Andersons pediatric cardiology 1120
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FIG.42.26 Thewaveforminseverepulmonarystenosisistallerandmore
square,withadelayedpointofmaximalpressureclosetotheendof
systole.
TherapeuticOptions
SurgicalTherapy
Althoughpulmonarystenosishasbeenrecognizedasapathologicentitysince
1761,managementofthisdiseasehasbeenpossibleonlyinthelast60yearsor
so.Thefirstreportedattempt,whichwasunsuccessful,waspublishedin1913.47
ThefirstsuccessfulpulmonaryvalvotomywasperformedinLondonbyHolmes
Sellors48inDecember1947.ThepatienthadtetralogyofFallot,andalthough
theintentionhadbeentoperformaBlalock-Taussigshunt,astenosedpulmonary
valvewaspalpable.Atransinfundibularapproachwasmadetoincisethe
stenosedpulmonaryvalveintwodirections,resultingintheimmediatereliefof
cyanosis.Perversely,thisoperationwasreported2weeksafterthereportby
Brockofhisownthreesuccessfuloperations,performedlaterin1948.49Brock
continuedalongthethemeofdirectreliefofpulmonarystenosisandtetralogyof
Fallotanddesignedacomplementaryseriesofinstrumentscomprisinga
valvotometocutthestenosedvalve,anexpandingdilatortosplitthevalve,and
aninfundibularpunchtoresectthethickenedinfundibularmuscle(Figs.42.27
and42.28).Hereportedthesuccessfuluseoftheseinstrumentsin195050and
describedamiraculoustransformationinhissubjects.TheBrockprocedurefor
tetralogyofFallotwasimmediatelyadoptedforpatientswithpulmonarystenosis
andanintactinterventricularseptum.Theintroductionofinflowocclusion,51,52
inflowocclusionandhypothermia,53andsubsequentlyextracorporeal
circulation54inthemid-1950schangedthesurgicalapproachtoamoreprecise
operationinvolvingsplittingofthefusedzonesofappositionoftheleafletsor
valvectomywithorwithoutatransannularpatch.
FIG.42.27 Instrumentsinventedforthefirstseriesofclosedpulmonary
valvotomies.(A)Curvedprobe,(B)curvedbougie,(C)valvotome.(From
BrockRC.Pulmonaryvalvulotomyforreliefofcongenitalpulmonary
stenosis.Reportofthreecases.BrMedJ.1948;1:1121–1126.)
FIG.42.28 Dilatinginstrumentinventedforthefirstseriesofclosed
pulmonaryvalvotomies.(FromBrockRC.Pulmonaryvalvulotomyforrelief
ofcongenitalpulmonarystenosis.Reportofthreecases.BrMedJ.
1948;1:1121–1126.)
InterventionalCatheterization
