[Show abstract][Hide abstract] ABSTRACT: The data of 93 patients (age 11.4 ± 9.4 years, range 8 months - 56 years) who underwent pulmonary balloon valvuloplasty (PBV) for valvular pulmonic stenosis (PS) in our institution are reviewed. The patients were classified into three groups: Group I (34 patients) had a right ventricular (RV) to aortic systolic pressure ratio of < 1, Group II (39 patients) had suprasystemic RV systolic pressures, and Group III (20 patients) included patients with elevated mean right atrial (RA) pressures irrespective of the RV systolic pressures. The percentage drop in immediate postdilatation peak systolic gradients (PSG) and the follow-up PSG were similar in the three groups and were not influenced by any predilatation patient characteristics. A balloon-annulus ratio < 1 predicted a poorer follow-up outcome. Nine patients, eight of Group III and one of Group II, experienced difficult procedures requiring sequential use of progressively larger balloon catheters. Eleven patients, six of Group II and five of Group III, experienced procedure-related events (hypotension, bradycardia/asystole, hypoxia, apnea, tachyarrhythmias, and seizures) and one patient (Group II) died. Although changes in immediate and follow-up gradients after PBV are not influenced by the severity of PS, difficult procedures and procedure-related events are particularly common in patients with severe PS and elevated RA pressures. A cautious and planned approach is therefore indicated in these patients.
[Show abstract][Hide abstract] ABSTRACT: Pulmonary balloon valvuloplasty (PBV) is an effective method to treat congenital valvular pulmonic stenosis, but the ideal balloon-anulus ratio (BAR) for this procedure remains unclear. We studied 71 procedures where BARs of 1.0-1.5 were used, since it has been shown that a ratio of < 1.0 is less effective and that of > 1.5 may produce more complications. A curvilinear relation was found between BAR and the fractional fall in haemodynamic parameters reflecting stenosis severity, both immediately after dilatation and at follow-up. Best results were observed with a BAR of 1.25, with progressive worsening on either side of this ratio. The relationship remained significant in multiple regression analysis involving age, sex and baseline haemodynamic variables. The data show that a BAR of 1.25 is probably the ideal ratio for PBV.
[Show abstract][Hide abstract] ABSTRACT: Major intimal dissections during coronary angioplasty are an important cause of early morbidity and mortality. In the recent past various non-surgical modalities to manage such dissections have been developed. The choice of therapy among these needs knowledge not only of immediate success but also of long term results. Data on long term follow up of patients managed with prolonged balloon inflations using a perfusion balloon catheter is limited. We herein report our experience of twenty seven consecutive patients managed by prolonged dilatations using Stack perfusion balloon catheter. All the patients had a long dissection with luminal compromise, 6 (22%) had in addition an acute complete occlusion, and in 4 (15%) there was a thrombus. Only 6 (22%) needed an emergency CABG, with the remaining having an event free hospital stay. At follow up after 6-26 months, 7/21 (33%) had severe symptoms and 5 of them underwent coronary arteriography with four having a repeat successful dilatation. The findings of this study suggest that the perfusion balloon catheter is a useful modality for management of major dissections with a restenosis rate similar to that of primary PTCA. Randomised controlled trials are required to assess its efficacy vis a vis the newer therapeutic options like stents, lasers and atherectomy.
