The carotid arterial approach for balloon dilation of critical aortic stenosis in neonates—immediate results and follow-up

Abstract

SummaryBalloon dilation of the aortic valve was performed in 20 consecutive neonates with critical aortic stenosis using an approach achieved by cutting down on the right carotid artery. The age of the patients ranged from one to 25 days (mean seven days) and their weight from 2.1 to 4.0 kg (mean 3.16 kg). All patients were evaluated before cardiac catheterization with cross-sectional and Doppler echocardiography so as to keep the catheterization procedure as short as possible. Balloon dilation was accomplished in all patients. The only complication was an apical perforation by the guide wire in two cases. The ensuing pericardial effusion was immediately drained with pericardiocentesis and the subsequent course of the procedure was uneventful. Immediate results showed dramatic improvement in cardiovascular conditions. The transvalvar pressure gradient fell from 80±40 to 27±20 mm Hg (p<0.001). Left ventricular ejection fraction evaluated by echocardiography increased from 30±21% before dilation to 54±18% 24-48 hours after the procedure (p<0.001). In all patients, the procedure was free from vascular complications. Aortic regurgitation was documented after the procedure in 11 patients, being severe in one, moderate in five and trivial in five. Seven patients died, although in only one was the death related directly to the procedure itself. Six patients died because of associated lesions despite an immediate satisfactory result of the balloon valvoplasty. The 13 surviving patients are doing well, and are receiving no medications. During a mean follow-up of 25 months (range 2-54 months), four patients have developed restenosis. One underwent surgical valvotomy at one year of age. The second was successfully redilated through the same approach at two months of age. The other two have a significant gradient, as assessed by Doppler measurements (60 and 70 mm Hg), with normal systolic ventricular function. Two patients have moderate aortic regurgitation. Balloon dilation achieved through cutdown on the right carotid artery is a safe and effective alternative to surgery in neonates with isolated aortic stenosis. The unfavorable results are mainly due to associated anomalies.

Critical aortic stenosis in the neonate. Clinical assessment and surgical outcome in 18 patients

“…It may be required in the near future in an additional 6 out of the 12 patients because they already show moderate aortic restenosis with a mean transaortic pressure gradient of 60mmHg. This occurred in the group operated upon and in the other that underwent dilation through balloon catheter, according to studies already published 2,3,5,6,9,11 . The risk of aortic regurgitation may be higher in the group undergoing the interventionist procedure through balloon catheter, but general evolution has been shown to be similar for both therapeutic managements 3,5,6,7,9,[11][12][13] .…”

“…This occurred in the group operated upon and in the other that underwent dilation through balloon catheter, according to studies already published 2,3,5,6,9,11 . The risk of aortic regurgitation may be higher in the group undergoing the interventionist procedure through balloon catheter, but general evolution has been shown to be similar for both therapeutic managements 3,5,6,7,9,[11][12][13] . After the neonatal period some features, such as aortic restenosis, aortic regurgitation, arrhythmias, and syncopes occurring in patients who underwent either surgery or balloon catheter dilation, increase long-term morbidity 2,3,[5][6][7]9,[11][12][13] .…”

“…The reports about experiences with neonates with critical aortic stenosis presented in the literature in a series of publications have stressed the high morbidity and mortality rates of this anomaly that occur irrespective of the type of treatment employed, either surgical 2-4 or through balloon catheter [10][11][12][13] . Published reports have emphasized that mortality relates to unfavorable anatomy, mainly small aortic and mitral rings, and the LV hypoplasia and endocardial fibroelastosis 1,4,11-13 .…”

“…Intervention is mandatory even though controversy exists in regard to the most adequate treatment: surgery [2][3][4][5][6] or balloon [7][8][9][10][11][12][13] (table I).…”

“…According to a series of experiments, mortality seems to relate more to the unfavorable anatomical type of the left side of the heart, mainly the size of the aortic and mitral rings, the size of the left ventricle (LV), and any associated defects including endocardial fibroelastosis, rather than to the type of treatment chosen [1][2][3][4][11][12][13] . We provide here short-and long-term outcomes of our experience in the surgical treatment of aortic stenosis, contributing to the literature that shows different results in the use of one or the other type of treatment [2][3][4][5][6][7][8][9][10][11][12][13] .…”