. This report describes our experience usleg the three techniques in twenty-five consecutive procedures. All techniques resulted in a significant decrease In transvalvular pressure gradient and an increase in calculated aortlc valve area, without slgnlflcant difference among the three. There was no Increase in the degree of aortlc regurgitatlon after valvuloplapty by any of the techniques. Vascular complications occurred only with the retrograde double balloon technique. Cardiac tamponade during balloon Inflation occurred with both the retrograde single and double balloon technique& Three deaths occurred; two during the antegrade technique and one after the retrograde double balloon technique. Thus, ‘balloon aortlc valvuloplasty can be effectively performed using any of the three techniques. However, the differing techniques have inherent advantages in specific sltuatlons, as well as potential complications. (AM HEART J 1989;117:11.)
Eric C. Orme, MD, Robert B. Wray, MD, William H. Barry, MD, Steven K. Krueger, MD, and Jay W. Mason, MD. Salt Luke City, Utah
The poor prognosis of patients with severe aortic stenosis is well recognized.1-3 Percutaneous balloon valvuloplasty of the stenotic aortic valve has been advocated as a palliative procedure for the elderly patient, the patient with a very high surgical risk or a contraindicati& to surgical valve replacement, and the patient who refuses surgical intervention. From the Division of Cardiology, University of Utah Medical Center. Received for publication June 23, 1988; accepted Aug 2, 1988. Reprint requests: Jay W. Mason, MD, Division of Cardiology, University of Utah Medical Center, 50 North Medical Drive, Salt Lake City, Utah 84132.
Recent reports by Cribier et al.,4 McKay et al.,5 Isner et al.,6 and Schneider et aL7 have demonstrated that percutaneous balloon catheter dilatation of stenotic aortic valves leads to an acute improvement in cardiac hemodynamics and symptoms caused by aortic stenosis. This report describes experience with twenty-two patients undergoing twenty-five valvuloplasty procedures by three different techniques. METHODS Study attempted
group.
Balloon
in 22 patients
aortic
(11 men,
valvuloplasty
11 women)
with
was
a mean 11
January
12
Orme et al.
Table
American
I. Technique used and hemodynamicsbefore and after valvuloplasty Patient
Mean
No
Procedure
1 2 3 4 5+’ 6+2
A A
B 9 10 11 12+3 13 14 15 16 17+* 18+’ 19 20+3 21 22 23
Mean SD
A A A
RS A (RS), RD RS (RS),RD RS RD RD RD RD RD (RSARD RD GW, RD RD A RD RD
gradient
(mm
Pre 84 50 74 23 76 58 46 79 68 30 53 29 75 77 85 57 48 77 80 24 33 55 28 56.9 21.2
(56) (27)
(47)
(42)
1989 Journal
--.__.
Hg)
AVA
(cm-‘)
Post
Pre
Post
58 33 34 19 67 32 38 54 29 21 35 13 32 38 34 33 46 38 19 13 15 32 12 32.4 + 14.43 p
0.30 0.60 0.50 0.76 0.58 0.35 0.50 0.51 0.38 0.57 0.57 0.63 0.38 0.51 0.48 0.48 0.41 0.51 0.42 0.50 0.62 0.49 0.76 0.51 It 0.12
0.46 0.78 0.90 0.92 0.81 0.63 0.80 0.73 0.86 0.78 0.76 1.10 0.76 0.73 0.82 0.67 0.50 0.73 0.98 0.73 1.20 1.33 1.50 0.85 f 0.24 p < 0.000
A, Antegrade technique; RS, retrograde single-balloon technique; (RS), retrograde single-balloon technique; RD, retrograde double-balloon technique; AVA, calculated aortic valve area. +Repeat valvuloplasty procedure, 3 to 4 months after initial valve dilatation.
age of 78 years (range, 68 to 93 years). All patients were symptomatic, with congestive heart failure, angina, or history of syncope.All patients had severeaortic stenosis (calculated aortic valve area of less than 0.8 cm2) determined by previous cardiac catheterization. Each patient was evaluated by both a cardiothoracic surgeon and cardiologist, both of who? presentedexpected results and relative risks of surgery and balloon valvuloplasty to the patient.. Fifteen patients were considered to have unacceptably high surgicalrisk, four had high surgicalrisk and thus refused surgery, and three refused surgical valve replacement despite only moderate risk. In three patients, symptoms of congestive heart failure returned 3 to 4 monthsafter an initially successfulvalve dilatation. They underwent repeat valvuloplasty after documentation by catheterization of recurrent, severe aortic stenosis.All patients gaveconsentfor the procedure,having beeninformed of the investigational nature of the technique andthe potential complicationsand risks asoutlined by the protocol approved by the University of Utah Medical Center Institutional Review Board. Three different techniques were usedto perform the twenty-five procedures. Antegrade technique. In nine patients, valvuloplasty was performed by antegrade transseptal left heart cathe-
Heart
technique
(0.65) (0.69)
(0.44) (0.65)
was performed
before
double-balloon
terization. Right heart catheterization was performed through the left femoral vein, and pulmonary capillary wedge and pulmonary artery pressureswere monitored throughout the procedure. Transseptal left heart catheterization was performed through the right femoral vein using a 8F Mullins transseptal sheath and dilator (USC1 Division of C. R. Bard, Billerica, Mass.) and a modified Brockenbrough needle. Heparin sulfate (10,000 U) was given intravenously, and a 7F Critikon catheter (Critikon, Inc., Tampa, Fla.) was passedthrough the transseptal sheath into the left atrium and directed into the left ventricle. Left heart pressures,the aortic transvalvular gradient, and cardiac output (Fick or thermodilution method) were measured.Then the Critikon catheter was advanced antegradely acrossthe stenotic aortic valve into the descending aorta. An 0.038-inch 400 cm length Jtipped exchange guide wire (Cook Incorporated, Bloomington, Ind.) was passedthrough the catheter into the descendingaorta and “snared” by a 8F Dotter Intravascular Retrieval Set (Cook Incorporated), which had been advanced retrogradely through a left femoral artery sheath. The retrieved end of the long guide wire was drawn out of the left femoral artery sheathand secured.A 14F sheath with sidearm (Universal Medical Instruments
Volume
117
Number
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Balloon aortic valvuEoplasty
ANTEGRADE:
TECHNIQUE,
AVG
RETROGRADE
SINGLE 8ALLOON
p =0.010
f-.
,
I,.
,
.
r*,
POST RETROGRADE
1.4 1
TECHNIQUE, AVG
p= 0.01
PRE ANTEGRADE
13
TECHNIQUE.
