Balloon valvuloplasty for recurrent aortic stenosis after surgical valvotomy in childhood: immediate and follow-up studies

The immediate and intermediate-term effects of balloon valvuloplasty were assessed at cardiac catheterization in nine children with recurrent stenosis after a previous surgical aortic valvotomy. At valvuloplasty the patients ranged in age from 0.35 to 16 years and had undergone surgical valvotomy 0.3 to 12.5 years previously. Balloon valvuloplasty immediately reduced the peak systolic aortic stenosis gradient by 53%, from 88 +/- 9 (mean +/- SEM) to 41 +/- 6 mm Hg (p = 0.004). The left ventricular systolic pressure was reduced from 189 +/- 8 to 157 +/- 8 mm Hg (p = 0.001) and the left ventricular end-diastolic pressure from 17 +/- 1 to 14 +/- 2 mm Hg (p = 0.025). The heart rate and cardiac index remained unchanged. Before valvuloplasty, one patient had 1 + and two patients had 2+ aortic insufficiency. In six of nine patients, balloon valvuloplasty caused no change in the degree of valvular insufficiency. Two patients had a 1 + increase (from 0 to 1 + insufficiency in both), and one patient with no insufficiency developed 2+ aortic insufficiency. Elective follow-up catheterization was performed 0.8 to 2.5 years (mean 1.5 +/- 0.2) after valvuloplasty. At follow-up, the peak aortic stenosis gradient remained significantly reduced from the gradient before valvuloplasty (37 +/- 5 versus 85 +/- 10 mm Hg, p = 0.002). The gradient had not changed significantly from that measured immediately after valvuloplasty (37 +/- 5 versus 38 +/- 5 mm Hg, p = 0.75). At follow-up, aortic insufficiency had decreased from that immediately after valvuloplasty in three patients and had increased in two.(ABSTRACT TRUNCATED AT 250 WORDS)     

经皮球囊扩张术治疗儿童先天性主动脉瓣狭窄

目的探讨儿童先天性主动脉瓣狭窄（aortic stenosis,AS）球囊扩张的治疗效果。方法选择21例单纯性AS患儿,其中1例合并动脉导管未闭（PDA）,3例因导管难以进入左室,2例左心导管测跨主动脉瓣压力阶差（AP）小于50mmHg（1mmHg=0．133kPa）而未扩张,其余16例采用与瓣环直径之比为0．98±0．04（0．92～1．10）的球囊扩张治疗,合并的PDA予Amplatzer伞片封堵治疗。结果即刻AP下降至原AP50％以上者13例,占81．25％;下降至原AP40％～50％者2例。随访6个月～5年,3例患儿AP回复至50mmHg以上,分别予第二次扩张或外科手术后好转。无一例轻度以上的主动脉瓣反流。结论AS经皮球囊扩张术结果表明,球囊扩张对单纯性AS具有一定疗效,由于其非开胸、方便且较安全地缓解左心室流出道梗阻,从而可替代或延缓外科开胸瓣膜切开术,为AS的治疗提供了另外一种选择。     

Short- and midterm results of balloon valvuloplasty for valvular aortic stenosis in children.

During a 27-month period, 21 consecutive children (aged 0.1 to 15.7 years) with isolated valvular aortic stenosis underwent percutaneous transfemoral balloon valvuloplasty. Ten children had undergone earlier surgical valvulotomy. The indication for treatment was ST-T-segment changes at rest or during bicycle-ergometry, a continuous-wave Doppler-derived transvalvular gradient greater than 60 mm Hg or syncope, or a combination. Mean peak systolic left ventricular pressure decreased from 165 +/- 19 to 131 +/- 19 mm Hg (p less than 0.001). Mean end-diastolic left ventricular pressure did not change significantly (12 +/- 3 vs 11 +/- 5 mm Hg). Mean peak systolic valve gradient decreased from 71 +/- 23 to 22 +/- 11 mm Hg (p less than 0.001). Mean cardiac index remained unchanged (2.9 +/- 0.8 vs. 3.0 +/- 0.7 liters.min-1.m-2). Aortic valve regurgitation on angiography appeared or increased in 9 patients (up to grade 3 in 3 children). Noninvasive follow-up studies were performed for 2 to 4.2 years (mean 2.8). ST-T changes on the electrocardiogram at rest or during exercise were present in 6 patients before balloon valvuloplasty and had disappeared in all at 6-month follow-up. Reoccurrence of ST-T changes after a longer follow-up was associated with severe valve regurgitation. Syncope was not observed after balloon valvuloplasty. The continuous-wave Doppler gradient decreased from 94 +/- 36 to 49 +/- 15 mm Hg (p less than 0.001). After a follow-up of 2 to 4.2 years (mean 2.8) it remained unchanged (43 +/- 13 mm Hg; p = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of single and double balloon valvuloplasty in children with aortic stenosis

