Pulmonary valvuloplasty in adults using the Inoue balloon catheter

Quadricuspid pulmonary valve stenosis treated by transcatheter pulmonary valvuloplasty with inoue balloon catheter

The quadricuspid pulmonary valve is a relatively common congenital anomaly which is rarely complicated clinically and also tends to be under-diagnosed. The following case report shows a 62-year-old man with exertional dyspnea due to quadricuspid pulmonary valve stenosis that was diagnosed by using electrocardiography-gated multiple detector computed tomography. He was then treated effectively by transcatheter balloon pulmonary valvuloplasty using an Inoue balloon catheter. <Learning Objective: The quadricuspid pulmonary valve is a congenital anomaly which is rarely complicated clinically and tends to be under-diagnosed. Electrocardiography-gated multiple detector computed tomography is a useful imaging modality for diagnosing the quadricusid pulmonary valve. Transcatheter pulmonary valvuloplasty with an Inoue balloon catheter was effective for treating quadricuspid pulmonary valve stenosis.>.

New Pulmonary Valvuloplasty Technique by Use of an Hourglass-Shaped Balloon in 3 Adults with Severe Pulmonary Valve Stenosis

Percutaneous balloon pulmonary valvuloplasty is the preferred therapy for pulmonary valve stenosis. However, the designs of the cylindrical balloons historically used for valvuloplasty have limitations, especially in patients who have large pulmonary annular diameters. The hourglass-shaped V8 Aortic Valvuloplasty Balloon may prove to be an effective alternative. The balloon has 2 large bulbous segments that are separated by a narrowed waist. The geometric shape is maintained throughout inflation, improving fixation and enabling broader leaflet opening. We present our first experience with the V8 balloon in 3 adults who had severe, symptomatic pulmonary valve stenosis. In addition to describing their cases, we detail our sizing technique for pulmonary valvuloplasty with the V8 balloon. Our successful results suggest that the V8 balloon is efficient and safe for balloon pulmonary valvuloplasty in adults with severe pulmonary valve stenosis.

Percutaneous balloon pulmonary valvuloplasty (PBPV) of extreme pulmonary valve stenosis by the use of Accura balloon

Transcatheter therapy of valvular pulmonary stenosis is one of first catheter interventions facilitating its application in field of structural heart disease and now treatment of choice for significant pulmonary stenosis. Myriads of balloon catheter have been used for this purpose starting from Diamond (Boston Scientific,Natick, MA USA), Marshal (Medi-Tech,Watertown MAUSA), Innoue balloon, Tyshak I and currently Tyshak II. Diameter and length of balloon depend on size of annulus and age group, respectively. Problem with shorter balloon is difficulty in keeping it across the annulus while inflation as it tends to slip distally whereas with longer balloon, potential of tricuspid leak or conduction block as it may impinge on adjacent structures. Potential advantage of Accura balloon over Tyshak balloon lies in its peculiar shape while inflation and variable diameter, making stepwise dilatation possible. Here, we report a case of successful balloon pulmonary valvuloplasty using Accura balloon (Vascular Concept, UK) with little modification of conventional technique.

Percutaneous balloon valvuloplasty with Inoue balloon catheter technique for pulmonary valve stenosis in adolescents and adults

Background

Percutaneous balloon pulmonary valvuloplasty is the procedure of choice for uncomplicated severe or symptomatic pulmonary stenosis. The present study describes our experience in balloon pulmonary valvuloplasty using the Inoue balloon catheter in adolescent and adult patients.

Aims

To assess the immediate and mid-term outcomes of percutaneous balloon valvuloplasty with Inoue balloon catheter in adolescent and adult patients.

