Arterial sheath insertion without prior skin incision.
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Cardiac Catheterization↗
Biomedical subjects
T Feldman
Publications and source records attributed to T Feldman.
Bail-out stenting for flow limiting dissections after rotational atherectomy in complex coronary lesions.
Flow limiting dissection may occur after rotational atherectomy and require urgent management. Important questions about the safety and effectiveness of bail-out stenting in this setting remain to be answered. We have observed that emergent stenting after rotational atherectomy can be accomplished successfully in most patients, high pressure stent dilatation is both necessary and well tolerated, and lesion debulking facilitates movement of stents into diseased arterial segments.
Aged↗
Improved technique for use of half-stents remounted on a stent delivery system.
The use of half-length intracoronary Johnson & Johnson stents has been described in a number of settings. Half-stents are useful for very short lesions, avoidance of bifurcations or side-branches, ostial stenosis, covering gaps between adjacent stents, and for dissection adjacent to stents caused by postdilatation. Previously described methods for use of half-stents have involved bare stents, or significant manipulation of either the stent or the delivery sheath for remounted half-stents. We describe a method for half-stent preparation and delivery that does not involve distortion of the stent or the delivery sheath. The risk of stent loss, as can occur with bare stents, is diminished. The geometry of the stent is preserved since it is not expanded and then recrimped, and the end of the delivery sheath is not flared or distorted, which may interfere with stent delivery.
Aged↗
Immediate and long-term results of balloon mitral commissurotomy for rheumatic mitral stenosis: comparison between Inoue and double-balloon techniques.
We examined the immediate results and 2-year follow-up of percutaneous transvenous mitral commissurotomy (PTMC) using the Inoue balloon (IB) and double-balloon (DB) techniques. Short-term comparisons have been described, but long-term comparisons have not been available. PTMC was performed in 208 adult patients with symptomatic mitral stenosis (MS) and mitral valve area (MVA) of 0.94 +/- 0.2 cm2, by use of the IB in 157 (73.4%) and the DB technique in 56 (26.3%). Procedures were performed successfully and without complications in 198 (93%) cases. Adequate mitral dilatation (MVA = 1.6 cm2) without significant regurgitation was obtained in 179 (86%) of 192 patients. The final MVA was 2.0 +/- 0.43 cm2 after IB and 2.06 +/- 0.51 cm2 after DB (not significant). Technical difficulties and complications were more frequent with DB (16% vs 3.8%; p<0.001). Severe mitral regurgitation (grade III to IV) occurred in 4.6% of IB and 4.1% of DB (not significant), whereas grade 1 mitral regurgitation was greater with IB (21% vs 10.2%; p=0.01). A total of 172 patients were monitored an average of 23.8 +/- 10.6 months, with 83% in New York Heart Association functional class 1, echocardiographic MVA of 1.84 +/- 0.44 cm2, and restenosis rate of 22% at 36 months. PTMC is a safe, effective treatment for symptomatic MS. Results of both IB and DB techniques are similar, but the IB is simpler and safer, Long-term clinical improvement is maintained, although the restenosis rate seems to be progressive and related to inadequate immediate results.
Adolescent↗
Rheumatic heart disease.
Rheumatic heart disease seems in many ways emblematic of an older era in medicine, without any prospects of new development or change in the current era. Many new findings have come to light in the past few years regarding this illness, which has a relatively low prevalence in the United States. Not only have the diagnostic Jones criteria for acute rheumatic fever changed, but substantial advances have been made in the use of penicillin prophylaxis for recurrent rheumatic attacks, the use of mitral valve repair or reconstruction for rheumatic mitral regurgitation, the management of rheumatic, aortic, and mitral valve disease, and the application of balloon commissurotomy for mitral stenosis. This review details some of these advances.
Adolescent↗
O2 supply dependence of respiration in patients with mitral stenosis undergoing valvuloplasty.
