Transcarotid balloon valvuloplasty in neonates and small infants with critical aortic valve stenosis utilizing continuous transesophageal echocardiographic guidance: A 22 year single center experience from the cath lab to the bedside

OBJECTIVE: Utilization of continuous transesophageal echocardiographic guidance (cTEE) during transcarotid balloon valvuloplasty (TCBV) in neonates and small infants with critical aortic valve stenosis (AS) allows for continuous hemodynamic assessment and improved outcomes. BACKGROUND: Preferred method of intervention for critical AS remains controversial due to conflicting results. METHODS: Since 1992, 30 neonates and small infants with critical AS and adequate left ventricular (LV) volumes underwent TCBV with cTEE. Critical AS was defined as ductal dependent systemic circulation, LV systolic dysfunction, or an echo gradient≥100 mm Hg with evidence of hypoperfusion. RESULTS: The median age at intervention was 4 days (range 1-54 days). Nineteen (63%) patients required PGE1 and 25 (85%) had LV dysfunction. All procedures were performed with cTEE guidance. The initial 15 patients were performed in the cath lab whereas the subsequent 15 patients were performed at the bedside without fluoroscopy. The peak systolic gradient decreased from 70 to 24 mm Hg (P<0.001). Four (13%) early deaths were secondary to associated cardiac anomalies although one patient developed severe aortic valve insufficiency (AI) immediately post intervention. At discharge, two patients (8%) had ≥moderate AI. At a mean follow-up of 9 years (range: 2.2-20 years), there were 15 additional aortic valve interventions. Freedom from aortic valve reintervention at 10 years was 55% and actuarial survival rate at 10 and 15 years was 82%. CONCLUSION: Bedsides TCBV with cTEE guidance is effective palliation for neonates and small infants with critical AS and allows for continuous hemodynamic assessment without the use of ionizing radiation. Our early and late results appear comparable to surgical valvotomy.