Balloon dilatation of critical stenosis of the pulmonary valve in neonates.

Abstract

Percutaneous balloon dilatation was attempted in 15 consecutive neonates (mean age 7.3 (range 1-27) days and weight 3.2 (range 2.5-4.1) kg) with critical stenosis of the pulmonary valve. Dilatation was successful in 11 (73%) patients. The mean balloon to annulus ratio was 1.1 (range 0.6-1.77). The ratio of right ventricle to femoral artery systolic pressure decreased from a mean (1 SD) of 1.4 (0.32) before to 0.8 (0.24) after dilatation and the transvalvar gradient decreased from 81 (29.7) mm Hg before to 33 (27.7) mm Hg after dilatation. All four (27%) patients in whom dilatation was unsuccessful underwent surgical valvotomy. Complications of balloon dilatation occurred in three (20%) patients; these included retroperitoneal haematoma (one) and iliofemoral venous occlusion (two). In one (7%) patient severe hypoxia and hypotension developed when the valve was crossed with a guide wire and balloon catheter. Despite successful dilatation he died 7 days after the procedure. During a mean (1 SD) follow up of 2 (1.7) years, seven (64%) of the 11 patients remained free of important restenosis. One patient required repeat dilatation three weeks after the initial procedure. In three (27%) patients restenosis developed 4-9 months after dilatation and all three had surgical valvotomy. Of the four patients initially referred for surgery three required a second operation and one required balloon dilatation. Percutaneous balloon dilatation gave effective relief of critical pulmonary stenosis in most neonates but complications and restenosis requiring surgery were common.

Balloon Valvuloplasty of Critical Pulmonary Valve Stenosis in a Premature Neonate

“…Premature infants and infants with low birth weight and critical pulmonary valve stenosis are a therapeutic challenge, since they encounter several specific problems, including avoidance of temperature loss during the procedure, venous access, and problems related to the small anatomical size of the cardiac structures. There are only few patients reported in the literature who underwent successful balloon dilatation of critical pulmonary valve stenosis with a body weight of less than 2.5 kg [5,7,8,12,14].…”

“…Further measurements, allowing us to obtain stable normothermia in our patient, were warming up of the catheterization laboratory, wrapping of the child in cotton, and additional covering of the extremities with aluminium foil. The 7-mm balloon catheter we used (Osypka, Grenzach-Whylen, Germany) proved ideal for the pulmonary valvuloplasty, since its low profile allowed it to be introduced through a 4 French sheath, thus avoiding the damage to the femoral vein that can be a major complication of balloon valvuloplasty [3,7,13]. Furthermore, due to the small diameter of the balloon catheter, a more time consuming multistep gradational approach using progressively larger balloons [3,5,11], or the application of a so-called transductal guidewire rail technique [8], were not necessary.…”

Single-stage balloon valvuloplasty for critical pulmonary valve stenosis in the neonate

“…Modifications of the original technique were developed to overcome difficulties in crossing the stenotic pulmonary valve, and to avoid hypoxia secondary to severe reduction of pulmonary blood flow during balloon inflation. Multistage or gradational techniques [3,4,6,7,9,10] include sequential predilation of the pulmonary valve with small low-profile balloons of increasing diameter, followed eventually by dilation with the appropriately sized balloon. These techniques have undoubtedly increased the effectiveness of the procedure; however, they are limited by their complexity.…”

“…Percutaneous balloon valvuloplasty is currently considered the treatment of choice in this setting [3][4][5], but it is limited by technical considerations-mainly the difficulty of crossing the pulmonary valve-and may be associated with considerable morbidity and mortality [3,4,[6][7][8]. Previous reports describe a variety of catheter/guidewire systems used to cross the pulmonary valve, with balloon valvuloplasty performed employing multistage or gradational dilation in the vast majority of the cases [3,6,7,[9][10][11]. These techniques are technically cumbersome and subject the infant to prolonged fluoroscopy exposure.…”

Reaccrediting general practice.

“…5 Given that attendance at courses is already included in the 1990 general practitioner contract adopting it for accreditation smacks of double counting, and there is little evidence that it is associated with better performance. Selecting and monitoring educational events and monitoring attendance-let alone how much learning actually goes onwould be difficult.…”