To compare the effectiveness of the single and double balloon techniques, the short-term results of percutaneous balloon valvuloplasty were assessed in two consecutive groups of children with valvular aortic stenosis. In 16 children (aged 3 months to 17 years) the single balloon technique was utilized; the ratio of balloon diameter to valve anulus diameter was 0.96 +/- 0.03 (mean +/- SEM). In 11 children (aged 3 months to 21 years) the double balloon technique was utilized in which two balloons are positioned across the valve and inflated simultaneously; the ratio of the balloon diameter sum to valve anulus diameter was 1.32 +/- 0.05. The groups were similar in age, weight, cardiac output, prevalvuloplasty gradient and valve anulus diameter. Overall, valvuloplasty reduced the peak systolic gradient by 53% from 80 +/- 4 to 38 +/- 3 mm Hg (p less than 0.0001). In the single balloon group the gradient decreased from 82 +/- 6 to 46 +/- 4 mm Hg (p less than 0.0001), whereas in the double balloon group the gradient decreased from 76 +/- 5 to 26 +/- 4 mm Hg (p less than 0.0001). The peak systolic gradient after valvuloplasty was 43% lower in the double balloon group (p less than 0.01). Furthermore, the single balloon technique reduced the gradient by an average of 43% compared with a 67% reduction with the double balloon technique (p less than 0.001). The short-term complications of valvuloplasty were similar, with an increase in aortic insufficiency occurring in three children in each group.(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)     

Gradient reduction, aortic valve regurgitation and prolapse after balloon aortic valvuloplasty in 32 consecutive patients with congenital aortic stenosis

From 1986 to 1988, balloon aortic valvuloplasty was performed in 32 patients with congenital valvular aortic stenosis. The patients ranged in age from 2 days to 28 years (mean +/- SD 8.3 +/- 5.9). One balloon was used in 17 patients and two balloons were used in 15 patients. Immediately after valvuloplasty, peak systolic pressure gradient across the aortic valve decreased significantly from 77 +/- 27 to 23 +/- 16 mm Hg (p less than 0.01), a 70% reduction in gradient. At early follow-up study (4.1 +/- 3.3 months after valvuloplasty), there was a 48 +/- 20.5% reduction in gradient compared with that before valvuloplasty, and at late follow-up evaluation (19.2 +/- 5.6 months), a reduction in gradient of 40 +/- 29% persisted. Echocardiography showed evidence of significantly increased aortic regurgitation in 10 patients (31%) and aortic valve prolapse in 7 patients (22%). There was no correlation between the balloon/anulus ratio and the subsequent development of aortic regurgitation or prolapse. In fact, no patient who showed a significant increase in aortic regurgitation had had a balloon/anulus ratio greater than 100%. It is concluded that balloon aortic valvuloplasty effectively reduces peak systolic pressure gradient across the aortic valve in patients with congenital aortic stenosis. However, subsequent aortic regurgitation and prolapse occur in a significant number of patients, even if appropriate technique and a balloon size no greater than that of the aortic anulus are used.     