[Show abstract][Hide abstract] ABSTRACT: To determine whether mitral valve (MV) morphology influences the result of balloon mitral valvuloplasty (BMV) for mitral stenosis, two-dimensional echocardiography was performed before BMV in 53 patients and in 25 normal controls. The two-dimensional echocardiographic features of MV leaflets: thickness, length and motion, diastolic MV excursion, chordal length, MV annular diameter (MVAnD), subvalvular distance ratio (SDR), and effective balloon dilating area (EBDA) and diameter (EBDD) were then correlated to the immediate post-BMV mitral valve area (MVA). For the total patient population, post-BMV MVA increased from 0.76 +/- 0.24 to 1.91 +/- 0.59 cm2 (p < 0.0001) and mean diastolic transmitral gradient decreased from 20.1 +/- 6.15 to 5.8 +/- 3.29 mm (p < 0.0001). The patients were divided into two groups on the basis of post-BMV MVA. Group I had post-BMV MVA < 2.0 cm2 and group II had post-BMV MVA > or = 2.0 cm2. A statistically significant difference was noted in SDR (0.33 +/- 0.057 vs 0.45 +/- 0.042, p < 0.0001); mid-MV anulus to tip of papillary muscle (PM) distance (20.0 +/- 3.8 vs 27.9 +/- 4.54 mm, p < 0.0001); chordal length (4.3 +/- 3.6 vs 9.8 +/- 3.9 mm, p < 0.0001); diastolic MV excursion (15.5 +/- 2.6 vs 18.2 +/- 4.2 mm, p < 0.01); leaflet mobility (p < 0.05); and EBDA (4.4 +/- 0.6 vs 4.9 +/- 0.5 cm2, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
American Heart Journal 12/1993; 126(5):1147-51. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hepatic venous outflow obstruction (HVOO) is a rare cause of portal hypertension and conservative treatment is usually ineffective. A large series of patients gave us an opportunity to devise a management protocol for this disorder. Between 1978 and 1992, we prospectively studied 75 patients with HVOO. The obstruction was in the hepatic vein in 24, in the inferior vena cava (IVC) in 44, and in both in 7. For hepatic vein obstruction proximal splenorenal shunts were done in 7 (2 died postoperatively); 4 shunts blocked and only 1 patient became completely symptom free. In 2 patients with partial obstruction we performed balloon dilatation of the right hepatic veins but within 6 months the obstruction recurred. In the next 6 patients we constructed a side-to-side portocaval shunt; 2 died of encephalopathy after discharge and 4 are alive and well. For IVC obstruction, after surgical procedures had yielded poor results in 14 patients, we changed to balloon angioplasty which was successful in 28 of the 30 other patients; restenosis occurred in 4. Of the 7 patients with a combined block, 3 have had balloon angioplasty followed by a side-to-side portocaval shunt; 1 died, 2 are well, and the remainder have not completed treatment. Of our 75 patients, 22 have died (5 in hospital and 17 after discharge), 7 have not completed treatment, and 2 have been lost to follow-up. However, 44 are symptom free. We did not encounter any case of hepatocellular carcinoma. We suggest that patients with HVOO should be actively managed with a side-to-side portocaval shunt for hepatic vein obstruction, balloon angioplasty for inferior vena caval obstruction, and perhaps both procedures for those with combined obstructions.
The Lancet 10/1993; 342(8873):718-22. · 39.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Over a 7-year period, 110 of 35,000 echocardiographic cases were diagnosed to have total anomalous pulmonary venous connection (TAPVC). Ages ranged from 7 days to 38 years (male 62, female, 48). In 60 cases the diagnosis was confirmed by angiography (n = 47) and/or surgery (n = 50). In 13 cases angiography was not performed; surgery was performed on the basis of echocardiographic diagnosis. Diagnosis of TAPVC was correctly made in all of the 60 confirmed cases. Drainage sites were correctly identified by echocardiography in 58 (96.7%) of these 60 cases. Of the five cases of mixed TAPVC, the second drainage site was missed by echocardiography in two cases. Of the 110 cases the drainage sites were as follows: supracardiac 70, cardiac 30, infracardiac 5, and mixed variety 5. Seventeen cases had Doppler echocardiographic evidence of obstruction along the course of the anomalous vein. The continuous wave Doppler signal for tricuspid regurgitation was present in 14 of 47 catheterized patients, and catheterization-measured peak pulmonary artery systolic pressure correlated well with that derived by Doppler study (r = 0.96, p = 0.001). Additionally, 17 patients had other cardiac anomalies that were correctly diagnosed by echocardiography. Combined two-dimensional and Doppler echocardiography is accurate in the diagnosis of TAPVC, identification of the site of drainage, presence of obstruction, and assessment of pulmonary arterial hypertension and other associated anomalies.
American Heart Journal 09/1993; 126(2):433-40. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Balloon size for balloon mitral valvotomy (BMV) must be chosen with care in order to achieve optimal increase in mitral valve area without significant regurgitation. Previous workers have suggested optimal ranges for the effective balloon dilating area indexed to body surface area.1 Oversizing of balloons was found to be associated with the development of mitral regurgitation. We present our experience regarding the relation between balloon size and the outcome of BMV in Indian patients. We analyzed the records of 69 patients who underwent BMV by a cylindrical balloon technique at our institution from 1985 to 1991. The patients were aged 21.9 ± 6.7 years, 47 women (71%) and 19 men (29%). No patient had significant subvalvular deformity on echocardiography.
