Valvular Heart Disease In Pediatric Age Group - RM Solutions

Valvular Heart Disease In
Pediatric Age Group
Maiy H. El Sayed, MD
Professor of Cardiology
Structural and Congenital heart disease Unit
Ain Shams University

Valvular Heart Disease In
Children
Congenital
Acquired
•Stenotic
•Regurgitant
•Imperforate
•Prolapsing
•Straddling
•Overriding
Rheumatic heart disease

Overview Of The Problem
• The child with significant valvular heart disease
may present in any single instance both the most
difficult of management decisions or a
surprisingly simple one.
• If a direct interventional or surgical approach on
the valve is feasible, the problems may very well
be quite simple and straightforward; conversely,
if complex intervention or valve replacement is
indicated such may not be the case.

Balloon Valvuloplasty Of Stenotic
Lesions 2008,2009
No M F
BPV 280 154 126
BAV 50 35 15
BMV 43 18 25
18% of total number of
pediatric cardiac
catheterization
procedures, 50% of
pediatric cardiac
interventions

Age
Mean age [ years ]
BPV 4.2
BAV 4.1
BMV 14.6

Gradient
before
[mmHg]
Gradient
after
[mmHg]
BPV 90.3 20
BAV 95.8 25
BMV 29.4 2.2

Technique
BPV

Valvuloplasty
Balloon Aortic Valvuloplasty
Valvuloplasty balloon passed retrograde across stenotic aortic valve

Antegrade BAV

Antegrade BAV

Antegrade BAV
Negative jet

Valvuloplasty
Balloon Mitral Valvuloplasty

Morphologic And Hemodynamic
Consequences After Balloon Pulmonary
Valvuloplasty In Infants: Medium Term
Follow Up
• N = 76 < 1 Y
• M = 62.5%, F = 37.5%
• 72 critical PS, 4 PA/IVS. [ imperforate valve]
• 2007 – 2009.
• Age:- 1w – 12m.
• Wt :- 3 – 9.5 kgs.
• BSA:- 0.22 – 0.56m 2.
• 31.8% cyanosis at rest.
• 85% immediate success rate [ reduction of
≥50% 0f RVP]

Stretched PFO with right to left shunt

Pulmonary valve morphology

Baseline Echocardiographic And Angiographic
Data
Mean ± SD
Range
Peak PG 93.3 ± 28.2 60 - 165
RVSP 115.6 ± 33.8 80 - 195
P.annulus (mm) 8.14 ±1.45 4 – 12
P. annulus Z score
PR 0%
TR 55.6%
RVH 72.3%
-1.11 ±1.03 -3.1 – 0.4

Procedural findings
Range
Balloon size(mm) 2.5-16
Ratio B/A ratio 0.9-1.6
Transvalvular PG before dilatation(mmHg) 50-135
Transvalvular PG after dilatation(mmHg) 5-65

28.1%
71.9%

Technique in neonates??
Wire support in PDA

Supra valvular – use of high pressure balloons

PTCA 2.5mm Balloon PTCA 3.5mm Balloon Double Balloon

PDA Stenting + PV perforation

PDA Stenting + PV perforation
3x18mm Apolo

PDA Stenting + PV perforation
Stiff end of 0.025 wire

2.5x20 Mavrek

10 m later - BPV
7x20mm Tyshak mini

10 m later - BPV
Diastole
Systole
Infundibular reaction
[ dynamic obstruction]

Immediate Hemodynamic And Morphologic
Effects Of BPV
mean

Immediate Hemodynamic And Morphologic
Effects Of BPV
Before BPV
After BPV
Pulmonary
regurgitation
0% 64%
Tricuspid
regurgitation 55.8% 55.8%

Relation Between Development Of Pulmonary
Regurgitation And Balloon/Annulus Ratio
PR None Mild Moderate Severe
B/A ratio 1.12±0.02 1.29±0.05 1.42±0.09 1.5±0.12

Complication Of BPV-PA/IVS
• Transient apnoea. 46%
• Sinus bradycardia 27.7%
• Self limiting perforations. 3.8%
• Transient loss of femoral pulse . 6.08%
• Death 6.5%
1 → PS → Pulmonary annulus rupture. (B/A= 1.25)
2 → critical PS – cardio pulmonary arrest during procedure
1 → PA/IVS one week after BPV (necrotizing enterocolitis).
1 → PA/IVS 10 days following procedure.

Follow Up After BPV
3,6,12months

Correlation between growth of pulmonary annulus (change of z
score) and the baseline annular size before dilatation
(inverse correlation)
increase in p annulus z score
3.5
3
2.5
2
1.5
1
0.5
R=0.74 & p=0.0001
-4 -3 -2 -1 0 1
P annulus Z score at baseline
0
The smaller the annulus, the more growth occurring in medium term follow
up

%
Follow Up

Multi-variant Analysis For Factors Affecting Successful
BPV
Variables
Successful (mean±SD
or %)
Unsuccessful
(mean±SD or %)
Age 5.833 ± 3.029 4.5 ± 2.784 0.368 (NS)
Gender (m/f) (62.96%/37.04%) (60%/40%) 0.9 (NS)
P
RV-PA before
PVBD (mmHg)
RV-PA PG
immediate
after PBV
82.407 ± 24.114 83 ± 24.393 0.96(NS)
15.852 ± 7.107 27.5 ± 14.434 0.013 (S)
SPAP (mmHg) 22.444 ± 7.607 25.5 ± 19.942 0.559 (NS)
B/A ratio 1.342 ± 0.153 1.494 ± 0.167 0.053 (NS)
RVSP before
(mmHg)
RVSP after
(mmHg)
PV annulus
(mm)
TV annulus
(mm)
Infundibular
hypertrophy
103.889 ± 25.508 109 ± 24.083 0.681 (NS)
40.482 ± 8.519 65 ± 19.149 0.000 (HS)
10.219 ± 1.631 8.833 ± 1.258 0.168 (NS)
15.944 ± 2.199 15.3 ± 1.609 0.628 (NS)
14.81% 40% 0.185 (NS)

Observations And
Conclusions
• RV dilatation starts to regress as early as 2 -3
weeks following successful BPV.
• Early intervention → better results.
• Balloon dilatation of critical PS is the treatment of
choice with surgery being reserved to the severely
dysplastic & deformed valves /supravalvular PS.
• Well equipped lab – trained personnel – PICU.