Balloon valvuloplasty in 30 dogs with pulmonic stenosis: effect of valve morphology and annular size on initial and 1-year outcome

Case records of 30 dogs in which valvular pulmonic stenosis (PS) was treated by balloon dilation were reviewed retrospectively. Physical examination, thoracic radiographs, 9-lead ECG, echocardiography, and Doppler studies were performed in all dogs. Two-dimensional and Doppler echocardiography were repeated after 24 h and 1 year after treatment. Dogs were divided into 2 groups based on their valvular anatomy on echocardiography and aortic:pulmonary ratio: 18 had type A PS with normal annulus diameter and aortic:pulmonary ratio < or = 1.2, and 12 had type B PS with pulmonary annulus hypoplasia and aortic:pulmonary ratio > 1.2. Most dogs in the type B group were brachycephalic and had no poststenotic dilatation on thoracic radiographs. Of the dogs with type A stenosis, 100% survived valvuloplasty with resolution of clinical signs. At 1-year follow-up, 94.4% were still alive and remained asymptomatic. Of those with type B stenosis, 66.6% had favorable outcome postvalvuloplasty. At 1-year follow-up, 66.6% of dogs were alive, and resolution of clinical signs was obtained in 50%. This study revealed the immediate and long-term efficacy of balloon valvuloplasty in dogs with PS.     

Balloon Valvuloplasty for Treatment of Pulmonic Stenosis in English Bulldogs with an Aberrant Coronary Artery

Background: English Bulldogs (EB) with pulmonic stenosis (PS) sometimes have an aberrant coronary artery (CA) type R2A encircling the pulmonary artery (PA). Balloon valvuloplasty (BV) is treatment of choice for severe PS, but is considered to be contraindicated in dogs with aberrant CA. Hypothesis: Conservative BV in EB with aberrant CA is safe and improves clinical signs and quality of life. Animals: Four client‐owned EB with severe PS were retrospectively reviewed/analysed. Methods: Retrospective study: Case records, echocardiography, BV, and follow‐up investigations of EB diagnosed with severe PS and treated with BV were reviewed. The ratios of PA to aortic (Ao) velocity time integral (VTI) were calculated to assess progression/improvement of PS. Results: An aberrant CA was confirmed on angiography in all EB. Conservative BV was performed, using a balloon of the size of the PA annulus or smaller (0.6–1 × PA annulus size). All dogs survived the procedure, but only a mild reduction in pressure gradient was achieved. There was an improvement in PA to Ao VTI in 3 of 4 dogs (P≤ .017), which were free of evidence of congestive heart failure (CHF) 5, 10, and 15 months after BV. One dog that had right‐sided CHF when BV was performed died due to progressive right‐sided CHF within 3 months. Conclusions: Conservative BV in EB might be safe and might improve quality and quantity of life.     

Restenosis after balloon valvuloplasty in a dog with pulmonary stenosis

A two-month-old female Chihuahua was diagnosed as severe pulmonary valvular stenosis (PS). Although balloon valvuloplasty (BV) was successfully performed, restenosis was observed 19 months after the procedure. Euthanasia was chosen due to low output syndrome during the surgical repair attempted when the dog was 5 years old. Postmortem examination revealed markedly thickened pulmonary valve due to the increase of extracellular matrix which might be produced by increased α smooth muscle actin-positive myofibroblasts. The thickening of the valve was associated with restriction of the valve’s motion, resulting in restenosis in the present case. This is the first case report documented histopathological and immunohistochemical findings of the restenotic pulmonary valve in dogs with PS after BV.     

High-pressure balloon valvuloplasty for severe pulmonary valve stenosis: a prospective observational pilot study in 25 dogs

Objectives

We aimed to evaluate safety and efficacy of high-pressure balloon valvuloplasty (HPBVP) for treatment of canine severe pulmonary valve stenosis (PS). A secondary aim was to provide pre-procedure predictors of success.

