Percutaneous pulmonary valvuloplasty in adults

Percutaneous balloon pulmonary valvuloplasty was performed in 6 adult patients (aged 21-59 years, mean age: 43 years) with congenital pulmonary valve stenosis and systolic pressure gradients of 50 to 120 mm Hg (mean: 78 mm Hg). In 5 patients the procedure was successful: mean systolic right ventricular pressure was reduced from 99 +/- 26 to 55 +/- 7 mm Hg and the trans-stenotic pressure gradient from 77 +/- 28 to 31 +/- 12 mm Hg. Valvuloplasty with a 20 mm balloon was not effective in a patient with a wide pulmonary anulus (diameter 25 mm). In 1 patient only, the balloon occlusion led to severe systemic hypotension with syncope. Short-term follow-up (3 months) demonstrated symptomatic improvement and persistent reduction of the pressure gradient in all successfully treated patients. In conclusion, percutaneous balloon pulmonary valvuloplasty appears to be an effective method with low risk of complications for the treatment of pulmonary valve stenosis in adults.     

Percutaneous transluminal balloon valvuloplasty of congenital pulmonary valve stenosis, with a special report on infants and neonates

Fifty-six percutaneous transluminal balloon valvuloplasty procedures were performed in 51 patients suffering from congenital pulmonary valve stenosis. The patients ranged in age from 1 day to 60 years (mean 6.9 years); 21 were infants less than 1 year of age, including 8 neonates. The peak systolic pressure gradient was greater than 50 mm Hg (mean 81.5) in 47 cases, and less than 50 mm Hg (mean 34.6) in 9. Valvuloplasty enabled a reduction in the mean right ventricular peak systolic pressure from 93.1 to 51.6 mm Hg (p less than 0.001), the mean transvalvular gradient from 73.4 to 27.0 mm Hg (p less than 0.001) and the mean right ventricular pressure expressed as a percent of systemic pressure from 99.5 to 52.0% (p less than 0.001). In infants and neonates, the mean right ventricular pressure expressed as a percent of systemic pressure decreased from 117.3 to 64.4% (p less than 0.001). In 23 patients, follow-up cardiac catheterization at 1 to 17 months revealed a significant change in the right ventricular systolic pressure, which decreased from 54.0 to 46.7 mm Hg (p less than 0.05), and in the peak systolic pressure gradient, which decreased from 27.3 to 22.6 mm Hg (p less than 0.05). Valvuloplasty is an effective procedure in relieving pulmonary stenosis in patients of all ages, including neonates.     

Results of balloon valvuloplasty in typical and dysplastic pulmonary valve stenosis: Doppler echocardiographic follow-up

To assess the usefulness of balloon valvuloplasty in patients with a dysplastic pulmonary valve, the files of 36 patients (aged 1 day to 18.5 years) who had two-dimensional echocardiography before and continuous wave Doppler echocardiography late after balloon valvuloplasty (balloon diameter greater than or equal to 20% anulus diameter) were reviewed. Results of relief of pulmonary stenosis were graded by catheter gradient in the catheterization laboratory and compared with Doppler echocardiographic findings at follow-up. There were 32 patients with typical pulmonary stenosis and 4 with a dysplastic valve. In the 32 patients with typical pulmonary stenosis, transvalvular gradient changed from a mean of 67 +/- 32 to 20 +/- 20 mm Hg (p less than 0.0001, mean reduction 72.6%). The gradients at follow-up by Doppler echocardiography averaged 20 mm Hg including 15 that increased, 3 that were unchanged and 14 that decreased. Only 3 (9%) of 32 patients had a gradient greater than 25 mm Hg at follow-up and only one gradient was greater than 35 mm Hg. All four patients with a dysplastic valve had a gradient that decreased with valvuloplasty from a mean of 85 +/- 33 to 33 +/- 20 mm Hg (p less than 0.05); gradient reduction in this group ranged from 40 to 85% (mean 57.5%). The gradient at follow-up increased in three of these four patients and decreased in one (the only late gradient less than 25 mm Hg). Late gradient was less than 35 mm Hg in two of the four patients and was reduced by 43 and 57%, respectively, in the other two.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous balloon valvuloplasty for pulmonary valve stenosis in infants and children

