Catheter management of aortic valve stenosis in neonates and children

Cardiovascular Intervention in Neonates Using an Umbilical Vein Approach

Cardiovascular catheterization has been applied in infant treatment for several decades. To date, considerable research attention has been paid to cardiovascular catheterization in small neonates. However, peripheral vascular routes of catheterization are possible obstacles for interventionists. Umbilical vein catheterization has been reported as a route for neonates, although few attempts have been made to investigate this approach. This study aimed to retrospectively review cardiovascular intervention using the umbilical vein approach as applied to infants admitted to a tertiary center from 2017 to 2020. Details including the perinatal variables, indication diagnoses, and procedure devices were collected. The enrollment included a total of 16 cases representing 17 intervention events, with infants born at a gestation age of 22–39 weeks and body weight ranging from 478 to 3685 g at the time of the procedure. The postnatal age ranged from 1 to 27 days. The catheter sizes ranged from 4 to 11 Fr. Indications included being admitted for patent ductus arteriosus occlusion (n = 15), balloon pulmonary valvuloplasty (n = 3), balloon atrial septostomy (BAS) (n = 3), pulmonary valve (PV) perforation (n = 1), and two interventions for catheter placement for continuous venovenous hemofiltration. The success rate for cardiovascular catheterization was 88.2% (15/17). There were two patients for which cannulation failed due to ductus venosus closure: one intraabdominal hemorrhage complication during continuous venovenous hemofiltration (CVVH), and one cardiac catheterization failure of PV perforation due to failure to insert the guiding catheter into the right ventricular outflow tract. Based on these findings, we conclude that cardiac catheterization and the placement of a large-sized catheter through an umbilical vein in a small infant represents a safe and time-saving method when catheterization is required.

Popular Hybrid Congenital Heart Procedures without Cardiopulmonary Bypass

As surgical and catheter interventions advance, patients with congenital heart disease are now offered alternative treatment options that cater to their individual needs. Furthermore, collaboration between interventional cardiologists and cardiac surgeons have led to the development of hybrid procedures, using the best techniques of each respective field to treat these complex cardiac entities from initial treatment in the pediatric patient to repeat intervention in the adult. We present a review of the increased popularity and trend in hybrid procedures in congenital heart disease without the use of cardiopulmonary bypass.

The mid-term outcome of primary open valvotomy for critical aortic stenosis in early infancy - a retrospective single center study over 18 years

Background

The objective of this study was to examine early and long-term results of surgical aortic valvotomy in neonates and infants aged less than four months and to identify predictors of outcome.

Methods

Between August 1994 and April 2012, 83 consecutive patients younger than 4 months of age underwent open heart valvotomy for critical aortic stenosis in our institution. Median age was 17 days (range 0-111 days). We examined clinical records to establish determinants of outcome and illustrate long-term results.

Results

Fifty-six patients (67 %) were neonates. Associated cardiac malformations were found in 24 patients (29 %), including multilevel left heart obstruction in 5. The median follow-up was 4.2 years. The time-related survival rate was 87 and 85 % at 5 and 15 years, respectively. The time-related survival without reintervention was respectively 51, 35 and 18 % at 5, 10 and 15 years. The time-related survival without aortic valve replacement was respectively 67, 54 and 39 % at 5, 10 and 15 years. Ventricular dysfunction (p = 0.04), delayed sternal closure (p = 0.007), endocardial fibroelastosis (p = 0.02) and low z-score of the aortic annulus (p = 0.04) were found predictors of global mortality. Ventricular dysfunction (p = 0.01) and endocardial fibroelastosis (p = 0.04) were found predictors of reintervention.

Conclusions

The experience, in our center, on the management of critical aortic stenosis, shows a low early and late mortality, but the aortic valvotomy is a palliative procedure and we see unfortunately a high rate of reintervention among which the aortic valve replacement. These results suggest to reconsider the use of aortic balloon valvotomy, and particularly for the neonates with a low cardiac output in order to avoid the myocardial stress and the neurological injury due to the cardiopulmonary bypass.

