Ishikura et al.
American
may be superior to other angioplastic catheters preventing the residual ASP after PTMC, and duration of the procedure or the manipulation of balloon may be correlated with the occurrence ASP.
in the the of
We thank Dr. Deepak Natarajan for his helpful comments on this work. REFERENCES
1. Reid C, Mackay CR, Chandraratna PAN, Kawanishi DT, Rahimotoola SH. Mechanisms of increase in mitral valve area and influence of anatomic feature in double-balloon, catheter balloon valvuloplasty in adults with rheumatic mitral stenosis; a Doppler and two-dimensional echocardiographic study. Circulation 1987;76:628-36. 2. Palacios IF, Block PC, Brandi S, Blanco P, Casal H, Pulido JI, Munoz S, D’Empaire G, Ortega MA, Jacobs M, Vlahakes G. Percutaneous balloon valvotomy for patients with severe mitral stenosis. Circulation 1987;75:778-84. 3. Field CD, Isner JM. Size of atria1 septostomy resulting from transseptal delivery of balloon catheters used for mitral valvuloplasty. Circulation 1988;78(suppl):II-488.
October 1990 Heart Journal
Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984;394402. Palacios IF, Block PC, Wilkins GT, Weyman AE. Follow-up of patients undergoing percutaneous mitral balloon valvotomy; analysis of factors determining restenosis. Circulation 1989;79:573-9. Vahanian A, Michel PL, Cormier B, Vitoux B, Michel X, Slama M, Sarano LE, Trabelsi S, Ismail MB, Acar J. Results of percutaneous mitral commisurotomy in 200 patients. Am J Cardiol 1989;63:847-52. Bernard Y, Schiele F, Jacoulet P, Anguenot T, Maurat JP, Bassand JP. Assessment with color flow mapping of mitral regurgitation and left-to-right atria1 shunting after percutaneous mitral valvuloplasty. Circulation 1988;78(suppl):II-1. 8. O’Shea JP, Abascal VM, Marshall JE, Wilkins GT, Thomas JD. Long-term persistence of atria1 septal defect following percutaneous mitral valvuloplasty: a Doppler echocardionranhic follow-un studv. Circulation 1988:78(SUDDlkII-1. 9. Palacios IF, Block PC. Atria1 septal defect during percutaneous mitral balloon valvotomy (PMV): immediate results and follow-up. Circulation 1988;78(suppl):II-529.
Results of repeat percutaneous bailoon valvuloplasty for pulmonary valvar restenosis Follow-up cardiac catheterization studies were used to evaluate 105 patients who had undergone percutaneous balloon pulmonary valvuloplasty. Fifteen of those patlents who had peak systolic pulmonary valve gradients >=40 mm Hg at follow-up underwent repeat balloon valvuloplasty. For the inltlal balloon pulmonary valvuloplasty, the mean ratio of the balloon dlameter to pulmonary valve annulus diameter was 0.98 f 0.2; at repeat valvuloplasty the mean was 1.19 2 0.12. The Immediate post-repeat balloon valvuloplasty results showed a reduction in the peak systolic gradient from a mean of 70.2 + 17.8 to 29.1 + 19.0 mm Hg (p < 0.001). This reduction In the gradient was maintained at a mean of 14.3 f 5.0 mm Hg in 8 of the 10 patients who underwent further follow-up studies. We conclude that successful repeat balloon pulmonary valvuloplasty with the use of larger sized balloons is feasible In patients who have restenosis after the Initial percutaneous balloon valvuloplasty-lncludlng partial but not complete dysplasia of the pulmonary valve. (AM HEART J 1990;120:878.)
M. A. Ali Khan, MD, Saad Al-Yousef, MD, John W. Moore, MD, and William Sawyer, MB, ChB. Riyadh, Saudi Arabia
Results of follow-up studies after percutaneous balloon valvulopasty for pulmonary stenosis have shown rates of significant valvar restenosis between 14% and 33 % L 2; inadequate balloon size334 and pulmonary valve dysplasia13 5-7 are factors that have been From Reprint Hospital, Received 4/l/22824
878
the Riyadh
Cardiac
Center,
Armed
Forces
Hospital.
requests: M. A. Ali Khan, MD, Pediatric Cardiology, PO Box ‘789’7, Riyadh 11159, Saudi Arabia. for publication
May
17, 1989;
accepted
May
Armed
21, 1990.
