Therapy and Prevention Valvuiar Heart Disease

Of 120 consecutive balloon aortic valvuloplasty procedures for critical aortic stenosis, valvuloplasty was performed in combination with coronary angioplasty in nine patients (average age 76 years). All nine patients were symptomatic with angina and congestive heart failure before combined procedures. Aortic valvuloplasty was performed with 20 to 23 mm balloon catheters advanced retrogradely from the femoral artery and resulted in an improvement in peak aortic valve gradient (60 + 19 to 33 + 13 mm Hg; p ' .01) and calculated aortic valve area (0.7 + 0.1 to 1.1 + 0.3 cm2; p ' .01). Single-vessel coronary angioplasty was performed via the femoral approach, with 2.0 to 3.5 mm balloon catheters, and resulted in a mean reduction of a critical coronary stenosis in each patient from 91 + 4% to 29 + 8%. The site of coronary angioplasty was the left anterior descending artery in three patients, the circumflex artery in three patients, the right coronary artery in two patients, and a bypass graft to the right coronary artery in one patient. Combined procedures were performed with a mean arterial time of 108 min. Complications included groin hematomas (n = 2), transient left bundle branch block (n = 1), and transient atrial fibrillation (n = 1). No patient experienced prolonged chest pain, myocardial infarction, major increase in aortic insufficiency, or embolic phenomena. Eight of the nine patients treated with combined procedures noted significant improvement in symptoms of angina and congestive heart failure and were discharged. The ninth patient experienced persistent angina and was treated successfully with aortic valve replacement and coronary artery bypass grafting. Clinical follow-up at a mean of 6 months after procedure has revealed persistent clinical improvement in seven patients, with both valvular and coronary restenosis occurring in one patient. We conclude that combined percutaneous aortic valvuloplasty and coronary angioplasty may be performed safely in adult patients with calcific aortic stenosis and anatomically suitable, single-vessel coronary artery disease. This procedure may be useful in the treatment of selected patients who refuse or who are deferred from surgical intervention because of high operative risk. Circulation 76, No. 6, 1298-1306, 1987. SURGICAL MORTALITY for aortic valve replacement in patients with isolated aortic stenosis is in general quite low, ranging from 1% to 5%.1-6 The presence of coexisting coronary artery disease and the subsequent need for additional coronary artery bypass From the Charles A. Dana Research Institute and the Harvard-Thorndike Laboratory of Beth Israel Hospital, Departments of Medicine (Cardiovascular Division), Beth Israel Hospital and Harvard Medical School, Boston. Supported in part by research training grant HL-07394 from the USPHS. Address for correspondence: Raymond G. McKay, M.D., Cardiovascular Division, Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215. Received April 9, 1987; revision accepted Sept. 3, 1987. 1298 grafting, however, may significantly raise the surgical risk, particularly in elderly patients.5'6 In a recent report on 259 consecutive patients undergoing aortic valve replacement,6 overall operative mortality was 6.9%, compared with 13.5% in patients undergoing aortic valve replacement combined with coronary artery bypass. Also of interest was the substantial increase in surgical risk for patients over 70 years of age, who had an operative mortality of 16.9%. Additional medical conditions such as congestive heart failure, pulmonary disease, and renal insufficiency may further raise the risk of surgical intervention. Previous reports by our laboratory7'8 and others91CIRCULATION by gest on A ril 3, 2017 http://ciajournals.org/ D ow nladed from THERAPY AND PREVENTION-VALVULAR HEART DISEASE have recently documented the utility of balloon aortic valvuloplasty as a palliative treatment for elderly patients with calcific aortic stenosis who refuse or who are deferred from aortic valve replacement. The efficacy of transluminal coronary angioplasty has likewise been documented in the elderly population.)2 13 The purpose of this study was to assess the potential utility of using both of these procedures in treating adult patients with combined valvular and coronary artery disease.