Mean Peak Systolic Pressure Gradient Research Articles

Simplified Tricuspid Polytetrafluoroethylene Valved Conduit: Midterm Results of Multicenter Study

Conduit survival without significant dysfunction is important when selecting the right ventricular outflow tract conduit. We made an expanded polytetrafluoroethylene tricuspid valved conduit using a simplified technique. We aimed to investigate the midterm functional results and longevity of this conduit. Between November 2008 and December 2016, four hospitals in Korea implanted 145 valved conduits. We retrospectively analyzed their functional results and longevity. The patients' median age at operation was 36.6 months; the median body weight was 11.3 kg. The mean follow-up duration was 32.3 ± 24.5 months. There were four inhospital deaths and three late deaths, but there were no conduit-related deaths. The mean peak systolic pressure gradient across the conduit was 14.7 ± 8.3 mm Hg and 31.6 ± 17.7 mm Hg at discharge and last follow-up, respectively. Six patients (4.4%) had moderate or more conduit valve regurgitation at last follow-up. Conduit dysfunction was observed in 30 patients (21.9%), mainly caused by increased pressure gradient (24 of 30, 80%). Freedom from conduit dysfunction was 88.1% and 58.5% at 3 and 5 years, respectively. Lower freedom from conduit dysfunction was observed in small conduits. Eleven patients (7.8%) underwent conduit explantation, and freedom from explantation was 94.8% and 81.7% at 3 and 5 years, respectively. The main cause of explantation was conduit stenosis. Small conduits tended to have lower freedom from explantation. Functional results and longevity of our expanded polytetrafluoroethylene tricuspid valved conduit are acceptable. Although our conduits tend to have increasing pressure gradient over time, especially in small conduits, they have low incidence of moderate or more regurgitation.

Late results of right ventricular outflow tract reconstruction with a bicuspid expanded polytetrafluoroethylene valved conduit.

We report the results of a bicuspid expanded polytetrafluoroethylene (ePTFE) valved conduit used for right ventricular outflow tract reconstruction (RVOTR). Between November 2005 and February 2009, 12 conduits were used for RVOTR. The mean age and weight of patients were 43.5 ± 46.4 months and 13.4 ± 8.6 kg. The main diagnosis was tetralogy of Fallot with pulmonary atresia in eight patients. The most common conduit size was 18 mm. The mean follow-up was 88.0 ± 35.9 months. There were no operative and late mortalities. At discharge, the mean peak systolic pressure gradient across the RVOT was 14.1 ± 11.3 mmHg. There was no conduit valve regurgitation in nine patients. At the latest echocardiography (mean follow-up: 84.3 ± 35.5 months), the mean peak systolic pressure gradient across the RVOT was 59.7 ± 20.2 mmHg, and there was no conduit valve regurgitation in six patients. Freedom from conduit malfunction was 100% and 83.3%, at 1 and 8 years, respectively. Two conduits were explanted due to sternal compression and four from conduit malfunction. Freedom from explantation was 83.3% and 74.2% at 2 and 8 years, respectively. ePTFE bicuspid valved conduit has good late function in terms of valve regurgitation, but the pressure gradient across the conduit increases with time, which is the main cause of conduit failure and explantation.