Balloon aortic valvuloplasty: results of the Valvuloplasty and Angioplasty of Congenital Anomalies Registry

Data from 204 children and infants who underwent aortic balloon valvuloplasty between 1982 and 1986, reported to the Valvuloplasty and Angioplasty of Congenital Anomalies Registry, were reviewed. Valvuloplasty was successful in 192 of 204 children, reducing the peak systolic left ventricular ejection gradient from 77 +/- 2 to 30 +/- 1 mm Hg, p less than 0.001. The same degree of aortic stenosis gradients reduction was noted in both the 38 children under 1 year of age and in the 166 children over 1 year of age. Significant complications included death, aortic regurgitation and femoral artery thrombosis or damage. The incidence of these complications correlated with the age of the child, the ratio of valvuloplasty balloon size/anulus size, or both. The data suggest that percutaneous balloon valvuloplasty provides effective acute relief of valvar aortic stenosis in both infants and children. However, long-term follow-up data are necessary before balloon valvuloplasty can be established as a treatment of choice for congenital valvar aortic stenosis.     

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.     

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.     

Congenital severe aortic stenosis with congestive heart failure in late childhood and adolescence: effect on left ventricular function after balloon valvuloplasty.

Left ventricular (LV) dysfunction with congestive heart failure (CHF) resulting from severe congenital aortic stenosis (AS) is a well-described condition in infancy, but it is rarely found in older children and adolescents. Aortic valve surgery in such cases may be associated with higher rates of morbidity and mortality. Aortic valve balloon dilatation (AVBD) is a viable alternative, but its effect on LV function has not been evaluated. We describe follow-up results of AVBD in 10 cases of severe congenital AS in older children and adolescents with CHF and LV dysfunction. The ages of these patients ranged from 5 to 18 yr (mean +/- SD: 10.8 +/- 4 yr), and nine were males. The follow-up period after AVBD ranged from 3 mo to 7 yr (mean +/- SD: 2.93 +/- 2.1 yr). Success was achieved in all cases, with no immediate complications. After valvuloplasty, the peak-to-peak systolic gradient declined from 74.7 +/- 30.8 to 33.9 +/- 18.2 mm Hg (P < 0.0001). The cardiac index increased slightly but significantly, from 1.9 +/- 0.27 to 2.2 +/- 0.5 L/min/m(2) (P < 0.015). Hemodynamic improvement was also confirmed by a significant decrease in mean pulmonary artery and pulmonary artery wedge pressures from 41.9 +/- 9 to 32.6 +/- 6.6 and from 25.5 +/- 2.9 to 19.3 +/- 3.4 mm Hg, respectively. The echocardiographically derived left ventricular ejection fraction (LVEF) improved from 21.6 +/- 5. 37% to 31 +/- 6.5% within 24 hr after AVBD, and it further improved in all cases on follow-up. Mean LVEF at last follow-up was 59.4 +/- 11.4%. The Doppler instantaneous peak systolic gradient (IPSG) increased from 37.3 +/- 18.8 to 64.8 +/- 30.7 mm Hg at late follow-up. Significant aortic regurgitation (AR) developed in 20% of patients. The Doppler IPSG across the aortic valve was > 60 mm Hg in five cases on follow-up. Two of these patients underwent another AVBD successfully 4 and 16 mo later, respectively. Aortic valve replacement was done in two patients, one for severe restenosis with mild AR 12 mo after AVBD and another for severe re-restenosis with moderate AR 21 mo after a second AVBD. Severe congenital AS can be associated with LV dysfunction and CHF in late childhood and adolescence. AVBD results in good palliation with improvement in LV function on follow-up.     

Results of balloon valvuloplasty in the treatment of congenital valvar pulmonary stenosis in children

Transluminal balloon valvuloplasty was used in the treatment of congenital valvar pulmonary stenosis in 19 children, aged 5 months to 18 years. The right ventricular (RV) systolic pressure and RV outflow tract gradient decreased significantly immediately after the procedure (95 +/- 29 vs 59 +/- 14 mm Hg, p less than 0.01, and 78 +/- 27 vs 38 +/- 13 mm Hg, p less than 0.01). Seven of these patients were evaluated at cardiac catheterization 1 year after balloon valvuloplasty. No significant change occurred in RV systolic pressure or RV outflow tract gradient at follow-up evaluation compared with measurements immediately after balloon valvuloplasty (60 +/- 5 mm Hg vs 56 +/- 12 mm Hg and 39 +/- 5 vs 38 +/- 10 mm Hg). In addition, follow-up evaluation was performed using noninvasive methods and included electrocardiography (n = 13), vectorcardiography (n = 11) and Doppler echocardiography (n = 11) Doppler echocardiography in 11 patients 15 +/- 9 months after balloon valvuloplasty showed a continued beneficial effect with a mild further decrease in RV outflow tract gradient. Thus, balloon valvuloplasty is effective in the relief of pulmonary stenosis.     