AVA
p = 0.003
SINGLE BALLOON TECHNIQUE, AVA
0.91
P=o.ma
084
/T
1.2 1 LONE 0.8-
l &I
*
.
0.2J PRE
POST
Fig. 1. Aortic valve pressure gradient (AVG) and calcuIated valve area (AVA) pre- and postantegrade aortic valvuloplasty. The technique resulted in a statistically significant decrease in AVG, and increase in AVA.
Corp., Ballston Spa, N.Y.) was exchanged for the right femoral vein transseptal sheath. The interatrial septal puncture site was then dilated with an 8 mm balloon-tipped catheter advanced along the guide wire through the right femoral vein. Dilatation of the interatrial septum allowed passage of the larger valvuloplasty balloon-tipped catheters from the right to the left atrium, and then to the left ventricular outflow tract, to be positioned across the aortic valve. Valvuloplasty balloon catheters (Mansfield Scientific Inc., Mansfield, Mass., or Cook Incorporated) with 15 mm, 18 mm, and 20 mm inflated diameter balloon tips were sequentially used for valve dilatation. The lengths of the balloons were either 3 or 5 cm, depending on availability. All balloons were inflated to 3 to 4 atm pressure, using dilute Renogaffin 60. Each balloon catheter was inflated an average of four times. The balloon was maintained in the fully inflated position for an average of 20 seconds (range, 5 to 45 seconds), and was maintained in good position across the valve annulus by controlling both ends of the long guide wire. Balloons were deflated when a significant drop in systemic blood pressure occurred. The valvuloplasty catheters were removed and the post-dilatation transaortic
0.3’
I I, PRE
81.
8 r < 1, POST
Fig. 2. Aortic valve pressure gradient (AVG) and calculated valve area (AVA) pre- and post-single balloon retrograde valvuloplasty. The technique resulted in a statistically significant decrease in AVG, and increase in AVA.
valvular pressure gradient was measured with a doublelumen catheter (Cook Incorporated) advanced antegradely through the right femoral vein to the left ventricle and a 5F pigtail catheter positioned in the ascending aorta. Cardiac output determination was repeated, and valve area was calculated by the Gorlin method.8 Single-balloon, retrograde technique. Seven patients underwent balloon aortic valvnloplasty in the retrograde single-balloon manner previously described by McKay et a1.6Four of these went on to have double-balloon dilatation when it was determined that the single-balloon technique resulted in suboptimal aortic pressure gradient reduction. The Ieft heart was catheterized retrogradely through a femoral artery, and a 5F pigtail catheter was advanced to the ascending aorta through the contralateral femoral artery for supraaortic pressure measurement. Transaortic valvular pressure gradient and cardiac output Wick or thermodilution) were measured. An 0.038-inch J-tipped guide wire was then positioned in the left ventricle and the left ventricular catheter was removed. A 4F arterial sheath with sidearm (Universal Medical Instruments Corp.) was exchanged for the arterial sheath. In five patients, single-balloon valvuloplasty was performed with a series of two or three single balloons; either 15,18, and 20 mm, or 15 and 20 mm inflated diameter balloons. In
January
14
Orme et al.
American
RETROGRADE DOUBLE BALLOON TECHNIQUE,AVG
COMPARISON
OF THE THREE
TECHNIQUES,
technique
o retrograde o retrograde
COMPARISON
OF THE THREE
TECHNIQUES,
1989 Journal
AVG
A antegrcde
60260 Lo :I . 20-
lieart
single technique double technique
AVA
0.97
RETROGRADE DOUBLE BALLOON TECHNWE. AVA 1.6 1.4 1.2
z
T
1.0
r PRE
o 0.6 i
0.6 0.4 0.2 J
8.4’
r’ PRE
1 - 1 - ‘E
’ g-l POST
Fig. 3. Aortic valve pressuregradient (AVG) and calculated valve area (AVA) pre- and post-double-balloon retrograde valvuloplasty. The technique resulted in a statisticahy significant decreasein AVG, and increasein AVA.
one patient, an 18 mm balloon only was used, and, in another, only one 20 mm balloon wasused. Balloons were typically inflated for an average of 15 seconds(range, 5 to 45 seconds),and deflated when blood pressuredropped significantly. Larger diameter balloons were exchanged when no waist in the balloon was seen with inflations. If a significant decrease in transaortic valve-pressure gradient was not produced with a 20 mm balloon, the patient went on to the double-balloon technique. After balloon dilatation, the balloon catheters were removed and a pigtail catheter was advanced to the left ventricle. Repeat pressurerecording and cardiac outputs were then performed. Double-balloon, retrograde technique. Thirteen patients underwent retrograde simultaneousdouble balloon valvuloplasty, four having undergone single-balloon dilatation followed by double-balloon dilatation. After left heart catheterization and measurementof the transvalvular pressuregradient and cardiac output, a secondpigtail catheter was passed across the aortic valve, and two 0.038-inch J-tipped exchangeguide wires were positioned in the left ventricle, one from each common femoral artery. Introducer sheaths(14F) with sidearms(Universal
,
r
r
,
,
POST
Fig. 4. Comparison of the mean aortic valve pressure
gradients (AVG) and calculated valve areas (AVA) preand postvalvuloplasty by the three different techniques. Statistical analysis showed no difference between the three techniques.
