Pulmonary Valve Morphology Research Articles

Association of Pulmonary Valve Morphology Differences With Outcomes in Tetralogy of Fallot Repair With Right Ventricular Outflow Tract Incision.

Background: Current observational studies may not have large samples to investigate the relationship between pulmonary valve (PV) morphology differences and outcomes after complete repair for tetralogy of Fallot (TOF) by right ventricular outflow tract (RVOT) incision. This study aimed to assess the impact of PV morphology differences on outcomes after complete repair for TOF.Methods: This is a retrospective cohort study. Consecutive patients who underwent TOF repair with RVOT incision at Fuwai Hospital from January 2012 to December 2017 were included and compared according to PV morphology differences (unicuspid or bicuspid was abnormal morphology, while the tricuspid valve was normal morphology). The primary outcome was defined as a composite of death, or reintervention, or significant annular peak gradient (APG), or significant pulmonary regurgitation (PR), whichever occurred first. Multivariable Cox model analysis was used to assess the relationships between PV morphology differences and outcomes. Subgroup analysis and Propensity-score analysis were performed as sensitivity analyses to assess the robustness of our results.Results: The cohort included a total of 1,861 patients with primary diagnosis of TOF, with 1,688 undergoing CR-TOF with RVOT incision. The median age was 318 days [interquartile range (IQR): 223–534 days], a median weight of 8.9 kg (IQR: 7.6–10.5 kg) and 60.0% (1,011) were male. Complete follow-up data were available for 1,673 CR-TOF patients with a median follow-up duration of 49 months. Adjusted risks for the primary outcome and significant APG were lower for patients with normal PV morphology at follow up [adjusted hazard ratio (HR): 0.68; 95% CI: 0.46–0.98; adjusted HR: 0.22; 95% CI: 0.07–0.71, respectively]. The trend for the primary outcome during follow-up remained unchanged, even in subgroups and propensity score matching analyses.Conclusions: In this analysis of data from a large TOF cohort, patients with normal tricuspid PVs were associated with a decreased risk of the primary outcome and a lower risk of significant APG, as compared with patients with abnormal unicuspid or bicuspid PVs.

Importance of pulmonary valve morphology for pulmonary valve preservation in tetralogy of Fallot surgery: comparison of the echocardiographic parameters.

BackgroundThe decision to use transannular patching (TAP) during tetralogy of Fallot (TOF) repair depends on the pulmonary valve annulus size; the z score of the pulmonary annulus is the most commonly used predictor. However, definitive results are not obtained with z scores as different z score data sets are used for different parameters.PurposeThis study aimed to identify the echocardiographic and other key factors that warranted a change in the surgical method during TOF surgery.MethodsSixty-two patients were enrolled and divided into a pulmonary valve (PV) preservation group and a TAP group. Their medical records were reviewed.ResultsThe z score for PV annulus (PVA), ratio of the PVA to aortic annulus size, and ratio of PVA to descending aorta (DAO) size were significantly different between the PV preservation and TAP groups (-1.72±1.52 vs. -3.07±1.94, P=0.004; 0.62±0.12 vs. 0.50±0.14, P=0.002; and 1.32±0.32 vs. 1.07±0.36, P= 0.008, respectively). For TAP repair, the PVA z score had a sensitivity of 65.4% and specificity of 73.1%, ratio of PVA to aortic annulus size had a sensitivity of 73.1% and specificity of 65.4%, and ratio of PVA to DAO size had a sensitivity of 69.2% and specificity of 57.7%. The TAP group showed more monocuspid PVs (P=0.011), while the PV preservation group showed more tricuspid PVs (P=0.027). Commissurotomy was more frequently performed in the PV preservation group than in the TAP group (P=0.001). Of patients with commissurotomy, 58% showed a PV z score<-2.ConclusionAlthough various echocardiographic parameters may serve as predictors for determining surgical methods for TOF patients, the PV morphology and tissue characteristics should also be considered.