Although systemic oxygen consumption (V O2) is independent of O2 delivery (Q O2) in normal subjects, studies have suggested that supply dependence of V O2 may occur in patients with chronic diseases associated with reduced Q O2. In this regard, we previously found that Q O2 and V O2 increased when cardiac output was improved after balloon valvuloplasty in patients with aortic stenosis. However, their increases in Q O2 were relatively small, and it was not known whether the increase in V O2 was caused by the increase in delivery or was merely a response to the transient hypotension induced by valvuloplasty. Because patients with mitral stenosis frequently exhibit greater improvements in cardiac output after valvuloplasty than do patients with aortic stenosis, the present study sought to determine (1) whether V O2 is increased after valvuloplasty in patients with mitral stenosis, and (2) whether the magnitude of the increase in V O2 correlates with the magnitude of the improvement in cardiac output and Q O2. Oxygen delivery, V O2, and hemodynamics were measured in 57 patients with mitral stenosis before and 20 to 30 min after undergoing balloon valvuloplasty. After valvuloplasty, Fick-derived oxygen delivery increased by 13.0% (95% confidence interval: 10.8 to 15.2%), whereas V O2 (expired gas) increased by 8.3% (95% confidence interval: 9.5 to 12.3%). A correlation between Fick-derived Q O2 and V O2 was found (p<0.005) with a slope of 0.66 (95% confidence interval: 0.07 to 1.24), but the O2 extraction ratio did not change (-1.0%; 95% confidence interval: -2.7 to 0.5%). A significant correlation between the change in Q O2 and the change in V O2 was also seen (p<0.02). These findings suggest that the increase in V O2 may have been a consequence of the increase in Q O2 rather than a response to the procedure itself.
Adult↗
High-speed rotational atherectomy for chronic total coronary occlusions.
Treatment of chronic total occlusions remains a limitation of percutaneous revascularization and is associated with lower immediates success and higher long-term restenosis rates compared to less severe stenoses. While part of the problem in dealing with total occlusions relates to successfully passing a wire across the occluded segment, most chronic occlusions contain large plaque burdens. Balloon dilatation sometimes falls to restore antegrade flow and often yields suboptimal angiographic results in these situations. Rotational atherectomy has proven useful in treating calcified and diffusely-diseased vessels and appears attractive for debulking lesions with large atheromatous plaques. We report our experience using rotational atherectomy in treating chronic total occlusions.
Aged↗
[Retinopathy and serum uric acid in diabetics].
Low serum uric acid (UA) levels have been reported in diabetics. In a group followed for 15 years it was reported that low UA levels preceded the onset of diabetic retinopathy. We studied 95 consecutive diabetic clinic patients between July and September 1992. There was no significant difference in UA levels between those with or without retinopathy: 5.0 +/- 1.2 (SD) mg--vs. 5.3 +/- 1.3, respectively. Multiple regression analysis showed that higher UA levels were related independently to high body mass index (overweight, obesity), and male gender, but not to age, duration of diabetes, glycosylated hemoglobin, diabetic treatment or retinopathy.
Body Mass Index↗
Inoue balloon mitral valvotomy in patients with severe valvular and subvalvular deformity.
OBJECTIVES: This study evaluated the immediate and long-term results of percutaneous Inoue balloon mitral valvotomy in patients with severe valvular and subvalvular deformity. METHODS: We reviewed the prevalvotomy transthoracic echocardiograms of patients from the North American multicenter Inoue registry with total Massachusetts General Hospital (MGH) echocardiographic scores > or = 10. The echocardiograms were rescored by two investigators to assess valvular and subvalvular morphology to eliminate interinstitutional variability. Ninety patients were originally assigned scores > or = 10. After rescoring, 18 patients (20%) were eliminated, leaving 72 study patients. RESULTS: Balloon mitral valvotomy was technically successful in 69 (96%) of the 72 patients. Mean (+/- SD) mitral valve area increased from 0.9 +/- 0.3 to 1.5 +/- 0.5 cm2. An immediate optimal result, defined as > or = 50% increase in mitral valve area or a final area > or = 1.5 cm2 with no major complications, was achieved in 46 patients (64%). End points for clinical follow-up (events) included mitral valve replacement, repeat valvotomy or death. At a mean follow-up of 22.9 +/- 11.0 months, 22 patients (31%) required mitral valve replacement or a second valvotomy, 9 patients (13%) died, and 32 patients (45%) were in New York Heart Association functional class I or II. Univariate predictors of an immediate optimal result included sinus rhythm, male gender and a lower University of Southern California commissural calcium score. Only sinus rhythm predicted an optimal result by multivariate analysis. Actuarial 3-year event-free survival was 42%. Univariate predictors of event-free survival were a lower grade of mitral regurgitation, lower MGH total echocardiographic score, lower MGH leaflet thickness subscore and lower prevalvotomy left ventricular systolic pressure. Only grade of mitral regurgitation after valvotomy predicted event-free survival by multivariate analysis. CONCLUSIONS: Inoue mitral valvotomy in patients with severe valvular and subvalvular deformity has a high technical success rate and good immediate hemodynamic result but a high cardiovascular event rate in follow-up. Mitral valve replacement should be considered in surgical candidates with an MGH total echocardiographic score > or = 10 because it may be able to provide better long-term event-free survival. Balloon valvotomy remains a reasonable palliative therapeutic option for some patients with severe valvular deformity and high surgical risk.