Long-Term Results of Balloon Valvuloplasty as Primary Treatment for Congenital Aortic Valve Stenosis: a 20-Year Review

In the presence of new surgical techniques, the treatment of congenital valvular aortic stenosis is under debate. We reviewed the results and late outcomes of all 93 patients aged 1 day to 18 years, treated with balloon valvuloplasty (BAV) as first-line therapy for congenital aortic valve stenosis in our center from January 1991 to May 2012. Mean age at procedure time was 2.4 years; 37 patients underwent BAV at age ≤30 days (neonates), 29 patients at age ≥1 month and <1 year (infants), and 27 patients were older than 1 year (children). The invasive BAV peak-to-peak aortic valve gradient (mean 59 ± 22 mmHg) was immediately reduced (mean 24 ± 12 mmHg). The observed diminution of gradient was similar for each age group. Four patients had significant post-BAV AI. Mean follow-up after BAV was 11.4 ± 7 years. The last echo peak aortic gradient was 37 ± 18 mmHg and mean gradient was 23 ± 10 mmHg, and two patients had significant AI. Actuarial survival for the whole cohort was 88.2 and 72.9 % for the neonates. All infants, except one, and all children survived. Sixty-six percent of patients were free from surgery, and 58 % were free from any reintervention, with no difference according to age. Freedom from surgery after BAV at 5, 10, and 20 years, respectively, was 82, 72, and 66 %. Our study confirms that BAV as primary treatment for congenital AS is an efficient and low-risk procedure in infants and children. In neonates, the prognosis is more severe and clearly related to "borderline LV."

Hybrid balloon valvuloplasty through the ascending aorta via median sternotomy in infants with severe congenital valvular aortic stenosis: feasibility of a new method†

OBJECTIVES

To evaluate a novel hybrid balloon valvuloplasty procedure for severe congenital valvular aortic stenosis in low-weight infants, performed through the ascending aorta via median sternotomy.

METHODS

Eighteen infants (<90 days of age) with severe congenital aortic stenosis were included in this study. Hybrid balloon valvuloplasty procedures were performed in a hybrid operating room. Patients were followed up at 3 months, 6 months, 1 year and then annually following the procedure.

RESULTS

The hybrid balloon valvuloplasty procedure was successful in all patients. Eight patients were successfully rescued from left ventricular systolic dysfunction by cardiac compression under direct vision. The aortic valve pressure gradient decreased from 80.3 ± 20.8 mmHg preoperatively to 16.0 ± 3.6 mmHg immediately postoperatively (P < 0.001). None of the patients developed significant aortic insufficiency. The fluoroscopy time was 6.2 ± 2.9 min. Intraoperative blood transfusions and pacing were not required. The patients were all alive and healthy at the end of the follow-up period (mean 21.3 months; range 3-41 months), and the aortic valve pressure gradient remained low (21.7 ± 5.3 mmHg). Reintervention was not required in any of the patients.

CONCLUSIONS

Hybrid balloon valvuloplasty through the ascending aorta via median sternotomy is an effective and safe procedure for infants with severe congenital aortic stenosis.

Neonatal Interventions for Left-Sided Obstructive Lesions: Alternatives to Surgery

Percutaneous neonatal cardiac interventions are effective in management strategies. Aortic valve dilation has become a first line therapy with excellent outcomes and low morbidity equivalent to surgery. Percutaneous intervention for coarctation of the aorta can safely postpone surgical intervention in small unwell neonates, allowing stabilization and growth. Stent implantation can provide a stable and predictable relief of obstruction; however, care should be taken to implant stents so that they can be removed subsequently. As experience increases, the role of percutaneous techniques in the management of high-risk neonates with coarctation of the aorta will become better defined and improve the outcomes.

Balloon Valvuloplasty of Aortic Valve Stenosis in Childhood: Midterm Results in a Children's Hospital, Mansoura University, Egypt

Background:

Balloon valvuloplasty was established as an alternative to surgery for treatment of aortic valve stenosis in childhood. Acute complications after balloon dilatation including aortic insufficiency or early death were described.