Forces
related to restenosis. Significant valvar restenosis after balloon pulmonary valvuloplasty may be managed by either repeat balloon valvuloplasty or surgery. Although immediate results of repeat balloon pulmonary valvuloplasty have been recorded,8-10 late results have not been fully described in the literature. This retrospective study reviews our results of repeat balloon pulmonary valvuloplasty in patients with significant pulmonary valvar restenosis, immediately after the procedure and at follow-up studies.
Volume Number
120 4
Balloon valvuloplasty for pulmonic stenosis
PULMONARY
200
GRADIENT
(MM
HG)
879
.............................~~..................................................................... 1
Before
After
1st.
1st.
F/U
~+’
1st.
Partial
After
F/U
Repeat
Repeat
Dysplasia
1. Pulmonary gradients in eight patients, before and after first balloon pulmonary valvuloplasty, at follow-up, after repeat balloon valvuloplasty, and at further follow-up, showing successful repeat balloon pulmonary valvuloplasty. F/U, follow-up.
Fig.
PULMONARY
GRADIENT
WI
HG)
250
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..~.........~...................................~~.~..~......~...~.............
I Before
1st
After
F/U
Supra
Valve
PS
1
I
I 1st
1st
After
F/U
repeat
Severe
repeat
Dysplasia
Fig. 2. Pulmonary gradients in two patients, before and after first balloon pulmonary vavuloplasty, at follow-up, after repeat balloon valvuloplasty, and at further follow-up, showing unsuccessful repeat balloon pulmonary valvuloplasty. F/U, follow-up.
880
Ali Khan et al. PULMONARY
American
GRADIENT
(MM
October 1990 Heart Journal
HG)
250 J- . . . . . . . . . . . . . . . ..~......~..............~~..............~.....................................................~.
Before
1st
After
V
1st
F/U
Partial
Dysplasia
1st
After
V
Typical
repeat
F/U
repeat
PS
Fig. 3. Pulmonary gradients in five patients, before and after first balloon pulmonary valvuloplasty at follow-up, showing possibly successful repeat pulmonary valvuloplasty. F/U, follow-up.
METHODS
At Riyadh Armed Forces Hospital 205 patients underwent percutaneous balloon pulmonary valvuloplasty between August 1984and June 1988,by meansof previously describedtechniques.l1 Resultsof follow-up evaluationsright-heart catheterization, with or without ultrasound examination including pulsed and continuous-wave Doppler studies,obtained a minimum of 3 months after balloon valvuloplasty-were available from 105patients. Advances in continuous-wave Doppler studies for the measurement of gradients have now made follow-up cardiac catheterization unnecessaryin the majority of patients who undergo balloon pulmonary valvuloplasty, except in those patients with clinical and noninvasive indications of restenosis. Although a peak pulmonary valvar systolic gradient >=50 mm Hg has been suggestedas an indication for balloon pulmonary valvuloplasty,12 in this study 15 of the 25 patients who had increasedgradients to >=40 mm Hg at follow-up catheterization underwent repeat balloon pulmonary valvuloplasty immediately, thus avoiding another diagnostic procedure to reassess the gradient again; the remainder included dysplastic valve, Noonan’s syndrome, hypoplastic right ventricle, and infundibular stenosisor reaction. Patients with gradients =40 mm Hg after initially successful balloon pulmonary valvuloplasty, the reduction of the gradient was maintained in eight, including one patient with mild dysplasia. The patients in whom restenosis developed had undergone initial balloon valvuloplasty with relatively small balloons, as illustrated by the differences in balloon-to-annulus diameter mean ratios for ini-
10.
11.
12.
