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0IMMEDIATE RESULTS OF BALLOON VALVULOPLASTY FOR PULMONARY STENOSIS DEPENDING ON THE TYPE OF
STENOSIS
Umarov M.M.
State Institution "Republican Specialized Scientific and Practical Medical Center of Surgery
named after Academician V. Vakhidov" https://doi.org/10.5281/zenodo.13636827
Abstract. Objective: To analyze the immediate outcomes of balloon valvuloplasty (BV) for pulmonary stenosis (PS) based on the type of narrowing.
Materials and Methods: The study included 180 patients with PA and RVOT stenoses who underwent BV at the State Institution "Republican Specialized Scientific and Practical Medical Center of Surgery named after Academician V. Vakhidov" from 2010 to 2022. Patients with isolated PA valve stenosis were included. Exclusion criteria were critical PA stenosis, pregnancy, and complex congenital heart disease. Patients were categorized by initial right ventricular (RV) systolic pressure: <100 mm Hg (43.3%), 101-150 mm Hg (30.0%), 151-200 mm Hg (16.7%), and >200 mm Hg (10.0%). To determine the dependence of the results on the type of PA obstruction, patients were divided into the following groups: valvular PS (n=144), valvular-subvalvular PS (n=27), valvular-supravalvular PS (n=9).
Results: In isolated valvular PS (n=144), RV systolic pressure decreasedfrom 118.2±14.7 mm Hg to 55.1±6.3 mm Hg, PA pressure increasedfrom 22.9±2.7 mm Hg to 28.5±2.9 mm Hg, and the RV-PA pressure gradient dropped from 94.0±10.4 mm Hg to 26.3±3.1 mm Hg. Good results were seen in 79.2%, satisfactory - in 13.9%, and unsatisfactory - in 6.9% of patients. For combined valvular-subvalvular PS (n=22), RV pressure decreasedfrom 148.6±16.8 mm Hg to 82.4±7.2 mm Hg, PA pressure increased from 21.3±2.5 mm Hg to 27.0±3.6 mm Hg, and the gradient fell from 129.1±14.3 mm Hg to 56.7±6.2 mm Hg. Good outcomes were achieved in 44.4%, satisfactory - in 33.3%, and unsatisfactory - in 22.2%. In valvular-supravalvular PS (n=9), RV pressure decreased from 130.4±2.5 mm Hg to 55.3±1.9 mm Hg, PA pressure increased to 28.5±1.5 mm Hg, and the gradient droppedfrom 113.6±1.8 mm Hg to 21.3±1.1 mm Hg. Good results were seen in 77.8% of patients.
Conclusion: BV effectively treats isolated valvular PS, significantly improving clinical and hemodynamic outcomes. The procedure is also beneficial for combined stenoses but with higher residual gradients. For valvular-supravalvular stenosis, BV shows high efficacy despite limited data.
Keywords: balloon valvuloplasty, pulmonary stenosis, valvular stenosis, combined stenosis, hemodynamics, right ventricular outflow tract, pressure gradient, clinical outcomes.
INTRODUCTION
Pulmonary stenosis (PS) is a significant cardiovascular condition characterized by the narrowing of the pulmonary artery, which impairs normal blood flow from the right ventricle to the lungs. This condition can present in various forms, such as valvular, subvalvular, and combined stenoses, each with unique clinical and hemodynamic features [1, 2].
Valvular stenosis of the pulmonary artery, often diagnosed in patients with congenital heart defects, involves narrowing at the level of the valve ring. Subvalvular stenosis occurs below the valve and may be caused by muscle hypertrophy or membranous obstructions. Combined stenosis incorporates elements of both types, complicating the clinical presentation and treatment [3, 4].
Balloon valvuloplasty (BV) is a key therapeutic method for correcting pulmonary artery stenosis. This procedure involves using a balloon that is inflated at the site of narrowing to expand the lumen and improve blood flow. Literature indicates that BV can significantly enhance clinical status and hemodynamic parameters in patients with various forms of stenosis. Studies have shown that BV is particularly effective for valvular stenosis, while outcomes may be less predictable in combined and subvalvular stenoses [5, 6].
