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J Thorac Cardiovasc Surg 1994;107:967-968
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Antegrade aortic balloon dilatation through an apical ventriculotomy under echocardiographic control

Adolph Basser Institute of Cardiology
Royal Alexandra Hospital for Children
Camperdown, Sydney, Australia

To the Editor:

We report the use of antegrade balloon aortic valvotomy through an apical ventriculotomy under echocardiographic control in an extremely small infant. The management of critical aortic stenosis in small infants remains difficult. With percutaneous femoral aortic balloon valvotomy, the femoral artery may be damaged ^1,2 or problems may be incurred related to manipulation of the catheter around the aortic arch ³ and across the aortic valve. Operations with either bypass or blind Hegar dilatation also carry special problems in small infants.

Aortic stenosis was diagnosed on day 1 in a 32-week gestational age, 1.52 kg male infant. Echocardiography demonstrated a peak instantaneous aortic valve pressure gradient of 70 mm Hg,normal left ventricular function, and a large persistent ductus arteriosus. There was no clinical or radiologic evidence of cardiac compromise. The persistent ductus arteriosus closed by day 4 without ill effect. On day 19 tachypnea and cardiomegaly developed. Echocardiography revealed left ventricular dysfunction (shortening fraction 20%), with peak instantaneous aortic valve gradient unchanged (75 mm Hg). Because of the infant's size, percutaneous retrograde balloon dilatation was considered inadvisable. We therefore performed an apical transventricular antegrade balloonaortic valvotomy. This was performed through a 3 cm anterolateral thoracotomy through the fifth left intercostal space with the patient in the right decubitus position. After placement of a pledget-supported ventriculotomy pursestring suture, a 4.5 mm (diameter) x 3 cm (length) ballooncatheter was advanced across the aortic valve with the introducing stylet in situ. Two-dimensional echocardiography was used to guide the catheter tip by means of parasternal long-axis views from the upper right sternal edge and midsternum. This allowed good visualization of the balloon catheter without interfering with the operative field. The balloon was inflated twice while across the aortic valve. The procedure was complicated by ventricular fibrillation and blood loss from the ventriculotomy. Ventricular fibrillation occurred as the catheter transiently abutted the ventricular septum, but sinus rhythm was restored with internal direct-current shock (5 J). Bleeding was caused by extension of the ventriculotomy. The balloon, despite being adequately positioned across the aortic valve, still protruded slightly from the insertion site, extending the ventriculotomy and its pursestring suture at inflation. The bleeding was controlled with a second pursestring suture. After valvotomy, the peak instantaneous aortic valve gradient was reduced to 25 mm Hg, with improved aortic valve opening and left ventricular function and only mild aortic incompetence. The postoperative recovery was complicated by coagulopathy, which resolved rapidly, and the infant was extubated 4 days after valvotomy (day 24). Six months after valvotomy, the patient's neurologic status, feeding, and growth were normal. Echocardiography revealed a peak instantaneous aortic valve gradient of 85 mm Hg, normal left ventricular function, mild aortic incompetence, but increasing left ventricular posterior wall thickness. A retrograde transarterial balloon dilatation was subsequently performed in the cardiac catheterization laboratory, successfully reducing the aortic valve gradient to 35 mm Hg.

Antegrade balloon aortic valvotomy under echocardiographic control through a limited anterolateral thoracotomy is a viable therapeutic alternative in extremely small infants with critical aortic stenosis and in those patients for whom conventional surgical valvotomy presents a high risk. Balloon valvuloplasty theoretically results in more uniform valve disruption than does a Hegar dilator, which applies force linearly to the valve. ³ Access through a limited anterolateral thoracotomy allows adequate exposure of the left ventricular apex and from there a direct line to the aperture of the doming aortic valve, avoiding the need for bypass. This approach allows use of two-dimensional echocardiography to guide balloon position from the upper right sternal edge without impinging on the sterile field. A flexible guide wire may reduce the risk of ventricular fibrillation by allowing rapid and accurate placement of the catheter. Use of a shorter balloon or placement of the catheter further around theaortic arch may avoid extension of the ventriculotomy. This combined surgical and echocardiographic technique may be useful in patients for whom an alternative to conventional surgery or catheter dilatation is required.

References

1. Burrows PE, Benson LN, Williams WG, et al. Iliofemoral arterial complications of balloon angioplasty for systemic obstructions in infants and children. Circulation 1990;82:1697-704.[Abstract/Free Full Text]
   
2. Kay S, Gilpin DG. Combined microsurgical and thrombolytic salvage of an ischaemic lower limb in a1079 gram preterm neonate. Br J Plast Surg 1991;44:310-1.[Medline]
   
3. Neish SR, O'Laughlin MP, Nihill MR, Ott DA, Cooley DA. Intraoperative balloon valvuloplasty for critical aortic valvular stenosis in neonates. Am J Cardiol 1991;68:807-10.[Medline]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Graham R. Nunn Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ward, C. J. Articles by Sholler, G. F. Search for Related Content PubMed PubMed Citation Articles by Ward, C. J. Articles by Sholler, G. F.