RF64 PULMONARY VALVE SPARING STRATEGIES IN TETRALOGY OF FALLOT REPAIR: A SINGLE CENTER EXPERIENCE

Background-Aim: Transannular patch (TAP) repair of tetralogy of Fallot (TOF) leads to chronic volume overload and significant late morbidity mortality. The pulmonary valve (PV) sparing strategy reduces pulmonary regurgitation with better long-term prognosis. The aim of this study is to examine the determinants for a successful PV-sparing strategy, by exploring PV morphology, annulus diameter, Z-scores and right/left ventricle pressures (Prv/Plv) ratio. Methods: From January 2005 to May 2017, 79 patients underwent TOF repair. 55.7% were males and 44.3% females. Depending on PV Z-scores, annulus size and morphology of PV, 21(26.6%) patients, Group A, underwent valve-sparing TOF repair and 58(73.4%), Group B, TAP approach. Data were retrospectively examined. Results: The median age was 33.7months in Group A and 21.7months in Group B. Mean PV annulus and PV Z-score were respectively 10.2 ± 2.9 mm and -1.6 ± 1.6, in Group A, and 7.5 ± 3.3 mm and -3.4 ± 2.0, in Group B. Mean Prv/Plv ratio was 0.6 ± 0.1 in Group A and 0.5 ± 0.2 in Group B. Z-scores were significantly higher (p = 0.0001) in Group A, while incidence of post-operative complications and reoperations were higher in Group B (p = 0.006 and p = 0.001, respectively). In hospital and ICU length of stay were significantly shorter (p = 0.03; p = 0.01) in Group A. Median follow-up was 27.6months in Group A and 64.8months in B. Conclusions: PV-sparing approach, whenever feasible, preserves RV function, reduces post-operative complications, leading to better long-term prognosis. 4 feasibility indicators must be taken into account: pre-operative PV Z-score higher than -3, adequate PV morphology and annulus according to age and BSA and intra-operative Prv/Plv ratio &lt;0.75.

Biomechanical and morphological stability of acellular scaffolds for tissue-engineered heart valves depends on different storage conditions

Currently available bioprosthetic heart valves have been successfully used clinically; however, they have several limitations. Alternatively, tissue-engineering techniques can be used. However, there are limited data concerning the impact of storage conditions of scaffolds on their biomechanics and morphology. The aim of this study was to determine the effect of different storage conditions on the biomechanics and morphology of pulmonary valve dedicated for the acellular scaffold preparation to achieve optimal conditions to obtain stable heart valve prostheses. Scaffold can then be used for the construction of tissue-engineered heart valve, for this reason evaluation of these parameters can determine the success of the clinical application this type of bioprosthesis. Pulmonary heart valves were collected from adult porcines. Materials were divided into five groups depending on the storage conditions. Biomechanical tests were performed, both the static tensile test, and examination of viscoelastic properties. Extracellular matrix morphology was evaluated using transmission electron microscopy and immunohistochemistry. Tissue stored at 4 °C exhibited a higher modulus of elasticity than the control (native) and fresh acellular, which indicated the stiffening of the tissue and changes of the viscoelastic properties. Such changes were not observed in the radial direction. Percent strain was not significantly different in the study groups. The storage conditions affected the acellularization efficiency and tissue morphology. To the best of our knowledge, this study is the first that attributes the mechanical properties of pulmonary valve tissue to the biomechanical changes in the collagen network due to different storage conditions. Storage conditions of scaffolds for tissue-engineered heart valves may have a significant impact on the haemodynamic and clinical effects of the used bioprostheses.

