Letter to the Editor

Anterograde TransumbilicalVenous Balloon AorticValvuloplasty

TO THE EDITOR

I read with interest “Catheter Intervention for CriticalAortic Stenosis in the Neonate” by Pass and Hellenbrand[1]. While the review is well written, the anterogradetransumbilical venous approach for neonatal balloon aor-tic valvuloplasty [2] was not mentioned and reader maybe interested in such an alternative method.

Transfemoral venous anterograde balloon aortic valvulo-plasty was initially described by Hausdorf et al. [3] andO’Laughlin et al. [4] and subsequently adopted by others[5,6]. Detailed comparison of retrograde and anterogradetechniques by Magee et al. [5] revealed similar results interms of feasibility and effectiveness in producing relief ofobstruction. However, the retrograde method was associ-ated with higher mortality, more severe aortic regurgitation,and higher incidence of arterial complications than thoseseen with the anterograde technique [5]. We have extendedthis technique [2] by performing the anterograde balloonaortic valvuloplasty via the umbilical vein. While it was ourpractice to perform balloon aortic valvuloplasty in the ne-onate via the umbilical arterial route [7], in this particularinfant [2] we were unable to position the balloon angio-plasty catheter across the stenotic aortic valve and thereforeattempted transumbilical venous route and performed bal-loon aortic valvuloplasty successfully. Since that time, wehave used transumbilical venous approach as a procedure ofchoice in the catheter management of critical aortic stenosisin the neonate. Subsequent to the previous report [2], weattempted this technique in five neonates; in four (80%), theprocedure was successful with excellent relief of obstruc-tion and without any complications. The single (20%) fail-ure is in an infant with a very small left ventricle and aguidewire could not be manipulated across the aortic valve.

The technique is described in detail in our previouspublication [2]. However, we have not found the need foruse of the snare in the last four infants. Also, we now useregular 0.021� guidewires (Cook, Bloomington, IN) andTyshak-II catheters (Braun, Bethlehem, PA) instead of

extra-stiff Amplatz wires (Cook) and ultrathin balloonangioplasty catheters (Meditech, Nautick, MA). Lessprobability for development of ventricular arrhythmiabecause of less stiffer wires and easy tracking of theTyshak-II catheters made this procedure less taxing thanthat observed during our initial experience [2].

In addition to the advantages of the anterograde tech-nique previously demonstrated [5], short procedure timeand avoidance of use of even the femoral vein are addi-tional benefits of the transumbilical venous anterogradetechnique. Therefore, we advocate and recommend useof the transumbilical venous anterograde approach asinitial route of choice in the transcatheter management ofneonatal critical aortic stenosis.

In summary, the article by Pass and Hellenbrand [1],while an excellent review of the topic, failed to mentiontransumbilical venous anterograde approach. I believethis approach has great potential and has obvious advan-tages compared to conventional retrograde (via femoraland umbilical arteries) and transfemoral venous antero-grade techniques in the transcatheter management ofcritical aortic stenosis in the neonate.

P. Syamasundar Rao, MDSaint Louis University School of MedicineCardinal Glennon Children’s HospitalSt. Louis, Missouri

REFERENCES

1. Pass RH, Hellenbrand WE. Catheter intervention for critical aorticstenosis in the neonate. Cathet Cardiovasc Intervent 2002;55:88–92.

2. Rao PS, Jureidini SB. Transumbilical venous, anterograde, snare-assisted balloon aortic valvuloplasty in a neonate with critical aorticstenosis. Cathet Cardiovasc Intervent 1998;45:144–148.

3. Hausdorf G, Schneider M, Schrimer KR, Schultze-Neick I, LangePE. Anterograde balloon valvuloplasty of aortic stenosis in chil-dren. Am J Cardiol 1993;71:460–462.

4. O’Laughlin MP, Slack MN, Grifka R, Mullins CE. Prograde doubleballoon dilatation of congenital aortic valve stenosis: a case report.Cathet Cardiovasc Diagn 1993;28:134–136.

5. Magee AG, Nykanen D, McCrindle BW, Wax D, Freedom RM,Benson LN. Balloon dilatation of severe aortic stenosis in theneonate: comparison of anterograde and retrograde catheter ap-proaches. J Am Coll Cardiol 1997;30:1061–1066.

6. Egito ES, Moore P, O’Sullivan J, Colan S, Perry SB, Lock JE,Keane JF. Transvascular balloon dilatation for neonatal criticalaortic stenosis: early and midterm results. J Am Coll Cardiol1997;29:442–447.

7. Rao PS. Balloon aortic valvuloplasty for aortic stenosis. In: Rao PS,editor. Transcatheter therapy in pediatric cardiology. New York:Wiley-Liss; 1993. p 105–127.

DOI 10.1002/ccd.10218Published online in Wiley InterScience (www.interscience.wiley.com).

Catheterization and Cardiovascular Interventions 56:439 (2002)

Published 2002 Wiley-Liss, Inc.