Recently, there has been increasing interest in analyzing the immediate results of BV, especially in relation to the type of stenosis. Work by Yin D et al. (2021) demonstrated that immediate procedural outcomes depend on the anatomical characteristics of the stenosis, including the degree of residual pressure gradient and changes in pressures within the right ventricle and left atrium [7]. Similar studies conducted by Iervolino A et al. (2021) confirm that the type of stenosis can significantly impact the effectiveness and long-term results of treatment [8].
Therefore, this study aims to systematically analyze the immediate results of balloon valvuloplasty for pulmonary artery stenosis, considering various types of narrowing. We seek to determine how the form of stenosis affects procedural outcomes and subsequent hemodynamic changes. This analysis will help optimize treatment approaches and improve prognoses for patients with different forms of pulmonary artery stenosis.
MATERIAL AND METHODS.
The clinical material was the results of treatment of 180 patients with PA and RVOT, who underwent various types of REV at the State Institution " Republican Specialized Scientific and Practical Medical Center of Surgery named after Academician V. Vakhidov " for the period from 2010 to 2022.
Inclusion criteria:
• Isolated PA valve stenosis diagnosed by echocardiography (EchoCG).
Exclusion criteria:
• Critical PA valve stenosis;
• Pregnancy;
• Complex CHD.
Infants (up to 1 year) accounted for only 4.4% (8 out of 180). The majority were schoolage (8-17 years), young (18-44 years) and middle-aged (45-59 years) patients (Table 1).
Table 1. Distribution of patients by gender and age
Age Gender Total
Male Female
Infancy (up to 1 year) 4 (2,2%) 4 (2,2%) 8 (4,4%)
Early childhood (1-3 years) 12 (6,7%) 8 (4,4%) 20 (11,1%)
Preschool (4-7 years) 12 (6,7%) 16 (8,9%) 28 (15,6%)
School age (8-17 years) 24 (13,3%) 20 (11,1%) 44 (24,4%)
Young age - 18-44 years 28 (15,6%) 27 (15,0%) 55 (30,6%)
Middle age - 45-59 years 14 (7,8%) 11 (6,1%) 25 (13,9%)
Total 94 (52,2%) 86 (47,8%) 180 (100%)
To determine the dependence of the results on the type of PA obstruction, patients were divided into the following groups (table 2):
Table 2. Distribution ofpatients depending on the anatomical variants of PA
Anatomical groups n %
Valvular PS 144 80,0%
Valvular-subvalvular PS 27 15,0%
Valvular-supravalvular PS 9 5,0%
Total 180 100%
The supravalvular component was a membrane located in the PA trunk at a distance of 1
to 2 cm above the level of the valve ring.
Depending on the initial systolic pressure in the RV, patients were divided into 4 groups:
- with an initial RV pressure of up to 100 mm Hg - 78 (43.3%);
- from 101 to 150 mm Hg - 54 (30.0%);
- from 151 to 200 mm Hg - 30 (16.7%);
- above 200 mm Hg - 18 (10.0%).
RESULTS
In patients with valvular PS (n=144), systolic pressure in the RV before BV varied within the range from 60 to 260 mmHg, in the PA - from 15 to 38 mmHg, SPG between the RV and PA - from 20 to 245 mmHg. Immediately after BV, systolic pressure in the RV decreased on average from 118.2±14.7 mmHg to 55.1±6.3 mmHg. In the PA, an increase in pressure was noted on average from 22.9±2.7 mmHg to 28.5±2.9 mmHg. The pressure gradient between the RV and PA decreased on average from 94.0±10.4 mmHg to 26.3±3.1 mmHg (Fig. 1).
valvular PS (n=144)
160 -118,2
RV pressure PA pressure SPG
■ before BV after BV
Fig. 1. Intracardiac hemodynamic parameters in the group of patients with valvular PS
(n=144)
In this group of patients, good results were achieved in 144 patients (79.2%), satisfactory in 20 patients (13.9%), and unsatisfactory in 10 patients (6.9%). In the group of patients with combined valvular-subvalvular pulmonary artery stenosis (SPA, n=22), the initial systolic pressure
in the right ventricle (RV) varied from 65 to 267 mm Hg, in the left atrium (LA) - from 15 to 30 mm Hg, and the pressure gradient between the RV and PA - from 45 to 245 mm Hg. After BV of PS, right ventricular (RV) systolic pressure decreased on average from 148.6±16.8 mmHg to 82.4±7.2 mmHg. Left atrial (LA) pressure increased on average from 21.3±2.5 mmHg to 27.0±3.6 mmHg. The RV-PA pressure gradient decreased on average from 129.1±14.3 mmHg to 56.7±6.2 mmHg (fig. 2).
