Acute pulmonary edema after percutaneous balloon valvuloplasty for pulmonary valve stenosis

Pulmonary reperfusion injury in post-palliative intervention of oligaemic cyanotic CHD: a new catastrophic consequence or just revisiting the same old story?

Pulmonary reperfusion injury is a well-recognised clinical entity in the setting pulmonary artery angioplasty for pulmonary artery stenosis or chronic thromboembolic disease, but not much is known about this complication in post-palliative intervention of oligaemic cyanotic CHD. The pathophysiology of pulmonary reperfusion injury in this population consists of both ischaemic and reperfusion injury, mainly resulting in oxidative stress from reactive oxygen species generation, followed by endothelial dysfunction, and cytokine storm that may induce multiple organ dysfunction. Other mechanisms of pulmonary reperfusion injury are "no-reflow" phenomenon, overcirculation from high pressure in pulmonary artery, and increased left ventricular end-diastolic pressure. Chronic hypoxia in cyanotic CHD eventually depletes endogenous antioxidant and increased the risk of pulmonary reperfusion injury, thus becoming a concern for palliative interventions in the oligaemic subgroup. The incidence of pulmonary reperfusion injury varies depending on multifactors. Despite its inconsistence occurrence, pulmonary reperfusion injury does occur and may lead to morbidity and mortality in this population. The current management of pulmonary reperfusion injury is supportive therapy to prevent deterioration of lung injury. Therefore, a general consensus on pulmonary reperfusion injury is necessary for the diagnosis and management of this complication as well as further studies to establish the use of novel and potential therapies for pulmonary reperfusion injury.

Non-cardiogenic pulmonary oedema complicating balloon valvuloplasty and stent angioplasty of severe pulmonary valve stenosis in four dogs

In dogs, balloon valvuloplasty is considered the treatment of choice for severe pulmonary valve stenosis, and this technique is currently performed routinely in specialist referral practices with low morbidity and mortality. Stent angioplasty has also been recently proposed as a viable treatment option. The present case series describes the clinical course of four dogs with severe pulmonary valve stenosis, treated with balloon valvuloplasty or stent angioplasty at four different institutions, which developed non-cardiogenic pulmonary oedema perioperatively after apparently successful dilation of the pulmonary valve. In three cases, there was evidence of some degree of pulmonary hypertension before ballooning. Despite intensive care, the complication proved fatal in three cases. Clinicians should therefore be aware of this life-threatening complication, previously undescribed in dogs.

Fatal acute lung injury after balloon valvuloplasty in a dog with pulmonary stenosis

A one-year-old French Bulldog was referred for the management of a severe form of pulmonary valve stenosis (PS) complicated by right-sided congestive heart failure. Echocardiography showed severe valvular PS with right ventricular concentric hypertrophy, dilatation and severe right atrial enlargement. A pulmonary balloon valvuloplasty (PBV) was performed with a balloon-to-pulmonary annulus ratio of 1.36. Echocardiography immediately after PBV showed a significant reduction in right atrial and ventricular size, improved opening and mobility of the pulmonary valve leaflets, and a 75% reduction in the pulmonary pressure gradient from 158 mmHg pre-operative to 40 mmHg post-operative. The dog recovered well from anesthesia, but 2 h later, it suddenly showed severe respiratory distress. Focus cardiac ultrasound showed increased left cardiac size with echocardiographic signs of high left ventricular filling pressure. Bedside lung ultrasound showed diffuse numerous-to-confluent B lines, compatible with a severe alveolar-interstitial syndrome. The dog was treated with furosemide, helmet continuous positive airway pressure, and then mechanical ventilation but without success. At post-mortem evaluation, histological examination of the lung showed diffuse, severe broncho-alveolar edema with mixed leukocyte, fibrin, and red blood cell infiltrate. Moreover, severe congestion and multifocal alveolar hemorrhages were evident. All findings were compatible with fatal acute lung injury after PBV secondary to pulmonary reperfusion-ischemia injury and increased pulmonary capillary hydrostatic pressure. Based on the present case, acute lung injury should be considered as a rare but serious complication of PBV.