Rao PS. Balloon dilatation in infants and children with dysplastic pulmonary valves: short-term and intermediate-term results. AM HEART J 1988;116:1168-73. Marantz PM, Huhta JC, Mullins CE, Murphy DJ, Nihill MR, Ludomirsky A, Yoon GY. Results of balloon valvuloplasty in typical and dysplastic pulmonary valve stenosis: Doppler echocardiographic follow-up. J Am Co11 Cardiol 1988;12: 476-9. Radtke W, Kean JL, Fellows KE, Lang P, Lock JE. Percutaneous balloon valvotomy of congenital pulmonary stenosis using oversized balloons. J Am Co11 Cardiol 1986;8:909-15. Rao PS. Influence of balloon size on short-term and long-term results of balloon pulmonary valvuloplasty. Texas Heart Inst J 1987;14:57-61. Musewe NN, Robertson MA, Benson LN, Smallhorn JF, Burrows PE, Freedom RM, Moes CAF, Rowe RD. The dysplastic pulmonary valve: echocardiographic features and results of balloon dilatation. Br Heart J 1987;57:364-70. Jeffery RJ, Moller JH, Amplatz K. The dysplastic pulmonary valve: a new roentgenographic entity. Am J Roentgen01 Radium Ther Nucl Med 1972;114:322-6. Koretzkv ED. Moller JH. Korns ME. Schwartz CJ. Edwards JE. Congenital pulmonary stenosis resulting from dysplasia of the valve. Circulation 1969;60:43-7. Rao PS, Mohider KT, Kutayli F. Causes of restenosis after balloon valvuloplasty for valvar pulmonary stenosis. Am J Cardiol 1988;62:979-82. Sullivan ID, Robinson PJ, Macartney FJ, Taylor JFN, Rees PG, Bull C, Deanfield JE. Percutaneous balloon valvuloplasty for pulmonary valve stenosis in infants and children. Br Heart J 1985;54:435-41. Rey C, Marache P, Francart C, Dupuis C. Percutaneous transluminal balloon valvuloplasty of congenital pulmonary valve stenosis, with a special report on infants and neonates. J Am Co11 Cardiol 1988;11:815-20. Ali Khan MA, Yousef SA, Mullins CE. Percutaneous transluminal balloon pulmonary valvuloplasty for the relief of pulmonary valve stenosis with special reference to double balloon technique. AM HEART J 1986;112:158-66. Rao PS. Indications for balloon pulmonary valvuloplasty. AM HEART
J 1988;1661-2.
American
may be superior to other angioplastic catheters preventing the residual ASP after PTMC, and duration of the procedure or the manipulation of balloon may be correlated with the occurrence ASP.
in the the of
We thank Dr. Deepak Natarajan for his helpful comments on this work. REFERENCES
1. Reid C, Mackay CR, Chandraratna PAN, Kawanishi DT, Rahimotoola SH. Mechanisms of increase in mitral valve area and influence of anatomic feature in double-balloon, catheter balloon valvuloplasty in adults with rheumatic mitral stenosis; a Doppler and two-dimensional echocardiographic study. Circulation 1987;76:628-36. 2. Palacios IF, Block PC, Brandi S, Blanco P, Casal H, Pulido JI, Munoz S, D’Empaire G, Ortega MA, Jacobs M, Vlahakes G. Percutaneous balloon valvotomy for patients with severe mitral stenosis. Circulation 1987;75:778-84. 3. Field CD, Isner JM. Size of atria1 septostomy resulting from transseptal delivery of balloon catheters used for mitral valvuloplasty. Circulation 1988;78(suppl):II-488.
October 1990 Heart Journal
Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984;394402. Palacios IF, Block PC, Wilkins GT, Weyman AE. Follow-up of patients undergoing percutaneous mitral balloon valvotomy; analysis of factors determining restenosis. Circulation 1989;79:573-9. Vahanian A, Michel PL, Cormier B, Vitoux B, Michel X, Slama M, Sarano LE, Trabelsi S, Ismail MB, Acar J. Results of percutaneous mitral commisurotomy in 200 patients. Am J Cardiol 1989;63:847-52. Bernard Y, Schiele F, Jacoulet P, Anguenot T, Maurat JP, Bassand JP. Assessment with color flow mapping of mitral regurgitation and left-to-right atria1 shunting after percutaneous mitral valvuloplasty. Circulation 1988;78(suppl):II-1. 8. O’Shea JP, Abascal VM, Marshall JE, Wilkins GT, Thomas JD. Long-term persistence of atria1 septal defect following percutaneous mitral valvuloplasty: a Doppler echocardionranhic follow-un studv. Circulation 1988:78(SUDDlkII-1. 9. Palacios IF, Block PC. Atria1 septal defect during percutaneous mitral balloon valvotomy (PMV): immediate results and follow-up. Circulation 1988;78(suppl):II-529.
