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Predictors of successful pulmonary balloon valvuloplasty: 10-year experience
A M Mendelsohn1, A Banerjee, R A Meyer
1Department of Pediatrics, Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
Insights
Pulmonary balloon valvuloplasty effectively reduced pressure gradients in infants and children, with 68% achieving successful long-term outcomes. Early intervention at lower gradients may improve results.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Interventional Cardiology
Background:
- Pulmonary valve stenosis is a significant congenital heart defect in children.
- Balloon valvuloplasty is a primary intervention for pulmonary valve stenosis.
- Long-term outcomes and predictors of success require further investigation.
Purpose of the Study:
- To evaluate the long-term efficacy and outcomes of pulmonary balloon valvuloplasty in infants and children.
- To identify factors associated with successful and unsuccessful long-term results.
- To determine optimal criteria for intervention.
Main Methods:
- Retrospective analysis of 55 infants and children undergoing pulmonary balloon valvuloplasty (1983-1993).
- Assessment of acute and long-term pressure gradients and systolic pressure ratios via echocardiography.
- Classification of outcomes into successful (gradients < 25 mmHg, ratios < 0.6) and unsuccessful groups.
Main Results:
- Acute reduction in systolic pressure gradients from 63.5 to 26.7 mmHg (P < 0.001).
- 68% of patients (34/50) achieved successful long-term outcomes (>2 years post-procedure).
- Successful outcomes were associated with lower pre-procedural gradients (<60 mmHg) and pressure ratios (<0.8).
Conclusions:
- Pulmonary balloon valvuloplasty offers a successful long-term treatment option for many children with pulmonary valve stenosis.
- Pre-procedural systolic pressure gradients < 60 mmHg and ratios < 0.8 predict better long-term success.
- Earlier intervention at lower gradient thresholds may be beneficial.
Abstract:
At our institution, 55 infants and children (ages 0.3-21 yr, median 2.5 yr) underwent pulmonary balloon valvuloplasty between August 1983 and May 1993. Systolic pressure gradients fell acutely following balloon valvuloplasty from 63.5 +/- 24.8 mmHg (mean +/- standard deviation) to 26.7 +/- 12.9 mmHg (P < 0.001) with a decrease in systolic pressure ratio from 0.81 +/- 0.25 to 0.42 +/- 0.12 (P < 0.0001). Fifty of the 55 patients had long-term echocardiographic evaluation performed > 2 yr following balloon valvuloplasty. Thirty-four of the 50 patients (Group A; 68%) were classified as having successful (residual systolic gradients < 25 mmHg, ventricular systolic pressure ratios < 0.6) long-term outcomes. Their peak systolic gradients fell acutely from 58.8 +/- 16.6 mmHg to 22.7 +/- 11.2 mmHg (P < 0.001). At 4.6 +/- 2.3 yr postvalvuloplasty, peak instantaneous pressure gradients were 17.8 +/- 5.7 mmHg (P = ns vs. acute postvalvuloplasty). Fifteen of the 50 patients (Group B; 30%) had unsuccessful (residual systolic gradients > or = 25 mmHg and/or ventricular systolic pressure ratios > 0.6) long-term outcomes. Their peak instantaneous systolic gradients fell acutely from 76.5 +/- 33.1 mmHg to 36.6 +/- 11.4 mmHg (P < 0.05). At 3.8 +/- 1.7 yr postvalvuloplasty, peak instantaneous pressure gradients were 35.1 +/- 9.1 mmHg (P = ns vs. acute postvalvuloplasty). One 3-yr-old patient (Group C, 2%) required repeat balloon valvuloplasty on two separate occasions for recurrent stenosis. There was no significant prevalvuloplasty difference between Groups A and B with regard to age, weight, or Z scores of the pulmonary annuli or balloon/annulus ratio; however, patients in Group A had significantly lower prevalvuloplasty gradients and lower systolic pressure ratios than patients in Group B. Total systolic gradient reduction between patients with successful and unsuccessful outcomes was not significantly different (Group A: 36.1 +/- 16.6 mmHg; Group B: 41 +/- 22.3 mmHg). At long-term follow-up, patients in Group A had fewer symptoms and a significantly lower rate of electrocardiographic right ventricular hypertrophy than Group B patients. Successful outcomes defined by our criteria following balloon valvuloplasty were achieved in 68% of patients with greatest long-term success in patients with prevalvuloplasty systolic gradients < 60 mmHg and systolic pressure ratios < 0.8. Intervention at lesser systolic gradients (40-60 mmHg) appears indicated to achieve lower long-term gradients and fewer symptoms as total systolic gradient reduction by this technique is limited.