Clinical and Doppler echocardiographic follow-up after percutaneous balloon valvuloplasty for aortic valve stenosis

Percutaneous balloon valvuloplasty has been shown to increase the aortic orifice area and to improve clinical symptoms. However, there are only few data concerning long-term results after balloon valvuloplasty. In this study, 36 patients (11 men, 25 women, mean age 75 +/- 8 years) were followed after balloon valvuloplasty for a period of up to 18 months by means of clinical parameters and repeated Doppler echocardiographic measurements after 1, 3, 6, 12 and 18 months. Invasive measurements revealed a decrease of the systolic peak gradient from 78 +/- 24 to 38 +/- 13 mm Hg (p less than 0.001), and an increase in the aortic orifice area from 0.58 +/- 0.23 to 0.93 +/- 0.2 cm2 (p less than 0.001). The Doppler echocardiographic approach revealed that the maximal instantaneous gradient decreased from 96 +/- 26 to 67 +/- 22 mm Hg (p less than 0.001). The aortic orifice area increased from 0.49 +/- 0.16 to 0.73 +/- 0.21 cm2 (p less than 0.001). Three patients (8%) died in the hospital. After hospital discharge, 16 patients (44%) died and 8 patients (22%) underwent successful aortic valve replacement after a mean follow-up of 8 +/- 6 months. Nine patients (25%) were alive after a follow-up period of 18 months. Seven of these (19%) remained clinically improved. During follow-up, the Doppler echocardiographic results revealed a continuous trend toward the preprocedural severity of the aortic valve stenosis. Progression of restenosis assessed by Doppler echocardiographic measurements was accelerated in the group of patients who subsequently died or underwent repeat balloon valvuloplasty or aortic valve replacement.     

Balloon valvuloplasty of calcified aortic stenosis is a realistic alternative to surgery: clinical and invasive results 17 months following the 1st or 2d dilatation

Aortic balloon valvuloplasty was performed in 33 elderly patients (age 60-84, mean 74 years). In six cases, repeat-valvuloplasty was performed six months later. Mean follow-up so far has been 17 months (10-24 months). Follow-up included 23 invasive controls and repeat Doppler-echocardiographic estimation of valve gradient in all patients. At valvuloplasty, peak aortic gradient was reduced from 84 +/- 27 mm Hg to 40 +/- 18 mm Hg, valve area was increased from 0.39 +/- 0.11 cm2 to 0.74 +/- 0.16 cm2. Immediately after valvuloplasty, 76% of the patients were asymptomatic or significantly improved. At follow-up, 10 patients died and 12 patients underwent surgical valve replacement. Only seven patients are still improved or asymptomatic after 1st or 2nd valvuloplasty. Invasive control six to nine months after the 1st valvuloplasty showed satisfactory results for valve gradient and valve area in only one patient. At repeat-valvuloplasty, a mean valve gradient of 29.6 +/- 12.5 mm Hg was achieved. All patients with repeat-valvuloplasty again had invasive control after six months; peak gradient then was 56 +/- 17 mm Hg. Balloon valvuloplasty of acquired aortic valve stenosis is a palliative procedure with a high restenosis-rate. At the most, aortic valve area is doubled. In our opinion, it is only indicated in patients with an unacceptable high surgical risk. Today, old age alone is no contraindication to surgical valve replacement.     

Balloon angioplasty of native coarctation of the aorta in adolescents and young adults.

