Bricelj, Vlado

Cijan, Andrej

Pavčnik, Dušan

English

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Radio/ Oncol 1993; 27: 175-9. Transcatheter balloon valvuloplasty Dušan Pavčnik, 1 Andrej Cijan, 2 Vlado Bricelj31 Institute of Radiology, Clinical Center, Ljubljana, Slovenia 2Department of Cardiology, Clinical Center, Ljubljana, Slovenia3 Department of Pediatrics, Clinical Center, Ljubljana, SloveniaAuthors describe percutaneous balloon valvuloplasty in congenital and acquired heart disease. In pulmonary, mitra! and aortic stenotic valve, balloon valvuloplasty splits fused commissures and fractures calcific deposits. Since 1987 we performed 13 pulmonary, 26 mitra! and 5 aortic valve dilatation. The method is recently used as a method of choice in isolated pulmonary valve stenosis, and as an alternative to surgical commissurotomy in mitra! valve stenosis. Aortic valvuloplasty is performed in patients who are not candidates far surgery or far whom surgery carries a very high ris k. Key words: heart valve diseases-therapy; angioplasty, balloon; percutaneous balloon valvuloplasty; pulmonary, mitra! and aortic val ve Introduction The idea that catheter could be used to treat pulmonary valve stenosis was first proposed by Limon Larson in 1960, but Dotter and Judkins first described a catheter technique to dilate peripleural arteries stenosis in 1964.1 In 1974,Andreas Gruntzig developed a noncompliant balloon and performed the first coronary angio­plasty in 1977. 2 Kan et al., in 1982 performedfist balloon valvuloplasty for pulmonary steno­sis, 3 Inoue et al. for mitra! valve stenosis4 and Lababidi et al. for aortic valve stenosis. 5 In our institution percutaneous valvuloplasty has been performed since 1987. 6• 7 Correspondence to: Prof. dr. Dušan Pavčnik, Institute of Radiology, Clinical Center, Zaloška 7, 61105 Ljub­ljana, Slovenia. UDC: 616.126.4-089.819.5 Material and methods Pulmonary valve Between 1987 and April 1993 balloon valvulo­plasty was used to treat congenital pulmonary valve stenosis (PS) in 13 patients. Their age ranged from 10 days to 18 years. Ali patients had isolated pulmonary valve stenosis with no associated cardiac defects. PS diagnosed by sector scan, pulsed, continuous and colour Doppler echocardiography underwent cardiac catheterisation and angiography. A pullback pressure recording across the pulmonary valve was performed. The mean peak systolic pulmo­nary valve gradient was 75 ± 26 mm Hg. The right sided 5-French catheter through the pulmonary valve was then replaced over 0.035 inch guide wire with balloon catheter (Meditech, Schnider or Balt). The balloons 176 Pavčnik D et al. Figure l. Two balloons of 8 mm in diameter centred across the stenotic pulmonary valve in an early phase of inflation - lateral view. were from 6 mm to 18 mm in diameter. Balloon diameters were approximately 10 % larger than the diameter of the pulmonary valve annulus. It can be used as single or double balloon technique (Figure 1). Mitra! valve Between 1988 and May 1993, we undertook balloon dilatation of mitra] stenosis in 16 female and 10 male patients. In this group of 26 patients the mean age was 46 years (range: 31-75 years), left atrium diameter (echo) was4.5 ± 6.7 mm X 7.5 ± 5.5 mm. Patients presen­ted with severe symptoms: 3 patients were inNYHA class II, 19 patients in class III and 4patients in class IV.Echocardiographic evaluation showed mild regurgitation (n = 6, Sellers grade 1). Fluoroscopy documented evidence of valve calcification in 6 patients. Babič's retrograde transarterial approach with double balloon tech­nique8 was performed in 11 patients and Inoue single balloon technique4 with transeptal ap­proach in 15 patients. The Inoue technique is simple and takes the shortest tiine in comparison with all other tech­niq ues. A curved guide wire of 0.025 inch is inserted in the left atrium after transseptal punc­ture. The septum is then dilated by a 14-French dilator. A single balloon (Toray