Pulmonary valvoplasty--experience of 100 cases

Balloon Dilatation in the Management of Congenital Obstructive Lesions of the Heart: Review of Author's Experiences and Observations-Part II

While investigating the outcomes of balloon dilatation procedures in patients with congenital obstructive lesions of the heart, several parallel observations were made. The purpose of this review is to present these observations/phenomena/innovations related to balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS), and aortic coarctation (AC). In subjects who had balloon pulmonary valvuloplasty (BPV), development of infundibular obstruction, electrocardiographic (ECG) changes, changes in right ventricular filling, role of balloon/annulus ratios on the results of BPV, and double balloon vs. single balloon BPV will be reviewed. In patients who had balloon aortic valvuloplasty (BAV), causes of aortic insufficiency and trans-umbilical venous approach for BAV are tackled. In children who had balloon angioplasty (BA) of AC, aortic remodeling and biophysical response after BA of AC are discussed.

Mid-Term Results of Balloon Pulmonary Valvuloplasty in Children at Queen Alia Heart Institute

Objective: To evaluate the mid-term results of balloon pulmonary valvuloplasty (BPV) in children. Design: Prospective study. Settings: Pediatric Cardiology Department of Queen Alia Heart (QAHI), Jordan. Methods: One hundred and thirty-two patients with a median age of 3 years (range 1 day to 16 years), underwent (BPV) between January 1999 and January 2006. We evaluated our patients with regard to peak pressure gradient across the right ventricular outflow tract before and after BPV. Thereafter we followed them at the Outpatient Clinic regarding the peak instantaneous gradient pressure, the pulmonary valve incompetence, right ventricular function based on echocardiographic findings, and the need for repeat BPV. Results: There was significant reduction in the peak to peak gradient from 93.5 ± 32.3 mmHg to 26.1 ± 9.6 mmHg (p <  0.001). Echo-Doppler data showed that residual peak instantaneous gradient dropped from 26.1 ± 9. 6 to 19 ± 6 mmHg; (p <  0.001) on follow-up for 6 years. Mild to moderarte pulmonary valve regurgitation was noticed in 34 patients (27.8%) at one year and in 43 patients (38%) at mid term follow-up, but non had right ventricular dilatation or paradoxical interventricular septal motion. Conclusions: The results of mid-term follow up after balloon dilatation of the pulmonary valve are encouraging. The degree of pulmonary regurgitation is increasing with time. Longer term follow-up studies should be undertaken to evaluate the significance of residual pulmonary regurgitation.

Development of Pediatric Cardiology in Latin America

Until the first quarter of the 20th century, most physicians were more than happy to differentiate congenital heart lesions from rheumatic heart disease, which then was rampant. As early as 1932, Dr Rodolfo Kreutzer, from Buenos Aires, Argentina, was already involved in the study of congenital heart defects. He started off assessing children with a stethoscope and with Einthoven electrocardiography equipment. The cardiac unit at the Buenos Aires Children’s Hospital was created in 1936. It established the onset of pediatric cardiology in Argentina and fueled its development in South America. Nearly at the same time, Agustin Castellanos from Cuba also became a pioneer in the assessment of congenital heart disease. He described the clinical applications of intravenous angiocardiography in 1937. Meanwhile in Mexico, Dr Ignacio Chavez founded the National Institute of Cardiology in 1944 in Mexico City. It was the first center in the world to be exclusively devoted to cardiology. From this center, Victor Rubio and Hugo Limon performed the first therapeutic cardiac catheterization in 1953. Meanwhile, Professor Euriclydes Zerbini from Sao Paulo, Brazil, built the largest and most important school of cardiac surgeons in South America. In Santiago, Chile, the Calvo Makenna Hospital was the center where Helmut Jaegger operated on the first infant with extracorporeal circulation in Latin America in 1956. The patient was a 1-month-old baby, with complete transposition of the great arteries, who underwent an Albert procedure. Currently, there are many fully equipped centers all over the region, capable of dealing with most lesions and of providing excellent medical, interventional, and surgical treatment. Outcomes have improved substantially over the last 20 years. These achievements have gone beyond our pioneers' dreams. However, many neonates and young infants die prior to surgery because referral centers are overburdened and have long surgical waiting lists. Clearly, we still have to mastermind and establish sustainable public health policies to overcome these challenges.

Long-term results (up to 17 years) of pulmonary balloon valvuloplasty in adults and its effects on concomitant severe infundibular stenosis and tricuspid regurgitation

BACKGROUND

Significant infundibular stenosis and significant tricuspid regurgitation (TR) occasionally result from severe pulmonary valve stenosis in adults, and these 2 conditions have an adverse impact on morbidity and mortality in patients who undergo corrective surgery. The goal of this study was (1) to evaluate the long-term (up to 17 years) outcome of pulmonary balloon valvuloplasty (PBV) in adults and (2) to determine the effect of successful PBV on severe infundibular stenosis and severe TR.