Methods and results

Between June 2010 and July 2015, we performed percutaneous balloon pulmonary valvuloplasty with Inoue balloon catheter in 32 patients (59.37% females) aged 8 to 54 years (mean 23.6 ± 11.5). Following the procedure, the mean right ventricular systolic pressure and the pulmonary valvular peak-to-peak systolic gradient decreased from (121.6 ± 42.4 to 61.19 ± 24.5 mmHg, p = 0.001) and (100.9 ± 43.3 to 36.4 ± 22.5 mmHg, p = 0.001), respectively. Twenty patients (Group A) showed immediate optimal results with post-procedure peak systolic gradient <36 mmHg while 12 patients (Group B) had suboptimal results. An increase in pulmonary regurgitation by one grade was detected in 17 patients (53.2%). Twenty-three patients available for follow-up (mean duration, 2.75 years [range 0.25–5 years]) had a mean residual peak gradient of 23.6 ± 2.51 mmHg on Doppler echocardiography with attenuation of reactive RVOT stenosis in all Group B patients. There was no further increase in grade of pulmonary regurgitation or restenosis on mid-term follow-up.

Conclusion

Percutaneous Inoue balloon technique is an attractive alternative with excellent mid-term results for adolescents and adults with isolated pulmonary stenosis.

Interventional Treatment of Pulmonary Valve Stenosis: A Single Center Experience

BACKGROUND

Percutaneous pulmonary valvuloplasty is well established treatment of choice in pulmonary valve stenosis.

AIM

The aim of our study was to present our experience with the interventional technique, its immediate and mid-term effectiveness as well as its complication rate.

MATERIAL AND METHODS

The study included 43 patients, where 33 (74%) of them were children between the age of 1 month and 15 years.

RESULTS

The procedure was successful in 38 patients or 90%. Mean peak to peak transvalvular gradient was reduced from 91.2 mmHg (55-150 mmHg) to 39.1 mmHg (20-80 mmHg). Follow- up of patients was between 2 and 13 years and included echocardiographic evaluation of pulmonary valve gradient, right heart dimensions and function as well as assessment of pulmonary regurgitation. We experienced one major complication pericardial effusion in a 5 months old child that required pericardiocenthesis. Six patients (13.9%) required a second intervention. During the follow up period there was significant improvement of right heart function and echocardiography parameters. Mild pulmonary regurgitation was noted in 24 (55%) patients, and four (9%) patients developed moderate regurgitation, without affecting the function of the right ventricle.

CONCLUSIONS

Percutaneous pulmonary valvuloplasty is an effective procedure in treatment of pulmonary stenosis with good short and mid-term results.

Percutaneous balloon pulmonary valvuloplasty: a modified over-the-wire Inoue balloon technique for difficult right ventricular anatomy

Percutaneous balloon pulmonary valvuloplasty (BPV) is the mainstay of treatment for significant pulmonary stenosis with doming leaflets. Various techniques have been described in the literature including the use of Inoue Percutaneous Transseptal Mitral Commissurotomy (PTMC) catheter with standard 0.025″ guidewire. But if right ventricular anatomy is not suitable, 0.025″ guidewire doesn't provide enough support to track the Inoue PTMC catheter. Here, we report a case of successful BPV using a novel technique of slenderizing the Inoue Percutaneous Transseptal Mitral Commissurotomy (PTMC) catheter over an Amplatz superstiff 0.035″ guidewire. This technique may be useful during BPV in difficult right ventricular inflow and outflow tract anatomy in patients with congenital pulmonary valve stenosis.

Percutaneous Therapies in the Treatment of Valvular Pulmonary Stenosis

Transcatheter balloon pulmonary valvuloplasty (BPV) is the standard of care in managing symptomatic patients with moderate-to-severe pulmonary valvular stenosis, or asymptomatic patients with severe pulmonary valvular stenosis or with moderate pulmonary stenosis and evidence of objective exercise intolerance or right ventricular dysfunction. This article discusses the incidence, causes, and pathophysiology of valvular pulmonary stenosis in adolescents and adults; its natural history and noninvasive evaluation; the current guideline-recommended indications for BPV; the technical aspects of performing BPV; the immediate and long-term outcomes after valvuloplasty; and the complications and safety of the procedure. Also discussed is the role of this procedure in neonatal critical pulmonary stenosis and in percutaneous pulmonary valve replacement for patients with prior pulmonic valve interventions or degenerated right ventricular pulmonary artery conduits.

