Catheterization and Cardiovascular Interventions 84:192–196 (2014)
PEDIATRIC AND CONGENITAL HEART DISEASE Original Studies Correlation of Echocardiographic and Angiographic Measurements of the Pulmonary Valve Annulus in Pulmonary Stenosis H. Chubb,1,2 MBBS, MRCP, MRCPCH, A. Ward,1 A. Worme,1 S.A. Qureshi,1,2 FRCP, E. Rosenthal,1,2 MD, FRCP, FRCPCH, and T. Krasemann,1,2* Dr. med., FRCP Objectives: The pulmonary valve (PV) annulus is routinely measured angiographically in PV stenosis prior to balloon dilation. We sought to establish whether this radiation exposure is justified, or whether echocardiographic measurements prior to the procedure are sufficient to guide balloon selection. Background: Previous studies have found a strong correlation between echocardiographic and angiographic measurements of the PV annulus. However, error of measurement and its implication for procedural practice has not been explored. Methods: A total of 90 procedures in 84 patients were analyzed, at a median age 7.6 months (range 1 day to 14.2 years). The contemporaneous echocardiographic and angiographic measurements were recorded, and the original echocardiograms were re-measured in the 72 available cases by two independent reviewers. Results: There was a good correlation between the two measurement methods (R2 5 0.87). However, the echocardiographic PV measurements were smaller on average, with a significant variation in that discrepancy (mean ratio 0.941 (60.16)). There was no significant reduction in error if extreme measurements (PV annulus z-score 3) demonstrates no significant improvement in echocardiographic accuracy. This study is retrospective, and is limited by the quality of the contemporaneous echocardiography. However, the use of contemporaneous measurements provides a realistic representation of the accuracy of echocardiographic measurements. There is a need for prospective and standardized echocardiographic evaluation of the PV in order to evaluate whether the error can be improved, and it may be found that echocardiographic assessment alone is sufficient in selected cases with good imaging quality and relatively normal valve dimensions. CONCLUSION
Based on these findings, BPV without angiographic PV measurement cannot be advocated. ACKNOWLEDGMENT
Authors thank Thomas Witter for his help with data collection. REFERENCES 1. Wren C. The epidemiology of cardiovascular malformations. In: Moller JH, Hoffman JIE, editors. Pediatric Cardiovascular Medicine. Wiley-Blackwell; Hoboken: 2012, pp 268–275.
2. Rao PS. Indications for balloon pulmonary valvuloplasty. Am Heart J 1988;116(6 Part 1):1661–1662. 3. Kan JS, White RI Jr, Mitchell SE, Gardner TJ. Percutaneous balloon valvuloplasty: A new method for treating congenital pulmonary-valve stenosis. N Engl J Med 1982;307:540–542. 4. Rao PS. Percutaneous balloon pulmonary valvuloplasty: State of the art. Catheter Cardiovasc Interv 2007;69:747–763. 5. Radtke W, Keane JF, Fellows KE, Lang P, Lock JE. Percutaneous balloon valvotomy of congenital pulmonary stenosis using oversized balloons. J Am Coll Cardiol 1986;8:909–915. 6. Hamidi-Manesh L, Tibby SM, Herman R, Rosenthal E, Qureshi SA, Krasemann T. Influence of balloon size on aortic regurgitation in neonates undergoing balloon aortic valvuloplasty—A retrospective study over an 11-year period. J Interv Cardiol 2013; 26:200–207. 7. Dev V, Radhakrishnan S, Rajani M, Das G, Sundar AS, Sharma S, et al. Echocardiographic assessment of the size of aortic and pulmonary valve annulus before balloon valvoplasty. Indian Heart J 1990;42:195–197. 8. Lopez L, Colan SD, Frommelt PC, Ensing,GJ, Kendall K, Younoszai AK, Lai WW, Geva T. Recommendations for quantification methods during the performance of a pediatric echocardiogram: A report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 2010;23:465–495. 9. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res 1999;8:135. 10. Pettersen MD, Du W, Skeens ME, Humes RA. Regression equations for calculation of z scores of cardiac structures in a large cohort of healthy infants, children, and adolescents: An echocardiographic study. J Am Soc Echocardiogr 2008;21: 922–934. 11. Smith BG, Tibby SM, Qureshi SA, Rosenthal E, Krasemann T. Quantification of temporal, procedural, and hardware-related factors influencing radiation exposure during pediatric cardiac catheterization. Catheter Cardiovasc Interv 2012;80:931–936. 12. Kim DH, Park S-J, Jung JW, Kim NK, Choi JY. The Comparison between the echocardiographic data to the cardiac catheterization data on the diagnosis, treatment, and follow-up in patients diagnosed as pulmonary valve stenosis. J Cardiovasc Ultrasound 2013;21:18–22.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
