Percutaneous balloon valvuloplasty of pulmonary valve stenosis: state of the art and future prospects

This study is aimed to delineate readers with an overview of percutaneous balloon pulmonary valvuloplasty (PBPV) of pulmonary valve stenosis (PVS) and highlighting outcome based on influential and recent studies. It has been four decades since Kan et al first introduce PBPV. Since then, PBPV has recognized as a gold standard therapy for PVS of all ages. Nowadays, PBPV is practiced for a broad range of indication such as PVS, PV dysplasia and pulmonary atresia. Typically, PBPV is recommended when gradient across the PV is >50 mmHg. The procedure involves the placement of one or more balloon catheters across the stenotic PV with the guidance of a guidewire; thereafter, inflation of the balloons is done by pressure, thus producing valvotomy. Nowadays, PBPV is done by echocardiographic guidance, but previously, it was done by fluoroscopic guidance. The main disadvantage of fluoroscopy was the radiation injury of patients. The recently recommended balloon/annulus ratio is 1.2 to 1.25. Following the procedure, the dramatic reduction of pressure gradient, free motion of the PV leaflets with less doming, the rise of cardiac output have been noted, whereas complications may occur but are unusual and minimal. Significant predictors of restenosis include balloon/annulus ratio <1.2 and immediate post-PBPV gradient ≥30 mmHg. Only a few percentages of patients needed repeat PBPV. Long-term follow-up results are surprisingly excellent. In conclusion, it is our opinion that PBPV is equally successful in patients of all ages, while worldwide recognized studies prove the safety, feasibility, and effectiveness. However, for early detection of any complication, life-long clinical follow-up is mandatory.

Transcatheter interventional therapy for pulmonary stenosis in infants / 中国实用儿科杂志

OBJECTIVE: To summarize the experience of percutaneous balloon pulmonary valvuloplasty for pulmonary stenosis in infants,and to evaluate its necessity,safety and effectiveness. METHODS: From January 2009 to December2018,68 cases of pulmonary stenosis were treated by percutaneous balloon pulmonary valvuloplasty. The clinical data before and after operation were analyzed retrospectively. RESULTS: The mean age was(6.34±3.6)months. The mean operation weight was(7.81±2.11)kg. The preoperative body weight/age Z score was-0.80±1.38,and growth restriction was in 22 cases(32.4%),cyanosis in 15 cases(22.1%)and tachypnea in 23 cases(33.8%). The mean right ventricular/left ventricular length-diameter ratio was 0.56±0.73 by echocardiography,the mean cardiothoracic ratio was 0.56±0.43 by chest radiography,and the average value of preoperative oxygen saturation was 94.74 ± 6.10. The mean systolic pressure ratio of right ventricle/left ventricle before operation was 0.68±0.26. After balloon dilation,the mean pressure gradient of pulmonary valve decreased from(75.57 ± 18.61)mmHg to(22.37 ± 5.21)mmHg,and the mean systolic pressure of right ventricle decreased from(83.78±22.44)mmHg to(54.16±20.81)mmHg. The immediate success rate of operation was 100%. There were no serious arrhythmia,cardiac perforation,rupture of tendon chordae,vascular injury or other complications during the operation. The proportion of mild to moderate pulmonary regurgitation was 53.3% in early stage after operation,and there was no severe regurgitation. The restenosis rate was 2.94% during the follow-up period of 3 months to 10 years. The pulmonary valve regurgitation degree of 32 children who were followed up for more than 5 years did not further aggravate,and no specific management was carried out. No obvious right ventricular dysfunction was found in all patients. Compared with the toddlerhood infants undergoing PBPV in our center,the babyhood infants had obvious clinical symptoms and serious condition. The early and medium-long-term follow-up after operation was satisfactory. There was no significant difference in the effect of operation in the low-weight or low-age infants in babyhood. CONCLUSION: PBPV is necessary for the treatment of pulmonary stenosis in infants. The technique is safe and feasible,and the follow-up results are effective.

