Long-term outcome of percutaneous balloon aortic valvuloplasty for children with congenital aortic valve stenosis / 中华心血管病杂志

Objective: To assess the efficacy and long-term outcome of percutaneous balloon aortic valvuloplasty (PBAV) for children with congenital aortic stenosis (CAS) and to explore risk factors for significant aortic regurgitation (AR) and reintervention after PBAV during follow up. Methods: This was a retrospective study. Children (≤18 years old) with CAS, who underwent PBAV in Guangdong Provincial Hospital from January 2004 to December 2018, were included in this study. Demographic, preoperative transthoracic echocardiography (TTE) and surgical data were collected. Postoperative complications were closely observed, and the patients were followed up at 1, 6, 12 months after the operation, and then at one year interval thereafter. Endpoint events included significant AR and reintervention. Reintervention was defined as any intervention that needed to be performed on the valve for various reasons, including re-PBAV, surgical valvuloplasty and valve replacement. Significant AR was defined as AR grade≥3 by TTE criteria. The results of the last TTE examination before the end of the study were collected. The Kaplan-Meier curve for long-term AR-free and intervention-free survival was plotted. Cox regression model was used to further analyze the risk factors for significant AR and reintervention after PBAV in CAS patients. Results: A total of 55 patients were enrolled in this study, and the age was 4.6(1.6, 6.5) years, with 37(67.3%) males. The peak systolic valve gradient fell from (80.3±30.6)mmHg to (38.5±18.5)mmHg(P<0.001, 1 mmHg=0.133 kPa). Surgical success rate was 89% (49/55). Acute post-PBAV AR occurred in 18 patients, including 3 patients with RA≥3 grade. In-hospital complications occurred in 6 patients (2 deaths, 2 cases of transient arrhythmia, and 2 cases of femoral artery embolization). Fifty patients accomplished the follow-up and the follow-up time was 6.2(3.4, 8.5) years. Significant AR was found in 20 patients. Significant AR-free survival rate was 53% at 5 years and 19% at 10 years. Reintervention was performed in 11 patients (4 with valvuloplasty and 7 with valve replacement), and the 5-year and 10-year intervention-free survival rates were 87% and 62%, respectively. Multivariate Cox regression analysis showed that acute post-PBAV AR was a risk factor for long-term significant AR (HR=2.398, 95%CI 1.007-5.712, P=0.048). Post-PBAV residual pressure gradient ≥ 35 mmHg (HR=4.747, 95%CI 1.116-19.329, P=0.030)and acute post-PBAV AR (HR=5.104, 95%CI 1.083-24.065, P=0.039)were risk factors for re-intervention. Conclusions: PBAV is safe and effective in the treatment of CAS in children, but attention should be paid on significant AR post procedure. Acute post-PBAV AR is a risk factor for re-intervention and significant AR post PBAV, and high post-PBAV residual pressure gradient is a risk factor for re-intervention.

Successful Percutaneous Balloon Dilatation of Membranous Sub-aortic Stenosis in a 22 Year Old Pregnant Patient

Congenital obstruction of the left ventricular outflow tract comprises a heterogeneous group of disorders, with obstruction potentially occurring below, above, or at the level of the aortic valve. Subvalvular stenosis is the second most common type of left ventricular outflow tract obstruction, of which discrete membranous type is the most common. Although surgical resection of the subaortic membrane is the treatment of choice in discrete membranous subaortic stenosis, in selected patients with isolated membranous subaortic stenosis, without significant aortic insufficiency, percutaneous balloon tearing of the membrane results in reduction in the degree of left ventricular outflow tract obstruction and symptomatic relief. We report a case of 22 year old pregnant patient admitted with NYHA class III breathlessness, found to have discrete membranous subaortic stenosis. Balloon aortic valvuloplasty was performed in the patient with good result. Patient underwent normal vaginal delivery at 38 weeks. Both mother and newborn were asymptomatic. Patient is asymptomatic on subsequent follow-ups.

Application for a Bridge Therapy of Percutaneous Balloon Aortic Valvuloplasty in the Era of Transcatheter Aortic Valve Replacement: A Single Center Experience / 中国循环杂志

