Neonate aortic stenosis: importance of myocardial perfusion in prognosis

Balloon Valvuloplasty of Aortic Valve Stenosis in Childhood: Midterm Results in a Children's Hospital, Mansoura University, Egypt

Background:

Balloon valvuloplasty was established as an alternative to surgery for treatment of aortic valve stenosis in childhood. Acute complications after balloon dilatation including aortic insufficiency or early death were described.

Aim of Work:

To analyze early outcome and midterm results of balloon aortic valvuloplasty (BAV) in Children’s Hospital, Mansoura University, Egypt.

Subjects and Methods:

Between April 2005–June 2008, all consecutive patients of age <18 years treated for aortic valve stenosis (AVS) with BAV were analyzed retrospectively. The study included 21 patients; 17 males, and 4 females. Their age ranged from the neonatal period to 10 years (mean age 5.6 ± 3.7 years). Patients with gradient ≥50 mmHg and aortic valve insufficiency (AI) up to grade I were included. All patients had isolated aortic valve stenosis except 3 patients (14.3%) had associated aortic coarctation. Six patients (28.6%) had bicuspid aortic valve. All patients had normal myocardial function except one (4.8%) had FS 15%. The duration of follow up was (mean ± SD: 18.5 ± 11.7 months).

Results:

Femoral artery approach was used in 20 patients (95.2%) and carotid artery in one neonate (4.8%). Balloon/annulus ratio was 0.83 ± 0.04. Significant reduction in pressure gradient was achieved (mean 66.7 ± 9.8 mmHg to 20.65 ± 2.99 mmHg) (P < 0.001). Nine patients (42.8%) developed grade I AI, 2 patients (9.5%) developed grade II AI and 1 patient (4.8%) developed grade III AI. Two early deaths (9.5%); one died due to heart failure caused by grade IV AI and a neonate died because of severely compromised LV function. One patient (4.8%) had femoral artery occlusion necessitating anticoagulation. Patients remained free from re-intervention during follow up.

Conclusion:

Balloon valvuloplasty of aortic valve stenosis significantly reduces gradient with low morbidity and mortality in children.

Ascending aortic approach for balloon aortic valvuloplasty with concomitant bilateral pulmonary artery banding in a very low-birth-weight neonate with critical aortic stenosis and poor left ventricular function

An 1186-g infant was born at 27 weeks' gestation. Echocardiography showed critical aortic stenosis, a dilated left ventricle (left ventricular end-diastolic diameter, 16.9 mm), and poor left ventricular function (left ventricular ejection fraction, 8.5%). Due to duct-dependent systemic circulation, the patient underwent a hybrid intervention consisting of bilateral pulmonary artery banding (PAB) and balloon aortic valvuloplasty (BAV) via the ascending aorta on day 2. A stainless steel tip and a 6-French introducer were combined to create an access device. The access device was inserted into the ascending aorta, through which balloon catheters were manipulated. On day 4, echocardiography showed a left ventricular ejection fraction of 48% and dominant antegrade blood flow in the aortic arch. The pulmonary artery bands were removed and the ductus was clipped on day 8 to establish in-line circulation. After re-balloon aortic valvuloplasty for restenosis, the patient was discharged from the hospital at 7 months of age. The clinical implications of this case are: the ascending aortic approach is feasible for BAV in low-birth-weight neonates; and bilateral PAB performed concomitantly with BAV may be efficient for neonates with critical aortic stenosis and poor left ventricular function.