Significance of infundibular obstruction following balloon valvuloplasty for valvar pulmonic stenosis

This study was designed to define the prevalence and significance of infundibular obstruction following balloon pulmonary valvuloplasty. Thirteen of 62 children had infundibular gradients prior to valvuloplasty; five of these disappeared following balloon valvuloplasty. Five other children without pre-valvuloplasty infundibular gradients but with angiographic infundibular narrowing developed new infundibular gradients following valvuloplasty. Propranolol was administered to six children because of severe infundibular constriction, with improvement. None required surgical intervention. At follow-up the infundibular gradients either diminished or disappeared. The infundibular gradients appear to be more frequent with increasing age and severity of pulmonary valvar obstruction. Children developing systemic or suprasystemic right ventricular pressures after balloon pulmonary valvuloplasty may be candidates for propranolol therapy. Regression of the infundibular stenosis at follow-up can be expected, as has been observed after surgical pulmonary valvotomy. Because the infundibular obstruction can be successfully managed, balloon pulmonary valvuloplasty remains the treatment of choice for isolated valvar pulmonary stenosis. Use of balloon valvuloplasty in children less than 5 years of age and/or prior to development of pulmonary gradients in excess of 80 mm Hg may reduce the chance for development of infundibular reaction.     

Side-wire technique for percutaneous pulmonary balloon valvuloplasty

On occasion during percutaneous pulmonary balloon valvuloplasty, a small balloon may slip into the pulmonary artery when dilating a stenotic pulmonary valve. In order to stabilize the balloon should a larger balloon size not be available, a side wire can be used without changing the original balloon.     

Use of propranolol for severe dynamic infundibular obstruction prior to balloon pulmonary valvuloplasty (a brief communication)

A case of severe pulmonary valvar stenosis and infundibular obstruction has been reported. Infundibular obstruction was so severe that no catheter could be advanced into the pulmonary artery. Propranolol, 0.5 mg given intravenously, reduced the obstruction and allowed the balloon dilatation of the pulmonary valve to be carried out without complication. Subsequently oral propranolol helped to remove the infundibular obstruction. We strongly recommend the use of propranolol when infundibular obstruction is present prior or after the balloon pulmonary valvuloplasty.     

Clinical follow-up after percutaneous aortic balloon valvuloplasty

Percutaneous aortic balloon valvuloplasty has been applied in a growing number of patients with severe symptomatic calcific aortic stenosis. Follow-up data from these patients have not been well characterized. In 88 patients (mean age, 80 +/- 8 years) who underwent percutaneous aortic balloon valvuloplasty, the average initial aortic valve area was 0.48 +/- 0.20 cm2, and it increased to 0.74 +/- 0.26 cm2 after dilation. The average duration of follow-up in survivors was 7.8 months. Actuarial survival at 6 and 12 months was 75% and 63%, respectively. Factors associated with subsequent death included more severe impairment from heart failure at baseline, smaller initial aortic valve area, smaller final aortic valve area, low baseline cardiac output, and low ejection fraction. Among the surviving patients, 50% had no cardiac symptoms, and 85% had improved symptoms from congestive heart failure. Percutaneous aortic balloon valvuloplasty is associated with continued increased mortality during follow-up, although symptomatic improvement in survivors is good. Percutaneous aortic balloon valvuloplasty can be considered a palliative approach for severely symptomatic patients at high risk for aortic valve operation or patients with a limited life span due to other medical problems, but it is not indicated in patients at acceptably low risk for aortic valve replacement.     

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.     

46例经皮球囊肺动脉瓣成形术后患儿运动功能的研究

目的经皮球囊肺动脉瓣成形术（percutaneous balloon pulmonary valvuloplasty,PBPV）已成为治疗肺动脉瓣狭窄的首选方法,本研究旨在应用平板运动试验观察PBPV后患儿运动耐量和运动心率、血压反应以及心电图变化,探讨相关因素对远期预后的影响。方法46例经皮球囊肺动脉瓣成形术后患儿采用Bruce方案进行平板运动试验,观察其运动耐量和运动心率、血压反应以及心电图变化。同期对294例健康儿童进行平板运动试验,测定各年龄组运动耐量均值,并从中随机选取46例年龄、性别相仿的儿童作为正常对照组。结果PBPV后患儿跨肺动脉瓣压差稳定在25mmHg（1mmHg=0．133kPa）以下,平均运动耐量可达正常同龄标准的90％左右,且运动所能达到的负荷量与PBPV前跨瓣压差无明显相关性。运动心率、血压反应正常。运动功能与术时年龄、PBPV所选用的球囊／瓣膜比值有关。5例患儿运动试验诱发室性心律失常,均为偶发室性早搏,运动试验过程中无一例出现ST段异常变化。结论早期解除右室流出道梗阻有利于远期运动功能的改善。PBPV时采用适度的球囊／瓣膜比值（1．2～1．4）值得推荐。但对于术后发生的肺动脉瓣反流仍应长期随访观察。     