Objectives: To explore the clinical experience for a bridge therapy of percutaneous balloon aortic valvuloplasty (PBAV) in treating the patients with severe aortic stenosis (AS). Methods: A total of 37 patients with severe AS who were not suitable for surgical valvular replacement received PBAV in our hospital from 2011-03 to 2017-03 were retrospectively studied. The patient's mean age was (74±12) years, their clinical and anatomical features, efficacy and safety of operation were observed and the outcomes were evaluated by follow-up study. Results: Patients presented the high surgical risk and worse cardiac function, 50% of them had bicuspid leaflet morphology with severe calcification [HU850=(856.0±658.2) mm3]. Balloon size was chosen by the intra-operative supra-annular diameters; at 7 days after operation, aortic valve orifice area (AVOA) was increased from (0.37±0.10) cm2to (0.87±1.10) cm2, the mean trans-aortic valve gradient pressure decreased form (55.1±22.9) mmHg to (44.8±17.8) mmHg, P<0.001 and LVEF elevated form(35.8±14.3)% to(41.0±12.2)%,P<0.001.There were 4 patients died in hospital,1 received permanent pacemaker and 1 developed severe aortic valve regurgitation. The patients were followed-up for (16.5±11.1)months after operation, 13/37 (35.1%) patients were in transition to surgical or transcatheter aortic valve replacement (TAVR). Conclusions: PBAV may have good early clinical efficacy in severe AS patients who were not suitable for surgical valvular replacement and TAVR; PBAV could be expected to become a bridge therapy, smaller supra-annular diameter was safe and effective for patients having bicuspid leaflet with severe calcification.

Midterm outcome of percutaneous balloon aortic valvuloplasty guided by single echocardiography for congenital aortic stenosis / 中国胸心血管外科临床杂志

@#Objective To analyze the midterm outcome of patients with congenital aortic stenosis undergoing percutaneous balloon aortic valvuloplasty (PBAV) by single echocardiographic guidance. Methods The clinical data of 12 patients with congenital aortic stenosis who underwent PBAV by single echocardiographic guidance at Fuwai Hospital from January 2016 to November 2017 were retrospectively analyzed. There were 7 males and 5 females with an average age of 18.27±15.30 years. The preoperative peak pressure gradient was 61.8–110.0 (80.30±24.50) mm Hg, and 50% of patients had aortic regurgitation. Results All patients successfully underwent PBAV. Aortic annulus diameter was 18.65±3.17 mm and balloon diameter was 17.62±3.77 mm, with balloon diameter to annulus diameter ratio of 0.92±0.07. The peak transaortic gradient was 16-51 (36.72±12.33) mm Hg immediately after procedure, which was significantly different from the preoperation (P=0.000). During the follow-up period, the peak transaortic gradient was 21-58 (37.06±13.52) mm Hg, and there was no significant difference between the follow-up and immediate postoperation (P=0.310). Immediately after procedure and during follow-up, 58% of patients had aortic regurgitation, which was not statistically different from the preoperation (P=0.682). Conclusion Systematic use of Doppler echocardiographic guidance for PBAV is feasible, and that it is associated with a high success rate and a very low complication rate.

Progress of interventional therapy of congenital valvular aortic stenosis / 中华实用儿科临床杂志

Congenital vahular aortic stenosis (AS),which refers to a congenital malformation of the aortic valve,is the most common causes of left ventricular outflow tract obstruction in chiidren.In 1983,percutaneous balloon aortic valvuloplasty (PBAV) was firstly described as the treatment for congenital AS in children.Over the past 30 years advancement in technique and equipment had radically improved the safety and outcome of balloon valvuloplasty of aortic valve.Nowadays the technique is widely regarded as the therapy of first choice for children with congenital AS.However,it is essential to make decisions about treatment and define which approach has the best chance of success for any given patient before the initial intervention,especially for the neonate with critical AS.PBAV is usually effective for acutely relieving left ventricular outflow obstruction and has excellent short term results in most childen with congenital AS.The mid-and long-trem outcome after a successful balloon dilation of congenital AS in childhood is also good,but late restenosis and valve regurgitation eventually necessitate reintervention in the majority of children,which included aortic valve replacement.PBAV was found to have a high incidence of complications and remains one of the most challenging procedures in the inttcventional therapy of congenital heart disease.Operators should not only acquire the necessary manual skills,but also have the ability to make sound clinical judgment and deal with critical events.Owing to its palliative nature of balloon dilation for congenital AS,the follow-up care of patients after procedure is quite important.