Medical Instruments Corp.) were exchangedfor the femoral arterial sheaths. In six patients, 15 mm and 20 mm balloon valvuloplasty catheters were used; in six patients, two 20mm balloon catheters wereused;and in onepatient, two 18 mm balloon catheters were used. The balloon valvuloplasty catheterswere advancedthrough the femoral arterial sheaths,positioned acrossthe aortic valve, and inflated simultaneously an average of three times for an averageof 15seconds(range,5to 60seconds).Balloonswere deflated when blood pressure dropped, and were kept inflated until a waist diminished or disappeared. After balloon dilatation, a pigtail catheter wasexchangedfor one balloon catheter and was positioned in the left ventricle. The secondballoon-tipped catheter was withdrawn to a supraaortic valve position, and repeat transvalvular pressure gradients and cardiac outputs were measured. In all patients, the catheters and vascular sheaths, except for a venous sheath, were removed immediately after the procedure, after reversal of heparin effect with protamine sulfate. Hemostasis was achieved by direct compression for 30 to 60 minutes. All patients were transported to the coronary care unit for observation for at least 18 hours. Aortography. In two patients, supravalvular aortography was performed in the LAO position before and immediately after valvuloplasty to determine the degree of aortic regurgitation. 2-D and Doppler schocerdiography. Two-dimensional,
Volume
117
Number
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Balloon aortic valvuloplasty
II. Degree of aortic regurgitation determined by aortography and colorflow and Doppler flow studies before and after valvuloplasty Table
Doppler and colorflow echocardiomphy
Aortogwhy
Patient No
Procedure
Pre
Post
Pre
Post
1 2 3 4 5+’ 6+2 I 8 9
A A A A A
-
-
0
1t TR 1+ -
-
0 1+ 1+ TR 2t 2t -
RS A VW,
RD
10
RS UW, RD
11 12” 13 14 15 16 17+2 18+’ 19 20+) 21 22 23
RS RD RD RD RD RD VW, RD (RS), RD A RD RD
RD RD
1-h TR -
-
1+ TR TR 2+ 2t 1+ 1+ 0 0 1t 1t 1t 1+ 1+ 2+ 2+ 2+ 2+ 1+ 1+ 1+
1+ 1t 0 0 2t 1t 1t 1+ 2t 2t 2t 2t 1t 1t 1t
Aortography and colorflow/Doppler studies are graded on a none (O), trace (TR), mild Cl+), moderate fZ+), moderately severe (3+), severe (4+) scale. A, Antegrade technique; RS, retrograde single-baboon techniques; (RS), retrograde single-balloon technique was performed before double-baboon technique; RD, retrograde double-balloon technique; AR, aortic regurgitation. +Repeat valvuloplasty procedure, 3 to 4 months after initial valve dilatation.
colorflow, pulsed, and continuous wave Doppler echocardiography was performed 24 hours before and within 48 hours after valvuloplasty with a Hewlett-Packard 7702OA imaging system (Hewlett-Packard Co., Andover, Mass.). Aortic valve peak instantaneous gradient was calculated according to the modified Bernoulli equation (gradient = 4 [V,z-V,z] where V, = peak flow velocity in the left ventricular outflow tract, and V, = peak flow velocity in the aortic root, determined by continuous wave Doppler study), and mean aortic pressuregradient was calculated. The degree of aortic regurgitation was determined by pulsed Doppler sampling and colorflow mapping of the left ventricular outflow tract immediately below the aortic valve leaflets in parasternal long- and short-axis views and in the apical four-chamber view. Statistics. Statistical analysis of the pre- and postvalvuloplasty hemodynamic results was performed for each technique using the paired Student t test. Data are
Table
15
Ill. Complications of aortic valvuloplasty
Antegrade (n = 9)
Retrograde single balloon (n = 7)
Retrograde double balloon (n = 13)
Vascular hemorrhage CompleteAV block
0
0
1
1
0
0
Cardiactamponade during balloon inflation Death
0
1
1
2
0
1 (6 hr later)
expressedas + standard deviation. Analysis of variance was usedto accessthe pre- and postvalvuloplasty hemodynamic differencesbetween the three techniques, aswell as the differences in systemic arterial pressure during balloon inflation produced by the different techniques. RESULTS
Twenty-five aortic valvuloplasty procedures were performed. Initially successful valve dilatation occurred in 20 of 22 patients. Three of these twenty patients underwent repeat valvuloplasty 3 to 4 months after the initial procedure, resulting in a total of 23 successful valvuloplasty procedures. In 2 patients, cardiovascular collapse occurred during the procedure, before or during valve dilatation (see below). These patients were excluded from the statistical analysis of the hemodynamic data. The hemodynamic results of the valvuloplasty procedures are shown in Table I, and comparison of the three techniques is made in Figs. 1, 2, 3, and 4. All three techniques resulted in a significant decrease in transvalvuhu pressure gradient, and an increase in calculated aortic valve area. Although the numbers of patients are small, there was no significant statistical difference between the three groups. While the results of the single- and double-balloon retrograde techniques are not statistically different, more than one half (4 of 7) of the single-balloon procedures required double-balloon dilatation to achieve maximal improvement in valve area. Degree of aortlc regurgitation. Aortography or color/Doppler flow study showed no change in the degree of aortic regurgitation after valvuloplasty in 21 of 23 procedures (Table II). In one patient who underwent the antegrade technique, the degree of aortic regurgitation increased from trace to mild; in another patient, who underwent the retrograde double-balloon technique, the degree increased from
January
16
Table
Orme et al.
American
Heart
1989 Journal
IV. Average mean systemic arterial pressureduring balloon inflations Retrograde single technique (n = 33 inflations)
Antegrade technique (n = 28 inflations)
Range
41 mmHg 25-62 mm Hg
Lp
= nsI
44 mm Hg 25-60 mm Hg , p = ns
mild to moderate (Table II). No patient who underwent repeat aortic valvuloplasty had an increase in degree of regurgitation after the second dilatation. Complications. The complications that occurred with the three techniques are listed in Table III. Three patients died, two during the antegrade technique and one after the retrograde double-balloon technique. Of the deaths occurring with the antegrade technique, the first occurred because of acute mitral regurgitation caused by rupture of posterior papillary muscle chordae tendineae during valvuloplasty balloon inflation. The second death occurred during transseptal catheterization, as the result of aortic root puncture with cardiac tamponade and irreversible cardiac failure even though the hemopericardium was successfully evacuated. The third death occurred 6 hours after a successful valve dilatation (patient 14) and was thought to be caused by pulmonary embolism. A significant femoral artery hemorrhage that produced marked hypotension occurred in one patient who underwent the retrograde double-balloon technique. No local vascular complications occurred in the antegrade group. Hemopericardium that caused cardiac tamponade developed during balloon inflation in two other patients; one was undergoing the retrograde singleballoon technique, the other was undergoing the retrograde double-balloon technique. These tamponades were successfully relieved with pericardiocentesis and there were no sequelae. Postdilatation hemodynamic measurements on the patients, once stabilized, showed successful valve dilatation in both. Arterial pressure drop during balloon inflation. Table IV shows the average mean arterial pressure during balloon inflation of the three techniques. All techniques resulted in marked hypotension during inflation, without significant differences between the three. DISCUSSION
Percutaneous balloon catheter dilatation of stenotic aortic valves is being viewed as an acceptable
