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J Thorac Cardiovasc Surg 1994;107:629-0630
© 1994 Mosby, Inc.
Letters to the Editor |
Department of Cardiology
Boston Childrens Hospital
Boston, MA 02115
To the Editor:
The article of Solymar and coworkers, "Balloon Dilation of Stenotic Aortic Valve in Children: An Intraoperative Study," is of interest to interventional cardiologists and surgeons in this field.
In this report, 10 patients with significant valvular obstruction, aged 3 through 17 years, underwent balloon dilation during cardiopulmonary bypass, with a balloon that was at least the size of the anulus in six. Immediately after the dilation, it was determined by visual inspection that a surgical valvuloplasty was necessary in all cases, without valve replacement. The authors reported that the angioplasty result was too extensive in one case, caused rupture into a valve leaflet in three cases, produced too short a separation in three cases, and was close to optimum only in the other three patients. At follow-up, on the basis of echocardiographic data, the average instantaneous gradient was 33 mm Hg, representing a reduction of about 55% to 60%. Aortic regurgitation was present at follow-up in eight patients but was mild in most. In the authors' view, the site and extent of the ruptures created by balloon dilation seemed inferior to results of surgical commissurotomy, and valve morphologic characteristics appeared to be an important determinant of outcome. The investigators emphasized their commendable degree of medical-surgical cooperation, which surely is not unique to their institution.
Surgical valvotomy in children with aortic stenosis is generally regarded as a palliative procedure, with valve replacement likely at some point in their lifetime. In the recently completed Natural History Study,
1 within 25 years after valvotomy in childhood, some 35% of patients have required reoperation; 51% had aortic regurgitation, deemed moderate or severe in 12%.
Balloon angioplasty in recent years has been introduced as an alternative first procedure. As performed in the catheterization laboratory, it is of course extremely different from the procedure undertaken by the authors. A balloon 90% of the anulus size is used first, after which cardiac output and residual gradient measurements and aortography for regurgitation are carried out before proceeding further. Because survivorship at 25 years in those with a peak-to-peak gradient of less than 50 mm Hg is 92% (Natural History Study), stenosis as great as this has been accepted by most investigators as an end point.
Because of the wide variation in valve morphologic characteristics, it is little short of miraculous that balloon angioplasty is as effective as it is in reducing the degree of stenosis. In our own and others' experience, 2-5 gradient reduction seems to be comparable with that in surgical series, although follow-up duration is obviously less. The major complication with balloon angioplasty to date is aortic regurgitation, new or increased in 31% to 43%. 3, 4 In most patients, this regurgitation is mild at most.
It is nevertheless clear that some patients have severe regurgitation after angioplasty. In our own 7-year experience of more than 130 patients aged 1 year or older at dilation, eight are known to date to have undergone valve replacement and one has undergone a valvuloplasty. Among these, three had had a prior surgical valvotomy. Operation, primarily for regurgitation, was performed in six patients; in one of these the valve was platelike, without any recognizable cusp or commissure formation, and would have required valve replacement even if the operation had been the initial procedure (Fig. 1).
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References
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