Pulmonary valve stenosis was relieved by balloon dilatation during cardiac catheterisation on 27 occasions in 23 infants and children aged 7 days to 12 years, median 31 months (three aged less than 2 weeks). Pulmonary valve diameter was estimated by cross sectional echocardiography to assist in the choice of balloon size. Before dilatation the right ventricular systolic pressure ranged from 41 to 190 (median 92) mm Hg and was suprasystemic in 10 patients. There were significant reductions in the ratio of right ventricular to systemic systolic pressure and pulmonary systolic pressure gradients immediately after balloon dilatation. Twelve patients underwent recatheterisation (11 at six months and one at one week after balloon dilatation), which showed further improvement with significant reductions in right ventricular pressure or pulmonary valve gradient or both, particularly in the patients with the least satisfactory initial results. This improvement was attributed to resolution of the obstruction at infundibular level. Repeat pulmonary valve dilatation was successfully performed in four patients who had poor results after initial dilatation. Balloon pulmonary valvotomy appears to provide good short term and medium term relief of pulmonary valve stenosis and may obviate the need for surgery in many cases. An apparently poor immediate haemodynamic result does not preclude a good longer term result.     

Percutaneous balloon valvuloplasty for pulmonary valve stenosis in infants and children.

Pulmonary valve stenosis was relieved by balloon dilatation during cardiac catheterisation on 27 occasions in 23 infants and children aged 7 days to 12 years, median 31 months (three aged less than 2 weeks). Pulmonary valve diameter was estimated by cross sectional echocardiography to assist in the choice of balloon size. Before dilatation the right ventricular systolic pressure ranged from 41 to 190 (median 92) mm Hg and was suprasystemic in 10 patients. There were significant reductions in the ratio of right ventricular to systemic systolic pressure and pulmonary systolic pressure gradients immediately after balloon dilatation. Twelve patients underwent recatheterisation (11 at six months and one at one week after balloon dilatation), which showed further improvement with significant reductions in right ventricular pressure or pulmonary valve gradient or both, particularly in the patients with the least satisfactory initial results. This improvement was attributed to resolution of the obstruction at infundibular level. Repeat pulmonary valve dilatation was successfully performed in four patients who had poor results after initial dilatation. Balloon pulmonary valvotomy appears to provide good short term and medium term relief of pulmonary valve stenosis and may obviate the need for surgery in many cases. An apparently poor immediate haemodynamic result does not preclude a good longer term result.     

Percutaneous balloon pulmonary valvuloplasty

Percutaneous balloon pulmonary valvuloplasty (BPV) was performed in 18 consecutive patients with valvular pulmonary stenosis (PS) with no associated cardiac defects. The patients were 11 months to 19 years of age. The balloon was positioned across the pulmonary valve and inflated to pressures of 80, 100, and 120 pounds/square inch (psi). Each inflation lasted approximately 10 seconds. Peak systolic pulmonary valve gradient (ΔP) and cardiac output were measured before and 15 minutes after BPV. There was no change in cardiac output, but all patients had an improved ΔP. The prevalvuloplasty ΔP was 81 ± 31 mm Hg, decreasing to 23 ± 11 mm Hg after BPV (p < 0.01). The right ventricular peak systolic pressure decreased from 106 ± 31 to 50 ± 12 mm Hg (p < 0.01). No pulmonary regurgitation was noted after BPV. The balloons were 12 or 15 mm in diameter, chosen according to the diameter of the pulmonary valve anulus. Pressures of 100 to 120 psi were required to achieve full inflation of the balloons. BPV also was performed in a patient with tetralogy of Fallot. Subsequent total repair provided an opportunity to observe the mechanism of the dilatation. Evidence of a small tear alongside the anterior valve raphe was noted. BPV induced a significant decrease in ΔP and may offer an alternative method for treating PS.     

Percutaneous transluminal balloon pulmonary valvoplasty--long-term results

Thirty-two patients with isolated valvar pulmonary stenosis (21 male; 11 female, age range 4 to 53 years, mean 14 years) underwent cardiac catheterization and balloon valvoplasty. Right ventricular systolic pressure before valvoplasty ranged from 65 to 210 mm Hg (mean 120.2 +/- 44.8 mm Hg). It fell to 24-200 mm Hg (mean 73.1 +/- 42.4 mm Hg) immediately after dilation. Peak systolic gradient across the pulmonary valve before valvoplasty ranged from 42 to 193 mm Hg (mean 98 +/- 45.3 mm Hg) and decreased significantly to 5 to 182 mm Hg (mean 52.7 +/- 43.1 mm Hg) immediately after dilation. At repeat cardiac catheterization in 21 patients 3 to 6 months after valvoplasty, a further significant fall of gradient was noted in 15 patients with no change in the remaining six patients. The right ventricular systolic pressure ranged from 30 to 100 mm Hg (mean 55.1 +/- 21.8 mm Hg) while the transpulmonary gradient varied from 12 to 84 mm Hg (mean 34 +/- 23.8 mm Hg). In the four patients evaluated 1 to 1 1/2 years after valvoplasty, the gradient further reduced in 2 patients and was unchanged in the remaining two patients. Patients with isolated valvar pulmonary stenosis can be adequately and safely treated with balloon valvoplasty, without recourse to surgery with excellent immediate and long-term results.     

