Jacob Green's research while affiliated with Emory University and other places

An 80-year-old woman was referred for transcatheter aortic valve implantation for correction of aortic stenosis. An echocardiogram at the author's institution revealed severe hypertrophy of the left ventricle with deep recesses into the myocardium and hypokinesis involving the left ventricular apex. In addition, there was subaortic stenosis secondary to a muscular ridge. The aortic valve was only mildly stenotic. In this Cardiology Grand Rounds, the authors present a rare case of ventricular noncompaction and review the literature on this subject and its association with other cardiac abnormalities.

Our aim was to describe the use of balloon aortic valvuloplasty (BAV) to select proper transcatheter heart valve (THV) size. Transesophageal echocardiogram (TEE) measurement alone of the aortic annulus may not be adequate to select a THV size. BAV can more accurately size the aortic annulus. We report our experience using this strategy in patients undergoing THV implantation. Twenty-seven patients underwent sizing of the aortic annulus by BAV and TEE. We implanted the minimal THV size that was greater than the annulus measured by BAV. The annulus measured by TEE was 21.3 +/- 1.6 mm and by BAV was 22.6 +/- 1.8 mm (p < 0.001). The number of balloon inflations was 2.7 +/- 0.7 (range 2 to 4), and the balloon sizes used were 22.0 +/- 1.8 mm (range 20 to 25 mm). Fourteen patients (52%) required upsizing of the initial balloon suggested by TEE; rapid pacing duration was 8 +/- 1.3 s (range 6 to 11 s). No change in aortic insufficiency or hemodynamic instability occurred with BAV. Fifteen patients (56%) received a 23-mm THV; 12 patients a 26-mm THV. No coronary occlusion, annular damage, or THV embolization occurred. Paravalvular leak was grade <or=1 in all patients. In 7 patients (26%), balloon sizing resulted in selection of a specific THV size that could not be done by TEE alone. BAV sizing of the aortic annulus is safe and is an important adjunct to TEE when selecting THV size. Implanting the minimal THV greater than the BAV annulus size resulted in no adverse events. These data suggest that use of BAV for THV selection may improve the safety and efficacy of THV implantation.

We sought to study the potential role of balloon aortic valvuloplasty (BAV) in sizing the aortic annulus in patients before transcatheter heart valve (THV) implantation. Despite clinicians' growing experience with THV procedures, the best method of annulus sizing remains unclear. Twenty-three patients with aortic stenosis (<1.0 cm(2)) who were undergoing surgical valve replacement were enrolled. Pre-operative echocardiographic measurements of the annulus and computed tomography measurements of valve calcium were made. Intraoperatively, a valvuloplasty balloon of known size and inflatable pressure was inserted into the aortic valve and inflated. The development of intraballoon pressure in addition to the nominal inflation pressure (AIBP) reflected the apposition of balloon and valve. Surgical annulus was measured by cylindrical sizers. In patients with tricuspid valves, AIBP was generated in 11 of 12 patients when the balloon diameter was greater than the surgically measured annulus, regardless of leaflet calcification (2 of 10 patients when balloon < or = surgical annulus). In bicuspid valves, high AIBP ( approximately 1 atm) was encountered with balloons that were within 1 mm of annulus size, and leaflet dehiscence occurred with larger balloons (n = 2 patients). Annulus size was underestimated by transthoracic echocardiogram and transesophageal echocardiogram compared with surgery (p < 0.001): transthoracic echocardiogram = 21.5 +/- 1.8 mm, transesophageal echocardiogram = 22.0 +/- 1.6 mm and surgical = 23.2 +/- 1.9 mm (range 20 to 27 mm, mode 22 mm). These data suggest that measuring AIBP during balloon aortic valvuloplasty in tricuspid valves is an important adjunctive measurement of the aortic annulus and may help in determining the appropriate THV size.

Transseptal (TS) catheterization was introduced in 1959 as a strategy to directly measure left atrial (LA) pressure. Despite acceptable feasibility and safety, TS catheterization has been replaced by indirect measurements of LA pressure using the Swan-Ganz catheter. Today, TS puncture is rarely performed for diagnostic purposes but continues to be performed for procedures such as balloon mitral valvuloplasty, antegrade balloon aortic valvuloplasty, and ablation of arrhythmias in the LA. Thus, the "art" of TS puncture has been lost, except in centers that perform these procedures with regularity. Recently, there has been a renewed interest in the TS technique because of emerging therapeutic procedures for structural heart disease and atrial fibrillation ablation. Invasive cardiologists will have to refamiliarize themselves with the TS technique, newer TS devices, and advanced ultrasound imaging for guidance of the procedure.