Catheter-based treatment in patients with critical pulmonary stenosis or pulmonary atresia with intact ventricular septum: a single institute experience with comparison between patients with and without additional procedure for pulmonary flow

Novel echocardiographic score to predict duct-dependency after percutaneous relief of critical pulmonary valve stenosis/atresia

Objectives

This study aimed to identify clinical, hemodynamic, or echocardiographic predictive features of persistent duct‐dependency of pulmonary circulation (PDDPC) after effective percutaneous relief of pulmonary atresia with the intact ventricular septum (PA‐IVS) or critical pulmonary stenosis (CPS).

Methods

From 2010 to 2021, 55 neonates with PA‐IVS or CPS underwent percutaneous right ventricle (RV) decompression at our Institution. After successfully relief of critical obstruction, 27 patients (group I) showed PDDPC, whereas RV was able to support the pulmonary circulation in the remaining 28 patients (group II). Clinical, hemodynamic, and echocardiographic features of these two groups were compared.

Results

No significant difference in clinical and hemodynamic data was found between the groups, although the group I had a lower oxygen saturation at hospital admission. However, tricuspid valve (TV) diameter <8.8 mm, TV z‐score ←2.12, tricuspid/mitral valve annular ratio <.78, pulmonary valve diameter <6.7 mm, pulmonary valve z‐score ←1.17, end‐diastolic RV area <1.35 cm², end‐systolic right atrium area >2.45 cm², percentage amount of interatrial right‐to‐left shunt >69.5%, moderate/severe tricuspid regurgitation, RV systolic pressure >42.5 mmHg, tricuspid E/E′ ratio >6.6 showed each significant predictive value of PDDPC. These parameters were used to build a composite echocardiographic score (PDDPC‐score), assigning one point each above the respective cut‐off value. A score ≥4.00 showed high sensitivity (100%) and specificity (86%) in predicting PDDPC.

Conclusion

Clinical and hemodynamic features fail to predict the short‐term fate of the pulmonary circulation after successful treatment of PA‐IVS/CPS. However, a simple, composite echocardiographic score is useful to predict PDDPC and could be crucial in the management of this frail subset of patients.

Type I and II pulmonary atresia with intact ventricular septum in infants: a 10-year experience in initial surgery at one center

Background

To explore the effect of initial surgery for type I and II pulmonary atresia with intact ventricular septum (PA/IVS).

Methods

50 children with type I PA/IVS and 50 with type II PA/IVS who had undergone initial surgery were enrolled. Children with Type I were divided into groups A (n = 25) and B (n = 25). Group A had received BT shunt combined with PDA ligation and balloon dilatation of pulmonary valve, whereas group B had undergone BT shunt combined with PDA ligation and pulmonary valve incision. Children with type II were divided into groups C (n = 25) and D (n = 25). Group C had received BT shunt combined with PDA ligation, right ventricular outflow tract (RVOT) incision and transannular patch. Group D had undergone BT shunt combined with PDA ligation, RVOT incision, transannular patch and artificial pulmonary valve implantation. The differences in mechanical ventilation time, length of ICU stay, mortality rate, tricuspid Z value, tricuspid regurgitation, oxygen saturation, pulmonary regurgitation, McGoon ratio, pulmonary artery transvalvular pressure, survival rate were compared between groups A and B, between groups C and D respectively.

Results

The ventilator assistance time and length of ICU stay were greater in group C than in group D (80.96 ± 8.42 h vs. 65.16 ± 4.85 h, P = 0.045; 222.00 ± 11.72 h vs. 162.48 ± 7.91 h, P = 0.048). The pulmonary artery transvalvular pressure was significantly higher in group A than in group B at 3, 6, 12, 24 and 36 months after surgery (64.86 ± 4.13 mmHg vs. 53.04 ± 5.64 mmHg, P = 0.045; 69.47 ± 1.93 mmHg vs. 55.95 ± 4.04 mmHg, P = 0.005; 80.16 ± 3.76 mmHg vs. 73.24 ± 2.34 mmHg, P = 0.035; 62.95 ± 5.64 mmHg vs. 48.47 ± 7.44 mmHg, P = 0.04; 53.69 ± 4.89 vs. 45.77 ± 3.26, P = 0.02). Furthermore, the tricuspid Z value was significantly greater in group B than in group A at 3 and 24 months after surgery (− (1.37 ± 0.04) vs. − (1.43 ± 0.06), P = 0.03; − (0.41 ± 0.06) vs. − (0.51 ± 0.11), P = 0.02).

Conclusions

The effect of BT shunt combined with PDA ligation and pulmonary valve incision is superior to BT shunt combined with PDA ligation and balloon dilatation of pulmonary valve, and the effect of BT shunt combined with PDA ligation, RVOT incision, transannular patch and artificial pulmonary valve implantation is superior to BT shunt combined with PDA ligation, RVOT incision and transannular patch.

Intervention in Patients with Critical Pulmonary Stenosis in the Ductal Stenting Era

We aimed to assess early and midterm outcomes of balloon valvuloplasty (BVP) procedure in patients with critical pulmonary stenosis (CPS) and to describe the predictors of the need for additional pulmonary flow and reintervention in this subgroup of patients. From 2005 to 2014, 56 neonates were diagnosed with CPS and were included in this study. All echocardiographic, catheterization and angiographic data obtained prior to the initial BVP and at follow-up were reviewed. BVP was successful in 55 neonates (98 %). Twenty-one neonates needed pulmonary blood flow augmentation after BVP (38 %). Ductal stenting (DS) was performed in 20. The patients' mean tricuspid valve (TV) annulus diameter was 10.4 ± 2 mm, and the Z score was -1.29 ± 1 (-3.7 to 0.78). The mean pulmonary valve (PV) annulus diameter was 6 ± 0.9 mm, and the Z score was -1.74 ± 1 (-4.34 to 0.05). A transcatheter or surgical reintervention was performed in 11 patients. A TV Z score < -1.93 SD predicted the need for pulmonary blood flow augmentation after a successful BVP, with a sensitivity of 63.2% and a specificity of 84.4%. A PV Z score < -1.69 SD predicted the need for pulmonary flow augmentation, with a sensitivity of 74 %. The presence of bipartite RV was found to be a significant predictor of the need for reintervention (odds ratio 9.6). Our study showed the excellent immediate outcomes of BPV and DS in a pure cohort of patients with CPS. Prophylactic DS in selected cases seems reasonable and safe.