Palliative Balloon Pulmonary Valvotomy in Tetralogy of Fallot: Is There a Role in 2021?
Abstract
:1. Introduction
2. Early Reports of BPV
3. Present Era
4. Role of Transcatheter Interventions for Palliation in Infants with TOF
5. BPV vs. RVOT Stenting
- Anterocephalad deviation of the outlet septum resulting in subpulmonary obstruction
- Hypertrophy of septoparietal trabeculations in the subvalvular region
- A hypoplastic pulmonary valve annulus
- The pulmonary valve itself may be bicuspid and stenotic
- Supravalvar narrowing and hypoplasia of the pulmonary artery branches
6. Technique of BPV
7. In Which Situations Would BPV Be Preferable to RVOT Stenting and Vice Versa?
8. Alternate Approaches for BPV
9. Complications of BPV
10. When Not to Consider BPV or RVOT Stenting in TOF
11. Conclusions
Funding
Conflicts of Interest
References
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Author and Publication | Era | Age | Weight | Baseline SpO2 | Post Balloon SpO2 | Post BPV Course | Complications |
---|---|---|---|---|---|---|---|
Qureshi et al. Br Heart J 1988 [7] | 1983–1986 | 3.3 months (0.5–9 months) | Mean 75% (range 46–97%) | Mean 87% (range 65–98%) | 4 systemic to PA shunts 1.6 months (range 0–3 months) after dilatation. 4 corrective operations 6–10 months (mean 8 months) after dilatation. Six-no further intervention after a mean follow up of 12.9 months. | 1 transient pulmonary edema, 1 worsening cyanosis requiring a Waterston shunt, 1 infective endocarditis which subsequently died. | |
15 patients, 24 procedures | |||||||
Sreeram et al. JACC 1991 [11] | 1983–1989 | Median age of 5 months (range 0.03 to 52 months) | 74% (range 46–99%) | 90.5% (range 45–100%) | Procedure unsuccessful in 3 patients (valve could not be crossed). 18 patients required an aortopulmonary shunt after their initial BPV. | 2 patients received an aortopulmonary shunt for significant cyanosis during the same hospital admission. 1 patient developed transient pulmonary edema after the procedure and required mechanical ventilation. 1 patient developed group D streptococcal septicemia. 2 patients (balloon/annulus ratio >2.5) developed cardiac tamponade and underwent emergency surgical repair of the right ventricular outflow tract, followed by insertion of an aortopulmonary shunt in 1 patient. | |
On follow up, the proportional change in the pulmonary annulus and pulmonary arterial diameters post BPV was greater than expected with growth alone. | |||||||
BPV done in 67 patients with TOF | Forty-two patients subsequently underwent total correction at 7–79 (median 33) months age. There was no difference in transannular patch between patients adequately treated by balloon dilation and those requiring a shunt. | ||||||
Median balloon/anulus ratio was 1.5 | 8 (12%) of the 67 patients died during the follow-up period. | ||||||
Heusch A et al. Cardiology in the Young 1999 [10] | 1990–1996 | Mean age 4.45 months (median 2.7; 3 days–21 months) | Mean weight 5.02 kg (median 4.6; 2.7–10.5) | 75 ± 8.5% | 85 ± 8.4% | The saturation increased significantly post BPV. The pulmonary annulus did not change post-procedure. PA Nakata index increased from 186 ± 95 mm2/m2 to 225 ± 100 mm2/m2. | 3 patients had cyanotic spells requiring IV Propranolol. 1 of these patients required emergency BT shunt due to hypoxia. 4 patients had venous thrombosis. |
BPV in 27 patients | Patients showed no significant improvement in the valve hypoplasia that was greater than expected with growth alone. Although PA sizes increased immediately after dilation, at follow-up, no proportional growth of the vessels was seen. | ||||||
Balloon/annulus ratio of 110–130% | Corrective surgery was performed in 22 patients after a mean 14.0 ± 12.8 months after palliation. Age at surgery was 21.3 ± 13.3 months. Four patients were lost to follow up and one died prior to corrective surgery. | ||||||
Sluysmans T et al. Circulation 1995 [9] | 1991–1993 | 1–20 weeks (median 9.5 weeks) | 2.3–7 kg (median 4.2) | Mean 78.9 ± 8% | Mean 90.1 ± 4.5% | 3 BT shunt for increasing cyanosis at 2, 3, and 7 months age and ICR later. 13 primary ICR at mean age of 6 months after BPV (age range 2.5–16 months). | 4 increased cyanotic spells within 1–2 h post BPV. 1 venous thrombosis of RFV requiring thrombolysis. |
