Follow-up results of balloon aortic valvuloplasty in children with special reference to causes of late aortic insufficiency

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

While investigating the outcomes of balloon dilatation procedures in patients with congenital obstructive lesions of the heart, several parallel observations were made. The purpose of this review is to present these observations/phenomena/innovations related to balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS), and aortic coarctation (AC). In subjects who had balloon pulmonary valvuloplasty (BPV), development of infundibular obstruction, electrocardiographic (ECG) changes, changes in right ventricular filling, role of balloon/annulus ratios on the results of BPV, and double balloon vs. single balloon BPV will be reviewed. In patients who had balloon aortic valvuloplasty (BAV), causes of aortic insufficiency and trans-umbilical venous approach for BAV are tackled. In children who had balloon angioplasty (BA) of AC, aortic remodeling and biophysical response after BA of AC are discussed.

Long-Term Results of Congenital Aortic Stenosis Treatment in the Era of Percutaneous Balloon Valvuloplasty: Up to 33 Years Follow-Up

Background The goal of this study was to evaluate long-term results of percutaneous balloon valvuloplasty (BVPL) used exclusively for initial management of congenital aortic stenosis in children. Methods and Results A total of 409 consecutive pediatric patients (134 newborns, 275 older patients) who underwent BVPL as initial treatment of aortic stenosis in a single nationwide pediatric center were subjected to a retrospective follow-up study. The resulting follow-up time reached a median of 18.5 (interquartile range, 12.2-25.1) years. Successful BVPL was defined by residual Doppler gradient <70/40 (systolic/mean) mm Hg. The primary end point was death; secondary end points included any valve reintervention, balloon revalvuloplasty, any aortic valve surgery, and aortic valve replacement, respectively. BVPL effectively reduced the peak and mean gradient both immediately and at the latest follow-up (P<0.001). There was significant procedure-related progression of aortic insufficiency (P<0.001). Higher aortic annulus z score was predictive for severe aortic regurgitation (P<0.05) and lower z score for insufficient gradient reduction (P<0.05). The actuarial probability of survival/survival free from any valve reintervention was 89.9%/59.9%, 85.9%/35.2%, and 82.0%/26.7% at 10, 20, and 30 years after first BVPL, respectively. Left ventricular dysfunction or arterial duct dependency as the indication for BVPL was predictive of both worse survival and survival free from any reintervention (P<0.001). Lower aortic annulus z score and lower balloon-to-annulus ratio were predictive of a need for revalvuloplasty (P<0.001). Conclusions Percutaneous BVPL provides good initial palliation. In patients with hypoplastic annuli and left ventricular or mitral valve comorbidity, the results are less favorable.

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.

Statistical Treatment of Clinical Investigations in Pediatric Cardiology

This paper describes various statistical methods used by the author during multiple studies conducted by the author. Initially, the data were scrutinized to ensure normal distribution, and expressed as mean ± standard deviation (SD) or standard error of mean (SEM) for normally distributed variables. Medians and ranges were given for the data with skewed distribution. Two tailed, paired t tests or independent sample t tests (analysis of variance) were used for normally distributed data, while non-parametric chi-square or similar other tests were utilized for data with skewed distribution. Statistical significance was set at a p value of < 0.05. Bonferroni correction was applied when the study involves multiple comparisons. A number of other statistical methods used during these studies were also discussed. Finally, special methods used in evaluating aortic remodeling subsequent to balloon angioplasty of native aortic coarctation were reviewed.

Echocardiographic versus angiographic measurement of the aortic valve annulus in children undergoing balloon aortic valvuloplasty: method affects outcomes

OBJECTIVE

Operators are mindful of the balloon-to-aortic annulus ratio when performing balloon aortic valvuloplasty. The method of measurement of the aortic valve annulus has not been standardised.

METHODS AND RESULTS

Patients who underwent aortic valvuloplasty at two paediatric centres between 2007 and 2014 were included. The valve annulus measured by echocardiography and angiography was used to calculate the balloon-to-aortic annulus ratio and measurements were compared. The primary endpoint was an increase in aortic insufficiency by ≥2 degrees. Ninety-eight patients with a median age at valvuloplasty of 2.1 months (Interquartile range (IQR): 0.2-105.5) were included. The angiographic-based annulus was 8.2 mm (IQR: 6.8-16.0), which was greater than echocardiogram-based annulus of 7.5 mm (IQR: 6.1-14.8) (p < 0.001). This corresponded to a significantly lower angiographic balloon-to-aortic annulus ratio of 0.9 (IQR: 0.9-1.0), compared to an echocardiographic ratio of 1.1 (IQR: 1.0-1.1) (p < 0.001). The degree of discrepancy in measured diameter increased with smaller valve diameters (p = 0.041) and in neonates (p = 0.044). There was significant disagreement between angiographic and echocardiographic balloon-to-aortic annulus ratio measures regarding "High" ratio of >1.2, with angiographic ratio flagging only 2/12 (16.7%) of patients flagged by echocardiographic ratio as "High" (p = 0.012). Patients who had an increase in the degree of aortic insufficiency post valvuloplasty, only 3 (5.5%) had angiographic ratio > 1.1, while 21 (38%) had echocardiographic ratio >1.1 (p < 0.001). Patients with resultant ≥ moderate insufficiency more often had an echocardiographic ratio of >1.1 than angiographic ratio of >1.1 There was no association between increase in balloon-to-aortic annulus ratio and gradient reduction.

CONCLUSIONS

Angiographic measurement is associated with a greater measured aortic valve annulus and the development of aortic insufficiency. Operators should use caution when relying solely on angiographic measurement when performing balloon aortic valvuloplasty.

