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| By Marie Cheine, Medical Writer Aortic Stenosis and Aortic Valvuloplasty Aortic Stenosis is a condition in which the aortic valve, which controls the flow of blood from the heart to the body, becomes narrowed. This usually occurs very gradually over years, and tends to run in families. As the valve becomes more narrowed, the patient begins to develop symptoms, which may include shortness of breath, fatigue, chest pain and lightheadedness. Once these symptoms develop, and the valve area becomes very small (typically less than 1.0 square centimeters), corrective treatment may be needed. In most cases, the best treatment is replacement of the narrowed valve with an artificial valve. However, in some patients, the risk of surgery may be too great. In these cases, a balloon may be used to help open the valve to lessen the severity of symptoms. The procedure is done in the catheterization laboratory, usually with light sedation, and lasts about one hour. Catheters (tubes) are passed to the heart from arteries and veins in both legs to the heart, where measurements are made. The valve is then crossed backwards with a catheter, and using a guidewire, the balloon is passed across the valve and then inflated several times to open it. The tubes are usually removed within a few hours, and the patient is observed in a monitored setting (ICU or monitored bed) overnight. Most patients have fully recovered from the procedure within a day. While the procedure usually produces only moderate improvement in the valve, the low risk and quick recovery from the procedure make it attractive for even very sick patients who could not normally be considered for valve surgery. Mitral Stenosis and Mitral Valvuloplasty or PTMC (Percutaneous Transvenous Mitral Commissurotomy) Mitral Stenosis is a condition in which the mitral valve, which regulates the flow of blood from the left atrium to the left ventricle, becomes narrowed. Usually the valve has become injured due to an earlier illness with rheumatic fever. Rheumatic fever is seen after strep infection (usually strep throat) when antibiotic treatment is not given. Over many years, the valves and sometimes the muscle of the heart may become scarred and injured. The mitral valve is the most commonly affected valve, but sometimes other valves are also involved. Injury to the mitral valve may cause both narrowing (stenosis) or leaking (regurgitation) of the valve. When the mitral valve becomes severely narrowed (less than 1.5 square centimeters), symptoms may occur. These include shortness of breath, fatigue, cough, wheezing and palpitations. When severe leaking of the valve is involved, a surgical repair or replacement of the valve is usually necessary. When leaking is minimal, and narrowing is the greater problem, the valve may be opened using a balloon without the need for open heart surgery. Evaluation of the valve beforehand includes a transesophageal echocardiogram (TEE). After sedation, a probe is passed through the mouth into the esophagus. Since the esophagus is directly behind the left atrium, excellent images of the heart and of the mitral valve are obtained, and it is also possible to see any blood clots in the heart that could cause a stroke. If the echo shows the valve to be suitable for valvuloplasty, the patient is moved to the catheterization laboratory, where catheters are passed to the heart by way of blood vessels in the legs for further measurements. If all appears favorable, the balloon is passed into the left atrium by crossing a thin membrane between the right atrium and left atrium. This often requires the use of a thin needle (transseptal puncture). The balloon inflations only last a few seconds, and usually there are few symptoms during inflation. By careful monitoring using X-ray and the Echo machine the valve can be opened without causing it to leak. Recovery in the hospital is usually one to two days, and usually a blood thinner (Coumadin) is given for at least a few weeks to prevent blood clots from forming at the site of the procedure. CardioSEAL Septal Closure Device The CardioSEAL septal closure device is a "double umbrella" device made of fabric and metal which may be used to close cardiac defects or "holes in the heart". Like an umbrella, the device may be collapsed to allow delivery of the device through a sheath or tube passed from a vein in the leg to the hole to be closed. It can then be opened up, first one side, and then the other, covering up the hole. The device is then left in place, and over a period of several weeks, the body grows tissue over it to completely close the hole. The CardioSEAL device has been approved for closure of holes between the upper chambers of the heart (patent foramen ovale) or holes between the lower chambers of the heart (ventricular septal defect). The device is also approved for the closure of a fenestrated Fontan conduit in patients with congenital heart disease. It is also possible to close other types of defects, but the device is not currently approved by the FDA for these purposes. In some cases, we have closed other types of defects when the patients were considered poor candidates for cardiac surgery. The most typical reason for closure of a patent foramen ovale is a paradoxical embolus. An embolus is a clot or other material which gets into the circulation, often originating in the veins of the leg or pelvis. Normally, if a clot breaks free, it is trapped by the lungs and destroyed. However, when a hole is present between the upper chambers of the heart it is possible for the embolus to cross over to the other side of the heart. It can then pass to other organs of the body such as the brain or the legs and can cause a stroke or other injury. Closing the hole prevents these events from occurring. Sometimes the hole allows a large amount of oxygen-poor blood to pass through the heart, causing problems with shortness of breath and fatigue. While the hole may be closed by open heart surgery, the CardioSEAL device allows the hole to be closed with a simple procedure with a quick recovery. Renal Artery Stenosis and Stenting Many hormones and factors help to regulate the body's fluid balance and blood pressure. Hypertension or high blood pressure occurs when this system of balance is upset, and may occur for many reasons. The kidney is very important in the regulation of blood pressure and fluid and electrolyte balance. In some cases, kidney disease may result in difficult to control blood pressure. One of the more easily correctable kidney disorders is obstruction of the circulation of the kidney or renal artery stenosis. In young people, the arteries may become blocked by a muscular condition called fibromuscular dysplasia. In patients with vascular disease, and especially in older people, atherosclerosis or cholesterol plaques may cause obstruction, just as is seen in the arteries to other organs. When the kidney is not receiving enough blood, it produces hormones which drive the blood pressure up. In addition, the blockage of the artery may eventually close completely and result in the loss of the kidney. Fibromuscular dysplasia may be treated with simple balloon angioplasty. A balloon is passed to the narrowing by way of a leg or arm vessel, and inflated to push the narrowing out of the way. This is often very effective. Atherosclerotic narrowing may also be opened with a balloon, but a stent (a metal tube) is placed in most cases to keep the artery from becoming obstructed again. In many cases, opening the renal artery obstruction may improve blood pressure control, but most patients continue to need some blood pressure medicine. When severe blockage is present, opening the blockage may help to restore better kidney function, and help to prevent the loss of the kidney, which could result in kidney failure and the need for dialysis treatment. |
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