Actuarial Analysis↗
Transesophageal echocardiographic evaluation of mitral valve morphology to predict outcome after balloon mitral valvotomy.
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Adult↗
Views for right coronary angiography.
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Aortic Dissection↗
Peripheral arterial angioplasty balloons as adjuncts to percutaneous coronary revascularization.
Although PTCA balloon technology has improved dramatically since the first catheters were introduced over a decade ago, some limitations remain. The largest conventional balloon size available is 4.0 mm diameter. Larger size balloons are sometimes necessary for saphenous vein graft dilatation or in very large native coronary arteries. Also, adjunctive balloon angioplasty is used frequently after atherectomy and other coronary device therapy. Current generation balloons are not always necessary in this setting, since a large lumen has already been established. Thus, it has become useful in our laboratory to use peripheral arterial angioplasty balloons for both large coronary vessel dilatation, and also for adjunctive dilatation after device use. We describe our initial experience with peripheral arterial angioplasty balloons as adjuncts to percutaneous coronary revascularization.
Aged↗
Effect of atrial septal occlusion on mitral area after Inoue balloon valvotomy.
The purpose of this study was to examine the influence of the atrial communication created during transseptal passage of the Inoue balloon catheter on calculated mitral valve area after balloon valvotomy for severe mitral stenosis. Even in the absence of oxymetric evidence for a shunt, atrial septal puncture may result in left-to-right shunting of blood with reported spurious increases in postvalvotomy mitral valve area calculations ranging from 16-29% in prior studies. Occlusion of the septal puncture site after double balloon valvotomy has previously been shown to result in decreased postvalvotomy mitral valve area determinations. We evaluated 20 patients undergoing mitral dilation. Each patient had three postvalvotomy measurements made: (1) with the Inoue balloon catheter positioned across the septum, (2) during septal occlusion with a 7F balloon-tip catheter, and (3) without any catheters across the septum. With the Inoue catheter across the septum after successful valvotomy, the cardiac output was 4.6 +/- 1.5 L/min and the calculated mitral valve area was 1.7 +/- 0.5 cm2. No difference was found in either cardiac output or valve area when the septum was unobstructed by catheters. During septal occlusion, however, the postvalvotomy cardiac output decreased to 4.3 +/- 1.3 L/min (P < 0.001) and the calculated mitral area decreased by 12% to 1.5 +/- 0.5 cm2 (P < 0.001). The calculated mitral valve areas determined with the Inoue catheter in place after valvotomy were in agreement with echo derived data. Although statistically significant differences in post-Inoue valvotomy cardiac output and calculated mitral valve area were found during septal occlusion, these differences were small.(ABSTRACT TRUNCATED AT 250 WORDS)
Cardiac Output↗
Direct percutaneous transluminal coronary angioplasty for patients with exclusions from thrombolysis.