Percutaneous transluminal balloon valvuloplasty in congenital pulmonary valve stenosis

From March 1984 to September 1986, 49 transluminal balloon valvuloplasties (TBVs) were performed in 44 consecutive patients with congenital pulmonary valve stenosis, aged 1 day to 60 years. Seventeen of the patients were infants aged less than 1 year, five of whom were neonates. The peak systolic gradient was greater than 50 mm Hg (mean, 80.0 mm Hg) in 36 patients and was less than 50 mm Hg (mean, 35.4 mm Hg) in eight. A single balloon catheter was used in 41 cases, and two balloon catheters were used in eight cases. In patients with a gradient greater than 50 mm Hg, the mean right ventricular peak systolic pressure was reduced from 99.8 to 51.8 mm Hg, and the mean transvalvular gradient was reduced from 80.0 to 22.4 mm Hg. In infants and neonates, the mean right ventricular pressure expressed as a percentage of systemic pressure decreased from 122.2% to 63.5%. Follow-up cardiac catheterization 1 to 17 months later (in 19 cases) revealed no significant change in the right ventricular systolic pressure (which had decreased from 53.0 to 48.5 mm Hg) or the peak systolic pressure gradient (which had decreased from 29.0 to 24.5 mm Hg), in comparison with the changes seen immediately after TBV. Thus, TBV is an effective method of relieving pulmonary stenosis in patients of all ages, including neonates.     

Results of three to 10 year follow up of balloon dilatation of the pulmonary valve

BACKGROUND: The results of immediate and short term follow up of balloon dilatation of the pulmonary valve have been well documented, but there is limited information on long term follow up. OBJECTIVE: To evaluate the results of three to 10 year follow up of balloon dilatation of the pulmonary valve in children and adolescents. SETTING: Tertiary care centre/university hospital. DESIGN: Retrospective study. METHODS AND RESULTS: 85 patients (aged between 1 day and 20 years, mean (SD) 7.0 (6.4) years) underwent balloon dilatation of the pulmonary valve during an 11 year period ending August 1994. There was a resultant reduction in the peak to peak gradient from 87 (38) to 26 (22) mm Hg. Immediate surgical intervention was not required. Residual gradients of 29 (17) mm Hg were measured by catheterisation (n = 47) and echo Doppler (n = 82) at intermediate term follow up (two years). When individual results were scrutinised, nine of 82 patients had restenosis, defined as a peak gradient of 50 mm Hg or more. Seven of these patients underwent repeat balloon dilatation of the pulmonary valve: peak gradients were reduced from 89 (40) to 38 (20) mm Hg. Clinical evaluation and echo Doppler data of 80 patients showed that residual peak instantaneous Doppler gradients were 17 (15) mm Hg at long term follow up (three to 10 years, median seven), with evidence for late restenosis in one patient (1.3%). Surgical intervention was necessary to relieve fixed infundibular stenosis in three patients and supravalvar pulmonary stenosis in one. Repeat balloon dilatation was performed to relieve restenosis in two patients. Actuarial reintervention free rates at one, two, five, and 10 years were 94%, 89%, 88%, and 84%, respectively. Pulmonary valve regurgitation was noted in 70 of 80 patients at late follow up, but neither right ventricular dilatation nor paradoxical interventricular septal motion developed. CONCLUSIONS: The results of late follow up of balloon dilatation of the pulmonary valve are excellent. Repeat balloon dilatation was performed in 11% of patients and surgical intervention for subvalvlar or supravalvar stenosis in 5%. Most patients had mild residual pulmonary regurgitation but right ventricular volume overload was not required. Balloon dilatation is the treatment of choice in the management of moderate to severe stenosis of the pulmonary valve. Further follow up studies should be undertaken to evaluate the significance of residual pulmonary regurgitation.     

