Comparative Long-Term results of surgery versus balloon valvuloplasty for pulmonary valve stenosis in infants and children

doi:10.1016/S0003-4975(03)00678-7

The Annals of Thoracic Surgery

Volume 76, Issue 4, October 2003, Pages 1078-1083

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.

https://doi.org/10.1016/S0003-4975(03)00678-7 Get rights and content

Abstract

Background

We compared the long-term results of surgical valvotomy (S) versus balloon valvuloplasty (BV) for pulmonary valve stenosis in infants and children.

Methods

Results after surgical pulmonary valvotomy (with concomitant ASD/VSD closure) (n = 62, age 2.9 ± 3.5 years) and balloon valvuloplasty (n = 108, age 3.6 ± 3.9 years) were analyzed. Transvalvular mean pressure gradient decrease, freedom from reintervention for restenosis, pulmonary valve insufficiency, and tricuspid valve insufficiency were considered.

Results

Mean pressure gradient decreased significantly more in the surgical group (from 64.8 ± 30.8 mm Hg to 12.8 ± 9.8 mm Hg at a mean follow-up of 9.8 years) than after BV (decreasing from 66.2 ± 21.4 mm Hg to 21.5 ± 15.9 mm Hg after a mean of 5.4 years; p < 0.001). Moderate pulmonary valve insufficiency occurred in 44% after surgery, and in 11% after BV (p < 0.001). Tricuspid valve insufficiency occurred in 2% after surgery, and in 5% after BV. Restenosis occurred in 3 surgical patients (5.6%), 2 patients required reoperation, and 1 patient required a balloon valvotomy. Restenosis developed in 13 BV patients (14.1%): 6 patients were redilated and 7 patients required surgery. Surgical valvotomy led to significantly less reinterventions than balloon valvuloplasty (p < 0.04).

Conclusions

Surgical relief of pulmonary valve stenosis produces lower long-term gradients and results in longer freedom from reintervention. Balloon valvuloplasty may remain, despite these results, the preferred therapy for isolated pulmonary valve stenosis, because it is less invasive, less expensive, and requires a shorter hospital stay. Surgery should remain the exclusive form of therapy in the presence of concomitant intracardiac defects, which need to be addressed.

Section snippets

Demographics

Between 1969 and 2000, surgical valvotomy and balloon valvuloplasty (BV) were performed in a homogeneous group of 170 patients with PVS at the Pediatric Heart Center of the Wilhelmina Children’s Hospital, Utrecht, The Netherlands. The indications for surgery and BV in our hospital are a mean transvalvular pressure gradient more than 60 mm Hg, or a mean gradient between 30 and 60 mm Hg with right axis deviation, right ventricular hypertrophy, and clinical symptoms.

All patients who underwent

Surgery and BV groups

The mean preoperative transvalvular pressure gradient in the sugery group (S) decreased from 64.8 ± 30.8 mm Hg to 17.4 ± 14.7 mm Hg postoperative (p < 0.001). Three patients (5.6%) in group S presented with postpericardiotomy syndrome with pericardial effusions significant enough to require echo-guided needle aspiration.

After BV, the mean pressure gradient was reduced from 66.2 ± 21.4 mm Hg to 23.8 ± 15.8 mm Hg (p < 0.001). Complications in this group included 1 patient (1.1%) with bleeding

Comment

Surgical repair of isolated pulmonary valve stenosis can effectively be performed at low risk, either as a closed procedure or by open commissurotomy/valvotomy using cardiopulmonary bypass. Although the Brock procedure, performed early on in our series, has been reported to give comparable satisfactory results, it has been abandoned at our institution. According to our protocol, as cardioplumonary bypass is inevitable for closure of a concomitant ASD or VSD, an open procedure on the pulmonary