Retrograde double technique (n = 36 inflations)
37 mm Hg
p = ns
27-50ym Hg J
palliative procedures for adult patients with high surgical risk or those who refuse surgical valve replacement. New techniques and equipment are being developed in an attempt to increase the efficacy, safety, and applicability of the procedure. Three different techniques have been described for percutaneously dilating stenotic aortic valves: Retrograde single-balloon,5 retrograde double-balloon,g and antegrade single-balloon techniques.1° In our study, we have found that all three techniques effectively reduce the aortic transvalvular pressure gradient acutely and increase the calculated aortic valve area, without significant statistical difference between the three. However, the doubleballoon technique did produce an improved clinical response, with a greater reduction in aortic valve gradient and increase in calculated aortic valve area. Furthermore, the degree of aortic regurgitation after the valve dilatation was not significantly increased by any one of these techniques. Because of the small number of procedures reported in this series, a true difference between the three valvuloplasty procedures may have been missed. In our experience, each of these techniques has potential complications and advantages. The antegrade technique requires transseptal catheterization of a heart that may have distorted anatomical landmarks because of a dilated aortic root, enlarged right and left atria, and a thickened interatrial septum. Directing the catheter and guide wire through the left ventricular chamber and into the aorta across the stenotic aortic valve is technically difficult. Furthermore, the operator must be extremely careful to keep the guiding wire and balloon dilatation catheters free of the mitral valve leaflets and subvalvular apparatus, so as to avoid disrupting the mitral valve structures. The antegrade technique we have described differs from that of Block and Palacios’O in that a 400~cm length guide wire was used to traverse the vascular system from the right femoral vein through the heart and out of the left femoral artery. This technique was developed to provide greater positional stability of the inflated balloons across the valve by providing con-
Volume
117
Number
1
trol of both ends of the guide wire. However, traction of both ends of the guide wire is potentially hazardous, as intolerable force may be placed on the submitral valvular apparatus, causing damage to papillary muscles, chordae tendineae, or leaflets. The antegrade technique avoids the potential arterial vascular complications that occur with the retrograde techniques, and this allows its performance in patients without peripheral arterial vascular access. By controlling both ends of the guide wire, better control of the balloon catheter position can be achieved. However, this maneuver is technically difficult and adds additional risk to the procedure. All three techniques may be complicated by the development of cardiac tamponade during balloon inflation.5 Two mechanisms are postulated to explain this. First, hemopericardium may result from perforation of the ventricular wall by the guiding wire used to initially cross the valve or by the balloon catheter tip itself, exacerbated by markedly increased left ventricular pressure caused by outflow tract obstruction by the dilating balloon(s). Or, hemopericardium may develop because of pressure-induced rupture of the left ventricular wall, occurring without previous guide wire perforation. The use of two balloon catheters to dilate stenotic aortic valves has been advocated because they achieve a larger combined diameter when inflated, and the two balloons provide a residual lumen through which the ventricle is vented, allowing some cardiac output during dilatation. Our observations regarding drop in blood pressure during retrograde double-balloon valvuloplasty differ with others who have used this technique.g During double-balloon valvuloplasty, a decrease in peripheral arterial pressure occurred, which did not differ from that associated with the antegrade and retrograde singleballoon techniques (Table IV). Also, the doubleballoon method did not prevent tamponade. However, the double-balloon technique was necessary in more than fifty percent of the single-balloon procedures, to obtain maximal aortic valve dilatation. In conclusion, comparison of the three currently
Balloon
aortic
valuuloplasty
17
used procedures for aortic valvuloplasty has shown no statistical difference in their ability to acutely reduce the transvalvular pressure gradient or increase the calculated valve area. The differing techniques have inherent advantages and potential complications, and specific circumstances may make a certain technique preferable. When there is no arterial access, the antegrade technique may be used. If balloon positioning is difficult, controlling both ends of the guide wire by traversing the vascular system may be advantageous. In our experience the retrograde double-balloon technique was frequently used to achieve improvement in aortic valve area when the single-balloon technique results were suboptimal. This occurred without increased complications, and the retrograde double balloon technique has therefore become our procedure of choice when adequate arterial access is present.
REFERENCES
1. Rapaport E: Natural history of aortic and mitral valve disease. Am J Cardiol 1975;35:221-7. 2. Frank S, Johnson A, Ross J Jr.: Natural history of valvular aortic stenosis. Br Heart J 1973;35:41-6. 3. Ross J Jr, Braunwald E: Aortic stenosis. Circulation 1968; 38(suppl 5):v61-7. 4. Cribier A, Savin T, Berland J, et al. Percutaneous transluminal balloon valvuloplasty of adult aortic stenosis: report of 92 cases. J Am Co11 Cardiol 1987;9:381-6. 5. McKav - R, Safian R. Lock J. et al. Assessment of left ventricular and aortic valve function after aortic balloon valvuloplasty in adult patients with critical aortic stenosis. Circulation 1987;75:192-203. 6. Isner J, Salem D, Desnogers M, et al. Treatment of calcific aortic stenosis by balloon valvuloplasty. Am J Cardiol 1987; 59313-7. 7. Schneider J, Wilson M, Gallant T: Percutaneous balloon aortic valvuloplasty for aortic stenosis in elderly patients at high risk for surgery. Ann Intern Med 1987;106:696-9. 8. Gorlin R, Gorlin G: Hydraulic formula for calculation of area of stenotic mitral valve, other valves, and central circulatory shunts. AM HEART J 1951;41:1-10. 9. Mullins C, Nihill M, Vick G III, et al. Double balloon technique for dilation of valvular or vessel stenosis in congenital and acquired heart disease. J Am Co11 Cardiol 1987; l&107-14. 10. Block P, Palacios I: Comparison of hemodynamic results of anterograde versus retrograde percutaneous balloon aortic valvuloplasty. Am J Cardiol 1987;60:659-62.
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Number
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Ds. Tc-99m MIBI (RP-30) and Tl-201 myocardial perfusion scintigraphy in patients with coronary artery disease: quantitative comparison of planar and tomographic techniques for uerfusion defect intensitv and defect reversibilitv _ IAbstractl. j Nd Med 1987;28:654: 51. Hakki A-H, Iskandrian AS, Kane SA, Amenta A. Thallium201 myocardial scintigraphy and left ventricular function at rest in patients with rest angina pectoris. AM HEART J 1984;108:326-32. J, Kiat H, Lew A, Shah P, Berman D. 52. Bellil D, Maddahi Significance of reversible rest-redistribution thallium-201 defects in patients with unstable angina: frequency and angiographic correlates [Abstract]. J Nucl Med 1988,29:768. 53. Kiat H, Maddahi J, Yang LD, et al. Late reversibility of tomographic myocardial thallium-201 defects: an accurate marker of myocardial viability. J Am Co11 Cardiol (in press).
