percutaneous double balloon valvuloplasty for severe tricuspid stenosis. ahj 1989

8/10/2019 Percutaneous Double Balloon Valvuloplasty for Severe Tricuspid Stenosis. AHJ 1989

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Volume 118

Number 2

Brief Communications

4 17

Fig. 3.

VVI bradycardia support systemworking after automatic defibrillator.

Top

Device sensing.

Mid-

dle,

Intracavitary electrogram.

Bottom,

Surface electrocardiogram.

D,

Defibrillation.

pacemaker unction wasnormal, and no ventricular tachy-

cardia was observed on Holter monitoring.

A multiprogrammable telemetric implantable automatic

defibrillator with a multiprogrammable VVI bradycardia

support system Telectronics Guardian, model4201,Telec-

tronics, Inc., Englewood, Colo.) was implanted and the

original VVI pacemakerwas explanted. The defibrillation

threshold was 18 oules. The device wasprogrammedwith

an initial energy of 28 joules (650 V, 8 msec) (safety

margin = 10 joules). The tachycardia detection interval

was 320 msec (Fig. 2) and after defibrillation, the VVI

bradycardia support systemcould be observed Fig. 3). One

month after implant, ventricular fibrillation was nduced

and automatic defibrillation wassuccessful. he patient is

doing well 4 months after implant. No dischargehasbeen

registeredand the bradycardia support of the defibrillator

is working as a VVI pacemaker.

This is the first report of an automatic implantable de-

fibrillator in Chagasdisease.Becausebifascicular or total

atrioventricular block are present in almost 50 of cha-

gasic patients who present with sustained ventricular

arrhythmias, automatic defibrillators with pacemaker

function will probably be very useful in selectedcasesof

chronic Chagasicmyocarditis.

REFERENCES

1. Mirowski M. The automatic mplantable ardioverter-de-

fibrillator. An overview.J Am Co11 ardiol

985;6:461-6.

2. PrataA. Natural historyof chagasicardiomyopathy.n: Pan

AmericanHealthOrganization, d.American rypanossomia-

sis esearch.Washington,C: Pan American Health Organi-

zation 1975:191.

3. Lopes ER Chapadeiro E. Morte subita em ara endemica de

doenca e Chagas. ev Sot BrasMed Trop 1983;16:79-83.

4. Mendoza , Camardo , Moleiro F, Castellanos, MedinaV,

Gomez J Acquatella H Casal H Tortoledo F Puigbo J. Sus-

tained ventricular tachycardia in chronic chagas ic myocardi-

tis: electrophysiologic and pharmacologic characteristics. Am

J Cardiol 1986;57:423-7.

Percutaneous double balloon valvuloplasty

for severe tricuspid stenosis

Irvin F. Goldenberg, MD, Wes Pedersen,MD,

Jeanne Olson, RDMS, JamesD. Madison, MD,

Michael R. Mooney, MD, and Fredarick L. Gobel, MD.

Minneapolis, Minn.

Balloon valvuloplasty hasemergedasan alternative treat-

ment to surgicalvalvotomy for somepatients with congen-

ital or acquired pulmonic, aortic, or mitral stenosis.1-4x-

perience with balloon valvuloplasty for the treatment of

tricuspid stenosis,however, hasbeen imited.5 We present

a caseof tricuspid balloon valvuloplasty in a patient with

rheumatic mitral, aortic, and tricuspid stenosis.

A 40-year-old womanpresentedwith complaints of pro-

gressively increasing fatigue and minimal dyspnea on

exertion. Clinical examination revealed jugular venous

distention and a diastolic rumble that increased with

inspiration, consistent with tricuspid stenosis.On exami-

nation this patient alsohad a diastolic rumble and opening

snap at the left sternal border, consistent with mitral

stenosis;a blowing diastolic murmur, consistent with aor-

tic insufficiency; and a grade II/VI systolic ejection mur-

mur. A chest roentgenogram evealed cardiomegaly, but

there were no signsof pulmonary congestion.An electro-

cardiogram revealed atria1 fibrillation with a frontal plane

QRS axis of +30 degrees.Doppler echocardiography ex-

amination revealed severe tricuspid valve stenosis,mild

mitral valve stenosis,and minimal aortic valve stenosis.

