Role of palliative balloon pulmonary valvuloplasty in babies with tetralogy of Fallot
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LETTER
Role of palliative balloon pulmonary valvuloplasty in babies with tetralogy of Fallot P. Syamasundar Rao1 Received: 28 April 2020 / Accepted: 15 May 2020 © Springer Japan KK, part of Springer Nature 2020
Muneuch and colleagues [1] sought to determine whether balloon pulmonary valvuloplasty (BPV) in babies with tetralogy of Fallot (TOF) prevented early surgical correction. The results of BPV in 31 babies at a mean age of 19 days (range 14–33 days) revealed that early palliative BPV avoided early corrective surgery in only half of the babies but, did not prevent the placement of transannular patch. The severity of infundibular obstruction appears to be responsible, at least in part, for lack benefit of BPV. This is a thoughtfully conducted and well-written study. However, there are some issues that are worthy of further discussion. First, the authors referenced papers using BPV published in 1990 and there-afterwards. There are several papers published prior to that date. We were among the first, if not the first to use BPV in babies with cyanotic congenital heart defects (CHDs), including TOF and report the results [2, 3]. When we presented the data at the Pediatric Cardiology International Congress meeting in Vienna, Austria, in February 1987 [2], the chairman of the session, Dr. Michael Tynan, complemented our work and thanked us for introducing a new indication for BPV. Subsequently, we published original papers [4], reviews [5–7], and book chapters [8–10] addressing various aspects related to BPV in cyanotic CHD. None of these were referenced in Muneuch’s paper [1]. Second, the indications for BPV that we have used are cardiac defects which are not amenable to surgical correction due to the age and size of the patient at the time of presentation, but nonetheless require palliation for pulmonary oligemia. We also required the presence of two or more sites of obstruction as a prerequisite when employing BPV [2–4]. The reasoning behind the adoption of this principle is This comment refers to the article available at https://doi. org/10.1007/s00380-019-01468-0.
because if valvar pulmonary stenosis is the sole obstruction, relief of such an obstruction may produce a marked increase in the pulmonary blood flow and the elevation of pulmonary artery pressure and pulmonary vascular resistance. With the relief of one obstruction, the remaining right ventricular outflow obstruction will keep the pulmonary artery pressures normal. Third, in the presence of two obstructions in series, the relief of one obstruction decreases the total resistance to flow into the lungs, with the resultant relief of pulmonary oligemia and improved oxygen saturation. In addition, we avoided the need for aorto-pumonary shunts in most babies, averted the need for early total surgical correction, and demonstrated growth of the pulmonary arteries so that later total surgical correction could be performed safely [3, 4]. In view of the current state of the art, with the feasibility of surgical repair at a younger age and some controversy
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