Rapid right ventricular pacing for balloon aortic valvuloplasty: expanding its routine use in neonates and infants

OBJECTIVE

Rapid right ventricular pacing during balloon aortic valvuloplasty is commonly used to achieve balloon stability in children and adults. There is no consensus for the use of the technique in neonates and infants. We sought to review our institutional experience with rapid right ventricular pacing-assisted balloon aortic valvuloplasty across all age groups and evaluate the safety and effectiveness of the technique in the sub-group of neonates and infants <12months.

METHODS

Retrospective study between February, 2011 and February, 2020.

RESULTS

A total of 37 patients (Group I: 21 neonates/infants <12months and Group II: 16 children 12 months-16 years) were analysed. Catheter-measured left ventricular to aortic gradient reduced from median of 66 mmHg (with a range from 30 to 125 mmHg) to 14 mmHg (with a range from 5 to 44 mmHg) in Group I and 44 mmHg (with a range from 28 to 93 mmHg) to 18 mmHg (with a range from 2 to 65 mmHg) in Group II (p < 0.001). Procedure and fluoroscopy times were identical in the two groups. Balloon:annulus ratio was 0.94 and 0.88 in Groups I and II, respectively. Freedom from reintervention was 100% for Group I at a median time of 3.2 years and 81% at 2.7 years for Group II. Reinterventions in Group II (3/16 pts) were performed predominantly for complex left ventricular outflow tract stenosis. At follow-up echocardiogram, 45% of patients in Group I had no aortic regurgitation, 30% trace-mild, 20% mild-moderate, and 5% moderate aortic regurgitation, whereas in Group II, 50% of patients had no aortic regurgitation, 32% had mild aortic regurgitation, and 18% mild-moderate aortic regurgitation. Unicuspid valves were only encountered in Group 1 (2/21 pts, 10%) and they were predictive of mild-aortic regurgitation during follow-up (p = 0.003). Ventricular fibrillation occurred in three neonates with suspicion of myocardial ischemia on the pre-procedure echocardiogram. All were successfully defibrillated.

CONCLUSIONS

Rapid right ventricular pacing can be expanded in neonates and infants to potentially decrease the incidence of aortic regurgitation and reintervention rates, hence avoiding high-risk surgical bail-out procedures for severe aortic regurgitation in the first year of life. Myocardial ischemia may predispose to ventricular dysrhythmias during rapid right ventricular pacing.

Rapid right ventricular pacing for balloon valvuloplasty in congenital aortic stenosis: A systematic review

BACKGROUND

Balloon aortic valvuloplasty (BAV) is a well-established treatment modality for congenital aortic valve stenosis.

AIM

To evaluate the role of rapid right ventricular pacing (RRVP) in balloon stabilization during BAV on aortic regurgitation (AR) in pediatric patients.

METHODS

A systematic review of the MEDLINE, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines (end-of-search date: July 8, 2020). The National Heart, Lung, and Blood Institute and Newcastle-Ottawa scales was utilized for quality assessment.

RESULTS

Five studies reporting on 72 patients were included. The studies investigated the use of RRVP-assisted BAV in infants (> 1 mo) and older children, but not in neonates. Ten (13.9%) patients had a history of some type of aortic valve surgical or catheterization procedure. Before BAV, 58 (84.0%), 7 (10.1%), 4 (5.9%) patients had AR grade 0 (none), 1 (trivial), 2 (mild), respectively. After BAV, 34 (49.3%), 6 (8.7%), 26 (37.7%), 3 (4.3%), patients had AR grade 0, 1, 2, and 3 (moderate), respectively. No patient developed severe AR after RRVP. One (1.4%) developed ventricular fibrillation and was defibrillated successfully. No additional arrhythmias or complications occurred during RRVP.

CONCLUSION

RRVP can be safely used to achieve balloon stability during pediatric BAV, which could potentially decrease AR rates.

Congenital Aortic Valve Stenosis

Aortic valve stenosis in children is a congenital heart defect that causes fixed form of hemodynamically significant left ventricular outflow tract obstruction with progressive course. Neonates and young infants who have aortic valve stenosis, usually develop congestive heart failure. Children and adolescents who have aortic valve stenosis, are mostly asymptomatic, although they may carry a small but significant risk of sudden death. Transcatheter or surgical intervention is indicated for symptomatic patients or those with moderate to severe left ventricular outflow tract obstruction. Many may need reintervention.

The Journey of an Indian Pediatric Cardiologist : Dr. K. C. Chaudhuri Lifetime Achievement Award/Oration at AIIMS, New Delhi, September 2017

The life journey of an Indian pediatric cardiologist, who bestowed considerable attention to the development of new knowledge and train/teach physicians around the world while providing care of patients with heart disease over a 45-y period, is reviewed. This appraisal focuses particular attention on the scientific contributions to the literature. These include spontaneous closure of physiologically advantageous ventricular septal defects, various issues related to a congenital heart defect namely, tricuspid atresia and transcatheter and, interventional pediatric cardiac procedures.

Long-term outcome of congenital aortic valve stenosis: predictors of reintervention

OBJECTIVES

To evaluate long-term outcome of initial aortic valve intervention in a paediatric population with congenital aortic stenosis, and to determine risk factors associated with reintervention.

PATIENTS AND METHODS

From 1985 to 2009, 77 patients with congenital aortic stenosis and a mean age of 5.8±5.6 years at diagnosis were followed up in our institution for 14.8±9.1 years.

RESULTS

First intervention was successful with 86% of patients having a residual peak aortic gradient 1 regurgitation increased by 7%. Long-term survival after the first procedure was excellent, with 91% survival at 25 years. At a mean interval of 7.6±5.3 years, 30 patients required a reintervention (39%), mainly because of a recurrent aortic stenosis. Freedom from reintervention was 97, 89, 75, 53, and 42% at 1, 10, 15, 20, and 25 years, respectively. Predictors of reintervention were residual peak aortic gradient (p=0.0001), aortic regurgitation post-intervention >1 (p=0.02), prior balloon aortic valvuloplasty (p=0.04), and increased left ventricular posterior wall thickness (p=0.1).

