Balloon Dilatation in the Management of Congenital Obstructive Lesions of the Heart: Review of Author’s Experiences and Observations—Part II

Figures

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  Figure 1. Line graph showing infundibular gradients before and immediately after balloon pulmonary valvuloplasty and at follow-up. Thirteen children had initial gradients; five disappeared immediately after valvuloplasty. New gradients appeared in five other patients. The gradients either improved or disappeared at follow-up. Modified from Reference [2].

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  Figure 2. Selected cine frames from right ventricular (RV) angiogram in lateral view, showing severe infundibular stenosis (arrow) (A) immediately after balloon pulmonary valvuloplasty. Note the wide-open right ventricular outflow tract (B) at cardiac catheterization 10 months after balloon valvuloplasty. The peak-to-peak pulmonary valvar pressure gradient at follow-up catheterization was 20 mmHg; there was no infundibular gradient. C, catheter; PA, pulmonary artery. Reproduced from Reference [4].

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  Figure 3. The main pulmonary artery Doppler flow velocities prior to (A), and one day (B) and ten months (C) following balloon pulmonary valvuloplasty are shown. Note that there is a significant fall in the peak flow velocity immediately after valvuloplasty, but a moderate (48 mmHg) gradient that has a characteristic triangular pattern, highly suggestive of infundibular obstruction (corresponding to Figure 2A) persisted. At 10-month follow-up, the flow velocity has markedly diminished, indicating the resolution of the infundibular obstruction (corresponding to Figure 2B). The residual calculated gradients are shown at the bottom of each panel. Reproduced from Reference [4].

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  Figure 4. The relationship between the prevalence of infundibular obstruction and age at valvuloplasty and severity of pulmonary valve obstruction. The prevalence of infundibular obstruction is higher with increasing age and increasing degree of pulmonary valve stenosis. Modified from Reference [2].

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  Figure 5. Plots of mean QRS vectors (axis) in the frontal (top) and horizontal (bottom) planes in group I (with good results) (left circles) and group II (with poor results) (right circles) prior to balloon pulmonary valvuloplasty (BPV) are shown. Note that no significant (p > 0.1) difference was seen between groups I and II. Reproduced from Reference [20].

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  Figure 6. Anterior (R waves in leads V3R, V1, and V2) and terminal rightward (S waves in leads V5 and V6) voltages in the electrocardiograms prior to balloon pulmonary valvuloplasty are compared between groups (Grp.) I (with good results) and group II (with poor results). Mean and standard error of mean (SEM) are shown. Note that no significant (p > 0.1) difference is shown between groups I and II. Reproduced from Reference [20].

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  Figure 7. Plots of mean QRS vectors (axis) in the frontal (top) and horizontal (bottom) planes in group I (with good results) prior to balloon pulmonary valvuloplasty (BPV) (left circles) and at follow-up (right circles) are shown. Note the significant (p < 0.05) improvement at follow-up. Reproduced from Reference [20].

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  Figure 8. Precordial ECG voltages (R waves in leads V3R and V1 and S waves in V6) prior to and at follow-up after balloon pulmonary valvuloplasty (BPV) in group I (with good results) (left panel) and group II (with poor results) (right panel) are depicted. The mean and standard deviation (SD) are shown. Note the significant (p < 0.05 to <0.01) decrease in the voltages in group I while there was no significant (p > 0.1) change in group II. Reproduced from Reference [20].

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  Figure 9. Precordial ECG voltages (R waves in leads V3R [circles] and V1 [squares]) prior to and at 3, 6, and 12 months following balloon pulmonary valvuloplasty (BPV) in group I patients (with good results). Note that a gradual improvement was shown; at 3-month follow-up, there was no statistically significant decrease (p > 0.05), but at 6 and 12 months, a significant (p < 0.05 to 0.001) decrease was observed. The mean and standard error of mean (SEM) are shown. Reproduced from Reference [19].

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  Figure 10. Precordial ECG voltages (S waves in leads V5 (circles) and V6 (squares)) prior to and at 3, 6, and 12 months following balloon pulmonary valvuloplasty (BPV) in group I patients (with good results). Note that a gradual improvement was shown; at 3-month follow-up, there was no statistically significant decrease (p > 0.1), but at 6 and 12 months, a significant (p < 0.02 to 0.001) decrease was observed. The mean and standard error of mean (SEM) are shown. Reproduced from Reference [19].

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  Figure 11. The relationship of residual pulmonary valve gradients at follow-up after balloon pulmonary valvuloplasty (BPV) and electrocardiogram (ECG) is plotted. Note that a normal ECG is found in patients with minimal residual pulmonary valve gradients (left panel) while RVH indicates a significant residual gradient, or that the ECGs were recorded earlier than six months after BPV. The mean and standard deviation (SD) are shown. Filled circles—ECGs recorded six months after BPV. Open circles—ECGs recorded prior to six months after BPV. ECGs recorded prior to six months after BPV exhibited RVH, despite reduced gradients; this may in part be related to not yet having had a chance for the complete resolution of RVH. Reproduced from Reference [20].

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  Figure 12. Selected video frames of the atrial septum, demonstrating a right-to-left shunt by color Doppler, across the patent foramen ovale prior to balloon pulmonary valvuloplasty (A) which has changed to a left-to-right shunt (B) 24 h later. LA, left atrium; RA, right atrium. Reproduced from Reference [20].