Protective effect of dexamethasone on stress response induced by intrauterine balloon aortic valvuloplasty in a fetal lamb model / 临床儿科杂志

Objective To investigate the protective effect of dexamethasone on stress response induced by intraute-rine balloon aortic valvuloplasty (IUBAV) in a fetal lamb model. Methods Twenty-four near term twin pregnant goats were randomly assigned to control group (n=12) and dexamethasone group (intracardiac injection of dexamethasone) (n=12). Ultrasound guided IUBAV model was established. According to the combination of treatment and operation, 48 fetal lambs were divided into four groups. The following parameters were dynamically monitored by ultrasound, which were fetal and neonatal heart rate (HR), cardiac rhythm, aortic resistance index (RI) and pulsatility index (PI). On established IUBAV model, blood samples and liver tissue specimens were taken from fetal/neonatal goats for detection of blood glucose (Glu), lactate acid (LA), plasma epinephrine (E), norepinephrine (NE), cortisol (Cort), hepatic glycogen staining. Results IUBAV resulted in increased values of Glu, LA, E, NE and Cort levels, and decreased pH value, there were significant differences between pre-and 3h-post procedure (P<0.05), and significant differences were also existed in these values between pre-and 3d-post procedure (P<0.05). After administrating dexamethasone, the changes of Glu, LA, E, NE, Cort and pH levels were suppressed effectively. Fetal hepatic glycogen was consumed in large amounts due to IUBAV while recovered 3 days after IUBAV by glycogen staining. After administrating dexamethasone, hepatic glycogen consumption related to IUBAV was obviously inhibited. After IUBAV, fetal aortic RI was increased, and there was significant differences compared with pre-procedure (P<0.05). Up to 3d-post procedure, the values of RI recovered to some extent, but statistical difference was exist-ed compared with pre-procedure (P<0.05). After administrating of dexamethasone, increased aortic RI was effectively sup-pressed. Conclusions IUBAV could lead to reversible stress response and increased aortic RI in a fetal lamb model which could be alleviated by dexamethasone.

Percutaneous Balloon Aortic Valvuloplasty (Pbav) in a Child With Congenital Severe Aortic Stenosis –A Case Report.

A 8 years old boy presented with shortness of breath, cough and palpitation and subsequently diagnosed as a case of severe aortic stenosis with bicuspid aortic valve. Percutaneous balloon aortic valvuloplasty (PBAV) was done and he became asymptomatic. Post procedure his aortic valve area and aortic systolic pressure increased, transaortic pressure gradient decreased. So good result, lower cost, elimination of drawbacks of thoracotomy and cardiopulmonary bypass suggest in children percutaneous balloon aortic valvuloplasty should be the treatment of choice for patients with severe aortic stenosis.

Estabilización del balón mediante estimulación cardíaca en la valvuloplastía aórtica / Balloon stabilization by means of cardiac stimulation during aortic valvuloplasty

Objetivo: Evaluar la estimulación ventricular rápida en la Valvuloplastía Aórtica Percutánea como estrategia para obtener estabilidad del balón. Material y métodos: En septiembre de 2004 se inició un protocolo prospectivo. Tres enfermos masculinos consecutivos con estenosis valvular aórtica significativa fueron tratados con este método. Las edades fueron 13, 6 y 5 años. En todos se colocó un electrodo bipolar en el ventrículo derecho. Durante el procedimiento se registró la presión arterial sistémica con un catéter en la aorta descendente. La estimulación ventricular se inició a una frecuencia de 150 por minuto y se aumentó hasta obtener un descenso del 50% en la presión arterial sistémica y entonces el balón se infló para realizar la valvuloplastía aórtica. La estimulación se suspendió hasta que el balón fue completamente desinflado. Resultados: Los gradientes transvalvulares antes de la valvuloplastía fueron 90 y 110 mmHg. Las presiones en aorta fueron de 90, 110 y 55 mmHg. Se obtuvo una reducción del 50% de la presión sistémica con 170, 250 y 220 por minuto de estimulación. La duración de la estimulación rápida en los tres casos fue de 15 segundos. Se logró estabilización del balón sin movimientos en los dos casos. Los gradientes obtenidos después de la valvuloplastía fueron 23, 28 y 15 mmHg. No hubo modificación en el grado de insuficiencia aórtica después del procedimiento. En el primero se mantuvo grado I y en el segundo y tercer casos, no se observó regurgitación en el aortograma. Conclusiones: La estimulación cardíaca rápida estabiliza el balón durante la valvuloplastía, es segura, efectiva y puede disminuir la incidencia de insuficiencia aórtica.