288 Residual hypertension and aortic wall abnormalities at mid-term follow-up after native aortic coarctation stenting

The feasibility of transcatheter primary stenting (TPS) to treat native aortic coarctation (Coa) is well-demonstrated as an alternative of surgical repair. However, information on mid-term follow-up remains scarce, especially regarding the frequency of systemic hypertension and the integrity of the aortic arch. We retrospectively studied the patient's outcome after TPS for Coa, paying particular attention to residual hypertension and aortic wall abnormalities, including arch obstruction, aneurysm and dissection. Since 2002, 20 patients (8 female) with Coa were treated by TPS at a median age and weight of 21 (7 to 52) years and 60 (27 to 94) kg, respectively. They were symptomatic in all cases with upper limb hypertension in 16. Twenty stents were successfully implanted and the mean peak systolic pressure gradient dropped from 31 (10 to 60) mmHg to 1,6 (0 to 15) mmHg. One major complication occurred in a patient who experienced bilateral groin hematomas, with hypotension and anemia necessitating transfusion. After a median follow-up of 2,9 (0,12 to 7,8) years, the 20 patients are asymptomatic. Residual upper limb hypertension is present in 7 cases (35%), including 3 (15%) with mild residual upper-to-lower limbs gradient (20 mmHg). One patient was successfully redilated for in-stent restenosis. By transthoracic echocardiography (n = 20), spiral computed tomography (n = 4), and magnetic resonance imaging (n = 13), there is no aortic aneurysm or dissection. TPS for Coa is successful with minimal morbidity. After mid-term follow-up, residual hypertension is similar to that observed after surgical repair, whereas aortic wall abnormalities are not encountered. Longer term follow-up is mandatory to confirm this favorable outcome.

Percutaneous transluminal angioplasty for stenosis of the aorta due to aortic arteritis in children.

Percutaneous transluminal balloon angioplasty for stenosis of the aorta due to aortic arteritis was attempted on 45 lesions in 41 children (age range, 4-14 years; mean, 9.9+/-4.2 years) presenting with symptoms of hypertension, severe congestive heart failure, and lower limb claudication. Balloon dilatation was technically successful in 38 (92.7%) patients for 41 stenotic lesions (91.1%). The mean peak systolic pressure gradient (PSG) decreased from 71.7 +/- 23.9 mmHg to 23.2 +/- 17.5 mmHg (p < 0.001) and the diameter of the stenosed segment increased from 3.3 +/- 1.1 mm to 7.5 +/- 2.2 mm (p < 0.001) immediately after angioplasty. Patients with short-segment (<3 cm) stenosis had a lower residual gradient (17.9 +/- 11.1 mmHg vs 30.5 +/- 22.6 mmHg; p < 0.05) and a wider diameter of the aorta (8.8 +/- 1.1 mm vs 7.5 +/- 2.2 mm; p < 0.02) compared to patients with long-segment (>/=3 cm) stenosis. Four patients required stent implantation; 2 for flow-limiting dissection, 1 for failure to reduce PSG by >50%, and 1 for recurrent restenosis. There was marked hemodynamic and angiographic improvement in these 4 patients. Hemodynamic and angiographic restudy in 21 of the 41 patients at mean follow-up period of 6.2 +/- 4.2 months (range, 3-24 months) showed restenosis in 4 (19%) patients. Restenosis was more common in patients with long-segment stenosis than those with short-segment stenosis (30% vs 9.1%). Late restudy in 8 patients, done at 3-7 years after first restudy, showed no recurrence of aortic narrowing. On clinical follow-up of 38 patients for a mean of 58.8 +/- 36.0 months (range, 8-146 months) there was marked improvement in symptoms. Hypertension was cured in 11 (29%), improved in 24 (63%), and persisted in 3 (8%). Six patients with associated severe renal artery stenosis showed further improvement in hypertension after successful renal angioplasty. Severe congestive heart failure improved in 21 (95.4%) of 22 patients. Mean left ventricular ejection fraction improved from 0.32 +/- 0.08 to 0. 48 +/- 0.10 (p < 0.001) at a mean follow-up of 28.7 +/- 8.4 months in these patients. Hemodynamic restudy in 10 of these patients showed improvements in left ventricular end-diastolic pressure from a mean 37 +/- 9 mmHg (range, 25-55 mmHg) to 16.4 +/- 6.2 mmHg (range, 6-25 mmHg) (p < 0.001). Lower limb claudication improved in all 4 patients. Our results suggest that percutaneous transluminal balloon angioplasty in children is safe and highly effective in relieving stenosis of the aorta due to aortic arteritis, with marked clinical improvement, and should be the treatment of choice particularly for discrete stenosis.

