Surgical approach to critical pulmonary valve stenosis in infants less than six months of age

During the past 7 1/2 years, 36 infants (less than or equal to 6 months of age) underwent surgical relief of critical pulmonary valve stenosis. The results of closed and open (cardiopulmonary bypass, CPB) procedures were compared. Closed procedures included Brock valvotomy (two patients) and normothermic inflow stasis with transpulmonary valvectomy (10 patients). Twenty-two patients had open procedures with valvectomy alone (five patients) and right ventricular outflow tract (RVOT) reconstruction (17 patients). Two additional patients had staged operations (shunt followed by open procedure at 3 and 5 months postoperatively). Patients who had the closed procedures, as compared with CPB, were significantly younger (10 versus 61 days, p less than 0.01) and more critically ill with congestive heart failure and acidosis. In addition, the mean peak systolic right ventricular-left ventricular pressure ratios (RVP/LVP) were higher (1.6 versus 1.4, p less than 0.02) in the closed group. There were no deaths in the closed group in contrast to six deaths among those having RVOT reconstruction (0/12 versus 6/17 or 35%, p less than 0.04). Critical obstruction of the pulmonary valve, tricuspid valve regurgitation, and hypoplastia of the right ventricle occurred more frequently in the closed group. All operative deaths resulted from right heart failure. There were no late deaths in the entire series. Three patients in the closed group (mean follow-up 2.8 years) required operations for recurrent pulmonary valve stenosis approximately 2 years postoperatively, and none in the open group (mean follow-up 2.0 years). In conclusion, despite current advances in infant CPB and care, the results from our experience suggests that closed procedures, especially inflow stasis and pulmonary valvectomy, are superior to the use of CPB and RVOT reconstruction, even in the presence of pulmonary valve dysplasia.