Long-term follow - up of percutaneous balloon pulmonary valvuloplasty in pulmonary valve stenosis in 230children / 中华实用儿科临床杂志

Objective To evaluate the safety and efficacy of percutaneous balloon pulmonary valvuloplasty (PBPV)in the treatment of the children with pulmonary stenosis (PS),and to observe the long - term prognosis and analyze the influencing factors. Methods The total of 230 children were collected,who had been diagnosed with pul-monary valve stenosis and had undergone percutaneous balloon pulmonary valvuloplasty between November 1987 and November 2015 in Shandong Provincial Hospital Affiliated to Shandong University. Their ages ranged from 4 months to 17 years,and the follow - up duration lasted from 1 month to 29 years. The data included clinical data and long - term follow - up data of hospitalized children,and the echocardiography data from the healthy peers in the same period. Then the data were analyzed statistically. Results In this study,228 cases of children were successfully performed PBPV, and the success rate was 99％(228 / 230 cases). The pulmonary transvalvular gradient (△P)of preoperation,24 hours postoperatively,half a year postoperatively,2 years postoperatively,5 years postoperatively,and 10 years postope-ratively was (63. 5 ± 23. 8)mmHg (1 mmHg = 0. 133 kPa),(26. 2 ± 11. 1)mmHg,(24. 8 ± 9. 8)mmHg,(20. 9 ± 8. 9)mmHg,(18. 1 ± 8. 7)mmHg,(15. 3 ± 7. 3)mmHg and (15. 3 ± 7. 3)mmHg,respectively. The immediate post-operative △P was significantly lower than that of preoperation (P < 0. 01),and the △P of the most children decreased in the long - term follow - up. The results of Logistic regression analysis showed that valve dysplasia with right ventricu-lar outflow tract stenosis and the immediate postoperative residual transvalvular gradient degree were the risk factors for long term curative effect of PBPV in children who could not reach the best standard. The restenosis rate was 4. 6％(3 /65 cases)with children followed up for more than 10 years. The incidence of long - term follow - up pulmonary valve regurgitation (83％)was significantly higher than that before operation (58％)and short term (68％)after operation, and the degree of regurgitation also increased (P < 0. 05),while the degree of regurgitation of the tricuspid regurgitation decreased gradually during the follow - up (P < 0. 05);the right ventricular diastolic diameter of the patients at 10 years or more after the operation was measured as (19. 27 ± 3. 03)mm,which was significantly higher than that (15. 24 ± 2. 89)mm of the healthy children of at the same term healthy age (P < 0. 05). Conclusions The PBPV has a high success rate in the treatment of children with PS,and it has good medium - long - term curative effect,less com-plications and lower restenosis rate. Therefore,PBPV can be used as the first choice for PS. However,the incidence and degree of pulmonary regurgitation has an increasing trend after PBPV and the right ventricular diastolic diameter is still larger than that of the healthy children. Therefore,the long - term follow - up is necessary out of the hospital.

Progress of percutaneous balloon pulmonary valveplasty application in children with pulmonary valve stenosis / 中华实用儿科临床杂志

Pulmonary valve stenosis (PS) is a relatively common congenital heart disease,and there are 2 treatment methods of surgical operation and intervention.Percutaneous balloon pulmonary valvuloplasty (PBPV) was applied successfully in children with PS for the first time by Kan.For more than 30 years,with the update of intervention equipment,improvement of operation method and accumulation of clinical experience,the application of PBPV continuously has made new progress.Most of the previous reports of the PBPV were for the immediate and short-term efficacy,while long-term follow-up data and some special types of PS review research were less.Now,combined with PBPV clinical data and long-term follow-up study in recent years,an overview of the application progress of PBPV including indications,methods,curative effect and follow-up,prevention and cure of complications and some special type of PS are provided.

The Comparison between the Echocardiographic Data to the Cardiac Catheterization Data on the Diagnosis, Treatment, and Follow-Up in Patients Diagnosed as Pulmonary Valve Stenosis