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A wide spectrum of pathology, both congenital and acquired, can affect the pulmonary arteries. While some of these are commonly seen in everyday clinical practice, some are rare. These entities may be discovered incidentally at imaging for other reasons in an asymptomatic patient, however patients may go on to develop symptoms over the course of their lifetime. Although an enlarged pulmonary artery can be visualized on chest X-ray (CXR), for the most part, CXR is insensitive for detecting abnormalities of the pulmonary arteries. Contrast-enhanced chest CT (CECT) is a better test to evaluate the pulmonary arteries as it is readily available, quick to perform, able to provide multiplanar reformatted images, and noninvasive. CECT is not only able to assess the lumen and wall of the pulmonary artery, but also provides a detailed evaluation of the entire thorax, including the heart, mediastinal structures, and lungs, often times picking up associated findings, and is the mainstay for evaluating disorders of the pulmonary vasculature. MRI allows for detailed evaluation of the vessel wall which can be especially helpful in cases where malignancy or vasculitis are suspected, and is also able to provide useful physiologic data such as quantification of flow. It is important for the radiologist to be aware of the many conditions which affect the pulmonary arteries, as some may require urgent treatment. This article will review normal pulmonary artery anatomy and physiology, as well as the various imaging findings of pulmonary vascular pathologies.
Outcomes after Balloon Pulmonary Valvuloplasty for Critical Pulmonary Stenosis and Incidence of Coronary Artery Fistulas
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Outcome data for neonates with critical pulmonary stenosis (PS) is limited. We aimed to review the outcomes after balloon pulmonary valvuloplasty (BPV) for neonates with critical PS at our institution. All neonates with critical PS who underwent BPV from 1990 to 2017 were included. A total of 44 neonates underwent BPV for critical PS. Nonright ventricular dependent coronary artery fistulas was seen in 6/44 (13.6%) patients. Tricuspid valve z-scores were −1.9 (interquartile range [IQR] −3.04, −0.48) in those with coronary artery fistulas as compared with −0.27 (IQR −0.5, 0.8) in those without (p = 0.03). Fifteen of forty-four subjects (34.1%) patients underwent reintervention with 10 patients (22.7%) requiring an alternate source of pulmonary blood flow (3 patients subsequently underwent right ventricular overhaul, 2 underwent Glenn operations, and 1 underwent repeat BPV). Five patients underwent reintervention for right ventricular outflow tract obstruction. Pulmonary valve annulus z-score was significantly smaller in those who needed reintervention −2.4 (IQR −2.9 to −0.95) versus −0.59 (IQR −1.3, −0.15); p = 0.02. At a median follow-up of 8.2 (IQR 3.4 to 13.1) years, moderate or severe pulmonary regurgitation was seen in 22/42 (53.7 %) patients with biventricular circulation, 3 requiring pulmonary valve repair/replacement. In conclusion, coronary artery fistulas occur in a significant number of patients with critical pulmonary stenosis, occurring more frequently in patients with small tricuspid valves. Reintervention is required for 1/3 of patients. Patients with small pulmonary valve annuli are more likely to undergo reintervention for right ventricular outflow tract obstruction. Significant pulmonary regurgitation is common and may require eventual pulmonary valve replacement.
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Determinar la asociación entre la proporción de las reintervenciones en los pacientes con la estenosis valvular pulmonar y la presencia de un gradiente transvalvular pulmonar final ≥25 mm Hg en pacientes menores de 21 años.
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En el grupo con el gradiente final ≥25 mm Hg, el 86,67% eran lactantes. Se encontró que en el grupo con el gradiente final < 25 mm Hg la mediana del gradiente inicial fue de 42 mm Hg IQ 25-75%: (34-59) en comparación con el grupo con el gradiente final ≥25 mm Hg, la mediana del gradiente inicial fue 70 mm Hg IQ 25-75%: (41-86). Al analizar los grupos por la variable reintervención, se observó que el cambio en la relación de las presiones entre el ventrículo derecho y el ventrículo izquierdo se asoció con menor necesidad de reintervención. OR 0,04; IC 95% (0,002-0,7). El tener un gradiente final después de la intervención ≥25 mm Hg se asoció a reintervención. OR 14,5; IC 95% (2,8-75).
Un gradiente final transvalvular pulmonar ≥25 mm Hg se asoció a mayor probabilidad de reintervención.
To determine the association between the proportion of reoperations in patients with pulmonary valvular stenosis and the presence of a final pulmonary transvalvular gradient of ≥25 mm Hg in patients under the age of 21.
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Patients between 0 months and 21 years of age who underwent balloon pulmonary valvuloplasty.
Description of the group and analysis in the subgroups given by the final transvalvular gradient of ≥25 mm Hg and reoperation. Pearson's chi-squared test was conducted for categorical variables. For the continuous variables, the Mann–Whitney U test was conducted. Logistic regression was used to define the association between variables and reoperation outcome.
In the group with the final gradient of ≥25 mm Hg, 86.67% were infants. The group with the final gradient of < 25 mm Hg the median of the initial gradient was 42 mm Hg IQ 25-75%: (34-59) in comparison to the group with the final gradient ≥25 mm Hg, the median of the initial gradient was 70 mm Hg IQ 25-75%: (41-86). By analysing both groups with the reoperation variable, it was observed that the change in the relationship of the pressured between the right ventricle and the left ventricle was associated with a lower need for reoperation. OR 0.04; CI 95% (0.002-0.7). Having a final gradient of ≥25 mm Hg after the surgery was associated to reoperation. OR 14.5; CI 95% (2.8-75).
Having a final pulmonary transvalvular gradient of ≥25 mm Hg was associated to a higher probability of reoperation.
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Original article: cardiovascularComparative Long-Term results of surgery versus balloon valvuloplasty for pulmonary valve stenosis in infants and children

Abstract

Background

Methods

Results

Conclusions

Section snippets

Demographics

Surgery and BV groups

Comment

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Int J Cardiol

Pulmonic stenosis

Pulmonary valvulotomy for the relief of congenital pulmonary stenosis. Report of three cases

Br Med J

Surgery of pulmonary stenosis. A case in which the pulmonary valve was succesfully devided

Lancet

Long term (10 to 13 years) follow up study after transventricular valvectomy for pulmonary stenosis with intact ventricular septum

Circulation

Results of open heart surgery in patients with pulmonic stenosis and intact ventricular septum. A report of 108 cases

Circulation

Original article: cardiovascular
Comparative Long-Term results of surgery versus balloon valvuloplasty for pulmonary valve stenosis in infants and children