Success determining factors in percutaneous transluminal balloon valvuloplasty of pulmonary valve stenosis

Twenty-two percutaneous transluminal balloon valvuloplasty procedures were performed on 21 patients with congenital pulmonary valve stenosis. The peak systolic pressure gradient was immediately reduced from 79.1 +/- 7.4 to 22.2 +/- 1.8 mmHg, (P less than 0.0001) and follow-up cardiac catheterization at 5.3 +/- 0.4 months in 19 patients revealed no further significant change in gradient (23.5 +/- 3.2 mmHg). The best results were obtained when balloons larger than the pulmonary annulus were used, i.e. an immediate residual transvalvular gradient of 22.0 +/- 2.2 mmHg with a balloon/annulus ratio greater than 1, as opposed to 44.2 +/- 5.4 with a balloon/annulus ratio = 1 (P less than 0.001). The angiographically determined cusp thickness of the stenotic pulmonary valves was significantly greater than that of the control group of 24 patients without pulmonary valve stenosis (1.21 +/- 0.09 vs 0.59 +/- 0.02 mmHg, P less than 0.00001). The relationship between this parameter and the residual transvalvular gradient at follow-up was found to be significant (r = 0.77, P less than 0.001). It is concluded that balloon size is a determinant factor in achieving good results with percutaneous balloon valvuloplasty although cusp thickness, a factor to which scant regard has hitherto been paid, also plays a significant role in the residual transvalvular gradient measured at follow-up.     

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.     

Further observations on the effect of balloon size on the short term and intermediate term results of balloon dilatation of the pulmonary valve

The relation between the size of the balloon used for dilatation of the pulmonary valve and the extent of relief of pulmonary stenosis both immediately after and at intermediate term follow up was studied. Sixty four balloon dilatation procedures in 56 patients were divided into group 1-12 in which the ratio of the diameter of the balloon to that of the pulmonary annulus was less than or equal to 1.0--and group 2-52 in which the ratio was greater than 1.0. Both groups had similar mean (SD) pressure drops across the pulmonary valve before dilatation. Immediately after dilatation there was a significant reduction in the pulmonary valve gradient in both group 1 (84.3 (39.2) v 43.6 (26.8) mm Hg) and group 2 (92.8 (42.1) v 22.4 (13.6)mm Hg). On intermediate term follow up (6-34 months), residual pulmonary valve gradients were significantly lower in group 2 (20.8 (18.5)mm Hg) than in group 1 (75.0 (49.4) mm Hg), suggesting that restenosis was more common after dilatation with small balloons. These data suggest that although the immediate results with either small or large balloons are good, balloons that are larger than the pulmonary valve annulus produce more sustained relief of pulmonary stenosis. Further analysis within the group treated with larger balloons showed that the subgroup with a balloon/annulus ratio of 1.01-1.2 had more recurrences of stenosis (need for repeat balloon dilatation and larger number of patients with residual pulmonary valve gradients greater than 30 mm Hg) than subgroups with balloon/annulus ratios for diameters of 1.21-1.41, greater than 1.41, and greater than 1.5, in which there were no recurrences. Balloons that were > 1.5 times the size of the pulmonary valve annulus had no additional advantage over the other subgroups, namely, 1.21-- 1.4 and > 1.41. These results and reports of damage to the right ventricular outflow tract by oversized (> 1.5) balloons indicate that balloons that give a balloon/annulus ratio 1.2 -- 1.5 are the best for dilatation of the pulmonary valve.     

Further observations on the effect of balloon size on the short term and intermediate term results of balloon dilatation of the pulmonary valve.