Direct percutaneous transluminal coronary angioplasty (PTCA) is a recognized alternative to intravenous thrombolytic therapy for early acute myocardial infarction (AMI). Fewer than one half of patients with AMI are candidates for thrombolytic therapy. We reviewed the records of 251 patients with the discharge diagnosis of AMI to determine the number of patients ineligible for thrombolysis who might be treatable with reperfusion methods other than intravenous thrombolysis. Forty percent of the patients (n = 101) were first seen within 6 hours and 51% (n = 128) were first seen within 12 hours of symptom onset. One third of the patients (n = 83) had no clear symptom at the time of initial examination. Exclusion criteria for intravenous thrombolysis were present in 187 of 251 patients (75%). Exclusion criteria for thrombolytic therapy included ECG ineligibility (n = 133), chest pain for more than 6 hours (n = 67), and age over 75 years (n = 64), comprising 79% of all exclusions. Of those first seen within 6 hours of symptom onset, 43 of 101 patients (43%) had an ineligible ECG, and 13 of 101 (13%) had age over 75 as exclusion criteria for thrombolysis. Forty-eight of 251 patients (19%) received intravenous thrombolysis. After early coronary angiography, intracoronary thrombolysis, direct PTCA, and emergency coronary artery bypass grafting were used in an additional 30 patients. The use of other forms of reperfusion therapy increased the number of patients treated early to 70 of 251 (28%) (p = 0.03). The use of a variety of forms of reperfusion therapy substantially increases the number of patients treated early compared with sole use of intravenous thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Sustained reversal of right-to-left atrial septal defect flow after pulmonic valvuloplasty in an adult.
A 60-year-old man with Noonan's syndrome presented with generalized weakness, dyspnoea, and paresthesias. He was known to have pulmonic stenosis and atrial septal defect with right-to-left shunting and had refused therapy for many years. On presentation there was cyanosis and the haematocrit was 63%. After phlebotomy he was treated with balloon valvuloplasty. There was marked reduction in the transpulmonic gradient and oximetric evidence for reversal of his right-to-left atrial septal defect flow. After 18 months follow-up he remained system free and had no rise in haematocrit, consistent with no return of right-to-left shunting.
Catheterization↗
Oxygen delivery and uptake relationships in patients with aortic stenosis.
Previous studies have reported finding supply-dependent O2 uptake (VO2) in patients with the adult respiratory distress syndrome, sepsis, chronic obstructive lung disease, sleep apnea, and other cardiopulmonary diseases. A common element among these diverse conditions is the potential to reduce systemic O2 delivery (QO2 = cardiac output.arterial O2 content). The aim of the present study was to determine whether patients with aortic stenosis also exhibit increases in VO2 when O2 delivery is increased after valvuloplasty. Fifty-six patients were studied while breathing room air in the supine position. Expired gases for determination of O2 uptake (VO2 [measured]), cardiac output (thermodilution), arterial and mixed venous blood gases, and hemodynamic measurements were obtained immediately before and within 30 min after aortic valvuloplasty. After valvuloplasty, VO2 (measured) increased from 3.03 +/- 0.51 to 3.24 +/- 0.62 ml/min/kg (p < 0.0001). However, O2 extraction ratio did not change from baseline levels (32.16 +/- 10.1%) after valvuloplasty (32.21 +/- 8.25%, p = not significant). These results could have occurred only if O2 delivery had also increased. Accordingly, Fick-derived Q and corresponding QO2 (Fick) both increased significantly, suggesting the presence of O2 supply-dependent VO2. However, neither Q (thermodilution) nor QO2 (thermodilution) changed significantly, and regression of VO2 (measured) against QO2 (thermodilution) failed to detect a relationship. We conclude that patients with aortic stenosis exhibit increases in O2 delivery and uptake after valvuloplasty, although this may or may not reflect covert tissue hypoxia.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Paradoxic improvement in regional wall motion during high-dose dobutamine stress echocardiography. A marker for hibernating myocardium?
Dobutamine stress echocardiography detects myocardial ischemia by inducing regional left ventricular systolic dysfunction. Augmentation of wall motion in hypokinetic segments has also been noted with low-dose dobutamine, suggesting myocardial viability. We report a case of regional ventricular improvement during high-dose dobutamine therapy, which may represent relief from myocardial hibernation or changes in regional loading conditions.
Aged↗