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Rao PS. Recent Advances in the Diagnosis and Management of Congenital Heart Disease. CHILDREN (BASEL, SWITZERLAND) 2024; 11:84. [PMID: 38255397 PMCID: PMC10814956 DOI: 10.3390/children11010084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024]
Abstract
Congenital heart defects (CHDs) are structural abnormalities of the heart or blood vessels that occur while cardiac structures are being formed in utero [...].
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Affiliation(s)
- P Syamasundar Rao
- Children's Heart Institute, University of Texas at Houston McGovern Medical School, Children's Memorial Hermann Hospital, 6410 Fannin Street, Suite #425, Houston, TX 77030, USA
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O'Halloran CP, Ramlogan S, Husain N, Fox J, Nugent AW, Tannous P. Echocardiogram-Guided Balloon Valvuloplasty of the Aortic Valve in Neonates and Infants Reduces Contrast Exposure with Maintained Efficacy and Less Aortic Regurgitation. Pediatr Cardiol 2023:10.1007/s00246-023-03188-9. [PMID: 37391604 DOI: 10.1007/s00246-023-03188-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/14/2023] [Indexed: 07/02/2023]
Abstract
Balloon aortic valvuloplasty (BAV) is performed in children with significant aortic stenosis (AS). Traditionally, contrast angiography measures the annulus and assesses aortic regurgitation (AR) after each dilation. Echocardiographic guidance is hypothesized to reduce contrast and radiation exposure, without compromising efficacy or safety. Patients < 10 kg undergoing BAV from 2013 to 2022 were retrospectively investigated. Agreement between echocardiographic and angiographic annulus measurements was assessed. Echocardiogram-guided (eBAV) and traditional angiogram-guided (tBAV) outcomes were compared controlling for weight, critical AS, and other congenital heart disease (CHD). Twelve eBAV and 19 tBAV procedures were performed. The median age was 33 days, median weight was 4.3 kg, 7 patients (23%) had critical AS, and 9 patients (29%) had other CHD. Annulus measurements by intraprocedural echocardiography and angiography displayed excellent correlation (ICC 0.95, p < 0.001). eBAV patients received less contrast (0.5 vs 3.5 ml/kg, p < 0.01). Five recent eBAV procedures were performed contrast free. Radiation exposure was not statistically different between the eBAV and tBAV groups (155 vs 313 µGy·M2, p = 0.12). One eBAV patient (8%) and 3 tBAV patients (16%, p = 0.62) experienced serious adverse events. Technical success (gradient < 35 mmHg and increase in AR by ≤ 1 grade) occurred in 11 eBAV patients (92%) and 16 tBAV patients (84%, p = 0.22). AR increased in 2 eBAV patients (17%) and 8 tBAV patients (44%, p = 0.02). eBAV was associated with similar efficacy and significantly lower contrast exposure and risk of aortic regurgitation. There was strong agreement between aortic valve annulus measurements by intraprocedural echocardiography and angiography, ultimately permitting contrast free BAV.
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Affiliation(s)
- Conor P O'Halloran
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Sandhya Ramlogan
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nazia Husain
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jeremy Fox
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Alan W Nugent
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Paul Tannous
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Beyazal M, Orun U, Dogan V, Dilli D. Outcomes of aortic balloon valvuloplasty in newborns: A single-centre experience. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2022. [DOI: 10.4103/ijca.ijca_18_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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4
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Papneja K, Blatman ZM, Kawpeng ID, Wheatley J, Oscé H, Li B, Lafreniere-Roula M, Fan CPS, Manlhiot C, Benson LN, Mertens L. Trajectory of Left Ventricular Remodeling in Children With Valvar Aortic Stenosis Following Balloon Aortic Valvuloplasty. Circ Cardiovasc Imaging 2022; 15:e013200. [PMID: 35041447 PMCID: PMC8772052 DOI: 10.1161/circimaging.121.013200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Aortic valve stenosis is the most common type of congenital left ventricular (LV) outflow tract obstruction. Balloon aortic valvuloplasty (BAV) has become the first-line treatment pathway in many centers. Our aim was to assess the trajectory of LV remodeling following BAV in children and its relationship to residual aortic stenosis (AS) and insufficiency (AI). Methods: Children <18 years of age who underwent BAV for isolated aortic stenosis from 2004 to 2012 were eligible for inclusion. Those with AI before BAV, other complex congenital heart lesions, or <2 accessible follow-up echocardiograms were excluded. Baseline and serial echocardiographic data pertaining to aortic valve and LV size and function were retrospectively collected through December 2017 or the first reintervention. Longitudinal data was assessed using per-patient time profiles with superimposed trend lines using locally estimated scatterplot smoothing. Associations with reintervention or death were also evaluated. Results: Among the 98 enrolled children, the median (interquartile range) age at BAV was 2.8 months (0.2–75). The median (interquartile range) follow-up was 6.8 years (1.9–9.0). Children with predominantly residual AI (n=11) demonstrated progressive increases in their LV end-diastolic dimension Z score within the first 3 years after the BAV, followed by a plateau (P<0.001). Their mean LV circumferential and longitudinal strain values remained within the normal range but lower than in the non-AI group (P<0.001 and P=0.001, respectively). Children with predominantly residual aortic stenosis (n=44) had no changes in LV dimensions but had a rapid early increase in mean LV circumferential and longitudinal strain. The cumulative proportion (95% CI) of reintervention at 5 years following BAV was 33.7% (23.6%–42.4%). Conclusions: Our study demonstrates that LV remodeling occurs mainly during the first 3 years in children with predominantly residual AI after BAV, with no subsequent significant functional changes over the medium term. These data improve our understanding of expected patient trajectories and thus may inform decisions on the timing of reintervention.
