Effectiveness of percutaneous balloon valvuloplasty in adults with pulmonic valve stenosis

stenotic tricuspid valves. Of their 28 patients, 16 (57%) had normal and 12 (43%) had diffusely fibrotic tricuspid valves. All of the latter 12 patients had postinflammatory (rheumatic) mitral and tricuspid valve disease. It is unclear whether some of the 28 patients reported by Hauck et al had associated aortic valve disease. The latter patients were excluded from our study. None of the 45 necropsy patients with pure tricuspid regurgitation reported by Waller et al l1 had pure mitral regurgitation. Because in recent years there has been a tendency to perform anuloplasty for tricuspid regurgitation associated with left-sided valvular heart disease rather than tricuspid valve replacement, it is likely that right-sided valve replacement would not have been performed in most of the patients described herein were the operation performed today. Thus, the opportunity to examine the tricuspid valve in similar fashion in patients with pure, chronic mitral regurgitation will be less likely in the future. In summary, the type of tricuspid valve dysfunction occurring in association with pure chronic mitral regurgitation is virtually always pure regurgitation, and the cause of the tricuspid valve regurgitation is usually dilatation of the tricuspid valve anulus.

Effectiveness of Percutaneous Pulmonic Valve Stenosis

1. Cohen SR, Sell JE, McIntosh CL, Clark RE. Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. I. Prevalence, diagnosis, and comparison of preoperative clinical and hemcdynamic features in patients with and without tricuspid regurgitation. J Thorac Cardiowsc Surg 1987;94: 481-487. 2. Cohen SR, Sell JE, McIntosh CL, Clark RE. Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement. J Thornc Cardiovasc Surg 1987;94:488-497. 3. Roberts WC, McIntosh CL, Wallace RB. Mechanisms of severe mitral regurgitation in mitral valve prolapse determined from analysis of operatively excised valves. Am Heart J 1987;113:1316-1323, 4. Dollar AL, Roberts WC. Morphologic comparison of patients with mitral valve prolapse who died suddenly with patients who died from severe valvular dysfunction or other conditions. J Am Co11 Cardiol 1991;17:921-931. 5. Roberts CS, Roberts WC. Morphologic features (of hypertrophic cardiomyopathy). Prog Cardiol 1989;2/2:3-32. 6. Roberts WC, Buchbinder NA. Healed left-sided infective endocarditis: a clinicopathologic study of 59 patients. Am J Cardiol 1977;40:876-888. 7. Harley JB, McIntosh CL, Kirklin JJW, Maron BJ. Gottdiener J, Roberts WC, Fauci AS. Atrioventricular valve replacement in the idiopathic hypereosinophilic syndrome. Am J Med 1982;73:77-81. 8. Roberts WC. Morphologic features of the normal and abnormal mitral valve. Am J Cardiol 1983;51:1005-1028. 9. Ross EM, Roberts WC. The carcinoid syndrome. Comparison of 21 necropsy subjects with carcinoid heart disease to 15 necropsy subjects without carcinoid heart disease. Am J Med 198379339-354. 10. Hauck AJ, Freeman DP, Ackerman” DM, Danielson GK, Edwards WD. Surgical pathology of the tricuspid valve. A study of 363 cases spanning 25 years. Mayo Chin Proc 1988;63:851-863.

11. Wailer BF, Moriarty AT, Eble JN, Davey DM, Hawley DA, Pless JE. Etiology of pure tricuspid regurgitation based on anular circumference and leaflet area: analysis of 45 necropsy patients with clinical and morphologic evidence of pure tricuspid regurgitation. J Am Coil Cardiol 1986;7:1063-1074.

Balloon

Valvuloplasty

Howard C. Herrmann, MD, James A. Hill, MD, Jane Krol, RN, J. Patrick and Carl J. Pepine, MD, for the M-Heart Registry

in Adults

with

Kleaveland, MD,

n children with congenital pulmonic stenosis (PS), Pennsylvania). Clinical status at follow-up was obpercutaneous balloon valvuloplasty has developed as tained by telephone contact with the patient, and peak an excellent treatment modality that can decrease gradient at follow-up was assessedby echocardiogratransvalvular gradient and right ventricular pressure with pb few complications both immediately and during followPercutaneous balloon valvuloplasty was perup.192 Less is known about the immediate results and formed by standard techniques using 1 balloon over a long-term follow-up of this procedure in adults with PS. guidewire through the femoral vein approach, asfirst We evaluated the immediate outcome, complications described by Kan et al.’ Balloon size varied asfollows: and course of valvuloplasty in adult patients with PS 23 (n = I), 2.5(n = 4) (Mansfield Scientific, Boston) recorded in a multicenter (M-Heart) balloon valvulo- and 27 mm (n = 2) (Cook, Indianapolis). All patients plasty registry. received heparin intravenously during the procedure

