Andersons pediatric cardiology 1131

FIG 42.39 Kaplan-Meier curves illustrating freedom from reintervention in isolated pulmonary valve stenosis managed by surgery in 54 patients and balloon dilation in 92 patients (From Peterson C, Schilthuis JJ, DodgeKhatami A, et al Comparative long-term results of surgery versus balloon valvuloplasty for pulmonary valve stenosis in infants and children Ann Thorac Surg 2003;76:1078–1082.) What can be said is that balloon valvuloplasty has a slightly higher incidence of reinterventions for residual pulmonary valve stenosis when compared to surgical therapy However, longer-term data are needed to compare the incidence of reinterventions for pulmonary regurgitation between surgical and transcatheter therapy Furthermore, one should consider that potential surgical repair of the pulmonary valve may be feasible in selected patients that have undergone balloon pulmonary valvuloplasty, which is usually not an option after surgical repair using a transannular patch.152 Nevertheless, in most centers, the less invasive, less expensive, and shorter hospital stay currently favor the routine use of balloon dilation over surgery for pulmonary stenosis Recommendations for Long-Term Follow-up Once pulmonary stenosis has been treated, usually by balloon dilation, follow-up is mandatory There is, however, a fairly wide variation as many units will have their own protocols for follow-up, laid down by senior members of the department Whereas some algorithms for follow-up of many congenital cardiac malformations have been published,153 many of those do not take into account the specific need to follow pulmonary regurgitation With the knowledge that some degree of pulmonary regurgitation is virtually universally present after balloon pulmonary valvuloplasty, but the degree not necessarily being immediately apparent, a reasonable approach that had been adopted by our group is to follow patients after transcatheter intervention at 1, 6, 12, and 24 months after the procedure At each follow-up visit, history and physical exam are of course mandatory, complemented by echocardiographic evaluation to assess the degree of pulmonary regurgitation and the degree of residual pulmonary valve stenosis Echocardiography is not needed at the 1month follow-up visit, provided the patient has undergone echocardiographic evaluation at the time of discharge Further follow-up always depends on the presence of clinical symptoms, possible arrhythmias, as well as the residual gradient and degree of pulmonary insufficiency Asymptomatic patients with no more than mild pulmonary insufficiency, a residual gradient of less than 30 mm Hg, and a nondilated right ventricle by echocardiography could be followed at 5yearly intervals, while patients with a residual gradient of 40 mm Hg or greater or clinical symptoms require an individualized approach to follow-up Patients who do not fall into either of these categories should probably be followed on a yearly basis Pediatric patients with mild-moderate or more pulmonary regurgitation can be followed by echocardiography alone initially, provided that there are no concerning right ventricular appearances or progressive dilatation Our group would, however, recommend performing serial interval cardiac MRI and cardiopulmonary exercise testing to assess the effects of pulmonary incompetence on the anatomy, physiology and functional state of the patient, and help to determine whether further interventions will be necessary in any patient with more than just mild pulmonary regurgitation Provided there are no additional concerns relating to the right ventricle, the first MRI can probably be delayed until the patient has matured enough to tolerate the test without the need for anesthesia, usually around 8 to 10 years of age, which would also be a good timing for a cardiovascular exercise test Patients that were older at the time of pulmonary valvuloplasty should ideally undergo cardiovascular MRI (and exercise testing) within 2 years of the procedure The frequency of repeating the MRI subsequently depends on the findings of the initial MRI, the age of the patient, and any progressive changes seen by echocardiography In most patients though it would be considered a good practice to repeat the MRI within 3 years Prophylaxis for Endocarditis Although endocarditis has been described in patients with pulmonary valve stenosis that have undergone balloon pulmonary valvuloplasty,154–156 its occurrence is rare The most recent guidelines for the use of antibiotics to prevent infective endocarditis no longer consider pulmonary valve stenosis to be a condition at high risk for endocarditis, either before or after balloon dilation.157,158 The current guidelines published by the American Heart Association recommend that those with repaired malformations but with residual defects at the site of a prosthetic patch or prosthetic device, which may inhibit endothelialization, are still to be considered to have an indication for prophylaxis Prophylaxis should be recommended, therefore, for patients with prosthetic material at the site of repair―for instance, a transannular patch, and in the presence of residual hemodynamic effects such as pulmonary stenosis or incompetence Recommendations for Exercise Prior to Intervention The recommendations for participation in exercise by patients with pulmonary stenosis is based on analysis of the known features of this disease by a taskforce of experts.159 For these recommendations, the classification of exercise intensity is also important (Fig 42.40).160 ... Patients who do not fall into either of these categories should probably be followed on a yearly basis Pediatric patients with mild-moderate or more pulmonary regurgitation can be followed by echocardiography alone initially, provided that