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Affiliation(s)
- Koyelle Papneja
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.).,Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at University of California Los Angeles, CA (K.P.)
| | - Zachary M Blatman
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Ian D Kawpeng
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Jacqueline Wheatley
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Hanne Oscé
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Boning Li
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Myriam Lafreniere-Roula
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Chun P S Fan
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Cedric Manlhiot
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Lee N Benson
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
| | - Luc Mertens
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada (K.P., Z.M.B., I.D.K., J.W., H.O., B.L., M.L.-R., C.P.S.F., C.M., L.N.B., L.M.)
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Semilunar Valve Interventions for Congenital Heart Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:71-79. [PMID: 33413944 DOI: 10.1016/j.jacc.2020.10.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 02/06/2023]
Abstract
Transcatheter balloon valvuloplasty for the treatment of aortic and pulmonary valve stenosis was first described nearly 40 years ago. Since that time, the technique has been refined in an effort to optimize acute outcomes while reducing the long-term need for reintervention and valve replacement. Balloon pulmonary valvuloplasty is considered first-line therapy for pulmonary valve stenosis and generally results in successful relief of valvar obstruction. Larger balloon to annulus (BAR) diameter ratios can increase the risk for significant valvar regurgitation. However, the development of regurgitation resulting in right ventricular dilation and dysfunction necessitating pulmonary valve replacement is uncommon in long-term follow-up. Balloon aortic valvuloplasty has generally been the first-line therapy for aortic valve stenosis, although some contemporary studies have documented improved outcomes following surgical valvuloplasty in a subset of patients who achieve tri-leaflet valve morphology following surgical repair. Over time, progressive aortic regurgitation is common and frequently results in the need for aortic valve replacement. Neonates with critical aortic valve stenosis remain a particularly high-risk group. More contemporary data suggest that acutely achieving an aortic valve gradient <35 mm Hg with mild aortic regurgitation may improve long-term valve performance and reduce the need for valve replacement. Continued study will help to further improve outcomes and reduce the need for future reinterventions.
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Herrmann JL, Clark AJ, Colgate C, Rodefeld MD, Hoyer MH, Turrentine MW, Brown JW. Surgical Valvuloplasty Versus Balloon Dilation for Congenital Aortic Stenosis in Pediatric Patients. World J Pediatr Congenit Heart Surg 2021; 11:444-451. [PMID: 32645785 DOI: 10.1177/2150135120918774] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For children with congenital aortic stenosis (AS) who are candidates for biventricular repair, valvuloplasty can be achieved by surgical aortic valvuloplasty (SAV) or by transcatheter balloon aortic dilation (BAD). We aimed to evaluate the longer term outcomes of SAV versus BAD at our institution. METHODS We retrospectively reviewed the outcomes of 2 months to 18 years old patients who underwent SAV or BAD at our institution between January 1990 and July 2018. Baseline and follow-up characteristics were assessed by echocardiography. Long-term survival, freedom from reintervention, freedom from aortic valve replacement (AVR), and aortic regurgitation were evaluated. RESULTS A total of 212 patients met inclusion criteria (SAV = 123; BAD = 89). Age, sex, aortic insufficiency (AI), and aortic valve gradient were similar between the groups. At 10 years, 27.9% (19/68) of SAV patients and 58.3% (28/48) of BAD patients had moderate or worse AI (P = .001), and reintervention occurred in 39.2% (29/74) of SAV patients and 78.6% (44/56) of BAD patients (P < .001). Kaplan-Meier analysis revealed overall survival was 96.8% (119/123) for SAV and 95.5% (85/89) for SAV (P = .87). At 10 years, 35% (23/66) of SAV patients and 54% (23/43) of BAD patients underwent AVR (P = .213). CONCLUSIONS Surgical aortic valvuloplasty demonstrated greater gradient reduction, less postoperative and long-term AI, and a lower reintervention rate at 10 years than BAD. There was no difference in survival or AVR reintervention rate. Surgical aortic valvuloplasty is a durable and efficacious intervention and should continue to be considered a favorable choice for palliation of valvular AS.
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Affiliation(s)
- Jeremy L Herrmann
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Aaron J Clark
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cameron Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark D Rodefeld
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Mark H Hoyer
- Riley Children's Health at IU Health, Indianapolis, IN, USA.,Section of Pediatric Cardiology, Department of Pediatrics, Indianapolis, IN, USA
| | - Mark W Turrentine
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - John W Brown
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Children's Health at IU Health, Indianapolis, IN, USA
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Balloon Valvuloplasty for Congenital Aortic Stenosis: Experience at a Tertiary Center in a Developing Country. J Interv Cardiol 2021; 2021:6681693. [PMID: 33519306 PMCID: PMC7815385 DOI: 10.1155/2021/6681693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/15/2020] [Accepted: 12/29/2020] [Indexed: 11/23/2022] Open
Abstract
Background Aortic valve stenosis accounts for 3–6% of congenital heart disease. Balloon aortic valvuloplasty (BAV) is the preferred therapeutic intervention in many centers. However, most of the reported data are from developed countries. Materials and Methods We performed a retrospective single-center study involving consecutive eligible neonates and infants with congenital aortic stenosis admitted for percutaneous BAV between January 2005 and January 2016 to our tertiary center. We evaluated the short- and mid-term outcomes associated with the use of BAV as a treatment for congenital aortic stenosis (CAS) at a tertiary center in a developing country. Similarly, we compared these outcomes to those reported in developed countries. Results During the study period, a total of thirty patients, newborns (n = 15) and infants/children (n = 15), underwent BAV. Left ventricular systolic dysfunction was present in 56% of the patients. Isolated AS was present in 19 patients (63%). Associated anomalies were present in 11 patients (37%): seven (21%) had coarctation of the aorta, two (6%) had restrictive ventricular septal defects, one had mild Ebstein anomaly, one had Shone's syndrome, and one had cleft mitral valve. BAV was not associated with perioperative or immediate postoperative mortality. Immediately following the valvuloplasty, a more than mild aortic regurgitation was noted only in two patients (7%). A none-to-mild aortic regurgitation was noted in the remaining 93%. One patient died three months after the procedure. At a mean follow-up of 7 years, twenty patients (69%) had more than mild aortic regurgitation, and four patients (13%) required surgical intervention. Kaplan–Meier freedom from aortic valve reintervention was 97% at 1 year and 87% at 10 years of follow-up. Conclusion Based on outcomes encountered at a tertiary center in a developing country, BAV is an effective and safe modality associated with low complication rates comparable to those reported in developed countries.
