Combined Echo and Fluoroscopy-Guided Pulmonary Valvuloplasty in Neonates and Infants: Efficacy and Safety

Brown NK, Husain N, Arzu J, Ramlogan SR, Nugent AW, Tannous P.Pediatr Cardiol. 2022 Mar;43(3):665-673. doi: 10.1007/s00246-021-02771-2. Epub 2021 Nov 28. PMID: 34839381 


Take Home Points:

  • Combining transthoracic echocardiography and fluoroscopy to guide balloon pulmonary valvuloplasty (BPV) is equally effective and safe as standard BPV in treating neonates and infants with isolated pulmonary valve stenosis.
  • Echo-guided BPV results in significantly reduced exposure to radiation and contrast by essentially eliminating the need for cine angiography to measure the pulmonary valve annulus.
  • The subcostal right anterior oblique view by echocardiography was most helpful for guiding the intervention.

Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:

Balloon pulmonary valvuloplasty (BPV) is the therapy of choice for isolated valvar pulmonary stenosis (PS). In an effort to reduce the secondary risks of radiation and contrast use, the authors of this study developed an institutional protocol using echocardiography guidance as an alternative to fluoroscopy and/or angiography for parts of the procedure. They report their initial experience and compare the results to standard BPV.

Between September 2019 and December 2020, 10 infants with isolated valvar PS (including two with critical PS) underwent echo-guided BPV. They were compared to 19 infants (including six with critical PS) who underwent standard BPV between December 2017 and October 2019. There was no difference in demographic or pre-procedural data between the two groups. All procedures were performed successfully (i.e. residual peak-to-peak gradient <35 mmHg) with no difference in residual cath gradient and no adverse events. There were no differences in the number of balloons used, final balloon-to-annulus ratio, and fluoroscopy time or total sheath time. Naturally, there was an 80% reduction in total dose area product (33.8 versus 167.4 cGY∙cm2, p<0.001) and an 84% reduction in contrast load (0.8 versus 5.0 ml/kg, p=0.003) in the echo-guided BPV group compared to the standard BPV group, principally owing to measuring the pulmonary valve by echo instead of angiography (Table 1).



Table 1. Comparison of results between standard and echo-guided BPV


Although this was a single-center retrospective case-control study, it shows that echo-guided BPV in neonates and infants can yield the same results as standard BPV while using much less radiation and contrast. In addition, the authors demonstrate a shallow learning curve, having performed five of their last six cases wholly without contrast. Their efforts underline the value of adopting a multi-disciplinary team approach in applying the ALARA (As Low as Reasonably Achievable) principle in pediatric cardiac catheterization, and should be emulated as much as possible.