Doppler examination also showedmoderate tricuspid in-

From the Minneapolis Heart Institute.

Reprint requests: Irvin F. Goldenberg MD Minneapolis Heart Institute

920 E. 28th St. Suite 160 Minneapolis MN 55407.


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4 1a Brief Communications

I

PRE TRICUSPID VALVlJLOPL 4STY

I

August 1989

American Heart Journal

RV

Tricuspid Valve Gradient

2

= I

Tricuspid Valve Area 1.64 cm2

c< rdiac Output

I

1

3.05 L/min

Fig. 1.

Simultaneous right atria1 (RA) and right ventricular (RV) pressure recordings before (top panel)

and after (bottom panel) tricuspid valve balloon valvu loplasty. Following balloon valvu loplasty there is a

marked reduction in the transtricuspid valve gradient.

suffic iency and minimal mitral and aortic insuff iciency.

Cardiac catheterization confirmed these findings. Because

her prominent lesion was tricuspid stenosis and her pre-

dominant sympt om was fatigue, we elected to perform

percutaneous balloon valvuloplasty of the tricuspid valve.

After informed, written consent was obtained, the pa-

tient was premeditated with 10 mg of diazepam. Aortic

pressure was monitored by placing a 5F catheter in the de-

scending aorta from the lef t femoral artery. Using the right

and lef t femoral veins, a 7F Swan-Ganz catheter (Baxter

Healthcare Corp., Edwards Division, Santa Ana, Calif. )

was placed in the right atrium and right ventricle . Trans-

tricuspid mean and end-diastolic pressure gradients, car-

diac output, and tricuspid valve area (Gorlin formula) were

calculated before and after tricuspid valvu loplasty. A right

ventriculogram was performed with a 7F Berman catheter

(Arrow, Reading, Pa.) before and after balloon valvulo-

plasty. After obtaining initial baseline hemodynamic mea-

surements, a 14F introducer was placed into both femoral

veins. Using a 7F Berman balloon wedge catheter, an

0.038-inch Teflon-coated exchange guide wire (250 cm

long) was advanced into the main pulmonary artery f rom

each femoral vein. A Mansfield 20 mm

x

3 cm balloon

catheter (Mansfield Scientific Inc. , Mansfield, Mass.) was

threaded over each guide wire and the balloons were posi-

tioned across the tricuspid valve. The first three inflations

were performed with only one balloon across the valv e. The

next eight inflations had both balloons across the valve.

The balloons were inflated to a maximum of 4 atm. The

mean transvalvu lar gradient decreased from 7 to 2 mm Hg

and the transtricuspid end-diastolic gradient decreased

from 5 to 0 mm Hg (Fig. 1). Tricuspid valv e area increased

from 0.82 to 1.64 cm2. Tricuspid insuffic iency that was

moderate initially did not change. The patients functional

status improved immediately following valvuloplasty, from

New York Heart Association class III to New York Heart

Association class II. The patient was discharged 48 hours

after admission. During a 3-month follow-up period, the

patients clinical improvement persisted.

Prior studies have shown that percutaneous balloon val-


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Volume 118

Number 2

Brief Communications

4 19

vuloplasty offers a promising alternative to surgical val-

votomy in somepatients with pulmonic, aortic, and mitral

stenosis.le4 his casedemonstrates hat tricuspid stenosis

can also espond o this treatment modality. The improve-

ment in tricuspid valve area and symptoms n our patient

are similar to those reported after tricuspid valve

commissurotomy.6n our case,however, improvement

was

obtained without the morbidity and cost of surgery. Al-

though we have demonstrated he feasibility of percutane-

ous balloon valvuloplasty for the treatment of severe

tricuspid stenosis,additional investigation will be needed

to assesshe long-term efficacy of this new therapeutic

modality.