A case of pulmonary stenosis after a repair for tetralogy of Fallot treated with percutaneous pulmonary valvuloplasty using a triple-balloon technique

The patient was a 37-year-old female who had undergone a repair for tetralogy of Fallot (TOF) at the age of 4 years. Postoperative pulmonary stenosis remained, but she continued to be managed medically. Approximately 3 years ago, at the age of 34, she exhibited a worsening of fatigue and dyspnea during exertion (New York Heart Association III), and was therefore hospitalized for a detailed examination. In cardiac catheterization, a right ventricle to pulmonary artery peak-to-peak gradient of about 90 mmHg was observed. Since it appeared that medical treatment alone would not sufficiently control her heart failure, pulmonary valvuloplasty using a triple-balloon technique was performed for the pulmonary stenosis. The peak-to-peak gradient immediately after the procedure decreased to 13 mmHg. There were no indications of restenosis approximately 6 months after the procedure, and the symptoms of heart failure in her daily life improved thereafter.

Percutaneous balloon valvuloplasty for congenital pulmonary valve stenosis in adults

BACKGROUND

Although pulmonary valvular stenosis is not uncommon in adults, there are few reports of percutaneous pulmonary valvuloplasty in adults, despite the possibility of avoiding heart surgery.

AIM

This report describes the experience in adult patients undergoing this procedure and evaluates its effectiveness and tolerance.

METHODS

Over an 8-year period (1989-1997), pulmonary valvuloplasty was considered in 22 adult patients [8 men, 14 women; mean age 28.0 years +/- standard deviation (SD) 10.3; range 16-46 years] with congenital pulmonary valve stenosis. Sixteen patients were asymptomatic with pulmonary systolic murmurs, although 6 patients presented with dyspnea. Before the procedure, the mean transpulmonary valve gradient was 53.2 +/- 24.8 mmHg SD, with a mean right ventricular systolic pressure of 74.6 +/- 28.4 mmHg SD, and mean pulmonary artery pressure was 21.4 +/- 6.4/10.2 +/-3.9 mmHg.

RESULTS

The procedure was successful in 19 patients (6 men, 13 women) and was well tolerated and free of complications. Following the procedure, the mean transvalvular gradient was 15.5 +/- 11.5 mmHg, with a mean right ventricular systolic pressure of 40.5 +/- 13.6 mmHg and a mean pulmonary systolic pressure of 24.3 +/- 7.4 mmHg. This represented mean fall in transpulmonary valve gradient of 42.4 +/- 22.0 mmHg (paired t-test, p < 0.0001). After a mean follow-up of 20.1 months (13.4 SD), most patients remained well and asymptomatic, although two patients required repeat valvuloplasty.

CONCLUSION

Pulmonary valvuloplasty is a well tolerated and effective treatment for pulmonary valve stenosis in adults, with few complications and no need for surgery. This procedure should be considered as the primary treatment of adult patients with pulmonary valve stenosis.

Percutaneous balloon pulmonary valvuloplasty: State of the art

Since the first description of balloon pulmonary valvuloplasty in 1982 by Kan, the procedure has been extensively utilized by several groups of workers for relief of pulmonary valve stenosis. It is generally recommended that the procedure be performed for peak-to-peak gradients in excess of 50 mmHg. The technique involves positioning one or more balloon catheters across the stenotic valve, usually over an extra-stiff guide wire and inflating the balloons with diluted contrast material, thus producing valvotomy. The procedural details are described in this paper. The currently recommended balloon/annulus ratio is 1.2 to 1.25. Immediate reduction of gradient, increase in jet width and free motion of the pulmonary valve leaflets with less doming have been observed following balloon dilatation. Improvement of right ventricular function, tricuspid insufficiency and right-to-left shunt has also occurred. Complication can occur, but are rare and minimal. At mid-term follow-up, both catheterization measured peak-to-peak gradients and Doppler-measured peak instantaneous gradients remain improved for the group as a whole. However, restenosis, defined as gradient >or=50 mmHg, has been observed in nearly 10% of children. Predictors of restenosis include balloon/annulus ratio <1.2 and immediate post-valvuloplasty gradient >or=30 mmHg. Small pulmonary valve annulus, earlier study year and post-surgical complex pulmonary stenosis have also been identified as factors predictive of restenosis. Redilatation with balloons that are larger than those used at the time of initial balloon valvuloplasty produces excellent results and redilatation is the procedure of choice in the management of restenosis after previous balloon pulmonary valvuloplasty. Long-term follow-up results are scanty, but the limited data reveal minimal additional restenosis, event-free rates in mid-80s and mid-70s at 10 and 15 years respectively and significant increase in prevalence of pulmonary insufficiency. Balloon pulmonary valvuloplasty is equally successful in neonates as well as in adult subjects. In conclusion, balloon pulmonary valvuloplasty is the treatment of choice for relief of pulmonary valve stenosis. Use of balloons 1.2 to 1.25 times larger than pulmonary valve annulus may produce optimal results. Life-long follow-up to identify the significance of residual pulmonary insufficiency is indicated.

