Valvuloplasty

Implantable valves, particularly mechanical valves which continue to encroach on tissue valves, are unique. Methods such as valvuloplasty, mitral valve repair, or use of ultrasound are unlikely to reduce the number of valve replacements into the twenty-first century. Valve selection remains in the hands of the surgeon because of the critical nature of the procedure. If anything goes wrong, the result can be catastrophic to the patient. Cost of a valve, from 3000— 4000, is a relatively small part of the cost of open-heart surgery which can mn as high as 30,000. Growth of the cardiovascular valve market has slowed in the United States with the decline of the threat of rheumatic fever. 

Clinicians from Hong Kong reported a case of potential danshen-warfarin interaction in a 48-year-old female with a history of rheumatic heart disease, atrial fibrillation, and mitral stenosis (11). The patient underwent successful transvenous mitral valvuloplasty for management of her medical conditions, and was discharged with 1 mg warfarin, as well as... 

Complications reported with this type of intervention are rare, Rupture of the annulus is reported. The tricuspid valve may also be damaged if a large diameter balloon catheter has been passed inadvertently through the tricuspid valve chordae. After inflation, the balloon is relatively bulky and as it is removed the tricuspid valve apparatus may be disrupted causing regurgitation. A procedure-associated death rate of 0.24% and a major complication rate of 0.35% were found in a large study comprising 822 balloon pulmonary valvuloplasty procedures (15). 

Mitral stenosis is seen typically as a consequence of chronic rheumatic fever. Isolated congenital mitral stenosis is very rare and not suitable for balloon valvuloplasty. Clinical symptoms depend on the degree of obstruction. Dyspnea, atrial fibrillation, embolic events, pulmonary edema, and right heart decompensation may occur and are all indications for treatment. Surgery and catheter intervention provide similar results. Balloon valvuloplasty produces best results in patients with little or no calcification of the mitral leaflets (20—23). 

During all valvuloplasty interventions antibiotics (e.g., cefuroxime, I, 5 g, i.v.) are administered. Patients allergic to penicillin should receive vancomycin I g intravenously. Most physicians perform transcatheter valvuloplasty in the fasting state under mild sedation, Substances that are frequently used are meperidine, promethazine, and chlorpromazine, given intramuscularly or intermittent doses of midazolam (0.05 to 0.1 mg/kg, i.v.) and/or fentanyl (0.5 to 1.0 Lig/kg, i.v.). Some operators also apply ketamine or general anesthesia for all interventional cases. 

Hywel Davies reported of temporarily treatment of aortic regurgitation with a parachute valve mounted onto a catheter tip in 1965 (34). Twenty-seven years later Andersen and his colleagues described the first experience with a bioprosthetic valve attached to a wire-based stent and mounted on a balloon valvuloplasty catheter (35). In 2002, Alain Cribier performed the first transcatheter valve implantation in an elderly patient with inoperable aortic stenosis using a prototype of a stent-mounted, pericardial, tricuspid aortic valve (36). 

Kan JS, White Rl Jr, Mitchell SE, et al. Percutaneous balloon valvuloplasty a new method for treating congenital pulmonary-valve stenosis. N Engl J Med 1982 307(9) 540-542. 

Stanger P Cassidy SC, Girod DA, et al. Balloon pulmonary valvuloplasty results of the valvuloplasty and angioplasty of congenital anomalies registry. AmJ Cardiol 1990 65(1 I) 775-783. 

Lababidi Z, Wu JR, Walls JT Percutaneous balloon aortic valvuloplasty results in 23 patients. Am J Cardiol 1984 53( I) 194-197. 

Cribier A, Savin T Saoudi N, et al. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients an alternative to valve replacement Lancet 1986 I (8472) 63-67. 

Otto CM, Mickel MC, Kennedy JW, et al. Three-year outcome after balloon aortic valvuloplasty, Insights into prognosis of valvular aortic stenosis, Circulation I 994 89(2) 642-650. 

Sievert H, Kober G, Bussmann WD, et al, Catheter valvuloplasty in mitral valve stenosis. Dtsch Med Wochenschr 1989 ... 

Against this backdrop, research into less invasive approaches to treat valvular disease has been intensified. In the surgical realm, minimally invasive techniques, with its attendant patient and procedural related limitations, have been tried with some success but traditional valvular operations still remain the norm. At the same time, great strides have been made in percutaneous approaches to treatment of valvular disease. Two valvular disease states in which percutaneous balloon valvuloplasty have had great success are in the treatment of pulmonic stenosis and mitral stenosis. 

The first use of percutaneous balloon valvuloplasty was described in 1982 for patients with pulmonic stenosis (3). By the late 1980s, this treatment modality... 

The limited clinical efficacy of balloon valvuloplasty alone in the treatment of aortic stenosis and... 

The prototypic percutaneous aortic valve was implanted in a 57-year-old male with calcified critical aortic stenosis who failed previous balloon valvuloplasty and was in cardiogenic shock as well as leg ischemia at the time of procedure. Following the procedure, the aortic pressure rose from a 70 mmHg systolic to 120 mm Hg with the aortic valve gradient decreased from 30 to 6 mm Hg. The calculated valve... 

Chen CR, Cheng TO, Huang T, et al. Percutaneous balloon valvuloplasty for pulmonic stenosis in adolescents and adults. N Eng J Med 1996 335 21-5. 

Reyes VP, Raju BS, Wynne J, et al. Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. NEJM 1994 331 961-7. 

Palacios IF, Sanchez PL, Harrell LC, et al. Which patients benefit from percutaneous mitral balloon valvuloplasty. Circulation 2002 105 1465-71. 

American Heart Assn. Percutaneous balloon aortic valvuloplasty. Acute and 30-day follow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry. Circulation 1991 Dec 84(6) 2383-97. 

Agarwal A, Kini AS, Attanti S, et al. Results of repeat balloon valvuloplasty for treatment of aortic stenosis in patients aged 59 to 104 years. Am J Cardiol 2005 Jan 1 95(l) 43-7. 

Lieberman EB, Bashore TM, Hermiller JB, et al. Balloon aortic valvuloplasty in adults failure of procedure to improve long-term survival. J Am Coll Cardiol 1995 Nov 15 26(6) 1522-8. 

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