Stent implantation for aortic coarctation and recoarctation

OBJECTIVETo determine the early results of balloon expandable stent implantation for aortic coarctation or recoarctation.DESIGNProspective observational study.SETTINGTwo paediatric cardiology tertiary referral centres.PATIENTS17 patients, median age 17 years (range 4.4 to...

Resultados a longo prazo da reconstrução da via de saída do ventrículo direito com monocúspide porcina

O beneficio hemodinâmico e funcionamento tardio das monocuspides implantada na via de saida do ventriculo direito sao pontos que continuam controversos na literatura. Com o objetivo de se estudar o comportamento tardio de uma monocuspide porcina montada em remendo de pericardio bovino, 45 pacientes selecionados, portadores de diversos tipos de cardiopatia congenita operados entre junho de 1989 e abril de 1996, foram acompanhados ate dezembro de 1996. A idade variou de 2 semanas a 18 anos (media 4,8 ± 4,7 anos). Ocorreram 5 obitos hospitalares, diretamente relacionados a condicao clinica pre-operatoria e a complexidade da doenca. Com 3 pacientes nao tendo sido encontrados para acompanhamento, 37 foram seguidos por um periodo que variou de 6 a 90 meses (media 4,8 ± 19,0 meses). Nao houve mortalidade tardia. Dois pacientes foram reoperados, sendo o primeiro apos 24 meses devido a insuficiencia pulmonar grave em crianca portadora de sindrome da valva pulmonar ausente e o segundo apos 23 meses devido a estenose pulmonar infundibular residual. A reoperacao, os enxertos mostravam-se bem conservados e sem sinais de calcificacao, o que foi confirmado pelos estudos histologicos das pecas retiradas. O segundo paciente recebeu uma nova monocuspide. Os demais 35 pacientes encontram-se assintomaticos. Trinta e seis pacientes tem sido avaliados periodicamente, atraves de ecocardiogramas seriados. A monocuspide permanece movel e funcionante em todos os casos, sem sinais de calcificacao, estenose ou dilatacao. O gradiente sistolico medio de pico atraves da via de saida do ventriculo direito tem sido de 19,0 ± 5,8 mmHg. Regurgitacao pulmonar esta ausente em (33%) 12 pacientes, e leve em 15 (42%) e moderada em 9 (25%). Em conclusao, a monocuspide porcina apresenta excelente desempenho hemodinâmico a longo prazo, sem evidencias de estenose tardia. Apresenta-se funcional e sincronica com o ciclo cardiaco ate 7 anos apos o implante.

Long-term effects of balloon coarctation angioplasty on arterial blood pressure in adolescent and adult patients.

In patients with coarctation of the aorta arterial hypertension frequently persists when surgical repair is performed after age 20 years. There are little data on the long-term effect of angioplasty and the question remains to be determined whether hypertension is sufficiently treated by this procedure. Twenty-nine consecutive patients (9 females and 20 males) 14 to 54 years old (median, 25) underwent angioplasty for native coarctation of the aorta. Twenty-five patients (86%) had pre-existing systolic arterial hypertension (> 140 mm Hg). The mean peak systolic pressure gradient decreased from 62 +/- 18 to 21 +/- 13 mm Hg immediately after angioplasty. At hospital discharge 13 patients still had hypertension. After a mean follow-up interval of 4.0 years (range, 0.3-9.5) the residual peak pressure gradient was 14 +/- 13 mm Hg. Blood pressure was normal without antihypertensive therapy in 23 patients (79%). In the six hypertensive patients the pressure gradients were 7, 13, 30, 30, 35, and 60 mm Hg. One patient died 8 months after angioplasty and another underwent surgery for aortic aneurysm. Although this was an uncontrolled study the data suggest that normalization of blood pressure may occur more frequently after angioplasty than after surgery in adolescents and adults with native coarctation.

