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

Immediate results of balloon valvuloplasty in congenital pulmonary valve stenosis

INTRODUCTION

Balloon Valvuloplasty is the first-line treatment for congenital valve pulmonary stenosis (PS) in children and adults.

METHODS

We reported immediate results of balloon valvuloplasty in congenital pulmonary stenosis from 2014 to 2019.

RESULTS

BPV was performed in 40 patients, the diagnosis was based on cardiac ultrasound data showing valvular dysplasia in 92% of cases, the main associated anomaly is FOP in 22.5% of cases,  immediate success (defined by a peak-to-peak gradient after the DPPC of less than 50mmHg) was found in 88% of cases, allowing a significant reduction in mean  peak to peak pressure among pulmonary valve  from 69.65mmHg to 30.19mmHg. After BV 11% of patients maintained a high gradient, the independent predictive factors were valvular dysplasia and the small diameter of the ring an immediate post procedural infundibular reaction was noted in 25% of cases mainly related to valvular dysplasia. The mortality of the procedure was zero and morbidity was low. mild pulmonary regurgitation was found in all patients.

CONCLUSION

PV has been established as the treatment of choice for valvular PR with few complications. Following its satisfactory immediate results, the indications quickly extended to critical pulmonary stenosis in newborns and late discovery forms in adults.

Immediate- and medium-term effects of balloon pulmonary valvuloplasty in infants with critical pulmonary stenoses during the first year of life: A prospective single center study

BACKGROUND

Balloon pulmonary valvuloplasty (BPV) represents the standard of management for all patients with severe pulmonary stenosis (PS) irrespective of their age. Nevertheless neonates and infants with critical PS represent a high-risk group that needs to be studied.

METHODS

The study population included 72 infants with severe congenital valvular PS and four infants with imperforate pulmonary valve (PV) who were subjected to detailed history taking, full clinical examination, resting 12-lead ECG, Chest roentgenogram and transthoracic echocardiography. BPV was attempted in all infants with a peak-to-peak gradient across the PV of 50 mmHg or greater at catheterization-laboratory. Full echocardiographic evaluation was done 24 hours after the procedure as well as 3 and 6 months later.

RESULTS

Seventy-six infants with severe PS or imperforate PV with a mean age of 5.63 ± 2.99 months were subjected to BPV with or without wire perforation. Immediately after the procedure patients had a significant reduction of the right ventricular systolic pressure (RVSP) (104.69 ± 24.98 mm Hg Vs 43.6 ± 13 mm Hg, p < 0.001) and RV-PA systolic pressure gradient (PG) (82.5 ± 23.76 mm Hg Vs 17.35 ± 8.96 mm Hg, p < 0.001). The immediate success rate defined as the drop in the RVSP to less than or equal to 50% of the baseline measurement was achieved in 85% of the cases. There was a progressive drop in the PG across the PV by Doppler echocardiogram throughout a follow-up period of six months from a mean of 93.3 ± 28.2 mm Hg to a mean of 17.4 ± 10.42 mm Hg (p < 0.001). There was a significant increase of the mean PV annulus diameter after balloon dilatation (p < 0.001). There was also a highly significant inverse correlation between the growth of the pulmonary annulus and the annular size at the baseline before dilatation (r = -0.74, p value <0.001). The incidence of PR significantly increased immediately after BPV to 64% followed by a progressive decline over a 6 months period of follow-up to 20%. There was a significant decrease in the incidence of tricuspid regurgitation (TR) over the same period of follow-up (from 55.6% at baseline to less than 20% at follow-up).

CONCLUSION

BPV is safe and effective to relieve critical PS in infants during the first year of life. The balloon promotes advantageous changes in both, pulmonary annulus and PG across the RVOT. In addition, the Doppler gradient observations during the follow-up support the expectation that BPV is a "curative" therapy.

Long-term follow-up of patients after surgical treatment for isolated pulmonary valve stenosis

OBJECTIVE

To determine the long-term outcome of patients after surgical repair for pulmonary valve stenosis (PVS).

PATIENTS AND METHODS

Fifty-three patients (30 males; mean - SD age, 10+/-13 years; range, 5 days to 50 years) were identified who had surgical treatment for PVS between 1951 and 1982. The status of each patient was determined by medical record review.

RESULTS

The mean +/- SD age at follow-up was 43+/-15 years (age range, 19-77 years). Mean follow-up was 33 years (range, 18-51 years). At a median follow-up of 34 years, 35 reinterventions had been performed in 28 patients (53%), Including pulmonary valve replacement for free pulmonary regurgitation in 21 patients (mean interval after initial surgery, 33 years; range, 14-45 years), open valvotomy in 5 and pulmonary balloon valvuloplasty in 3 for residual PVS, closure of atrial septal defect in 2, right ventricular outflow tract reconstruction in 1, closure of iatrogenic ventricular septal defect in 1, ligation of aortopulmonary fistula in 1, and tricuspid valve annuloplasty with simultaneous coronary artery bypass grafting in 1. In addition, atrial and ventricular arrhythmias were common, occurring in 20 patients (38%). Patients who underwent reintervention were more likely to have undergone closed pulmonary valvotomy as the initial repair (P=.008).

CONCLUSION

Although overall survival after surgical treatment of isolated PVS remains excellent, many patients undergo late reintervention after 30 years of follow-up, emphasizing the need for lifelong cardiac follow-up.

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.