The relation between the size of the balloon used for dilatation of the pulmonary valve and the extent of relief of pulmonary stenosis both immediately after and at intermediate term follow up was studied. Sixty four balloon dilatation procedures in 56 patients were divided into group 1-12 in which the ratio of the diameter of the balloon to that of the pulmonary annulus was less than or equal to 1.0--and group 2-52 in which the ratio was greater than 1.0. Both groups had similar mean (SD) pressure drops across the pulmonary valve before dilatation. Immediately after dilatation there was a significant reduction in the pulmonary valve gradient in both group 1 (84.3 (39.2) v 43.6 (26.8) mm Hg) and group 2 (92.8 (42.1) v 22.4 (13.6)mm Hg). On intermediate term follow up (6-34 months), residual pulmonary valve gradients were significantly lower in group 2 (20.8 (18.5)mm Hg) than in group 1 (75.0 (49.4) mm Hg), suggesting that restenosis was more common after dilatation with small balloons. These data suggest that although the immediate results with either small or large balloons are good, balloons that are larger than the pulmonary valve annulus produce more sustained relief of pulmonary stenosis. Further analysis within the group treated with larger balloons showed that the subgroup with a balloon/annulus ratio of 1.01-1.2 had more recurrences of stenosis (need for repeat balloon dilatation and larger number of patients with residual pulmonary valve gradients greater than 30 mm Hg) than subgroups with balloon/annulus ratios for diameters of 1.21-1.41, greater than 1.41, and greater than 1.5, in which there were no recurrences. Balloons that were > 1.5 times the size of the pulmonary valve annulus had no additional advantage over the other subgroups, namely, 1.21-- 1.4 and > 1.41. These results and reports of damage to the right ventricular outflow tract by oversized (> 1.5) balloons indicate that balloons that give a balloon/annulus ratio 1.2 -- 1.5 are the best for dilatation of the pulmonary valve.     

Percutaneous valvuloplasty of congenital pulmonary stenosis in adults over 50 years of age

The authors report three cases of congenital pulmonary stenosis in adults over 50 years of age treated by percutaneous balloon valvuloplasty. Three symptomatic women aged 74, 80 and 51, had systolic pressure gradients ranging from 107 to 113 mmHg between the right ventricle and pulmonary artery. After valvuloplasty with two balloons or one trefoil balloon, the transvalvular pressure gradient fell to 25 to 30 mmHg. It was only 14 mmHg in one patient controlled after one year's follow-up. The cardiac index was initially decreased and did not change very much immediately after the procedure, increasing from 1.68 1/m2/mn to 1.77 1/m2/mn. The pulmonary valve surface area increased from 0.22 to 0.43 cm2. There were no complications and in one patient, reviewed two years later, the clinical improvement was maintained. Percutaneous valvuloplasty is indicated in severe and/or poorly tolerated pulmonary stenosis. With the 10 other previously reported cases of patients over 50 years of age, the procedure was successful in 12 out of 13 patients (92%). In these patients of 51 to 80 years of age, the systolic pressure gradient between the right ventricle and pulmonary artery was reduced from 112 +/- 46 mmHg to 43 +/- 26 mmHg (-62%). Slight pulmonary regurgitation appeared in 5 out of 9 cases. Valvuloplasty was usually well tolerated and there were no fatalities. There were no signs of restenosis in 5 cases controlled 10 days to 1 year after dilatation. In the future, systematic Doppler echocardiographic examinations should help comparison of cardiac haemodynamics before, immediately after valvuloplasty and at long-term.(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon pulmonary valvuloplasty: a review

Balloon pulmonary valvuloplasty has been used successfully over the last few years for the relief of moderate to severe valvar pulmonic stenosis in neonates, infants, children, and adults. Both immediate and intermediate term follow-up results have been well documented by cardiac catheterization studies. Electrocardiographic and echo-Doppler evaluation at follow-up is reflective of the results and may avoid the need for recatheterization. The results of balloon valvuloplasty are either comparable to or better than those reported with surgical valvuloplasty. The causes of restenosis have been identified, and appropriate modifications in the technique, particularly the recommended use of a balloon/annulus ratio of 1.2 to 1.5, should give better results than previously documented. Complications of the procedure have been minimal. Further refinement of the catheters and technique may reduce the complication rate even further. The indications for balloon valvuloplasty have not been clearly defined but should probably be similar to those used for surgical valvotomy; only patients with moderate to severe valvar pulmonic stenosis are candidates for balloon valvuloplasty. Previous surgery and pulmonary valve dysplasia are not contraindications for balloon valvuloplasty. The procedure is also applicable to pulmonary stenosis associated with other complex cardiac defects and stenosis of bioprosthetic valves in pulmonary position. Miniaturatization of balloon/catheter systems to further reduce the complication rate and documentation of favorable result at 5- to 10-year follow-up are necessary.     

