Pediatric Valvar Aortic Stenosis Medication
- Author: Howard S Weber, MD, FSCAI; Chief Editor: Steven R Neish, MD, SM more...
Treatment with prostaglandin E1 is necessary for neonates with critical aortic stenosis and low cardiac output. This agent establishes patency of the ductus arteriosus and can restore adequate systemic blood flow and the perfusion of vital organs.
Prostaglandin E1 is used for the treatment of ductal-dependent, cyanotic congenital heart disease caused by decreased pulmonary blood flow. Patients with critical aortic stenosis and low cardiac output require resuscitation with prostaglandin E1. Establishing the patency of the ductus arteriosus can restore systemic blood flow and the perfusion of vital organs.
Alprostadil is a first-line palliative therapy to temporarily maintain patency of the ductus arteriosus before surgery. It produces vasodilation and increases cardiac output. Each 1 mL ampule contains 500 mcg/mL.
This drug is effective in relaxing the smooth muscle of the ductus arteriosus. It is beneficial in infants with congenital defects that restrict pulmonary or systemic blood flow and who depend on a patent ductus arteriosus to get adequate oxygenation and lower body perfusion.
Inotropic drugs, such as dopamine, dobutamine, and epinephrine, are indicated in cases of reduced cardiac output in aortic stenosis.
Dopamine is a naturally occurring endogenous catecholamine that stimulates beta1 and alpha1 adrenergic and dopaminergic receptors in a dose-dependent fashion; it stimulates the release of norepinephrine.
Dobutamine produces vasodilation and increases the inotropic state. At higher dosages, it may cause an increased heart rate, exacerbating myocardial ischemia.
Epinephrine has alpha-agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Beta2-agonist effects include bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.
Loop diuretics such as intravenous furosemide may be used carefully in pediatric patients with reduced cardiac function and/or significant mitral valve insufficiency when associated with severe aortic valve stenosis. The benefit is to reduce pulmonary venous congestion secondary to elevated left atrial pressures.
Furosemide is a loop diuretic that increases excretion of water by interfering with the chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule. It increases renal blood flow without increasing the filtration rate. It increases potassium, sodium, calcium, and magnesium excretion.
Yetman AT, Rosenberg HC, Joubert GI. Progression of asymptomatic aortic stenosis identified in the neonatal period. Am J Cardiol. 1995 Mar 15. 75(8):636-7. [Medline].
Ten Harkel AD, Berkhout M, Hop WC, Witsenburg M, Helbing WA. Congenital valvular aortic stenosis: limited progression during childhood. Arch Dis Child. 2009 Jul. 94(7):531-5. [Medline].
Maron BJ, Zipes DP. Introduction: eligibility recommendations for competitive athletes with cardiovascular abnormalities-general considerations. J Am Coll Cardiol. 2005 Apr 19. 45(8):1318-21. [Medline].
Egito ES, Moore P, O'Sullivan J, Colan S, Perry SB, Lock JE, et al. Transvascular balloon dilation for neonatal critical aortic stenosis: early and midterm results. J Am Coll Cardiol. 1997 Feb. 29(2):442-7. [Medline].
McElhinney DB, Lacro RV, Gauvreau K, O'Brien CM, Yaroglu Kazanci S, Vogel M, et al. Dilation of the ascending aorta after balloon valvuloplasty for aortic stenosis during infancy and childhood. Am J Cardiol. 2012 Sep 1. 110(5):702-8. [Medline].
Magee AG, Nykanen D, McCrindle BW, Wax D, Freedom RM, Benson LN. Balloon dilation of severe aortic stenosis in the neonate: comparison of anterograde and retrograde catheter approaches. J Am Coll Cardiol. 1997 Oct. 30(4):1061-6. [Medline].
Alekyan BG, Petrosyan YS, Coulson JD, Danilov YY, Vinokurov AV. Right subscapular artery catheterization for balloon valvuloplasty of critical aortic stenosis in infants. Am J Cardiol. 1995 Nov 15. 76(14):1049-52. [Medline].
Fischer DR, Ettedgui JA, Park SC, Siewers RD, del Nido PJ. Carotid artery approach for balloon dilation of aortic valve stenosis in the neonate: a preliminary report. J Am Coll Cardiol. 1990 Jun. 15(7):1633-6. [Medline].
Weber HS, Mart CR, Myers JL. Transcarotid balloon valvuloplasty for critical aortic valve stenosis at the bedside via continuous transesophageal echocardiographic guidance. Catheter Cardiovasc Interv. 2000 Jul. 50(3):326-9. [Medline].
Turley K, Bove EL, Amato JJ, Iannettoni M, Yeh J, Cotroneo JV, et al. Neonatal aortic stenosis. J Thorac Cardiovasc Surg. 1990 Apr. 99(4):679-83; discussion 683-4. [Medline].
McCrindle BW, Blackstone EH, Williams WG, Sittiwangkul R, Spray TL, Azakie A, et al. Are outcomes of surgical versus transcatheter balloon valvotomy equivalent in neonatal critical aortic stenosis?. Circulation. 2001 Sep 18. 104(12 Suppl 1):I152-8. [Medline].
Siddiqui J, Brizard CP, Galati JC, Iyengar AJ, Hutchinson D, Konstantinov IE. Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization. J Am Coll Cardiol. 2013 Dec 3. 62(22):2134-40. [Medline].