METHODS

Pulmonary balloon valvuloplasty was performed in 90 consecutive patients (49 women, 41 men) of mean age 23 +/- 9 years (range 15-54 years) with congenital pulmonary valve stenosis. Clinical and echocardiographic assessment was performed 2 to 17 years (mean 10 +/- 3.9 years) after PBV. Repeat cardiac catheterization was performed 6 to 24 months after PBV in 43 patients who had concomitant moderate to severe infundibular stenosis (infundibular gradient > or = 30 mm Hg).

RESULTS

There were no immediate or late deaths. The mean catheter peak pulmonary gradient (gradient between pulmonary artery and right ventricular body) before and immediately after PBV was 105 +/- 39 and 34 +/- 26 (P < .0001), respectively. The corresponding values for right ventricular pressure were 125 +/- 38 and 59 +/- 21 mm Hg (P < .0001), respectively. The infundibular gradient (in 43 patients) immediately after PBV was 42.9 +/- 24.8 (30-113) mm Hg, and it regressed at second catheterization to 13.5 +/- 8.3 mm Hg (P < .0001), whereas cardiac index improved from 2.68 +/- 0.73 to 3.1 +/- 0.4 L min(-1) m(-2) (P < .05). Doppler pulmonary gradient before PBV and at 1-year and long-term follow-up were 91 +/- 33 (range 36-200), 28 +/- 12 (range 10-60) (P < .0001), and 26 +/- 11 (range 7-60) mm Hg (P = .2), respectively. New mild pulmonary regurgitation was noted in 24 patients (28%) after PBV. Significant TR in 7 patients either regressed or disappeared after PBV.

CONCLUSIONS

Long-term results of PBV in adults are excellent. Severe infundibular stenosis and severe TR regressed after successful PBV. Therefore, PBV should be considered as the treatment of choice for adult patients with valvular pulmonary stenosis even in the presence of severe infundibular stenosis or severe TR.

Double balloon pulmonary valvuloplasty: Multi-track system versus conventional technique

OBJECTIVES

To evaluate whether double balloon pulmonary valvuloplasty (DBPV) with the Multi-Track system (MTS) may help to simplify the procedure.

BACKGROUND

DBPV is usually required for patients with pulmonary valve stenosis with large annulus. However, it needs two venous accesses and can be technically demanding.

METHODS

From 07/03, 20 consecutive patients (19 +/- 10 yrs) with typical pulmonary valve stenosis underwent DBPV using the MTS (G1). The results were compared with those achieved by conventional DBPV performed in a matched historical group of 28 patients (21 +/- 11 yrs; P = NS) (G2).

RESULTS

MTS balloons were easily advanced through the skin and inflated across the valve. Similar results were observed in regards to residual gradients (12 +/- 11 vs 14 +/- 10 mm Hg; P = NS) and right ventricular to systemic pressures (0.35 +/- 0.22 vs 0.37 +/- 0.26; P = NS). Procedure and fluoroscopic times were significant lower in G1 (78 +/- 24 vs 126 +/- 28; 15 +/- 12 vs 25 +/- 8 min, respectively; both P < 0.001). There was no major complication. Median follow-up was 1.8 yr for G1 and 5 yr for G2 (P = 0.037). At the last visit, peak instantaneous gradient across the right ventricular outflow tract by echocardiography was a mean 22 +/- 10 mm Hg for G1 and 25 +/- 9 mm Hg for G2 (P = NS). No patient had severe pulmonary insufficiency or required reintervention.

CONCLUSIONS

The use of the MTS helped to expedite the procedure providing satisfactory midterm clinical outcomes, similar to those observed with the conventional DBPV technique.

Long-term invasive and noninvasive results of percutaneous balloon pulmonary valvuloplasty in children, adolescents, and adults

BACKGROUND

Short-term and mid-term results of percutaneous balloon pulmonary valvuloplasty (BPV) are well known. However, data documenting long-term effectiveness of BPV are scarce.

