No abstract

Percutaneous balloon dilatation of the mitral valve is a promising new approach to the management of rheumatic mitral stenosis.1w But at this early stage little is known about the criteria for patient selection or the mechanism by which balloon dilatation increases mitral valve area. Previous experience with closed surgical commissurotomy suggests that mitral valve pliability and the degree of leaflet thickening have an important effect on subsequent outcome.'"" Because cross sectional echocardiography shows the structure of the mitral apparatus, the severity of the stenotic lesion, and changes in chamber size"617 it should provide information that will predict the likely outcome of balloon dilatation. Patients and methodsWe studied the first 22 patients (four men and 18 women) who had percutaneous balloon dilatationRequests for reprints to Dr

Background-Although populations referred for coronary angiography are increasingly diverse, there is limited information on coronary artery disease (CAD) prevalence and in-hospital mortality other than for predominately white male patients. Methods and Results-We examined gender and ethnic differences in CAD prevalence and in-hospital mortality in a prospective cohort of patients referred for angiographic evaluation of stable angina (nϭ375 886) or acute coronary syndromes (ACS; unstable angina or myocardial infarction, nϭ450 329) at 388 US hospitals participating in the American College of Cardiology-National Cardiovascular Data Registry, an angiographic registry. Univariable and multivariable (with covariates that included risk factors, symptoms, and comorbidities) logistic regression models were used to estimate significant CAD, defined as Ն70% stenosis, and in-hospital mortality. Within stable angina and ACS cohorts, 7% of patients were black, 2% were Hispanic, 0.3% were Native American, 1% were Asian, and 90% were white, respectively. In stable angina, the risk-adjusted OR for significant CAD was 0.34 for women compared with men (PϽ0.0001), with black women having the lowest risk-adjusted odds (PϽ0.0001) compared with other females. Among ACS patients, the risk-adjusted OR of significant CAD was 0.47 for women compared with men (PϽ0.0001); similarly, black women had the lowest risk-adjusted odds (PϽ0.0001) compared with other females. Higher in-hospital mortality was reported for white women presenting with stable angina (PϽ0.00001). White women had a 1.34-fold (95% CI 1.21 to 1.48) higher risk-adjusted odds ratio for mortality than white men with stable angina (PϽ0.0001), with higher rates noted for white women who were older or had significant CAD (both PϽ0.0001). Lower utilization of elective coronary revascularization, aspirin, and glycoprotein IIb/IIIa inhibitors (all PϽ0.0001) may have contributed to higher in-hospital mortality for white women. In ACS, higher in-hospital mortality was reported for Hispanic (Pϭ0.015) and white (PϽ0.0001) women; however, neither white (Pϭ0.51) or Hispanic (Pϭ0.13) women had higher in-hospital risk-adjusted mortality. Conclusions-The likelihood for significant CAD at coronary angiography and for in-hospital mortality varied significantly by ethnicity and gender. Future clinical practice guidelines should be tailored to gender subsets of the population, in particular for black women, to improve the efficient use of angiographic laboratories and to target at-risk populations of women and men.

, we attempted percutaneous transcatheter closure of seven ventricular septal defects (VSD) in six patients; none of the patients was a candidate for operative management. Patients' ages ranged from 8 months to 82 years (6.0-70 kg); diagnoses included postinfarction VSD (n = 4), congenital VSD (n = 1), and postoperative congenital VSD (n = 2). Indications for VSD closure were shock or respiratory failure (n = 5) or multiple episodes of endocarditis (n = 1). Closure was attempted with a Rashkind double umbrella: VSDs were crossed via the left ventricle and a guide wire was advanced to the right heart, snared with a venous catheter, and used to direct a long sheath (and ultimately the double umbrella) across the VSD. We crossed the VSD in all seven attempts, and a 17-mm double umbrella was successfully placed in each VSD. In the first (postinfarction) patient with the largest (12 mm) VSD, the umbrella embolized after 20 seconds to the pulmonary artery (without reducing flow). The other six umbrellas remained in position, either diminishing or abolishing the left-to-right shunts. Postinfarction patients had increasing VSD shunting over the next several days and died; at postmortem, the umbrellas remained well positioned in the septum, with other VSDs present. All three congenital VSDs had absent or diminished shunts after umbrella closure. These preliminary data indicate that transcatheter VSD closure is feasible in selected cases.

Background To identify predictors of long-term outcome after balloon aortic valvuloplasty, we analyzed data on 674 adults (mean age, 78±9 years; 56% were women) undergoing

MA-TF TAVR can be performed with minimal morbidity and mortality and equivalent effectiveness compared with SA-TF TAVR. The shorter length of stay and lower resource use with MA-TF TAVR significantly lowers hospital costs.

Background-Thromboembolism due to atrial fibrillation (AF) is a frequent cause of stroke. More than 90% of thrombi in AF form in the left atrial appendage (LAA). Obliteration of the appendage may prevent embolic complications. Methods and Results-We evaluated the feasibility and safety of implanting a novel device for percutaneous left atrial appendage transcatheter occlusion (PLAATO). LAA occlusion using the PLAATO system was attempted in 15 patients with chronic AF at high risk for stroke, who are poor candidates for long-term warfarin therapy. The implant consists of a self-expanding nitinol cage covered with a polymeric membrane (ePTFE). The LAA was successfully occluded in 15/15 patients (100%). Angiography and transesophageal echocardiography (TEE) during the procedure showed that the device was well-seated in all patients and that there was no evidence of perforation, device embolization, or interference with surrounding structures. In 1 patient, the first procedure was complicated by a hemopericardium, which occurred during LAA access. A second attempt 30 days later was successful with no untoward sequela. No other complications occurred. At 1-month follow-up, chest fluoroscopy and TEE revealed continued stable implant position with smooth atrial-facing surface and no evidence of thrombus. Conclusions-Thus, transcatheter closure of the LAA is feasible in humans. This novel implant technology may be appropriate for patients with AF who are not suitable candidates for anticoagulation therapy. Further trials are needed to show the long-term safety and its efficacy in reducing stroke.

Cereal fortified with folic acid has the potential to increase plasma folic acid levels and reduce plasma homocyst(e)ine levels. Further clinical trials are required to determine whether folic acid fortification may prevent vascular disease. Until then, our results suggest that folic acid fortification at levels higher than that recommended by the FDA may be warranted.