Transcarotid balloon valvuloplasty in neonates and small infants with critical aortic valve stenosis utilizing continuous transesophageal echocardiographic guidance: A 22 year single center experience from the cath lab to the bedside

Perioperative and Anesthetic Considerations in Pediatric Valvar and Subvalvar Aortic Stenosis

Aortic stenosis (AS) is a common form of left ventricular outflow tract obstruction (LVOTO) in children with congenital heart disease. This review specifically considers the perioperative features of valvar (VAS) and subvalvar AS (subAS) in the pediatric patient. Although VAS and subAS share some clinical features and diagnostic approaches, they are distinct clinical entities with separate therapeutic options, which range from transcatheter intervention to surgical repair. We detail the pathophysiology of AS and highlight the range of treatment strategies with a focus on anesthetic considerations for the care of these patients before, during, and after intervention.

Balloon aortic valvuloplasty in neonates: short- and long-term effects and predictors of successful outcome

Introduction

Balloon aortic valvuloplasty (BAV) is a common treatment method of aortic valve (AV) stenosis in neonates. Long-term BAV effects are suboptimal, and their predictors are not well acknowledged.

Aim

To identify predictors of suboptimal short- and long-term BAV results.

Material and methods

The study group comprised forty-three neonates (8 females; weight 3.34 ±0.56 kg) who underwent BAV between 1998 and 2021. Seventeen patients (39.53%) had critical AV stenosis. AV was bicuspid in 22 patients, tricuspid in 12, unicuspid in 2, and undefined in 7 patients. The mean balloon/annulus ratio was 0.9 ±0.07. Catheterization, clinical, and follow-up data were analysed.

Results

The peak-to-peak gradient decreased from 67.5 ±26.3 to 21.3 ±12.6 mm Hg. Twenty-eight patients (65.1%) had adequate early outcome. Aortic regurgitation (AR) occurred in 13 (30.2%) patients. No predictors of inadequate early outcome were found. Twenty-year survival was 90.7%. Eleven (35.5%) patients underwent reintervention at a median of 12 (1–215) months; BAV in 5 patients, surgical valvuloplasty in 2, Ross operation in 2, AV replacement in 1, and Norwood operation in 1 patient. Fifteen-year freedom from reintervention (FFR) was 48%. Adequate early outcome resulted in higher FFR (71% vs. 22%), and so did no significant AR (60% vs. 30%).

Conclusions

BAV provides satisfying early results. AR remains a significant aftermath of BAV. Risk factors and procedural techniques improving the outcome of BAV are unclear. Further research is needed to improve FFR.

Carotid versus femoral access for transcatheter aortic valve implantation: a propensity score inverse probability weighting study

OBJECTIVES

The transcarotid (TC) approach for transcatheter aortic valve implantation (TAVI) is potentially an optimal alternative to the transfemoral (TF) approach. Our goal was to compare the safety and efficacy of TC- and TF-TAVI.

METHODS

Patients who underwent TF-TAVI or TC-TAVI in the prospectively collected FRANCE TAVI registry between January 2013 and December 2015 were compared. Propensity score inverse probability weighting methods were employed to minimize the impact of bias related to non-random treatment assignment.

RESULTS

Of the 11 033 patients included in the current study, 10 598 (96%) underwent a TF-TAVI and 435 (4.1%) had a TC-TAVI. Patients in the TC-TAVI access group presented with a higher risk profile but were significantly younger. There were no differences in the perioperative and 2-year mortality rates after adjustment [odds ratio (OR) 1.02, 95% confidence interval (CI) 0.62-1.68; P = 0.99 and hazard ratio 1.03, 95% CI 0.7-1.35; P = 0.83). TC-TAVI was associated with a significant risk of stroke (OR 2.42, 95% CI 2.01-2.92; P < 0.001), ST-elevation myocardial infarction (OR 7.32, 95% CI 3.87-13.87; P < 0.001), infections (OR 2.36, 95% CI 2.04-2.71; P < 0.001), bleeding (OR 2.01, 95% CI 1.76-2.29; P < 0.001), renal failure (OR 2.23, 95% CI 1.90-2.60; P < 0.001) and need for dialysis (OR 2.36, 95% CI 2.01-2.76, P < 0.001). Conversely, TC-TAVI was not confirmed as a risk factor for pacemaker implantation after adjustment (OR 1.05, 95% CI 0.96-1.15; P < 0.28) and was a protective factor for vascular complications (OR 0.37, 95% CI 0.32-0.43; P < 0.001).

CONCLUSIONS

TC-TAVI is a safe procedure compared to TF-TAVI, although it holds an increased risk of perioperative complications. It should be considered in case of non-femoral peripheral access as the second access choice, to increase the overall safety of TAVI procedures.

Surgical and Transcatheter Treatments in Children with Congenital Aortic Stenosis

BACKGROUND

 For patients with congenital aortic valve stenosis (AVS), comprehensive analysis of surgical aortic valvuloplasty (SAV) or balloon dilation (BD) is scarce and remains controversial.