Acute pulmonary edema in a dog with severe pulmonary valve stenosis: A rare complication after balloon valvuloplasty

Pulmonic stenosis is a frequent congenital heart disease in dogs, and the treatment of choice is balloon valvuloplasty which is usually safe and successful. The authors describe for the first time a severe complication after balloon valvuloplasty in a five-month-old dog. After effective treatment, with a considerable drop in right ventricular pressures, the dog developed hypoxemia and dyspnea due to pulmonary edema. The dog underwent intensive care and symptoms improved after a few hours of oxygen therapy, continuous positive airway pressure, and furosemide. Although this event is rare, it could have a large impact on patient survival and should be considered in the treatment of severe pulmonary valve stenosis in the future.

Balloon pulmonary valvotomy--not just a simple balloon dilatation

Balloon pulmonary valvotomy is the preferred mode of treatment in patients with isolated pulmonary valvar stenosis and has shown good long term results. It is generally considered a safe procedure with few complications. There have been however, case reports of potentially fatal acute severe pulmonary edema occurring after the procedure in some patients. The cause of this complication and its pathophysiology is still not clear. Its occurrence is also infrequent with less than 5 cases reported till now. We report a case of pulmonary valvar stenosis which developed acute severe refractory pulmonary edema immediately after balloon pulmonary valvotomy.

Entrapped Catheter across the Fossa Ovalis in an Adult with Pulmonary Stenosis - A Case Report of Surgical Relief

Percutaneous pulmonary balloon valvuloplasty as a procedure of choice in adults has been established since the last three decades. Even though the complications are rare, they are scarcely reported in the literature. We report such a case in an adult female patient of severe pulmonary valular stenosis in whom, entrapped catheter across the fossa ovalis was noted in chest x-ray and echocardiogram following unsuccessful percutaneous pulmonary balloon valvuloplasty. Our case emphasizes this rare complication and its successful surgical outcome.

Percutaneous Therapies in the Treatment of Valvular Pulmonary Stenosis

Transcatheter balloon pulmonary valvuloplasty (BPV) is the standard of care in managing symptomatic patients with moderate-to-severe pulmonary valvular stenosis, or asymptomatic patients with severe pulmonary valvular stenosis or with moderate pulmonary stenosis and evidence of objective exercise intolerance or right ventricular dysfunction. This article discusses the incidence, causes, and pathophysiology of valvular pulmonary stenosis in adolescents and adults; its natural history and noninvasive evaluation; the current guideline-recommended indications for BPV; the technical aspects of performing BPV; the immediate and long-term outcomes after valvuloplasty; and the complications and safety of the procedure. Also discussed is the role of this procedure in neonatal critical pulmonary stenosis and in percutaneous pulmonary valve replacement for patients with prior pulmonic valve interventions or degenerated right ventricular pulmonary artery conduits.

Acute pulmonary reperfusion hemorrhage: a rare complication after oversized percutaneous balloon valvuloplasty for pulmonary valve stenosis

Balloon valvuloplasty became the treatment of choice for valvular pulmonary stenosis following its first description in 1982 by Kan et al, and has almost replaced surgical pulmonary valvotomy in the present day. It is a safe and effective method for children for relief of right ventricular obstruction. The results of the procedure are excellent, without significant complications. This report describes the case of a 12-year-old boy who received successful balloon valvuloplasty for critical pulmonary valve stenosis complicated by an episode of acute pulmonary hemorrhage. Because of cyanosis, hypotension and bradycardia, he received emergent endotracheal intubation with 100% oxygen supplement and the highest infusion rate of inotropic agents. Venoarterial mode extracorporeal membrane oxygenation was indicated for life support due to the persistent high oxygenation index. Extracorporeal membrane oxygenation played a key role in the survival of this patient during the course of treatment.