经皮球囊肺动脉瓣成型术治疗肺动脉瓣狭窄86例临床分析

目的评价经皮球囊肺动脉瓣成形术(PBPV)治疗肺动脉瓣狭窄(PS)的近期和远期疗效及安全性.方法总结近10年行PBPV术86例患者术后即刻、术后3天、术后3个月、术后1年的心电图、心脏彩超等检查结果,观察PBPV的安全可靠性,并与同期外科手术的疗效比较.结果 PBPV术后即刻右心室收缩压由(98±28)mmHg降至(56±19)mmHg(P＜0.01),肺动脉与右心室跨瓣压差(ΔP)由(64±27)mmHg降至(34±11)mmHg(P＜0.01);心电图Tv1由直立变为倒置26例(30%).术后3天、3个月及1年经超声测定ΔP分别为(21±9)mmHg、(13±7)mmHg、(10±5)mmHg;心电图Tv1变为倒置例数分别为64例、84例和85例,与同期外科手术疗效比较差异无显著性.结论 PBPV术后即刻右心室压力可明显下降,若病例选择适当,几乎可以代替外科手术.PBPV操作简便,疗效可靠,不失为治疗PS的首选方案.     

经皮肺动脉瓣成形术治疗肺动脉瓣狭窄的临床分析

目的:探讨应用Inouc球囊经皮肺动脉瓣成形术(PBPV)治疗肺动脉瓣狭窄(PVS)的临床疗效。方法:PVS 患者18例,采用PBPV进行治疗,并以超声多普勒评价其疗效。结果:18例行PBPV患者术后即刻右心室收缩压由 (101．4±28．2)mmHg降至(48．5±16．7)mmHg(P<0．01)。右房压由(16．9±7．5)mmHg降至(9．8±4．3)mmHg (P<0．05),肺动脉压由(15．2±3．1)mmHg升至(23．1±5．6)mmHg(P<0．05),肺动脉与右心室跨瓣压差 (△P)由(76．5±25)mm Hg降至(21．7±12．2)mmHg(P<0．01)。多普勒超声随访:术后3个月跨瓣压差较术后即刻进一步显著下降(P<0．05)。结论:经皮球囊肺动脉成形术治疗肺动脉瓣狭窄安全有效。     

二尖瓣球囊成形术长期随访结果

目的 :随访经皮二尖瓣球囊成形术 （PBMV）治疗风湿性二尖瓣狭窄长期疗效。方法 :采用 Inoue单球囊扩张狭窄的二尖瓣 ,对 PBMV术患者 2 2 7例进行追踪随访 ,评价临床心功能和瓣口状况。平均随访时间 （6 .3± 2 .1）年。结果 :PBMV术后二尖瓣口面积 （MVA ）显著扩大 ,从 （1.0 1± 0 .2 8） cm 2扩至 （2 .34± 0 .17） cm2 （P<0 .0 1） ,长期随访 ,MVA逐渐减小至 （1.6 6± 0 .37） cm2 （P<0 .0 1）。再狭窄率为 2 2 .9%。二尖瓣跨瓣压差 （MVG）从 （19.5± 6 .2 ）mm Hg分别减少至术后、随访的 （7.4± 5 .1）和 （10 .1± 4.9） m m Hg,差别显著 （P<0 .0 1）。随访中临床心功能改善仍然维持 1个级别以上者达 77.1%。随访射血分数 （EF）变化不大、二尖瓣返流 （MR）较术前、后明显加重 （P<0 .0 1）。结论 :PBMV治疗二尖瓣狭窄长期临床疗效良好     

Incidence and treatment of reactive infundibular obstruction after balloon dilatation of critical pulmonary valve stenoses]

Seventeen consecutive newborn and premature babies with critical pulmonary stenosis underwent a technically successful balloon valvuloplasty at our institution from March 1991 to February 1998. The only major complication was a thrombosis of the femoral vein in one patient, causing no clinical problems. Four patients (24%) showed a reactive infundibular obstruction after balloon valvuloplasty. The outflow tract obstruction became evident immediately after successful dilatation of the pulmonary valve with persistently high pressures in the right ventricle. Pathognomonic was a typical notch in the ascending part of the right ventricular pressure curve. We were unable to predict this reaction based on echocardiography or angiography. To relieve the muscular subvalvar obstruction, we treated the first two patients with i.v. Propranolol (0.05 mg/kg over 2 min). The last 2 patients received Esmolol (0.5 mg/kg over 2 min followed by a continuous infusion with 100 micrograms/kg/min), a very short acting beta-blocker. In the medium-term follow-up, all 17 patients had a very good result with only mild pulmonary valve regurgitation. All 4 patients with a reactive infundibular obstruction required no repeat intervention. In the medium-term follow-up there were no differences between these 4 patients and the whole group.     