Balloon angioplasty of the aorta in Takayasu's arteritis: Initial and long-term results

Percutaneous transluminal balloon angioplasty for stenosis of the aorta was performed in 36 patients with Takayasu's arteritis (age range, 8 to 36 years; mean, 19.1 ± 7.7 years). Balloon dilatation was successful in 34 patients and resulted in a decrease in the mean peak systolic pressure gradient (PSG) from 75.2 ± 29.1 mm Hg to 24.8 ± 19 mm Hg ( p < 0.001) and a mean increase in the diameter of the stenosed segments from 4.5 ± 2.2 mm to 9.6 ± 3.8 mm ( p < 0.001). Hemodynamic and angiographic restudy, which was performed in 20 patients at a mean follow-up period of 7.7 ± 4.1 months (range, 3 to 24 months), showed a further decrease in PSG (≥ 15 mm Hg) in seven patients (from 40.0 ± 11.2 mm Hg to 15.7 ± 10.2 mm Hg; p < 0.01), no significant change in PSG in 12 patients (17.1 ± 13.6 mm Hg vs 16.6 ± 12.7 mm Hg; p = NS, and an increase in PSG from 15 mm Hg to 85 mm Hg in one patient. The patient who showed restenosis underwent successful redilatation. Six patients who underwent late recatheterization and angiography at 36 to 60 months (mean, 43 ± 9.4 months) show continued relief of stenosis (mean PSG, 8.8 ± 7.8 mm Hg). Patients with short-segment (< 4 cm) stenosis experience more relief than patients with long-segment (≥ 4 cm) stenosis (residual PSG, 18.6 ± 8.2 mm Hg vs 40 ± 16 mm Hg; p < 0.01). All successfully treated patients experienced improvement in their symptoms and hypertension. There were no significant complications. No patient showed evidence of an aneurysm immediately after percutaneous transluminal balloon angioplasty or during follow-up aortography. Percutaneous transluminal balloon angioplasty for stenosis of the aorta in patients with Takayasu's arteritis is safe and highly effective and produces sustained improvement.

Percutaneous transluminal angioplasty in Takayasu arteritis.

Percutaneous transluminal balloon angioplasty (PTBA) was performed in 87 patients for 111 stenotic lesions due to Takayasu arteritis. Of the lesions attempted for dilatation, 35 were in the aorta, 64 in renal arteries, 9 in subclavian, and 3 in common iliac arteries. The stenosis of aorta could be successfully dilated in 33 of 35 (94.3%) patients with fall in peak systolic pressure gradient (PSG) from 77.7 +/- 28.4 mmHg to 26.4 +/- 20.6 mmHg (P < 0.001) and increase in luminal diameter from 4.7 +/- 2.4 mm to 10.1 +/- 4.1 mm (P < 0.001). On hemodynamic and angiographic restudy in 20 patients at 3-24 months (mean 7.7 +/- 4.1 months) further fall in PSG (> or = 15 mmHg) was observed in 7 patients, no significant change in 12 patients and restenosis with increase in PSG in one patient which could be successfully redilated. Late restudy at 36-60 months (mean 43 +/- 9.4) in six patients showed continued relief of stenosis (mean PSG 8.8 +/- 7.8 mmHg). Of the 64 stenotic lesions of the renal arteries, 58 (90.6%) could be successfully dilated with decrease in stenosis from 89.1 +/- 10.1% to 29.9 +/- 14.9% (P < 0.001). Follow-up intra-arterial digital subtraction angiography in 25 patients at a mean follow-up period of 13.1 months (range 3-29 months) showed restenosis in 5/36 (13.9%) lesions which could be successfully redilated. Angioplasty was also successful in dilating 8/9 (88.9%) subclavian and all 3 common iliac artery stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid artery approach for balloon dilation of aortic valve stenosis in the neonate: A preliminary report

