Balloon valvuloplasty for critical aortic stenosis in the newborn: Influence of new catheter technology

Abstract

Between 1986 and July 1990, balloon valvuloplasty was attempted in eight newborns (less than 28 days of age) with isolated critical aortic valve stenosis. Balloon valvuloplasty could not be successfully accomplished in any of the three infants presenting before 1989. Since March 1989, when improved catheter technology became available, all five neonates presenting with critical aortic stenosis were treated successfully by balloon valvuloplasty. A transumbilical approach was utilized in all four infants in whom umbilical artery access could be obtained. One newborn who was 25 days of age underwent transfemoral balloon valvuloplasty. Balloon valvuloplasty was immediately successful in all five newborns, as evidenced by a decrease in valve gradient and improvement in left ventricular function and cardiac output. Peak systolic gradient was reduced by 64% from 69 +/- 8 to 25 +/- 3 mm Hg (p = 0.005). Left ventricular systolic pressure decreased from 128 +/- 9 to 95 +/- 9 mm Hg (p = 0.02) and left ventricular end-diastolic pressure decreased from 20 +/- 2 to 11 +/- 1 mm Hg (p = 0.02). Moderate (2+) aortic regurgitation was documented in two infants after valvuloplasty. The time from first catheter insertion to valve dilation averaged 57 +/- 14 min (range 26 to 94) and the median length of the hospital stay was 4 days. With the use of recently available catheters, the transumbilical technique of balloon valvuloplasty can be performed quickly, safely and effectively in the newborn with critical aortic stenosis. It does not require general anesthesia, cardiopulmonary bypass or a left ventricular apical incision and it preserves the femoral arteries for future transcatheter intervention should significant aortic stenosis recur.

Carotid Artery Approach to Balloon Aortic Valvuloplasty in Infants with Critical Aortic Valve Stenosis

“…There were two serious complications among four cases for which this approach was used, which is a higher rate than reported by others [2,5,7]. This result reveals the difficulty of BAV in small infants, although we have had many good results with BAV in children older than 1 year and much experience with balloon pulmonary valvuloplasty in infants with critical pulmonary valve stenosis.…”

Transapical aortic balloon valvuloplasty in a 890‐gram infant: Hybrid is better!

“…Usual routes to the aortic valve include the antegrade approach from either the umbilical vein or the femoral vein and the retrograde approach either from the umbilical artery, the femoral artery or the carotid artery [4][5][6][7].…”

Transcarotid balloon valvuloplasty for critical aortic valve stenosis at the bedside via continuous transesophageal echocardiographic guidance

“…Early reports of transcatheter balloon dilation [4,5] were encouraging, although morbidity related to aortic valve insufficiency and femoral artery compromise were considered limitations of the procedure. With the recent introduction of improved catheter technology, additional methods to perform the balloon dilation procedure including transumbilical [6], transvenous antegrade [7], and transcarotid [8] have been advocated by different centers. Our previous report [9] using transcarotid balloon valvuloplasty with continuous transesophageal echocardiographic (TEE) guidance for critical neonatal aortic valve stenosis demonstrated equivalent results to that obtained with surgical transventricular aortic valvotomy.…”