Aim of Work:

To analyze early outcome and midterm results of balloon aortic valvuloplasty (BAV) in Children’s Hospital, Mansoura University, Egypt.

Subjects and Methods:

Between April 2005–June 2008, all consecutive patients of age <18 years treated for aortic valve stenosis (AVS) with BAV were analyzed retrospectively. The study included 21 patients; 17 males, and 4 females. Their age ranged from the neonatal period to 10 years (mean age 5.6 ± 3.7 years). Patients with gradient ≥50 mmHg and aortic valve insufficiency (AI) up to grade I were included. All patients had isolated aortic valve stenosis except 3 patients (14.3%) had associated aortic coarctation. Six patients (28.6%) had bicuspid aortic valve. All patients had normal myocardial function except one (4.8%) had FS 15%. The duration of follow up was (mean ± SD: 18.5 ± 11.7 months).

Results:

Femoral artery approach was used in 20 patients (95.2%) and carotid artery in one neonate (4.8%). Balloon/annulus ratio was 0.83 ± 0.04. Significant reduction in pressure gradient was achieved (mean 66.7 ± 9.8 mmHg to 20.65 ± 2.99 mmHg) (P < 0.001). Nine patients (42.8%) developed grade I AI, 2 patients (9.5%) developed grade II AI and 1 patient (4.8%) developed grade III AI. Two early deaths (9.5%); one died due to heart failure caused by grade IV AI and a neonate died because of severely compromised LV function. One patient (4.8%) had femoral artery occlusion necessitating anticoagulation. Patients remained free from re-intervention during follow up.

Conclusion:

Balloon valvuloplasty of aortic valve stenosis significantly reduces gradient with low morbidity and mortality in children.

Percutaneous Balloon Valvuloplasty for Aortic Stenosis in Newborns and Children

In all cases of congenital valvar aortic stenosis (AS), reduced effective orifice area leads to obstruction to flow, usually resulting from thickening and reduced motion of the valve leaflets. The most severe cases of valvar AS present soon after birth, with low cardiac output secondary to left ventricular dysfunction. Interventional treatment options consist of open surgical valvotomy or balloon valvuloplasty, with both therapies providing excellent but usually only temporary relief of stenosis. This article focuses on balloon aortic valvuloplasty as a therapy for congenital valvar AS in infants and children, focusing on established techniques, outcomes, and future challenges.

Balloon aortic valvuloplasty for congenital aortic stenosis using the femoral and the carotid artery approach: a 16-year experience from a single center

OBJECTIVES

The aim of this article is to report a 16-year experience with percutaneous balloon aortic valvuloplasty (BAVP) in newborns and young infants up to 3 months of age in a tertiary care cardiac reference center in a developing country and to determine its value in postponing open heart surgery.

BACKGROUND

Congenital aortic stenosis (AS) is a potentially life threatening disorder. BAVP and surgical procedures have similar short and medium-term efficacy.

METHODS

Thirty-one consecutive newborns and young infants with critical AS underwent BAVP in our department from 1991 to 2007. Mean patient age at time of the procedure was 22 days (range 2-92 days) and mean weight was 3,310 g (1,840-4,400 g).

RESULTS

There was a significant reduction in mean Doppler-derived peak gradient across the aortic valve immediately after the procedure (75.1 ± 22 versus 32.2 ± 13.02, P < 0.001), and this finding was maintained throughout follow-up. Since 2003, when the carotid approach became routine practice, no major vascular complications were observed. Mean time of follow-up was 81 months (5 days-196 months) with only two deaths (7.4%). Only 24% patients required surgical reintervention on the aortic valve during follow-up. Survival free from aortic valve surgery was 80% at 24 months, 66% at 63 months, and 50% at 80 months.

CONCLUSION

Percutaneous intervention for relief of critical aortic stenosis in newborns in a tertiary center of a developing country is safe and has excellent short and long-term results comparable to other centers throughout the world.

Balloon valvuloplasty in the treatment of congenital aortic valve stenosis--a retrospective multicenter survey of more than 1000 patients

BACKGROUND

The value of balloon valvuloplasty of the aortic valve in childhood is still under debate.

