Balloon Valvuloplasty For Aortic Stenosis Research Articles

Left ventricular systolic function impairment in children after balloon valvuloplasty for congenital aortic stenosis assessed by 2D speckle tracking echocardiography.

The aim of the study was to evaluate left ventricular (LV) remodeling and systolic function using two-dimensional speckle tracking echocardiographic (2D STE) imaging in children at a long-term (more than 36 months, 107.5±57.8 months) after balloon valvuloplasty for aortic stenosis (BAV). 40 patients (mean age 9,68 years, 75% male) after BAV and 62 control subjects matched to the age and heart rate were prospectively evaluated. The 2D STE assessment of LV longitudinal and circumferential strain and strain rate was performed. Left ventricular eccentric hypertrophy (LVEH) was diagnosed in 75% of patients in the study group. Left ventricular ejection fraction (LVEF) was normal in all patients. In study group, global longitudinal strain (GLS), global longitudinal strain rate (GLSr) were significantly lower compared with the controls: GLS (-19.7±2.22% vs. -22.3±1.5%, P< 0.001), GLSr (-0.89±0.15/s vs. -1.04 ±0.12/s, P < 0.001). Regional (basal, middle and apical segments) strain and strain rate were also lower compared with control group. Global circumferential strain (GCS), global circumferential strain rate (GCSr) as well as regional (basal, middle and apical segments) strain and strain rate were normal. Multivariable logistic regression analysis included: instantaneous peak systolic Doppler gradient across aortic valve (PGmax), grade of aortic regurgitation (AR), left ventricular mass index (LVMI), left ventricular relative wall thickness (LVRWT), left ventricular end-diastolic diameter (LVEDd), peak systolic mitral annular velocity of the septal and lateral corner (S'spt, S'lat), LVEF before BAV and time after BAV and showed that the only predictor of reduced GLS was LV eccentric hypertrophy [odds ratio 6.9; (95% CI: 1.37-12.5), P = 0.045]. Patients at long-term observation after BAV present the subclinical LV systolic impairment, which is associated with the presence of its remodeling. Longitudinal deformation is the most sensitive marker of LV systolic impairment in this group of patients.

Assessment and Acute Management of Decompensated Heart Valves in the Intensive Care Unit - a Current Review

The acute valvular dysfunction is a rapidly growing and critical condition in the intensive care unit with a cardiogenic shock as the most serious clinical entity. There are clearly defined guidelines for the diagnosis and treatment of heart failure and for stable patients with valvular heart disease. However, data regarding acutely valvular decompensated patients are currently limited. In case of secondary organ dysfunction despite optimal medical treatment, various percutaneous interventional procedures such as TAVI and MitraClip are now available besides surgical valvular repair. Moreover, balloon valvuloplasty for aortic stenosis and percutaneous mechanical circulatory support devices are emerging tools for the treatment and stabilization of valvular decompensated patients in the intensive care unit.

Оцінка безпосередніх та віддалених результатів балонної вальвулопластики при аортальному стенозі у новонароджених

Оцінка безпосередніх та віддалених результатів балонної вальвулопластики при аортальному стенозі у новонароджених

TCTAP A-163 Follow-Up Results of Balloon Valvuloplasty in Aortic Stenosis of Rheumatic Etiology

TCTAP A-163 Follow-Up Results of Balloon Valvuloplasty in Aortic Stenosis of Rheumatic Etiology

Dilation of the Ascending Aorta After Balloon Valvuloplasty for Aortic Stenosis During Infancy and Childhood

Dilation of the ascending aorta (AA) is common in patients with a bicuspid aortic valve. The natural history of the aortic root and AA and the risk factors for dilation have not been characterized in patients with congenital aortic stenosis (AS) treated with balloon valvuloplasty during childhood. The present study was performed to determine the prevalence of aortic dilation in patients with congenital AS before and up to 20 years after balloon valvuloplasty performed during childhood. In patients who underwent balloon valvuloplasty for AS at age ≤ 18 years from 1984 to 2005, the aortic diameter measurements before intervention and at 5-year intervals afterward were recorded and the Z scores calculated. Among 156 patients (median age 1.5 years at valvuloplasty), the AA Z scores were significantly larger than normal before intervention (median Z score 1.5) and at all follow-up points (all p <0.001). Using mixed modeling, with time as a categorical variable (before intervention, 5-year window, 10-year window, and so forth), the mean AA Z score was greater at all postvalvuloplasty points than before the intervention, with mean Z score increases of 1.20 at 5 years and 2.11 at 20 years (p <0.001). Moderate or greater aortic regurgitation early after valvuloplasty was associated with greater AA Z scores than mild or less aortic regurgitation, with a progressive difference over time. More significant residual AS after valvuloplasty was associated with lower AA Z scores over time. In conclusion, AA dilation is common in children with congenital AS and continues to progress over many years after balloon valvuloplasty.