Balloon valvuloplasty in neonates with severe aortic valve stenosis is limited by difficulties in catheter manipulation around the arch and across the valve and by the risk of femoral artery complications. A right common carotid artery cutdown was utilized for balloon aortic valvuloplasty in five neonates 1 to 20 days of age, weighing 3.1 to 3.9 kg. Standard balloon valvuloplasty was performed through a 6F sheath inserted in the right carotid artery. The arteriotomy was repaired at the end of the procedure.Mean left ventricular systolic pressure was reduced from 142 to 97 mm Hg, with a decrease in mean peak systolic pressure gradient from 76 to 33 mm Hg. Only one patient developed mild aortic regurgitation. One patient with a hypoplastic left ventricle died, and one patient required open valvotomy. All four survivors have a normal carotid pulse and no neurologic sequelae. Two of these patients required repeat balloon dilation to treat residual aortic valve stenosis at 8 and 10 months of age, respectively. Balloon valvaloplasty using a carotid artery approach is feasible and was safe in five neonates with severe aortic valve stenosis.

Balloon angioplasty-branch pulmonary artery stenosis: Results from the Valvuloplasty and Angioplasty of Congenital Anomalies Registry

Balloon angioplasty for branch pulmonary artery stenosis was reported from 27 institutions to the Valvuloplasty and Angioplasty of Congenital Anomalies Registry. One hundred eighty-two procedures were performed in 156 patients ranging in age from 0.2 to 46.2 years (mean 7.7). Short-term angiographic appearance, hemodynamic results and immediate complications were recorded. Vessel dimension at the site of stenosis increased from 4.5 ± 2.0 (mean ± standard deviation) to 6.8 ± 3.0 mm (p < 0.001) with greater increases in vessel dimension at the site of stenosis if the balloon diameter was >3 X the original dimension of the stenosis. There was no significant benefit related to age or prior surgical intervention. The mean peak systolic pressure gradient was reduced from 49 ± 25 to 37 ± 26 mm Hg (p < 0.001) and pressure proximal to the stenosis decreased from 69 ± 25 to 63 ± 24 mm Hg (p < 0.001). Complications occurred in 21 patients and included vessel rupture and death in 2 patients, vessel perforation or rupture with survival in 3, cardiac arrest and death in 1, paradoxical embolism and death in 1 and low output and death in 1. Balloon angioplasty for branch pulmonary artery stenosis increases vessel dimension at the site of stenosis, reduces systolic pressure gradient and to a minor degree, reduces proximal pressure. Long-term outcome and potential complications are as yet uncertain.

Medical management of three asymptomatic infants with severe valvar aortic stenosis.

We report on the clinical course and serial hemodynamic studies of three patients with severe valvar aortic stenosis diagnosed in the neonatal period. None of the children were symptomatic in the first year of life. In each case, a conservative initial management approach was adopted. Between the time of initial study (mean age, 1.8 months) and the follow-up at 12-27 months of age (mean, 14.3 months), mean left ventricular systolic pressure decreased from 151 to 125 mmHg, the mean peak systolic pressure gradient across the aortic valve decreased from 61 to 33 mmHg, and the mean calculated aortic valve area index increased from 0.24 to 0.60 cm2/m2. One patient was operated on for symptoms that appeared at 14 months of age. The patient followed longest is now 5 years old, is growing well, has a normal electrocardiogram and an echo-predicted left ventricular systolic pressure of 128 mmHg. This experience suggests that not all asymptomatic neonates with severe valvar aortic stenosis require surgical intervention early in life. In some, the aortic valve orifice may increase in size with somatic growth and obviate the need for surgery in infancy or early childhood.

Percutaneous pulmonary valvuloplasty with a double-balloon technique.

Percutaneous pulmonary valvuloplasty with a double-balloon technique was used in eight patients, aged 10-40 years, in whom valvuloplasty with a single 20-mm balloon resulted in inadequate dilatation of the stenosis. The diameters of the additional balloon varied from 10 to 20 mm. Balloons were inflated manually at about 30-45 psi (206.7-310.1 kPa) and deflated immediately after disappearance of the balloon waist. The mean peak systolic pressure gradient was 85 mm Hg +/- 37 before valvuloplasty, and it decreased to 38 mm Hg +/- 28 afterward (P less than .05). Double-balloon dilation and simultaneous computed tomography were done in two cardiac specimens from adult cadavers. At inflations at 30 and 45 psi (206.7 and 310.1 kPa), the outflow tract was elongated, and the balloons also deformed into ovoid shape at the lower pressure. The double-balloon technique appears to be safe and effective for relief of pulmonary valvular stenosis in those cases in which single-balloon technique is inadequate, especially in older children and adults.