CONCLUSIONS

Aortic valve intervention is a safe and effective procedure for congenital aortic stenosis with excellent survival results. However, rate of reintervention is high and influenced by increased left ventricular posterior wall thickness pre-intervention, prior balloon valvuloplasty, higher residual peak systolic valve gradient, and more than mild regurgitation post-intervention. The study highlights that long-term follow-up is recommended for these patients.

Percutaneous balloon aortic valvuloplasty in different age groups

Aortic stenosis is a congenital or acquired reduction in the area of the aortic valve, resulting in obstruction of the blood flow from the left ventricle to the aorta. Aortic stenosis accounts for 2-5% of all congenital heart defects and is a potentially life-threatening disorder. In adults aortic stenosis represents 34% of all valvular heart diseases. Degenerative etiology is present in 80% of cases. Patients with mild aortic stenosis are usually asymptomatic. Symptoms of the disease occur along with the disappearance of effective compensatory mechanisms. These are symptoms of low cardiac output syndrome manifested as fainting, dizziness, ischemic pains, exercise intolerance, arrhythmias with the risk of sudden cardiac death, and heart failure. As soon as the symptoms occur the prognosis significantly worsens, which is associated with a high risk of death. Percutaneous aortic valvuloplasty is a palliative method of treatment of aortic stenosis. The aim of the procedure is to relieve left ventricular outflow tract obstruction, thereby improving cardiac output. The etiology, course of the aortic stenosis and treatment methods, including invasive procedures, vary depending on the patients' age. The purpose of this paper is to present the characteristics of the aortic valve disease and the strategy of aortic balloon valvuloplasty in different age groups.

Repeat balloon aortic valvuloplasty effectively delays surgical intervention in children with recurrent aortic stenosis

OBJECTIVE

Balloon aortic valvuloplasty (BAV) is the primary therapy for congenital aortic stenosis (AS). Recurrent AS following initial BAV or initial surgical valvotomy (SV) may require a second BAV (BAV2). We sought to determine the longterm outcomes of BAV2.

DESIGN

We reviewed all cases of BAV2, defined as BAV following primary BAV or SV between 1988 and 2009. Cases were reviewed for pre- and post-BAV2 echocardiographic and procedural details.

SETTING

Tertiary care dedicated children's hospital.

PATIENTS

Between 1985 and 2009, 43 patients underwent BAV2 (23 primary SV, 20 primary BAV) at median age 1.9 years (1 month-21 years) and median weight 15 (3.3-55) kg.

INTERVENTIONS

BAV2 performed following primary SV or primary BAV.

MAIN OUTCOME MEASURES

We evaluated the following endpoints: ≥ moderate AI post-BAV2, aortic valve replacement (AVR), additional BAV or SV post-BAV2, death and heart transplantation.

RESULTS

The gradient decreased from 61.4 ± 16.0 mm Hg to 26.0 ± 13.6 post-BAV2 (P < 0.01). Gradient prior to BAV2 was higher in primary SV patients (66 ± 13 mm Hg) than in primary BAV patients (56 ± 18 mm Hg, P = 0.04). 24 patients had no further events after BAV2, while 19 patients (44%) experienced 23 events including: AVR (n = 8), SV (n = 6), BAV3 (n = 2), death (n = 5), and transplant (n = 1). Regression demonstrated that adverse events were associated with higher post-BAV2 gradient (P < 0.01). Repeat intervention on the aortic valve and AVR were associated with higher post BAV2 gradient (P = 0.04, P = 0.01). Prior to BAV2, 7 patients (17%) had AI > mild, compared to 21 (51%) patients after BAV2. Cox regression revealed that primary BAV was associated with development of AI > mild after BAV2 (P < 0.01).

CONCLUSION

BAV2 is associated with decreased valve gradient, though with an increase in AI. However, residual AS, not AI, is associated with poor outcomes following BAV2. BAV2 effectively treats recurrent AS and postpones need for surgical intervention.

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.

[Interventional cardiac catheterization in children]

With the technological progress, the role of the cardiac catheterization has dramatically changed, moving from diagnostic to therapeutic and becoming adjuvant to surgical procedures. In various congenital heart defects, it allows to postpone the need for surgery or even cancel the surgical indication being less invasive and as powerful as surgery. It is thanks to many technological advances, in particular with the development of devices with memory alloy, that the catheterization makes such great strides today, and the miniaturization of the prosthetic material makes it possible to push back more and more the limits of feasibility which remain related to the smallness of the vascular accesses at the newborn age. The future of this discipline lies in the hybrid procedures, where a true teamwork between the surgeons and the pediatric cardiologists makes it possible to bring the best therapeutic strategy for patients with congenital heart defects.