Balloon angioplasty of native coarctation of the aorta was performed in 35 consecutive adolescents and young adults, aged 14 to 37 years (mean 22.6 +/- 7.1). Twenty-eight (80%) patients had isolated discrete coarctation, six (17.1%) had tubular hypoplasia of the aortic isthmus, and one (2.9%) had hypoplasia of the post-coarctation aorta. The peak systolic pressure gradient decreased from 78.5 +/- 23.9 to 15.7 +/- 11.6 mm Hg (p less than 0.001), and the mean coarctation diameter increased from 4.7 +/- 2.4 to 13.1 +/- 2.7 mm (p less than 0.001) immediately after angioplasty. Patients with discrete-type coarctation had significantly less residual gradient than patients with long-segment tubular coarctation (12.3 +/- 10.7 vs 27.2 +/- 6.6 mm Hg, p less than 0.01). On recatheterization and angiography in 26 patients at 12.6 +/- 1.5 months after dilatation, there was no significant change in gradient (15.5 +/- 13.3 mm Hg) and diameter (13.1 +/- 1.8 mm) from the immediate post-angioplasty results. However, two patients had an increase in gradient and three had small aortic aneurysms with no change in appearance on restudy after 2 years. After 3 to 67 months' (mean 32.7 +/- 19.2) follow-up, all patients showed continued clinical improvement. Hypertension was relieved in 37.5% (12/32) and improved in 59.4% (19/32). Our experience suggests that balloon angioplasty of native aortic coarctation in adolescents and young adults is safe and highly effective with sustained improvement on intermediate-term follow-up.     

Valvuloplasty of congenital aortic stenosis

While percutaneous transluminal valvuloplasty has largely replaced open commissurotomy for congenital pulmonary valve stenosis, the experience with valvuloplasty for congenital aortic stenosis is limited. Between August, 1984 and June, 1987, a total of 27 valvuloplasties were carried out in 25 patients with congenital aortic stenosis; nine infants and 16 patients ranging in age from four to 25 years (mean age 13 +/- 6 years). The indication for valvuloplasty was established on the basis of congestive heart failure or severe stenosis in infants and in the presence of a pressure gradient in excess of 60 mm Hg in those older than one year of age. In eight infants, valvuloplasty reduced the transvalvular pressure gradient from 73 +/- 5 to 36 +/- 9 mm Hg (p less than 0.01; Figure 1). In the 16 patients older than one year of age, the pressure gradient was reduced from 93 +/- 25 to 49 +/- 15 mm Hg (p less than 0.01; Figure 2). The size of the balloon chosen was based on two-dimensional echocardiographic measurements of the aortic ring diameter from inner edge to inner edge. In infants, coronary artery dilating catheters and balloon catheters with an inflated diameter of 4.2 to 8 mm were employed; in children, the balloon diameter selected was 1 to 3 mm less than that of the valve ring diameter, in 15 cases a single-balloon catheter and in one a trefoil catheter. After puncture of the femoral artery and retrograde advancement of a guide-wire into the left ventricle, the balloon catheter was positioned via the guide-wire across the aortic valve.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of a 3 French system for balloon aortic valvuloplasty in infants.

For infants with valvar aortic stenosis, balloon aortic valvuloplasty has supplanted surgical valvotomy as the initial treatment of choice at most institutions. Technological innovations have resulted in further miniaturization of balloon dilation catheters, allowing this procedure to be performed through smaller sheath sizes. Currently, the Tyshak-Mini balloon dilation catheter (B. Braun Medical) allows passage of up to an 8 mm dilation balloon catheter through a 3 Fr hemostatic sheath. The efficacy of this system for the treatment of valvar aortic stenosis in infants less than 6 months of age was evaluated in 20 patients undergoing 22 procedures. Mean age at the time of intervention was 26 +/- 46 days. Mean transvalvar gradient was 76 +/- 22 mm Hg prior to balloon dilation. Following balloon valvuloplasty, residual gradient was 26 +/- 12 mm Hg, reflecting a mean change in peak-to-peak gradient of 49 +/- 19 mm Hg. Postintervention increase in aortic insufficiency was one grade or less in 19/22 procedures, two grades in 2 procedures, and three grades in 1 procedure. There were no significant vascular complications reported immediately following the procedure. Repeat valvuloplasty was performed in three patients in which the 3 Fr system was used in two patients. The 3 Fr system for balloon aortic valvuloplasty in infants less than 6 months of age is effective and safe.     

Double-transseptal, double-balloon valvuloplasty for congenital mitral stenosis.