Pulmonary Valve Morphology in Patients with Bicuspid Aortic Valves

The aortic and pulmonary valve share a common developmental origin from the embryonic arterial trunk. Bicuspid aortic valve is the most common congenital anomaly and can occur isolated as well as in association with other congenital heart disease (CHD). Data on pulmonary valve morphology in these cases are scarce. In this study, we aimed to determine pulmonary valve morphology in hearts with BAV associated with CHD. In 83 post-mortem heart specimens with BAV and associated CHD, pulmonary valve morphology was studied and related to BAV morphology. In 14/83 (17%) hearts, the pulmonary valve was affected, bicuspid in 8/83 (10%), dome-shaped in 3/83 (4%) and atretic in 3/83 (4%). In specimens with a bicuspid pulmonary valve, 5/8 (63%) had a strictly bicuspid aortic valve (without raphe), 2/3 hearts (67%) with dome-shaped pulmonary valves and 2/3 hearts (67%) with atretic pulmonary valves had BAV without raphe. Six out of eight (75%) specimens with a bicuspid pulmonary valve had a perimembranous ventricular septal defect (VSD). 4/8 (50%) specimens with a bicuspid pulmonary valve were associated with chromosomal abnormalities: 3 (38%) had trisomy 18 and 1 (13%) had trisomy 13. In BAV with associated CHD, abnormal pulmonary valve morphology was observed in 17% of the hearts. The majority of hearts with abnormal pulmonary valve morphology had a Type B bicuspid aortic valve (without raphe). Bilateral semilunar valvular disease is associated with Type B BAVs and in many cases related to chromosomal abnormalities. As this study was performed in post-mortem specimens with high frequency of associated CHD, caution is warranted with application of these results to the general BAV population.

Spectrum of pulmonary valve morphology and its relationship to pulmonary trunk in tetralogy of Fallot.

Background:Tetralogy of Fallot (TOF) is a complex congenital heart disease with anatomic variations. Although the pulmonary valve in TOF is abnormal, it has not been studied well, especially on newer imaging modalities such as multidetector computed tomography (CT), which gives excellent anatomic detail.Aims:The aim of this study was to assess the morphology of pulmonary valve in TOF on CT and evaluate its association with the degree of hypoplasia of infundibulum and pulmonary trunk.Materials and Methods:The cardiac CT scans of 30 patients with TOF were reviewed to evaluate the morphology of the pulmonary valve, infundibulum, and pulmonary arteries. Fisher's exact test was performed to examine the association between pulmonary valve morphology and degree of hypoplasia of the infundibulum and pulmonary trunk.Results:16.7% of patients with TOF had pulmonary atresia. The prevalence of tricuspid, bicuspid, and absent valves were 10%, 53.3% and 6.7%, respectively. In another 13.3% of patients, although valve tissue was present, exact morphology could not be determined on CT. The commissures of 62.5% of the bicuspid valves were at 12 o’clock and 6 o’clock or slightly off the midline. There was statistically significant association between valve morphology and degree of infundibular hypoplasia (P < 0.001) and calibre of pulmonary trunk (P < 0.001).Conclusion:Morphological abnormality of the pulmonary valve is common in TOF. The most common type of pulmonary valve in TOF patients is bicuspid valve with commissures at 12 o’clock and 6 o’clock or slightly off the midline. Fewer cusps of the pulmonary valve are associated with a more severe degree of pulmonary artery hypoplasia.

