Balloon Dilatation in the Management of Congenital Obstructive Lesions of the Heart: Review of Author\u27s Experiences and Observations-Part II

While investigating the outcomes of balloon dilatation procedures in patients with congenital obstructive lesions of the heart, several parallel observations were made. The purpose of this review is to present these observations/phenomena/innovations related to balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS), and aortic coarctation (AC). In subjects who had balloon pulmonary valvuloplasty (BPV), development of infundibular obstruction, electrocardiographic (ECG) changes, changes in right ventricular filling, role of balloon/annulus ratios on the results of BPV, and double balloon vs. single balloon BPV will be reviewed. In patients who had balloon aortic valvuloplasty (BAV), causes of aortic insufficiency and trans-umbilical venous approach for BAV are tackled. In children who had balloon angioplasty (BA) of AC, aortic remodeling and biophysical response after BA of AC are discussed

Balloon Dilatation in the Management of Congenital Obstructive Lesions of the Heart: Review of Author\u27s Experiences and Observations-Part I

Balloon dilatation techniques became available to treat congenital obstructive lesions of the heart in the early/mid-1980s. The purpose of this review is to present the author\u27s experiences and observations on the techniques and outcomes of balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS) and aortic coarctation (AC), both native and postsurgical re-coarctations. Balloon dilatation resulted in a reduction of peak pressure gradient across the obstructive lesion at the time of the procedure as well as at short-term and long-term follow-ups. Complications such as recurrence of stenosis, valvar insufficiency (for PS and AS cases) and aneurysm formation (for AC cases) have been reported, but infrequently. It was recommended that strategies be developed to prevent the reported complications

Perspective Chapter: Transcatheter Interventions in the Management of Aortic Valve Stenosis

Transcatheter interventions that are useful in the management of valvar aortic stenosis will be reviewed. This chapter focuses on congenital aortic valve stenosis. The procedure of balloon aortic valvuloplasty (BAV) and the results were reviewed; BAV offers good relief of aortic valve obstruction and serves as substitute to surgery and is considered a favored option in the management of aortic stenosis in all age groups. However, BAV in elderly patients with calcific aortic stenosis offers only a temporary relief of aortic valve obstruction and BAV is not recommended for this subgroup of patients. Except for neonates, most patients are discharged home within 24-hours after BAV. While there is conclusive data for provision of pressure gradient relief both acutely and at follow-up as well as deferral of any surgery after BAV, the development of aortic insufficiency (AI) at long-term follow-up is a most important drawback. In neonates, severe AI may develop necessitating surgical intervention. Notwithstanding these drawbacks, BAV is presently believed to be a therapeutic procedure of option in the treatment of valvar aortic stenosis in pediatric and young adult patients. Methodical follow-up to identify reappearance of aortic obstruction and development of substantial AI is suggested

Fontan Operation: A Comprehensive Review

Since the first description of the Fontan operation in the early 1970s, a number of modifications have been introduced and currently staged, total cavopulmonary connection with fenestration has become the most commonly used multistage surgery in diverting the vena caval blood flow into the lungs. The existing ventricle, whether it is left or right, is utilized to supply systemic circuit. During Stage I, palliative surgery is performed, usually at presentation in the neonatal period/early infancy, on the basis of pathophysiology of the cardiac defect. During Stage II, a bidirectional Glenn procedure is undertaken in which the superior vena caval flow is diverted into the lungs at an approximate age of 6 months. During Stage IIIA, the blood flow from the inferior vena cava (IVC) is rerouted into the pulmonary arteries, typically by an extra-cardiac conduit along with a fenestration, generally around 2 years of age. During Stage IIIB, the fenestration is closed by transcatheter methodology 6–12 months after Stage IIIA. The evolution of Fontan concepts, the indications for Fontan surgery, and the results of old and current types of Fontan operation form the focus of this review

Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children

AbstractObjectives. To evaluate the usefulness of balloon angioplasty for relief of native aortic coarctation, we reviewed our experience with this procedure, with special emphasis on follow-up results.Background. Controversy exists with regard to the role of balloon angioplasty in the treatment of native aortic coarctation.Methods. During an 8.7-year period ending September 1993, 67 neonates, infants and children underwent balloon angioplasty for native aortic coarctation. A retrospective review of this experience with emphasis on long-term follow-up forms the basis of this study.Results. Balloon angioplasty produced a reduction in the peak-to-peak coarctation gradient from 46 ± 17 (mean ± SD) to 11 ± 9 mm Hg (p < 0.001). No patient required immediate surgical intervention. At intermediate-term follow-up (14 ± 11 months), catheterization (58 patients) and blood pressure (2 patients) data revealed a residual gradient of 16 ± 15 mm Hg (p > 0.1). When individual results were scrutinized, 15 (25%) of 60 had recoarctation, defined as peak gradient >20 mm Hg. Recoarctation was higher (p < 0.01) in neonates (5 [83%] of 6) and infants (7 [39%] of 18) than in children (3 [8%] of 36), respectively. Two infants in our early experience had surgical resection with excellent results. Three patients had no discrete narrowing but had normal arm blood pressure and had no intervention. The remaining 10 patients had repeat balloon angioplasty with reduction in peak gradient from 52 ± 13 to 9 ± 8 mm Hg (p < 0.001). Reexamination 31 ± 18 months after repeat angioplasty revealed a residual gradient of 3 to 19 mm Hg (mean 11 ± 6). Three (5%) of 58 patients who underwent follow-up angiography developed an aneurysm. Detailed evaluation of the femoral artery performed in 51 (88%) of 58 patients at follow-up catheterization revealed patency of the femoral artery in 44 (86%) of 51 patients. Femoral artery occlusion, complete in three (6%) and partial in four (8%), was observed, but all had excellent collateral flow. Blood pressure, echocardiography-Doppler ultrasound and repeat angiographic or magnetic resonance imaging data 5 to 9 years after angioplasty revealed no new aneurysms and minimal (2%) late recoarctation.Conclusions. On the basis of these data, it is concluded that balloon angioplasty is safe and effective in the treatment of native aortic coarctation; significant incidence of recoarctation is seen in neonates and infants; repeat balloon angioplasty for recoarctation is feasible and effective; and the time has come to consider balloon angioplasty as a therapeutic procedure of choice for the treatment of native aortic coarctation

Echocardiographic estimation of balloon-stretched diameter of secundum atrial septal defect for transcatheter occlusion

Stretched diameter of the atrial septal defect (ASD), determined by balloon sizing at cardiac catheterization, is commonly used to select the sizes of the devices used for transcatheter closure of the secundum ASD. We have previously evaluated the utility of pulmonary/systemic flow ratio and angiographic and echocardiographic (echo) sizes of the ASD in estimating stretched ASD diameter in a group of 16 patients and determined that echo diameter had the best correlation with stretched diameter (r = 0.82; p p &gt; 0.1) from the measured stretched diameter. The correlation between predicted and measured stretched ASD sizes was excellent (r = 0.9; p &lt; 0.001). The mean squared error was 2.4. The differences between measured and predicted values were within 2 mm in all but three patients. It is concluded that stretched ASD diameter can be estimated accurately by two-dimensional subcostal echo measurements, which in turn could be used for selection of device size for occlusion of the ASD.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29960/1/0000322.pd