Measurement of Effective Aortic Valve Area Using Three‐Dimensional Echocardiography in Children Undergoing Aortic Balloon Valvuloplasty for Aortic Stenosis

Pressure gradient is used for timing of balloon aortic valvuloplasty for aortic stenosis (AS) in children, but does not correlate well with outcome and is limited if ventricular function is poor. In adults, effective orifice area (EOA) is used to assess AS severity, but EOA by continuity equation or 2D echo is unreliable in children. Three-dimensional echocardiography (3DE) may reliably assess EOA but has not been studied in children. We assessed measurement of aortic valve EOA by 3DE in children with AS before and after balloon aortic valvuloplasty and compared results with change in aortic valve gradient. 3DE was performed at time of catheterization before and after balloon aortic valvuloplasty. Using 3DE multiplanar review mode, valve annulus diameter, area, and EOA were measured and compared with change in aortic gradient and degree of aortic insufficiency. Twenty-four 3DE studies in 12 children (mean age 4.4 ± 5.0 years) were analyzed. EOA was measurable in all. Catheter peak gradient decreased from 45 ± 10 to 26 ± 17 mmHg (P = 0.0018). 3DE EOA increased after balloon aortic valvuloplasty (0.59 ± 0.52 cm(2) vs 0.80 ± 0.70 cm(2) ; P = 0.03), without change in valve diameter. EOA change correlated with change in peak (r = 0.77; P = 0.005) and mean (r = 0.60; P = 0.03) aortic valve gradient post balloon aortic valvuloplasty. 3DE facilitates EOA measurement in pediatric AS and correlates with change in aortic valve gradient after balloon valvuloplasty.

The Application of a Bi-ventricular Assist Device for a Low Weight (2.4 kg) Neonate with Coarctation of the Aorta and Critical Aortic Stenosis

A 5-day-old neonate (body weight=2.4 ㎏) with coarctation of the aorta and critical aortic stenosis underwent an interventional balloon valvuloplasty for aortic stenosis. During the intervention, cardiac arrest occurred due to injury of the right carotid artery by the guide wire. An extracorporeal membrane oxygenator (ECMO) was applied. After 1 day’s support, total surgical correction was achieved; however, in the immediate postoperative period, cardiac function was severely depressed. We applied a bi-ventricular assist device (bi-VAD) instead of an ECMO and we were able to wean the patient off the bi-VAD device after 3 days’ support. The patient was discharged without severe complications.

Vancomycin use in pediatric cardiothoracic surgery patients.

Vancomycin use in pediatric cardiothoracic surgery patients.

Recent developments in balloon valvuloplasty techniques

The long-term outcome after mitral valvuloplasty is excellent and compares well with surgical treatment of mitral stenosis. Compared with the double balloon technique, the Inoue method is technically easier and may reduce acute complications without any adverse effect on long-term outcomes. Excellent long-term outcome is also seen after balloon valvuloplasty of aortic stenosis in the young and in pulmonary stenosis at all ages. Finally, although balloon aortic valvuloplasty in the elderly may not change the terrible prognosis of such patients, it does improve functional status and is a useful bridge to surgery in selected patients.

Anterograde balloon valvuloplasty of aortic stenosis in children

In congenital aortic stenosis, percutaneous balloon valvuloplasty is an alternative to surgical valvotomy with promising results. 1,2 However, particularly in children, the high incidence of iliofemoral complications is disappointing. 1,3 Furthermore, retrograde passage across the stenotic valve is often difficult and potentially harmful for the aortic valve. 4 Because of these disadvantages, aortic valvuloplasty has been performed through a right common carotid artery cutdown, 5 through the umbilical artery 6 and intraoperatively through a stab wound in the left ventricular apex. 7 As an alternative approach, we performed aortic valvuloplasty in 9 consecutive children with congenital aortic stenosis anterograde from the right femoral vein.