The American Journal of Cardiology 07/1993; 71(16):1469-70. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Twenty-one patients (17 men and 4 women, aged 20 to 40 years) with end-stage renal disease (creatinine clearance persistently < 5 ml/min for > 3 months) were evaluated for left ventricular (LV) diastolic function by Doppler echocardiography before and after hemodialysis. Fifteen patients were on maintenance hemodialysis (group A) and 6 were studied before and after their first hemodialysis (group B). The following indexes of LV diastolic function were studied: (1) isovolumic relaxation time; and (2) Doppler indexes from mitral inflow signal--peak early velocity, peak late velocity (atrial), deceleration of early filling phase, and deceleration time of early filling phase. LV systolic function in groups A and B (LV ejection fraction 68 +/- 6 and 77 +/- 5%, fractional shortening 0.39 +/- 0.06 and 0.46 +/- 0.05%) was normal and did not change after hemodialysis. Group A had a prolonged isovolumic relaxation time of 80 +/- 22 ms, which decreased to 57 +/- 14 ms (p < 0.005). Deceleration time decreased from 248 +/- 58 to 184 +/- 38 ms (p < 0.00005) and the deceleration slope increased from 4.3 +/- 1.8 to 5.1 +/- 1.6 m/s2 (p < 0.005) after hemodialysis. In group B, isovolumic relaxation time decreased from 87 +/- 21 to 73 +/- 15 ms (p < 0.05), deceleration time decreased from 256 +/- 43 to 185 +/- 34 ms (p < 0.05), and deceleration slope increased from 3.5 +/- 0.8 to 4.2 +/- 1.1 m/s2 (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
The American Journal of Cardiology 07/1993; 71(16):1427-30. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Concurrent percutaneous balloon valvotomy of aortic and tricuspid valve was successfully performed in a 20-year-old male with severe rheumatic aortic and tricuspid stenosis. Balloon valvotomy was done using a 18-mm single balloon for aortic and 20 + 20-mm double balloon for the tricuspid valve. Immediately after valvotomy the peak transaortic systolic gradient decreased from 120 to 32 mmHg and the aortic valve area increased from 0.27 to 1.1 cm2, the mean and end-diastolic trans-tricuspid gradient decreased from 14 and 18 to 1.5 and 2 mmHg, respectively, the tricuspid valve area increased from 0.8 to 3.6 cm2 and the cardiac-index increased from 2 to 2.9 l/mt/m2. At 1 year of follow-up the clinical (NYHA class 1) and hemodynamic improvement was maintained.
International Journal of Cardiology 03/1993; 38(2):183-6. · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Isolated valvular pulmonic stenosis (PS) in association with tricuspid regurgitation and congestive heart failure (CHF) is rarely encountered after infancy, and there is very little information available regarding the application of pulmonary balloon valvotomy (PBV) for this subset of patients. Since 1985, 10 patients (5 males, 5 females; mean age: 12.4 +/- 7.5 years, range 4-25 years) underwent PBV for severe valvular PS with CHF in our institution. All patients had associated tricuspid regurgitation and cardiomegaly. Before PBV, the mean peak systolic gradient across the right ventricular outflow was 131 +/- 36 mmHg and the mean right atrial pressure was 14.4 +/- 5.4 mmHg. Specific modifications in the PBV technique included the sequential use of progressively larger balloon catheters and the use of an extra stiff guidewire to support the dilatation assembly. One patient underwent PBV via the right internal jugular vein. Problems encountered during PBV included hypotension and bradycardia (2 patients) and respiratory arrest, which was transient in one patient, and prolonged and eventually fatal in one patient. A successful outcome was achieved in 8 patients (4 of these required 2 PBV attempts) with a final residual gradient of 40 mmHg or less, mean 28 +/- 7; range: 21-38 mmHg) and complete resolution of CHF. One patient has had no significant change in gradients and awaits repeat dilatation. Patients with isolated severe valvular PS with TR and CHF represent a relatively high risk group for PBV. A successful outcome is, however, feasible if a carefully planned and cautious approach is used.
Catheterization and Cardiovascular Diagnosis 03/1993; 28(2):137-41.
[Show abstract][Hide abstract] ABSTRACT: The hemodynamic response to closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty was compared using 20 patients in each group. All patients had symptomatic rheumatic mitral stenosis with a mitral valve area < 1 cm2, without any left atrial clot, mitral valve calcification, or mitral regurgitation. There was a significant improvement in hemodynamics following intervention in all three groups. The mean pulmonary artery pressure decreased from 49.1 +/- 17.5 to 28.6 +/- 8.3 mm Hg (p < 0.001), 48.8 +/- 12.3 to 34.0 +/- 13.9 mm Hg (p < 0.001), and 46.7 +/- 18.0 to 26.3 +/- 13.7 mm Hg (p < 0.001) in the closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty groups, respectively. The mitral valve area increased from 0.62 +/- 0.27 to 1.5 +/- 0.5 cm2 (p < 0.001), 0.68 +/- 0.24 to 1.5 +/- 0.4 cm2 (p < 0.001), and 0.68 +/- 0.25 to 1.9 +/- 0.8 cm2 (p < 0.001) in the closed mitral commissurotomy, single-balloon, and double-balloon mitral valvuloplasty groups, respectively. The increase in the mitral valve area was maximum in the group with double-balloon mitral valvuloplasty. In the closed mitral commissurotomy group there was a significant rise in left ventricular end-diastolic pressure, from 6.8 +/- 3.9 to 9.3 +/- 3.1 mm Hg (p < 0.001), but this remained unchanged in the single-balloon and double-balloon mitral valvuloplasty groups. Our study shows that single-balloon and double-balloon mitral valvuloplasty are comparable to closed mitral commissurotomy in the immediate hemodynamic response, with a larger valve area in the double-balloon mitral valvuloplasty group.