Double balloon pulmonary valvuloplasty: Multi-track system versus conventional technique

OBJECTIVES

To evaluate whether double balloon pulmonary valvuloplasty (DBPV) with the Multi-Track system (MTS) may help to simplify the procedure.

BACKGROUND

DBPV is usually required for patients with pulmonary valve stenosis with large annulus. However, it needs two venous accesses and can be technically demanding.

METHODS

From 07/03, 20 consecutive patients (19 +/- 10 yrs) with typical pulmonary valve stenosis underwent DBPV using the MTS (G1). The results were compared with those achieved by conventional DBPV performed in a matched historical group of 28 patients (21 +/- 11 yrs; P = NS) (G2).

RESULTS

MTS balloons were easily advanced through the skin and inflated across the valve. Similar results were observed in regards to residual gradients (12 +/- 11 vs 14 +/- 10 mm Hg; P = NS) and right ventricular to systemic pressures (0.35 +/- 0.22 vs 0.37 +/- 0.26; P = NS). Procedure and fluoroscopic times were significant lower in G1 (78 +/- 24 vs 126 +/- 28; 15 +/- 12 vs 25 +/- 8 min, respectively; both P < 0.001). There was no major complication. Median follow-up was 1.8 yr for G1 and 5 yr for G2 (P = 0.037). At the last visit, peak instantaneous gradient across the right ventricular outflow tract by echocardiography was a mean 22 +/- 10 mm Hg for G1 and 25 +/- 9 mm Hg for G2 (P = NS). No patient had severe pulmonary insufficiency or required reintervention.

CONCLUSIONS

The use of the MTS helped to expedite the procedure providing satisfactory midterm clinical outcomes, similar to those observed with the conventional DBPV technique.

Versatility of Inoue balloon catheter

Inoue rubber nylon single balloon catheter is being used worldwide for performing balloon mitral valvuloplasty (BMV). The popularity of Inoue balloon is attributed to its self-positioning configuration, size-adjustability, rapid inflation-deflation sequence and the ease of performance. We report its use in performing various non-mitral interventions. Its utility in treating patients with mitral stenosis and combined mitral and tricuspid stenosis is well established. Seventeen patients with valvular pulmonic stenosis (age 32+/-16 years; 11 males and 6 females) achieved significant reduction of peak systolic gradient (PSG) from 125+/-28 to 32+/-16 mmHg (P<0.005). Four patients with inferior vena-cava obstruction (age 20-48 years; 3 males and 1 female) derived symptomatic benefit following successful dilatation. Inoue balloon was used to create percutaneous pericardial window in four cases (age 43-68 years; 2 males and 2 females) of recurrent pericardial collection secondary to carcinoma lung/breast, thus alleviating the symptoms of tamponade. One patient each with coarctation of aorta (32 years, male), discrete subaortic membrane (16 years, female), and critical valvular aortic stenosis (13 years, male) derived immediate hemodynamic improvement with Inoue balloon dilatation. No major complications were encountered. We conclude that Inoue balloon can be used to successfully manage various stenotic lesions.

