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|Year : 2010
: 13 | Issue : 3 | Page
|Controlled transient respiratory arrest along with rapid right ventricular pacing for improving balloon stability during balloon valvuloplasty in pediatric patients with congenital aortic stenosis - A retrospective case series analysis
Sampa Dutta Gupta1, Soumi Das1, Tapas Ghose2, Achyut Sarkar3, Anupam Goswami1, Sudeshna Kundu1
1 Department of Anaesthesiology, Institute of Postgraduate Medical Education and Research/SSKM Hospital, Kolkata, India
2 School of Digestive and Liver Disease, Institute of Postgraduate Medical Education and Research/SSKM Hospital, Kolkata, India
3 Department of Cardiology, Institute of Postgraduate Medical Education and Research/SSKM Hospital, Kolkata, India
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|Date of Submission||17-Dec-2009|
|Date of Acceptance||10-Jul-2010|
|Date of Web Publication||6-Sep-2010|
| Abstract|| |
Rapid right ventricular pacing is safe, effective, and established method to provide balloon stability during balloon aortic valvuloplasty (BAV). Controlled transient respiratory arrest at this point of time may further reduce left ventricular stroke volume, providing an additional benefit to maintain balloon stability. Two groups were studied. Among the 10 patients, five had rapid pacing alone (Group A), while the other five were provided with cessation of positive pressure breathing as well (Group B). The outcomes of BAV in the two groups of patients were studied. One patient in Group A had failed balloon dilatation even after the fourth attempt, while in Group B there were no failures. The peak systolic gradient reduction was higher in Group B (70.05% in comparison to 52.16% of group A). In Group A, five subjects developed aortic regurgitation (grade 2 in four and grade 3 in one, while no grade 3 aortic regurgitation developed in any patient in Group B). Controlled transient respiratory arrest along with rapid ventricular pacing may be effective in maintaining balloon stability and improve the outcome of BAV.
Keywords: Balloon dilatation, balloon stability, controlled transient respiratory arrest, rapid right ventricular pacing, valvular aortic stenosis
|How to cite this article:|
Gupta SD, Das S, Ghose T, Sarkar A, Goswami A, Kundu S. Controlled transient respiratory arrest along with rapid right ventricular pacing for improving balloon stability during balloon valvuloplasty in pediatric patients with congenital aortic stenosis - A retrospective case series analysis. Ann Card Anaesth 2010;13:236-40
|How to cite this URL:|
Gupta SD, Das S, Ghose T, Sarkar A, Goswami A, Kundu S. Controlled transient respiratory arrest along with rapid right ventricular pacing for improving balloon stability during balloon valvuloplasty in pediatric patients with congenital aortic stenosis - A retrospective case series analysis. Ann Card Anaesth [serial online] 2010 [cited 2020 Jan 25];13:236-40. Available from: http://www.annals.in/text.asp?2010/13/3/236/69076
| Introduction|| |
Hemodynamically significant congenital valvular aortic stenosis in children may require intervention like balloon aortic valvuloplasty (BAV)  or surgical valvotomy. In this era, balloon dilatation has almost completely replaced primary surgical valvotomy in children;  that too with good immediate and short term results.  BAV is relatively safe and effective and can be performed, maintaining a normal circulation without the use of a cardiopulmonary bypass (CPB). It involves the placement of an angioplasty balloon at the level of the aortic valve followed by balloon dilatation to relieve the stenosis. Balloon stability appears to be an important issue during this procedure,  but cardiac contraction and pulsatile-blood flow may cause movement of the inflated balloon interfering with its proper positioning, thus leading to failure, suboptimal results from the procedure, damage of great vessels or intraluminal structures,  and even death. 
Balloon movement may be prevented by various maneuvers such as using extra-stiff guide wires and double balloons,  or left ventricular-assist device,  adenosine, , and esmolol. They are not without limitations and complications.
Rapid ventricular pacing has been found to be effective in maintaining balloon stability. It reduces stroke volume and cardiac output leading to decreased blood pressure and decreased blood pressure amplitude without causing cardiac standstill. 
Frequency-dependent effect of physical inertia of the interventional system contributes to device stability. 
Studies showed that despite rapid pacing, balloon movement during the procedure still occurred. ,
During intermittent positive pressure ventilation (IPPV), movement of the lungs contributes to left atrial filling, thereby affecting left ventricular stroke output. Ceasing positive pressure breathing may help stabilizing the balloon by preventing fluctuation in the cardiac chamber pressures.
| Material and Methods|| |
Ten consecutive patients with congenital valvular aortic stenosis aged between 1 and 13 years belonging to New York Heart Association (NYHA) class II and III, underwent balloon aortic valvuloplasty in the tertiary referral centre between June 2006 and August 2009.
Among the patients studied, five had rapid pacing alone (Group A) while the other five were provided with cessation of positive pressure breathing (Group B) as well.
None of the children had any other associated cardiac lesion, decompensated heart failure, or failure to thrive.
