TRANSCAROTID BALLOON VALVULOPLASTY WITH CONTINUOUS TRANSESOPHAGEAL ECHOCARDIOGRAPHIC GUIDANCE FOR NEONATAL CRITICAL AORTIC-VALVE STENOSIS -AN ALTERNATIVE TO SURGICAL PALLIATION

Neonatal critical aortic valve stenosis is a life-threatening malforma tion if untreated. Before the late 1980s, the preferred treatment was surgical valvotomy; however, operative mortality was high. Early repor ts of transcatheter balloon dilation were encouraging, although femora l artery damage and aortic valve insufficiency were procedural limitat ions. With new balloon catheter technology, transumbilical, transvenou s, and transcarotid approaches have been advocated, although a compari son with recent surgical results has not been performed. We compared a ll neonates who presented to our institution since 1985 with the diagn osis of critical aortic stenosis. Ten patients underwent surgical tran sventricular valvotomy and 13 patients underwent balloon valvuloplasty via a right carotid cutdown with continuous transesophageal echocardi ographic guidance. Prior to intervention, all patients had either left ventricular dysfunction, an aortic valve gradient >100 mmHg, signific ant mitral valve insufficiency, and/or ductal dependent systemic blood flow. All patients had successful relief of aortic valve obstruction with normalization of left ventricular function and successful discont inuation of prostaglandin E-1. Use of continuous transesophageal echoc ardiographic guidance resulted in fluoroscopic exposure of only 12 +/- 8 minutes. At the latest follow-up, a similar proportion of patients has required additional aortic valve procedures (38% vs 25%) and overa ll mortality (20% vs 15%) is similar. In the transcarotid group, 9 of 13 patients (69%) have a normal appearing right carotid artery by Dupl ex imaging, and no neurologic events have been reported. Balloon aorti c valvuloplasty via a right transcarotid approach is safe, simplifies crossing the valve, and is effective for the initial palliation of neo natal critical aortic stenosis. The use of transesophageal echocardiog raphic guidance reduces fluoroscopy exposure, enables accurate assessm ent of hemodynamics without catheter manipulation or angiography, and avoids femoral artery injury.