Journal of Thoracic and Cardiovascular Surgery 12/1992; 104(5):1264-7. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Twenty consecutive symptomatic patients of mitral valve prolapse (MVP) and 20 normal age, sex and symptom matched controls were studied. Ambulatory monitoring studies revealed the presence of atrial premature beats (APC) in 16 subjects in each group. Isolated ventricular premature beats (VPC) were observed in 12 patients with MVP and 15 subjects in control group (p = ns). Complex VPCs (Lown IVa, IVb) were recorded in 4 patients of MVP vs 3 controls (p = ns). There was no correlation between the occurrence of arrhythmias with the degree of MVP or the degree of mitral regurgitation. Likewise, MVP patients with prolonged QTc interval did not show higher incidence of spontaneous arrhythmias when compared to those with normal QTc interval. Nineteen patients underwent electrophysiological studies. Two patients showed evidence of abnormal sinus node function. Both these patients in addition had AV nodal abnormalities, manifested by prolonged AH interval. Programmed stimulation studies induced AV nodal tachycardia in one and non-sustained ventricular tachycardia in two (polymorphic in one and monomorphic in the other). Ambulatory monitoring in both these patients did not show any evidence of complex VPCs or VT, indicating poor correlation between inducibility and presence of spontaneous complex VPCs. Patients with MVP do not have a higher prevalence of spontaneous atrial or ventricular arrhythmias when compared to matched normal controls with similar symptomatology. The presence of mitral regurgitation, severity of MVP and associated prolonged QTc interval is not associated with higher prevalence of arrhythmias. The correlation between spontaneous and inducible arrhythmias is poor.(ABSTRACT TRUNCATED AT 250 WORDS)
The Journal of the Association of Physicians of India 07/1992; 40(6):367-70.
[Show abstract][Hide abstract] ABSTRACT: We performed transluminal angioplasty for an eccentric, calcific stenosis of the thoracic aorta in a patient with nonspecific aortoarteritis and encountered an iatrogenic aortic dissection. Follow-up by intravenous digital subtraction angiography at 12 hours and at one week showed no change in the picture. He is asymptomatic at 6 months except for residual hypertension. Eccentric, localized thoracic stenosis may constitute an unfavourable angiographic morphology for angioplasty.
International Journal of Cardiology 06/1992; 35(2):264-7. · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We have evaluated the effect of fish oil supplementation in the prevention of restenosis after percutaneous transluminal coronary angioplasty by a randomised trial conducted in 107 patients. The treatment group (n = 58, 96 significant coronary narrowings) received 10 capsules of fish oil (1.8 g eicosapentaenoic acid, 1.2 g docosahexaenoic acid) besides aspirin and calcium blockers, beginning 4.3 (SD 2.9) days before coronary angioplasty. The conventional medical treatment group (n = 49, 81 significant coronary narrowings) received only aspirin and calcium blockers. Enrollment required the presence of angina pectoris and successful dilatation of all significant coronary narrowings. All patients were followed-up for at least 6 months. Restenosis was identified by symptoms and exercise testing and confirmed by angiography. The incidence of angiographic restenosis was 32% in the fish oil group and 27% in the conventional treatment group. Biochemical investigations showed a greater decrease in serum triglyceride levels in fish oil group as compared to the conventional treatment group. There was no significant difference in the cholesterol levels over the treatment period. Administration of fish oil in a dose of 3 g per day did not reduce the incidence of early restenosis after coronary angioplasty.
International Journal of Cardiology 05/1992; 35(1):87-93. · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report herein 2 cases with complete obstruction of the suprahepatic portion of the inferior vena cava successfully treated by balloon angioplasty after crossing the obstructing segment with the stiff end of the guidewire in 1 case and the Brockenbrough's trans-septal needle in the other. The gradients across the obstruction fell from 13 and 20 mm Hg to 3 and 4 mm Hg, respectively. Angioplasty resulted in dramatic clinical hemodynamic and angiographic improvement.
