1. Pediatric cardiac catheterization Part 1 - balloon procedures David Shim, MD The Heart Center Children’s Hospital Medical Center Cincinnati, Ohio

2. Pediatric interventional catheterization
Diagnosis redirected from catheterization suite to the echocardiography suite
Therapy redirected from the surgical suite to the catheterization suite
Neonatal caths (Shim et al, 1999)
% interventional (BAS)
% varied interventions (p=0.003)

3. Balloon septostomy Miller and Rashkind, 1966
Allows mixing in transposition of the great arteries
Inflated balloon pulled from left atrium to right atrium
Modified use with blade septostomy or static balloon dilation

4. Balloon septostomy: pre-echo

5. Balloon septostomy: the pull

6. Balloon septostomy: post-echo

7. Balloon valvuloplasty
Originally a balloon pull-through
Static dilation to separate commissures
Success dependant on annulus size and valve morphology
Side effect: valve insufficiency

8. Pulmonary stenosis Kan, 1982 - 1st static balloon dilation
Treatment of choice in all centers (>80% success rate)
Risk of restenosis 15-20% if dilation required prior to a year of age, rare if over a year old

9. Pulmonary valvuloplasty
Indications
asymptomatic patients with gradients >50 mmHg (Mendelsohn et al - utility of balloon valvuloplasty at gradients >40 mmHg)
symptomatic patients
CHF or cyanosis in the newborn syncope, dyspnea
Methods
balloon size equal to times the annulus size

10. Pulmonary valvuloplasty

11. Pulmonary valvuloplasty

12. Pulmonary valvuloplasty

13. Aortic stenosis Lababidi, 1984 Treatment of choice of many centers
Palliative only
Methods
single balloon - equal aortic valve annulus (in general, neonates usually require 7 mm balloon)
double balloon times the aortic valve annulus
Complication
aortic insufficiency

14. Aortic valvuloplasty Results Sholler et al, 1988
demonstrated that balloon:annulus ratio > 1.0 did not improve gradient relief but did increase regurgitation
Rocchini et al, 1990
61% acute gradient reduction in 204 patients

15. Aortic valvuloplasty Results (continued) Shim et al, 1997
repeat balloon valvuloplasty resulted in adequate gradient relief in 11/15 patients (73%) while producing worsening aortic regurgitation in 4 patients (27%)
- no severe regurgitation
- compares favorably to first dilations
- 3/4 patients with unsatisfactory gradient relief were on their third aortic valve intervention

16. Balloon angioplasty
Stretch stenotic vessels by creating a tear in the intima and media
Risks: rupture or dissection of the vessel (balloon size and inflation pressure)
Ideally will grow with patient after relief of obstruction
Contraindication: calcification

17. Balloon angioplasty Pulmonary artery stenosis Coarctation of the aorta
Venous (SVC) stenosis
Others: baffles, conduits
Does not work with pulmonary vein stenosis

18. Coarctation of the aorta
Historical perspective
Sos et al, 1979 and Lock et al, 1982: performed balloon dilation on surgically removed CoA segments
Singer et al, 1982: performed balloon dilation on restenosis of CoA repair
Lababidi et al, 1983: described first balloon dilation on native CoA

19. Aorta angioplasty Indications recurrent CoA
- resting gradient >20mmHg, hypertension, and/or symptoms (claudication)
native CoA
- greater than 1 yr old with above

20. Aorta angioplasty Results (native)
Tynan et al, 1990: VACA study of 140 patients with 82% relief (48+19 to mmHg)
Mendelsohn et al, 1994: 78% immediate success rate and 64% positive long-term results
Rao et al, 1996: 77 patients with gradient relief from to 11+9 mmHg with restenosis in 83% of neonates, 39% of infants, and 8% of children

21. Peripheral pulmonary stenosis
Historical perspective
Lock et al, described balloon dilation of branch pulmonary artery stenosis in 5/7 patients
Rocchini et al, described successful dilation in 5 and unsuccessful in 8 patients

22. Peripheral pulmonary angioplasty
Causes
Congenital
- TOF, low pulmonary flow
- LPA coarctation
- Williams, Alagille, and rubella
Acquired
- pulmonary emboli
Postsurgical
- shunts (Waterston, BT)
- Glenn/Fontan anastomosis

23. Peripheral pulmonary angioplasty
Indications
Symptoms of cyanosis, heart failure, or dyspnea
RV pressure of >2/3 systemic
Severe pulmonary insufficiency with MPA pressure >40 mmHg
RV pressure >50 mmHg with unilateral obstruction causing marked disparity in pulmonary blood flow

24. Peripheral pulmonary angioplasty
Results
Kan et al, VACA with 182 procedures in 156 patients with moderate results (systolic gradient 49 to 37 mmHg)
Hosking et al, VACA follow-up with 53% success in 72 patients
Gentles et al, use of high-pressure balloon (17-20 atm) with success rate 63% in previously dilated arteries and 81% in native stenosis