METHODS

 This study reviewed AVS data (aortic peak gradient, aortic insufficiency, and survival and reoperation) for patients who were suitable for biventricular repair at our center in 2008 to 2018. Patients were categorized into two subgroups based on age (≤3 or >3 months).

RESULTS

 A total of 194 patients were treated, including 124 with SAV and 70 with BD. Resulting data revealed that residual aortic gradient at discharge was worse for BD (p = 0.001). While for patients younger than 3 months, the relief of AVS was comparable between the two groups (p = 0.624). There was no significant difference in time-related survival between the two groups (log-rank p = 0.644). Multivariate analysis demonstrated that preoperative left ventricular end-diastolic dimension predicted early death (p = 0.045). Survival in the two groups after 10 years was 96.8% in SAV and 95.7% in BD (p = 0.644). Freedom from reoperation after 10 years was 58.1% in SAV and 41.8% in BD patients (p = 0.01). There was no significant difference in freedom from reoperation between SAV and BD in patients younger than 3 months (p = 0.84). Multivariate analysis indicated that residual aortic peak gradient was predictive of reoperation (p = 0.038).

CONCLUSION

 Both methods achieved excellent survival outcomes at our center. SAV achieved superior gradient reduction and minimized the necessity for reoperation. For patients younger than 3 months, BD rivaled SAV both in aortic stenosis relief and freedom from reoperation.

Short- and intermediate-term results of balloon aortic valvuloplasty and surgical aortic valvotomy in neonates

BACKGROUND

Balloon aortic valvuloplasty and open surgical valvotomy are procedures to treat neonatal aortic stenosis, and there is controversy as to which method has superior outcomes.

METHODS

We reviewed the records of patients at our institution since 2000 who had a balloon aortic valvuloplasty or surgical valvotomy via an open commissurotomy prior to 2 months of age.

RESULTS

Forty patients had balloon aortic valvuloplasty and 15 patients had surgical valvotomy via an open commissurotomy. There was no difference in post-procedure mean gradient by transthoracic echocardiogram, which were 25.8 mmHg for balloon aortic valvuloplasty and 26.2 mmHg for surgical valvotomy, p = 0.87. Post-procedure, 15% of balloon aortic valvuloplasty patients had moderate aortic insufficiency and 2.5% of patients had severe aortic insufficiency, while no surgical valvotomy patients had moderate or severe aortic insufficiency. The average number of post-procedure hospital days was 14.2 for balloon aortic valvuloplasty and 19.8 for surgical valvotomy (p = 0.52). Freedom from re-intervention was 69% for balloon aortic valvuloplasty and 67% for surgical valvotomy at 1 year, and 43% for balloon aortic valvuloplasty and 67% for surgical valvotomy at 5 years (p = 0.60).

CONCLUSIONS

Balloon aortic valvuloplasty and surgical valvotomy provide similar short-term reduction in valve gradient. Balloon aortic valvuloplasty has a slightly shorter but not statistically significant hospital stay. Freedom from re-intervention is similar at 1 year. At 5 years, it is slightly higher in surgical valvotomy, though not statistically different. Balloon aortic valvuloplasty had a higher incidence of significant aortic insufficiency. Long-term comparisons cannot be made given the lack of long-term follow-up with surgical valvotomy.

Left Ventricular Strain Normalizes After Balloon Aortic Valvuloplasty in Infants with Congenital Aortic Stenosis

Severe aortic stenosis (AS) causes left ventricular (LV) afterload and subendocardial ischemia. Despite this, most infants with AS have normal LV ejection fraction (EF). Strain analysis using two-dimensional speckle tracking echocardiography (2DSTE) may identify more sensitive markers of systolic dysfunction. We sought to show changes in LV strain after balloon aortic valvuloplasty (BAV) in infants with AS. Twenty-seven infants ≤ 1 year of age with AS who underwent BAV from 2007 to 2017 were included. Echocardiograms before/after BAV were retrospectively analyzed with 2DSTE. Median age was 29 days (interquartile range 3-52) and LV EF was 64 ± 10%. Global longitudinal strain (GLS) significantly improved post-BAV (- 17 ± 5 vs. - 20 ± 4%, p = 0.001) with no difference in global circumferential strain. Peak longitudinal strain was abnormal at the inferoseptal base and mid-ventricle (- 15 ± 6 and - 17 ± 5 = 7%, respectively) and significantly improved in the basal and mid-anterolateral segments (- 17 ± 5 vs. - 21 ± 5%, p < 0.01; - 17 ± 6% vs. - 20 ± 5%, p = 0.01, respectively). Five (20%) patients underwent reintervention, and had significantly higher peak-to-peak pre and post-BAV AS gradients (86 ± 14 vs. 61 ± 20 mmHg, p = 0.02; 33 ± 17 vs. 21 ± 10 mmHg, p = 0.04, respectively). In conclusion, longitudinal strain is abnormal in infants with AS and improves to previously published normal values after BAV.

