Experience in a single centre with percutaneous aortic valvoplasty in children, including those with associated cardiovascular lesions

Abstract

Balloon valvoplasty is a safe and effective method for the treatment of congenital aortic stenosis. Prior surgery to the aortic valve, reintervention, associated cardiovascular lesions, and the anatomy of the valve predict a less effective reduction in the gradient. Major complications and catheterization-related death are mainly secondary to very young age, but not to associated cardiac lesions.

Congenital Aortic Stenosis in Childhood

“…It consists on electrically stimulating the right ventricle rapidly to accelerate the ventricular frequency until a 50% systolic aortic pressure drop is achieved, and inflating the balloon at this point (David et al, 2007). An effective relief of the obstruction is usually achieved by the valvoplasty, with a 50-70% reduction of the pressure gradient in children with isolated aortic stenosis and in those with associated cardiovascular lesions (Crespo et al, 2009;Gatzoulis et al, 1995;Kusa et al, 2004;McCrindle et al, 1996;Rao et al, 1989). Independent risk factors for suboptimal gradient reduction are high pre-valvoplasty transaortic gradient, children aged less than a month or more than 14 years, high pre-procedural left ventricle end diastolic pressure, the use of a balloon to annulus ratio less than 0.9, and fused bicuspid valve as opposed to pure bicuspid valve (Crespo et al, 2009;Kusa et al, 2004;McCrindle et al, 1996).…”

“…An effective relief of the obstruction is usually achieved by the valvoplasty, with a 50-70% reduction of the pressure gradient in children with isolated aortic stenosis and in those with associated cardiovascular lesions (Crespo et al, 2009;Gatzoulis et al, 1995;Kusa et al, 2004;McCrindle et al, 1996;Rao et al, 1989). Independent risk factors for suboptimal gradient reduction are high pre-valvoplasty transaortic gradient, children aged less than a month or more than 14 years, high pre-procedural left ventricle end diastolic pressure, the use of a balloon to annulus ratio less than 0.9, and fused bicuspid valve as opposed to pure bicuspid valve (Crespo et al, 2009;Kusa et al, 2004;McCrindle et al, 1996). Repeated balloon dilatation, and valvoplasty for residual stenosis after surgical valvotomy seem to be efficient (Crespo et al, 2009;Meliones et al, 1989;Phillips et al, 1987;Shim et al, 1997;Sholler et al, 1988).…”

“…Independent risk factors for suboptimal gradient reduction are high pre-valvoplasty transaortic gradient, children aged less than a month or more than 14 years, high pre-procedural left ventricle end diastolic pressure, the use of a balloon to annulus ratio less than 0.9, and fused bicuspid valve as opposed to pure bicuspid valve (Crespo et al, 2009;Kusa et al, 2004;McCrindle et al, 1996). Repeated balloon dilatation, and valvoplasty for residual stenosis after surgical valvotomy seem to be efficient (Crespo et al, 2009;Meliones et al, 1989;Phillips et al, 1987;Shim et al, 1997;Sholler et al, 1988). Valvoplasty may cause aortic regurgitation as the result of commissural avulsion, cusp dehiscence and or tear perforation.…”

“…This iatrogenic regurgitation, which was described to be associated with fused bicuspid valves (Reich et al, 2004), has been proven to be related to oversized balloons which lead to improve practice and guidelines, therefore high degrees of immediate post procedural insufficiency became uncommon (McCrindle et al, 1996;Phillips et al, 1987;Sholler et al, 1988). The rate of at least moderate aortic regurgitation shortly after the procedure is between 7.3-22.6% and may progress afterwards (Crespo et al, 2009;Fratz et al, 2008;McCrindle et al, 1996;McElhinney et al, 2005;Reich et al, 2004). Iatrogenic aortic insufficiency, severe hypotension, ventricular arrhythmias, vessel damage, complete atrioventricular block, cardiac tamponade and mitral valve injury are the main serious procedural related complications.…”

“…In a large multi-institutional series of 630 balloon dilatations which did not exclude children with associated cardiovascular anomalies major complications occured in 7.1%, significantly more frequent in newborns (McCrindle et al, 1996). Mortality attributable to the valvoplasty varies between 0 and 2.1%, again with a clearly higher incidence during the neonatal period (Kusa et al, 2004;McCrindle et al, 1996;Crespo et al, 2009;Moore et al, 1996). Both progressive worsening of aortic regurgitation and an increase in residual transvalvar gradient seem to be inevitable.…”