I

The study group (Table I> consisted of adults (aged >21 years) with PS undergoing valvuloplasty at 7 hospitals3 from May 1986 to September 1989. Baseline clinical information and hemodynamic results were recorded on a standardized form and forwarded to a central data analysis center (University of From the Cardiovascular Section, 9 Founders Pavilion, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. Manuscript received March 8, 1991; revised manuscript received and accepted June 25,199 1.

and gave informed consent as required by each center’s institutional review board. Results are expressed as mean values f standard error of the mean. Hemodynamic data were compared before and after valvuloplasty using the paired t test, and p values
REPORTS

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11

TABLE

I Baseline

Characteristics

Pt. No.

Age (yr) & Sex

1 2 3 4 5 6 7 8 Mean

23 24 28 38 41 46 54 66 40

& SEM

NYHA = New York Heart Association;

NYHA Class

Etiology

F F F F M F F F k 5

Congenital Congenital Congenital Congenital Congenital Congenital Rheumatic Carcinoid

PA = pulmonary

Peak Gradient

(mm/Hg)

II II I I II II IV Ill 2.1 k 0.4

artery; RV = right ventricle;

SEM = standard

42 50 75 65

101 54 80 25 62 t- 8

RV Systolic Pressure (mm/Hg) 62 88 95 80 115 80

110 42 a4 z!z 9

Mean PA Pressure (mm/H@ 14 24 14 12

10 12 22 13 15 f 2

1

error of the mean.

rheumatic heart disease (no. 7) had valvular calcium Anotherpatient (no. 5) developed infundibular obstruction with hypotension after valvuloplasty, and visible by jluoroscopy. Valvuloplasty was performed was treated with intravenous verapamil (I 0 mg) and in 6 patients because of symptoms that included fameasurements tigue, peripheral edema, dyspnea on exertion, and propranolol (5 mg). Hemodynamic chest pain. Two minimally symptomatic patients un- demonstrated a reduction in the valvular gradient derwent valvuloplasty to reduce a large gradient. In- from 101 to 14 mm Hg with the development of a new 50 mm Hg gradient across the right ventricular outfundibular stenosis or hypertrophy waspresent angioflow tract. Follow-up studies in this patient demongraphically before valvuloplasty in 6 patients. strated a progressive decrease in the infundibular graPercutaneous balloon valvuloplasty was technicaldient to 33 mm Hg 48 hours after the procedure and ly successful in all 8 patients. Peak transpulmonic to 1.5 mm Hg 4 months later. The total right ventricvalve gradient decreased from 62 f 8 to 22 f 6 mm artery peak gradient assessed by Hg (p
*p
FIGURE 1. Peak transpulmonic valve gradii assessed by Doppler echocardiography. F/U = follow-up; POST = after vahwk@asty; PRE (ar pre) = before vatvuloplasty. *p CO.001 versus Wore valvulolasty.

PEAK GRADIENT (mm W

0: PRE (62 2 8)