19 infants | |||||||
Godart et al. European Heart Journal 1998 [24] | June 1990–January 1997 | Mean age 3.3 ± 2.7 months (range 3 days to 11 months) | Mean weight 4.8 ± 1.3 kg (range 2.7–8 kg) | Mean 76 ± 9% | Mean 88 ± 7% | A mean of 6.1 ± 4.5 months after dilatation, pulmonary annulus increased from a mean Z score of −4.1 ± 0.9 SD to −2.5 ± 1.1 SD | Four patients had transient arrhythmia during inflation (atrial tachycardia in 2; bradycardia in 1 and complete heart block 1). |
Small infundibular perforation in one patient | |||||||
33 infants (7 neonates) with TOF underwent BPV. | At late follow-up (mean of 9 months after dilatation, range 3–54 months), 28 patients underwent complete repair. Trans-annular patching was required in 43% of patients. Four post-operative deaths were observed, none dilatation related. | Four patients had recurrent cyanotic spells leading to surgical repair within 30 days of BPV (three modified BT shunts and one complete repair). | |||||
Remadevi et al. Ann Pediatr Card 2008 [2] | 2004–2007 | Median age: 33 days, range: 10–90 days | 3.47 ± 0.87 kg | Mean 73 ± 7% | Mean 90 ± 3.68% | 2 babies developed significant desaturation requiring early surgery within 6 months: 1 underwent BT shunt 1.5 months after BPV, another underwent corrective surgery 4 months after BPV | RVOT perforation and pericardial tamponade in 1 patient. |
17 infants. | |||||||
Kohli et al. Pediatric Cardiology 2008 [25] | 2008 | 25 days | 1.8 kg | 55–60% | 95% | Infant 1: Underwent complete repair after 1 year | Patient 2 had cyanotic spells and desaturations post BPV which improved gradually |
2 preterm infants | 28 days | 1.6 kg | 60% | 90% | Infant 2: Saturations of 82% after 6 months, awaiting complete repair | ||
Wilder et al. JTCVS 2017 [12] | 2000–2012 | Median age 13 (range 1–306) | Median BSA 0.37 m2 (range 0.24–0.78 m2) | Not specifically listed for BPV. 11% underwent reoperations after primary TOF repair in transcatheter intervention group. Freedom from reintervention 31% for transcatheter intervention group. | |||
BPV in 9 patients | |||||||
Kim et al. Congenital Heart Disease 2016 [26] | 2008–2014 | Mean age 26.3 ± 23.6 days | Mean weight 3.6 ± 1.0 kg | Mean 81.3 ± 5.1% | Mean 91.2 ± 6.6% (reported as preoperative saturation) | Successful BPV in 90%. Age at total correction for BPV | Three patients needed early palliation such as a modified BT shunt (two pts) or infundibulectomy (one patient) after BPV because of recurrent cyanotic spells. The patient who underwent infundibulectomy developed RVOT aneurysm. |
31 patients underwent BPV as palliation for TOF. The authors took SpO2 < 85% or recurrent cyanotic episodes as an indication for BPV. | group: 6.4 ± 2.4 months. Body weight at operation: 7.7 ± 1.2 kg. Intraoperative pulmonary z-score: −1.26 ± 1.25. TAP required in 29.0%. | ||||||
Lingaswamy et al. Cardiology in the Young 2020 [5] | 2016–2019 | Median age 32 days | 3.7 ± 1.4 kg | 65 ± 12% | Not specifically listed for BPV. For transcatheter palliation patients: at mean duration of 7 months, 36% complete repair, 24% required additional palliative interventions/surgery. One death due to biliary atresia. Median time to next intervention 210 days. | Not specifically listed for BPV: sepsis, seizures, transient CHB reported. | |
18 BPV in infants |
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Sen, S.; Dalvi, B. Palliative Balloon Pulmonary Valvotomy in Tetralogy of Fallot: Is There a Role in 2021? Hearts 2021, 2, 224-233. https://doi.org/10.3390/hearts2020018
Sen S, Dalvi B. Palliative Balloon Pulmonary Valvotomy in Tetralogy of Fallot: Is There a Role in 2021? Hearts. 2021; 2(2):224-233. https://doi.org/10.3390/hearts2020018
Chicago/Turabian StyleSen, Supratim, and Bharat Dalvi. 2021. "Palliative Balloon Pulmonary Valvotomy in Tetralogy of Fallot: Is There a Role in 2021?" Hearts 2, no. 2: 224-233. https://doi.org/10.3390/hearts2020018
APA StyleSen, S., & Dalvi, B. (2021). Palliative Balloon Pulmonary Valvotomy in Tetralogy of Fallot: Is There a Role in 2021? Hearts, 2(2), 224-233. https://doi.org/10.3390/hearts2020018