Objective: To evaluate rapid ventricular pacing in balloon aortic valvuloplasty, an initial strategy to achieve balloon stability. Material and methods: From September to December 2004, a prospective protocol was started: three male consecutive patients with aortic valve stenosis were treated by this strategy. Age of the patients were 13, 6 and 5 years old. All had a bipoplar pacing catheter placed in the right ventricle. Invasive systemic pressures were documented with a catheter in the descending aorta. Rapid ventricular pacing was initiated at the rate of 150 per minute and increased to a rate required to achieve a drop in systemic pressure by 50%. The balloon was inflated only after the pacing rate was reached and the blood pressure dropped. Pacing was continued until the balloon was completely deflated. Results: The systolic gradients across the aortic valve before balloon dilatation were 90, 110 and 55 mmHg. The systolic pressures in aorta were 90 and 110 mmHg. The pacing rate to drop the pressure by 50% were 170, 250 and 220 per minute. The pacing time was 15 seconds in all patients. Balloon stability at time of inflation was achieved in all cases with no balloon movement. The post-ballooning gradients were 23, 28 and 15 mmHg. Angiogram performed post balloon dilatation showed no change compared with the pre-balloning angiogram in aorta: trivial aortic incompetence in the first case and none in the second and third cases. Conclusions: Rapid ventricular pacing to stabilise the balloon during balloon aortic valvuloplasty seems to be safe and effective and may decrease the incidence of aortic incompetence.

Study for Balloon Aortic Valvuloplasty in Congenital Aortic Stenosis

PURPOSE: The aims of this study are to investigate the results of balloon aortic valvuloplasty (BAV) in congenital aortic stenosis(CAS) and, especially, to compare the results between BAV performed before two months of age(Group A) and BAV after two month of age(Group B). METHODS: From January 1993 to June 2000, 14 patients who were diagnosed as CAS were treated with BAV. Indications for BAV were 1) critical aortic stenosis and 2) a peak-to-peak systolic pressure gradient in excess of 50mmHg or a gradient > OR =40mmHg with either symptoms or EKG changes. RESULTS: In Group A, the procedures were performed through femoral artery, carotid, or femoral vein approach. In Group B, however, all procedures were performed through femoral artery approach. After the BAV, a peak-to-peak systolic pressure gradient was reduced from 66.5+/-31.3 mmHg to 30.1+/-15.5mmHg(Group A; from 42.3+/-23.8mmHg to 22.0+/-15.3mmHg, Group B; from 88.9+/-16.8mmHg to 38.1+/-11.5mmHg). Repeated BAV were tried in 3 of these cases. There were 3 mortality cases in Group A. One of them was related with the procedure. CONCLUSION: The result of BAV after 2 months of age is acceptable, but that before 2 months of age is not satisfactory. However this result of BAV on early infants is thought to be mainly related to the poor pre-BAV conditions. So BAV may still be considered as a first intervention for CAS in this period. In such cases, other approachs rather than femoral artery should be considered.

The Management of Three Infants with Critical Valvular Aortic Stenosis by Transcarotid Balloon Aortic Valvuloplasty

Critical valvular aortic stenosis(AS) is a life threatening congenital heart anomaly in neonates or infants. The main cause of death is rapidly progressing left ventricular failure. The treatment goal of critical AS is to save left ventricular function early. Before the 1980s, the preferred treatment was surgical valvotomy, however, that operative method had a high mortality rate and risk of re- procedure. These surgical problems encouraged balloon aortic valvuloplasty technique for initial life saving. There were some vascular approaches for balloon aortic valvuloplasty(e.g. femoral artery and vein, umbilical artery and vein, carotid artery). Each approach has some advantages and disadvantages. Balloon aortic valvuloplasty through the right carotid artery makes access to the aortic valve easy, has less vascular complication, and short procedure time and effect of saving femoral artery for reballooning. We had three cases of transcarotid balloon aortic valvuloplasty in infants with critical AS. In our long-term follow up, we had good results, except carotid artery thrombosis in one case. We report the first three Korean cases of balloon aortic valvuloplasty though carotid artery cutdown procedure for critical AS with a brief review of literatures. (J Korean Pediatr Soc 2000;43:820-827)

Seguimento clínico e ecodopplercardiográfico de idosos submetidos a valvuloplastia aórtica por cateter-baläo / Clinical and Doppler echocardiographic follow-up of elderly patients subjected to aortic balloon valvuloplasty

Purpose­To evaluate the evolution of patients with critical aortic stenosis (AS) submitted to balloon aortic valvuloplasty (BAV). Patients and Methods­sixteen patients (mean age 74.0 ± 5.1 years), 11 (68.7%) women. The study periods consisted during the 3 rd (post-1) and 15th month (post-2) after dilatation. Results­The functional class of angina and dyspnea persisted in all patients during period post-1, in 75% of theo patients, during period post-2 in relation to intra-hospital evaluation. However, in period post-1, 53% of the patients had significant reduction of aortic valve area, trend which remained in period post-2. Simultaneously, progressive (insignificant) elevation of the left ventricular aortic peak to peak gradient was noticed in the periods post-1 and post-2. Two deaths and two aortic valve replacements occurred during the study. Conclusion­BAV is associated to maintenance of functional class improvement obtained immediatly after dilatation despite the aortic valve restenosis registered by echodopplercardiography