Pulmonary artery dissection following pulmonary balloon valvuloplasty in dogs

Introduction/objectivesPulmonary artery dissection is a rare complication following balloon valvuloplasty for pulmonic stenosis. We sought to report the rate of this complication in dogs and describe the demographic, clinical, procedural, and outcome data in affected dogs.Animals, materials and methodsMedical records at a single academic institution between 2002 and 2021 were reviewed for dogs with pulmonic stenosis treated by a balloon valvuloplasty. Dogs were included for evaluation if there was evidence of pulmonary artery dissection on echocardiography or necropsy following balloon valvuloplasty. The demographic, clinical, surgical, and follow-up information were then recorded.ResultsSix dogs were included from 210 balloon valvuloplasty procedures for pulmonic stenosis giving a 3.9% rate of pulmonary dissection. There was a variety of signalment, pulmonary valve morphologies, and balloon catheter types used in each dog. All dogs had severe pulmonic stenosis (median pressure gradient of 208 mmHg, range 94–220 mmHg) with 5/6 dogs having a pressure gradient >144 mmHg. The median balloon to pulmonary valve annulus ratio was 1.35 (range 1.25–1.5). Three dogs died perioperatively, and three dogs were alive at follow up 3.3, 4.0, and 4.1 years postoperatively.ConclusionPulmonary artery dissection is a rare complication following balloon valvuloplasty for pulmonic stenosis. Extreme elevations in preoperative pulmonary valve flow velocity were common. Prognosis is variable, with a potential 50% perioperative survival rate, but extended survival times were noted in those patients discharged from hospital.     

Volume loading-related changes in tissue Doppler images derived from the tricuspid valve annulus in dogs

OBJECTIVE: To investigate the relationship between preload and tricuspid valve annulus-derived tissue Doppler imaging (TDI) as an index of right ventricular (RV) filling in dogs. ANIMALS: 7 Beagles. PROCEDURES: Peak systolic RV pressure and RV end-diastolic pressure (RVEDP) were measured in anesthetized dogs. Pulsed Doppler was used to measure tricuspid valve inflow and pulmonary valve outflow velocities. The TDI velocities were measured at the lateral corner of the tricuspid valve annulus. Lactated Ringer's solution was infused at 200 mL/kg/h for 60 minutes via the cephalic vein. RESULTS: IV infusion significantly increased heart rate, RV pressure, and RVEDP. Early diastolic flow (E-wave) and ejection time significantly increased. The myocardial performance index (MPI) significantly decreased. Intravenous infusion significantly increased the ratio of the E'-wave (peak myocardial velocity during early diastole) to the A'-wave (peak myocardial velocity during late diastole; E':A' ratio) and myocardial velocity during systole (S'), early diastole (E'), and late diastole (A'). The TDI-isovolumic relaxation time and TDI-MPI decreased significantly. The RVEDP was correlated with late diastolic flow (A-wave), ratio of the E-wave to the A-wave (E:A ratio), E'-wave, A'-wave, S'-wave (peak myocardial velocity during systole), TDI-isovolumic relaxation time, TDI-MPI, and ratio of the E-wave to the E'-wave (E: E' ratio). The A-wave and E:A ratio and TDI-derived isovolumic relaxation time, S' duration, and E'-wave could predict the RVEDP. CONCLUSIONS AND CLINICAL RELEVANCE: The TDI velocities were affected by RV filling pressure in healthy dogs, whereas other TDI profiles, such as MPI and E':A' ratio, were independent of acute filling abnormalities.     

Stent angioplasty for treatment of canine valvular pulmonic stenosis

Four dogs presented for evaluation and treatment of severe pulmonic valve stenosis and underwent stenting of the pulmonic valve annulus using bare-metal balloon-expandable stents. All dogs survived the procedure with immediate reduction of the transpulmonary valve pressure gradient and increase in activity levels. One dog had a stent fracture and migration 1 month after the intervention. This dog underwent a second procedure, in which multiple stents were used to alleviate the obstruction. The stents that were placed at the level of the right ventricular outflow tract fractured within 1 month of the procedure, and the patient died when a third (surgical) approach was attempted. The other three dogs remain alive 54, 42, and 29 months after the procedure. Stent angioplasty may be a viable option for dogs with valvular pulmonic stenosis in which routine balloon valvuloplasty does not provide a successful outcome. Aggressive attempts to diminish RVOT dynamic obstruction with high-dose beta blockade and avoiding deployment of the stent within the RVOT are recommended to prevent stent fracture and migration.     