BACKGROUND: Isolated pulmonary valve stenosis (PS) makes up 6-9% of all congenital heart defects among children. The initial gold standard for diagnosis, follow-up of PS is by echocardiography. However, the most accurate diagnosis still remains to be measurement of the pressure gradient through transcatheterization. The purpose of this study is to compare the difference between the echocardiographic data to the cardiac catheterization data on the diagnosis, treatment, and follow-up in patients diagnosed as PS, and to see what parameters should be closely monitored. METHODS: A total of 112 patients (Male : Female = 46 : 66) who underwent balloon pulmonary valvuloplasty (BPV) at Severance Cardiovascular Hospital, between December, 2002 to August, 2012 were retrospectively analyzed. The patients were all under 16 years of age and critical PS patients who underwent BPV were excluded from this study. RESULTS: The pre-BPV right ventricle (RV)-pulmonary artery (PA) systolic pressure gradient and post-BPV systolic pressure gradient showed statistically significant decrease. The pre-BPV RV-PA systolic pressure gradient and 3 month post-BPV systolic pressure gradient showed statistically significant decrease. The consistency between the echocardiographic data and cardiac catheterization data shows statistically significant consistency. The mean pressure gradient and systolic pressure gradient on the echocardiography shows high consistency when comparing with the cardiac catheterization data. CONCLUSION: Our study shows that BPV in PS is a safe and effective procedure in children and adolescent. The standard echocardiographic evaluation of PS, during diagnosis and follow-up, should include mean transpulmonic pressure gradient, as well as the peak systolic pressure gradient. The success of the procedure should be held off until at least 3 months, only if the patients do not show any symptoms.

Prophylaxis and treatment for the complications of the percutaneous balloon pulmonary valvuloplasty in children with pulmonary valve stenosis / 国际儿科学杂志

Percutaneous balloon pulmonary valvuloplasty has replaced surgery as the first choice for pulmonary valve stenosis,especially for the isolated ones in children.However,there still happen to be some complications which could lead to a bad prognosis or even death,when the procedure has already been a recognized safe one.This paper reviews these complications with their causal factors as well as the ways to prevent and treat them.

Tratamiento percutáneo de estenosis valvular pulmonar crítica en una mujer de 40 años con cianosis / Percutaneous Balloon Pulmonary Valvuloplasty in a 40-Year Old Woman with Cyanosis / Percutaneous Balloon Pulmonary Valvuloplasty in a 40-Year Old Woman with Cyanosis

La estenosis valvular pulmonar aislada es poco frecuente. Se diagnostica y se trata casi siempre durante la infancia, razón por la cual es poco común encontrarla en la edad adulta. En esta presentación se describe el caso de una paciente de 40 años con disnea ante pequeños esfuerzos, cianosis central y uñas en vidrio de reloj, que presentaba una estenosis valvular pulmonar crítica con cortocircuito de derecha a izquierda a través del foramen oval. El gradiente transvalvular pulmonar era de 150 mm Hg. Se realizó una valvulotomía pulmonar percutánea con un catéter balón Nucleus de Numed Cardiac Diagnostics. El gradiente medido por cateterismo y ecocardiograma inmediatamente después del procedimiento fue de 23 mm Hg. Seis meses después había desaparecido la cianosis y el gradiente transvalvular pulmonar fue de 19 mm Hg. La paciente lleva una vida normal, sin limitaciones en su calidad y estilo de vida.

Isolated pulmonary valve stenosis is uncommon. As the diagnosis and treatment of this condition is made during childhood, it is a rare finding in adult patients. We describe the case of a 40-year old female patient with dyspnea during slight exertion, central cyanosis and nail clubbing with a critical pulmonary valve stenosis and right-to-left shunt through a patent foramen ovale. The pulmonary valve gradient was 150 mm Hg. Percutaneous pulmonary valvuloplasty was performed using a Nucleus balloon catheter (Numed Cardiac Diagnostics). Immediately after the procedure, the pulmonary gradient measured by cardiac catheterization and echocardiography decreased to 23 mm Hg. Six months later the cyanosis had disappeared and the gradient was 19 mm Hg. The patient lives a normal life with no limitations in her quality of life and lifestyle.

Diagnosis and treatment of children with pulmonary stenosis / 国际儿科学杂志

Pulmonary valve stenosis is a common congenital heart disease,and its early diagnosis and treatment can improve growth and prognosis in children with pulmonary valve stenosis.With the development of the diagnostics and treatment,percutaneous balloon pulmonary valvuloplasty has replaced surgery as the first choice for isolated pulmonary valve stenosis.This paper reviews the recent progress in diagnosis and treatment of pulmonary valve stenosis.

Short term results of balloon pulmonary valvuloplasty in children: a single centre study over a period of 42 months.

