Balloon Valvuloplasty and RF Perforation for PA-IVS and Critical Pulmonary Stenosis

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Balloon Valvuloplasty and RF Perforation for PA-IVS and Critical Pulmonary Stenosis Daniel Levi, MD, FSCAI Associate Professor of Pediatrics UCLA Biomedical Engineering Mattel Children s Hospital at UCLA, Division of Pediatric Cardiology Active Materials Lab

Disclosure Information Balloon Valvuloplasty and RF Perforation for PA-IVS and Critical Pulmonary Stenosis Daniel S Levi, MD, FSCAI As a faculty member for this program, I disclose the following relationships with industry: (GRS): Grant/Research Support (C): Consultant (SB): Speaker s Bureau (MSH): Major Stock Holder (AB): Advisory Board (E): Employment (O):Other Financial or Material Support pfm Medical: C Atrium Medical: C Neurosigma Vascular: AB NIH Challenge Grant, AHA Innovative Research Grant

Pulmonary Stenosis Pathology Fused leaflets, raphea Doming/windsock Dysplasia Atresia History 60+ years 1950 s Alvarez ureteral catheter and wire Semb 1979 Berman pull Kan/Greuntzig static balloon 1982 1. Rubio-Alvarez V, Limon R and Soni J. Valvulotomias intracardiacas por medio de un cateter. Arch Inst Cardiol Mex 1953; 23: 183 192. 2. Kan JS et al. Percutaneous balloon valvuloplasty: a new method for treating congenital pulmonary valve stenosis.n Engl J Med 1982; 307: 540 542.

Presentation & Indication Presentation critical PS Moderate-Severe Mild -Non-newborns Indications Newborn/cyanosis ECHO gradient (mm Hg): 45? 55? 65? Symptoms? ECG? RVH? Awake versus Asleep Peak inst versus Peak to peak

Physiology of Pulmonary Regurgitation Prevalence Common with surgical or BPV significant PR: audible VS echo Physiology 80% of RV output has diffused to thedistal pulmonary capillaries end systole 20% left for PR to low diastolic Ppa Discrepancy with MRI data Free PR versus moderate PR

Pulmonary Stenosis: Cath Tips Angiogram LAT, AP +/- cranial Measure PV at hinge points/end systole Precautions Blood on standby Indwelling arterial line +/- General anesthesia Tips Wire SuperStiff? Use of balloon catheters Length matters!! 2-3cm infants, 3-5 cm in older

Pulmonary Stenosis: Balloon Size and Number Single VS Double Advantages to each approach Double venting, minimizes largest sheath Primarily for older children, adults Single Simple, good for smaller patients Picking a diameter Mullins 135-150% Rao 120-130% ball park approach

Pulmonary Valvuloplasty: Double Balloon De = D1 + D2 + D1/2 + D2 3.14126/2 +1 = 2.57 De = 2.57 (D1 + D2) De = 0.82 (D1 + D2)

Pulmonary Valvuloplasty: Outcome Comparable to surgical outcomes Immediate/Long Term Results Allows for RV growth Long Term Results 80-90% freedom from re-intervention at 10 years, 90+% freedom from PS Data from: McCrindle, Kan, Ganty, O Conner, Masura PR is prevalent, significant PR rare More PR with B:A ratio >1.4?

1. McCrindle BW. Independent predictors of long-term results after balloon pulmonary valuloplasty. Valvuloplasty and Angioplasty of Congenital Anomalies (VACA) Registry Investigators. Circulation 1994; 89(4): 1751 1759. 2. Mullins CE et al. Balloon valvuloplasty for pulmonic valve stenosis a two-year follow-up: hemodynamic and Doppler evaluation. Cathet Cardiovasc Diagn 1988; 14(2): 76 81.

Angiography

Angiography

Pulmonary Valvuloplasty: Balloons Cordis Opta Pro Nucleus Z-Med/Z-Med II BIB? Coronary Balloons? Sterling? Atlas/Conquest? MiniGhost TyShaq Mini TyShaq 2

8mm PV - Balloon Choice?

Improved?

Pulmonary Valvuloplasty: Complications Annular Rupture/disruption B:A ratio >1.4? Higher pressure balloons Post op versus native Tricuspid valve damage Double waist? Use of balloon tipped catheter Pulmonary artery damage Central versus wedge injury Type of wire

PAIVS RF Perforation Rule-out RVDCC Well developed RVOT High Risk LAB precautions/discussions Equipment Generator Coaxial and Micro- catheters Catheter position 5 Fr JR (at least 4.1) BiPlane Real Target Stent PDA? Low threshold Two-fer

PAIVS Assessment RV injection Direct catheter into RV Shaped or deflected wire Position in RV cavity Berman useful Coronary angiography With decompressed RV Aortogram (often inadequate) Selective coronary injections Evaluation ALL branches

RVDCC?

RVDCC?

FUTURE? Importance of technique PA-IVS PS get it right Long term results New Toys Balloons Beyond Nucleus/TyShaq Stereotaxis? Transcatheter valves

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