Results of repeat percutaneous bailoon valvuloplasty for pulmonary valvar restenosis Follow-up cardiac catheterization studies were used to evaluate 105 patients who had undergone percutaneous balloon pulmonary valvuloplasty. Fifteen of those patlents who had peak systolic pulmonary valve gradients >=40 mm Hg at follow-up underwent repeat balloon valvuloplasty. For the inltlal balloon pulmonary valvuloplasty, the mean ratio of the balloon dlameter to pulmonary valve annulus diameter was 0.98 f 0.2; at repeat valvuloplasty the mean was 1.19 2 0.12. The Immediate post-repeat balloon valvuloplasty results showed a reduction in the peak systolic gradient from a mean of 70.2 + 17.8 to 29.1 + 19.0 mm Hg (p < 0.001). This reduction In the gradient was maintained at a mean of 14.3 f 5.0 mm Hg in 8 of the 10 patients who underwent further follow-up studies. We conclude that successful repeat balloon pulmonary valvuloplasty with the use of larger sized balloons is feasible In patients who have restenosis after the Initial percutaneous balloon valvuloplasty-lncludlng partial but not complete dysplasia of the pulmonary valve. (AM HEART J 1990;120:878.)
M. A. Ali Khan, MD, Saad Al-Yousef, MD, John W. Moore, MD, and William Sawyer, MB, ChB. Riyadh, Saudi Arabia
Results of follow-up studies after percutaneous balloon valvulopasty for pulmonary stenosis have shown rates of significant valvar restenosis between 14% and 33 % L 2; inadequate balloon size334 and pulmonary valve dysplasia13 5-7 are factors that have been From Reprint Hospital, Received 4/l/22824
878
the Riyadh
Cardiac
Center,
Armed
Forces
Hospital.
requests: M. A. Ali Khan, MD, Pediatric Cardiology, PO Box ‘789’7, Riyadh 11159, Saudi Arabia. for publication
May
17, 1989;
accepted
May
Armed
21, 1990.
Forces
related to restenosis. Significant valvar restenosis after balloon pulmonary valvuloplasty may be managed by either repeat balloon valvuloplasty or surgery. Although immediate results of repeat balloon pulmonary valvuloplasty have been recorded,8-10 late results have not been fully described in the literature. This retrospective study reviews our results of repeat balloon pulmonary valvuloplasty in patients with significant pulmonary valvar restenosis, immediately after the procedure and at follow-up studies.
Volume Number
120 4
Balloon valvuloplasty for pulmonic stenosis
PULMONARY
200
GRADIENT
(MM
HG)
879
.............................~~..................................................................... 1
Before
After
1st.
1st.
F/U
~+’
1st.
Partial
After
F/U
Repeat
Repeat
Dysplasia
1. Pulmonary gradients in eight patients, before and after first balloon pulmonary valvuloplasty, at follow-up, after repeat balloon valvuloplasty, and at further follow-up, showing successful repeat balloon pulmonary valvuloplasty. F/U, follow-up.
Fig.
PULMONARY
GRADIENT
WI
HG)
250
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..~.........~...................................~~.~..~......~...~.............
I Before
1st
After
F/U
Supra
Valve
PS
1
I
I 1st
1st
After
F/U
repeat
Severe
repeat
Dysplasia
Fig. 2. Pulmonary gradients in two patients, before and after first balloon pulmonary vavuloplasty, at follow-up, after repeat balloon valvuloplasty, and at further follow-up, showing unsuccessful repeat balloon pulmonary valvuloplasty. F/U, follow-up.
880
Ali Khan et al. PULMONARY
American
GRADIENT
(MM
October 1990 Heart Journal
HG)
250 J- . . . . . . . . . . . . . . . ..~......~..............~~..............~.....................................................~.