Twenty-five year experience with balloon aortic valvuloplasty for congenital aortic stenosis

Balloon aortic valvuloplasty (BAV) is the primary therapy for congenital aortic stenosis (AS). Few reports describe long-term outcomes. In this study, a retrospective single-institution review was performed of patients who underwent BAV for congenital AS. The following end points were evaluated: moderate or severe aortic insufficiency (AI) by echocardiography, aortic valve replacement, repeat BAV, surgical aortic valvotomy, and transplantation or death. From 1985 to 2009, 272 patients who underwent BAV at ages 1 day to 30.5 years were followed for 5.8 ± 6.7 years. Transplantation or death occurred in 24 patients (9%) and was associated with depressed baseline left ventricular shortening fraction (LVSF) (p = 0.04). Aortic valve replacement occurred in 42 patients (15%) at a median of 3.5 years (interquartile range 75 days to 5.9 years) after BAV and was associated with post-BAV gradient ≥25 mm Hg (p = 0.02), the presence of post-BAV AI (p = 0.03), and below-average baseline LVSF (p = 0.04). AI was found in 83 patients (31%) at a median of 4.8 years (interquartile range 1.4 to 8.7) and was inversely related to post-BAV gradient ≥25 mm Hg (p <0.04). AI was associated with depressed baseline LVSF (p = 0.02). Repeat valvuloplasty (balloon or surgical) occurred in 37 patients (15%) at a median of 0.51 years (interquartile range 0.10 to 5.15) and was associated with neonatal BAV (p <0.01), post-BAV gradient ≥25 mm Hg (p = 0.03), and depressed baseline LVSF (p = 0.05). In conclusion, BAV confers long-term benefits to most patients with congenital AS. Neonates, patients with post-BAV gradients ≥25 mm Hg, and patients with lower baseline LVSF experienced worse outcomes.

Experience in a single centre with percutaneous aortic valvoplasty in children, including those with associated cardiovascular lesions

BACKGROUND

We report the experience in a single institution with balloon aortic valvoplasty for congenital aortic stenosis. Unlike most other reported series, we included patients with associated lesions involving the left side of the heart.

METHODS

Between November, 1986, and November, 2006, we performed 161 interventions on 143 patients, of whom 33 were neonates, 33 infants, and 77 children, just over one-quarter (28.6%) having associated lesions.

RESULTS

The overall reduction in peak-to-peak gradient of 60 ± 24% (p < 0.01), was more effective in primary versus secondary intervention (63 ± 24% versus 47 ± 23%; p < 0.03), and in those with fused bifoliate as opposed to truly bifoliate valves (66 ± 17% versus 53 ± 30%; p = 0.01). Patients with associated lesions were younger (40.89 ± 60.92 months versus 81.9 ± 72.9 months; p = 0.001), and were less likely to achieve a final pressure gradient of less than 20 mmHg (35.0% versus 61.2%; p < 0.01). Overall mortality was higher in cases with associated lesions (27.5% versus 1.9%; p < 0.0001) but not catheter-related death (2.5% versus 1.9%; p = 1.0). Reintervention was more frequently required in infants (p = 0.02) but not in cases with associated lesions (p = 0.35).

CONCLUSIONS

Balloon valvoplasty is a safe and effective method for the treatment of congenital aortic stenosis. Prior surgery to the aortic valve, reintervention, associated cardiovascular lesions, and the anatomy of the valve predict a less effective reduction in the gradient. Major complications and catheterization-related death are mainly secondary to very young age, but not to associated cardiac lesions.

Usefulness of Doppler echocardiography guidance during balloon aortic valvuloplasty for the treatment of congenital aortic stenosis

INTRODUCTION

Few data exist regarding the potential benefits of continuous echocardiographic guidance during balloon aortic valvuloplasty (BAV) for the treatment of congenital aortic stenosis (AS). The objectives of this study were 1) to prospectively evaluate, in a series of consecutive patients with severe AS, the efficacy of BAV guided by Doppler echocardiography (DE) in relieving AS while preventing the appearance of significant aortic regurgitation (AR), and 2) to compare the results obtained by BAV-DE with those obtained in a historical series of patients who underwent BAV without echocardiographic guidance (BAV guided by angiography, BAV-A).

METHODS

From 1995 to 2006 a total of 36 consecutive patients with AS (median age 6 years, range, 1 day to 26 years) underwent BAV in our center, with systematic application of continuous DE guidance since 2003. BAV-DE consisted of measuring the aortic annulus, choosing balloon diameters and evaluating the results of each balloon dilation on the basis of DE.

RESULTS

Seventeen patients underwent BAV-DE (transthoracic and transesophageal DE in 3 and 14 patients, respectively) with successful transaortic gradient relief in 88% of them. None of the patients complicated with moderate or severe AR. At 17+/-13 months follow-up there had been 3 cardiac events (18%), all of them related to aortic restenosis. BAV-A was associated with longer fluoroscopic times (35 min vs 16 min, p=0.005 after adjusting for age and weight differences between groups) and a higher degree of AR following BAV (>or=2 degrees increase in AR, 32% vs 0%, p=0.045 after adjusting for age and weight). Angiographic measurements of the aortic annulus were higher than those obtained by DE (mean overestimation+2.5+/-1.8 mm, range 0 to +6 mm, p<0.0001).

CONCLUSION

BAV-DE provides successful gradient relief of severe AS with lower fluoroscopy time and a lower degree of AR compared to BAV-A. Overestimation of aortic annulus diameters by angiographic measurements might partially explain the high rate of significant AR associated with BAV in the absence of echocardiographic guidance.

Aortic Valvuloplasty in Pediatric Patients Substantially Postpones the Need for Aortic Valve Surgery

Background— Aortic valvuloplasty (AoVP) is an established procedure regarded as a valid alternative for surgical management of congenital aortic valve stenosis. However, its long-term efficacy in preventing or postponing aortic valve surgery remains uncertain for the individual patient. Therefore, the aim of this study was to study the long-term results of AoVP in pediatric patients and its efficacy in preventing or postponing aortic valve surgery.

Methods and Results— We reviewed up to 17.5 years of follow-up data of all 188 patients who received AoVP at the Deutsches Herzzentrum München. The patients were divided into those <1 month of age (group <1 month; n=68) and those ≥1 month of age (group ≥1 month; n=120) at the time of AoVP. After the first and second AoVP, moderate and severe aortic regurgitation developed in 29% and 14%, respectively, of the patients in group <1 month and in 19% and 29%, respectively, of the patients in group ≥1 month. Survival after 10 years free from aortic valve surgery was 59% (95% confidence interval, 45 to 73) in group <1 month and 70% (95% confidence interval, 59 to 81) in group ≥1 month.