Percutaneous pulmonary valvuloplasty

Five patients (aged between 11 and 59 years) with valvular pulmonary artery stenosis and pressure gradients between 60 and 143 mm Hg underwent percutaneous transluminal balloon valvuloplasty. Selection of the appropriate balloon size was based on the measurement of the dimension of the value anulus as a determinant from the angiogram. Balloon catheters were used with a diameter of 18 to 20 mm. After placement in the stenotic valve the balloon was filled with diluted contrast material for 10-20 s. The balloon indention by the stenotic valve disappeared suddenly during expansion with one to three atmospheres. The pressure gradient in individual patients decreased from 60 to 25, from 143 to 60, 100 to 55, 143 to 60, and 60 to 37 mm Hg, in the mean from 101 to 52 mm Hg. All patients were discharged two to four days after the procedure. During follow-up with recatheterization after three to nine months (four patients) the gradients decreased as compared to the value immediately after valvuloplasty. The exercise capacity increased in all patients. No complications were observed. Balloon valvuloplasty of pulmonary valvular stenosis seems to be an alternative to the operative procedure.     

The dysplastic pulmonary valve: echocardiographic features and results of balloon dilatation

The feasibility of using balloon dilatation to relieve stenosis caused by dysplasia of the pulmonary valve was assessed in seven patients (five female, mean age two years) with angiographically confirmed dysplasia who were identified among 38 patients with pulmonary valve stenosis selected for balloon dilatation over a two year period. The clinical features in three patients were consistent with Noonan's syndrome. In all patients the gradient across the valve was assessed by cross sectional echocardiography and Doppler echocardiography before cardiac catheterisation. Balloon dilatation was performed by conventional techniques. In one patient, who had balloon dilatation in the operating room before surgical valvectomy, the diameter of the valve orifice increased from 3 mm to 10 mm. Inspection showed a tear along the anterior commissure. The mean (SD) pressure gradients between the right ventricle and pulmonary artery before and immediately after dilatation in five patients were not significantly different (58 (28) and 47 (12) mm Hg) respectively. There was no overall significant change in the degree of stenosis when four of these patients were examined by Doppler echocardiography six months after operation (44 (17) mm Hg), although one patient (case 5) did show a significant reduction in gradient. This patient had angiographic and echocardiographic features of dysplasia and commissural fusion. Several echographic features were common to all patients and distinguished them from cases of typical pulmonary valve stenosis. These were: pronounced thickening of leaflets; leaflet immobility in diastole and systole; no dilatation of the sinuses of Valsalva in diastole, and supra-annular narrowing. These poor results of balloon dilatation suggest that commissural fusion is not an important mechanism for causing stenosis in the dysplastic pulmonary valve. When dysplasia of the pulmonary valve is identified clinically and echocardiographically, balloon dilatation is unlikely to improve haemodynamic function; it should be attempted if commissural fusion is present.     

The dysplastic pulmonary valve: echocardiographic features and results of balloon dilatation.

The feasibility of using balloon dilatation to relieve stenosis caused by dysplasia of the pulmonary valve was assessed in seven patients (five female, mean age two years) with angiographically confirmed dysplasia who were identified among 38 patients with pulmonary valve stenosis selected for balloon dilatation over a two year period. The clinical features in three patients were consistent with Noonan's syndrome. In all patients the gradient across the valve was assessed by cross sectional echocardiography and Doppler echocardiography before cardiac catheterisation. Balloon dilatation was performed by conventional techniques. In one patient, who had balloon dilatation in the operating room before surgical valvectomy, the diameter of the valve orifice increased from 3 mm to 10 mm. Inspection showed a tear along the anterior commissure. The mean (SD) pressure gradients between the right ventricle and pulmonary artery before and immediately after dilatation in five patients were not significantly different (58 (28) and 47 (12) mm Hg) respectively. There was no overall significant change in the degree of stenosis when four of these patients were examined by Doppler echocardiography six months after operation (44 (17) mm Hg), although one patient (case 5) did show a significant reduction in gradient. This patient had angiographic and echocardiographic features of dysplasia and commissural fusion. Several echographic features were common to all patients and distinguished them from cases of typical pulmonary valve stenosis. These were: pronounced thickening of leaflets; leaflet immobility in diastole and systole; no dilatation of the sinuses of Valsalva in diastole, and supra-annular narrowing. These poor results of balloon dilatation suggest that commissural fusion is not an important mechanism for causing stenosis in the dysplastic pulmonary valve. When dysplasia of the pulmonary valve is identified clinically and echocardiographically, balloon dilatation is unlikely to improve haemodynamic function; it should be attempted if commissural fusion is present.     

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.     