200 150 100 50 0
148,6
valvular-subvalvular PS (n=27)
21,3 27
RV pressure
PA pressure before BV after BV
SPG
Fig. 2. Intracardiac hemodynamic parameters in the group of patients with valvular-
subvalvular PS (n=27)
Good results were achieved in 12 patients (44.4%), satisfactory results were observed in 9 patients (33.3%), and unsatisfactory results were observed in 6 patients (22.2%).
In 9 patients with valvular-supravalvular stenosis of the PA, the systolic pressure in the RV was 130.4±2.5 mmHg, the pressure in the PA was 18.3±1.5 mmHg, and the pressure gradient between the RV and PA was 113.6±1.8 mmHg (fig. 3).
200 150 100 50 0
valvular-supravalvular PS (n=9)
130,4
113,6
18,3
28,5
RV pressure PA pressure
■ before BV after BV
SPG
Fig. 3. Intracardiac hemodynamic parameters in the group of patients with valvular-
supravalvular PS (n=9)
After balloon valvuloplasty, right ventricular (RV) systolic pressure decreased to 55.3 ± 1.9 mmHg, left atrial (LA) pressure was 28.5 ± 1.5 mmHg, and the RV-PA pressure gradient decreased from 113.6 ± 1.8 to 21.3 ± 1.1 mmHg and from 113 to 31 mmHg. Good results were achieved in 77.8% of patients, satisfactory results were shown in 22.2%, and there were no unsatisfactory results.
The results of the study demonstrate that immediately after the procedure in patients with isolated PS, RV systolic pressure decreased more than twofold, PA pressure increased by more than 5 mmHg, and PS decreased by more than 1.5 mmHg, and the pressure gradient between the RV and PA decreased more than threefold.
Patients showed clinical improvement, ECG parameters were improved, weakening of systolic murmur during auscultation, and with improvement of the functional class. In the group of patients with combined valvular-subvalvular stenosis, the results of balloon valvuloplasty were also quite positive.
The pressure in the PA increased by an average of 6 mm Hg, the pressure in the RV decreased by 1.8 times, and the pressure gradient between the RV and PA decreased by 2.3 times. However, the residual pressure gradient between the RV and PA after the procedure was higher in patients with combined stenosis compared to patients with isolated valvular stenosis.
22,2%
6,9%
Valvular PS
0,0%
Valvular-subvalvular PS Valvular-supravalvular
PS
Fig. 4. Frequency of unsatisfactory results of BV in PS depending on the type of stenosis of
the PA
The failure rate was significantly higher in patients with combined valvular-subvalvular pulmonary artery stenosis. The underlying cause in most cases was residual obstruction in the right ventricular outflow tract. Despite the presence of residual pressure gradient in some cases, all patients showed positive improvement in clinical condition after balloon valvuloplasty. Despite the limited amount of data on balloon dilation in valvular-supravalvular pulmonary artery stenosis, our experience has shown that in cases of combined valvular stenosis and supravalvular membranous stenosis, balloon dilation is a highly effective correction method that completely normalizes cardiac hemodynamics.
Thus, after BV, patients with isolated valvular stenosis showed a significant improvement in the clinical condition, ECG parameters were improved, with weakening of the systolic murmur, and positive dynamics in the assessment of the functional class. Patients with combined stenosis also showed an improvement, but the residual pressure gradient was higher compared to patients
with isolated valvular stenosis. Balloon dilation in the case of valvular-supravalvular stenosis
demonstrated high efficiency, despite the limited number of observations.
Unsatisfactory results were more common in patients with combined stenosis, which is
associated with residual obstruction in the outflow tract of the right ventricle.
CONCLUSION.
Balloon valvuloplasty has been shown to be an effective treatment for PS, especially for
isolated valvular stenosis, and less effective for combined and supravalvular stenoses.
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