BACKGROUND. Eight patients with severe congenital mitral stenosis underwent double transseptal, double-balloon valvuloplasty; two had isolated congenital mitral stenosis, six had additional cardiac defects, and one had previous surgical valvotomy. Ages ranged from 0.6 to 36 years (median, 9 years). METHODS AND RESULTS. All procedures were tolerated well. After valvuloplasty, the left atrial a wave minus the left ventricular end-diastolic pressure (LVEDP) gradient was reduced from 25 +/- 6 mm Hg to 9 +/- 3 mm Hg (p less than 0.001), the mitral valve mean gradient was reduced from 18 +/- 7 mm Hg to 8 +/- 3 mm Hg (p = 0.003), and the LVEDP was unchanged. All patients had marked clinical improvement. Only one patient developed significant mitral regurgitation. Two of the first four patients underwent repeat balloon valvuloplasty 7 months later. Follow-up evaluation on six patients from 4 to 54 months revealed no recurrence of symptoms or increased mitral regurgitation. CONCLUSIONS. Double transseptal, double-balloon valvuloplasty is an effective treatment for many forms of congenital mitral stenosis. Mitral regurgitation is uncommon after this procedure. The double transseptal approach results in less trauma to the atrial septum and femoral veins and allows easy assessment of any residual postvalvuloplasty gradient.     

Percutaneous balloon valvuloplasty for treatment of congenital pulmonary valvular stenosis in children

Percutaneous balloon pulmonary valvuloplasty was performed in seven children with moderate to severe valvular pulmonary stenosis (right ventricular to pulmonary artery pressure gradient greater than 50 mm Hg). All patients experienced a decrease in right ventricular peak systolic pressure from 108 +/- 30 to 60 +/- 5.6 mm Hg (p less than 0.001), decrease in right ventricular to pulmonary artery gradient from 90.1 +/- 30 to 38.8 +/- 5 mm Hg (p less than 0.001) and increase in pulmonary valve area from 0.33 +/- 0.06 to 0.55 +/- 0.15 cm2/m2 (p less than 0.001). In the two patients who underwent supine bicycle exercise before and after valvuloplasty, a significant decrease in both the maximal right ventricular peak systolic pressure (212 to 140 and 175 to 125 mm Hg, respectively) and in right ventricular to pulmonary artery peak pressure gradient (185 to 110 and 151 to 85 mm Hg, respectively) occurred. All patients tolerated the procedure well and no serious complications were observed. It is concluded that percutaneous balloon valvuloplasty is a safe and effective method for relief of right ventricular obstruction due to moderate or severe valvular pulmonary stenosis. However, long-term results remain unknown.     

Balloon pulmonary valvuloplasty in the management of cyanotic congenital heart defects.

Twenty-three children with cyanotic congenital heart defects, aged 3 days to 11.5 years, weighing 2.9 to 30 kg, underwent percutaneous balloon pulmonary valvuloplasty to improve pulmonary oligemia. The patients were divided into two groups: group I with intact ventricular septum and group II with ventricular septal defect. In 12 group I patients, there was an increase of systemic arterial oxygen saturation [83 +/- 8% (mean +/- SD) vs. 94 +/- 5%, P less than 0.001] and pulmonary-to-systemic flow ratio (0.7 +/- 0.1 vs. 1.0 +/- 0.2, P less than 0.001). Peak systolic pressure gradient across the pulmonary valve decreased (P less than 0.001) from 105 +/- 48 to 25 +/- 18 mm Hg. In 11 group II patients, arterial oxygen saturation (67 +/- 13 vs. 83 +/- 13%, P less than 0.01) and pulmonary-to-systemic flow ratio (0.7 +/- 0.4 vs. 1.2 +/- 0.5, P less than 0.02) increased following valvuloplasty. Peak systolic pressure gradient across the pulmonic valve (52 +/- 16 vs. 32 +/- 22 mm Hg, P less than 0.05) decreased while infundibular and total pulmonary outflow tract gradients were unchanged (P greater than 0.1). Immediate surgical intervention was avoided in all cases in both groups. On follow-up, 1 to 36 months after valvuloplasty, arterial oxygen saturation, pulmonary-to-systemic flow ratio, and pulmonary valve gradients remain improved in both groups. However, in group I, repeat balloon valvuloplasty was required in two children. In group II, six children with tetralogy of Fallot (TOF) underwent successful total surgical correction 4 months to 2 years after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)