Balloon dilation of critical valvar pulmonary stenosis in the first month of life

Abstract

Between 1985 and 1992, 36 consecutive neonates, aged 1-29 days, weight 2.4-5.0 kg, with critical valvar pulmonary stenosis underwent attempted balloon dilation (BD). At catheterization, 30 were on prostaglandin (PGE1) therapy and 20 were intubated. The valve was successfully crossed and dilated in 34/36 (94%), including three with an echocardiographic diagnosis of valvar pulmonary atresia and a right ventricle of adequate size. The valve was first dilated with a 2- to 5-mm balloon and then with serially larger ones (up to 12 mm) to a final balloon/annulus value of 126%. The RV/systemic pressure value fell from 150 +/- 32 to 83 +/- 30%, O2 saturation rose from 91 +/- 6% to 96 +/- 4%, and PGE1 was discontinued at the end of the procedure. There were 11 complications (31%) including one early death from sepsis and necrotizing enterocolitis, endocarditis in another, two myocardial perforations, one femoral-iliac vein tear, and one transient pulse loss. A repeat BD was carried out in five patients, two of whom subsequently had surgery. At follow-up (33 +/- 23 months), the 31 patients managed by BD alone were well and had echocardiographic gradients of < 30 mm Hg in 90% and pulmonary regurgitation, considered mild in most, in 52%. In neonates with critical valvar pulmonary stenosis, we believe BD mortality is less than with surgery and is the treatment of choice.

Balloon Valvuloplasty of Critical Pulmonary Valve Stenosis in a Premature Neonate

“…Several studies have shown that balloon dilatation is a good alternative to surgical treatment of critical pulmo- Pediatric Cardiology nary stenosis in neonates [3,5,6,12]. Premature infants and infants with low birth weight and critical pulmonary valve stenosis are a therapeutic challenge, since they encounter several specific problems, including avoidance of temperature loss during the procedure, venous access, and problems related to the small anatomical size of the cardiac structures.…”

“…Further measurements, allowing us to obtain stable normothermia in our patient, were warming up of the catheterization laboratory, wrapping of the child in cotton, and additional covering of the extremities with aluminium foil. The 7-mm balloon catheter we used (Osypka, Grenzach-Whylen, Germany) proved ideal for the pulmonary valvuloplasty, since its low profile allowed it to be introduced through a 4 French sheath, thus avoiding the damage to the femoral vein that can be a major complication of balloon valvuloplasty [3,7,13]. Furthermore, due to the small diameter of the balloon catheter, a more time consuming multistep gradational approach using progressively larger balloons [3,5,11], or the application of a so-called transductal guidewire rail technique [8], were not necessary.…”

“…In many centers, pulmonary balloon valvuloplasty has become the method of choice for the treatment of infants with critical pulmonary valve stenosis [1,3,4,5]. Although the morbidity and mortality of this procedure is certainly higher in infants than in older patients with congenital pulmonary valve stenosis, the results of balloon valvuloplasty in infants compare favorably with the results of surgical valvotomy [1,2,4,6].…”

Balloon Pulmonary Valvuloplasty

“…Echocardiographic evaluations reveal average residual gradients of 15-20 mmHg. In reports where such data are available, between 10 and 20% of patients had doppler gradients over 30 mmHg [4,10]. Doppler evidence of moderate pulmonary insufficiency has been reported in perhaps 20% of cases at follow-up.…”

“…Patients have often been brought to the catheterization laboratory with a diagnosis of pulmonary atresia, found to have critical stenosis with tiny valve orifice, and undergone balloon dilation [4]. Given the successful outcome in these patients, it is not surprising that several groups attempted to develop techniques for crossing and dilating atretic pulmonary valves.…”