Comparison
of
Tc-MIBI
and thallium 201
54. Brunken R, Schwaiger M, Grover-Mckay M, Phelps ME, Tillisch J, Schelhert HR. Positron emission tomography detects tissue metabolic activity in myocardial segments with persistent thallium perfusion defects. J Am Co11 Cardiol 1987;10:557-67. 55. Tamaki N, Yonekura Y, Senda M, et al. Value and limitations of stress thallium-201 single photon emission computed tomography: comparison with nitrogen-13 ammonia positron tomography. J Nucl Med 1988;29:1181-7. 56. Friedman J, Van Train K, Maddahi J, et al. “Upward creep” of the heart: a frequent source of false-positive reversible defects on Tl-201 stress-redistribution SPECT [Abstract]. J Nucl Med 1986;27:899-900. 57. Sporn V, Balini NP, Holman L, et al. Simultaneous measurement of ventricular function and myocardial perfusion using the technetium-99m isonitriles. Clin Nucl Med 1988;13:7781.
Comparison of three techniques for percutaneous balloon aortic valvuloplasty aortic stenosis in adults
of
Three different techniques for percutaneous balloon aortic vakuloplasty have been described: retrograde single balloon, retrograde double balloon,,and antegrade techniques. This report describes our experience usleg the three techniques in twenty-five consecutive procedures. All techniques resulted in a significant decrease In transvalvular pressure gradient and an increase in calculated aortlc valve area, without slgnlflcant difference among the three. There was no Increase in the degree of aortlc regurgitatlon after valvuloplapty by any of the techniques. Vascular complications occurred only with the retrograde double balloon technique. Cardiac tamponade during balloon Inflation occurred with both the retrograde single and double balloon technique& Three deaths occurred; two during the antegrade technique and one after the retrograde double balloon technique. Thus, ‘balloon aortlc valvuloplasty can be effectively performed using any of the three techniques. However, the differing techniques have inherent advantages in specific sltuatlons, as well as potential complications. (AM HEART J 1989;117:11.)
Eric C. Orme, MD, Robert B. Wray, MD, William H. Barry, MD, Steven K. Krueger, MD, and Jay W. Mason, MD. Salt Luke City, Utah
The poor prognosis of patients with severe aortic stenosis is well recognized.1-3 Percutaneous balloon valvuloplasty of the stenotic aortic valve has been advocated as a palliative procedure for the elderly patient, the patient with a very high surgical risk or a contraindicati& to surgical valve replacement, and the patient who refuses surgical intervention. From the Division of Cardiology, University of Utah Medical Center. Received for publication June 23, 1988; accepted Aug 2, 1988. Reprint requests: Jay W. Mason, MD, Division of Cardiology, University of Utah Medical Center, 50 North Medical Drive, Salt Lake City, Utah 84132.
Recent reports by Cribier et al.,4 McKay et al.,5 Isner et al.,6 and Schneider et aL7 have demonstrated that percutaneous balloon catheter dilatation of stenotic aortic valves leads to an acute improvement in cardiac hemodynamics and symptoms caused by aortic stenosis. This report describes experience with twenty-two patients undergoing twenty-five valvuloplasty procedures by three different techniques. METHODS Study attempted
group.
Balloon
in 22 patients
aortic
(11 men,
valvuloplasty
11 women)
with
was
a mean 11
January
12
Orme et al.
Table
American
I. Technique used and hemodynamicsbefore and after valvuloplasty Patient
Mean
No
Procedure
1 2 3 4 5+’ 6+2
A A
B 9 10 11 12+3 13 14 15 16 17+* 18+’ 19 20+3 21 22 23
Mean SD
A A A
RS A (RS), RD RS (RS),RD RS RD RD RD RD RD (RSARD RD GW, RD RD A RD RD
gradient
(mm
Pre 84 50 74 23 76 58 46 79 68 30 53 29 75 77 85 57 48 77 80 24 33 55 28 56.9 21.2
(56) (27)
(47)
(42)
1989 Journal
--.__.
Hg)
AVA
(cm-‘)
Post
Pre
Post
58 33 34 19 67 32 38 54 29 21 35 13 32 38 34 33 46 38 19 13 15 32 12 32.4 + 14.43 p
0.30 0.60 0.50 0.76 0.58 0.35 0.50 0.51 0.38 0.57 0.57 0.63 0.38 0.51 0.48 0.48 0.41 0.51 0.42 0.50 0.62 0.49 0.76 0.51 It 0.12
0.46 0.78 0.90 0.92 0.81 0.63 0.80 0.73 0.86 0.78 0.76 1.10 0.76 0.73 0.82 0.67 0.50 0.73 0.98 0.73 1.20 1.33 1.50 0.85 f 0.24 p < 0.000
A, Antegrade technique; RS, retrograde single-balloon technique; (RS), retrograde single-balloon technique; RD, retrograde double-balloon technique; AVA, calculated aortic valve area. +Repeat valvuloplasty procedure, 3 to 4 months after initial valve dilatation.
age of 78 years (range, 68 to 93 years). All patients were symptomatic, with congestive heart failure, angina, or history of syncope.All patients had severeaortic stenosis (calculated aortic valve area of less than 0.8 cm2) determined by previous cardiac catheterization. Each patient was evaluated by both a cardiothoracic surgeon and cardiologist, both of who? presentedexpected results and relative risks of surgery and balloon valvuloplasty to the patient.. Fifteen patients were considered to have unacceptably high surgicalrisk, four had high surgicalrisk and thus refused surgery, and three refused surgical valve replacement despite only moderate risk. In three patients, symptoms of congestive heart failure returned 3 to 4 monthsafter an initially successfulvalve dilatation. They underwent repeat valvuloplasty after documentation by catheterization of recurrent, severe aortic stenosis.All patients gaveconsentfor the procedure,having beeninformed of the investigational nature of the technique andthe potential complicationsand risks asoutlined by the protocol approved by the University of Utah Medical Center Institutional Review Board. Three different techniques were usedto perform the twenty-five procedures. Antegrade technique. In nine patients, valvuloplasty was performed by antegrade transseptal left heart cathe-
Heart
technique
(0.65) (0.69)
(0.44) (0.65)
was performed
before
double-balloon
terization. Right heart catheterization was performed through the left femoral vein, and pulmonary capillary wedge and pulmonary artery pressureswere monitored throughout the procedure. Transseptal left heart catheterization was performed through the right femoral vein using a 8F Mullins transseptal sheath and dilator (USC1 Division of C. R. Bard, Billerica, Mass.) and a modified Brockenbrough needle. Heparin sulfate (10,000 U) was given intravenously, and a 7F Critikon catheter (Critikon, Inc., Tampa, Fla.) was passedthrough the transseptal sheath into the left atrium and directed into the left ventricle. Left heart pressures,the aortic transvalvular gradient, and cardiac output (Fick or thermodilution method) were measured.Then the Critikon catheter was advanced antegradely acrossthe stenotic aortic valve into the descending aorta. An 0.038-inch 400 cm length Jtipped exchange guide wire (Cook Incorporated, Bloomington, Ind.) was passedthrough the catheter into the descendingaorta and “snared” by a 8F Dotter Intravascular Retrieval Set (Cook Incorporated), which had been advanced retrogradely through a left femoral artery sheath. The retrieved end of the long guide wire was drawn out of the left femoral artery sheathand secured.A 14F sheath with sidearm (Universal Medical Instruments
Volume
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Number
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Balloon aortic valvuEoplasty
ANTEGRADE:
TECHNIQUE,
AVG
RETROGRADE
SINGLE 8ALLOON
p =0.010
f-.
