Pulmonary valvotomy with echocardiographic guidance in neonates with pulmonary atresia and intact ventricular septum.

BACKGROUND: Percutaneous transcatheter valvotomy of the atretic pulmonary valve (PV) carries a risk of perforation of the right ventricle (RV) and requires standby of the cardiac surgical team for potential emergent cardiac management. The objective of this study was to introduce a successful and safe transcatheter wire perforation of the atretic PV using echocardiographic guidance in neonates with pulmonary atresia and an intact ventricular septum.

METHODS: In addition to fluoroscopic guidance, echocardiography was used throughout the procedure. For positioning the Judkins right (JR) catheter at the point of 'tenting' indicating center of the PV, the morphology and position of the PV were confirmed using a left-tilted parasternal long axis view and a slight counterclockwise-rotated parasternal short axis view. After the JR catheter was positioned at the point of tenting of the atretic PV, the stiff end of the 0.014 mm PTCA wire was advanced through the PV toward the main pulmonary artery using echocardiographic guidance. During the first portion of the procedure, accurate perforation using echocardiographic imaging was confirmed. After then, pulmonary valvuloplasty with increasingly larger balloons, beginning with an initial 2.5 × 20 mm(2) PTCA balloon and finishing with a final 8 × 20 mm(2) PTA balloon was performed.

RESULTS: In all patients, successful valve perforation and balloon valvuloplasty were achieved. There were no significant cardiac complications, including perforation of the RV.

CONCLUSIONS: Pulmonary valvotomy using transthoracic echocardiographic guidance can reduce the risk of perforation of the RV and be more successful compared with that using only fluoroscopic guidance.