Andersons pediatric cardiology 1120

FIG 42.26 The waveform in severe pulmonary stenosis is taller and more square, with a delayed point of maximal pressure close to the end of systole Therapeutic Options Surgical Therapy Although pulmonary stenosis has been recognized as a pathologic entity since 1761, management of this disease has been possible only in the last 60 years or so The first reported attempt, which was unsuccessful, was published in 1913.47 The first successful pulmonary valvotomy was performed in London by Holmes Sellors48 in December 1947 The patient had tetralogy of Fallot, and although the intention had been to perform a Blalock-Taussig shunt, a stenosed pulmonary valve was palpable A transinfundibular approach was made to incise the stenosed pulmonary valve in two directions, resulting in the immediate relief of cyanosis Perversely, this operation was reported 2 weeks after the report by Brock of his own three successful operations, performed later in 1948.49 Brock continued along the theme of direct relief of pulmonary stenosis and tetralogy of Fallot and designed a complementary series of instruments comprising a valvotome to cut the stenosed valve, an expanding dilator to split the valve, and an infundibular punch to resect the thickened infundibular muscle (Figs 42.27 and 42.28) He reported the successful use of these instruments in 195050 and described a miraculous transformation in his subjects The Brock procedure for tetralogy of Fallot was immediately adopted for patients with pulmonary stenosis and an intact interventricular septum The introduction of inflow occlusion,51,52 inflow occlusion and hypothermia,53 and subsequently extracorporeal circulation54 in the mid-1950s changed the surgical approach to a more precise operation involving splitting of the fused zones of apposition of the leaflets or valvectomy with or without a transannular patch FIG 42.27 Instruments invented for the first series of closed pulmonary valvotomies (A) Curved probe, (B) curved bougie, (C) valvotome (From Brock RC Pulmonary valvulotomy for relief of congenital pulmonary stenosis Report of three cases Br Med J 1948;1:1121–1126.) FIG 42.28 Dilating instrument invented for the first series of closed pulmonary valvotomies (From Brock RC Pulmonary valvulotomy for relief of congenital pulmonary stenosis Report of three cases Br Med J 1948;1:1121–1126.) Interventional Catheterization