Controversies in percutaneous balloon pulmonary valvuloplasty: timing, patient selection and technique

Balloon valvuloplasty is currently the preferred therapeutic alternative to surgical valvotomy in selected patients with isolated congenital pulmonary stenosis. Not only does pulmonary valvuloplasty consistently afford safe and dramatic reduction of the valvular obstruction, it also produces less trauma and an equivalent sustained gradient relief when compared to surgical intervention. However, despite its established role, controversies persist in certain aspects of balloon pulmonary valvuloplasty (BPV). They include the timing of intervention, the suitability of certain valve morphologies and the choice of balloon techniques. Based on clinical experience, the following recommendations can be made: 1. BPV is currently recommended for moderate to severe pulmonary stenosis. Patients with mild stenosis are better served by conservative management and serial echocardiographic assessments. 2. Classic pulmonary stenosis is most suitable for BPV. However, patients with milder forms of dysplastic valves are still potential candidates for BPV. 3. Adequate dilatation with optimal relief of obstruction can be achieved with either the single or double balloon technique. Whether the Inoue or fixed-balloon system is used is a personal preference. Equally good results can potentially be obtained by either balloon design.