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.     

Pulmonary balloon valvoplasty in late adult life

A case of severe valvar pulmonary stenosis in a 60-year-old woman is described. Percutaneous balloon valvoplasty was performed without complication and reduced the right ventricular outflow pressure gradient from 95 mm Hg to 25 mm Hg. Balloon valvoplasty is an effective alternative to surgical valvotomy in adults as well as children.     

Continuous wave Doppler assessment of patients subjected to pulmonary balloon valvoplasty

To evaluate the role of Doppler ultrasound in accurately quantitating patients with valvar pulmonary stenosis, we studied 30 patients (20 patients undergoing balloon pulmonary valvoplasty before and after the procedure, and 10 patients who had previously undergone pulmonary balloon valvoplasty) by Doppler echocardiography and cardiac catheterization. The peak systolic gradient was calculated by the two methods within 24 hours of each other. The maximal velocity of blood flow was obtained by non-imaging, continuous wave Doppler ultrasound examination performed from various parasternal and subcostal positions and the valve gradient was calculated using a modified Bernoulli's equation. Transpulmonary peak systolic gradient calculated by Doppler examination ranged from 9 to 159 mm Hg (mean 54.8 +/- 34.5 mm Hg) and correlated well with values obtained at cardiac catheterization (r = 0.94, P less than 0.001). Thus our study shows that accurate quantification of pulmonary valve stenosis can be reliably undertaken non-invasively utilizing Doppler echocardiography.     

Pulmonary regurgitation after percutaneous balloon valvoplasty for isolated pulmonary valvar stenosis in childhood

OBJECTIVES: A retrospective study was undertaken to determine the degree of pulmonary regurgitation following percutaneous balloon valvoplasty for isolated pulmonary valvar stenosis. BACKGROUND: Percutaneous balloon valvoplasty is the recognised treatment of choice in pulmonary valvar stenosis with effective relief of gradient. Few studies have reviewed the degree of pulmonary regurgitation after the balloon valvoplasty. METHODS: We reviewed all patients with isolated pulmonary valvar stenosis undergoing percutaneous balloon valvoplasty at a tertiary centre between December 1984 and August 1996. Those with an associated haemodynamically insignificant atrial septal defect or patent oval foramen were also included. Their medical records, echocardiograms and angiograms were studied. Colour flow Doppler was used as a semi-quantitative way of assessing the pulmonary incompetence. RESULTS: Over the period of review, 57 procedures had been performed in 49 patients. The median age at the time of the procedure was 1.08 years, with a range from 0.01 to 13.3 years. The median period of follow-up was 5.64 years, with a range from 3.00 to 14.26 years. Immediately following the dilation of the pulmonary valve, the peak-to-peak instantaneous systolic pressure gradient was significantly reduced. Seven patients required a second dilation of the valve. Their median age at the first valvoplasty, at 0.49 year, was significantly lower than those who required only one procedure, at a median of 1.50 years. Following the valvoplasty, mild pulmonary incompetence was noted in 26 out of 42 patients the day after the procedure, but only 7% had moderate incompetence. On follow-up, there was an increase in the number of patients with moderate to severe pulmonary incompetence, from 7% to 29%. Those patients in whom the procedure was performed at a younger age had more significant pulmonary incompetence. Neither the initial gradient across the pulmonary valve, nor the size of the balloon used, were related with statistical significance to the subsequent development of pulmonary incompetence. CONCLUSIONS: The majority of the patients with congenital isolated pulmonary valvar stenosis had only a mild increase in the degree of pulmonary incompetence following a single pulmonary valvoplasty. Patients who required the procedure early in life were more likely to develop significant pulmonary incompetence. The ratio of the size of the balloon to the diameter of the valve did not significantly affect the outcome. We suggest that those patients who had more severe stenosis because of a more abnormal pulmonary valve, and hence required early intervention, were more likely to develop greater pulmonary incompetence after the valvoplasty.     