REFERENCES

1.

2.

3.

4.

5.

6.

Kan JS, White RI, Mitchell SE, Gardner TJ. Percutaneous

balloon valvu loplasty: a new method fo r treating congenital

pulmonary valve stenosis. N Engl J Med 1982;307:540-2.

Waldman JD,

Schoen

J, Fitzpatrick SE, Mathewson JW,

George L, Lambert JJ. Balloon dilatation of stenotic porcine

pulmonary valves. Clin Res 1987;35:204A.

Cribier A, Savin T, Berland J, et al. Percutaneous translumi-

nal balloon valvu loplasty of adult aortic stenosis: report of 92

cases. J Am Co11 Cardiol 1987;9:381-6.

Kveselis DA, Rocchini AP, Beekman R, et al. Balloon angio-

plasty for congenital and rheumatic mitral stenosis. Am J

Cardiol 1986,57:348-50.

Ribeiro PA, Zaibag MA, Kasab SA, Idris M, Halim M, Abdul-

lah M, Shahed M. Percutaneous double balloon valvotomy for

rheumatic tricuspid stenosios. Am J Cardiol 198&61:660-l.

Trace HD, Bailey CP, Wendhos MH. Tricuspid valve com-

missurotomy with a one-year follow up.

AM HEART J 1954;

47:613-17.

Presbyesophagus masquerading as an

extracardiac mass on echocardiography

Brian D. Hoit, MD, and Dave Eppert, RDMS.

Cincinnati, Ohio

Two-dimensional echocardiography has proven useful for

the detection of mediastinal masses.Although the esoph-

aguscourses hrough the posterior mediastinum with an

intimate spatial relationship to the heart, cardiac compres-

sion due to esophageal isease s infrequently reported.2p

In this report, we describe a case n which an asymptom-

atic, functional disorder of esophagealmotility presented

as an extracardiac masson two-dimensional echocardio-

wvb.

A 75-year-old man was admitted to University of Cin-

cinnati Hospital with a history of lethargy and fatigue.

There was no dysphagia or prior symptoms of upper gas-

trointestinal disease.On physical examination the patient

From the University of Cincinnati Medical Center Division of Cardiology.

Reprint requests: Brian D. Hoit MD University of Cincinnati Medical

Center D ivision of Cardiology 231 Bethesda Ave. M.L. 542 Cincinnati OH

45267.

Fig. 1. Left parasternal long-axis

(upper panel)

and

apical four-chamber

(lower panel)

two-dimensional

echocardiogram.A large, echogenicmass M) compresses

the posterior wall of the left atrium.

wasconfused.The vital signsand ugular venouspressure

were normal. The lungswere clear. The heart soundswere

normal and there was a 2/6 late systolic ejection murmur

at the lower left sternal border. The abdomen was dis-

tended, and the prostate wasenlarged.There wasbilateral

lower extremity edema. An anteroposterior chest radio-

gram wasnormal. Electrocardiogram revealed evidence of

an anteroseptal myocardial infarction of undetermined

age. Abdominal distension was relieved by insertion of a

Foley catheter, which drained 1800 cc of urine. The

patients mental status improved, and an echocardiogram

wasperformed to evaluate the systolic murmur.

Two-dimensional echocardiography (Fig. 1) revealed a

large masscompressing he posterior border of the left

atrium. A color Doppler study revealed a late systolic et of

mitral regurgitation that wasdeflected towards the lateral

wall of the left atrium by the mass.A computed tomogra-

phy (CT) scanof the chest evealeda distended, luid-filled

esophagusrom the esophagogastricunction to the upper

esophageal phincter. The remainder of the mediastinum

was

normal. An air-fluid level with a very poor stripping

percutaneous double balloon valvuloplasty for severe tricuspid stenosis. ahj 1989

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