Balloon Pulmonary Valvuloplasty in Congenital Isolated Valvular Pulmonic Stenosis - A Follow Up Analysis of 107 Patients Over 22 Years
Department of cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
E. Babu, A. Ajith, K. Geofi George, P. Arun Prasath, B. Karthikeyan, S. Santhosh, P. Gobu, R. Selvaraj, J. Balachander
Background: Balloon pulmonary valvuloplasty has been the first line of definitive treatment for congenital isolated valvular pulmonic stenosis. This study aimed to analyse the effectiveness of Balloon Pulmonary Valvuloplasty (BPV) in congenital isolated Valvular Pulmonic Stenosis (VPS).
Methods: This retrospective study included patients with congenital isolated VPS who underwent BPV from December 1988 to August 2010 in our institute. Those diagnosed to have more than mild VPS with peak instantaneous gradient across PV at least 50 mm Hg on transthoracic echocardiography were considered for BPV. Right heart catheterization including right ventriculogram was routinely performed to confirm the diagnosis and to rule out any significant infundibular stenosis. The size of the balloon chosen was 120 to 140 % of the diameter of annulus of Pulmonary Valve (PV) measured in lateral view of angiography. Intervention was declared as ‘Successful BPV’ when the right ventricle to pulmonary artery peak to peak gradient was reduced by 50 % or more at cardiac catheterization and as ‘Partially Successful BPV’ when the gradient was reduced by less than 50 %. All the patients were pretreated with beta-blockers.
Results: Out of 114 subjects planned for BPV based on echocardiography, 7 subjects were excluded following right ventriculogram and the remaining 107 patients were included in our study. There were 48 (44.86 %) males and 59 (55.14 %) females including 40 (37.38 %) children less than 12 years of age. The mean age was 16.74 years (range: 6 months to 45 years). Balloon could not be negotiated through the stenosed PV in 3 (2.8 %) patients and the procedure was declared ‘Failed BPV’ in them. Among those who underwent balloon dilatation, single balloon technique was employed in 103 (96.26 %) patients and double balloon technique in the remaining 1 (0.93%) patient. Balloons with step-up diameter were utilized in 29 (27.1 %) patients. The mean of transvalvular peak to peak gradient measured before and after BPV was 103.77 ± 34.47 and 35.56 ± 17.73 mm Hg (p < 0.0001). The mean of percentage reduction in the gradient was 65.81 ± 11.49 %. Intervention resulted in ‘Successful BPV’ in 99 (92.52 %) subjects and ‘Partially Successful BPV’ in 5 (4.67 %) subjects. Out of 4 (3.74 %) patients with dysplastic PV, ‘Partially Successful BPV’ and ‘Successful BPV’ were seen in 1 and 3 patients respectively. The overall complications noted were vasovagal syncope in 8 (7.48 %) patients, complete heart block in 1 (0.93 %) patient, cardiac arrest in 1 (0.93 %) patient, left hemiplegia in 1 (0.93 %) patient and femoral vein thrombosis in 1 (0.93 %) patient. Patients were put on oral beta-blockers and followed up with annual echocardiographic assessment. There was further 16 % reduction in the peak gradient and mild to moderate regurgitation of PV could be demonstrated in 68 % of patients. About 13 to 18 years later, 2 (1.87 %) patients developed ‘Restenosis’ (echocardiographic peak gradient across PV at least 50 mm Hg). Redo procedure resulted in ‘Successful BPV’ in them.
Conclusion: Our study underscores the fact that balloon pulmonary valvuloplasty is definitive curative therapy in congenital isolated valvular pulmonic stenosis. The incidence of restenosis is truly low. On follow up, these patients do extremely well.