Medica! Co., Tokyo) which fits well into the annulus is inflated until waist disappears. Haemodynamic parameters (PCW, MG, PT and CO) and echocardiography (MV A) were compared before and after procedure. Statisti­cal analysis was made. The long term observa­tion of clinical state and measurement were performed in 15 patients. Aortic valve Percutaneous balloon valvuloplasty was perfor­med between 1989 and 1993 in 5 patients. One patient, 22 years of age, had congenital aortic valve stenosis and 4 patients (mean age 81 years) had severe calcified aortic stenosis, and were not candidates for surgery. The technique of dilatation is grossly similar to that mentioned above. Left heart catheterisation is done by the femoral route, the aortic orifice is crossed with standard 0.038 inch or 0.035 inch guide wire. Over the wire a standard 7-French catheter is introduced into the left ventricle and left ventri­cular and aortic pressures are recorded to mea­sure the transvalvular systolic gradient. Then 300 m long 0.038 inch guide wire is positioned through the 7-French catheter into the left ventricle, the catheter is removed and the bal­loon catheter (Meditech or Balt) is introduced over the wire across the aortic valve. Balloons are 40 mm long and inflated diameter is up to 30 mm. The balloon is inflated with diluted contrast medium for a few seconds. Results Pulmonary valve Technically successful dilatation was achieved in 12 of the 13 patients. In one case we were Transcatheter ba/loon valvuloplasty 177 not able to cross the critical stenosis with a guide wire , and the patient later underwent surgery. In 12 patients dilatation was successful. Transvalvular gradient was reduced from 75 ±26 mm Hg to 29 ± 1 6  mm Hg after valvuloplasty (p < 0.001). We had one complication - perforation of the right ventricle outflow tract with a 0.021 inch e 1982, the efficacy and safety of this pulmonary valve stenosis in an attempt to per­form balloon dilatation of the pulmonary valve. The complication was diagnosed by contrast injection into the pericardium. The infant was followed by sector scan echocardiography and recovered completely from the injury. The dila­tation was successfully repeated a few days Iater with a soft tipped wire to cross the pulmo­nary valve. Mitra! valve Successful dilatation produced a functional im­provement in 24 of the 26 patients. In those cases valvuloplasty resulted in significant de­crease in PCW from 24.3 ± 5.2mm Hg to 1 4.5 ± 4.2mm Hg (p < 0.0001), mitral gradient from 15.7 ± 4.1mm Hg to 6.9 ± 3.1 mm Hg (p < 0.0001). Mitra) valve area increased from 1.00 ± 0.002 cm2 to 1.8 ± 0.03 cm2 (p < 0.0001). Follow up of 15 patients revealed slight re­duction of MV A in ali patients. In 3 patients replacement of mitra) valve after 12-1 6 months was done. Twelve patients are stili in good haemodynamic and clinical state (3 6 months). At the end of the hospital stay 18 patients were in NYHA clas I or II, 6 in class III and two in class IV. We had some mild complications as menshe­ned bellow, but no death or embolic pheno­mena occurred in this serie. Four patients had insignificant left to right shunt of atrial septum. There were two unsuccessful procedures. Mi­tra! regurgitation developed in one patient with calcified valve and in another pulmonary oe­dema developed. Mitral valve replacement was necessary. Aortic valve In ali five patients dilatation of the valve was successful, transvalvular gradient was reduced. In patients with congenital aortic valve stenosis the transvalvular pressure gradient was reduced from 75 to 30 mm Hg. In this case a mild aortic regurgitatation increased from I to stage II after procedure. One additional aortic regurgi­tation was noted in the remaining 4 patients. No further complications occurred. Redilata­tion was performed in one patient with residual stenosis. Discussion Pulmonary valve Pathology that occurs in congenital pulmonary valve stenosis is characterized by commissural fusion of the cusps. In cases with central or Iateral perforation a tipical dome shaped defor­mity is recognizable. In such valve deformity, balloon dilatation can be successfully applied with low risk.9 Significant reductions of pulmo­nary valve pressure gradients immediately after percutaneous balloon valvuloplasty and at fol­low-up studies indicate that the relief of pulmo­nary stenosis from commissural splitting or cusp teating is almost permanent. 