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Echocardiographic versus angiographic measurement of the aortic valve annulus in children undergoing balloon aortic valvuloplasty: method affects outcomes. Cardiol Young 2020; 30:1923-1929. [PMID: 33050969 DOI: 10.1017/s1047951120003194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Rapid right ventricular pacing for balloon aortic valvuloplasty: expanding its routine use in neonates and infants. Cardiol Young 2020; 30:1890-1895. [PMID: 33021192 DOI: 10.1017/s1047951120003133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Mylonas KS, Ziogas IA, Mylona CS, Avgerinos DV, Bakoyiannis C, Mitropoulos F, Tzifa A. Rapid right ventricular pacing for balloon valvuloplasty in congenital aortic stenosis: A systematic review. World J Cardiol 2020; 12:540-549. [PMID: 33312439 PMCID: PMC7701905 DOI: 10.4330/wjc.v12.i11.540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Konstantinos S Mylonas
- Department of Cardiothoracic Surgery, Yale New Haven Hospital, New Haven, CT 06510, United States
| | - Ioannis A Ziogas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Charitini S Mylona
- Department of Pediatrics, Trikala General Hospital, Trikala 42100, Greece
| | - Dimitrios V Avgerinos
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital, New York, NY 10065, United States
| | - Christos Bakoyiannis
- Division of Vascular Surgery, First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Fotios Mitropoulos
- Department of Pediatric Cardiac Surgery, Mitera Children’s Hospital, Athens 15123, Greece
| | - Aphrodite Tzifa
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, Mitera Children’s Hospital, Athens 15123, Greece
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Decision-Making in the Catheter Laboratory: The Most Important Variable in Successful Outcomes. Pediatr Cardiol 2020; 41:459-468. [PMID: 32198590 DOI: 10.1007/s00246-020-02295-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/17/2020] [Indexed: 10/24/2022]
Abstract
Increasingly the importance of how and why we make decisions in the medical arena has been questioned. Traditionally the aeronautical and business worlds have shed a light on this complex area of human decision-making. In this review we reflect on what we already know about the complexity of decision-making in addition to directing particular focus on the challenges to decision-making in the high-intensity environment of the pediatric cardiac catheterization laboratory. We propose that the most critical factor in outcomes for children in the catheterization lab may not be technical failures but rather human factors and the lack of preparation and robust shared decision-making process between the catheterization team. Key technical factors involved in the decision-making process include understanding the anatomy, the indications and objective to be achieved, equipment availability, procedural flow, having a back-up plan and post-procedural care plan. Increased awareness, pre-catheterization planning, use of standardized clinical assessment and management plans and artificial intelligence may provide solutions to pitfalls in decision-making. Further research and efforts should be directed towards studying the impact of human factors in the cardiac catheterization laboratory as well as the broader medical environment.
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Singh GK. Congenital Aortic Valve Stenosis. CHILDREN-BASEL 2019; 6:children6050069. [PMID: 31086112 PMCID: PMC6560383 DOI: 10.3390/children6050069] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/01/2019] [Accepted: 05/08/2019] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Gautam K Singh
- Washington University School of Medicine, Department of Pediatrics, Campus Box 8116-NWT, 1 Children's Place, Saint Louis, MO 63110, USA.
- St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA.
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Variations in Practice Patterns and Consistency With Published Guidelines for Balloon Aortic and Pulmonary Valvuloplasty: An Analysis of Data From the IMPACT Registry. JACC Cardiovasc Interv 2019; 11:529-538. [PMID: 29566797 DOI: 10.1016/j.jcin.2018.01.253] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/18/2017] [Accepted: 01/16/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The authors sought to study variation in the practice of balloon aortic (BAV) and pulmonary valvuloplasty (BPV). BACKGROUND The IMPACT (IMProving Adult and Congenital Treatment) registry provides an opportunity to study practice variation in transcatheter interventions for congenital heart disease. METHODS The authors studied BAV and BPV in the IMPACT registry from January 1, 2011, to September 30, 2015, using hierarchical multivariable models to measure hospital-level variation in: 1) the distribution of indications for intervention; and 2) in cases with "high resting gradient" as the indication, consistency with published guidelines. RESULTS A total of 1,071 BAV cases at 60 hospitals and 2,207 BPV cases at 75 hospitals were included. The indication for BAV was high resting gradient in 82%, abnormal stress test or electrocardiogram (2%), left ventricular dysfunction (11%), and symptoms (5%). Indications for BPV were high resting gradient in 82%, right-left shunt (6%), right ventricular dysfunction (7%), and symptoms (5%). No association between hospital characteristics and distribution of indications was demonstrated. Among interventions performed for "high resting gradient," there was significant adjusted hospital-level variation in the rates of cases performed consistently with guidelines. For BAV, significant differences were seen across census regions, with hospitals in the East and South more likely to practice consistently than those in the Midwest and West (p = 0.005). For BPV, no association was found between hospital factors and rates of consistent practice, but there was significant interhospital variation (median rate ratio: 1.4; 95% confidence interval: 1.2 to 1.6; p < 0.001). CONCLUSIONS There is measurable hospital-level variation in the practice of BAV and BPV. Further research is necessary to determine whether this affects outcomes or resource use.