THE UNNATURAL HISTORY OF AORTIC STENOSIS

We report on the clinical course and serial hemodynamic studies of three patients with severe valvar aortic stenosis diagnosed in the neonatal period. None of the subjects was symptomatic in the first year of life. In each case, a conservative initial management approach was adopted. Between the time of initial study (mean age 1.8 months) and the follow up at 12-27 months of age (mean 14.3 months), mean left ventricular systolic pressure fell from 151 to 135 mmHg, the mean peak systolic pressure gradient across the aortic valve fell from 54 to 42 mraHg, and the mean calculated aortic valve area index increased from 0.20 to 0.39 cm2/meter2. One of the patients was operated on for symptoms which appeared at 14 months of age. The patient followed longest is now 5 years old, is growing well, has a normal electrocardiogram and an echo-predicted left ventricular systolic pressure of 128 mmHg. This experience suggests that not all asymptomatic neonates with severe valvar aortic stenosis require surgical intervention early in life. In some, the aortic valve orifice may increase in size with somatic growth and obviate the need for surgery in early childhood.

Right ventricular outflow tract reconstruction with a bovine pericardial monocusp patch: Long-term clinical and hemodynamic evaluation

A bovine pericardial monocusp patch was used in 21 patients with a variety of congenital heart defects for reconstruction of obstructed right ventricular outflow tract. Two early postoperative deaths and one late death occurred, and these were unrelated to monocusp patch function. Survivors have completed a mean follow-up of 113 months (range 29 to 141 months). They are all asymptomatic, and their physical activity is unrestricted. Seventeen patients have completed more than 5 years of follow-up and, of these, 11 patients have completed more than 10 years of follow-up. Eleven patients have been reinvestigated by sequential postoperative hemodynamic and angiographic studies at mean periods of 16, 48, and 100 months. The mean peak systolic pressure gradient across the right ventricular outflow tract under conditions of normal flow was 13 +/- 2.4 mm Hg at 16 months, and it has shown no significant change when measured at intervals of up to 124 months after the operation. This lack of change suggests effective long-term relief of the outflow tract obstruction. Serial radiographic screening of all patients and angiographic studies in 11 patients disclosed no evidence of graft calcification, stenosis, or dilatation. The monocusp valve remained functional and effectively abolished or reduced pulmonary valve incompetence. In 11 patients who had residual pulmonary regurgitation, the regurgitation was mild and, up to 12 years after operation, had not resulted in any adverse clinical sequelae.

Transluminal balloon coarctation angioplasty: Experience with 27 patients

Transluminal balloon angioplasty (BA) was performed in 27 consecutive patients with coarctation of the aorta (COA), including 7 infants with preductal COA, 7 patients with restenosed COA after surgical repair, and 13 older children and 1 adult with unoperated COA. The patients were 4 days to 27 years old. The balloon was positioned across the COA and inflated sequentially to pressures of 100 and 120 psi, each inflation lasting for 5 to 10 seconds. Peak systolic pressure gradient (PSG) across the COA was recorded and an aortogram was performed before and immediately after BA. PSG also was recorded during follow-up studies performed in 13 patients 3 to 24 months after BA. BA was performed without complications in each patient. Immediately after BA, the mean PSG was reduced from 49 +/- 21 to 10 +/- 7 mm Hg (p less than 0.01), and the mean COA diameter increased from 3.9 +/- 1.4 to 9.6 +/- 3.6 mm (p less than 0.01). After a follow-up period of 3 to 24 months, the mean PSG remained low (15 +/- 11 mm Hg) and the mean COA diameter increased to 10.5 +/- 4.6 mm. BA can be performed safely. It can be a useful palliative treatment in seriously ill infants with COA.