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Inerventional catheterisation in the treatment of patients with congenital heart disease has expanded dramatically since Rashkind first introduced balloon atrial septostomy in 1966. In many centres up to half of all cardiac catheterisations in congenital heart disease are therapeutic rather than diagnostic. Developments in plastics and alloy engineering have led to improvements in equipment for balloon or stent treatment and these techniques are playing an increasing role in the management of adults with congenital heart disease. The only existing guidelines, which represent the American consensus of opinion, have been published by the American Council on Cardiovascular Disease in the Young.1
Right ventricular outflow obstruction
Pulmonary valve stenosis
Balloon dilatation has proved extraordinarily successful in the treatment of pulmonary stenosis at any age. Improvements in guide wire technology and in balloon design have allowed successful transvenous valvoplasty to be carried out at very low risk even in the premature neonate and, in contrast to treatment of aortic stenosis, ballooning the pulmonary valve is effective even in the presence of cusp calcification in adult life.
There are no absolute indications for intervention in pulmonary stenosis and different centres vary in their threshold for treatment. In general pulmonary stenosis is a well tolerated lesion and the risk of sudden death is much lower than with obstruction to left ventricular outflow. Pulmonary stenosis does not always become more severe with age and may occasionally improve or even resolve spontaneously. Clinical signs and symptoms (usually exercise intolerance if the obstruction is severe), ECG changes, and echocardiographic findings all play a part in timing of intervention. As an approximate generalisation the combination of right ventricular hypertrophy and a peak flow velocity of 4 m/s or greater would encourage most cardiologists in the UK to intervene. Technically pulmonary balloon valvoplasty is usually straightforward,2 with optimum results being obtained with a balloon diameter …