Balloon pulmonary valvuloplasty: A systematic review

Abstract

There is conclusive evidence for relief of pulmonary valve obstruction immediately after balloon pulmonary valvuloplasty (BPV) and at follow-up. Development of infundibular obstruction is seen in more severe PS cases and in older subjects. Reappearance of PS was observed in approximately 10 % of patients following BPV. The reasons for recurrence were found to be balloon/annulus ratio less than 1.2 and immediate post-BPV pulmonary valve peak gradients greater than 30 mmHg. Recurrent stenosis is successfully addressed by repeating BPV with lager balloons than used initially. Long-term results revealed continue relief of obstruction, but with development of pulmonary insufficiency, some patients requiring replacement of the pulmonary valve. It was concluded that BPV is the treatment of choice in the management valvar PS and that balloon/annuls ratio used for BPV should be lowered to 1.2 to 1.25. It was also suggested that strategies should be developed to prevent/reduce pulmonary insufficiency at long-term follow-up.

Keywords: Balloon pulmonary valvuloplasty; Long-term results; Pulmonary insufficiency; Pulmonary stenosis; Restenosis.

Fig. 1

The main pulmonary artery Doppler flow velocities prior to (A), and one day (B) and ten months (C) following balloon pulmonary valvuloplasty are shown. Note that there is a significant fall in the peak flow velocity immediately after valvuloplasty, but a moderate (48 mmHg) gradient that has a characteristic triangular pattern, highly suggestive of infundibular obstruction (corresponding to Fig. 2A) persisted. At 10-month follow-up, the flow velocity has markedly diminished, indicating the resolution of the infundibular obstruction (corresponding to Fig. 2B). The residual calculated gradients are shown at the bottom of each panel. Reproduced from Reference.

Fig. 2

Selected cine frames from right ventricular (RV) angiogram in lateral view, showing severe infundibular stenosis (arrow) (A) immediately after balloon pulmonary valvuloplasty. Note the wide-open right ventricular outflow tract (B) at cardiac catheterization 10 months after balloon valvuloplasty. The peak-to-peak pulmonary valvar pressure gradient at follow-up catheterization was 20 mmHg; there was no infundibular gradient. C, catheter; PA, pulmonary artery. Reproduced from Reference.

Fig. 3

Bar graph demonstrating the results of repeat balloon pulmonary valvuloplasty (BPV) of patients who had restenosis after initial balloon valvuloplasty. The initial pulmonary valve gradients were reduced (p < 0.05) significantly after BPV (pre vs. post) but returned toward pre-BPV values (p > 0.1) at intermediate-term follow-up (ITFU). Repeat valvuloplasty (RE-BAL) again reduced the gradient (p < 0.01), which had decreased further (p < 0.05) at long-term follow-up (LFU) and continued to be lower than the gradients prior to the first (p < 0.001) and second (p < 0.001) BPV procedures. The mean + standard deviation (SD) is shown. Modified from Rao PS, et al, Am Heart J 1996; 132:403–407.

Fig. 4

Bar graph demonstrating maximum peak instantaneous Doppler gradients prior to (Pre) and one day following (Post) balloon pulmonary valvuloplasty (BPV), and at intermediate-term (ITFU) and long-term (LTFU) follow-up. Note the significant reduction (p < 0.001) after BPV, which remains unchanged (p > 0.1) at ITFU. However, at LTFU there was a further fall (p < 0.001) in the Doppler gradients. The mean + standard deviation (SD) is shown. Modified from Rao PS, et al, Heart 1998; 80:591–595.

Fig. 5

Actuarial event free rates after balloon pulmonary valvuloplasty. The re-intervention-free rates at one, two, five, and ten years after the procedure are 94 %, 89 %, 88 %, and 84 %, respectively. Modified from Rao PS, et al, Heart 1998; 80:591–595.

Fig. 6

Bar graph showing Doppler graded pulmonary insufficiency (PI) prior to (Pre) and one day after (Post) balloon pulmonary valvuloplasty and at intermediate-term (ITFU) and long-term (LTFU) follow up. 0, No PI; 1+, 2+, 3+, PI grade as per Table III above. A gradual but significant increase (p < 0.05 to p < 0.001) in the incidence of PI is seen. Modified from Rao PS, et al, Heart 1998; 80:591–595.