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Interventional Treatment of Cardiac Emergencies in Children with Congenital Heart Diseases. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2019. [DOI: 10.2478/jce-2019-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Abstract
Cardiac emergencies in children represent an extremely important issue in medical practice. In general, interventional treatment could be optional in many situations, however it can be indicated in emergency conditions. There are many diseases at pediatric age that can benefit from interventional treatment, thus reducing the surgical risks and subsequent complications. Balloon atrioseptostomy, patent ductus arteriosus (PDA) closure, percutaneous or hybrid closure of a ventricular septal defect, pulmonary or aortic valvuloplasty, balloon angioplasty for aortic coarctation, implantation of a stent for coarctation of the aorta, for severe stenosis of the infundibulum of the right ventricle, or for PDA correction are among the procedures that can be performed in emergency situations. This review aims to present the current state of the art in the field of pediatric interventional cardiology.
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Congenital Heart Disease Classification, Epidemiology, Diagnosis, Treatment, and Outcome. CONGENIT HEART DIS 2019. [DOI: 10.1007/978-3-319-78423-6_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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16
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State of the art and prospective for percutaneous treatment for left ventricular outflow tract obstruction. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Complex Decision Making in the Pediatric Catheterization Laboratory: Catheterizer, Know Thyself and the Data. Pediatr Cardiol 2018; 39:1281-1289. [PMID: 30105465 DOI: 10.1007/s00246-018-1949-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/03/2018] [Indexed: 12/24/2022]
Abstract
Optimal outcomes are as much influenced by critical decision making pathways as by the technical skill of the operator. The complexity and potential cognitive traps underlying critical decision making has long been recognized in the aviation and business communities, however, remains a largely subconscious, unexamined discipline amongst congenital cardiac interventionalists. Challenges to making good decisions in the catheterization laboratory include heuristics, biases, and cognitive traps. In this paper we discuss some of the more common decision making challenges encountered and we address potential solutions to such decision making with particular focus towards standardization.
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Jones TK. What Is the IMPACT of Practice Variation in Congenital Interventional Cardiology? JACC Cardiovasc Interv 2018; 11:539-540. [DOI: 10.1016/j.jcin.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
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Hijazi ZM, Kenny D. The Impact of IMPACT-Contemporary Outcomes With Balloon Aortic Valvuloplasty: Are We Doing the Right Thing? JACC Cardiovasc Interv 2017; 10:1727-1728. [PMID: 28882283 DOI: 10.1016/j.jcin.2017.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 07/26/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Ziyad M Hijazi
- Sidra Cardiac Program, Sidra Medical & Research Center, Doha-Qatar and Weill Cornell Medicine, New York, New York.
| | - Damien Kenny
- Division of Pediatric Cardiology, Our Lady's Children's Hospital, Dublin, Ireland
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Acute Success of Balloon Aortic Valvuloplasty in the Current Era. JACC Cardiovasc Interv 2017; 10:1717-1726. [DOI: 10.1016/j.jcin.2017.08.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 11/19/2022]
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Moustafa GA, Kolokythas A, Charitakis K, Avgerinos DV. Therapeutic Utilities of Pediatric Cardiac Catheterization. Curr Cardiol Rev 2016; 12:258-269. [PMID: 26926291 PMCID: PMC5304250 DOI: 10.2174/1573403x12666160301121253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 12/17/2015] [Accepted: 12/27/2015] [Indexed: 11/29/2022] Open
Abstract
In an era when less invasive techniques are favored, therapeutic cardiac catheterization constantly evolves and widens its spectrum of usage in the pediatric population. The advent of sophisticated devices and well-designed equipment has made the management of many congenital cardiac lesions more efficient and safer, while providing more comfort to the patient. Nowadays, a large variety of heart diseases are managed with transcatheter techniques, such as patent foramen ovale, atrial and ventricular septal defects, valve stenosis, patent ductus arteriosus, aortic coarctation, pulmonary artery and vein stenosis and arteriovenous malformations. Moreover, hybrid procedures and catheter ablation have opened new paths in the treatment of complex cardiac lesions and arrhythmias, respectively. In this article, the main therapeutic utilities of cardiac catheterization in children are discussed.
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Affiliation(s)
| | | | | | - Dimitrios V Avgerinos
- Department of Cardiothoracic Surgery, Athens Medical Center & Center for Percutaneous Valves and Aortic Diseases, 5-7 Distomou Street, 15125, Marousi, Attica, Greece.
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Stout KK, Broberg CS, Book WM, Cecchin F, Chen JM, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Law Y, Martin CM, Murphy AM, Ross HJ, Singh G, Spray TL. Chronic Heart Failure in Congenital Heart Disease. Circulation 2016; 133:770-801. [DOI: 10.1161/cir.0000000000000352] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
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.