Outcomes of neonatal Ebstein's anomaly without right ventricular forward flow

ObjectiveIn neonates with Ebstein's anomaly and absent right ventricular forward flow, pulmonary valve morphology is normal or abnormal. Although initial postnatal presentations of these 2 conditions are similar, clinical courses and therapeutic strategies for each category differ greatly. MethodsAmong 29 neonates with Ebstein's anomaly without right ventricular forward flow on initial postnatal echocardiography, 16 had a normal pulmonary valve and 13 had an abnormal pulmonary valve. ResultsDuring the postnatal follow-up of the normal pulmonary valve group, right ventricular forward flow commenced approximately 10 days after birth (1-15 days). The ductus arteriosus was surgically ligated in 3 neonates to facilitate right ventricular forward flow. Biventricular or 1 1/2 ventricular physiology was eventually achieved in 14 patients in the normal pulmonary valve group (14/16, 88%) and 2 patients in the abnormal pulmonary valve group (2/13, 15.3%). With respect to the preoperative echocardiographic findings, the normal pulmonary valve group had a significantly larger pulmonary valve annulus (8.2 ± 1.4 mm in the normal pulmonary valve group and 6.4 ± 1.8 mm in the abnormal pulmonary valve group, P = .002) and smaller cardiothoracic ratio (0.79 ± 0.05 in the normal pulmonary valve group and 0.85 ± 0.07 in the abnormal pulmonary valve group, P = .03). Mild to moderate pulmonary regurgitation was present in all patients (16/16, 100%) in the normal pulmonary valve group, but 3 patients (3/13, 23%) in the abnormal pulmonary valve group also had pulmonary regurgitation. On logistic regression analysis, only pulmonary valve annulus size remained as an indicator of a normal pulmonary valve (P = .03). ConclusionsIn patients with Ebstein's anomaly and absent right ventricular forward flow, large pulmonary valve annulus size indicated a normal pulmonary valve. Patients with a normal pulmonary valve showed better survival and had a higher probability of achieving biventricular hemodynamics.

3D transthoracic echocardiography to assess pulmonary valve morphology and annulus size in patients with Tetralogy of Fallot

Accurate evaluation of the pulmonary valve (PV) is crucial before surgical repair of Tetralogy of Fallot (TOF). To assess PV and pulmonary annulus (PA) morphology using three-dimensional (3D) transthoracic echocardiography (TTE) in infants referred for surgical repair of TOF. Also, to compare PA measurements obtained by 3D TTE with those from other imaging modalities, including two-dimensional (2D) TTE and computed tomography (CT), with reference to surgical measurements. 3D zoom mode was used to assess PV morphology. 2D TTE and CT PA diameters were compared to both vertical and horizontal diameters obtained from 3D datasets. Surgical PA diameters were measured using Hegar's dilators. A total of 29 patients with TOF (median [range] age 6 [3-24] months) were included and all successfully underwent 2D and 3D TTE; 22 also underwent CT. The number of pulmonary leaflets could be visualized in 24 patients (82.8%), with complete concordance with surgical findings. Vertical diameter was significantly longer than horizontal diameter (P<0.001)-underlying PA eccentricity-and was more important in bicuspid than tricuspid valves. Correlations between 2D and 3D TTE diameters were good. Surgical diameter was better correlated with 2D and 3D diameters than with CT diameter. 3D minimum, 2D and CT diameters were significantly lower than surgical diameters, but 3D mean and maximum diameters were not. 3D TTE is accurate to assess PV morphology and PA size in patients with TOF. 2D TTE and CT underestimate PA diameter with reference to surgical diameter, however 3D mean and maximum diameters did not differ significantly.

0443: 3D transthoracic echocardiography assessment of the pulmonary valve in patients with TOF