PEDIATRIC AND CONGENITAL HEART DISEASE Original Studies Correlation of Echocardiographic and Angiographic Measurements of the Pulmonary Valve Annulus in Pulmonary Stenosis H. Chubb,1,2 MBBS, MRCP, MRCPCH, A. Ward,1 A. Worme,1 S.A. Qureshi,1,2 FRCP, E. Rosenthal,1,2 MD, FRCP, FRCPCH, and T. Krasemann,1,2* Dr. med., FRCP Objectives: The pulmonary valve (PV) annulus is routinely measured angiographically in PV stenosis prior to balloon dilation. We sought to establish whether this radiation exposure is justified, or whether echocardiographic measurements prior to the procedure are sufficient to guide balloon selection. Background: Previous studies have found a strong correlation between echocardiographic and angiographic measurements of the PV annulus. However, error of measurement and its implication for procedural practice has not been explored. Methods: A total of 90 procedures in 84 patients were analyzed, at a median age 7.6 months (range 1 day to 14.2 years). The contemporaneous echocardiographic and angiographic measurements were recorded, and the original echocardiograms were re-measured in the 72 available cases by two independent reviewers. Results: There was a good correlation between the two measurement methods (R2 5 0.87). However, the echocardiographic PV measurements were smaller on average, with a significant variation in that discrepancy (mean ratio 0.941 (60.16)). There was no significant reduction in error if extreme measurements (PV annulus z-score 3) demonstrates no significant improvement in echocardiographic accuracy. This study is retrospective, and is limited by the quality of the contemporaneous echocardiography. However, the use of contemporaneous measurements provides a realistic representation of the accuracy of echocardiographic measurements. There is a need for prospective and standardized echocardiographic evaluation of the PV in order to evaluate whether the error can be improved, and it may be found that echocardiographic assessment alone is sufficient in selected cases with good imaging quality and relatively normal valve dimensions. CONCLUSION
Based on these findings, BPV without angiographic PV measurement cannot be advocated. ACKNOWLEDGMENT
Authors thank Thomas Witter for his help with data collection. REFERENCES 1. Wren C. The epidemiology of cardiovascular malformations. In: Moller JH, Hoffman JIE, editors. Pediatric Cardiovascular Medicine. Wiley-Blackwell; Hoboken: 2012, pp 268–275.
2. Rao PS. Indications for balloon pulmonary valvuloplasty. Am Heart J 1988;116(6 Part 1):1661–1662. 3. Kan JS, White RI Jr, Mitchell SE, Gardner TJ. Percutaneous balloon valvuloplasty: A new method for treating congenital pulmonary-valve stenosis. N Engl J Med 1982;307:540–542. 4. Rao PS. Percutaneous balloon pulmonary valvuloplasty: State of the art. Catheter Cardiovasc Interv 2007;69:747–763. 5. Radtke W, Keane JF, Fellows KE, Lang P, Lock JE. Percutaneous balloon valvotomy of congenital pulmonary stenosis using oversized balloons. J Am Coll Cardiol 1986;8:909–915. 6. Hamidi-Manesh L, Tibby SM, Herman R, Rosenthal E, Qureshi SA, Krasemann T. Influence of balloon size on aortic regurgitation in neonates undergoing balloon aortic valvuloplasty—A retrospective study over an 11-year period. J Interv Cardiol 2013; 26:200–207. 7. Dev V, Radhakrishnan S, Rajani M, Das G, Sundar AS, Sharma S, et al. Echocardiographic assessment of the size of aortic and pulmonary valve annulus before balloon valvoplasty. Indian Heart J 1990;42:195–197. 8. Lopez L, Colan SD, Frommelt PC, Ensing,GJ, Kendall K, Younoszai AK, Lai WW, Geva T. Recommendations for quantification methods during the performance of a pediatric echocardiogram: A report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 2010;23:465–495. 9. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res 1999;8:135. 10. Pettersen MD, Du W, Skeens ME, Humes RA. Regression equations for calculation of z scores of cardiac structures in a large cohort of healthy infants, children, and adolescents: An echocardiographic study. J Am Soc Echocardiogr 2008;21: 922–934. 11. Smith BG, Tibby SM, Qureshi SA, Rosenthal E, Krasemann T. Quantification of temporal, procedural, and hardware-related factors influencing radiation exposure during pediatric cardiac catheterization. Catheter Cardiovasc Interv 2012;80:931–936. 12. Kim DH, Park S-J, Jung JW, Kim NK, Choi JY. The Comparison between the echocardiographic data to the cardiac catheterization data on the diagnosis, treatment, and follow-up in patients diagnosed as pulmonary valve stenosis. J Cardiovasc Ultrasound 2013;21:18–22.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