Informed consent from the parents for the intervention was obtained. All children received premedication and infective endocarditis prophylaxis. Standard monitors were attached. Following intravenous access and preoxygenation, patients were induced using intravenous administration of midazolam 0.1-0.2 mg/kg.b.w., fentanyl 1-1.5 ΅g/kg.b.w., and inhalation of halothane in O 2 . Trachea was intubated using injection vecuronium 0.08-0.10 mg/kg i.v. Anesthesia was maintained with 0.5-0.75 % halothane in O 2 with further doses of vecuronium if required. Femoral arterial and venous cannulation were carried out by the cardiologist, four French bipolar pacing catheter was introduced up to the right ventricle and the ventricular mode was chosen
The ventricle was paced with such a rate, so as to produce a 50% decrease in prepacing aortic root blood pressure, and the balloon dilatation system was positioned at the level of the aortic valve. The balloon was inflated till the waist disappeared and then kept inflated for 10 s and deflated thereafter. Pressure readings were taken from the left ventricular outflow tract and aortic root. SpO 2 was monitored in all patients throughout the procedure, the group B patients had cessation of IPPV in addition during BAV.
A single cardiologist performed all the procedures. The peak systolic gradient, grading of aortic regurgitation (AR) before and after the dilatation, difference between aortic and internal jugular venous oxygen tension in mmHg before and after the dilatation (in Group B patients)and number of attempts required for successful dilatation were recorded.
Difference between aortic and internal jugular venous oxygen tension in mmHg was observed in patients in Group B to see whether there were any deleterious effect of the combined technique of rapid pacing and controlled respiratory arrest over that of rapid right ventricular pacing technique alone.
Success of the procedure was determined by successful balloon placement, reduction in peak systolic gradient across aortic valve by ≥40% and AR < grade 3.  [Table 1]
|Table 1: Aortic regurgitation graded angiographically using a scale of-4|
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The initial balloon size chosen was 80%-100% of angiographically measured aortic annulus  in each group. At the end of the procedure, the neuromuscular block was reversed and the patients were transferred to pediatric ICCU for monitoring.
| Results|| |
Ten children in equal numbers were compared, demographic characteristics [Table 2] of both the groups were analyzed.
Median age, sex distribution, and median body weight [Table 3] were comparable between groups (P > 0.05)[Table 3].
The success rate vis-ΰ-vis the number of attempts is also presented in [Table 3]. In Group A, one patient had failed dilatation even after the fourth attempt, while in Group B there were no failures and in only one subject,v multiple attempts were required [Table 4].
The peak systolic gradient reductions [Table 3] in group A and B were 52.16% and 70.05%, respectively (P = 0.251). In Group A, four subjects developed grade 2 AR and one developed grade 3 AR. No grade 3 AR developed in any patient of group B [Table 3]. This difference was not statistically significant (P > 0.05).
No marked changes in arteriovenous difference in oxygen tension was seen before or after BAV in any of the patients in Group B [Table 4].
Time taken from the placement of balloon to its deflation and establishment of ventilation did not exceed 16 s in any of the patients. No sustained arrhythmias developed in any of the patients after cessation of ventricular stimulation. No patient developed any neurological symptom or sign at the time or after the procedure. SpO 2 was maintained at 100% in all the patients throughout the procedure. There was no significant difference in pre- and post-procedural blood gas analysis in Group B patients [Table 4].
| Discussion|| |
Rapid pacing may significantly reduce left ventricular ejection and prevent balloon dislodgement during BAV. Withholding ventilation further reduces stroke volume by reducing the inflow of blood into the left heart from the lungs. Transient cessation to prevent left ventricular filling is an established concept in cardiac anesthesia and is used in closed mitral valvotomy without a cardiopulmonary bypass. It prevents over distension of the left ventricle associated with reduction of stroke volume without any known harmful effect.
The combination of pacing and controlled transient respiratory arrest during balloon inflation does not increase further the duration of reduced cardiac output over and above that produced by balloon inflation alone. Moreover, cessation of ventilation provides a field of work with less movement for proper placement of balloon to provide balloon stability during dilatation.
In the study of Daehnert et al.,  rapid right ventricular pacing was performed in 14 patients with a success rate on first attempt of 78.57%. In our series, the success rate on first attempt in Group A was 0%, whereas in Group B it was 80%, and the difference was statistically significant [Table 3].
BAV is replacing surgical valvotomy of the stenosed aortic valve. However, success of the procedure depends on a stable balloon position during dilatation, which may also lead to less development of AR. In BAV, AR is induced or worsened in 35%-60% of patients. 
In this study outcome of BAV in patients who were rendered apnoeic by cessation of positive pressure ventilation and whose right ventricle was rapidly paced (Group B) was studied, clinically significant AR (≥grade 3) developed in one of the (20%) Group A patients. Although, post-procedural AR developed in Group B patients, these were clinically insignificant (< grade 3).
There was a failure to stabilize the balloon in the sixth child on three such attempts when a decision was taken on the spot to initiate dilatation on fourth attempt by withholding IPPV along with rapid right ventricular pacing, and the procedure was successful. This idea for using the combined technique of rapid right ventricular pacing along with controlled transient respiratory arrest was utilized in the next five patients for BAV (Group B).
Hence, controlled transient respiratory arrest along with rapid ventricular pacing was presumed to be effective in maintaining balloon stability during balloon placement for successful dilatation of congenital valvular aortic stenosis.
Weaknesses of this study were that our patients were not followed up for the development of AR or restenosis, which may develop at a later period. Group B patients had less severe AS to start with than the patients in Group A, thereby expecting them to do better regardless of the technique, from this retrospective analysis The total number of patients is small, that is yet another weakness.
| Acknowledgments|| |
We thank Dr. Avijit Hazra, MD, Associate Professor, Department of Pharmacology, Institute of Post Graduate Medical Education and Research for statistical analysis of this research work, without his help and cooperation this study would not have been possible.
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Sampa Dutta Gupta
42 Lake Place, Kolkata - 700 029
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]
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