Balloon valvuloplasty for pulmonic valve stenosis--two-year follow-up: hemodynamic and Doppler evaluation

The purpose of this investigation was to evaluate the efficacy, technique, and follow-up results of balloon dilation angioplasty for valvular pulmonary stenosis. Percutaneous dilation was performed on 63 patients with pulmonary stenosis (ages 3 months to 76 years, mean = 4.3 years). In 43 patients, a single balloon was used; in 20 patients two balloons were used simultaneously. The pressure gradient across the pulmonary valve was determined with right ventricular and main pulmonary artery catheters. Pressure gradients simultaneously were estimated by continuous wave Doppler (CWD) during catheterization. The peak systolic ejection gradient was obtained by both techniques both pre- and postangioplasty. There was excellent linear correlation between the simultaneous catheter pressure gradient and the pressure gradient estimated by Doppler (r = 0.99). Follow-up pressure gradient estimations by Doppler echocardiogram were obtained in 30 patients between 6 months and 30 months postcatheterization (mean = 13 months). The mean preangioplasty gradient of 64 mm Hg (range 30-160 mm Hg) was reduced to 22 mm Hg (range 2-31 mm Hg). A significant reduction of transvalvular gradient (52-95%, mean 68%) occurred in each patient. A linear correlation was found between the predilation gradient and the pressure gradient drop (r = 0.92). Mean follow-up gradient by Doppler was 20 mm Hg (range 0-31 mm Hg), and there was no significant difference between these gradients and the postdilation gradient. No important complications were noted. These data confirm that balloon dilation angioplasty for valvular pulmonary stenosis is safe and effective, and suggest that stenosis does not recur.     

Balloon valvuloplasty for pulmonic valve stenosis—two-year follow-up: Hemodynamic and doppler evaluation

The purpose of this investigation was to evaluate the efficacy, technique, and follow-up results of balloon dilation angioplasty for valvular pulmonary stenosis. Percutaneous dilation was performed on 63 patients with pulmonary stenosis (ages 3 months to 76 years, mean = 4.3 years). In 43 patients, a single balloon was used; in 20 patients two balloons were used simultaneously. The pressure gradient across the pulmonary valve was determined with right ventricular and main pulmonary artery catheters. Pressure gradients simultaneously were estimated by continuous wave Doppler (CWD) during catheterization. The peak systolic ejection gradient was obtained by both techniques both pre- and postangioplasty. There was excellent linear correlation between the simultaneous catheter pressure gradient and the pressure gradient estimated by Doppler (r = 0.99). Follow-up pressure gradient estimations by Doppler echocardiogram were obtained in 30 patients between 6 months and 30 months postcatheterization (mean = 13 months). The mean preangioplasty gradient of 64 mm Hg (range 30–160 mm Hg) was reduced to 22 mm Hg (range 2–31 mm Hg). A significant reduction of transvalvular gradient (52–95%, mean 68%) occurred in each patient. A linear correlation was found between the predilation gradient and the pressure gradient drop (r = 0.92). Mean follow-up gradient by Doppler was 20 mm Hg (range 0–31 mm Hg), and there was no significant difference between these gradients and the postdilation gradient. No important complications were noted. These data confirm that balloon dilation angioplasty for valvular pulmonary stenosis is safe and effective, and suggest that stenosis does not recur.     

The morphology of the right ventricular outflow tract after percutaneous pulmonary valvotomy: long term follow up.

Twenty nine patients (19 male, mean (SD) age 6.25 (0.5) years (range 0.16-15 years] with typical pulmonary valve stenosis were treated by balloon dilatation of the pulmonary valve. They were studied by echocardiography before the procedure, immediately after it, and at follow up (mean (SD) 10.2 (5.6) months, n = 18). The morphology of the pulmonary valve, the right ventricular-pulmonary artery gradient, and ratio of the systolic to diastolic endocardial dimensions (infundibular ratio) were examined. No patient had pulmonary regurgitation before the study. The valve gradient was significantly reduced (47%) from a mean (SD) of 72 (31) to 37 (23) mm Hg with no short term change in cardiac index after dilatation with a balloon with a mean (SD) diameter that was 118 (10.8)% of the valve annulus. The infundibular ratio was unchanged by the procedure (0.49 (0.11) (n = 21) before dilatation and 0.47 (0.14) (n = 16) after dilatation). In twenty seven patients the commissure of the pulmonary valve was seen to be torn after dilatation. Two patients with bicuspid valves had flail leaflets. Doppler examination at follow up showed mild pulmonary insufficiency in all 29 patients; the mean (SD) valve gradient (31 (+/- 21) mm Hg) at follow up was no different from the gradient found immediately after the procedure and infundibular ratio (0.58 (0.15) was not abnormal. These data indicate that commissural tears are the primary mechanism of valve disruption and demonstrate that the dynamic right ventricular outflow tract obstruction relaxes and gradient reduction persists at follow up.     