METHODS AND RESULTS

The long-term results of 62 patients were assessed by catheterization and Doppler echocardiography 1 to 10 years (mean 6.4 +/- 3.4) after BPV. Mean age of the patients was 13.5 +/- 10.5 years (range 9 months to 44 years). Twenty patients were 16 years of age or older. Right ventricular peak systolic pressure was systemic or suprasystemic in 72% of patients. A double-balloon technique was used in 29 patients. The balloon-to-pulmonary valve diameter ratio was 1.4 +/- 0.38 (range 1 to 1.8). Total systolic transpulmonary pressure gradient in excess of 50 mm Hg in all patients before BPV decreased from 98 +/- 40 to 32 +/- 23 immediately after BPV and to 19 +/- 9 mm Hg at follow-up (P <.001). Infundibular gradient increased from 8 +/- 10 to 14 +/- 24 mm Hg after BPV and fell to 1 +/- 4 mm Hg at follow-up (P <.01). In 16 patients it was >/=20 mm Hg and virtually disappeared spontaneously in all at follow-up. The valvar gradient fell from 93 +/- 39 to 19 +/- 11 (P <.001) and was 18 +/- 9 mm Hg at follow-up. It remained unchanged in 3 patients (range 36 to 45 mm Hg). In 3 (4.8%) other patients, a new gradient >35 mm Hg developed that was >/=50 mm Hg in all 3. Among 5 patients having dysplastic valves, 3 had a gradient >35 mm Hg. There were no predictors of a gradient >35 mm Hg at long-term follow-up by univariate or multivariate Cox proportional hazards analysis. Mild to moderate pulmonary regurgitation was present in 39% of patients. On electrocardiography, right ventricular hypertrophy decreased significantly in 90% of patients.

CONCLUSIONS

BPV as a treatment of typical pulmonic valve stenosis produces excellent long-term results. Restenosis is rare (4.8%) and occurs more frequently in patients with dysplastic valves. There is a constant spontaneous regression of associated infundibular obstruction.

Independent predictors of long-term results after balloon pulmonary valvuloplasty. Valvuloplasty and Angioplasty of Congenital Anomalies (VACA) Registry Investigators

BACKGROUND

This study was performed to determine independent predictors of long-term outcome after percutaneous balloon dilation of congenital pulmonary valve stenosis. Smaller follow-up series of patients after balloon pulmonary valvuloplasty have shown inconsistent results regarding the independent relation between prognostic factors and long-term outcome, as many patient selection and technical factors are correlated.

METHODS AND RESULTS

Follow-up data were obtained for 533 patients from 22 institutions at up to 8.7 years after an initial balloon pulmonary valvuloplasty. Patients were grouped based on defined long-term outcomes, and the independent effects of patient selection and technical factors were sought in multivariate statistical analyses. At follow-up, 23% of patients were noted to have an outcome judged to be suboptimal because of either a residual right ventricle to pulmonary artery peak systolic gradient of > or = 36 mm Hg or further treatment of pulmonary stenosis requiring repeat balloon pulmonary valvuloplasty or surgical therapy. Significant independent predictors of a suboptimal long-term outcome included an earlier study year of the initial valvuloplasty (adjusted odds ratio, 0.71 per consecutive year), a small valve hinge point diameter (0.81 per 1-mm increase), and a higher immediate residual gradient (1.32 per 10 mm Hg increase). A smaller ratio of balloon to valve hinge point diameter significantly predicted suboptimal outcomes for patients with valve morphologies classified as typical (0.52 per 0.1 increase in ratio) and complex (primarily postsurgical valvotomy, 0.43) but not for patients with dysplastic (0.95) or combined morphologies (dysplasia with commissural fusion, 1.01). Patient age, the presence of Noonan's syndrome or associated cardiac lesions, pre-balloon valvuloplasty hemodynamic parameters, and the use of a simultaneous double-balloon technique did not independently predict follow-up outcomes.

CONCLUSIONS

Accurate prognostication after balloon pulmonary valvuloplasty depends on the careful determination of valvar anatomy. The use of an appropriate ratio of balloon to valve hinge point diameter in the setting of typical valve morphology will optimize the chance of long-term success.

