Catheter treatment of critical aortic valve stenosis in the neonate: Choice of approach

Abstract

Critical aortic valve stenosis AS in the neonate is an uncommon form of congenital heart disease. Neonates with this condition often present in the immediate neonatal period in shock and very low cardiac output. When a neonate is diagnosed to have critical AS, the most important question raised is the size of the left ventricle (LV) and if the ventricle is adequate to sustain a biventricular state. Once the LV is deemed to be sufficient to support the systemic circulation, the decision in each center has to be focused on the best approach to relieve obstruction, mainly surgical versus catheter to open the critically narrowed valve. However, prior to this, neonates with this condition have to be stabilized, including the use of prostaglandin to main patency of the ductus, inotropic support, and maintenance of a normal acid-base balance. The decision to proceed is institution-dependent. However, in the presence of good interventional team, it is advisable to proceed with catheter intervention and keep the use of surgery as a backup option. Neonates with critical AS should be mechanically ventilated; this facilitates the performance of the intended procedure and optimizes their acid-base equilibrium. In the catheterization laboratory, one important decision to make is the approach to dilate the aortic valve.Currently, there are four different techniques to cross the valve and perform the valvuloplasty. One, the standard retrograde femoral arterial route. Most cardiologists are familiar with and use this approach due to its ease. Potential complications resulting from this technique include damage to the femoral artery used, perforation of one of the valve cusps, and the inability to cross the valve. Two, retrograde via carotid artery cutdown. This technique is being used more commonly. The cutdown is usually performed by a cardiac or a pediatric surgeon using magnifying glasses. The valve is crossed relatively easily using a Judkins right coronary catheter. The vessel can be repaired easily after the procedure. Potential complications include the loss of the carotid artery and potential perforation of the valve cusp. The major advantages using this technique is the obvious preservation of the femoral artery and the procedure can be done at the bed side under transesophageal echocardiographic guidance. Three, anterograde via femoral vein. The main advantages of this technique are the preservation of the femoral artery and potentially less chance of cusp perforation. Four, anterograde via umbilical vein. Obviously, this technique has even more advantages of femoral vessel vein/artery preservation and again less chance of cusp perforation. Both anterograde techniques are more challenging and potentially may require longer fluoroscopy and procedure time.In this issue, Peuster et al. describe their experience using the anterograde technique in 17 neonates with critical AS. The procedure was possible in all 17 neonates. Four neonates underwent the procedure via the umbilical vein and the remaining 13 via the femoral vein....