Insights on the mechanism of balloon valvuloplasty in aortic stenosis

An analysis of the mechanisms of action of balloon valvuloplasty in adult aortic stenosis (AS), based on postmortem studies on fresh specimens and on clinical experience with 300 consecutive cases, is reported. When maximally inflated, a 20-mm diameter balloon (occupying a 3.14 cm 2 cross-sectional area) significantly enlarges the stenosed valve orifice by 3 mechanisms: stretching of valve tissue, rupturing of commissural fusion and breaking of calcific deposits. These last 2 mechanisms are the most effective, in both tricuspid and bicuspid forms of AS, to render the cusps more flexible and able to open during systole and to close at the time of ventricular diastole. The marked increase in valve area obtained by the dilatation procedure was clearly demonstrated on fresh postmortem specimens and also on postmortem examination of cases that had had balloon valvuloplasty during life. Stretching alone may give only a temporary increase in valve area with an elastic return of the leaflets to their initial stenosing position and may explain, at least in part, the occurrence of restenosis. Inflation of the balloon is well tolerated with no deleterious decrease in blood pressure in two-thirds of the cases because the balloon opens the commissures, allowing blood ejection through these openings. It does not produce calcific emboli, probably because calcium deposits remain imbedded in the leaflets, covered by the endothelium. Finally, it very infrequently produces acute severe aortic regurgitation. Careful choice of balloon size is necessary to obtain an effective opening; most often a 20-mm diameter balloon but sometimes a balloon up to 23 mm is used. Before using a large size balloon, one must keep in mind the risk, however rare, of a rupture complication that could involve the leaflets or, more importantly, the aortic anulus or the adjacent myocardium.

Clinical and noninvasive hemodynamic results after aortic balloon valvuloplasty for aortic stenosis

Balloon valvuloplasty has been shown to be an effective treatment for adults with aortic stenosis, typically providing a 50 to 80% increase in aortic valve area and marked improvement in exertional dyspnea, angina and syncope. However, the duration of this hemodynamic and clinical improvement is uncertain. Forty-two patients were followed for 10.2 ± 0.5 months. Balloon valvuloplasty caused dramatic immediate reduction in the number of patients with moderate or severe dyspnea (80 to 14%), moderate or severe angina (39 to 2%) and syncope (30 to 2%). Furthermore, this improvement in symptoms continued for the duration of the follow-up period in most patients. Echocardiographic aortic valve mean gradient and area determined at 3-month intervals, however, showed a trend toward or return to prevalvuloplasty levels by 9 months' follow-up in 13 of 25 patients (52%), whereas 12 of 25 patients showed no deterioration in their hemodynamic parameters. This trend toward restenosis was accompanied by symptomatic deterioration in 5 of 13 patients (38%). This tendency toward restenosis in >50% of patients by 9 months underscores the need for further technical improvements if balloon valvuloplasty is to be widely applied. Even with these limitations, however, balloon valvuloplasty seems to provide a significant improvement in actuarial survival compared with the natural history of elderly patients with severe aortic stenosis.

Doppler echocardiographic observations during percutaneous aortic balloon valvuloplasty

To evaluate the hemodynamic changes occurring with percutaneous aortic balloon valvuloplasty for aortic stenosis, Doppler echocardiography was performed during the procedure in 16 patients. During balloon inflation, peak velocity and ejection time of the aortic valve systolic signals increased (26 and 30%, respectively; p < 0.001). Aortic regurgitationdeceleration time decreased from 1,337 to 625 ms (p < 0.001). In three patients, aortic regurgitation stopped before end-diastole; in four patients, end-diastole forward flow across the aortic valve was documented. The deceleration time of the mitral valve inflow signal decreased from 303 to 194 ms (p < 0.001) during balloon inflation, concurrently with an increase in left ventricular diastolic pressure. Mitral regurgitation signals became more prominent during inflation in 10 patients.Changes that occur during balloon inflation in the aortic valve include progressive left ventricular outflow obstruction, equalization of diastolic aortic and left ventricular pressures and changes in diastolic compliance.