Balloon pulmonary valvoplasty: factors determining short- and long-term results

Balloon pulmonary valvoplasty was performed in 139 patients (age 2-44 years) with pulmonary valve stenosis. The right ventricular peak systolic pressure decreased from 137.1 +/- 46.8 mmHg to 76 +/- 51.3 mmHg (P < 0.001) and the right ventricle to pulmonary artery peak systolic gradient decreased from 116.3 +/- 49 mmHg to 54.4 +/- 51.9 mmHg (p < 0.001). There was no significant change in systemic artery systolic pressure. The right ventricular peak systolic pressure to systemic artery systolic pressure ratio decreased from 1.13 +/- 0.41 to 0.63 +/- 0.42 (P < 0.001). Patients with incomplete immediate relief of obstruction (right ventricle to pulmonary artery peak systolic gradient > 35 mmHg) had higher pre-dilatation right ventricular peak systolic pressure (161.1 +/- 45.3 mmHg vs. 93.9 +/- 38.8 mmHg, P < 0.001) and higher right ventricular peak systolic pressure to systemic artery systolic pressure ratio (1.31 +/- 0.42 vs 0.98 +/- 0.33, P < 0.001) pre-dilatation and were older (17.2 +/- 8.6 years vs. 12.8 +/- 9.7 years, P < 0.01). The residual right ventricle to pulmonary artery peak systolic gradients in the majority of patients were infundibular, which regressed at follow up even in patients who did not receive long-term oral beta blockers. Follow up catheterisation in 79 patients after 13 +/- 8.7 months showed a further fall in right ventricular peak systolic-pressure (P < 0.001) and right ventricle-to-pulmonary artery peak systolic gradient (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of typical and dysplastic pulmonic stenosis, uncomplicated or associated with complex intracardiac defects, in juveniles and adults: use of percutaneous balloon pulmonary valvuloplasty with eight-month hemodynamic follow-up

To alleviate large fixed right ventricular (RV) outflow gradients, percutaneous balloon dilatation of pulmonic stenosis (PS) was performed in 38 patients with mean age of 14 +/- 14 years (median: 9 years, age range: 9 months to 63 years). There were 21 males and 17 females. Thirty-four patients had typical PS (5 of them also having other complex congenital cardiac anomalies, while 13 additional patients had a patent foramen ovale); 2 further subjects had subpulmonic, and 2 dysplastic pulmonary valvular obstructions. Sixteen patients were in the New York Heart Association (NYHA) Class I, 15 in Class II, 6 in Class III, and 1 in Class IV. Electrocardiographic (ECG) evidence of right ventricular hypertrophy (RVH) was present in 29 patients (76%); 3 patients had right bundle branch block (RBBB). For the entire group, there was a marked decrease in the mean systolic transpulmonic gradient in the immediate post-valvuloplasty period (from 97 +/- 43 to 26 +/- 17 mmHg; P < 0.0001). One patient expired 8 hours post-valvuloplasty (he was in the NYHA Class IV, and had severe RV failure). No other cardiovascular complications were encountered; the median hospital stay was 3 days (range: 1-10 days). At an 8-month follow-up, 12 patients who were reevaluated invasively had a median transpulmonic gradient of 27 mmHg (range: 5-92 mmHg) as compared to their pre-valvuloplasty values of 84 mmHg (range: 49-142 mmHg; P < 0.004).(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary valvuloplasty in adults using the Inoue balloon catheter

This report describes a new balloon pulmonary valvuloplasty technique using the Inoue balloon catheter performed in 14 consecutive adult patients, aged 17-47 years (mean 27). The mean right ventricular systolic pressure and the pulmonary valvular peak-to-peak systolic gradient decreased from 102 +/- 41 to 52 +/- 19 mm Hg (p = 0.001) and 81 +/- 40 to 7 +/- 7 mm Hg (p = 0.0002), respectively. An infundibular peak-to-peak systolic gradient either developed (n = 13) or increased (n = 1). None of the patients were treated with beta-adrenergic blockers before or after the valvuloplasty. Eight patients underwent repeat hemodynamic study 12-30 months (mean 17) after treatment, and had no evidence of valvular restenosis. The mean right ventricular systolic pressure and the mean infundibular peak-to-peak systolic gradient decreased, compared to the values immediately after valvuloplasty (54 to 40 mm Hg, p = 0.03, and 28 to 10 mm Hg, p = 0.03, respectively). The study suggests that pulmonary valvuloplasty in adults using the Inoue balloon catheter technique is feasible, safe, and effective.

Transcatheter treatment of pulmonary outflow tract obstruction: a review

The role of transcatheter methods in the management of pulmonary outflow tract obstruction are discussed in this review. Balloon pulmonary valvuloplasty for relief of isolated pulmonary valve stenosis has been successfully used by many investigators and is the procedure of choice for the management of these lesions. Supravalvar pulmonic stenosis, if discrete, can be relieved by balloon dilatation. Cyanotic children with interatrial right-to-left shunts secondary to severe valvar pulmonary stenosis respond in a manner similar to that observed with isolated pulmonary valve stenosis. In these patients, balloon valvuloplasty is the treatment of choice and may be corrective in most patients. In patients with interventricular right-to-left shunting secondary to pulmonary outflow tract obstruction and in patients with narrowed BT shunts, balloon dilatation may be an effective palliative procedure in a substantial proportion of patients obviating the need for an initial or second palliative shunt. Balloon dilatation is recommended if the patient's size or cardiac anatomy make them unsuitable for safe total surgical correction. In patients with pulmonary atresia, either initial opening of the atretic pulmonary valve by laser or by surgery with subsequent balloon dilatation are potentially beneficial in reducing the total number of surgical procedures that these children are likely to require. However, further clinical trials are needed before their general use.