10 When infundibu­lar stenosis accompanied pulmonary stenosis the procedure was less efficient.9 Since 1982, the efficacy and safety of this technique has been fully established and more than 1000 cases have been reported. It is con­sidered a procedure of choice for the pulmony valve stenosis. It is the most common interven­tional procedure performed on cardiac catheri­zations in children.10Mitra! valve Mitral valve stenosis remains the commonest of ali cardiac valve disorders as a result of rheuma­tic heart disease in the developing countries. Since 1983 three technique have been develo­ped. Antegrade double balloon technique, re-178 Pavčnik D et al. Figure 2. Inoue balloon mitra] valvuloplasty. Inflated balloon across the narrow mitra] valve. trograde double balloon technique and Inoue balloon technique.4• 8• 9 Antegrade double bal­loon technique was in the past the most widely used technique. Besides complications resulting from transseptal puncture, embolic phenomenon or mitra[ regurgitation which can happen in ali the techniques, left to right shunting is frequent in this technique as the atrial septum has to be dilated to insert dilation balloon catheters. Du­ring follow-up period, most of the shunts disap­pear. A well conducted study has shown that about 10 % of ali the patients who underwent this technique, had a significant shunt after a period of 6 months. 11• 12 We never used thistechnique in our hospital. Retrograde double balloon technique. In this technique, the balloons are inserted through the femoral arteries over long guide wires which are inserted in the femoral vein and brough into the aorta through a transseptal puncture and exteriorised through femoral arteries by the help of a snare. This procedure has the advantage of not producing any left to right shunt. This technique is relatively complex. Local complications at the site of femoral arte­ries are more frequent. 13 This technique was used in our hospital in 11 patients. Inoue balloon technique. Inoue who has per­formed more than 1000 cases of mitra! balloon valvuloplasties has named this procedure as percutaneous transluminal mitra! commissuro­tomy (PTMC). This technique has a lot of advantages over other techniques, however, the major drawback has been the short tirne available for the procedure in order to minimize the complications rate14 (Figure 2). Closed mitra! commissurotomy was for a long tirne the only effective treatment for mitra! stenosis.15 Balloon mitra! valvuloplasty is un­doubtedly an attractive alternative to surgical commissurotomy. Initially, it was limited to young patients with pliable non-calcified valves. Mitra) valvuloplasty has now been extended to calcified valves and in patients with moderate involvement of the subvalvular apparatus. The commissural splitting is a mechanism in success­ful balloon technique. A good haemodynamic stability was achieved in 70 % of patients for five years if one commissure was split and in 89 % of patients if both commissures were split. In patients with calcified valves dilatation im­proves valve area through commissural opening and fracturing the nodular depozit.16· 17Its use in recurrent mitra! stenosis is safe and effective. The main contraindications for this technique is presence of fresh thrombus and significant mitra! regurgitation. Aortic valve The clinical improvement of dilated patients is often dramatic, but restenosis note is consider­ably high.18 It is unknown which patients willreceive long term benefits from