Catheterization and Cardiovascular Diagnosis 05/1992; 25(4):320-2.
[Show abstract][Hide abstract] ABSTRACT: Sixteen patients (12 male and 4 female, age 2-46 years) with endomyocardial biopsy-proven myocarditis were prospectively evaluated with immunosuppressive therapy including azathioprine and prednisolone in addition to other standard measures. Patients were either in NYHA class IV (n = 12) or class III (n = 4). Twelve patients showed improvement and the remaining 4 continued to deteriorate: 2 died at 1 and 2 months after therapy and the other 2 were lost to follow-up after 4-6 weeks of therapy. Three of the 12 patients who showed significant improvement, after sudden omission of therapy (at 8 weeks, 6 and 8 months) worsened and died. One patient who showed significant improvement died suddenly after 9 months of therapy while playing football. The remaining patients have shown significant clinical and haemodynamic improvement with normalization of myocardial morphology. Serial haemodynamic studies revealed a significant fall in cardiothoracic ratio (before: 62.3 +/- 4.7%; 3 months: 55.1 +/- 3.1%, P less than 0.0001; 6-12 months: 50.6 +/- 1.5%, P less than 0.0001), mean pulmonary artery pressure (before: 34.3 +/- 13.05 mm; 3 months: 20.4 +/- 8.71 mm, P less than 0.01; 6-12 months: 20.0 +/- 2.75 mm, P less than 0.01) and mean pulmonary artery wedge pressure (before: 26.0 +/- 9.07 mm; 3 months 14.0 +/- 5.63 mm, P less than 0.001; 6-12 months: 13.2 +/- 4.57 mm, P less than 0.001). The left ventricular ejection fraction improved from 24.3 +/- 8.36% to 35.8 +/- 9.72% (P less than 0.001) at 3 months and 49.8 +/- 18.2% (P less than 0.0001) at 6-12 months of therapy. Two patients have been subsequently lost to follow-up whereas the remaining 6 patients are on follow-up for 1-4 years after therapy and are doing fine. Our uncontrolled observations suggest that immunosuppressive therapy may be useful in patients with inflammatory myocarditis.
International Journal of Cardiology 03/1992; 34(2):157-66. · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Data of 44 patients with congenital complete heart block and structurally normal heart have been analysed. Thirty one patients were asymptomatic (group I) and 13 patients had symptoms of low cerebral perfusion like syncope, near syncope or convulsions (group II). A ventricular rate on surface ECG was found to be significantly lower in the symptomatic group (56.7 +/- 13.2 beats per minute, bpm, in group I and 46.5 +/- 6.0 bpm in group II). Similarly wide QRS escape rhythm of greater than 0.10 seconds was more often seen in group II (2/13) as compared to group I (2/31) though the difference did not reach statistical significance. Presence of pauses of more than 3.0 seconds on ambulatory ECG monitoring were infrequent in both the groups (group I 1/7, group II 2/7), however more often seen in group II. Electrophysiological studies carried out in 11 patients were not helpful in differentiating the two groups and all the patients including two with a wide QRS escape rhythm on surface ECG showed suprahisian level of block. The corrected junctional recovery time in two groups did not show any statistical difference. A persistently slow ventricular rate of less than 50 bpm during waking hours, wide QRS escape rhythm and pauses of greater than 3 seconds on ambulatory monitoring are suggestive of high risk to the patient and may justify implantation of permanent pacemaker even in asymptomatic patients.
[Show abstract][Hide abstract] ABSTRACT: Twenty high risk patients with severe angina were subjected to balloon angioplasty after instituting percutaneous cardiopulmonary bypass support to enhance the safety of high risk elective coronary angioplasty. All patients had a low ejection fraction, a large amount of viable myocardium perfused by the targeted artery or both (left ventricular ejection fraction < or = 25% in 15 patients). Three vessel disease was present in all. Angioplasty of the only remaining vessel was done in 14 patients, 2 vessels in 5 patients and a sequential graft in 1 patient. Bypass flows ranged from 2.8-4.5 litres. Bypass was discontinued after a mean bypass time of 35 min. Haemostasis was achieved by external clamp compression in 16 patients. The angioplasty was successfully performed in all the patients and the procedure was well tolerated. During the bypass period the pulmonary artery diastolic pressures ranged from 0-8 mm Hg. There was 1 hospital death due to abrupt vessel closure. Two patients required surgical help to repair femoral artery. During the follow up period of 1-12 months, 67% patients have no angina and only 1 has died. Our experience demonstrates the safety and efficacy of percutaneous bypass support in selected patients undergoing high risk coronary angioplasty.