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

doi:10.1016/0003-4975(92)91453-G

The Annals of Thoracic Surgery

Volume 53, Issue 5, May 1992, Pages 864-870

https://doi.org/10.1016/0003-4975(92)91453-G Get rights and content

Abstract

During a $21 / 2$ -year period, staged procedures of transventricular closed pulmonary valvotomy followed by balloon valvuloplasty were attempted in 12 babies with pulmonary atresia and an intact ventricular septum. All babies immediately underwent valvotomy when echocardiography revealed a tripartite right ventricle with adequate inflow and outflow dimensions and without sinusoidal-coronary arterial fistulas. After valvotomy, the overall mortality rate was 25% ( $3 / 12$ ), but the only surgical death ( $1 / 12, 8%$ ) was due to failure to establish continuity between the right ventricular cavity and the pulmonary trunk. The other 2 babies died of neonatal complications after successful valvotomy. Angiocardiography performed 5 to 18 months after valvotomy documented substantial growth of the right ventricular inflow and outflow dimensions in the 9 survivors. Twelve balloon dilation procedures were then performed in 7 babies. All except 1 achieved a significant drop in the right ventricular to left ventricular peak systolic pressure ratio (0.96 ± 0.40 to 0.56 ± 0.28; p < 0.01). Balloon valvuloplasty was not required in 1 baby and failed in the other, who then underwent successful right ventricular outflow tract reconstruction. After these staged procedures, follow-up at 1 month to 20 months (mean follow-up, 14.8 months) revealed resting cyanosis in 3 babies, which was related to severe residual infundibular stenosis (55 mm Hg) in 1 and a subnormal tricuspid valve annulus in 2. The remaining 5 babies (including 1 who required no valvuloplasty) were active and pink (saturation > 97%) and had a mean Doppler estimated gradient of 19 mm Hg (range, 8 to 36 mm Hg) across the pulmonary valve. Our results suggest that for babies with pulmonary atresia and intact ventricular septum, if echocardiography reveals an adequate tripartite right ventricle free from sinusoidal-coronary arterial fistulas, transventricular closed pulmonary valvotomy followed by balloon valvuloplasty is a simple biventricular staged repair with an acceptable outcome.

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Cited by (10)

Pulmonary atresia with intact ventricular septum percutaneous radiofrequency-assisted valvotomy and balloon dilation versus surgical valvotomy and Blalock Taussig shunt
2000, Journal of the American College of Cardiology
Citation Excerpt :
Transcatheter valvotomy and balloon dilation offer a promising alternative as the primary therapy in selected patients with PA-IVS. Perforation of the atretic pulmonary valve can be achieved using laser guidewire or RF wire, and balloon dilation can then be performed in the conventional way (6,7,22). The sharp, stiff end of a coronary guidewire has been successfully used to perforate the atretic pulmonary valve (23), but this technique has been rendered largely obsolete with the availability of laser and RF wires.
OBJECTIVE
We compared the result of radiofrequency (RF)-assisted valvotomy and balloon dilation with closed surgical valvotomy and Blalock Taussig (BT) shunt as primary treatment in selected patients with pulmonary atresia and intact ventricular septum (PA-IVS).
BACKGROUND
Patients with PA-IVS who have mild to moderate hypoplasia of the right ventricle (RV) and patent infundiblum have the greatest potential for complete biventricular circulation. The use of RF or laser wires to perforate the atretic valve followed by balloon dilation provides an alternative to surgery.
METHODS
Between May 1990 and March 1998, 33 selected patients underwent either percutaneous RF valvotomy and balloon dilation (group 1, n = 21; two crossed over to group 2) or surgical valvotomy with concomitant BT shunt (group 2, n = 14). Second RV decompression by balloon dilation or right ventricular outflow tract (RVOT) reconstruction were performed if necessary. Patients who remained cyanosed were subjected to transcatheter trial closure of the interatrial communication. Partial biventricular repair was offered to those with inadequate growth of the RV.
RESULTS
The primary procedure was successful in 19 patients in group 1. There was one in-hospital death and two late deaths. Of the remaining 16 survivors, 12 achieved complete biventricular circulation, 7 of whom required no further interventions. Two patients required repeat balloon dilation, 1 RVOT reconstruction and 2 transcatheter closure of interatrial communication. Two patients underwent partial biventricular repair. In group 2, there were 3 in-hospital deaths after the primary procedure and 1 patient died four months later. All survivors (n = 10) required a second RV decompression, 8 by balloon dilation and 2 by RVOT reconstruction, after which, two patients died. Of the final 8 survivors, 7 achieved complete biventricular circulation, 5 after coil occlusion of the BT shunt and 2 after closure of interatrial communication.
CONCLUSIONS
Radiofrequency valvotomy and balloon dilation is more efficacious and safe compared with closed pulmonary valvotomy and BT shunt in selected patients with PA-IVS.
Management evolution of pulmonary atresia and intact ventricular septum
1993, The American Journal of Cardiology
To examine the impact on survival and clinical course of incorporating the morphologic classification of the right ventricle into the evolving management strategy for babies with pulmonary atresia and intact ventricular septum, the surgical results and follow-up status of the first 62 consecutive patients managed in this hospital between 1979 and 1990 were reviewed. Before 1984, all 23 babies from group I underwent primary right ventricular outflow reconstruction irrespective of right ventricular morphology and size. Since 1984, depending on the morphology and size of the right ventricle, 39 babies from group II had either closed transventricular pulmonary valvotomy (n = 31) or a shunt operation (n = 8). There were 10 hospital (43%) and 2 late deaths (total mortality 52%) in our group I patients. Three of the 11 long-term survivors had cyanosis at rest but none had any residual pressure gradient across the pulmonary outflow. Group II had 6 hospital (15%) and 4 late deaths (total mortality = 26%). Of the 29 long-term survivors, 9 had a secondstage right ventricular outflow reconstruction, 8 had balloon valvuloplasty and 2 had successful Fontan operation. At the latest follow-up, 5 children from this group have cyanosis at rest, 1 has a residual gradient (55 mm tig) across the infundibulum, and 3 have right ventricular dysfunction. The hospital and total mortality for babies in group II was significantly lower than that in group I (p < 0.01). These data suggest that tailoring the treatment to the right ventricular anatomy results in a lower overall mortality although long term postoperative hemodynamic abnormalities are observed in both groups.
Pulmonary atresia and intact ventricular septum
2016, Moss and Adams' Heart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adult: Ninth Edition
Pulmonary atresia and intact ventricular septum
2013, Moss and Adams' Heart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adult: Eighth Edition
Evolution of the management approach for pulmonary atresia with intact ventricular septum
2005, Heart
Pulmonary valvulotomy with the Nykanen radiofrequency guide in pulmonary atresia with intact interventricular septum
2003, Archives des Maladies du Coeur et des Vaisseaux

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

Abstract

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Pediatr Clin North Am

The morphologic variations of pulmonary atresia with intact ventricular septum: guidelines for surgical intervention

Pediatr Cardiol

Pulmonary atresia and intact ventricular septum: surgical management based on a revised classification

Circulation

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