Faculty Bibliography

Left atrial to femoral arterial bypass was evaluated as a means of supporting patients who were considered to be at high risk for the performance of percutaneous transluminal coronary angioplasty. A 20 French drainage catheter was inserted percutaneously into the left atrium via a modified transseptal technique. Blood was withdrawn from the left atrium and returned through a femoral arterial cannula using a roller pump. Thirteen patients were treated in this fashion with excellent circulatory support. Pump flows varied from 1.5 to 3 liters per minute and bypass time ranged from 27 to 106 min (mean = 43 +/- 17). Aortic mean pressure was well supported during balloon inflation. No significant complications were encountered. Neither an oxygenator nor a perfusionist is required. The ability to obtain direct left ventricular decompression offers a major potential advantage. Further evaluation of this technique for the support of such patients is indicated

Clinical decisions utilizing either Doppler echocardiographic or cardiac catheterization data were compared in adult patients with isolated or combined aortic and mitral valve disease. A clinical decision to operate, not operate or remain uncertain was made by experienced cardiologists given either Doppler echocardiographic or cardiac catheterization data. A prospective evaluation was performed on 189 consecutive patients (mean age 67 years) with valvular heart disease who were being considered for surgical treatment on the basis of clinical information. All patients underwent cardiac catheterization and detailed Doppler echocardiographic examination. Three sets of two cardiologist decision makers who did not know patient identity were given clinical information in combination with either Doppler echocardiographic or cardiac catheterization data. The combination of Doppler echocardiographic and clinical data was considered inadequate for clinical decision making in 21% of patients with aortic and 5% of patients with mitral valve disease. The combination of cardiac catheterization and clinical data was considered inadequate in 2% of patients with aortic and 2% of patients with mitral valve disease. Among the remaining patients, the cardiologists using echocardiographic or angiographic data were in agreement on the decision to operate or not operate in 113 (76% overall). When the data were analyzed by specific valve lesion, decisions based on Doppler echocardiography or catheterization were in agreement in 92%, 90%, 83% and 69%, respectively, of patients with aortic regurgitation, mitral stenosis, aortic stenosis and mitral regurgitation. Differences in cardiac output determination, estimation of valvular regurgitation and information concerning coronary anatomy were the main reasons for different clinical management decisions. These results suggest that for most adult patients with aortic or mitral valve disease, alone or in combination, Doppler echocardiographic data enable the clinician to make the same decision reached with catheterization data

Left atrial thrombi are common in patients with mitral stenosis. When percutaneous balloon mitral valvuloplasty is performed on such patients, there is a potential risk of thrombus dislodgment and embolization. In this study conventional transthoracic echocardiography and transesophageal echocardiography were performed for percutaneous balloon mitral valvuloplasty on 19 consecutive candidates (6 men, 13 women, 23 to 81 years old). In five patients (26%), transesophageal echocardiography revealed a left atrial thrombus; in only one of these was there a suspicion of left atrial thrombus on transthoracic echocardiography. Balloon mitral valvuloplasty was canceled in four of the five patients. Three underwent mitral valve surgery that confirmed the echocardiographic findings. Transesophageal echocardiography is better than conventional transthoracic echocardiography in detecting left atrial clots in candidates for balloon mitral valvuloplasty. Because of the potential risk of embolization, transesophageal echocardiography is recommended in all candidates for balloon mitral valvuloplasty

The diagnosis of ostial stenosis of the left main coronary artery is usually made by use of coronary angiography. However, positioning of the catheter across the obstruction may obscure this diagnosis during contrast injection. Although a damping of arterial pressure when the catheter enters the left coronary artery may suggest ostial stenosis, it may not be possible to make this diagnosis with certainty during cardiac catheterization. We report a series of four patients in whom the left coronary ostium and proximal left coronary arteries were visualized by means of transesophageal echocardiography. Both ostial narrowing by plaque and abnormally fast flow velocities were seen. In each case the echocardiographic findings contributed to the subsequent management of the patients

This is a description of the first two reported cases of double-balloon valvuloplasty in the treatment of porcine bioprosthetic valve stenosis in the tricuspid position. In both cases, the double-balloon technique resulted in a better hemodynamic improvement than single-balloon valvuloplasty and was well tolerated. Double-balloon valvuloplasty is a reasonable alternative to surgical replacement of a stenotic bioprosthesis in the tricuspid position

The hemodynamic manifestations of the Valsalva maneuver are in part the result of changes in the venous return accompanying changes in intrathoracic pressure. Doppler echocardiography was performed during Valsalva maneuver in 13 normal subjects. Superior vena cava flow velocities and flow velocity integrals were measured in all 13 subjects. In the 5 subjects in whom the superior vena cava was clearly visualized throughout the maneuver, vena cava diameter was also analyzed. The superior vena cava flow velocity integral at rest was 17 +/- 2 cm. It diminished significantly, disappeared or reversed (-13 +/- 6 cm, p less than 0.001) with phase I of the maneuver. During the maintenance phase (phase II), the flow velocity integral increased significantly (31 +/- 2 cm, p = 0.05 vs baseline and phase I) and was associated with a decrease in superior vena cava lumen diameter at the time of Valsalva and continuing throughout the strain. With release of the maneuver (phase III), there was a sudden significant increase in flow velocity integral (61 +/- 2 cm, p = 0.005 vs phase II) and superior vena cava lumen diameter. Subsequently, superior vena cava flow velocity integral returned to baseline values. This study suggests that one of the ways in which the Valsalva maneuver leads to decreased venous return may be by direct external compression of the superior vena cava