,
I,.
,
.
r*,
POST RETROGRADE
1.4 1
TECHNIQUE, AVG
p= 0.01
PRE ANTEGRADE
13
TECHNIQUE.
AVA
p = 0.003
SINGLE BALLOON TECHNIQUE, AVA
0.91
P=o.ma
084
/T
1.2 1 LONE 0.8-
l &I
*
.
0.2J PRE
POST
Fig. 1. Aortic valve pressure gradient (AVG) and calcuIated valve area (AVA) pre- and postantegrade aortic valvuloplasty. The technique resulted in a statistically significant decrease in AVG, and increase in AVA.
Corp., Ballston Spa, N.Y.) was exchanged for the right femoral vein transseptal sheath. The interatrial septal puncture site was then dilated with an 8 mm balloon-tipped catheter advanced along the guide wire through the right femoral vein. Dilatation of the interatrial septum allowed passage of the larger valvuloplasty balloon-tipped catheters from the right to the left atrium, and then to the left ventricular outflow tract, to be positioned across the aortic valve. Valvuloplasty balloon catheters (Mansfield Scientific Inc., Mansfield, Mass., or Cook Incorporated) with 15 mm, 18 mm, and 20 mm inflated diameter balloon tips were sequentially used for valve dilatation. The lengths of the balloons were either 3 or 5 cm, depending on availability. All balloons were inflated to 3 to 4 atm pressure, using dilute Renogaffin 60. Each balloon catheter was inflated an average of four times. The balloon was maintained in the fully inflated position for an average of 20 seconds (range, 5 to 45 seconds), and was maintained in good position across the valve annulus by controlling both ends of the long guide wire. Balloons were deflated when a significant drop in systemic blood pressure occurred. The valvuloplasty catheters were removed and the post-dilatation transaortic
0.3’
I I, PRE
81.
8 r < 1, POST
Fig. 2. Aortic valve pressure gradient (AVG) and calculated valve area (AVA) pre- and post-single balloon retrograde valvuloplasty. The technique resulted in a statistically significant decrease in AVG, and increase in AVA.
valvular pressure gradient was measured with a doublelumen catheter (Cook Incorporated) advanced antegradely through the right femoral vein to the left ventricle and a 5F pigtail catheter positioned in the ascending aorta. Cardiac output determination was repeated, and valve area was calculated by the Gorlin method.8 Single-balloon, retrograde technique. Seven patients underwent balloon aortic valvnloplasty in the retrograde single-balloon manner previously described by McKay et a1.6Four of these went on to have double-balloon dilatation when it was determined that the single-balloon technique resulted in suboptimal aortic pressure gradient reduction. The Ieft heart was catheterized retrogradely through a femoral artery, and a 5F pigtail catheter was advanced to the ascending aorta through the contralateral femoral artery for supraaortic pressure measurement. Transaortic valvular pressure gradient and cardiac output Wick or thermodilution) were measured. An 0.038-inch J-tipped guide wire was then positioned in the left ventricle and the left ventricular catheter was removed. A 4F arterial sheath with sidearm (Universal Medical Instruments Corp.) was exchanged for the arterial sheath. In five patients, single-balloon valvuloplasty was performed with a series of two or three single balloons; either 15,18, and 20 mm, or 15 and 20 mm inflated diameter balloons. In
January
14
Orme et al.
American
RETROGRADE DOUBLE BALLOON TECHNIQUE,AVG
COMPARISON
OF THE THREE
TECHNIQUES,
technique
o retrograde o retrograde
COMPARISON
OF THE THREE
TECHNIQUES,
1989 Journal
AVG
A antegrcde
60260 Lo :I . 20-
lieart
single technique double technique
AVA
0.97
RETROGRADE DOUBLE BALLOON TECHNWE. AVA 1.6 1.4 1.2
z
T
1.0
r PRE
o 0.6 i
0.6 0.4 0.2 J
8.4’
r’ PRE
1 - 1 - ‘E
’ g-l POST
Fig. 3. Aortic valve pressuregradient (AVG) and calculated valve area (AVA) pre- and post-double-balloon retrograde valvuloplasty. The technique resulted in a statisticahy significant decreasein AVG, and increasein AVA.
one patient, an 18 mm balloon only was used, and, in another, only one 20 mm balloon wasused. Balloons were typically inflated for an average of 15 seconds(range, 5 to 45 seconds),and deflated when blood pressuredropped significantly. Larger diameter balloons were exchanged when no waist in the balloon was seen with inflations. If a significant decrease in transaortic valve-pressure gradient was not produced with a 20 mm balloon, the patient went on to the double-balloon technique. After balloon dilatation, the balloon catheters were removed and a pigtail catheter was advanced to the left ventricle. Repeat pressurerecording and cardiac outputs were then performed. Double-balloon, retrograde technique. Thirteen patients underwent retrograde simultaneousdouble balloon valvuloplasty, four having undergone single-balloon dilatation followed by double-balloon dilatation. After left heart catheterization and measurementof the transvalvular pressuregradient and cardiac output, a secondpigtail catheter was passed across the aortic valve, and two 0.038-inch J-tipped exchangeguide wires were positioned in the left ventricle, one from each common femoral artery. Introducer sheaths(14F) with sidearms(Universal
,
r
r
,
,
POST
Fig. 4. Comparison of the mean aortic valve pressure
gradients (AVG) and calculated valve areas (AVA) preand postvalvuloplasty by the three different techniques. Statistical analysis showed no difference between the three techniques.