Objectives: To evaluate the efficacy and safety of balloon pulmonary valvuloplasty (BPV) in children. Design, setting and method: This is a retrospective review of 101 consecutive patients with pulmonary stenosis who underwent BPV at the Lady Ridgeway Hospital for Children over a period of 42 months. Four patients were excluded as they had complex cardiac problems. Data was obtained from Excel based cardiac catheterization reports in the Department of Paediatric Cardiology. Reduction of pressure gradient across pulmonary valve to less than 25 mmHg was defined as a successful procedure. Results: Ninety seven BPVs were performed in 94 patients. The mean age, bodyweight and height were 19 months, 9.5 kg and 80 cm respectively. Sex distribution was equal. The mean of the balloon to pulmonary annular ratio was 108% (range 50-150%). After the BPV, mean peak to peak pressure gradient across the pulmonary valve dropped from 70±29 mmHg to 24.7±16.8 mmHg. Overall success rate was 55.7%. Mortality was 3.1%. Major complications were haemopericardium (4.1%), bradycardia (2%) endocardial damage (1%) and pulmonary oedema (1%). The correlation between pulmonary annulus on echocardiography and angiography was significant (p<0.01).

Clinical application of pulmonary artery valvuloplasty with repaired tetralogy of fallot / 中国综合临床

Objective To discuss clinic effect of pulmonary artery valvuloplasty for right ventricle outflow tract (RVOT) reconstruction in patients with repaired tetralogy of fallot (TOF). Methods A total of 93 cases TOF were randomly divided into Group A (n = 49) or Group B (n = 44) to perform the procedure with repaired tetralogy of fallot Group A received autogenous pericardium to enlarge RVOT and pulmonary valvuloplasty.Group B received autogenous pericardium to enlarge RVOT by routine therapy. Pulmonary regurgitation index (PRi) and the ratio between pulmonary regurgitant jet width and pulmonary annulus diameter were measured with echoeardiography. Results The mean follow-up was 3. 1 ± 0. 2 years. The PRi and the ratio between pulmonary regurgitant jet width and pulmonary annulus diameter in Group A were-significantly lower than Group B (0. 55 ± 0. 13 vs. 0. 61 ± 0. 10, t = 2. 685, P < 0.01) and ([52.0 ± 10.4] % vs. [57.1 ± 10. 5]% ,t = 2. 349, P < 0.05) . Three-dimensional ultrasound examination showed that 69% (34/69) of pulmonary valves in Group A was developed well. Conclusion Pulmonary valvuloplasty during transannular patch for repaired TOF may prevent fre'e pulmonary regurgitation and can obtain good clinical outcome.

Pulmonary Trunk Aneurysm with Ascending Aortic Aneurysm, Concomitant with Bilateral Semilunar Valve Insufficiency / 日本心臓血管外科学会雑誌

Simultaneous pulmonary trunk and ascending aortic aneurysms are very rare, and the role of surgery in this entity is not well defined. We report a rare case of aneurysm of both the pulmonary trunk and the ascending aorta, associated with pulmonary and aortic valve insufficiency in a 17-year-old boy. Cardiac disease had been diagnosed at the age of 5, and at that time, pulmonary and aortic valve insufficiency were found by ultrasound cardiography (UCG). At regular follow-up, both cardiac valve regurgitation and the dilatation of the aneurysm gradually increased. A recent computed tomographic scan revealed that the ascending aortic aneurysm was 55 mm and the pulmonary trunk aneurysm was 60 mm. A UCG also showed severe aortic valve regurgitation and moderate pulmonary valve regurgitation with no pulmonary hypertension. Surgical repair was performed successfully. The aortic valve was replaced with a mechanical valve. The dilated ascending aortic aneurysm was excised and replaced with a Dacron graft. The pulmonary trunk aneurysm was incised longitudinally. The pulmonary valve was tricuspid, and no organic leaflets change was observed. Pulmonary valvuloplasty by commissure plication of the prolapsed cusps was performed. A large portion of the anterior pulmonary aneurysm wall was excised and plicated to reduce the radius diameter. The pathology of the aneurysm wall showed infiltration of inflammatory cells in the tunica media, fragmentation and decrease of elastic fiber, loss of muscular tissue, and increase in collagen fibers. No cystic medial necrosis was observed in the pathologic specimen. The postoperative course was uneventful, and there were no adverse events or complications at 2 years follow-up. The following image study revealed the normal size of the great vessels.

