Surgical closed pulmonary valvotomy for critical pulmonary stenosis: implications for the balloon valvuloplasty era.

Abstract

Background Closed pulmonary valvotomy for critical pulmonary stenosis has no apparent advantage over the percutaneous balloon technique, though it is used when balloon valvuloplasty fails. Experience of this technique at the Heart Institute, Tel Hashomer, since it was first used in 1973 has been reviewed. Methods Thirty eight infants up to 1 year old (25 of them neonates-that is, nil to 1 month old) with critical pulmonary stenosis were operated on from 1973 to 1989. All had a transventricular valvotomy, by a modification of the Brock method, and all underwent cardiac catheterisation before surgery. Results Five of the 25 neonates (20%) died, but none of the other infants, so that the total mortality (five out of 38) was 13%. Three of the 38 required an aortopulmonary shunt. All 38 survivors were followed up-from one month to 14 years (mean 7-5 years). All were symptom free at the last check up. Fifteen of the survivors had required further surgery; this was successful in all cases.Conclusions For the balloon valvuloplasty era surgical pulmonary valvotomy provides a good back up for failed attempts at percutaneous valvuloplasty. Review of outcome provides data for comparison with balloon valvuloplasty in the future.

Balloon dilation of critical valvar pulmonary stenosis in the first month of life

“…Critical VPS in the neonate has been treated surgically until recent years. In contrast to older children, mortality rates, however, have been higher, ranging from 0 to 57% (mean 29), using different procedures 1 [17][18][19][20][21][22][23][24]. However, in a recent series of 101 consecutive babies from 1987 to 1991, Hanley et al [22] noted that although the mortality among all 62 undergoing an outflow procedure using a variety of techniques was 22.6%, surgical valvotomy with cardiopulmonary bypass or open with inflow stasis was without mortality.…”

“…In surgical series in the past, this has been considered a risk factor by some 123,241 but not by others [17,19,21,22]. An increase in RV size postoperatively has been described and also following BD [8,11,14].…”

Critical Pulmonary Stenosis in Infants and Neonates in the Era of Interventional Cardiology

“…From reports early in the balloon valvuloplasty era and even later, the mortality rates from various forms of surgery to relieve severe RV outflow obstruction by closed or open valvotomy, with or without cardiopulmonary bypass, were considerably high. [8][9][10] In a more recent prospective multi-institutional report involving 101 babies with severe critical pulmonary stenosis, the mortality rate in 62 who underwent surgery using a variety of techniques was 22.6%, whereas the mortality rate among 34 who underwent balloon dilatation was 6%. 11 It is perhaps in the light of this experience and the rapid improvement in the results of balloon valvuloplasty that this procedure remains the preferred mode of treatment in many institutions.…”

Interventional cardiology

“…The aim of the procedure is to ablate the valve, as the resultant pulmonary regurgitation is mild and well tolerated. Valvuloplasty has been especially useful in neonates with critical pulmonary stenosis where surgery previously carried a high mortality 5. In neonates with the more extreme form of pulmonary atresia with intact ventricular septum, valvuloplasty can still be accomplished by first perforating the pulmonary valve with a hot wire 6.…”