Object

Title: The results of percutaneous balloon valvuloplasty in the treatment of pulmonary valve stenosis in children

Abstract:

Isolated pulmonary valve stenosis (PVS) is encountered in approximately 0.33/1000 live births and accounts for approximately 6-9% of congenital heart defects. The mechanism underlying the abnormality may be commissural fusion or dysplasia of pulmonary valve leaflets (in 10 % of patients). Pulmonary valve stenosis is often found in Noonan’s, LEOPARD, or Allagil syndrome. The form of the stenosis may be a decisive factor in selecting surgical/intervention treatment. Since the first report on percutaneous balloon valvuloplasty (BVP) published by Kan et al. in 1982, this is the method of choice in the management of patients (pts) with pulmonary valve stenosis (PVS) of moderate to severe degree. In spite of the fact that BVP has been employed for the past 25 years, interest continues to focus on immediate and long-term results depending on the degree of PVS, age of patients and the employed technique. The subject of the present investigation – in addition to reduction of gradient across PVS – is normalization of hemodynamic disturbances, the incidence of recurrent stenosis and various complications, as well as monitoring the development of children subjected to therapy. Objective: to assess the results of BVP in subsequent patients with PVS (excluding newborns with critical PVS) treated in Department of Pediatric Cardiology, Collegium Medicum, Jagiellonian University, in the years 1988-2004, in relation to: 1. type of valvular lesions and degree of stenosis, 2. age of patients subjected to BVP and such technical aspects of the procedure as: a. balloon diameter and its ratio to the valve annulus, b. types of balloon catheters employed, c. the need for employing double balloon technique, 3. restrictions in employing the method resulting from the types of valvular morphological lesions, 4. immediate BVP results, including: a. reduction of pressure gradient across the pulmonary valve, b. development of valve insufficiency, c. development of other procedure-associated complications, 5. early and late results, including: a. recurrent stenosis, b. significant (>IIo ) pulmonary valve insufficiency, c. the need for re-intervention, d. assessment of physical development of patients and their physical efficiency (NYHA classification). Material: 137 (76 M+61 F) children, aged between 1 month and 16.3 years of life (x=5.3 ±4.8) with isolated PVS diagnosed by physical examination, ECG, chest X-ray, comprehensive echocardiography and detailed hemodynamic and angiocardiographic assessment. They were qualified to BPV between 28.03.1988-31.12.2004, based on echo studies (Doppler gradient > 25 mmHg). Newborns with critical PVS were excluded from the study. Three patients with PVS had been previously subjected to a surgical valvulotomy (when 1 month, 2 and 2.5 years old, respectively) and BPV was recommended due to recurrent stenosis (after 4 and 8 years postoperatively, respectively). One patient with coarctation of the aorta and PVS had undergone a Waldhausen operation when 2 weeks old, and was qualified to BPV when 14 months old. Methods: During BPV, the following parameters were analyzed: the type of PVS, the degree of stenosis and right ventricular load (assessment of systolic, end-diastolic right ventricular pressure, pulmonary systolic pressure, pressure gradient across PVS), the balloon diameter and its ratio to annulus diameter, the type of balloon catheter, and the need for double balloon technique employment. Immediately after BPV, the analysis included a decrease of gradient across PVS, a decrease of right ventricular end-diastolic pressure, changes of pulmonary systolic pressure, development/intensification of subventricular PVS, development of valve insufficiency and development of complications. A successful procedure was defined as one resulting in at least 50% decrease of pressure gradient across PVS. ; The patients were divided into three groups, depending on their right ventricular systolic pressure (RVSP) as compared to systemic pressure and assessed by hemodynamic studies: Group 1 (N=58) – mild to moderate PVS (RVSP ≤ 75 % of systemic pressure); Group 2 (N=41) – high degree PVS (RVSP = 76-100 % of systemic pressure), Group 3 (N=38) – severe PVS (with suprasystemic right ventricular pressure - RVSP > 100 % of systemic pressure). In each group, the analysis included age at BPV, results of clinical assessment and basic tests (ECG and chest X-ray), comprehensive echocardiographic evaluation and intervention management. Results: The follow-up period was between 1 year and 10 years, x = 6.1 years (SD – 3.4 years). The age of pts at BPV was as follows: Group 1 – x = 6.0 ±4.9 years, Group 2 – x = 4.1 ±3.8 years, Group 3 – x = 5.6 ±5.6 years. In each group, BPV was most commonly performed in patients aged 2-6 years. At the same time, the percentage of infants increased (8.6 %, 24.4 % and 28.9 %, respectively). In Group 1, the sex ratio was equal. A predominance of males was noted with an increasing degree of stenosis (Group 2 – 56.1 %, Group 3 – 63.2 %). As it follows from the analysis of clinical signs, with the increase of PVS, cardiac murmur was louder and split 2nd sound in the pulmonary artery area was more common, along with right ventricular impulse. The results of physical examination showed the highest degree of discrimination between Groups 1 and 2 and 1 and 3, being the most similar in Groups 2 and 3. ECG showed right ventricular hypertrophy in the majority of children from Group 1 and 2 and in all Group 3 patients. ECG recording was normal in 24.1% of Group 1 and 12.2% of Group 2 patients. Chest X-ray showed that an increasing degree of PVS was accompanied by an increasing cardiothoracic ratio (↑CTR) and lobulated contour of the main pulmonary artery (↑LCMPA) – Group 1: ↑CTR – 17.2% and ↑LCMPA – 13.8%, Group 2 - ↑CTR – 31.7% and ↑LCMPA – 46.3%, Group 3 - ↑CTR – 57.9% and ↑LCMPA – 63.2%, As it followed from the analysis of echocardiographic results, the majority of patients (92.4%) demonstrated a typical form of PVS, while the dysplastic form was observed in 10 children only (7.3%) (4/41 Group 2 and 6/38 Group 3 patients, with the highest degree of stenosis). The most common finding (67.7%) was a three-leaflet form of PV, but in approximately 20% of pts the structure of the defect could not have been determined. Pulmonary valve insufficiency (PVI) >IIo and subvalvular pulmonary stenosis (SVPS) were seen infrequently (3/137 and 7/137, respectively). The incidence of SVPS slightly increased with an increasing PVS degree. No statistical significance was noted in SVPS (P = 0.07) and PVI (P = 0.07) incidence in particular groups. However, tricuspid valve insufficiency was found to occur significantly more commonly in Group 3 (9/38) as compared to Group 1 (0/58) and Group 2 (3/41) (P<0.002). The analysis of selected parameters as assessed by echocardiography vs. angiocardiography showed (all values represented as mean): - the respective diameter of pulmonary valve annulus in Group 1 was 15.0 mm vs. 15.7 mm, in Group 2 – 13.1 mm vs. 13.9 mm, in Group 3 – 11.8 mm vs. 13.9 mm. No statistical differences were noted between the results of both examinations (Group 1-3: P = 0.08, P = 0.09 and P = 0.1, respectively). - the respective mean values of systolic pressure gradient were as follows: Group 1 – 56.8 mmHg vs. 49.3 mmHg, Group 2 – 73.5 mmHg vs. 75.6 mmHg and Group 3 – 99.1 mmHg vs. 115.6 mmHg. Significant differences were observed between the results obtained using the two methods in Group 1 children, where echocardiography significantly overestimated the gradient, and in Group 3, where the said examination significantly underestimated its value (P<0.001). In Group 2 children, however, the two results did not differ significantly (P = 0.09). As it follows from the comparison of both methods, echocardiography underestimated

Level of degree:

2 - studia doktoranckie

Degree discipline:

choroby układu krążenia ; pediatria

Degree grantor:

Wydział Lekarski

Promoter:

Andrzej Rudziński

Date issued:

2007

Format:

application/pdf

Identifier:

oai:dl.cm-uj.krakow.pl:1023

Call number:

ZB-107981

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Location of original object:

Biblioteka Medyczna Uniwersytetu Jagiellońskiego - Collegium Medicum

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Last modified:

Jun 27, 2019

In our library since:

Nov 21, 2012

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