Medical Instruments Corp.) were exchangedfor the femoral arterial sheaths. In six patients, 15 mm and 20 mm balloon valvuloplasty catheters were used; in six patients, two 20mm balloon catheters wereused;and in onepatient, two 18 mm balloon catheters were used. The balloon valvuloplasty catheterswere advancedthrough the femoral arterial sheaths,positioned acrossthe aortic valve, and inflated simultaneously an average of three times for an averageof 15seconds(range,5to 60seconds).Balloonswere deflated when blood pressure dropped, and were kept inflated until a waist diminished or disappeared. After balloon dilatation, a pigtail catheter wasexchangedfor one balloon catheter and was positioned in the left ventricle. The secondballoon-tipped catheter was withdrawn to a supraaortic valve position, and repeat transvalvular pressure gradients and cardiac outputs were measured. In all patients, the catheters and vascular sheaths, except for a venous sheath, were removed immediately after the procedure, after reversal of heparin effect with protamine sulfate. Hemostasis was achieved by direct compression for 30 to 60 minutes. All patients were transported to the coronary care unit for observation for at least 18 hours. Aortography. In two patients, supravalvular aortography was performed in the LAO position before and immediately after valvuloplasty to determine the degree of aortic regurgitation. 2-D and Doppler schocerdiography. Two-dimensional,
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Balloon aortic valvuloplasty
II. Degree of aortic regurgitation determined by aortography and colorflow and Doppler flow studies before and after valvuloplasty Table
Doppler and colorflow echocardiomphy
Aortogwhy
Patient No
Procedure
Pre
Post
Pre
Post
1 2 3 4 5+’ 6+2 I 8 9
A A A A A
-
-
0
1t TR 1+ -
-
0 1+ 1+ TR 2t 2t -
RS A VW,
RD
10
RS UW, RD
11 12” 13 14 15 16 17+2 18+’ 19 20+) 21 22 23
RS RD RD RD RD RD VW, RD (RS), RD A RD RD
RD RD
1-h TR -
-
1+ TR TR 2+ 2t 1+ 1+ 0 0 1t 1t 1t 1+ 1+ 2+ 2+ 2+ 2+ 1+ 1+ 1+
1+ 1t 0 0 2t 1t 1t 1+ 2t 2t 2t 2t 1t 1t 1t
Aortography and colorflow/Doppler studies are graded on a none (O), trace (TR), mild Cl+), moderate fZ+), moderately severe (3+), severe (4+) scale. A, Antegrade technique; RS, retrograde single-baboon techniques; (RS), retrograde single-balloon technique was performed before double-baboon technique; RD, retrograde double-balloon technique; AR, aortic regurgitation. +Repeat valvuloplasty procedure, 3 to 4 months after initial valve dilatation.
colorflow, pulsed, and continuous wave Doppler echocardiography was performed 24 hours before and within 48 hours after valvuloplasty with a Hewlett-Packard 7702OA imaging system (Hewlett-Packard Co., Andover, Mass.). Aortic valve peak instantaneous gradient was calculated according to the modified Bernoulli equation (gradient = 4 [V,z-V,z] where V, = peak flow velocity in the left ventricular outflow tract, and V, = peak flow velocity in the aortic root, determined by continuous wave Doppler study), and mean aortic pressuregradient was calculated. The degree of aortic regurgitation was determined by pulsed Doppler sampling and colorflow mapping of the left ventricular outflow tract immediately below the aortic valve leaflets in parasternal long- and short-axis views and in the apical four-chamber view. Statistics. Statistical analysis of the pre- and postvalvuloplasty hemodynamic results was performed for each technique using the paired Student t test. Data are
Table
15
Ill. Complications of aortic valvuloplasty
Antegrade (n = 9)
Retrograde single balloon (n = 7)
Retrograde double balloon (n = 13)
Vascular hemorrhage CompleteAV block
0
0
1
1
0
0
Cardiactamponade during balloon inflation Death
0
1
1
2
0
1 (6 hr later)
expressedas + standard deviation. Analysis of variance was usedto accessthe pre- and postvalvuloplasty hemodynamic differencesbetween the three techniques, aswell as the differences in systemic arterial pressure during balloon inflation produced by the different techniques. RESULTS
Twenty-five aortic valvuloplasty procedures were performed. Initially successful valve dilatation occurred in 20 of 22 patients. Three of these twenty patients underwent repeat valvuloplasty 3 to 4 months after the initial procedure, resulting in a total of 23 successful valvuloplasty procedures. In 2 patients, cardiovascular collapse occurred during the procedure, before or during valve dilatation (see below). These patients were excluded from the statistical analysis of the hemodynamic data. The hemodynamic results of the valvuloplasty procedures are shown in Table I, and comparison of the three techniques is made in Figs. 1, 2, 3, and 4. All three techniques resulted in a significant decrease in transvalvuhu pressure gradient, and an increase in calculated aortic valve area. Although the numbers of patients are small, there was no significant statistical difference between the three groups. While the results of the single- and double-balloon retrograde techniques are not statistically different, more than one half (4 of 7) of the single-balloon procedures required double-balloon dilatation to achieve maximal improvement in valve area. Degree of aortlc regurgitation. Aortography or color/Doppler flow study showed no change in the degree of aortic regurgitation after valvuloplasty in 21 of 23 procedures (Table II). In one patient who underwent the antegrade technique, the degree of aortic regurgitation increased from trace to mild; in another patient, who underwent the retrograde double-balloon technique, the degree increased from
January
16
Table
Orme et al.