Double Balloon Technique for Percutaneous Balloon Pulmonary Valvuloplasty: Comparison with Single Balloon Technique

This study was designed to document our results of double balloon pulmonary valvuloplasty and to evaluate if the double balloon technique is preferable to single balloon valvuloplasty in the relief of isolated valvar pulmonic stenosis. Double balloon valvuloplasty in twelve patients reduced the pulmonary valvar gradient from 100.5 ± 28.0 (mean ± SD) to 26.6 ± 12.5 mm Hg (P < 0.001) which remained improved, 17.5 ± 10.2 mm Hg (P < 0.001) at 6 to 14 month follow-up. Single balloon valvuloplasty with equivalent balloon/pulmonary valve annulus ratios (1.19 ± 0.14 vs 1.19 ± 0.15, P > 0.1) in another 12 patients also reduced (P < 0.001) the gradient from 96.3 ± 40.1 to 28.3 ± 17.3 mm Hg immediately following the procedure which at 6 to 13 month follow-up was 12.8 ± 9.9 mm Hg. The right ventricular peak systolic pressures (116.6 ± 24.5 vs 113.8 ± 41.5 mm Hg) and pulmonary valvar gradients (100.5 ± 28.0 vs 96.3 ± 40.1 mm Hg) prior to valvuloplasty, residual right ventricular pressures (47.4 ± 12.2 vs 54.3 ± 14.2 mm Hg) and pulmonary valve gradients (26.6 ± 12.5 vs 28.3 ± 17.3 mm Hg) immediately after valvuloplasty, and residual right ventricular pressures (43.1 ± 10.9 vs 41.1 + 12.5 mm Hg) and pulmonary valvar gradients (17.5 ± 10.2 vs 12.8 ± 9.9 mm Hg) on follow-up were similar (P ± 0.1) in both groups.
These data indicate that results of double balloon valvuloplasty are excellent but not superior to single balloon valvuloplasty. It is suggested that the double balloon valvuloplasty should be used if the pulmonary valve annulus is too large to dilate with a single balloon. There is no need for double balloon valvuloplasty if the pulmonary valve can be dilated with a commercially available single balloon.     

Initial and late results after catheter intervention for neonatal critical pulmonary valve stenosis and atresia with intact ventricular septum: a technique in continual evolution.

Critical pulmonary valve stenosis or atresia with intact ventricular septum is a rare congenital cardiac defect that can be technically difficult to alleviate in the catheterization laboratory. Over the past 10 years, several techniques and modifications with variable results have been advocated to facilitate the valvuloplasty procedure. This report describes a single operator's experience using various techniques in 28 neonates with critical pulmonary stenosis or atresia who were considered candidates for transcatheter intervention. The first two patients underwent a gradational balloon valvuloplasty approach that resulted in prolonged fluoroscopy exposure. Thereafter, a "snare assisted" umbilical artery approach was developed which facilitated the valvuloplasty procedure and resulted in significantly fewer balloons used and shorter fluoroscopy times. Early in our experience, stiff guidewire perforation of atretic pulmonary valves was used, whereas in our last two patients, a simplified perforation technique with a new 0.9-mm excimer laser catheter was used. Late echocardiographic and clinical follow-up evaluation in 27 patients demonstrates persistent gradient relief, resolution of tricuspid valve insufficiency, and elimination of right to left shunting at the atrial level. Balloon valvuloplasty is the treatment of choice for critical pulmonary valve stenosis or atresia with intact ventricular septum. When necessary, the use of umbilical artery "snare assistance" facilitates the valvuloplasty technique and shortens procedure time while laser perforation is currently preferable for perforation of the atretic pulmonary valve.     