Accurate evaluation of pulmonary valve (PV) morphology and pulmonary annulus (PA) diameter is crucial before surgical correction of tetralogy of Fallot (TOF). Our aim was to assess PV morphology using three-dimensional transthoracic echocardiography (3D-TTE) in infants with TOF before surgical correction. And to compare PA diameter obtained by different imaging modalities. 30 patients with TOF were prospectively included. All patients underwent 2D and 3D-TTE, 23 patients underwent CT-Scan and 7 cardiac catheterization. PA diameter was measured using 2D-TTE in parasternal short axis view as recommended. 3D dataset was acquired using zoom mode at PV. Both vertical (Dv) and horizontal (Dh) diameters of PA were measured. Mean 3D diameter (3DD) was calculated as (Dv+Dh/2). Eccentricity index (EI) of PA was calculated (Dv—Dh/Dv). These measurements were compared to CT-Scan and angiography when available and to perioperative measurements. Mean age 7.4 months (3-24 months), mean weight 6.6kg (4.5-13.5kg). PV was described as bicuspid in 15/30 patients by 3D-TTE from en face view, with 75% agreement between 3D-TTE and perioperative finding (20/30 patients). PA geometry was slightly asymmetric by 3D-TTE. Dv was significantly larger than Dh (8.4mm vs 7.4mm, p=0.001), and mean EI of PA was (10%). PA was more asymmetric in bicuspid valves rather than in tricuspid valves (EI 14% vs 7%, p=0.002). PA diameter didn’t differ significantly between 2D-TTE, Dh, CT scan and angiography, and were significantly lower than mean 3DD and Dv. There was a very strong correlation between 3DD and perioperative measurement. PA was conserved in 53.3% without significant residual stenosis immediately and after a 20 month of follow-up (except 1 patient requiring balloon dilatation). 3D-TTE in patients with TOF is an accurate method to describe PV, and to measure PA size. Thus could help the surgical repair and the preservation of PV function.

P04.05: Prognostic factors of fetal Ebstein anomaly

Due to the increased number of prenatal screenings, the number of cases diagnosed as Ebstein anomaly has been increasing. However, Ebstein anomaly remains a condition associated with a poor prognosis. The purpose of this study is to clarify prognostic factors of fetal Ebstein anomaly diagnosed by prenatal screening, which may provide information for improved counseling. Fifty-six fetuses with an antenatal diagnosis of Ebstein anomaly were included in the study. At screening, the gestational age was 20 to 39 weeks (median: 34). Outcomes of the fetuses were abortion in 14, fetal death in 14, neonatal death in 12, and live birth in 20. The following complications were observed: hydrops fetalis (n = 13), chromosome aberration (n = 2), and myocardial anomaly (n = 10). We assigned 42 cases excluding 14 abortions to fetal or neonatal death (D group; n = 22) and live birth (S group; n = 20) groups to compare fetal echocardiography findings and outcomes. We compared non-cardiac complications, as well as the parameters of fetal echocardiography findings including the morphology of the pulmonary valve (presence/absence of anterograde flow), cardio-thoracic area ratio (CTAR), maximal TR flow (TR), and left-ventricular (LV) Tei index between the two groups. The cut-off values for survival were calculated from receiver operating characteristic (ROC) curve analysis. The following results were obtained (D vs. S): complication rate, 65 vs. 19% (p = 0.002); morphology of pulmonary valve (presence of anterograde flow), 17 vs. 82% (p < 0.0001); CTAR, 63 ± 11 vs. 50 ± 9% (p = 0.002); TR, 2.0 ± 0.4 vs. 3.3 ± 0.5 m/s (p < 0.0001); LV Tei, 1.0 ± 0.3 vs. 0.6 ± 0.2 (p < 0.0001). Cut-off values were CTAR, 56% (sensitivity, 62%; specificity, 80%), TR, 2.7 m/s (sensitivity, 94%; specificity, 99%), and LV Tei, 0.73 (sensitivity, 82%; specificity, 90%). The right ventricular function evaluated by TR and morphology of the pulmonary valve can be used to predict the outcome of fetal Ebstein anomaly.

Isolated bicuspid pulmonary valve in adult diagnosed by three-dimensional transthoracic echocardiography

Isolated bicuspid pulmonary valve is a rare arterial valve anomaly with very few reports in the literature, which regard overall cases of postmortem diagnosis. However, the true incidence of bicuspid pulmonary valve could be underestimated because of the difficulty in imaging pulmonary valve morphology with conventional two-dimensional transthoracic echocardiography (TTE). We report a case of isolated bicuspid pulmonary valve in an adult diagnosed by three-dimensional TTE. Off line multidimensional analysis of full-volume 3D allowed to obtain a short axis view of pulmonary valve showing a bicuspid valve characterized by an anterior and a posterior cups, normally thickened and with preserved systolic opening.