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Torres A, Vincent JA, Everett A, Lim S, Foerster SR, Marshall AC, Beekman RH, Murphy J, Trucco SM, Gauvreau K, Holzer R, Bergersen L, Porras D. Balloon valvuloplasty for congenital aortic stenosis: Multi-center safety and efficacy outcome assessment. Catheter Cardiovasc Interv 2015; 86:808-20. [DOI: 10.1002/ccd.25969] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/28/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Alejandro Torres
- Division of Pediatric Cardiology; Morgan Stanley Children's Hospital of New York Presbyterian; New York New York
| | - Julie A. Vincent
- Division of Pediatric Cardiology; Morgan Stanley Children's Hospital of New York Presbyterian; New York New York
| | - Allen Everett
- Division of Pediatric Cardiology; Johns Hopkins University; Baltimore Maryland
| | - Scott Lim
- Division of Pediatric Cardiology; University of Virginia; Charlottesville Virginia
| | - Susan R. Foerster
- Division of Pediatric Cardiology; Children's Hospital of Wisconsin; Milwaukee Wisconsin
| | - Audrey C. Marshall
- Department of Cardiology; Boston Children's Hospital, Boston Massachusetts, Children's Hospital Boston; Boston Massachusetts
| | - Robert H. Beekman
- Division of Pediatric Cardiology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Joshua Murphy
- Division of Pediatric Cardiology; Washington University in St. Louis; St. Louis Missouri
| | - Sara M. Trucco
- Division of Pediatric Cardiology; Children's Hospital of Pittsburgh; Pittsburgh Pennsylvania
| | - Kimberlee Gauvreau
- Department of Cardiology; Boston Children's Hospital, Boston Massachusetts, Children's Hospital Boston; Boston Massachusetts
| | - Ralf Holzer
- Division of Pediatric Cardiology; Nationwide Children's Hospital; Columbus Ohio
| | - Lisa Bergersen
- Department of Cardiology; Boston Children's Hospital, Boston Massachusetts, Children's Hospital Boston; Boston Massachusetts
| | - Diego Porras
- Department of Cardiology; Boston Children's Hospital, Boston Massachusetts, Children's Hospital Boston; Boston Massachusetts
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Figueras-Coll M, Martí-Aguasca G, Pérez-Hoyos S, Casaldàliga-Ferrer J. Valvuloplastia aórtica pediátrica: estudio de variables con influencia en los resultados a largo plazo. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Prijic SM, Vukomanovic VA, Stajevic MS, Bjelakovic BB, Zdravkovic MD, Sehic IN, Kosutic JL. Balloon dilation and surgical valvotomy comparison in non-critical congenital aortic valve stenosis. Pediatr Cardiol 2015; 36:616-24. [PMID: 25388630 DOI: 10.1007/s00246-014-1056-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 10/31/2014] [Indexed: 11/24/2022]
Abstract
Percutaneous balloon aortic valvoplasty (BAV) and surgical aortic valvotomy (SAV) are palliative procedures in patients with non-critical congenital valve stenosis. The aim of the study was to evaluate long-term BAV and SAV results after up to 24 years of follow-up. From 1987 to 2013, 74 consecutive interventions were performed in patients with aortic stenosis, and 62 were included in the study (39 BAVs and 23 SAVs). Age of BAV patients was 1.3 months to 17 years, and of SAV patients 1.2 months to 15 years. Although BAV patients were older, there was no difference between groups according to sex, valve function/morphology, and early/late follow-up results, with exception to hospitalization period. Significant pressure gradient reduction and aortic regurgitation increment were registered after procedures. Three patients did not survive early period after surgery. Follow-up period was 7.0 ± 5.4 and 9.0 ± 8.0 years after BAV and SAV, respectively (p = 0.242). Follow-up pressure gradient rose only in the BAV group, and was emphasized after 10-year-follow-up (p = 0.020). Significant aortic insufficiency progression was registered after 15 years of follow-up in both groups (p = 0.007 and p = 0.009, respectively). Mean reintervention-free survival was 12.0 years in the BAV and 14.5 years in the SAV group (p = 0.733), and mean survival without aortic valve replacement was 15.2 and 17.4 years, respectively (p = 0.877). BAV and SAV in patients with congenital aortic stenosis are very comparable in both early and late follow-up results.
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Affiliation(s)
- Sergej M Prijic
- Cardiology Department, Mother and Child Health Institute of Serbia, R. Dakica St. 6-8, 11070, Belgrade, Serbia
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Moore JW, Vincent RN, Beekman RH, Benson L, Bergersen L, Holzer R, Jayaram N, Jenkins K, Li Y, Ringel R, Rome J, Martin GR. Procedural Results and Safety of Common Interventional Procedures in Congenital Heart Disease. J Am Coll Cardiol 2014; 64:2439-51. [DOI: 10.1016/j.jacc.2014.09.045] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 09/08/2014] [Accepted: 09/16/2014] [Indexed: 11/16/2022]
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Porras D, Bergersen L. Standardizing care in congenital heart disease: approaches in the catheterization laboratory. Interv Cardiol 2014. [DOI: 10.2217/ica.13.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Porras D, Brown DW, Rathod R, Friedman K, Gauvreau K, Lock JE, Esch JJ, Bergersen L, Marshall AC. Acute outcomes after introduction of a standardized clinical assessment and management plan (SCAMP) for balloon aortic valvuloplasty in congenital aortic stenosis. CONGENIT HEART DIS 2013; 9:316-25. [PMID: 24127834 DOI: 10.1111/chd.12142] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Standardization of care can reduce practice variation, optimize resource utilization, and improve clinical outcomes. We have created a standardized clinical assessment and management plan (SCAMP) for patients having balloon aortic valvuloplasty (BAV) for congenital aortic stenosis (AS). This study compares acute outcomes of BAV at our institution before and after introduction of this SCAMP. METHODS In this retrospective matched cohort study, each SCAMP patient was matched to four historical controls. Outcomes were categorized based on the combination of residual AS and aortic regurgitation (AR) as: (1) Optimal: gradient ≤ 35 mm Hg and trivial or no AR; (2) Adequate: gradient ≤ 35 mm Hg and mild AR; (3) Inadequate: gradient > 35 mm Hg and/or moderate or severe AR. RESULTS All 23 SCAMP patients achieved a residual AS gradient ≤ 35 mm Hg; the median residual AS gradient for the SCAMP group was lower (25 [10-35] mm Hg) than in matched controls (30 [0-65] mm Hg; P = 0.005). The two groups did not differ with regard to degree of AR grade after BAV. Compared with controls, SCAMP patients were more likely to have an optimal result and less likely to have an inadequate result (52% vs. 34% and 17% vs. 45%, respectively; P = 0.02) CONCLUSIONS: A SCAMP for BAV resulted in optimal acute results in half of the initial 23 patients enrolled, and outcomes in this group were better than those of matched historical controls. Whether these improved acute outcomes translate into better long-term outcomes for this patient population remains to be seen.