American
Heart
1989 Journal
IV. Average mean systemic arterial pressureduring balloon inflations Retrograde single technique (n = 33 inflations)
Antegrade technique (n = 28 inflations)
Range
41 mmHg 25-62 mm Hg
Lp
= nsI
44 mm Hg 25-60 mm Hg , p = ns
mild to moderate (Table II). No patient who underwent repeat aortic valvuloplasty had an increase in degree of regurgitation after the second dilatation. Complications. The complications that occurred with the three techniques are listed in Table III. Three patients died, two during the antegrade technique and one after the retrograde double-balloon technique. Of the deaths occurring with the antegrade technique, the first occurred because of acute mitral regurgitation caused by rupture of posterior papillary muscle chordae tendineae during valvuloplasty balloon inflation. The second death occurred during transseptal catheterization, as the result of aortic root puncture with cardiac tamponade and irreversible cardiac failure even though the hemopericardium was successfully evacuated. The third death occurred 6 hours after a successful valve dilatation (patient 14) and was thought to be caused by pulmonary embolism. A significant femoral artery hemorrhage that produced marked hypotension occurred in one patient who underwent the retrograde double-balloon technique. No local vascular complications occurred in the antegrade group. Hemopericardium that caused cardiac tamponade developed during balloon inflation in two other patients; one was undergoing the retrograde singleballoon technique, the other was undergoing the retrograde double-balloon technique. These tamponades were successfully relieved with pericardiocentesis and there were no sequelae. Postdilatation hemodynamic measurements on the patients, once stabilized, showed successful valve dilatation in both. Arterial pressure drop during balloon inflation. Table IV shows the average mean arterial pressure during balloon inflation of the three techniques. All techniques resulted in marked hypotension during inflation, without significant differences between the three. DISCUSSION
Percutaneous balloon catheter dilatation of stenotic aortic valves is being viewed as an acceptable
Retrograde double technique (n = 36 inflations)
37 mm Hg
p = ns
27-50ym Hg J
palliative procedures for adult patients with high surgical risk or those who refuse surgical valve replacement. New techniques and equipment are being developed in an attempt to increase the efficacy, safety, and applicability of the procedure. Three different techniques have been described for percutaneously dilating stenotic aortic valves: Retrograde single-balloon,5 retrograde double-balloon,g and antegrade single-balloon techniques.1° In our study, we have found that all three techniques effectively reduce the aortic transvalvular pressure gradient acutely and increase the calculated aortic valve area, without significant statistical difference between the three. However, the doubleballoon technique did produce an improved clinical response, with a greater reduction in aortic valve gradient and increase in calculated aortic valve area. Furthermore, the degree of aortic regurgitation after the valve dilatation was not significantly increased by any one of these techniques. Because of the small number of procedures reported in this series, a true difference between the three valvuloplasty procedures may have been missed. In our experience, each of these techniques has potential complications and advantages. The antegrade technique requires transseptal catheterization of a heart that may have distorted anatomical landmarks because of a dilated aortic root, enlarged right and left atria, and a thickened interatrial septum. Directing the catheter and guide wire through the left ventricular chamber and into the aorta across the stenotic aortic valve is technically difficult. Furthermore, the operator must be extremely careful to keep the guiding wire and balloon dilatation catheters free of the mitral valve leaflets and subvalvular apparatus, so as to avoid disrupting the mitral valve structures. The antegrade technique we have described differs from that of Block and Palacios’O in that a 400~cm length guide wire was used to traverse the vascular system from the right femoral vein through the heart and out of the left femoral artery. This technique was developed to provide greater positional stability of the inflated balloons across the valve by providing con-
Volume
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Number
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trol of both ends of the guide wire. However, traction of both ends of the guide wire is potentially hazardous, as intolerable force may be placed on the submitral valvular apparatus, causing damage to papillary muscles, chordae tendineae, or leaflets. The antegrade technique avoids the potential arterial vascular complications that occur with the retrograde techniques, and this allows its performance in patients without peripheral arterial vascular access. By controlling both ends of the guide wire, better control of the balloon catheter position can be achieved. However, this maneuver is technically difficult and adds additional risk to the procedure. All three techniques may be complicated by the development of cardiac tamponade during balloon inflation.5 Two mechanisms are postulated to explain this. First, hemopericardium may result from perforation of the ventricular wall by the guiding wire used to initially cross the valve or by the balloon catheter tip itself, exacerbated by markedly increased left ventricular pressure caused by outflow tract obstruction by the dilating balloon(s). Or, hemopericardium may develop because of pressure-induced rupture of the left ventricular wall, occurring without previous guide wire perforation. The use of two balloon catheters to dilate stenotic aortic valves has been advocated because they achieve a larger combined diameter when inflated, and the two balloons provide a residual lumen through which the ventricle is vented, allowing some cardiac output during dilatation. Our observations regarding drop in blood pressure during retrograde double-balloon valvuloplasty differ with others who have used this technique.g During double-balloon valvuloplasty, a decrease in peripheral arterial pressure occurred, which did not differ from that associated with the antegrade and retrograde singleballoon techniques (Table IV). Also, the doubleballoon method did not prevent tamponade. However, the double-balloon technique was necessary in more than fifty percent of the single-balloon procedures, to obtain maximal aortic valve dilatation. In conclusion, comparison of the three currently
Balloon
aortic
valuuloplasty
17
used procedures for aortic valvuloplasty has shown no statistical difference in their ability to acutely reduce the transvalvular pressure gradient or increase the calculated valve area. The differing techniques have inherent advantages and potential complications, and specific circumstances may make a certain technique preferable. When there is no arterial access, the antegrade technique may be used. If balloon positioning is difficult, controlling both ends of the guide wire by traversing the vascular system may be advantageous. In our experience the retrograde double-balloon technique was frequently used to achieve improvement in aortic valve area when the single-balloon technique results were suboptimal. This occurred without increased complications, and the retrograde double balloon technique has therefore become our procedure of choice when adequate arterial access is present.
REFERENCES
1. Rapaport E: Natural history of aortic and mitral valve disease. Am J Cardiol 1975;35:221-7. 2. Frank S, Johnson A, Ross J Jr.: Natural history of valvular aortic stenosis. Br Heart J 1973;35:41-6. 3. Ross J Jr, Braunwald E: Aortic stenosis. Circulation 1968; 38(suppl 5):v61-7. 4. Cribier A, Savin T, Berland J, et al. Percutaneous transluminal balloon valvuloplasty of adult aortic stenosis: report of 92 cases. J Am Co11 Cardiol 1987;9:381-6. 5. McKav - R, Safian R. Lock J. et al. Assessment of left ventricular and aortic valve function after aortic balloon valvuloplasty in adult patients with critical aortic stenosis. Circulation 1987;75:192-203. 6. Isner J, Salem D, Desnogers M, et al. Treatment of calcific aortic stenosis by balloon valvuloplasty. Am J Cardiol 1987; 59313-7. 7. Schneider J, Wilson M, Gallant T: Percutaneous balloon aortic valvuloplasty for aortic stenosis in elderly patients at high risk for surgery. Ann Intern Med 1987;106:696-9. 8. Gorlin R, Gorlin G: Hydraulic formula for calculation of area of stenotic mitral valve, other valves, and central circulatory shunts. AM HEART J 1951;41:1-10. 9. Mullins C, Nihill M, Vick G III, et al. Double balloon technique for dilation of valvular or vessel stenosis in congenital and acquired heart disease. J Am Co11 Cardiol 1987; l&107-14. 10. Block P, Palacios I: Comparison of hemodynamic results of anterograde versus retrograde percutaneous balloon aortic valvuloplasty. Am J Cardiol 1987;60:659-62.