Effects of balloon pulmonary valvuloplasty on atrial shunting--a patient with pulmonary valve stenosis and a large secundum atrial septal defect

Percutaneous balloon valvuloplasty has been established as an effective treatment for pulmonary valve stenosis (PS) in children and adults. However, there are few reports of the use of this technique in patients with other cardiac anomalies. We report the performance of balloon pulmonary valvuloplasty in a 72-year-old woman with a large atrial septal defect (ASD). This patient had a PS with a right ventricular pressure of 108/18 mmHg and a pulmonary arterial pressure of 42/21 mmHg, corresponding to a 66 mmHg pressure gradient. The ASD measured 32 x 27 mm. Balloon pulmonary valvuloplasty reduced the pressure gradient to 5 mmHg immediately after the procedure and to 2 mmHg 40 days after the procedure. The left-to-right shunt ratio was reduced from 17% before to 12% immediately after and to 36% 40 days after the procedure. In contrast, the right-to-left shunt ratio showed a transient increase from 16% before to 28% immediately after the procedure before decreasing to 11% 40 days after the procedure. The arterial blood oxygen tension was 53 Torr before, 46 Torr immediately after and 55 Torr 40 days after the procedure. The grade of heart failure decreased from New York Heart Association class IV before to class II in the chronic stage. These findings indicated that balloon pulmonary valvuloplasty in a patient with ASD transiently increased the right-to-left shunting associated with a decrease in oxygen tension, but that the change in the chronic stage was slight. In our patient with ASD valvuloplasty was useful in relieving the symptoms associated with elevated right ventricular pressure but could not reduce the hypoxemia caused by right-to-left shunting. In conclusion, valvuloplasty in patients with ASD should be considered as a preoperative treatment with the aim of reducing the risk of surgery and to treat symptoms in patients who refuse to undergo surgery.

Percutaneous balloon valvuloplasty for pulmonic stenosis in adolescents and adults

BACKGROUND

Percutaneous balloon valvuloplasty has been the accepted first-line treatment for congenital pulmonic stenosis in children. Its efficacy in adolescents and adults is less well defined.

METHODS

Between December 1985 and July 1995 we performed percutaneous pulmonic valvuloplasty with a single Inoue balloon catheter in 53 adolescent or adult patients 13 to 55 years of age (mean [+/- SD], 26 +/- 11). Follow-up studies were performed 0.2 to 9.8 years after the procedure (mean, 6.9 +/- 3.1) by Doppler echocardiography (in all the patients) and by cardiac catheterization and angiography (in nine patients).

RESULTS

After balloon valvuloplasty, the systolic pressure gradient across the pulmonic valve decreased from 91 +/- 46 mm Hg to 38 +/- 32 mm Hg (P < 0.001), and the diameter of the pulmonic-valve orifice increased from 8.9 +/- 3.6 mm to 17.4 +/- 4.6 mm (P < 0.001). In the nine patients catheterized at follow-up, the systolic gradient decreased from 107 +/- 48 mm Hg before valvuloplasty to 50 +/- 29 mm Hg after valvuloplasty and to 30 +/- 16 mm Hg at follow-up (P < 0.001 for the comparison of the gradient before and after valvuloplasty; P < 0.001 for the comparison before valvuloplasty and at follow-up; and P < 0.05 for the comparison after valvuloplasty and at follow-up). In the same nine patients, the diameter of the pulmonic valve, as measured by right ventricular angiography, increased from 8.3 +/- 1.4 mm before valvuloplasty to 17.2 +/- 2.0 mm after valvuloplasty (P < 0.001) and to 18.4 +/- 1.4 mm at follow-up (P = 0.08). Incompetence of the pulmonic valve was noted in 7 of the 53 patients (13 percent) after balloon valvuloplasty, but it had disappeared at follow-up in all of them.

CONCLUSIONS

Patients with congenital pulmonic stenosis who present in late adolescence or adult life can be treated with percutaneous balloon valvuloplasty with excellent short-term and long-term results that are similar to those in young children.

Pulmonary valvuloplasty using Inoue balloon catheter

We report balloon pulmonary valvuloplasty using the Inoue catheter in three patients with severe valvular pulmonic stenosis. The mean right ventricular systolic pressure and the pulmonary valvular peak to peak systolic gradients decreased from 140 +/- 23 to 40 +/- 26 mmHg (P < 0.001) and 120 +/- 26 to 8 +/- 8 mmHg (P < 0.001) respectively. This report suggests that pulmonary valvuloplasty using the Inoue balloon catheter technique is feasible, safe and effective.