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Affiliation(s)
- Diego Porras
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA; Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
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Hamidi-Manesh L, Tibby SM, Herman R, Rosenthal E, Qureshi SA, Krasemann T. Influence of balloon size on aortic regurgitation in neonates undergoing balloon aortic valvuloplasty--a retrospective study over an 11-year period. J Interv Cardiol 2013; 26:200-7. [PMID: 23406402 DOI: 10.1111/j.1540-8183.2013.12018.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Transcatheter balloon aortic valvuloplasty has become the first-line treatment for critical or severe aortic stenosis in neonates in many centers. Aortic regurgitation following balloon aortic valvuloplasty remains a major concern. An optimal balloon size to aortic annulus ratio in order to minimize aortic regurgitation postprocedure, while relieving the obstruction, has not yet been identified. METHODS AND RESULTS In this retrospective study, data from 29 neonates with critical or severe congenital aortic valve stenosis, who underwent balloon aortic valvuloplasty in the first 28 days of life, over an 11-year period, was evaluated. The balloon size used, ranged from 71% to 160% of the annulus size, with an average of 89%, based on the aortic annulus size as measured on angiography. The aortic regurgitation immediately following the procedure was trivial in 8 (27.6%), mild in 13 (44.8%), moderate in 7 (24.1%), and severe in 1 (3.4%) patient. The balloon to annulus ratio had no statistically significant effect on the degree of aortic regurgitation immediately after the procedure (P-value of 0.25), at first follow-up within 6 weeks of the procedure (P-value of 0.76) or at follow-up at 1 year (P-value of 0.52). CONCLUSION This study did not show any significant relationship between the balloon to annulus ratio during interventional dilatation and the degree of aortic regurgitation following the procedure.
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Affiliation(s)
- Laila Hamidi-Manesh
- Department of Paediatric Cardiology, Evelina Children's Hospital, Guy's & St. Thomas NHS Foundation Trust & King's College, London, UK
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Neonatal Interventions for Left-Sided Obstructive Lesions: Alternatives to Surgery. Interv Cardiol Clin 2013; 2:11-22. [PMID: 28581977 DOI: 10.1016/j.iccl.2012.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Maskatia SA, Justino H, Ing FF, Crystal MA, Mattamal RJ, Petit CJ. Aortic valve morphology is associated with outcomes following balloon valvuloplasty for congenital aortic stenosis. Catheter Cardiovasc Interv 2012; 81:90-5. [DOI: 10.1002/ccd.24286] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 12/07/2011] [Indexed: 11/08/2022]
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Brown JW, Rodefeld MD, Ruzmetov M, Eltayeb O, Yurdakok O, Turrentine MW. Surgical valvuloplasty versus balloon aortic dilation for congenital aortic stenosis: are evidence-based outcomes relevant? Ann Thorac Surg 2012; 94:146-53; discussion 153-5. [PMID: 22537535 DOI: 10.1016/j.athoracsur.2012.02.054] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 02/06/2012] [Accepted: 02/10/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND For children with congenital aortic stenosis (AS) who are selected for biventricular repair, valvuloplasty can be achieved by surgical aortic valvuloplasty (SAV) or by transcatheter balloon aortic dilation (BAD). A retrospective study was undertaken to compare the effectiveness of BAD versus SAV, evaluating the long-term survival, incidence of aortic valve restenosis or aortic insufficiency (AI) or both, and freedom from reoperation for repeated valve repair or replacement. Neonates less than 2 months of age were excluded from this comparison. METHODS We reviewed the outcomes of children undergoing repair by SAV (n = 89) and BAD (n = 69) at our institution during a recent 20-year period. Clinical and echocardiographic follow-up were analyzed. The patient groups were compared with regard to the persistence or recurrence of postoperative aortic gradients and valve insufficiency and valve-related reintervention, including aortic valve replacement (AVR). RESULTS There was no significant difference between the groups with respect to mean age, body surface area, valve anatomy, sex, and preoperative gradients. Our data demonstrate that gradient reduction, AI, and the need for reintervention were worse for BAD. Aortic gradients at last follow-up were similar in both cohorts, but return of a significant gradient occurred sooner for patients who had BAD. Aortic gradient at discharge was significantly better for the patients who underwent SAV. Kaplan-Meier analysis showed that at 10 years, comparison of SAV and BAD was as follows: freedom from reintervention, 72% versus 53% (p = 0.02) and freedom from AVR, 80% versus 75% (p = 0.32). CONCLUSIONS BAD yields less gradient reduction, more postprocedural AI, and a shorter interval between initial and subsequent reintervention than does SAV. Our results demonstrate that SAV is safe and effective and that residual gradients and degree of AI are low. After SAV, the need for AVR can usually be delayed until the child is significantly older. The long-term functional stability after SAV is excellent. BAD in comparison is associated with an increased frequency and severity of AI and the need for earlier reintervention and valve replacement. SAV should be offered to all patients beyond the newborn period because it gives superior and longer lasting palliation.
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Affiliation(s)
- John W Brown
- Section of Cardiothoracic Surgery and Pediatric Cardiology, James W. Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA.