Survival times in dogs with severe subvalvular aortic stenosis treated with balloon valvuloplasty or atenolol

OBJECTIVE: To determine survival times in dogs with severe subvalvular aortic stenosis (SAS) treated by means of balloon valvuloplasty or with atenolol, a beta-adrenoceptor blocking drug. DESIGN: Prospective study. ANIMALS: 38 dogs < 24 months old with severe SAS (peak systolic pressure gradient > or = 80 mm Hg). PROCEDURE: 10 dogs underwent balloon valvuloplasty and were reexamined 6 weeks later to determine the feasibility of the procedure. The remaining 28 dogs were randomly assigned to undergo balloon valvuloplasty (n = 15) or to be treated with atenolol long term (13) and were reexamined annually for 9 years or until the time of death. RESULTS: For the first 10 dogs, mean pressure gradient 6 weeks after balloon valvuloplasty (mean +/- SD, 119 +/- 32.6 mm Hg) was significantly decreased, compared with mean baseline pressure gradient (167 +/- 40.1 mm Hg). Median survival time for dogs that underwent balloon valvuloplasty (55 months) was not significantly different from median survival time for dogs treated with atenolol (56 months). CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that balloon valvuloplasty can result in a significant decrease in the peak systolic pressure gradient in dogs with severe SAS, at least for the short term. No clear benefit in survival times was seen for dogs that underwent balloon valvuloplasty versus dogs that were treated with atenolol.     

Stenting of the right ventricular outflow tract in 2 dogs for palliation of dysplastic pulmonary valve stenosis and right-to-left intracardiac shunting defects

Two dogs with severe dysplastic pulmonary valve stenosis and right-to-left shunting defects (patent foramen ovale, perimembranous ventricular septal defect) underwent palliative stenting of the right ventricular outflow tract and pulmonary valve annulus using balloon expandable stents. One dog received 2 over-lapping bare metal stents placed 7 months apart; the other received a single covered stent. Both procedures were considered technically successful with a reduction in the transpulmonary valve pressure gradient from 202 to 90 mmHg in 1 dog and from 168 to 95 mmHg in the other. Clinical signs of exercise intolerance and syncope were temporarily resolved in both dogs. However, progressive right ventricular concentric hypertrophy, recurrent stenosis, and erythrocytosis were observed over the subsequent 6 months leading to poor long-term outcomes. Stenting of the right ventricular outflow tract is feasible in dogs with severe dysplastic pulmonary valve stenosis, though further study and optimization of the procedure is required.     

Treatment of Congenital Pulmonic Stenosis in Two Dogs by Balloon Valvuloplasty

Balloon valvuloplasty was performed on two dogs with pulmonic valve stenosis. Immediately following balloon valvuloplasty, peak right ventricular systolic pressure declined from 92 to 44 mm Hg in the first dog and from 108 to 46 mm Hg in the second dog. The peak systolic pressure gradient across the pulmonic valve declined from 60 to 12 mm Hg in the first dog and from 84 to 22 mm Hg in the second dog. Hemodynamic improvement was sustained in both dogs at the time of recatheterization 3 months later. Both dogs tolerated the procedure well and there were no serious complications. It was concluded that balloon valvuloplasty offers an alternative to surgery for the treatment of valvular pulmonic stenosis in dogs. The exact indications for and limitations of balloon valvuloplasty must await the results of additional and more long-term studies.     

Fatal acute lung injury after balloon valvuloplasty in a dog with pulmonary stenosis

A one-year-old French Bulldog was referred for the management of a severe form of pulmonary valve stenosis (PS) complicated by right-sided congestive heart failure.Echocardiography showed severe valvular PS with right ventricular concentric hypertrophy, dilatation and severe right atrial enlargement. A pulmonary balloon valvuloplasty (PBV) was performed with a balloon-to-pulmonary annulus ratio of 1.36. Echocardiography immediately after PBV showed a significant reduction in right atrial and ventricular size, improved opening and mobility of the pulmonary valve leaflets, and a 75% reduction in the pulmonary pressure gradient from 158 mmHg pre-operative to 40 mmHg post-operative. The dog recovered well from anesthesia, but 2 h later, it suddenly showed severe respiratory distress. Focus cardiac ultrasound showed increased left cardiac size with echocardiographic signs of high left ventricular filling pressure. Bedside lung ultrasound showed diffuse numerous-to-confluent B lines, compatible with a severe alveolar-interstitial syndrome. The dog was treated with furosemide, helmet continuous positive airway pressure, and then mechanical ventilation but without success.At post-mortem evaluation, histological examination of the lung showed diffuse, severe broncho-alveolar edema with mixed leukocyte, fibrin, and red blood cell infiltrate. Moreover, severe congestion and multifocal alveolar hemorrhages were evident. All findings were compatible with fatal acute lung injury after PBV secondary to pulmonary reperfusion-ischemia injury and increased pulmonary capillary hydrostatic pressure. Based on the present case, acute lung injury should be considered as a rare but serious complication of PBV.     