balloon dilata­tions.19It appears to be a technique of choice in patients who are not surgical candidates or for whom surgery carries a very high risk, i.e. mainly in elderly patients. It is also considered as an effective and less invasive alternative to surgical valvotomy in infants and children par­ticularly in the cases of restenosis after surgical valvotomy where the need for the implantation of a prosthetic val ve is otherwise mandatory. Transcatheter balloon valvuloplasty 179 References l. Dotter CT, Judkins MP. Transluminal treatmentof arteriosclerotic obstruction. Description of anew technic and a preliminary report of its appli­cation Circulation 1964; 30: 654-70.2. Gruntzig AR. Transluminal dilatation of coronaryartery stenosis. Lancet 1978; 1: 263-4.3. Kan JS, White Rl, Mitchell SE, Gardner TJ.Percutaneous balloon valvuloplasty: A new met­hod for treating congenital pulmonary valve steno­sis. N Engl J Med 1982; 370: 540---3.4. Inoue K, Owaki T, Nakamura T, Kitamura F,Miyamoto N. Clinical application of transvenousmitra! commissurotomy by a new balloon catheter.J Thorac Cardiovasc Surg 1984; 87: 394-402.5. Lababidi Z, Wu JR. Walls JT. Percutaneous bal­loon aortic valvuloplasty: Results in 23 patients.Am J Cardiol 1984; 53: 194-7.6. Robida A, Pavčnik D. Perforation of the heart ina newborn with critical valvar pulmonary stenosisduring balloon valvoplasty. lntervent J Cardiol1990; 26: 111-2.7. Pavčnik D, Cijan A, Robida A, Šurlan M. Posegiintervencijske radiologije v prsnem košu. 10 Ra­denski dnevi 1989; 46 (abstract).8. Babic U, Pejčic P, Djurišic Z, Vučinic M, GrujičicS. Percutaneous transarterial balloon valvuloplastyfor mitra! valve stenosis. Am J Cardiol 1986; 57:1101-4.9. Becker AE, Hoedemaker G. Balloon valvulopla­sty in congenital and acquired heart disease: Mor­phologic consideration. Z Kardiol 1987; 76 (6):73-9.10. Stanger P, Cassidy SC, Girod DA. Balloon pulmo­nary valvuloplasty: Results of valvuloplasty andangioplasty of congenital anomalies. Radiology1990; 177: 599---{500.11. Vahanian A, Michel PL, Cormier B, et al. Resultsof percutaneous mitra! commissurotomy in 200patients. Am J Cardiol 1989; 63: 847-52 .12. Reid CL, McKay CR, Chandraratna PA, Kawa­nishi DT, Rahimtoola SH. Mechanisms of increasein mitra! valve area and influence of anatomicfeatures in double-balloon, catheter balloon valvu­loplasty in adults with rheumatic mitra! stenosis:A Doppler and two dimensional echocardiograp­hic study. Circulation 1987; 76 (3): 628-36.13. Babic U, Dorros G, Pejčic P, Djurišic Z, GrujičicS. Percutaneous mitra! valvuloplasty: Retrograde,transarterial double-balloon technique utilising thetransseptal approach. Catheterzation and cardio­.vascular diagnosis 1988; 14: 229-37.14. Nobuyoshi M, Hamasaki N, Kimura T, Chen CH.Indications, complications and short-team clinicaloutcome of percutaneous transvenous mitra! com­missurotomy. Circulation 1989; 80: 782-92.15. Belcher RJ. Closed mitra! valvotomy. In: JacksonWJ ed. Operative surge1y, Fundamental internatio­nal technique cardiothoracic surge,y. London, Bo­ston: Butterworth, 1978: 158---{53.16. Kaplan JD, Isner JM, Karas RH. In vitro analysisof mechanisms of balloon valvuloplasty of stenoticmitra! valves. Am J Cardiol 1987; 59: 318-23.17. Block PC, Pallacios IF, Jacobs M, Fallon JJ. Themechanism of successful mitra! valvotomy in hu­mans. Am J Cardiol 1987; 59: 178-82.18. Cribier AI, Berland J, Savin T, Koning R, Mech­meche R, Letac B. Percutaneous aortic valvedilatation: Indications and results in adult acquiredcalcified aortic stenosis. Z Kardiol 1987; 76 (6):90---103.19. Davidson DJ, Harrison JK, Leithe ME. Failureof balloon aortic valvuloplasty to result in sustai­ned clinical improvement in patients with depres­sed left ventricular function. Am J Cardiol 1990;65: 72-7.

Transcatheter balloon valvuloplasty

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Transcatheter balloon valvuloplasty

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