Results of repeat percutaneous balloon valvuloplasty for pulmonary valvar restenosis

Follow-up cardiac catheterization studies were used to evaluate 105 patients who had undergone percutaneous balloon pulmonary valvuloplasty. Fifteen of those patients who had peak systolic pulmonary valve gradients greater than = 40 mm Hg at follow-up underwent repeat balloon valvuloplasty. For the initial balloon pulmonary valvuloplasty, the mean ratio of the balloon diameter to pulmonary valve annulus diameter was 0.98 +/- 0.2; at repeat valvuloplasty the mean was 1.19 +/- 0.12. The immediate post-repeat balloon valvuloplasty results showed a reduction in the peak systolic gradient from a mean of 70.2 +/- 17.8 to 29.1 +/- 19.0 mm Hg (p less than 0.001). This reduction in the gradient was maintained at a mean of 14.3 +/- 5.0 mm Hg in 8 of the 10 patients who underwent further follow-up studies. We conclude that successful repeat balloon pulmonary valvuloplasty with the use of larger sized balloons is feasible in patients who have restenosis after the initial percutaneous balloon valvuloplasty--including partial but not complete dysplasia of the pulmonary valve.     

经皮肺动脉瓣球囊成形术疗效及其影响因素

目的 评价经皮肺动脉瓣球囊成形术(PBPV)治疗单纯肺动脉瓣狭窄(PS)的疗效,探讨影响疗效的相关因素.方法 自1996年2月至2003年3月PBPV治疗PS 65例.年龄1～48(13.5±9.3)岁.65例术前超声心动图均提示不同程度PS.使用单、双球囊和Inoue球囊分别为41、6及18例.球囊直径选择依据肺动脉瓣环的大小,球瓣比1.00～1.19、1.20～1.39和≥1.40分别为19、42和4例.定义术后即刻跨肺动脉瓣压力阶差(PTG)<36 mm Hg(1 mm Hg=0.133 kPa)为手术即刻成功标准.25例6～12个月随访,行右心导管术或超声心动网评价PTG.结果 65例患者术前PTG为(86.4±33.6)mm Hg,右心室收缩压(107.5±36.5)mm Hg,术后即刻PTG降至(31.5±23.4)mm Hg,术后即刻右心室收缩压降至(55.0±23.6)mm Hg,53例(81.5%)术后即刻PTG<36 mm Hg.Inoue球囊组术后即刻PTG低于单、双球囊组,球瓣比1.20～1.39组术后即刻PTG低于球囊比1.00～1.19及≥1.40组,但差异无统计学意义.术后2例出现三尖瓣反流,26例发生继发性流出道狭窄,Inoue球囊组占13例.25例12个月随访时PTG为(35.7±23.9)mm Hg,其中3例出现肺动脉瓣关闭不全,末给予特殊处理,无再狭窄发生.术后即刻6例PTG≥36 mm Hg患者,随访中PTG均降低.随访11例继发性流出道狭窄右心窒收缩压逐渐降低(P<0.01).结论 PBPV即刻和中期疗效好,是PS的首选治疗方法 .选择球瓣比1.20～1.39和Inoue球囊疗效较佳.     

经皮球囊二尖瓣扩张术并发症的外科治疗

本院自１９８７年１０月至１９９５年９月，３５０例行经皮球囊二尖瓣成形术后发生并发症需要外科治疗的８例患者，其中心脏穿破致急性心包填塞３例、脑栓塞１例、创伤性重度二尖瓣关闭不全２例、创伤性房间隔缺损５例。外科采用紧急开胸止血、左心房血栓清除、修补创伤性房间隔缺损、二尖瓣置换、左径二尖瓣扩张术等治疗方法。作者认为：经皮球囊二尖瓣成形术后发生并发症，应及时采用适当的外科治疗措施，切勿延误治疗时机；经皮球囊二尖瓣成形术需有一定的适应证，不能完全替代二尖瓣置换术或直视二尖瓣成形术。     

New triple-lumen balloon catheter for percutaneous (pulmonary) valvuloplasty

Percutaneous transluminal balloon pulmonary valvuloplasty has been performed since 1982. In publications, the most critical problems mentioned are severe systemic hypotension and bradycardia due to stasis of blood flow. A triple-lumen balloon was developed to allow more rapid inflation and deflation and to preserve the preexistent forward blood flow during maximal inflation. Only a slight systemic hypotension and no bradycardia were seen in the first two patients with pulmonary valve stenosis treated with this type of balloon. Thus, the maximal inflation time is not a critical parameter, whereas with the former types of balloon, maximal inflation times were critical, and, if longer than 5 to 10 sec, severe systemic hypotension was registered. We conclude that the triple-lumen pulmonary valve-dilatation balloon catheter is superior to the single-lumen balloon catheter used up to now.     

Trefoil balloon for percutaneous valvuloplasty

A new balloon (Trefoil balloon) was developed to avoid complete interruption of blood flow during percutaneous balloon valvuloplasty. It consists of three identical 2- to 4-cm-long angioplasty balloons mounted in a parallel fashion on a single catheter. Filled simultaneously, they assume the cross section of a rosette, allowing for continued blood flow. Trefoil balloons of various sizes were tested in five dogs (aorta and aortic valve). They created a gradient ranging from 5 to 40 mmHg where conventional, single balloons of comparable size were completely obstructive. In three consecutive patients with congenital pulmonary stenosis, Trefoil balloons were used successfully and without significant complications. Continued transvalvular blood flow during the actual dilatation process was documented in all cases. The Trefoil balloon is a promising new device for percutaneous valvuloplasty and, perhaps, coronary angioplasty.