Influence of balloon size on short-term and long-term results of balloon pulmonary valvuloplasty

This article studies the relationship between the size of the balloon used for balloon pulmonary valvuloplasty (BPV) and the degree of relief of pulmonary stenosis. Twenty-six BPVs in 22 patients were divided into two groups: (A) those in which the balloon/pulmonary annulus ratio was 1.0 or less and (B) those in which the ratio was more than 1.0. In group A (which consisted of 9 BPVs), the mean ratio was 0.89 (range, 0.79 to 1.0, whereas in group B (which included 17 BPVs), the mean ratio was 1.32 (range, 1.01 to 1.69). The two groups had similar pre-BPV pulmonary valve (PV) gradients [93 +/- 41 (mean +/- SD) vs 103 +/- 40 mm Hg] (p > 0.1). Immediately after BPV, neither the absolute residual PV gradient (43 +/- 29 vs 37 +/- 21 mm Hg) nor the percentage of residual PV gradient (44 +/- 14 vs 36 +/- 17 percent) differed significantly (p > 0.1) from group to group. However, long-term follow-up (which ranged from 6 to 28 months, with a mean of 12 months), showed the residual PV gradient in group B (18 +/- 8 mm Hg) to be lower (p < 0.02) than that in group A (80 +/- 52 mm Hg). Similarly, the percentage of residual gradient (83 +/- 41 vs 20 +/- 10 percent) was also lower in group B. Repeat BPV was required in four patients from group A, but in none from group B. Although the immediate results of BPV are similar with either small or large balloons, balloons larger than the PV annulus appear to produce more sustained relief of pulmonary stenosis. Therefore, balloons larger than the PV annulus are recommended for pulmonary valvuloplasty.     

Indications and outcome of valvuloplasty

Balloon valvuloplasty is widely practiced, but its result depends on the pathology considered. Percutaneous mitral balloon valvuloplasty evolved from the earlier development of percutaneous balloon valvotomy of the pulmonic valve into an effective method for the treatment of patients with mitral stenosis. Percutaneous aortic balloon valvotomy has been used as an alternative to aortic valve replacement in elderly patients with degenerative calcific aortic stenosis, but immediate results are suboptimal and the short-term rate of restenosis is high. In congenital pulmonary valve stenosis, balloon valvotomy produces a dramatic relief of the pressure gradient with excellent long-term follow-up results.     

Pulmonary valvuloplasty in a case of vascular Ehlers-Danlos syndrome.

A 15-year-old girl with known Ehlers-Danlos syndrome (EDS) type IV presented with severe pulmonary valve stenosis requiring intervention. We describe successful pulmonary valvuloplasty using a 90% balloon/annulus angioplasty balloon. The procedure was complicated by early restenosis suggesting an abnormal scarring response in EDS IV.     

Pulmonary valvuloplasty in adolescents and adults: 2 year follow-up by continuous Doppler

The purpose of this study is the long term follow-up of the first pulmonary valvuloplasties performed by our group. From september 1984 to march 1988, 10 patients (4 men and 6 women) aged 8 to 58 (mean: 21) with severe or moderate pulmonary valve stenosis underwent pulmonary valvotomy. In all cases the balloon diameter was equal to or 1 mm smaller than the valvular annulus. The results were satisfactory with a significant mean gradient reduction of 51.7%. A follow-up gradient estimation by Doppler echocardiogram was obtained 10 to 37 months after valvuloplasty (mean: 23 months). The mean follow-up gradient by Doppler (31.3 +/- 9.9 mmHg) was not significantly different from the mean hemodynamic post-dilatation gradient (35.6 +/- 14.7 mmHg). A linear correlation was found between the post-dilatation hemodynamic mean gradient and the mean gradient by Doppler follow-up (r = 0.66, p less than 0.05, SEE = 4.1 mmHg). No restenosis were observed. These results suggest that the benefits of valvuloplasty are long lasting. Continuous Doppler is an excellent technique for the follow-up of these patients.     

Percutaneous balloon valvuloplasty for congenital pulmonary valve stenosis in adults.