Conclusions— This study shows that the long-term results of AoVP of congenital aortic valve stenosis in pediatric patients and its efficacy in preventing or postponing aortic valve surgery are very good. About two thirds of the patients are free from aortic valve surgery 10 years after AoVP.

Cardiac pacing in balloon aortic valvuloplasty

OBJECTIVE

To evaluate the rapid ventricular pacing in balloon aortic valvuloplasty to achieve balloon stability.

MATERIAL AND METHODS

From September 2004 to July 2005, a prospective protocol was carried out: ten patients with aortic valve stenosis were treated with this method. Patient's age ranged from 3 to 16 years with mean age of 10.2+/-4.3 years. In all cases a bipolar pacing catheter was placed in the right ventricle. Rapid ventricular pacing was initiated at the rate of 150 per minute and was gradually increased to achieve a 50% drop in systemic pressure. The balloon was inflated only after the pacing rate was reached and the blood pressure dropped. Pacing was continued until the balloon was completely deflated.

RESULTS

The systolic gradients across the aortic valve before balloon dilatation ranged from 40 to 110 mm Hg, mean 68.5+/-20 mm Hg. The pacing rate required to drop the pressure by 50% ranged from 170 to 250 per minute, mean 209+/-25. Balloon stability at time of inflation was achieved in all cases with no balloon movement. The post ballooning gradients ranged from 5 to 28 mm Hg, mean 19.7+/-8.3 mm Hg (p<0.001). In all cases there was no change in aortograms, performed before and after balloon dilatation in aorta, except in one patient who developed grade I aortic regurgitation.

CONCLUSIONS

Rapid ventricular pacing appears to be an effective and a safe procedure to stabilize the balloon during balloon aortic valvuloplasty and is thought to decrease the incidence of aortic insufficiency.

Outcomes after balloon dilation of congenital aortic stenosis in children and adolescents

OBJECTIVES

To determine the long-term outcomes and risk factors for, reintervention after balloon dilation of congenital aortic stenosis in children aged 6 months or older.

BACKGROUND

Although balloon dilation of congenital aortic stenosis has become a primary therapeutic strategy, few data are available regarding long-term outcomes.

METHODS

We carried out a retrospective review of 87 children who had undergone balloon dilation of the aortic valve at median age of 6.9 years.

RESULTS

The procedure was completed in 98% of the children, with an average reduction in the gradient across the valve of 64 +/- 28%, and without mortality. Of the children, 76 had been followed for a mean of 6.3 +/- 4.2 years. Reintervention on the aortic valve was required in 32 children, with 12 undergoing reintervention within 6 months, with 1 death. Another patient had died over the period of follow-up due to a non-cardiac event. Estimated freedom from reintervention was 86% at 1 year, 67% at 5 years, and 46% at 12 years. Parametric modeling of the hazard function showed a brief early phase of increased risk, superimposed on an ongoing constant risk. The only incremental risk factor for the early phase was a residual gradient immediately subsequent to the procedure greater than 30 mmHg. Incremental risk factors for the constant phase included the presence of symmetric valvar opening, and greater than moderate regurgitation immediately after dilation.

CONCLUSION

Long-term survival was excellent, albeit that the need for further reintervention was high due to the palliative nature of the procedure.

Long term results of percutaneous balloon valvoplasty of congenital aortic stenosis: independent predictors of outcome

OBJECTIVE

To evaluate long term results and independent predictors of outcome of aortic valvoplasty.

DESIGN

Retrospective follow up study. Independent predictors of outcome identified by multiple logistic regression.

SETTING

Tertiary referral centre.

PATIENTS

269 consecutive patients treated at the median age of 8 months (0-23 years): 80 (30%) under 4 weeks, 59 (22%) between 4 weeks and 1 year, and 130 (48%) over 1 year. The follow up period was up to 14.8 years (median 5.3, in survivors 6.4 years).

INTERVENTIONS

Percutaneous balloon valvoplasty with mean (SD) balloon to annulus ratio 0.97 (0.08).

MAIN OUTCOME MEASURES

Restenosis > or = 70 mm Hg, grade 3 aortic insufficiency, cusps disruption, surgery, death, and valvoplasty failure (significant restenosis or insufficiency or surgery or death).

RESULTS

The mortality rate was 10.4% (n = 28), the restenosis rate was 16.7% (n = 45), significant insufficiency developed in 22.3% (n = 60), surgery was needed in 20.1% (n = 54), and "valvoplasty failure" occurred in 41.6% (n = 112) patients. Mean (SEM) survival probability 14.4 years after the procedure was 0.89 (0.02) and mean (SEM) probability of surgery-free survival was 0.50 (0.08). The independent predictors were as follows. For restenosis: small aortic annulus; for cusp disruption: large aortic annulus; for insufficiency: bicuspid aortic valve; for need for surgery: bicuspid aortic valve; for death: small aortic annulus, low left ventricular shortening fraction, and low sequential number of the valvoplasty; and for valvoplasty failure: small aortic annulus, bicuspid aortic valve, and high grade of mitral insufficiency.

CONCLUSION

Independent predictors of unfavourable outcome are small aortic annulus, bicuspid aortic valve, poor function of left ventricle or mitral valve, and limited operator experience.

Balloon aortic valvoplasty in paediatric patients: progressive aortic regurgitation is common

OBJECTIVE

To evaluate immediate and midterm results after balloon valvoplasty in a paediatric population with congenital aortic stenosis, giving special consideration to aortic regurgitation.

