Reply to the letter by Dr. Rao: Role of palliative balloon pulmonary valvuloplasty in babies with tetralogy of Fallot
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LETTER
Reply to the letter by Dr. Rao: Role of palliative balloon pulmonary valvuloplasty in babies with tetralogy of Fallot Jun Muneuchi1 Received: 7 May 2020 / Accepted: 15 May 2020 © Springer Japan KK, part of Springer Nature 2020
Dear Dr. Rao We thank Dr. Rao for his interest in our recent manuscript regarding early palliative balloon valvuloplasty (BPV) in 31 babies with tetralogy of Fallot (TOF) [1]. We believe that early BPV can prevent early surgical interventions for TOF to some extent. We really respect Dr. Rao and his colleagues as pioneers for BPV in children with cyanotic congenital heart disease, and praise your previous studies which provide fundamental knowledge and technology of BPV. Rao’s reports and textbooks are absolutely worthy to be cited in our article [2–10]. Because of the limited space, we mainly cited articles published in the recent era. Dr. Rao pointed out our indications for early palliative BPV, because a relief of the pulmonary valvular stenosis may produce a marked increase in the pulmonary blood flow, elevation of pulmonary arterial pressure and pulmonary vascular resistance. As described in our article, our cohort consisted of TOF infants with small pulmonary valve annular diameter, or Z score less than − 2.00, who were not expected to develop excessive pulmonary blood flow resulting in pulmonary hypertension. In fact, there was no subject who developed pulmonary hypertension in our study. We fairly agree that the relief of one obstruction, i.e. pulmonary valvular stenosis, decrease the total resistance to pulmonary flow in babies with TOF, which can contribute to avoid the need for aortopulmonary shunts or early corrective surgery. However, we consider that it still remains
controversial whether the pulmonary valvular annuls can adequately grow up after BVP. Our study also suggested that early “prophylactic” BPV within 30 days of age could prevent early surgical intervention in acyanotic TOF patients who were expected to develop cyanosis during infancy. We herein show two right ventriculograms in a patient with TOF (Fig. 1). A left panel shows a right ventriculogram in the lateral view at the age of 28 days, while a right panel shows that at the age of 11 months. Infundibular obstruction developed postnatally, which might evoke cyanotic spell. We assume that early “prophylactic” BPV may prevent such a development of infundibular obstruction in neonates with TOF. Therefore, aggressive intervention should be warranted among them, nevertheless the presence of cyanosis. Dr. Rao’s criteria for BPV seems to be reasonable. However, as a recent report suggests that early primary corrective repair for neonates with TOF increase the rate of surgical reoperation [11], we consider that corrective repair should be carried out during midterm to late infancy. We offer an extension of the criteria: neonate with multiple obstructions in series are present and the relief of pulmonary valvular obstruction contribute to prevent the development of infundibular obstruction thereafter.
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