BACKGROUND: Although pulmonary valvular stenosis is not uncommon in adults, there are few reports of percutaneous pulmonary valvuloplasty in adults, despite the possibility of avoiding heart surgery. AIM: This report describes the experience in adult patients undergoing this procedure and evaluates its effectiveness and tolerance. METHODS: Over an 8-year period (1989-1997), pulmonary valvuloplasty was considered in 22 adult patients [8 men, 14 women; mean age 28.0 years +/- standard deviation (SD) 10.3; range 16-46 years] with congenital pulmonary valve stenosis. Sixteen patients were asymptomatic with pulmonary systolic murmurs, although 6 patients presented with dyspnea. Before the procedure, the mean transpulmonary valve gradient was 53.2 +/- 24.8 mmHg SD, with a mean right ventricular systolic pressure of 74.6 +/- 28.4 mmHg SD, and mean pulmonary artery pressure was 21.4 +/- 6.4/10.2 +/-3.9 mmHg. RESULTS: The procedure was successful in 19 patients (6 men, 13 women) and was well tolerated and free of complications. Following the procedure, the mean transvalvular gradient was 15.5 +/- 11.5 mmHg, with a mean right ventricular systolic pressure of 40.5 +/- 13.6 mmHg and a mean pulmonary systolic pressure of 24.3 +/- 7.4 mmHg. This represented mean fall in transpulmonary valve gradient of 42.4 +/- 22.0 mmHg (paired t-test, p < 0.0001). After a mean follow-up of 20.1 months (13.4 SD), most patients remained well and asymptomatic, although two patients required repeat valvuloplasty. CONCLUSION: Pulmonary valvuloplasty is a well tolerated and effective treatment for pulmonary valve stenosis in adults, with few complications and no need for surgery. This procedure should be considered as the primary treatment of adult patients with pulmonary valve stenosis.     

Hemodynamic findings during exercise on a bicycle ergometer following balloon valvuloplasty of pulmonary stenosis in children and adolescents.

Eleven patients (4 female, 7 male), age range 3.3 to 24.8 years (mean 11.10 years) treated for isolated pulmonary stenosis underwent cardiac catheterization and percutaneous transluminal balloon valvuloplasty (PTVP). The right ventricular systolic pressure (RVSP) before valvuloplasty ranged from 31 to 127 mmHg (mean 79 mmHg) decreasing to 28 to 62 mmHg (mean 42 mmHg) immediately after the dilatation. The peak systolic gradient of the pulmonary valve (delta p RV-PA) before valvuloplasty ranged from 22 to 107 mmHg (mean 61 mmHg) and decreased to a range of 14 and 45 mmHg (mean 23 mmHg) immediately after the dilatation. Balloon valvuloplasty was performed using balloons of 13 to 31 mm in diameter. On 11 patients cardiac catheterization and Doppler echocardiography were repeated between 11 months and 5.3 years (mean 3.11 years) after the balloon valvuloplasty showed a further significant fall in the gradient of pressure. The right ventricular systolic pressure ranged from 20 to 51 mmHg (mean 31.7 mmHg) while the transpulmonary gradient varied from 3 to 24 mmHg (mean 11.6 mmHg). At the time of follow-up examination the patients were aged between 7.2 and 25.7 years (mean 15.9 years). On average the second catheterization was performed 3.11 years following the first hemodynamic study. The follow-up examination encompassed clinical examination, electrocardiogram, Doppler echocardiography, and right heart cardiac catheterization. During right heart cardiac catheterization the children exercised on a bicycle ergometer for three min at 50 or 100 W depending on their body surface area. During this exertion, pressures of the right ventricle and the pulmonary artery as well as heart rate and oxygen saturation were recorded.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intermediate-term outcome after pulmonary balloon valvuloplasty: comparison with a matched surgical control group.