DESIGN

Retrospective study.

SETTING

Two tertiary referral centres for paediatric cardiology.

PATIENTS

70 consecutive patients, with an age range of 0-16.4 years. Group A infants < 3 months old (n = 21). Group B children > 3 months old (n = 49). Median follow up time was 19.8 months, range 0-158 months.

INTERVENTION

All patients underwent balloon aortic valvoplasty. The balloon to annulus ratio was selected at a mean of 0.90 (range 0.67-1.0).

MAIN OUTCOME MEASURES

Doppler gradients and degree of aortic regurgitation.

RESULTS

The pressure gradient dropped significantly with the intervention and increased mildly at follow up. Freedom from relevant aortic regurgitation (that is, moderate and severe) was initially lower in group A (75% v 90% after one month) but after two years the difference between the two groups was not significant (50% v 61%). Freedom from reintervention was significantly lower in group A (with 35% v 80%) after three years.

CONCLUSION

Aortic balloon valvoplasty is safe and effective but has a high rate of early reintervention in infants with critical aortic stenosis. The major long term problem is progressive aortic regurgitation, which does not seem to be prevented by the use of small balloons.

Recent advances in pediatric cardiology--electrophysiology, transcatheter and surgical advances

Whereas the medical advances were reviewed in the previous paper, electrophysiological, transcatheter and surgical advances will be the focus in this review. Greater understanding of the arrhythmias, development of non-pharmacological treatment, namely catheter ablation and internal cardioverter-defibrillator (ICD) and miniaturization pacemakers and IDs have occurred in the last decade so that the methods could be applied to smaller and more complex patient population. Surgery has been the traditional treatment option for palliation and correction of congenital and acquired heart defects in infants and children. During the last one to one and one-half decades, a remarkable number of transcatheter methods were developed and refined. These developments during the last decade were reviewed and include long-term results of balloon dilatation procedures, transcatheter closure of atrial septal defects, patent ductus arteriosus, and ventricular septal defect, percutaneous valve replacement, intravascular stents to manage vascular obstructive lesions that can not be satisfactorily balloon-dilated, catheter completion of Fontan procedure, myocardial reduction in hypertrophic cardiomyopathy and other miscellaneous procedures. Recent advances in the transcatheter modes of therapy have added a new dimension to the management of neonates, infants and children with heart disease. They should now be added to the armamentarium available to the Pediatrician and Pediatric Cardiologist in the management of cardiac problems in the pediatric patient. Surgical methods and concepts have been greatly refined such that surgery can be undertaken even in the sickest and most complex patient. The majority of congenital heart defects can be corrected by open heart surgery; some require prior palliation and others can be operated without prior palliation. Recent advances in various defects were reviewed.

Outcomes of uncomplicated aortic valve stenosis presenting in infants

BACKGROUND

The management of uncomplicated aortic valve stenosis presenting with critical obstruction in infants continues to be associated with significant morbidity and mortality. However, not all infants have critical obstruction, and outcomes spanning the broader spectrum of disease severity are less well defined.

METHODS

In a 12-year period, 55 infants (<3 months of age) were seen with aortic valve stenosis and with anatomy suitable for biventricular repair. Clinical, echocardiographic, angiographic, management, and outcome data were reviewed.

RESULTS

Status at presentation (median age 6 days) included signs of congestive heart failure in 20 patients, cardiovascular collapse in 5 patients, and an asymptomatic heart murmur in 30 patients. The initial echocardiogram showed reduced left ventricular function in 26% of patients, with a mean peak instantaneous gradient of 69 +/- 30 mm Hg in patients with normal function. There were 5 deaths (9%), all in patients with poor ventricular function. The initial intervention was balloon valvotomy in 24 patients and surgical valvotomy in 20 patients, with 11 patients having no intervention to date. The freedom-from-intervention rate was 69% at age 1 week, 58% at 1 month, 36% at 3 months, and 28% at 1 year. Patients without cardiovascular collapse, normal left ventricular function, and gradients <60 mm Hg at presentation (n =1 9) had better survival and longer freedom from intervention than patients with poor ventricular function or gradients >or=60 mm Hg (n = 36, P =.0001).

CONCLUSION

Most infants with aortic valve stenosis receive intervention, although this may be safely delayed in selected patients with lower initial gradients and good left ventricular function.

Percutaneous aortic valvoplasty in congenital aortic valvar stenosis

OBJECTIVE

To evaluate immediate and midterm results with percutaneous aortic valvoplasty.

MATERIAL AND METHODS

We reviewed the records of 141 patients undergoing percutaneous aortic valvopasty over a period of 13 years.

RESULTS

The patients were aged from 2 months to 40 years, with a mean of 10.9 +/- 9.9 years. Of the total, 90 (63+/%) were male. The initial systolic peak-to-peak gradient decreased from 163 +/- 52 mmHg to 32 +/- 18 mmHg (p < 0.01) after valvoplasty in all 141 patients, while the proportional reduction ranged from 0 to 100%, with a mean of 72 +/- 27%. The index of the size of the balloon to the diameter of the valvar orifice was 0.88 +/- 0.19 in 128 patients. The follow-up ranged from 6 to 168 months, with a mean 51 +/- 48 months in 70 patients. A significant difference was found in those failing after dilation when the initial evaluation was compared to the final evaluation of patients with follow-up. In those failing, the number of patients rose from 12 (17%) to 21 (30%) (p < 0.01). In contrast, in those in whom we achieved success, there was not such a great difference between the initial and final evaluation: 58 (83%) versus 49 (70%) (p < 0.1). The actuarial freedom curve of patients not needing new percutaneous aortic valvoplasty or surgery, by 182 months, was at 87% and 82% respectively.