Failure of balloon dilatation of the pulmonary valve in carcinoid pulmonary stenosis

BACKGROUND

Carcinoid heart disease typically results in pulmonary stenosis and tricuspid incompetence. Percutaneous balloon dilatation is an effective treatment for congenital pulmonary stenosis and has been applied successfully to tricuspid stenosis caused by carcinoid heart disease. The value of balloon dilatation of the pulmonary valve in carcinoid pulmonary stenosis was assessed.

METHODS

Two patients with severe congestive heart failure secondary to carcinoid heart disease and with documented pulmonary stenosis had balloon dilatation of the pulmonary valve. In both cases tricuspid regurgitation was also present together with reduced cardiac output.

RESULTS

The procedure was technically successful in both patients. One patient experienced symptomatic benefit for two months and the other experienced no improvement. Both patients subsequently required combined tricuspid and pulmonary valve replacement from which good results and symptomatic improvement were obtained.

CONCLUSION

Though balloon dilatation of the pulmonary valve is technically feasible it is unlikely to provide useful palliation in carcinoid heart disease. Valve surgery should be considered in patients in whom the malignancy is controlled but carcinoid heart disease is producing drug resistant congestive heart failure.

Long-term results after balloon pulmonary valvuloplasty

BACKGROUND

The objective of this study was to determine the long-term outcome of patients after percutaneous balloon pulmonary valvuloplasty (BPV) treatment of congenital pulmonary valve stenosis.

METHODS AND RESULTS

This study represents a case series with duration (mean +/- SD) of follow-up of 4.6 +/- 1.9 years. Forty-six patients with a median age of 4.6 years (range, 3 months to 56 years) had BPV at one academic institution between June 1981 and December 1986. Mean peak systolic pressure gradients from the right ventricle to the pulmonary artery were as follows: before BPV, 70 +/- 36 mm Hg; immediately after BPV, 23 +/- 14 mm Hg; at intermediate follow-up by cardiac catheterization or Doppler echocardiography at less than 2 years after BPV, 23 +/- 16 mm Hg (n = 33); and at long-term follow-up by Doppler at more than 2 years after BPV, 20 +/- 13 mm Hg (n = 42). BPV acutely reduced the gradient to less than 36 mm Hg for 41 of 46 (89%) patients. Available gradients at long-term follow-up were less than 36 mm Hg for 36 of 42 (86%) patients without additional procedures. A patient age of less than 2 years at the initial BPV was a significant risk factor for gradients over 36 mm Hg at follow-up.

CONCLUSIONS

BPV provides long-term relief of pulmonary valvular obstruction in the majority of patients. Close follow-up of patients who require BPV at less than 2 years of age is warranted.

Operative findings after percutaneous pulmonary balloon dilatation of the right ventricular outflow tract in tetralogy of Fallot

Since 1983 percutaneous balloon dilatation of the right ventricular outflow tract has been performed as an alternative to surgical palliation in selected cases of tetralogy of Fallot at the Royal Liverpool Children's Hospital. From 31 December 1984 to 31 December 1988, 27 of these patients underwent subsequent surgical correction. Age at operation ranged from 7 to 58 months (median 2.7 years). The mean interval between balloon dilatation and correction was 15.6 months (range 3-39 months). Two patients had a systemic pulmonary shunt operation performed before dilatation and a further five required one afterwards. Overall 20 (74%) patients had some anatomical alteration as the result of balloon dilatation, while in seven (26%) there was no discernible change in the right ventricular outflow tract. There was no consistent relation between the ratio of balloon size to pulmonary annulus diameter and the morphological findings. Balloon dilatation may obviate the need for systemic-pulmonary shunt at the expense of some structural damage, particularly to the posterior cusp. The present data suggest that dilatation does not bring about growth of the annulus to such an extent that transannular patch is no longer needed at intracardiac repair.

Perforation of the heart in a newborn with critical valvar pulmonary stenosis during balloon valvoplasty

We describe the perforation of the right ventricular outflow tract with a 0.021 inch wire in a newborn infant with critical pulmonary valvar stenosis in an attempt to balloon dilatation of the pulmonary valve. The complication was diagnosed by contrast injection into the pericardium. The infant was followed with sector scan echocardiography and recovered completely from that injury. The dilatation was successfully repeated a few days later with the use of a soft tipped wire to cross the pulmonary valve.