Pulmonary valvoplasty--experience of 100 cases

One-hundred patients with pulmonary valve stenosis underwent pulmonary valvoplasty, their ages ranging from 1 to 59 years. The systolic gradient across the valve ranged from 47 to 260 mm Hg (97.67 +/- 41.15) prior to the valvoplasty, and from 0 to 55 mm Hg (14.72 +/- 11.40) immediately after dilatation (P less than 0.0001). The clinical follow-up of 18.2 months of 56 patients showed a tendency for the systolic thrill to disappear, the systolic murmur became softer and there was a tendency to normalization of the electrocardiogram. A hemodynamic restudy was carried out in 54 patients and the systolic gradients across the valve ranged from 21.55 +/- 23.86. Seven patients required redilatation. In patients with hypertrophy of the infundibulum prior to valvoplasty this was observed to regress, indicating that infundibular hypertrophy is reversible.     

The morphology of the right ventricular outflow tract after percutaneous pulmonary valvotomy: long term follow up

Twenty nine patients (19 male, mean (SD) age 6.25 (0.5) years (range 0.16-15 years] with typical pulmonary valve stenosis were treated by balloon dilatation of the pulmonary valve. They were studied by echocardiography before the procedure, immediately after it, and at follow up (mean (SD) 10.2 (5.6) months, n = 18). The morphology of the pulmonary valve, the right ventricular-pulmonary artery gradient, and ratio of the systolic to diastolic endocardial dimensions (infundibular ratio) were examined. No patient had pulmonary regurgitation before the study. The valve gradient was significantly reduced (47%) from a mean (SD) of 72 (31) to 37 (23) mm Hg with no short term change in cardiac index after dilatation with a balloon with a mean (SD) diameter that was 118 (10.8)% of the valve annulus. The infundibular ratio was unchanged by the procedure (0.49 (0.11) (n = 21) before dilatation and 0.47 (0.14) (n = 16) after dilatation). In twenty seven patients the commissure of the pulmonary valve was seen to be torn after dilatation. Two patients with bicuspid valves had flail leaflets. Doppler examination at follow up showed mild pulmonary insufficiency in all 29 patients; the mean (SD) valve gradient (31 (+/- 21) mm Hg) at follow up was no different from the gradient found immediately after the procedure and infundibular ratio (0.58 (0.15) was not abnormal. These data indicate that commissural tears are the primary mechanism of valve disruption and demonstrate that the dynamic right ventricular outflow tract obstruction relaxes and gradient reduction persists at follow up.     

Balloon dilation of critical pulmonary stenosis in the first week of life

Although balloon dilation or valvular pulmonary stenosis is established in infants and children, the techniques for and results of balloon dilation in neonates with critical pulmonary stenosis remain largely unreported. Since January 1, 1985, six successive neonates with critical pulmonary stenosis (aged 1 to 6 days) underwent attempted balloon dilation. Each was cyanotic and three of the six were on prostaglandin E₁therapy and three required tracheal intubation and ventilation. All had suprasystemic right ventricular pressures (mean 122.8 ± 6.6 mm Hg).After hemodynamic evaluation and right ventricular angiography, the valve was crossed in five patients, and was first dilated with a low profile, 5 or 6 mm diameter, 2 cm long balloon. At least one more balloon was used in each patient, the largest being 95 to 133% of the diameter of the pulmonary valve anulus. The anulus size was 6.8 ± 1.1 mm and the largest balloon size used was 6 to 10 mm.Right ventricular pressure decreased to nearly systemic level or less in live of five patients (58.8 ± 6.7 mm Hg). Pressure gradients, measured in four infants, were 7, 12, 16 and 35 mm Hg, respectively, but were unreliable indicators of obstruction because of a patent ductus arteriosus. The five patients were discharged 3 to 8 (days after balloon dilation. All are currently symptom free 10.6 ± 11.7 months later, and all but one are believed clinically to have mild obstruction. Complications included iliac vein occlusion (n = 1) and complete right bundle branch block (n = 1).Although follow-up has been brief, neonates with critical pulmonary stenosis can safely undergo balloon dilation, usually with good short-term results.     

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.