Balloon valvuloplasty in a dog with congenital bicuspid aortic valve and supravalvar aortic stenosis (atypical Shone's complex)

An 8-month-old intact female pug was presented for evaluation and possible balloon valvuloplasty (BV) for severe aortic stenosis. A bicuspid, severely stenotic aortic valve of type 3 morphology with a supravalvar stenosis component was diagnosed, consistent with the diagnosis of atypical Shone's complex. There was severe concentric hypertrophy of the left ventricle, with increased echogenicity of the myocardium nearest to the endocardial border. Mild left atrial enlargement was observed. Selective angiography and transesophageal echocardiography revealed an enlarged and relatively tortuous ascending aorta. The changes to the ascending aorta and the anatomy of the lesion made retrograde access to the left ventricle challenging. Ultimately, BV was successful using a pediatric valvuloplasty balloon catheter and rapid right ventricular pacing, and the pressure gradient across the aortic valve was decreased by more than 50% compared with preoperative measurements. Although valvar aortic stenosis is rare in veterinary medicine, this report highlights the potential challenges and feasibility of BV for this disease.

Interventional Cardiology for Congenital Heart Disease

Congenital heart interventions are now replacing surgical palliation and correction in an evolving number of congenital heart defects. Right ventricular outflow tract and ductus arteriosus stenting have demonstrated favorable outcomes compared to surgical systemic to pulmonary artery shunting, and it is likely surgical pulmonary valve replacement will become an uncommon procedure within the next decade, mirroring current practices in the treatment of atrial septal defects. Challenges remain, including the lack of device design focused on smaller infants and the inevitable consequences of somatic growth. Increasing parental and physician expectancy has inevitably lead to higher risk interventions on smaller infants and appreciation of the consequences of these interventions on departmental outcome data needs to be considered. Registry data evaluating congenital heart interventions remain less robust than surgical registries, leading to a lack of insight into the longer-term consequences of our interventions. Increasing collaboration with surgical colleagues has not been met with necessary development of dedicated equipment for hybrid interventions aimed at minimizing the longer-term consequences of scar to the heart. Therefore, great challenges remain to ensure children and adults with congenital heart disease continue to benefit from an exponential growth in minimally invasive interventions and technology. This can only be achieved through a concerted collaborative approach from physicians, industry, academia and regulatory bodies supporting great innovators to continue the philosophy of thinking beyond the limits that has been the foundation of our specialty for the past 50 years.

A Comparison of Anterograde Versus Retrograde Approaches for Neonatal Balloon Aortic Valvuloplasty

In neonates requiring balloon aortic valvuloplasty, both anterograde and retrograde approaches are feasible. A recent comparison of these two approaches is lacking. A retrospective cohort study of neonates at a single center undergoing BAV from 9/00 to 7/14 was performed. Records were reviewed including pre- and post-intervention echocardiograms and catheterization data. Comparisons of acute efficacy and procedural safety were made based on type of approach utilized. Forty-two neonates underwent BAV. Eleven cases utilized exclusively an anterograde approach, while 31 included a retrograde approach (including 4 with both approaches used). There were no significant differences between groups in baseline demographic and clinical characteristics. Additionally, by both pre-intervention echocardiogram and catheterization, there were no differences based on approach in aortic valve gradient, degree of aortic insufficiency (AI), or degree of mitral regurgitation (MR). Both approaches were equally efficacious in gradient reduction (45 ± 17 vs. 44 ± 21 mmHg, p = 0.97), and there was no difference in post-intervention AI as assessed by both catheterization and echocardiogram (52% vs. 64% none or trivial, p = 0.74). Additionally, there was no difference in the proportion of patients with an increased severity of MR after BAV (15% vs. 22%, p = 0.52). The retrograde approach required a larger arterial catheter and was associated with a higher rate of arterial thrombosis (61% vs. 18%, p = 0.014). Both anterograde and retrograde approaches to neonatal BAV appear to be equally efficacious in the short term. The anterograde approach avoids the need for a larger arterial catheter and may reduce the risk of arterial thrombosis.

Current Status and Future Potential of Transcatheter Interventions in Congenital Heart Disease

Percutaneous therapies for congenital heart disease have evolved rapidly in the past 3 decades. This has occurred despite limited investment from industry and support from regulatory bodies resulting in a lack of specific device development. Indeed, many devices remain off-label with a best-fit approach often required, spurning an innovative culture within the subspecialty, which had arguably laid the foundation for many of the current and evolving structural heart interventions. Challenges remain, not least encouraging device design focused on smaller infants and the inevitable consequences of somatic growth. Data collection tools are emerging but remain behind adult cardiology and cardiac surgery and leading to partial blindness as to the longer-term consequences of our interventions. Tail coating on the back of developments in other fields of adult intervention will soon fail to meet the expanding needs for more precise interventions and biological materials. Increasing collaboration with surgical colleagues will require development of dedicated equipment for hybrid interventions aimed at minimizing the longer-term consequences of scar to the heart. Therefore, great challenges remain to ensure that children and adults with congenital heart disease continue to benefit from an exponential growth in minimally invasive interventions and technology. This can only be achieved through a concerted collaborative approach from physicians, industry, academia, and regulatory bodies supporting great innovators to continue the philosophy of thinking beyond the limits that has been the foundation of our specialty for the past 50 years.