CONCLUSION

We have reviewed the largest series of patients in Latin-America reported thus far after undergoing percutaneous aortic valvoplasty, concentrating on mid term follow-up and limitations. New prospective and multicentric studies are needed from our region.

Aortic stenosis

Valvular aortic stenosis in pediatric age group is mostly congenital in origin. The aortic valve may be unicuspid, bicuspid, tricuspid or rarely quadricuspid. Left ventricle undergoes concentric hypertrophy secondary to obstruction to its outflow tract. In neonatal aortic stenosis, left ventricle may be hypoplastic. The pathophysiology and clinical presentation vary with the age of onset and severity of obstruction. Echocardiography and Doppler are indispensible for the diagnosis of aortic stenosis and its severity. Cardiac catheterization is not necessary for the diagnosis, however it is performed as a part of balloon aortic valvuloplasty in severe cases. Balloon valvuloplasty is an effective alternative to surgery in pediatric age group. Some of these patients require surgical valve repair or replacement on follow-up. Neonates and young infants with critical aortic stenosis present with cardiogenic shock and need aggressive treatment with prostaglandin E1 infusion along with inotropic support. In experienced hands, balloon valvuloplasty is a safe procedure in neonates and infants with critical stenosis. Patients with mild and moderate aortic stenosis may be left on medical follow-up.

Valve-sparing operation for balloon-induced aortic regurgitation in congenital aortic stenosis

OBJECTIVE

Aortic regurgitation after balloon dilation of congenital aortic stenosis may be treated with valve repair as an alternative to replacement.

METHODS

Charts and echocardiograms of all patients undergoing aortic valve operations after balloon dilation of congenital aortic stenosis at our institution between January 1988 and December 1999 were reviewed.

RESULTS

Twenty-one patients underwent valvuloplasty for predominant aortic regurgitation 9 months to 15 years (mean, 6.1 years) after balloon dilation. The mean +/- SD age at the time of the operation was 11 +/- 7 years. Aortic regurgitation was caused by a combination of commissural avulsion (10), cusp dehiscence with retraction (9), cusp tear (5), central incompetence (2), perforated cusp (1), or cusp adhesion to the aortic wall (1). Repair techniques included commissural reconstruction with a pericardial patch (8), pericardial patch cusp augmentation (6), primary suture repair (6), raphae release and debridement (4), commissurotomy (4), commissural resuspension with sutures (3), and cusp release (1). There were no deaths. At a mean follow-up of 30.1 months (range, 9 months-8 years), all patients were asymptomatic, and the grade of aortic regurgitation had been significantly reduced (P <.001). Left ventricular end-diastolic dimension z scores and proximal regurgitant jet/aortic anulus diameter ratios were significantly reduced (P <.001) and remained so over time. Freedom from reoperation for late failure was 100%, and overall freedom from reintervention was 80% at 3 years.

CONCLUSION

Aortic valve repair for balloon-induced aortic regurgitation is reproducible and durable at medium-term follow-up.

Balloon aortic valvuloplasty in children: a multicenter study in Japan

A questionnaire was used to survey the experience of 8 Japanese institutions with percutaneous transluminal aortic valvuloplasty (PTAV) in children. Among 99 procedures reported in 88 patients, sufficient data for analysis was obtained from 76 procedures in 72 patients. In those 76 procedures the pressure gradient decreased significantly from 68+/-25 (20-140) to 33+/-22 (0-100) mmHg (p<0.01), whereas aortic regurgitation (AR) increased at least one grade in 26 cases (34%). None of the parameters analyzed in this study were predictors of an increase in AR. The reduction in pressure gradient was judged as good in 44 of the 76 procedures (58%). A larger ring diameter, larger balloon diameter and larger ratio balloon diameter/the normal predicted diameter of the aortic valve ring significantly contributed to an effective reduction of pressure gradient. Follow up data (mean interval, 4 years) was available for 26 of 39 clinically effective procedures. AR progressed at least 1 grade in 11 (42%), and the pressure gradient re-developed to more than 50mmHg in 2 cases (8%). In Japan, PTAV has been accepted as a useful procedure for valvular aortic stenosis in children, but progressive AR or re-development of the pressure gradient is not uncommon even after clinically effective PTAV.

Critical aortic stenosis in the neonate: a multi-institutional study of management, outcomes, and risk factors. Congenital Heart Surgeons Society

OBJECTIVES

We sought to determine factors that would predict whether a biventricular repair or Norwood procedure pathway would give the best survival in neonates with critical aortic stenosis.

METHODS

Survival and risk factors were determined with parametric time-dependent event analysis for patients undergoing either the Norwood procedure or biventricular repair, and predicted optimal pathway and survival benefit were derived from multivariable linear regression.

RESULTS

From 1994 to 2000, 320 neonates with critical left ventricular outflow obstruction were entered into a prospective multi-institutional study. Patients who died without intervention (n = 19) and those with primary cardiac transplantation (n = 6) were excluded. An initial intended biventricular repair pathway was indicated in 116 patients, with survival of 70% at 5 years. An initial Norwood procedure was performed in 179 patients, with survival of 60% at 5 years. Using predictions from separate multivariable hazard models for survival with each of the 2 pathways, we determined predicted optimal pathway and survival benefit for each patient. Significant independent factors associated with greater survival benefit for the Norwood procedure versus biventricular repair included younger age at entry, lower z-score of the aortic valve and left ventricular length, higher grade of endocardial fibroelastosis, absence of important tricuspid regurgitation, and larger ascending aorta. Predicted survival benefit favored the Norwood procedure in 50% of patients who had biventricular repair, and it favored biventricular repair in 20% of patients who had the Norwood procedure.