To assess late (4 to 5 years) gradient reduction after pulmonary balloon valvuloplasty in childhood, and to compare the effectiveness of valvuloplasty with that of surgical valvotomy, 20 valvuloplasty-treated children and their age- and gradient-matched surgical control patients underwent prospective, noninvasive evaluation. The average age at intervention was 4.3 +/- 1 years for the valvuloplasty group versus 4.7 +/- 0.8 years for the surgical control group (p = NS). Before intervention the peak systolic pulmonary stenosis gradient was 76 +/- 5 and 74 +/- 4.4 mm Hg for the valvuloplasty and surgery groups, respectively (p = NS). Late evaluation consisted of clinical examination, two-dimensional echocardiogram and Doppler study, 24-hour Holter monitoring, 12-lead electrocardiogram, exercise treadmill study and chest radiograph performed an average of 5.3 +/- 0.3 years after valvuloplasty and 11.7 +/- 0.5 years after surgery (p less than 0.01). The patients treated with balloon valvuloplasty had no evidence of restenosis; the residual pulmonary stenosis gradient at follow-up was 24 +/- 2.7 mm Hg (range 8 to 48) versus 35 +/- 3.6 mm Hg (range 19 to 70) immediately after valvuloplasty (p = NS). Comparison of the late residual gradients between treatment groups showed no hemodynamically significant difference (24 +/- 2.7 versus 16 +/- 1.5 mm Hg, balloon versus surgery; p less than 0.01). However, there was, a significant difference in the degree and severity of pulmonary valve insufficiency and ventricular ectopic activity between groups. In the balloon valvuloplasty group 11 patients had no pulmonary insufficiency, and the remaining 9 had mild insufficiency.(ABSTRACT TRUNCATED AT 250 WORDS)     

Late Results of Pulmonary Balloon Valvuloplasty in Adults Using Double Balloon Technique

Between July 1985 and July 1987, 18 consecutive adult patients with congenital pulmonary stenosis underwent pulmonary balloon valvuloplasty (PBV). There were 11 males and 7 females, aged 15–45 years (mean 25). A double balloon technique was used in 14 patients and a single balloon in four. The size of the balloon used was 0.9 to 1.4 times the size of the pulmonary annulus. Eleven patients were restudied by repeat cardiac catheterization 6 months later. Student's t-test was used for comparison of data. Right ventricular (R V) systolic pressure before dilatation ranged from 84 to 180 (mean 123 ± 28.3) mmHg and the right ventricular to pulmonary artery (PA) peak systolic gradient ranged from 60 to 165 (mean 105 ± 30.2) mmHg. Immediately after dilatation, the RVsystolic pressure dropped to 30–80 (mean 53 ± 14.2) mmHg (P < 0.001). RV to PA peak systolic gradient dropped to 10–57 (mean 32 ± 14.2) mmHg (P < 0.001). A restudy of 11 patients 6 months later showed a further drop of RV systolic pressure to 35–65 (mean 49 ± 11.3) mmHg (P < 0.05). RV to PA peak systolic gradient continued to drop to 10–48 (mean 26 ± 11.3) mmHg (P < 0.01). Cardiac index improved from 2.68 ± 0.73 to 3.03 ± 0.40 L/min/m², P < 0.05. No complication was noted apart from either sinus bradycardia or extrasystole in a few patients. It was noted that balloon to annulus ratios of 1.1 to 1.4 produced sustained relief of the pulmonary valve stenosis. We concluded that PBV is the treatment of choice for congenital pulmonary stenosis. It reduced the hospital stay to 2 days and avoids the ri±k of open heart surgery. (J Interven Cardiol 1988:1:1)     

Balloon dilatation for discrete subaortic stenosis: immediate and intermediate-term results

Six children with subvalvar aortic stenosis underwent percutaneous balloon angioplasty over a 15-month-period ending October 1989. The mean systolic pressure gradient across the left ventricular outflow tract decreased from 56 +/- 19 (mean +/- SD) to 12 +/- 7 mmHg (p less than 0.001) immediately following valvuloplasty and the degree of aortic insufficiency did not significantly increase. Follow-up Doppler data (in all 6 patients) were available 3 to 16 months (mean, 11 months) after angioplasty and revealed a residual aortic subvalvar gradient of 21 +/- 5 mmHg, which continues to be significantly lower (p less than 0.001) than that prior to angioplasty. There was no increase in aortic insufficiency. The single infant with increase in gradient at followup was determined to have fibromuscular, tunnel type of subaortic obstruction. None of the five patients with discrete membranous obstruction had significantly increased their gradients. Use of balloons larger than aortic valve anulus did not produce any adverse effect, particularly aortic insufficiency. We surmise that the immediate and intermediate-term follow-up results of balloon angioplasty are encouraging and balloon angioplasty should be considered as a treatment option in the initial management of discrete subaortic membranous stenosis.