ii

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THE AMERICAN

JOURNAL

OF CARDIOLOGY

F/U (20 5 3)*

POST (22 2 6) *

VOLUME

68

OCTOBER

15,

1991

Follow-up of pediatric patients has demonstrated sustained improvement after successful balloon dilation. McCrindle and Kan2 demonstrated by Doppler echocardiography no change in gradient 4 years after valvuloplasty,2 and Thapar and Raott demonstrated a further reduction or disappearance of an infundibular gradient in 13 children 10 months after dilation. In Fawzy et al’s7 In 1982, Kan et al1 performed a percutaneous balloon series of adults, peak transvalvular gradient decreased valvuloplasty in an g-year-old child, and this has subsequently become the procedure of choice in infants and during 12.6 month follow-up from 38 to 18 mm Hg, and children.4 In the large multicenter valvuloplasty and an- peak right ventricular systolic pressure decreased from gioplasty of congenital anomalies registry of almost 800 59 to 43 mm Hg. Echocardiographic follow-up was obchildren5 mean gradient decreased from 71 to 28 mm tained in 6 of our patients at a mean of 2 years after Hg after valvuloplasty. Other studies have provided simi- dilation and demonstrated sustained decreases in peak lar hemodynamic results and also demonstrated that the pulrnonic valve gradient. All of these patients also had improvement is sustained.2 marked improvement in symptoms of fatigue and chest In comparison, much less data are available on the discomfort. results of valvuloplasty in adults. In 1982, Pepine et al6 Percutaneous balloon valvuloplasty is a promising described the successful reduction in valvular gradient in technique for the treatment of adult patients with either a 59-year-old woman. Recently, Fawzy et al7 described a acquired or congenital PS. The immediate hemodynamic series of 22 adults in Saudi Arabia with severe congenital results appear similar to previous reports in infants and PS. In that study, peak transvalvular gradient decreased children, with a reduction in peak gradient to approxifrom 111 to 38 mm Hg immediately after valvuloplasty mately 20 mm Hg and sustained improvement during 2 and decreased further to 18 mm Hg in a subgroup under- year follow-up. Major complications are rare. Percutanegoing repeat catheterization 1 year later. Our patients ous balloon dilation appears warranted as the primary were older than those in the series of Fawzy (mean age treatment of adult patients with severe PS. 40 vs 2.5 years) and had less severe PS (right ventricular systolic pressure 84 vs 129 mm Hg). Final right ventricu1. Kan JS, White RI, Mitchell SE, Gardner TI. Percutaneous balloon valvulolar systolic pressure and peak gradient after valvuloplasty plasty: a new method for treating congenital pulmonary valve stenosis. N Engl J were both lower in our series. However, there was a large Med 1982;307:540-542. incidence of infundibular stenosis in the series of Fawzy 2. McCrindle BW, Kan JS. Long-term results after balloon pulmonary valvuloplasty. Cimdafion 1991;83:1915-1922. with subsequent regression of the outflow tract gradient 3. Herrmann HC, Kleaveland JP, Hill JA, Cowley MJ, Margolis JR, Nocero that may have accounted for part of this difference.7 MA, Zalewski A, Pepine CJ. The M-heart percutaneous balloon mitral valvuloMajor complications of balloon valvuloplasty for PS plasty registry: initial results and early follow-up. J Am Co11 Cardiol 1990; were reported from the valvuloplasty and angioplasty of 4.15:1221-1226. Rao PS. Indications for balloon pulmonary valvuloplasty. Am Heart J congenital anomalies registry, including death (0.2%), 1988:1661-1662. cardiac perforation (0.1) and tricuspid insufficiency 5. Stanger P, Cassidy SC, Girod DA, Kan JS, Labadidi Z, Shapiro SR. Balloon pulmonary valvnloplasty: results of the valvuloplasty and angioplasty of congenital (0.2), as well as minor complications and incidents (1 to anomalies registry. Am J Cardiol 1990;65:775-783. 3).5 One death occurred in our series (an elderly woman 6. Pepine CJ, Gessner IH, Feldman RL. Percutaneous balloon valvuloplasty for valve stenosis in the adult. Am J Cardiol 1982;50:1442-1445. who developed sepsis after the procedure). Because a pulmonic 7. Fawzy ME, Gala 0, Dunn B, Shikh A, Sriram R, Duran CMG. Regression of small incidence of infection has been reported in other infundibular pulmonary stenosis after successful balloon pulmonary valvuloplasty studies of balloon valvuloplasty in adult patients8 we in adults. C&et Cardiouasc Diagn 1990;21:77-81, 8. Cujec B, McMeekin J, Lopez J. Bacterial endocarditis after percutaneous recommend periprocedural antibiotic prophylaxis during aortic valvuloplasty. Anz Heart J 1988;115:178-179. all valvuloplasty procedures. The occurrence and regres- 9. Ben-Shachar G, Cohen MH, Sivakoff MC, Portman MA, Riemenschneider TA, Van Hceckeren DW. Development of infundibular obstruction after percutasion of an infundibular gradient due to hypertrophy and neous pulmonary balloon VaIvuloplasty. J Am Coil Cardiol 1985;5:754-756. spasm have been previously described; the administration 10. Fontes VS, Esteves CA, Sousa JE, Silva MVD, Bembom MCB. Regression of hypertrophy after pulmonary valvuloplasty for pulmonic stenosis. of calcium antagonists and P-blocking agents, acutely infundibular J Cardiol 1988;62:977-979. and until regression is documented, has been advo- Am 11. Thapar MK, Rae PS. Significance of infundibular obstruction following cated.7,9Jo balloon valvuloplasty for valvar pulmonic stenosis. Am Heart J 1989;118:99-103. was not statistically significant. Peak transpulmonic valve gradient assessed by Doppler echocardiography (20 f 3 mmHg) remained improved at follow-up (p
BRIEF REPORTS

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