Balloon valvuloplasty after pulmonary valvotomy for babies with pulmonary atresia and intact ventricular septum

Evolution of the management approach for pulmonary atresia with intact ventricular septum

OBJECTIVE

To review the evolution of the management approach for pulmonary atresia with intact ventricular septum (PAIVS) in the past two decades and to assess its impact on patient outcomes.

DESIGN AND PATIENTS

Retrospective review of the management and outcomes of 94 patients (55 male patients) with PAIVS diagnosed between July 1980 and August 2003.

SETTINGS

Tertiary paediatric cardiac centre.

RESULTS

Seven patients died before interventions. Of the remaining 87 patients who underwent intervention at a median age of 9 days (from 1 day to 2 years), 12 had right ventricular outflow tract reconstruction (RVOTR), 42 had closed pulmonary valvotomy (CPV), and 15 had laser assisted valvotomy with balloon valvoplasty. A systemic-pulmonary shunt was inserted in 18 patients, six of whom had subsequent RVOTR (n = 4) or laser assisted valvotomy (n = 2). Since 1990, catheter intervention accounted for 38% (17 of 45) of the right ventricular outflow procedures. The mean (SEM) freedom from reintervention was 93 (7)%, 71 (12)%, and 57 (13)% after RVOTR, 75 (7)%, 40 (8)%, and 14 (6)% after CPV, and 54 (13)%, 24 (12)%, and 16 (10)% after laser assisted valvotomy at one month, six months, and one year, respectively (RVOTR versus CPV, p < 0.001; RVOTR versus laser assisted valvotomy, p = 0.001). Low cardiac output syndrome was significantly less common after catheter intervention than after RVOTR (0% v 44%, p = 0.003) or CPV (0% v 29%, p = 0.01). The overall mean (SEM) survival was 77 (5)% and 70 (5)% at one and five years, respectively, and the overall mortality was 33% (29 of 87). There were no significant differences in survival between the three groups.

CONCLUSIONS

Multiple interventions are often required in the treatment algorithm of PAIVS. The shift towards increased use of the transcatheter approach has reduced the occurrence of postprocedural low cardiac output syndrome.

Pulmonary atresia with intact ventricular septum percutaneous radiofrequency-assisted valvotomy and balloon dilation versus surgical valvotomy and Blalock Taussig shunt

OBJECTIVE

We compared the result of radiofrequency (RF)-assisted valvotomy and balloon dilation with closed surgical valvotomy and Blalock Taussig (BT) shunt as primary treatment in selected patients with pulmonary atresia and intact ventricular septum (PA-IVS).

BACKGROUND

Patients with PA-IVS who have mild to moderate hypoplasia of the right ventricle (RV) and patent infundibulum have the greatest potential for complete biventricular circulation. The use of RF or laser wires to perforate the atretic valve followed by balloon dilation provides an alternative to surgery.

METHODS

Between May 1990 and March 1998, 33 selected patients underwent either percutaneous RF valvotomy and balloon dilation (group 1, n = 21; two crossed over to group 2) or surgical valvotomy with concomitant BT shunt (group 2, n = 14). Second RV decompression by balloon dilation or right ventricular outflow tract (RVOT) reconstruction were performed if necessary. Patients who remained cyanosed were subjected to transcatheter trial closure of the interatrial communication. Partial biventricular repair was offered to those with inadequate growth of the RV.

RESULTS

The primary procedure was successful in 19 patients in group 1. There was one in-hospital death and two late deaths. Of the remaining 16 survivors, 12 achieved complete biventricular circulation, 7 of whom required no further interventions. Two patients required repeat balloon dilation, 1 RVOT reconstruction and 2 transcatheter closure of interatrial communication. Two patients underwent partial biventricular repair. In group 2, there were 3 in-hospital deaths after the primary procedure and 1 patient died four months later. All survivors (n = 10) required a second RV decompression, 8 by balloon dilation and 2 by RVOT reconstruction, after which, two patients died. Of the final 8 survivors, 7 achieved complete biventricular circulation, 5 after coil occlusion of the BT shunt and 2 after closure of interatrial communication.

CONCLUSIONS

Radiofrequency valvotomy and balloon dilation is more efficacious and safe compared with closed pulmonary valvotomy and BT shunt in selected patients with PA-IVS.

Laser valvotomy with balloon valvoplasty for pulmonary atresia with intact ventricular septum: five years' experience

OBJECTIVE

To assess immediate and medium term results of transcatheter laser valvotomy with balloon valvoplasty in selected infants with pulmonary atresia and intact ventricular septum.

DESIGN

Prospective study.

SETTING

Tertiary cardiac unit.

PATIENTS

All infants with pulmonary atresia and intact septum with no more than minor tricuspid valve hypoplasia referred between November 1990 and June 1995. Laser valvotomy was attempted in nine infants of median age 4-5 days and median weight 3.6 kg.

INTERVENTION

The pulmonary valve was perforated using a 0.018 inch fibreoptic guidewire attached to a NdYag laser and introduced through a catheter positioned beneath the valve. After perforation the valve was dilated with progressively larger balloons.

MAIN OUTCOME MEASURES

Successful laser valvotomy and balloon dilatation, complications, pulse oximetry, right ventricular outflow velocities, and need for surgical treatment.

RESULTS

Valvotomy was successful in all but one case, the failure being due to laser breakdown. After perforation the valve was dilated to 6-8 mm diameter. Prostaglandin E was withdrawn immediately in six of the eight duct dependent infants, and 28 and 49 days later in two. No patient required an aortopulmonary shunt. Two patients had repeat valvoplasty at 20 days and three months of age, respectively; one required infundibular resection and closure of the atrial septum at age four and one is awaiting similar treatment.

CONCLUSIONS

Laser valvotomy with balloon valvoplasty is safe and effective treatment for selected patients with pulmonary atresia and intact ventricular septum and should be considered as first line treatment in place of surgical valvotomy.

Management evolution of pulmonary atresia and intact ventricular septum

To examine the impact on survival and clinical course of incorporating the morphologic classification of the right ventricle into the evolving management strategy for babies with pulmonary atresia and intact ventricular septum, the surgical results and follow-up status of the first 62 consecutive patients managed in this hospital between 1979 and 1990 were reviewed. Before 1984, all 23 babies from group I underwent primary right ventricular outflow reconstruction irrespective of right ventricular morphology and size. Since 1984, depending on the morphology and size of the right ventricle, 39 babies from group II had either closed transventricular pulmonary valvotomy (n = 31) or a shunt operation (n = 8). There were 10 hospital (43%) and 2 late deaths (total mortality 52%) in our group I patients. Three of the 11 long-term survivors had cyanosis at rest but none had any residual pressure gradient across the pulmonary outflow. Group II had 6 hospital (15%) and 4 late deaths (total mortality = 26%). Of the 29 long-term survivors, 9 had a second-stage right ventricular outflow reconstruction, 8 had balloon valvuloplasty and 2 had successful Fontan operation. At the latest follow-up, 5 children from this group have cyanosis at rest, 1 has a residual gradient (55 mm Hg) across the infundibulum, and 3 have right ventricular dysfunction. The hospital and total mortality for babies in group II was significantly lower than that in group I (p < 0.01). These data suggest that tailoring the treatment to the right ventricular anatomy results in a lower overall mortality although long term postoperative hemodynamic abnormalities are observed in both groups.