Accuracy of continuous wave Doppler predicted gradient in patients undergoing balloon pulmonary valvoplasty

14 patients who underwent balloon valvoplasty had trans-pulmonic gradient evaluated by continuous wave Doppler echocardiography. Maximum systolic gradients measured from Doppler flow velocities were correlated with peak to peak gradient obtained at cardiac catheterisation. Prior to valvoplasty, there was good correlation between the Doppler maximum gradient (92.85 +/- 34.7mm Hg) and the peak to peak catheter gradient (105.57 +/- 56.60 mm Hg), (r = 0.91, p = less than 0.001). Immediately after balloon valvoplasty, the maximum Doppler gradient did not correlate with the peak to peak catheter gradient (r = 0.33, p = NS). Exclusion of patients with infundibular gradients improved the correlation coefficient between the Doppler maximum and peak to peak catheter gradient to 0.69. At late restudy following valvoplasty, when regression of infundibular stenosis was noted in 6 out of 8 patients, the Doppler maximum and catheter peak to peak gradient had excellent correlation (r = 0.97, p = less than 0.001). In patients with lone valvular gradient immediately following valvoplasty and at late restudy, maximum Doppler gradients correlated well with catheter gradients in 14 estimations (r = 0.66, p = less than 0.01). This study shows that the non-invasive quantification of pulmonary valve stenosis can be reliably undertaken, using continuous wave Doppler echocardiography before balloon valvoplasty and during follow-up, after the procedure when the infundibular stenosis has regressed. The presence of an infundibular gradient immediately after balloon dilatation makes the Doppler prediction less reliable.     

Doppler ultrasound in the prediction of transvalvar pressure gradients in patients with valvar pulmonary stenosis

Good correlation between Doppler-derived and catheterization-measured pulmonary valvar pressure gradients has previously been reported. The purpose of this paper was to present two groups of patients who did not show such correlation, namely those with very severe stenosis and those measured immediately following balloon pulmonary valvoplasty. Twenty-two patients, aged 4 months to 20 years, in whom Doppler and catheterization pressure gradients were measured within 24 hours of each other were included in the study. There were 35 pairs of such data. The correlation coefficient for the entire group was 0.61 which improved to 0.91 when the five patients with severe stenosis (gradients of 94 to 190 mm Hg) and one patient with severe right ventricular infundibular stenosis immediately following balloon valvoplasty were excluded from analysis. Although the possibility exists, technical aspects of Doppler recording did not appear to be causing this lack of correlation. Cone-shaped spray formation rather than a focused jet in patients with extremely severe pulmonary stenosis may be postulated to be responsible for poor prediction by Doppler of catheterization gradient. Once these two groups of patients are excluded, there is excellent correlation between Doppler and catheterization gradients in patients with pulmonic stenosis.     

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.     

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.     

Anterograde balloon valvuloplasty for the treatment of neonatal critical valvar aortic stenosis.

We report our experience with anterograde balloon valvuloplasty in 17 neonates treated between November 1996 and June 2001 for critical aortic stenosis. Patients with hypoplastic left heart syndrome were excluded. Anterograde balloon valvoplasty of the aortic valve was possible in all 17 patients. The mean peak systolic gradient prior to cardiac catheterization was 73 mm Hg (range, 30-117 mm Hg) and decreased to 37 mm Hg (range, 21-60 mm Hg) after the dilation. Aortic regurgitation after balloon valvoplasty was absent or mild in 14/17 patients, moderate in 2 patients, and severe in 1 patient. There was no mortality or echocardiographic evidence for aortic cusp perforation or mitral regurgitation associated with the procedure. Redilation was necessary in 3/17 patients. Two patients are awaiting elective Ross operation. One patient with endocardial fibroelastosis died at 11 months of age. Anterograde balloon valvoplasty can be safely and effectively performed to palliate neonates with critical aortic valve stenosis.     

Echocardiographic assessment of the size of aortic and pulmonary valve annulus before balloon valvoplasty

Two dimensional echocardiographic measurements of the size of aortic and pulmonary valve annulus were made in 60 patients before balloon valvoplasty and compared to the angiographic measurements. Aortic valve annulus was measured in 34 patients (26 with valvar aortic stenosis and 8 with discrete subaortic stenosis) in the parasternal long axis or apical 5-chamber views. The pulmonary valve annulus was measured in 26 patients with valvar pulmonary stenosis (PS) in the parasternal short axis view of the right ventricular outflow view. The visualization of the annulus was good in all except 2 patients with valvar PS. Angiographic measurements of the aortic and pulmonary valve annulus were made in aortic root and right ventricular angiograms respectively, taken in both right and left anterior oblique views. There was an excellent correlation between the measurements of the annulus size by the two techniques (r value for pulmonary valve 0.91; for aortic valve 0.96; over all 0.94). Echocardiography can accurately measure valve annulus size and help in choosing balloon dilatation catheter of appropriate size before the valvoplasty procedure.     