Outcomes in Neonates with Pulmonary Atresia and Intact Ventricular Septum Underwent Pulmonary Valvulotomy and Valvuloplasty Using a Flexible 2-French Radiofrequency Catheter

PURPOSE: Outcomes in 6 neonates with pulmonary atresia and intact ventricular septum (PAIVS) undergoing radiofrequency pulmonary valvulotomy and valvuloplasty (RPVV) were reported to identify the factors favorable for RPVV as the treatment of choice. MATERIALS AND METHODS: From May 2000 to January 2008, 6 patients with PAIVS were included in this retrospective study. They were aged 1 day to 90 days old. Study modalities included review of recordings of presentations and profiles of chest radiography, electrocardiography, echocardiography, and cardiac catheterization with angiography. Hemodynamic profiles from the echocardiography and the cardiac catheterization were analyzed. RESULTS: Echocardiography showed severe tricuspid regurgitation, membranous atresia of the pulmonary valve, intact ventricular septum, patent ductus arteriosus, and hypoplastic right ventricle in 6 patients. The pulmonary valve annulus were 4.2 to 6.9 mm in diameters, and those of the tricuspid valve were 7.1 to 10.1 mm. Elevated serum level of cardiac enzymes were found in 1 patient with ventriculocoronary communication (VCC). At cardiac catheterization, the ratio of systolic pressure of the right ventricle to that of the left ventricle ranged from 1.43 to 2.33 before RPVV, and from 0.54 to 1.15 after RPVV (p=0.027). The pressure gradients ranged from 76 to 136 mmHg before RPVV, and from 15 to 39 mmHg after RPVV (p=0.028). The echocardiographic gradients ranged from 16 to 32 mmHg within 24 hours after RPVV, and from 15 to 50 mmHg at the follow-ups. CONCLUSION: RPVV can be a treatment of choice for neonates with PAIVS, if there is patent infundibulum, no right-ventricular dependent coronary circulation, and adequate tricuspid valve and pulmonary valve.

Valvuloplastía pulmonar con balón, experiencia de 15 años en el Centro Médico Nacional Siglo XXI IMSS / Balloon pulmonary valvuloplasty: 15-years experience at the Centro Médico Nacional "Siglo XXI", IMSS

Objetivo: Evaluar la experiencia de 15 años, de la valvuloplastía pulmonar con balón en el Centro Médico Nacional Siglo XXI. Material y métodos: Se estudiaron 150 pacientes 73 (48.7%) masculino y 77 (51.7%) femenino. La edad promedio de los 141 en quienes se realizó la valvuloplastía pulmonar con balón fue de 10.5 ± 11.3 años. Resultados: El gradiente promedio prevalvuloplastía de 86 ± 35 descendió a 21.67 ± 12.20 mm Hg p < .001. La presión sistólica del ventrículo derecho de 106 ± 34.8 mm Hg disminuyó a 53 ± 27 mm Hg p < 0.0001. El gradiente valvular pulmonar en el seguimiento promedio de 48 ± 44 meses fue de 13.43 ± 8.73 mm Hg p < 0.001. Se presentaron complicaciones en 9 (6%) pacientes. Se obtuvo éxito técnico inmediato post en 111 (74%) y fracaso inmediato en 39 (26%). Al final del seguimiento se obtuvo éxito en 104 (89.6%) y fracaso en 12 (10.4%) pacientes, p < 0.0001, con una mortalidad global de 2 (1.33 %) pacientes. Las variables significativas para fracaso fueron: la edad de, 1.5 ± 1.33 años para falla de procedimiento, p < .004; morfología valvular displásica p < 0.001. gradiente valvular pulmonar prevalvuloplastía elevado con p < 0.002 y presión sistólica del ventrículo derecho pre valvuloplastía elevados. p < 0.0001, no descendiendo ambos en el post inmediato. Conclusión: La valvuloplastía pulmonar con balón es el tratamiento de elección, efectivo y seguro de la estenosis valvular pulmonar congénita.