"Vanishing" pulmonary valve stenosis

Objective:Both spontaneous resolution and progression of mild pulmonary valve stenosis (PS) have been reported. We reviewed characteristics of the pulmonary valve (PV) to determine factors that could influence resolution of mild PS.Methods:Fifteen asymptomatic pediatric patients with spontaneous resolution of isolated mild PS were retrospectively reviewed.Results:There was no correlation between the PV gradient, clinical presentation, age at diagnosis, or PV morphology. The PV annulus was small at initial presentation, which normalized at follow up. When corrected for the body surface area (z-score), the PV annulus was normal in all patients, including at initial evaluation.Conclusions:Based on our observation, neither age at diagnosis, nor PV-morphology-influenced resolution of mild PS. The variable clinical presentation makes it difficult to categorize and observe mild PS by auscultation alone. The PV annulus z-score could be a useful adjunct to determine the course and serial observation of mild PS.

Assessment of severity of pulmonary regurgitation: reply

I personally thank Petronella Pieper and Candice Silversides for their interesting comments. In our ‘imaging world’, Doppler echocardiography remains the most reliable non-invasive imaging modality for the diagnosis and evaluation of pulmonary regurgitation (PR). As for each valve, the echo examination starts with a two-dimensional echocardiographic assessment of pulmonary valve morphology to identify significant valvular defect in favour of severe PR. Then, a careful assessment of the regurgitant jet by colour Doppler, using multiple views, can rapidly diagnose minimal PR, which is …

Feasibility of Pulmonary Valve Imaging Using Three-Dimensional Transthoracic Echocardiography

The pulmonary valve (PV) is rarely visualized in short axis with conventional two-dimensional transthoracic echocardiography (TTE). Thus, the true incidence of abnormal PV morphology in patients undergoing TTE is unknown. This study sought to evaluate the feasibility of using three-dimensional echocardiography in the morphologic assessment of the PV in short-axis. A total of 200 consecutive patients referred for routine TTE were prospectively evaluated (mean age 64 ± 16 years; 113 males). Live3D and full-volume 3D (FV3D) were performed with the feasibility of visualizing PV morphology assessed. McNemar's test was used as a nonparametric comparator between Live3D and FV3D results and to assess for any significant learning curve. Chi-square test was used to determine the association between variables. PV morphology detection rates were significantly different (P < .0001) between Live3D (60%) and FV3D (23%). The optimal plane for Live3D was the parasternal view (99%), using zoom over the PV and rotating to a short-axis image. PV short-axis cusp detection using Live3D was dependent on the initial two-dimensional PV image quality (P < .0001). Live3D is feasible in evaluating PV short-axis morphology and provides incremental value in the TTE examination.

Transoesophageal echocardiography in critically ill patients. A comprehensive approach

Transoesophageal echocardiography in critically ill patients. A comprehensive approach

Transesophageal echocardiographic monitoring of interventional cardiac catheterization in children

Transesophageal echocardiography was used prospectively in 22 children scheduled for interventional cardiac catheterization (9 with pulmonary valvuloplasty, 5 with aortic valvuloplasty, 1 with pulmonary angioplasty, 2 with aortic angioplasty, 2 with patent ductus arteriosus occlusion and 3 with Mustard baffle dilation) to determine its potential value as a monitoring technique. The patients ranged in age from 0.9 to 14.6 years (mean 5.4) and in weight from 9.5 to 49.2 kg (mean 21.1).Studies were completed in all patients without complications. Preintervention studies provided important new information in two patients, leading to cancellation of the planned procedure. Major contributions of transesophageal monitoring included 1) a real time assessment of catheter placement across either atrioventricular valve and the aortic valve during balloon valvuloplasty; 2) immediate assessment of aortic valve and aortic wall morphology during balloon dilation; and 3) detailed morphologic and hemodynamic information together with enhanced catheter guidance during Mustard baffle dilation.After pulmonary valvuloplasty, partial chordal rupture of the tricuspid valve was documented in one patient. In two patients, balloon catheter position was modified according to the transesophageal findings. The assessment of changes in pulmonary valve morphology and transcatheter occlusion of a patent ductus arteriosus was not enhanced by single-plane transesophageal monitoring. Pulsed wave Doppler studies contributed additional information in the assessment of immediate hemodynamic changes after interventional procedures.Transesophageal echocardiography is a new important guiding and monitoring technique during interventional cardiac catheterization procedures in children. It can provide additional real time imaging information, immediate identification of complications and assessment of hemodynamic changes.