CONCLUSIONS

Morphologic and functional factors can be used to predict optimal pathway and survival benefit in neonates with critical left ventricular outflow obstruction.

Congenital severe aortic stenosis with congestive heart failure in late childhood and adolescence: effect on left ventricular function after balloon valvuloplasty

Left ventricular (LV) dysfunction with congestive heart failure (CHF) resulting from severe congenital aortic stenosis (AS) is a well-described condition in infancy, but it is rarely found in older children and adolescents. Aortic valve surgery in such cases may be associated with higher rates of morbidity and mortality. Aortic valve balloon dilatation (AVBD) is a viable alternative, but its effect on LV function has not been evaluated. We describe follow-up results of AVBD in 10 cases of severe congenital AS in older children and adolescents with CHF and LV dysfunction. The ages of these patients ranged from 5 to 18 yr (mean +/- SD: 10.8 +/- 4 yr), and nine were males. The follow-up period after AVBD ranged from 3 mo to 7 yr (mean +/- SD: 2.93 +/- 2.1 yr). Success was achieved in all cases, with no immediate complications. After valvuloplasty, the peak-to-peak systolic gradient declined from 74.7 +/- 30.8 to 33.9 +/- 18.2 mm Hg (P < 0.0001). The cardiac index increased slightly but significantly, from 1.9 +/- 0.27 to 2.2 +/- 0.5 L/min/m(2) (P < 0.015). Hemodynamic improvement was also confirmed by a significant decrease in mean pulmonary artery and pulmonary artery wedge pressures from 41.9 +/- 9 to 32.6 +/- 6.6 and from 25.5 +/- 2.9 to 19.3 +/- 3.4 mm Hg, respectively. The echocardiographically derived left ventricular ejection fraction (LVEF) improved from 21.6 +/- 5. 37% to 31 +/- 6.5% within 24 hr after AVBD, and it further improved in all cases on follow-up. Mean LVEF at last follow-up was 59.4 +/- 11.4%. The Doppler instantaneous peak systolic gradient (IPSG) increased from 37.3 +/- 18.8 to 64.8 +/- 30.7 mm Hg at late follow-up. Significant aortic regurgitation (AR) developed in 20% of patients. The Doppler IPSG across the aortic valve was > 60 mm Hg in five cases on follow-up. Two of these patients underwent another AVBD successfully 4 and 16 mo later, respectively. Aortic valve replacement was done in two patients, one for severe restenosis with mild AR 12 mo after AVBD and another for severe re-restenosis with moderate AR 21 mo after a second AVBD. Severe congenital AS can be associated with LV dysfunction and CHF in late childhood and adolescence. AVBD results in good palliation with improvement in LV function on follow-up.

Radiographic evaluation of the neonate with congenital heart disease

Remarkable advances in pediatric cardiology have been spurred by the explosion of technologies both in interventional and surgical techniques and the ability to manipulate the genome of experimental animals. After a brief discussion concerning the striking advances in the molecular understanding of congenital heart disease, this article focuses on clues to the diagnosis of congenital heart disease and on chest radiography and common, specific lesions of the neonate such as hypoplastic left heart, transposition of the great vessels, and severe tetralogy of Fallot. The impact of treatment protocols involving interventional cardiology in the neonate also are discussed.

Long-term follow-up results after balloon dilatation of pulmonic stenosis, aortic stenosis, and coarctation of the aorta: a review

Although immediate and intermediate-term results after balloon dilatation of congenital stenotic lesions of the heart in children are well studied, long-term results have not been documented. Therefore, we reviewed our experience along with the limited published data to address this issue. Late follow-up after balloon pulmonary and aortic valvuloplasty shows low-residual gradients, reintervention-free rates in the mid-80s for pulmonic and in the mid-50s for aortic stenosis, and an increase in degree and prevalence of similunar valve insufficiency. Balloon angioplasty of aortic coarctation results in low-residual gradients, residual hypertension in a minority of patients, low prevalence of aneurysms, and high rates of recurrence in the neonate and young infant. Overall, balloon dilatation is a useful technique in relieving congenital obstructive lesions of the heart in the pediatric patient, but continued study of (1) late pulmonary and aortic insufficiency after valvuloplasty, (2) recurrence and aneurysms after balloon angioplasty of coarctations and, (3) femoral artery compromise in lesions requiring transfemoral artery approach is warranted.

Interventional cardiac catheterization

Over the past decade, transcatheter interventions have become increasingly important in the treatment of patients with congenital heart lesions. These procedures may be broadly grouped as dilations (e.g., septostomy, valvuloplasty, angioplasty, and endovascular stenting) or as closures (e.g., vascular embolization and device closure of defects). Balloon valvuloplasty has become the treatment of choice for patients in all age groups with simple valvar pulmonic stenosis and, although not curative, seems at least comparable to surgery for congenital aortic stenosis in newborns to young adults. Balloon angioplasty is successfully applied to a wide range of aortic, pulmonary artery, and venous stenoses. Stents are useful in dilating lesions of which the intrinsic elasticity results in vessel recoil after balloon dilation alone. Catheter-delivered coils are used to embolize a wide range of arterial, venous, and prosthetic vascular connections. Although some devices remain investigational, they have been successfully used for closure of many arterial ducts and atrial and ventricular septal defects. In the therapy for patients with complex CHD, best results may be achieved by combining cardiac surgery with interventional catheterization. The cooperation among interventional cardiologists and cardiac surgeons was highlighted in a report of an algorithm to manage patients with tetralogy of Fallot or pulmonary atresia with diminutive pulmonary arteries, involving balloon dilation, coil embolization of collaterals, and intraoperative stent placement. In this setting, well-planned catheterization procedures have an important role in reducing the overall number of procedures that patients may require over a lifetime, with improved outcomes.