Patent oval foramen protects against severe hemodynamic changes during percutaneous balloon pulmonary valvoplasty

Our report concerns three adult patients with severe valvar pulmonary stenosis, who also had a patent oval foramen. In these cases the percutaneous balloon pulmonary valvoplasty only led to moderate hemodynamic changes without major subjective symptoms.     

Restenosis is a common feature of the angiographic follow-up after balloon valvoplasty of calcified aortic stenoses

Balloon dilatation of calcified aortic stenosis was attempted in 12 patients, 6 men and 6 women, aged 38-82 years. Two patients underwent emergency surgery because of myocardial injury or pericardial tamponade. One patient with severe depressed left ventricular function in whom the procedure was attempted in cardiogenic shock died during the procedure. One patient experienced severe aortic insufficiency after dilatation. The remaining pressure gradient was higher than 50 mm Hg in another patient. Seven dilatations were considered to be successful with a remaining pressure gradient below 50 mm Hg and a mean gradient reduction of 53 mm Hg. In one of these 7 patients, who suffered from severe heart failure, valvoplasty had been carried out to make aortic valve replacement possible. The operation was performed 2 weeks later without complications. Five of 6 patients treated medically after successful valvoplasty had restenosis within 3 to 12 months. One of them exhibited a good result at 3 months but severe restenosis after one year. It is concluded that balloon valvoplasty of calcified aortic stenosis cannot be considered an alternative to surgery. If, however, left ventricular function improves after successful valvoplasty, valve replacement will then carry less risk.     

Unusual electrocardiographic response during pulmonary balloon valvoplasty.

An 18-year-old girl with severe valvar pulmonary stenosis was subjected to balloon valvoplasty. During each inflation of the balloon, we observed transient electrocardiographic disappearance of 'R' waves in the monitoring lead. The possible explanations for this observation include sudden severe right ventricular strain and ischemia.     

Cutaneous oozing of lymphatic fluid after interventional cardiac catheterization in a patient with Noonan syndrome.

A 15-year-old girl with Noonan syndrome, intestinal lymphangiectasia and severe valvar pulmonary stenosis had an abnormal lymphangioscintigram that showed intense activity in the inguinal regions bilaterally. Cutaneous oozing of lymphatic fluid from the groin wound complicated percutaneous balloon pulmonary valvoplasty. This previously unreported complication highlights the risk of damage to abnormal lymphatic channels in patients with Noonan syndrome who undergo interventional catheterization.     

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.     

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.     

Electrocardiographic Changes Following Balloon Dilatation of Valvar Pulmonic Stenosis

The purpose of this paper was to study the electrocardiographic changes following balloon pulmonary valvuloplasty for pulmonic stenosis and to see if such changes reflect improvement in pulmonary valve gradient following balloon valvuloplasty. Forty-one patients, ages 7 days to 20 years, underwent balloon valvuloplasty for severe valvar pulmonic stenosis. In 35 of these patients ECGs were available 3 to 34 months (mean 11) following valvuloplasty and were compared with pre-valvu-loplasty electrocardiograms. In 30 children with excellent relief of pulmonic stenosis (group I), frontal plane mean QRS vector moved toward the left from 127 ±25° to 81 ±47°as did the horizontal plane mean QRS vector, 88 ± 36° to 27 ±51°. The amplitude of R wave in V_1, 19 ± 11.6 mm, and V₂, 19.7 ± 12.2 mm, decreased respectively to 9.5 ± 5.9 mm and 11.3 ±6.1 mm. S wave amplitude in V₅ and V₆ also decreased. The improvement in the electrocardiogram is associated with a decrease in pulmonary valve gradient from 95 ± 50 to 29 ± 23 mm Hg. In five children with significant residual pulmonary valve gradient (group II), the electrocardiograms did not show any significant change. Evaluation of the time course of ECG changes in group I revealed that recognizable electrocardiographic improvement was first observed at 6 months following successful balloon pulmonary valvuloplasty. Normal electrocardiogram suggests minimal residual pulmonary valve gradient while right ventricular hypertrophy suggests significant residual obstruction unless the electrocardiogram was recorded at or before six months following balloon valvuloplasty. These data suggest that electrocardiogram is a good indicator of improvement following balloon pulmonary valvuloplasty. (J. Interven Cardiol 1988:1:3)     

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)     

Aneurysm of the pulmonary trunk in association with minimal pulmonary stenosis

We report a rare instance of aneurysm of the pulmonary trunk (maximum diameter 6.8 cm) in association with trivial valvar pulmonary stenosis (peak gradient 18 mm Hg). The relevant literature is briefly reviewed.     

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.