J Thorac Cardiovasc Surg 1994;107:630-0631
© 1994 Mosby, Inc.
Invited letter concerning: Balloon dilation of stenotic aortic valve in children—An intraoperative study (J THORAC CARDIOVASC SURG 1992;104:1709-13)
Laszlo Solymar, MD,
Göran Südow, MD,
Håkan Berggren, MD,
Bengt O. Eriksson, MD
Department of Pediatrics
University of Gothenburg
Gothenburg, Sweden
Reply to the Editor:
We thank Dr. Keane for his valuable comments and criticism of our article. As one of the pioneers of interventional cardiology, his vast experience is unquestioned. There are, however, some aspects of the problems concerning the management of valvular aortic stenosis on which we have a different view. As pointed out by Dr. Keane, surgical valvotomy is regarded as a palliative procedure, with valve replacement considered likely at some point later in life.
About 35% in the Natural History Study required reoperation, and 51% had aortic regurgitation within 25 years after valvotomy. Although the prevalence of reoperations and aortic insufficiency after operation is taken as an argument in favor of abandoning commissurotomy for balloon dilation, we would use the same data to advocate the opposite course. If careful separation of fused commissures under direct vision has such a high failure rate, there is reason to believe that the less-controlled balloon dilation would have even less success and a shorter duration of the palliation with the native valve in place.
The primary advantage of balloon dilation is that it can be repeated much more often than an operation. Relief of the stenosis could thus be achieved repeatedly, but to justify this regimen the prevalence of aortic insufficiency must be significantly less than with operation. Data so far have not shown any advantage in this respect. In our study, there were three patients in whom balloon dilation caused rupture into the valve tissue. This would have caused significant regurgitation in two if left uncorrected. Although the lesions could be repaired and did not necessitate valve replacement, these patients were found to have the most significant regurgitation at follow-up and would surely have been better off with a simple comissurotomy. Because there appears to be a connection between valve morphologic characteristics and adverse effects of balloon dilation, we reemphasize our closing remarks that more studies characterizing suitable or unsuitable cases for balloon dilation are necessary before this technique is widely applied in the treatment of aortic valve stenosis in childhood.