Hemodynamic evaluation and morphological changes of right ventricular out-flow tract and pulmonary valve after balloon pulmonary valvuloplasty.

Balloon pulmonary valvuloplasty (BPV) was attempted in 38 cases of congenital pulmonary valve stenosis. It was effective and was done without complication in 36 cases, however it was not effective in two cases of pulmonary valve dysplasia. The balloon used was 20-50% larger in diameter than the pulmonary valve annulus. In the seven cases in which the transvalvular pressure gradient was above 100 mmHg on cardiac catheterization, right ventriculography demonstrated that the functional obstruction of the right ventricular outflow tract increased immediately after BPV, however it subsequently improved at one year after the procedure. At between one and three months after BPV, two-dimensional echocardiography demonstrated that the morphological obstruction to the right ventricular outflow tract had diminished. In two cases, localized right ventricular septal hypertrophy with severe pulmonary valve stenosis was observed by two-dimensional echocardiography and right ventriculography, and persisted at one year. In all cases, two-dimensional echocardiography and angiography demonstrated doming pulmonary valves with valve stenosis, which was diminished by BPV. The pulmonary valve morphology was observed by two-dimensional echocardiography in three cases following BPV. In one case, partial relief of pulmonary valve obstruction was seen to be due to commissural splitting and in the other two, to tearing of cusp tissue. Inspection of the pulmonary valve at operation was made in one case who underwent elective surgery for repair of an atrial septal defect which was associated with pulmonary valve stenosis. It demonstrated partial relief of pulmonary valve stenosis by tearing of cusp tissue. In conclusion, BPV is as effective a treatment for congenital pulmonary valve stenosis as open valvulotomy. In our follow-up study, it has shown no apparent complications. The transient obstruction in the right ventricular outflow tract immediately after BPV improved within one month and improved further after three months and one year. However, in the more long-standing cases the localized right ventricular septal hypertrophy persisted and these cases will require, a long term follow-up.

Pulmonary valve morphology after balloon dilatation of pulmonary valve stenosis

Percutaneous balloon valvuloplasty (BV) for pulmonic valve stenosis (PS) is increasingly becoming a nonsurgical alternative in patient management. However, the mechanism by which BV dilates the obstructive lesion has not been firmly established. We have had the opportunity to examine the effects of BV in the setting of PS and present two illustrative cases documenting the morphology after BV of the stenotic bicuspid and tricuspid pulmonary valve.

Lack of correlation between echocardiographic pulmonary valve morphology and simultaneous pulmonary arterial pressure

Pulmonary valve echograms recorded simultaneously with right heart pressures were correlated with mean and end-diastolic pulmonary arterial pressures and the peak magnitude of the right atrial a wave in an attempt to predict noninvasively levels and changes in pulmonary arterial pressure. Satisfactory pulmonary valve echograms were obtained in 16 of 29 patients studied. No significant correlation was found between hemodynamic measurements and the echographic pulmonary valve a wave amplitude, diastolic E-F slope or the systolic opening B-C slope. Changes in hemodynamic measurements observed in serial observations were not associated with predictable changes in configuration of the pulmonary valve echogram. The combination of mid systolic pulmonary valve notching and an absent a wave was observed in more advanced degrees of pulmonary hypertension and was specific, but not sensitive, for that condition.