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Petit CJ, Ing FF, Mattamal R, Pignatelli RH, Mullins CE, Justino H. Diminished left ventricular function is associated with poor mid-term outcomes in neonates after balloon aortic valvuloplasty. Catheter Cardiovasc Interv 2012; 80:1190-9. [DOI: 10.1002/ccd.23500] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 11/21/2011] [Indexed: 11/08/2022]
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Al Marshafawy H, Al Sawah GA, Hafez M, Matter M, El Gamal A, Sheishaa AG, El Kair MA. Balloon Valvuloplasty of Aortic Valve Stenosis in Childhood: Midterm Results in a Children's Hospital, Mansoura University, Egypt. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2012; 6:57-64. [PMID: 22412302 PMCID: PMC3296496 DOI: 10.4137/cmc.s8602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
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.
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Kenny D, Hijazi ZM. Percutaneous Balloon Valvuloplasty for Aortic Stenosis in Newborns and Children. Interv Cardiol Clin 2012; 1:121-128. [PMID: 28582062 DOI: 10.1016/j.iccl.2011.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Damien Kenny
- Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center, 1653 West Congress Parkway, Chicago, IL 60612, USA.
| | - Ziyad M Hijazi
- Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center, 1653 West Congress Parkway, Chicago, IL 60612, USA
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Maskatia SA, Ing FF, Justino H, Crystal MA, Mullins CE, Mattamal RJ, O'Brian Smith E, Petit CJ. Twenty-five year experience with balloon aortic valvuloplasty for congenital aortic stenosis. Am J Cardiol 2011; 108:1024-8. [PMID: 21791328 DOI: 10.1016/j.amjcard.2011.05.040] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 05/12/2011] [Accepted: 05/12/2011] [Indexed: 10/18/2022]
Abstract
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.
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Feltes TF, Bacha E, Beekman RH, Cheatham JP, Feinstein JA, Gomes AS, Hijazi ZM, Ing FF, de Moor M, Morrow WR, Mullins CE, Taubert KA, Zahn EM. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation 2011; 123:2607-52. [PMID: 21536996 DOI: 10.1161/cir.0b013e31821b1f10] [Citation(s) in RCA: 492] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Brown DW, Dipilato AE, Chong EC, Lock JE, McElhinney DB. Aortic valve reinterventions after balloon aortic valvuloplasty for congenital aortic stenosis intermediate and late follow-up. J Am Coll Cardiol 2011; 56:1740-9. [PMID: 21070926 DOI: 10.1016/j.jacc.2010.06.040] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 05/27/2010] [Accepted: 06/16/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES the aim of this study was to evaluate the long-term results of transcatheter balloon aortic valvuloplasty, the preferred treatment for congenital aortic stenosis (AS). BACKGROUND aortic valve function and reintervention late after this procedure are not well characterized. METHODS from 1985 to 2008, 563 patients underwent balloon dilation for congenital AS. After excluding those converted to univentricular circulation and/or died ≤ 30 days after the procedure, 509 patients constituted the study cohort. RESULTS The median follow-up period was 9.3 years (range 0.1 to 23.6 years); cumulative follow-up was 5,003 patient-years. The median age was 2.4 years (range 1 day to 40.5 years), and most patients (73%) had isolated native AS. Peak AS gradients decreased significantly after dilation (median decrease, 35 mm Hg), and acute post-dilation aortic regurgitation was moderate or greater in 70 patients (14%). Older patients more often had post-dilation aortic regurgitation (p < 0.001). During follow-up, 225 patients (44%) underwent aortic valve reintervention: repeat balloon dilation in 115 (23%), aortic valve repair in 65 (13%), and aortic valve replacement in 116 (23%). Survival free from any aortic valve reintervention was 89 ± 1% at 1 year, 72 ± 2% at 5 years, 54 ± 3% at 10 years, and 27 ± 3% at 20 years. Freedom from aortic valve replacement was 90 ± 2% at 5 years, 79 ± 3% at 10 years, and 53 ± 4% at 20 years. In multivariate analyses, lower post-dilation AS gradient and lower grade of post-dilation aortic regurgitation were associated with longer freedom from aortic valve replacement, but age, era, and pre-dilation AS severity were not. CONCLUSIONS although transcatheter aortic valvuloplasty is effective for relief of congenital AS, there are steady long-term hazards for surgical aortic valve reintervention and replacement that are independent of age at initial intervention or AS severity.
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Affiliation(s)
- David W Brown
- Department of Cardiology, Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Brown DW, Dipilato AE, Chong EC, Gauvreau K, McElhinney DB, Colan SD, Lock JE. Sudden Unexpected Death After Balloon Valvuloplasty for Congenital Aortic Stenosis. J Am Coll Cardiol 2010; 56:1939-46. [DOI: 10.1016/j.jacc.2010.06.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 06/18/2010] [Accepted: 06/21/2010] [Indexed: 10/18/2022]
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Siu SC, Silversides CK. Bicuspid aortic valve disease. J Am Coll Cardiol 2010; 55:2789-800. [PMID: 20579534 DOI: 10.1016/j.jacc.2009.12.068] [Citation(s) in RCA: 620] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 11/06/2009] [Accepted: 12/17/2009] [Indexed: 12/13/2022]
Abstract
Bicuspid aortic valve (BAV) disease is the most common congenital cardiac defect. While the BAV can be found in isolation, it is often associated with other congenital cardiac lesions. The most frequent associated finding is dilation of the proximal ascending aorta secondary to abnormalities of the aortic media. Changes in the aortic media are present independent of whether the valve is functionally normal, stenotic, or incompetent. Although symptoms often manifest in adulthood, there is a wide spectrum of presentations ranging from severe disease detected in utero to asymptomatic disease in old age. Complications can include aortic valve stenosis or incompetence, endocarditis, aortic aneurysm formation, and aortic dissection. Despite the potential complications, 2 large contemporary series have demonstrated that life expectancy in adults with BAV disease is not shortened when compared with the general population. Because BAV is a disease of both the valve and the aorta, surgical decision making is more complicated, and many undergoing aortic valve replacement will also need aortic root surgery. With or without surgery, patients with BAV require continued surveillance. Recent studies have improved our understanding of the genetics, the pathobiology, and the clinical course of the disease, but questions are still unanswered. In the future, medical treatment strategies and timing of interventions will likely be refined. This review summarizes our current understanding of the pathology, genetics, and clinical aspects of BAV disease with a focus on BAV disease in adulthood.