Before
1st
After
V
1st
F/U
Partial
Dysplasia
1st
After
V
Typical
repeat
F/U
repeat
PS
Fig. 3. Pulmonary gradients in five patients, before and after first balloon pulmonary valvuloplasty at follow-up, showing possibly successful repeat pulmonary valvuloplasty. F/U, follow-up.
METHODS
At Riyadh Armed Forces Hospital 205 patients underwent percutaneous balloon pulmonary valvuloplasty between August 1984and June 1988,by meansof previously describedtechniques.l1 Resultsof follow-up evaluationsright-heart catheterization, with or without ultrasound examination including pulsed and continuous-wave Doppler studies,obtained a minimum of 3 months after balloon valvuloplasty-were available from 105patients. Advances in continuous-wave Doppler studies for the measurement of gradients have now made follow-up cardiac catheterization unnecessaryin the majority of patients who undergo balloon pulmonary valvuloplasty, except in those patients with clinical and noninvasive indications of restenosis. Although a peak pulmonary valvar systolic gradient >=50 mm Hg has been suggestedas an indication for balloon pulmonary valvuloplasty,12 in this study 15 of the 25 patients who had increasedgradients to >=40 mm Hg at follow-up catheterization underwent repeat balloon pulmonary valvuloplasty immediately, thus avoiding another diagnostic procedure to reassess the gradient again; the remainder included dysplastic valve, Noonan’s syndrome, hypoplastic right ventricle, and infundibular stenosisor reaction. Patients with gradients =40 mm Hg after initially successful balloon pulmonary valvuloplasty, the reduction of the gradient was maintained in eight, including one patient with mild dysplasia. The patients in whom restenosis developed had undergone initial balloon valvuloplasty with relatively small balloons, as illustrated by the differences in balloon-to-annulus diameter mean ratios for ini-
10.
11.
12.
Rao PS. Balloon dilatation in infants and children with dysplastic pulmonary valves: short-term and intermediate-term results. AM HEART J 1988;116:1168-73. Marantz PM, Huhta JC, Mullins CE, Murphy DJ, Nihill MR, Ludomirsky A, Yoon GY. Results of balloon valvuloplasty in typical and dysplastic pulmonary valve stenosis: Doppler echocardiographic follow-up. J Am Co11 Cardiol 1988;12: 476-9. Radtke W, Kean JL, Fellows KE, Lang P, Lock JE. Percutaneous balloon valvotomy of congenital pulmonary stenosis using oversized balloons. J Am Co11 Cardiol 1986;8:909-15. Rao PS. Influence of balloon size on short-term and long-term results of balloon pulmonary valvuloplasty. Texas Heart Inst J 1987;14:57-61. Musewe NN, Robertson MA, Benson LN, Smallhorn JF, Burrows PE, Freedom RM, Moes CAF, Rowe RD. The dysplastic pulmonary valve: echocardiographic features and results of balloon dilatation. Br Heart J 1987;57:364-70. Jeffery RJ, Moller JH, Amplatz K. The dysplastic pulmonary valve: a new roentgenographic entity. Am J Roentgen01 Radium Ther Nucl Med 1972;114:322-6. Koretzkv ED. Moller JH. Korns ME. Schwartz CJ. Edwards JE. Congenital pulmonary stenosis resulting from dysplasia of the valve. Circulation 1969;60:43-7. Rao PS, Mohider KT, Kutayli F. Causes of restenosis after balloon valvuloplasty for valvar pulmonary stenosis. Am J Cardiol 1988;62:979-82. Sullivan ID, Robinson PJ, Macartney FJ, Taylor JFN, Rees PG, Bull C, Deanfield JE. Percutaneous balloon valvuloplasty for pulmonary valve stenosis in infants and children. Br Heart J 1985;54:435-41. Rey C, Marache P, Francart C, Dupuis C. Percutaneous transluminal balloon valvuloplasty of congenital pulmonary valve stenosis, with a special report on infants and neonates. J Am Co11 Cardiol 1988;11:815-20. Ali Khan MA, Yousef SA, Mullins CE. Percutaneous transluminal balloon pulmonary valvuloplasty for the relief of pulmonary valve stenosis with special reference to double balloon technique. AM HEART J 1986;112:158-66. Rao PS. Indications for balloon pulmonary valvuloplasty. AM HEART
J 1988;1661-2.
