Andersons pediatric cardiology 1130

FIG.42.37 Adultpatientundergoingballoonpulmonaryvalvuloplastyfor
moderatepulmonaryvalvestenosis.Notethesomewhatunremarkable
appearanceoftherightventricularoutflowtractpriortovalvuloplasty(A),
withnotablesubpulmonarynarrowingafterreliefofthevalvarobstruction
(B).

FIG.42.38 Pulmonaryvalvargradientsbefore,immediatelyafter,andlate
afterballoonpulmonaryvalvuloplasty.(FromSadr-AmeliMA,
SheikholeslamiF,FirooziI,etal.Lateresultsofballoonpulmonary
valvuloplastyinadults.AmJCardiol.1998;82:398–400.)

Dataontheincidenceandriskfactorsformoderatetoseverepulmonary
regurgitationafterpulmonaryballoonvalvuloplastyarelimited.Devanagondi


andcolleaguesreportedanincidenceof60%ofpatientshavingatleastmoderate
pulmonaryregurgitationatamedianfollow-upof15.1years.145Inmultivariate
analysis,onlyabodysurfaceareabelow0.3m2wasidentifiedasanindependent
riskfactorforatleastmoderatepulmonaryregurgitationafterballoonpulmonary
valvuloplasty.Theproblemthoughwiththisstudyaswithmanyothersisthe
incompleteavailabilityofdataand,mostimportantly,thefactthatthedegreeof
pulmonaryregurgitationisusuallyassessedbyechocardiographyratherthan
cardiovascularMRI.Assuch,itisdifficulttodrawanyfirmconclusionsfrom
thoseretrospectivestudies.
Oneofthemostcomprehensiverecentstudiestoevaluatetheprevalenceand
predictorsofpulmonaryregurgitationafterballoonpulmonaryvalvuloplastyas
wellasexercisetolerancewasreportedasaprospectivesingle-centerstudyby
Harrildandcolleagues.146Thestudyincluded41patientsthatunderwentcardiac
magneticresonanceimagingandexercisetestingatamedianof13.1yearsafter
balloonpulmonaryvalvuloplasty.Theresultsdocumentedthat34%ofpatients
hadapulmonaryregurgitantfractiongreaterthan15%,rightventriculardilation

withaz-scoreof2orgreaterwaspresentin40%ofpatients,andaz-scoreof4
orgreaterwaspresentin11%ofpatients.Peakoxygenconsumption(VO2)was
belowaverage(92%±17%).Itisimportantthoughtobearinmindthatexercise
performanceismultifactorial.LarryLatsonpointedoutinaneditorialrelatedto
thisarticlethatamongmanycardiovascularfactorsthisalsoincludesgenetic
makeup,conditioningandmotivation.147Similarly,Guoandcolleaguesreported
areducedexercisecapacityafterballoonpulmonaryvalvuloplastyofabout90%
whencomparedwithhealthychildren,withsimilarconcernsrelatingto
conditioningandotherfactorsthatcouldinfluencetheseresults.148
ItisimportanttonotethatthestudybyHarrildandcolleaguesalsofoundthat
thepulmonaryregurgitantfractionwassignificantlyassociatedwiththeballoonto-annulusratio.146However,thedataalsofoundthatthereisno“safe”ratio
belowwhichmoderatetoseverepulmonaryregurgitationcanbeavoided
altogether,andnoratioabovewhichonewouldautomaticallyexpectmoderate
toseverepulmonaryinsufficiency.AsLatsonidentified,thefindingsdonot
addresstheproblemofwhattodowhenamoreconservativeuseofaballoon
sizeresultsinsignificantresidualstenosis.147Havingsaidthis,itisprobably
reasonabletobemoreconservativeinitiallyusingaballoontoannulusratioof
notmuchmorethan1.2:1,ratherthanthe1.2to1.4thatearlierstudies
suggested.Pathakandcolleaguescomparedtheresultsofpatientsinwhoma


ratioof1.2orlesswaschosentothoseofmorethan1.2andfoundnosignificant
differenceinthegradientreductionbetweenthetwogroups.149

SurgeryasOpposedtoBalloonDilation
Comparinglong-termsurgicalandtranscatheteroutcomedataisdifficultand
inconclusiveatthistime.Althoughdataonthelong-termneedfor
reinterventionsforresidualpulmonarystenosisareavailableforboththesurgical
andthetranscathetergroup,long-termdataontheneedforreinterventionsasa
resultofpulmonaryregurgitationarelimited.Furthermore,eventhoughsinglecenterdataareavailableforeachofthetreatmentmodalities,veryfewstudies

havepublisheddirectcomparisonsbetweensurgicalandtranscathetertherapy.
Inalargeseriesof170patientsinasingleDutchcenter,directcomparison
betweensurgicalvalvotomyandballoondilationwaspossible.150Surgicalrelief
ofpulmonarystenosisyieldedlowerlong-termgradientsandalongerfreedom
fromreintervention(Fig.42.39).However,meanfollow-upofthesurgicalgroup
wasjust9.8years.Voetandcolleaguesrecentlycomparedacohortof79
surgicallytreatedpatientswith139patientsthatunderwentballoonpulmonary
valvuloplasty.151Themedianfollow-upforthesurgicalgroupwas22.5years
andforthetranscathetergroup6.0years.Theoverallneedforreinterventionin
thesurgicalgroupwas20.3%(noneforresidualpulmonarystenosis),and9.4%
afterballoonpulmonaryvalvuloplasty(85%forresidualpulmonaryvalve
stenosis).Freedomfromreinterventionat5and10yearsforthesurgicalgroup
was93.5%and87%,respectively,andforthetranscathetergroup87.5%and
84.4%,respectively.