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Affiliation(s)
- Samuel C Siu
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
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Experience in a single centre with percutaneous aortic valvoplasty in children, including those with associated cardiovascular lesions. Cardiol Young 2009; 19:372-82. [PMID: 19519967 DOI: 10.1017/s1047951109990308] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Vivas D, Pérez de Isla L, Zamorano J. Using echocardiography to guide interventional procedures. CURRENT CARDIOVASCULAR IMAGING REPORTS 2009. [DOI: 10.1007/s12410-008-0004-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1-142. [PMID: 18848134 DOI: 10.1016/j.jacc.2008.05.007] [Citation(s) in RCA: 1057] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523-661. [PMID: 18820172 DOI: 10.1161/circulationaha.108.190748] [Citation(s) in RCA: 802] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Bourgault C, Rodés-Cabau J, Côté JM, Chetaille P, Delisle G, Perron J, Dugas MA, Leblanc MH, Houde C. Usefulness of Doppler echocardiography guidance during balloon aortic valvuloplasty for the treatment of congenital aortic stenosis. Int J Cardiol 2008; 128:30-7. [PMID: 17689749 DOI: 10.1016/j.ijcard.2007.05.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 04/22/2007] [Accepted: 05/19/2007] [Indexed: 11/17/2022]
Abstract
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.
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Knirsch W, Berger F, Harpes P, Kretschmar O. Balloon valvuloplasty of aortic valve stenosis in childhood: early and medium term results. Clin Res Cardiol 2008; 97:587-93. [DOI: 10.1007/s00392-008-0655-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Accepted: 02/19/2008] [Indexed: 11/30/2022]
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Fratz S, Gildein HP, Balling G, Sebening W, Genz T, Eicken A, Hess J. Aortic Valvuloplasty in Pediatric Patients Substantially Postpones the Need for Aortic Valve Surgery. Circulation 2008; 117:1201-6. [DOI: 10.1161/circulationaha.107.687764] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Sohrab Fratz
- From the Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Munich, Germany
| | - Hans Peter Gildein
- From the Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Munich, Germany
| | - Gunter Balling
- From the Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Munich, Germany
| | - Walter Sebening
- From the Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Munich, Germany
| | - Thomas Genz
- From the Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Munich, Germany
| | - Andreas Eicken
- From the Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Munich, Germany
| | - John Hess
- From the Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Munich, Germany
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Han RK, Gurofsky RC, Lee KJ, Dipchand AI, Williams WG, Smallhorn JF, McCrindle BW. Outcome and growth potential of left heart structures after neonatal intervention for aortic valve stenosis. J Am Coll Cardiol 2008; 50:2406-14. [PMID: 18154967 DOI: 10.1016/j.jacc.2007.07.082] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Accepted: 07/25/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The purpose of this study was to determine trends of growth of left heart structures after intervention for neonatal aortic valve stenosis. BACKGROUND The growth potential of left heart structures in neonatal aortic valve stenosis after relief of obstruction might influence risk for subsequent outcomes. METHODS From 1994 to 2004, 53 patients underwent neonatal (< or =30 days old) balloon aortic valve dilation. Factors associated with time-related outcomes (death, reintervention, aortic valve replacement) and longitudinal changes in normalized left heart dimensions were sought. RESULTS The median age at intervention was 3.5 days (range 1 to 30 days). During a median follow-up of 3.2 years ranging up to 10.9 years, there were 31 reinterventions on the aortic valve in 21 (40%) patients and 7 deaths (13%). The presence of moderate or severe left ventricular (LV) endocardial fibroelastosis was the only independent predictor for time-related mortality (hazard ratio 22.1; p = 0.004), and a smaller initial aortic valve annulus z-score was a significant independent predictor for aortic valve replacement (hazard ratio 0.63 per 1-U change; p = 0.007). Aortic valve annulus, aortic sinus, and LV dimension z-scores significantly increased over time, whereas mitral valve z-scores remained below normal. The structure's initial z-score and concomitant size of other left heart structures were significant independent factors associated with subsequent z-scores. CONCLUSIONS There is potential catch-up growth of the aortic valve and LV over time for neonates after intervention for aortic valve stenosis. However, the continued hypoplasia of the mitral valve warrants further consideration in the long-term management of these patients.
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Affiliation(s)
- Ra K Han
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
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Hraska V, Photiadis J, Arenz C. Open valvotomy for aortic valve stenosis in newborns and infants. Multimed Man Cardiothorac Surg 2007; 2007:mmcts.2006.002311. [PMID: 24414321 DOI: 10.1510/mmcts.2006.002311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The most appropriate management of aortic stenosis in children remains controversial. Both balloon and surgical valvotomy are firmly established as effective initial treatments with encouraging survival rates even in the troublesome neonatal group. Improved early results are based rather on the better understanding of the limits of a biventricular repair than on the method of treatment. Valvotomy of any kind is a palliative procedure and reintervention remains frequent. Direct surgical intervention, where exact splitting of fused commissures and shaving off of obstructing nodules can produce a better valve with maximum valve orifice without causing regurgitation, might offer superior longer-lasting results in comparison with blind ballooning.
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Affiliation(s)
- Viktor Hraska
- Department of Pediatric Cardiac Surgery, German Pediatric Heart Center, Asklepios Clinic Sankt Augustin, Arnold Jansen Str. 29, 53757 Sankt Augustin, Germany
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