Rest and exercise hemodynamics in pulmonary stenosis: comparison of children and adults

Balloon Dilatation in the Management of Congenital Obstructive Lesions of the Heart: Review of Author's Experiences and Observations-Part I

Balloon dilatation techniques became available to treat congenital obstructive lesions of the heart in the early/mid-1980s. The purpose of this review is to present the author's experiences and observations on the techniques and outcomes of balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS) and aortic coarctation (AC), both native and postsurgical re-coarctations. Balloon dilatation resulted in a reduction of peak pressure gradient across the obstructive lesion at the time of the procedure as well as at short-term and long-term follow-ups. Complications such as recurrence of stenosis, valvar insufficiency (for PS and AS cases) and aneurysm formation (for AC cases) have been reported, but infrequently. It was recommended that strategies be developed to prevent the reported complications.

Right ventricular outflow tract anomalies: Neonatal interventions and outcomes

Right ventricular outflow tract (RVOT) anomalies comprise a wide spectrum of congenital heart disease, typically characterized by obstruction to flow from the right ventricle to pulmonary arteries. This review highlights important considerations surrounding management strategy as well as clinical outcomes for the neonate with RVOT anomaly, including: pulmonary atresia with intact ventricular septum, congenital pulmonary valve stenosis, tetralogy of Fallot, and Ebstein anomaly with anatomic or physiologic RVOT obstruction.

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.

Right ventricular function in congenital heart disease: pressure and volume overload lesions

The right ventricle is often subject to both pressure and volume overload in congenital heart disease. Evaluating right ventricular function in both the native lesion and after surgery in light of these loading conditions, presents a unique challenge for investigators studying these misshapen hearts. The purpose of this article is to briefly delineate what is generally known about right ventricular function in congenital heart disease and to touch on some noninvasive imaging modalities which have helped shed some light on this matter.

Role of exercise in the management of cardiovascular disease in children and youth

Most cardiovascular disease in children and youth is the result of congenital anomalies. Surgical techniques for repair of these defects have improved greatly since they were first developed, and a high percentage of patients become healthy, active adults. Less frequently, other types of cardiovascular disease may be acquired sometime after birth. In patients with either congenital or acquired heart disease, there is often some degree of exercise limitation. Appropriately, there is an increasing interest in the use of exercise testing and training in the clinical management of both congenital and acquired cardiovascular disease in children and youth. This review describes the exercise responses of patients with various forms of cardiovascular disease and discusses the use of exercise training to improve the well-being of these children and adolescents.

Transluminal balloon valvotomy for pulmonic stenosis in an adult

Transluminal balloon valvotomy has become a widely used nonsurgical approach to treatment of certain valvular lesions in children. In adults, however, experience with this technique is limited. We performed balloon valvotomy in a 61-year-old woman who had pulmonic stenosis. Four months after the procedure, her exercise tolerance had increased and she no longer had exertional dyspnea. Among the few reported cases of balloon valvotomy in adult patients with pulmonary stenosis, the systolic pressure gradient and the peak systolic ventricular pressure have been considerably reduced. Possible mechanisms by which transluminal balloon valvotomy relieves obstruction are tearing or deformation of the valve cusps, separation of fused commissures, fracture of valvular calcification, dilation of the annulus, or some combination of these factors. Balloon valvotomy seems to be an appropriate therapeutic choice for pulmonic stenosis in adult patients.