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Rapid right ventricular pacing for balloon aortic valvuloplasty: expanding its routine use in neonates and infants

Published online by Cambridge University Press:  06 October 2020

Konstantinos S. Mylonas Open the ORCID record for Konstantinos S. Mylonas [Opens in a new window] ,
Charalampos Kavvouras ,
Panagiota Karouli ,
Dimosthenis Avramidis ,
Ioannis Papagiannis ,
David Anderson ,
Fotios Mitropoulos  and
Aphrodite Tzifa Open the ORCID record for Aphrodite Tzifa [Opens in a new window]
Konstantinos S. Mylonas
Affiliation:
Department of Pediatric Cardiology and Adult Congenital Heart Disease, Mitera Children’s Hospital, Athens, Greece Department of Pediatric Cardiac Surgery, Mitera Children’s Hospital, Athens, Greece
Charalampos Kavvouras
Affiliation:
Department of Pediatric Cardiology and Adult Congenital Heart Disease, Mitera Children’s Hospital, Athens, Greece
Panagiota Karouli
Affiliation:
Department of Pediatric Cardiology and Adult Congenital Heart Disease, Mitera Children’s Hospital, Athens, Greece
Dimosthenis Avramidis
Affiliation:
Department of Pediatric Cardiology and Adult Congenital Heart Disease, Mitera Children’s Hospital, Athens, Greece
Ioannis Papagiannis
Affiliation:
Department of Pediatric Cardiology and Adult Congenital Heart Disease, Mitera Children’s Hospital, Athens, Greece
David Anderson
Affiliation:
Department of Pediatric Cardiac Surgery, Mitera Children’s Hospital, Athens, Greece Division of Biomedical Engineering and Imaging Sciences, King’s College, London, UK
Fotios Mitropoulos
Affiliation:
Department of Pediatric Cardiac Surgery, Mitera Children’s Hospital, Athens, Greece
Aphrodite Tzifa*
Affiliation:
Department of Pediatric Cardiology and Adult Congenital Heart Disease, Mitera Children’s Hospital, Athens, Greece Division of Biomedical Engineering and Imaging Sciences, King’s College, London, UK
*
Author for correspondence: Aphrodite Tzifa MD (Res), FRCPCH, Director of Pediatric Cardiology and Adult Congenital Heart Disease Department, Mitera Children’s Hospital, Hygeia Group, Erythrou Stavrou 6, Athens 15123, Greece. Tel: + 30 6908999961; Fax: + 30 2106869197. E-mail: a.tzifa@btinternet.com
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Abstract

Objective:

Rapid right ventricular pacing during balloon aortic valvuloplasty is commonly used to achieve balloon stability in children and adults. There is no consensus for the use of the technique in neonates and infants. We sought to review our institutional experience with rapid right ventricular pacing-assisted balloon aortic valvuloplasty across all age groups and evaluate the safety and effectiveness of the technique in the sub-group of neonates and infants <12months.

Methods:

Retrospective study between February, 2011 and February, 2020.

Results:

A total of 37 patients (Group I: 21 neonates/infants <12months and Group II: 16 children 12 months–16 years) were analysed. Catheter-measured left ventricular to aortic gradient reduced from median of 66 mmHg (with a range from 30 to 125 mmHg) to 14 mmHg (with a range from 5 to 44 mmHg) in Group I and 44 mmHg (with a range from 28 to 93 mmHg) to 18 mmHg (with a range from 2 to 65 mmHg) in Group II (p < 0.001). Procedure and fluoroscopy times were identical in the two groups. Balloon:annulus ratio was 0.94 and 0.88 in Groups I and II, respectively. Freedom from reintervention was 100% for Group I at a median time of 3.2 years and 81% at 2.7 years for Group II. Reinterventions in Group II (3/16 pts) were performed predominantly for complex left ventricular outflow tract stenosis. At follow-up echocardiogram, 45% of patients in Group I had no aortic regurgitation, 30% trace-mild, 20% mild-moderate, and 5% moderate aortic regurgitation, whereas in Group II, 50% of patients had no aortic regurgitation, 32% had mild aortic regurgitation, and 18% mild-moderate aortic regurgitation. Unicuspid valves were only encountered in Group 1 (2/21 pts, 10%) and they were predictive of mild-aortic regurgitation during follow-up (p = 0.003). Ventricular fibrillation occurred in three neonates with suspicion of myocardial ischemia on the pre-procedure echocardiogram. All were successfully defibrillated.

Conclusions:

Rapid right ventricular pacing can be expanded in neonates and infants to potentially decrease the incidence of aortic regurgitation and reintervention rates, hence avoiding high-risk surgical bail-out procedures for severe aortic regurgitation in the first year of life. Myocardial ischemia may predispose to ventricular dysrhythmias during rapid right ventricular pacing.

Keywords

Rapid right ventricular pacingballoon aortic valvuloplastycongenital aortic valve stenosisneonatesinfants
Type
Original Article
Information
Cardiology in the Young , Volume 30 , Issue 12 , December 2020 , pp. 1890 - 1895
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Copyright
© The Author(s), 2020. Published by Cambridge University Press

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