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Abstract
Summary
V
alvular pulmonary stenosis with intact ventricular septum is a common CHD, it occurs in about 10 percent of patients with CHD (Steinberger& Moller, 1999). Severe right ventricular outflow tract obstructions are life-threatening conditions, and immediate treatment is mandatory. Pulmonary balloon valvuloplasty has been proposed as an alternative to surgical valvotomy to avoid surgical hazards (Bartolome et al, 1999).
The purpose of this study was to assess the short-term outcome for a period of one year in infants with congenital valvular pulmonary stenosis in whom percutaneous pulmonary balloon valvuloplasty was attempted.
The study has been a prospective cohort study, which conducted on 28 infants with congenital valvular pulmonary stenosis subjected to pulmonary balloon valvuloplasty at catheterization-laboratory at CUPH, and they were followed up for one year while attending the pediatric cardiology clinic and echocardiographic laboratory in Abou El-Reish Hospital of Cairo University from June 2002 through March 2004.
All the studied patients were subjected to history, complete general& local examination of the heart, chest & heart roentgenographic examination, electrocardiogram (ECG), and two-dimensional color Doppler echocardiography. Pulmonary balloon valvuloplasty was attempted in all infants with congenital valvular pulmonary stenosis with a peak-to-peak gradient across the pulmonary valve 50 mmHg or greater. Clinical evaluation and echo Doppler studies were done at 2 weeks, 3 months, 6 months, and one year after balloon dilatation.
The studied patients were subdivided into two groups; one group of 8 patients with critical PS having a mean age of 1.97±1.31 months, and their weight ranged from 3 kg to 5 kg with a mean of 3.75±0.65 kg. The other group with severe PS included 20 patients having a mean age of 7.70±3.01 months, and their weight ranged from 5-10.5 kg with a mean of 7.79±1.61kg.
Pulmonary balloon valvuloplasty was immediately favorable in 6 patients (75%) of critical PS group and in 18 patients (90%) of severe PS group. Immediately after dilatation, in critical PS; right ventricular systolic pressure decreased from 152.87±25.80 mmHg to 90.37±29.46 mmHg with highly significant differences, and right ventricular-pulmonary artery systolic pressure reduced from 126.00±25.87 mmHg to 43.50±24.73 mmHg, with highly significant differences. Oxygen saturation measured by percutaneous pulse oximeter showed significant increase from 73.37±9.32% to 88.38±6.37%. In severe PS; there was significant reduction of RVSP as well as RVPASP compared to mean values before pulmonary valvuloplasty (97.25±32.02 mmHg versus 44.75±16.03 mmHg and (75.7±23.46 mmHg versus 25.45±15.57 mmHg, with significant increase of oxygen saturation measured by percutaneous pulse oximeter from 90.35±5.31% to 95.70±2.20%.
One patient died (3.57%) from critical PS group after one week after favorable procedure from hypothermia, and 3 patients required repeated balloon dilatation (12.5%) belonging to severe PS group. Freedom from reintervention was 85.71% in critical PS group and 84.21% in severe PS group at one year follow-up. Satisfactory improvement was obtained on the clinical manifestations, almost all patients free of symptoms and signs when compared to before PBV in both groups.
Repeated echo-Doppler studies were done at 2 weeks, 3 months, 6 months, and one year after balloon dilatation for assessment of right ventricular enlargement and hypertrophy, evaluation of growth of the PV annulus and right ventricle, determination the gradient across the pulmonary valve, grade of pulmonary regurgitation, and tricuspid regurgitation.
In the studied groups, the right ventricular size decreased immediately following balloon dilatation, while there was increase in right ventricular size at 3 months, 6months, one year follow-up, these values were within the normal range for the age. As well as the RVAW thickness gradually decreased at, 2 weeks, 3 months, 6 months, one year follow-up.
In critical PS group, the mean diameter of pulmonary valve annulus increased from 6.76±1.19 mm to 11.58±0.19 mm at one year follow-up with highly significant differences. The mean Z values of it increased from -1.04±0.79 before PBV to 0.65±0.46 at one year follow-up with highly significant differences. As well as the mean diameter of tricuspid valve annulus increased from 12.26±1.01mm before balloon dilatation to 17.27±1.58 mm, with highly significant differences .Its Z values highly significantly increased from -2.50 ±0.67 before balloon dilatation to 1.13±0.58 after balloon dilatation at one year follow-up.
Moreover in severe PS group, the mean pulmonary valve annulus diameter after balloon dilatation increased from 9.55±1.72 mm before PBV to 12.62±1.54 mm at one year after PBV with highly significant differences. The mean Z values of the pulmonary valve annulus increased from -0.49±0.96 mm to 0.49±0.71mm with highly significant differences. In addition, the mean diameter of tricuspid valve annulus increased from 16.37±1.18 mm before balloon dilatation to 20.61±2.42 mm at one year after balloon dilatation with highly significant differences. Z value also increased from 0.21±0.62 mm to 1.14±0.74 mm with statistically significant differences, which reveal growth of the right ventricle structures in the two groups.
The peak transvalvular pressure gradient highly significantly decreased from 102.12±12.02 mm Hg to 39.71±18.98 mm Hg at 2 weeks follow-up after PBV and maintains 15.33±2.27 mmHg at one year follow-up in critical PS group. In severe PS patients, the peak transvalvular pressure gradient decreased from 73.30±14.46 mm Hg to 19.63±12.87 mm Hg with highly significant differences at one year follow-up after PBV. There was gradual decrease in the severity and the number of patients with tricuspid regurgitation at short-term follow-up in both groups.
Regarding complications, no important major complication was noted in the immediate course, transient pedal pulse loss occurred in two patients (7.14%) during immediate follow-up, their age less than 6 months, one patient from critical PS and the other belong to severe PS group, the pedal pulse returned to normal after treatment with anticoagulant at the follow-up. Pulmonary regurgitation occurred in 5 patients (83.3%) in critical PS group, 2 of them (40%) had grade II PR at one year follow-up. In severe PS group, PR occurred in 17 patients (89.5%), 9 of them (52.94%) had grade II PR at one year follow-up, but it was not significant as it was in mostly not more than grade II.
from the pervious study we conclude that:
-Percutaneous pulmonary balloon valvuloplasty is an effective, safe, beneficial procedure, and requires a shorter hospital stay. It considered the first choice of treatment for infants with critical or severe PS, with low index of mortality, morbidity & complications, and low rate of reintervention.
-Short-term outcome after PBV demonstrate sustained transvalvular obstruction relief and support maturation of the right ventricle and pulmonary valve annulus, with the expectation of a good long-term outcome.
-This study demonstrates high degree of accuracy of Doppler echocardiography for these patients in precathterization selection, postcathterization evaluation as well as noninvasive follow-up of patients.
-Only transient pedal pulse loss occurred in two patients (7.14%) during immediate follow-up. the incidence of PR is increased but it was not significant as no patients developed symptoms or signs of PR, right ventricular volume overload did not develop and surgical intervention was not required.
We suggest the following recommendations depending on the results of this study:
-Further long-term follow-up studies to document long-term effectiveness of PBV and to evaluate the significance of residual pulmonary regurgitation
-A larger number of patients should be included to ensure statistical significance of the results.
-Good selection of balloon size by echocardiography to avoid the complications; re-stenosis and pulmonary regurgitation.
-PBV is considered a valid alternative to surgery in critical PS patients as in severe PS patients.