[Combined mitral and tricuspid valve stenosis].
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The authors report 3 cases of pulmonary stenosis with an intact interventricular septum and tricuspid incompetence. The tricuspid regurgitation was corrected in all 3 cases. After recalling the clinical features, they emphasize the importance of seeking for this condition and correcting it in every case if the immediate and long-term results are to be satisfactory.
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Five years prior to presentation, a 29-year-old woman received a transvenous pacemaker (DDD) for sick sinus syndrome and nodo-hisian pathology. After pacemaker insertion, she complained of recurrent febrile episodes. Her pacemaker related endocarditis was quite unusual for the infecting organism (a micrococcus) and for an acquired tricuspid valve stenosis. The suspected cause was confirmed at surgery.
Heart involvement is usually the cause of death in patients with carcinoid syndrome, who may survive a long time even after the disease has entered an advanced stage. For this reason, carcinoid heart disease patients have undergone surgical replacement of affected valves. Two of our patients were not good candidates for surgery, due to the extent of hepatic metastasis. Alternatively, we performed percutaneous balloon valvuloplasty on both the tricuspid and pulmonary valves in both patients. To our knowledge, there has been only 1 previous report of successful tricuspid valvuloplasty in a case of carcinoid heart disease, and this did not involve concomitant pulmonary valvuloplasty. Before the procedure, both of our patients had low cardiac output with restriction in the right ventricle, pulmonary and tricuspid stenosis, and moderate tricuspid regurgitation. In the 1st patient, valvuloplasty reduced tricuspid and pulmonary gradients without change in cardiac output. This patient experienced initial clinical improvement but died 8 months after the procedure, of portal hypertension and extensive hepatic metastasis. The 2nd patient showed notably diminished gradients and a very significant increase in cardiac output. She advanced from New York Heart Association functional class IV to class I, and is now maintained with diuretic therapy. In our judgment, balloon valvuloplasty is a sound alternative to surgery for patients with carcinoid heart disease, especially when stenosis is the dominant symptom. Valvuloplasty is contraindicated in cases of severe tricuspid regurgitation.
We present the case of a 66-year-old man with a history of coronary artery disease and chronic lymphocytic leukemia (CLL) who was admitted to the hospital complaining of chest discomfort and shortness of breath on exertion. The echocardiogram revealed a severe pericardial effusion and a large echogenic mass that infiltrated the lateral wall of the right atrium and ventricle and created a moderate tricuspid valve stenosis. B cell intracardiac non-Hodgkin lymphoma/CLL was diagnosed, and the patient was treated with six courses of CHOP chemotherapy. After the third course, the mass disappeared and the patient's general condition was substantially improved.
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Inoue rubber nylon single balloon catheter is being used worldwide for performing balloon mitral valvuloplasty (BMV). The popularity of Inoue balloon is attributed to its self-positioning configuration, size-adjustability, rapid inflation-deflation sequence and the ease of performance. We report its use in performing various non-mitral interventions. Its utility in treating patients with mitral stenosis and combined mitral and tricuspid stenosis is well established. Seventeen patients with valvular pulmonic stenosis (age 32+/-16 years; 11 males and 6 females) achieved significant reduction of peak systolic gradient (PSG) from 125+/-28 to 32+/-16 mmHg (P<0.005). Four patients with inferior vena-cava obstruction (age 20-48 years; 3 males and 1 female) derived symptomatic benefit following successful dilatation. Inoue balloon was used to create percutaneous pericardial window in four cases (age 43-68 years; 2 males and 2 females) of recurrent pericardial collection secondary to carcinoma lung/breast, thus alleviating the symptoms of tamponade. One patient each with coarctation of aorta (32 years, male), discrete subaortic membrane (16 years, female), and critical valvular aortic stenosis (13 years, male) derived immediate hemodynamic improvement with Inoue balloon dilatation. No major complications were encountered. We conclude that Inoue balloon can be used to successfully manage various stenotic lesions.
The purpose of this paper was to examine valvar involvement in patients with intracardiac masses. Seven patients with intracardiac masses were studied by cross-sectional and Doppler echocardiography. In one, a candida vegetation on a mitral Starr-Edwards prosthesis obstructed the aortic valve with a peak transvalvar velocity of 2 m/sec and aortic regurgitation. Another patient with endocarditis demonstrated mitral stenosis as did two patients with left atrial myxomata. Tricuspid stenosis was demonstrated in three patients with right ventricular intracardiac masses (primary and secondary tumour and thrombus). By Doppler, the mitral and tricuspid stenosis was similar to from that seen in rheumatic heart disease with increased peak transvalvar velocity and prolonged pressure half-time. Because of the hazards associated with cardiac catheterisation in intracardiac masses, we conclude that Doppler ultrasound allows for the adequate assessment of the haemodynamic alterations so as to complement the images obtained by cross-sectional echocardiography.
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