OBJECTIVE

To evaluate the results of the procedure in a retrospective multicenter survey of a large cohort over a long time interval.

METHODS

Retrospective analysis of 1004 patients with balloon valvuloplasty of the aortic valve performed between 9/1985 and 10/2006 at 20 centers in Germany, Austria and Switzerland. Amongst others, the following parameters were evaluated before and after the procedure as well as at the end of follow-up or before surgery: clinical status, left ventricular function, transaortic pressure gradient, degree of aortic regurgitation, freedom from re-intervention or surgery.

PATIENTS

Patients from 1 day to 18 years of age with aortic valve stenosis were divided into four groups: 334 newborns (1-28 days); 249 infants (29-365 days); 211 children (1-10 years), and 210 adolescents (10-18 years).

RESULTS

Median follow-up was 32 months (0 days to 17.5 years). After dilatation the pressure gradient decreased from 65 (± 24)mm Hg to 26 (± 16)mm Hg and remained stable during follow-up. The newborns were the most affected patients. Approximately 60% of them had clinical symptoms and impaired left ventricular function before intervention. Complication rate was 15% in newborns, 11% in infants and 6% in older children. Independently of age, 50% of all patients were free from surgery 10 years after intervention.

CONCLUSIONS

In this retrospective multicenter study, balloon valvuloplasty of the aortic valve has effectively postponed the need for surgery in infants, children and adolescents up to 18 years of age.

Balloon dilation of neonatal critical aortic valvar stenosis via the umbilical artery

OBJECTIVES

To report our experience with balloon dilation of critical aortic valvar stenosis in neonates via the umbilical artery using currently available catheters.

BACKGROUND

There is no agreement regarding the optimal vascular approach for balloon dilation of critical aortic valvar stenosis in neonates.

METHODS

Since June of 2005, we have attempted to obtain umbilical arterial access within the first week after birth in all neonates with critical aortic valvar stenosis. In patients in whom umbilical artery access was obtained, we proceeded with an attempt at balloon dilation.

RESULTS

We were presented with 5 patients with critical aortic valvar stenosis within the first week after birth, and the umbilical arterial approach was obtained in all, with effective relief of the stenosis achieved in 4.

CONCLUSIONS

The umbilical arterial approach should always be considered for balloon dilation of neonatal critical aortic valvar stenosis. Using currently available catheters, the procedure is safe, simple, and effective even in patients weighing less than 2.5 kilograms. Further experience using this approach is warranted.

Congenital heart disease in 111 225 births in Belgium: birth prevalence, treatment and survival in the 21st century

AIM

To investigate the birth prevalence, treatment modalities and short-term survival of children with congenital heart disease who were born in 2002.

METHODS

We undertook a retrospective review of medical records of all patients who were born in 2002, and were diagnosed, treated and/or followed-up in one of the seven-paediatric cardiology programmes in Belgium.

RESULTS

In 111 225 births, 921 children with congenital heart disease were detected, yielding a birth prevalence of 8.3 per 1000. The most frequently occurring conditions were ventricular septal defects (VSDs) (33%), ostium secundum atrial septal defects (18%) and pulmonary valve abnormalities (10%). Thirty-nine percent of the children either had a cardiosurgical operation or catheter intervention. In this study, 4% of the children died. The actuarial survival at 6 months and 1 year of age was 97% and 96%, respectively and remained stable after then. Compared to other heart defects, mortality was higher in univentricular physiology, pulmonary atresia with VSD, left ventricle outflow obstruction and tetralogy of Fallot.

CONCLUSION

Survival of congenital heart disease is excellent and continued to improve in the early 21st century. New therapeutic options are increasingly used. This study provides baseline data for the longitudinal follow-up of this cohort.

Interventional therapy for neonates with critical congenital heart disease

Transcatheter interventional therapies for children continue to evolve at a remarkable rate. Perhaps no where are these procedures more important than in the critically ill newborn. In this core curriculum review article several of the most commonly performed interventions performed in critically ill newborns are discussed with regards to technique and outcomes.