Objective: To evaluate 15 years of experience with balloon pulmonary valvuloplasty in a single third level health care center. Material and methods: Hundred-fifty patients underwent the procedure, 73 (48%) men and 77 (52%) women, mean age 10.5 ± 11.3 years. Results: The initial systolic gradient decreased from 86 ± 35 to 21.67 ± 12.20 mm Hg, p < 0.001, whereas the initial right ventricular systolic pressure decreased from 106 ± 34-8 to 53 ± 27 mm Hg, p < 0.0001. At the end of the follow-up, 48 ± 44 months, the systolic gradient was 13.43 ± 8.73 mm Hg, p < 0.001. Major complications occurred in 9 (6.4%) patients. Immediate technical success was achieved in 111 (74%) patients and failure in 39 (26%). At the end of the follow-up period, successful outcomes were achieved in 104 (89.6%); in contrast, failures were present in 12 (10.4%) patients, p < 0.001. Death occurred in 2 (1.33%) patients. The predictors for failure were age < 1.5 ± 1-33 years (p < 0.004), dysplastic valve (p < 0.001), high initial systolic gradient (p < 0.002), and high initial systolic right ventricular pressure (p < 0.0001). Conclusion: Balloon pulmonary valvuloplasty is an effective, safe, and first choice treatment for congenital pulmonary valve stenosis. (Arch Cardiol Mex 2003; 73:190-196).

Medico-Surgical Cooperative Treatment of Pulmonary Atresia with Intact Ventricular Septum

PURPOSE: The actual clinical examples of co-appliance of catheter intervention with surgical procedures in the treatment of pulmonary atresia with an intact ventricular septum(PA/IVS) which we have experienced in our institution are here shown, and the anatomical and hemodynamical profiles between each method is compared. METHODS: Medical records of 33 patients with PA/IVS who underwent various treatment from January, 1995 to December, 2000 were reviewed for a retrograde study. RESULTS: In three out of 10 patients who underwent percutaneous balloon pulmonary valvotomy (PPV), residual pulmonary stenosis were observed in their out patient department(OPD) follow-ups, eventually necessitatig balloon pulmonary valvuloplasty(BPV). One out of three patients exhibited deterioration of tricuspid regurgitation after BPV, requiring surgical tricuspid annuloplasty(TAP). Two out of the seven patients who received primarily surgical right ventricle outlet tract(RVOT) repair without any systemic-pulmonary shunt or intervention needed additional intervention employing cardiac catheterization after operation. Two patients received interventional catheterization before surgical RVOT repair. In five out of 11 cases of Fontan type operation, coil embolization of collateral circulation was done before total cavo-pulmonary connection(TCPC), and in three cases, interventional catheterization was needed after TCPC. CONCLUSION: Both medical and surgical treatment modalities are widely used in management of PA/IVS patients, and recent results prove that medico-surgical cooperative treatment is essential.

Valvuloplastia pulmonar percutanea en el Centro Cardiovascular de la Universidad de Los Andes / Percutaneous pulmonary valvuloplasty at the Centro Cardiovascular de la Universidad de Los Andes

Objetivo - Comparar a valvoplastia por cateter-baläo com a valvotomia cirúrgica no tratamento da estenose pulmonar. Casuística e Métodos - Estenose valvar foi dilatada com cateter-baläo em dez pacientes consecutivos, 6 mulheres, com idade dos 3 aos 19 (média: 11) anos, entre abril de 1987 e novembro de 1988. Resultados - Os resultados hemodinâmicos e angiográficos imediatos foram: diminuiçäo do pico de gradiente transvalvar de 93 ñ 42 para 39 ñ 36 mmHg (p < 0,01), da pressäo sistólica de ventrículo direito de 108 ñ 16 para ñ 27 (p < 0,01), aumento do diâmetro da valva pulmonar de 9,59 ñ 3,28 para 19,55 ñ 6,16 mm (p < 0,01) e da pressäo sistólica da artéria pulmonar de 15,5 ñ 3,28 para 1,84 ñ 6mmHg (näo siginificativo). Näo foi demonstrada correlaçäo para o pico de gradiente transvalvar e a pressäo diastólica final do ventrículo direito, Insuficiência pulmonar discreta foi complicaçäo do procedimento, em apenas um caso. Foram reestudados invasivamente 4 dos 10 pacientes entre 7 e 14 meses após a dilataçäo, e em todos se manteve o resultado inicial. Conclusäo - Os resutlados obtidos mediante esta técnica säo similares aos da valvoplastia cirúrgica