Electrocardiography‐gated cardiac CT angiography can differentiate brachycephalic dogs with and without pulmonary valve stenosis and findings differ from transthoracic echocardiography

Pulmonary valve stenosis (PS) is one of the most commonly diagnosed congenital heart defects in dogs. Currently, transthoracic echocardiography (TTE) is the standard modality used to evaluate PS. Image acquisition by TTE can be challenging in some brachycephalic breeds of dogs. The use of echocardiographic‐gated CT angiography (ECG‐gated CTA) in veterinary medicine is limited. This retrospective method comparison study investigated right and left ventricular outflow diameters by sedated ECG‐gated CTA and unsedated TTE in 14 brachycephalic dogs with PS and 12 brachycephalic dogs without PS. Measurements of ventricular outflow structures were made in early systole and end diastole for both modalities and then compared for significance between systolic and diastolic phases, as well as between the two modalities. Ratios of the pulmonary trunk diameter to the aorta at different locations (aortic valve, aortic annulus, and ascending aorta) and in different planes (transverse, sagittal) were compared between dogs with PS and without PS, as well as within dogs, by both TTE and ECG‐gated CTA. Transthoracic echocardiography and ECG‐gated CTA both detected significantly greater pulmonary trunk to aorta ratios in dogs with PS at all aortic locations (P < 0.05). Pulmonary valve to aortic valve ratios were significantly smaller in dogs with PS (P < 0.05). Pulmonary trunk to aorta and pulmonary valve to aorta ratios were achieved with good anatomic detail using ECG‐gated CTA. Ratios of the pulmonary trunk and pulmonary valve relative to the aorta may be useful to evaluate for PS using a modality that is underutilized for cardiac assessment.     

Assessment of balloon pulmonary valvuloplasty in six dogs

The effectiveness of balloon valvuloplasty was assessed, clinically and haemodynamically, in six dogs with moderate to severe pulmonic stenosis. The haemodynamic assessment was based on Doppler echocardiography, with colour flow mapping, in the conscious dog and by direct catheterisation in the anaesthetised dog, before and after balloon valve dilatation. Four of the six dogs were presented with exercise intolerance, of which two were in congestive heart failure. Balloon valvuloplasty resulted in improved exercise tolerance and resolution of congestive heart failure in these dogs. The average Doppler and catheter transvalvular pressure gradients were reduced to 43 per cent and 46 per cent of the preoperative gradient, respectively. The average pressure gradient obtained by catheter, in the anaesthetised dog, was 59 per cent of the pressure gradient obtained by spectral Doppler echocardiography in the conscious dog. Balloon valvuloplasty was considered successful in five out of the six dogs. Postoperative pulmonic regurgitation was not found to be a complication of balloon valvuloplasty.     

Balloon valvuloplasty of congenital mitral stenosis

Radiographic, echocardiographic, fluoroscopic, and angiographic images from 2 dogs with severe congenital mitral valve stenosis that underwent cardiac catheterization and balloon valvuloplasty are presented. Both dogs displayed systolic doming of the mitral valve leaflets, increased diastolic pressure gradient across the left atrium and ventricle, and decreased mitral inflow E to F slope. Balloon valvuloplasty was performed on both dogs using atrial transeptal puncture.     

Non-cardiogenic pulmonary oedema complicating balloon valvuloplasty and stent angioplasty of severe pulmonary valve stenosis in four dogs

In dogs, balloon valvuloplasty is considered the treatment of choice for severe pulmonary valve stenosis, and this technique is currently performed routinely in specialist referral practices with low morbidity and mortality. Stent angioplasty has also been recently proposed as a viable treatment option. The present case series describes the clinical course of four dogs with severe pulmonary valve stenosis, treated with balloon valvuloplasty or stent angioplasty at four different institutions, which developed non-cardiogenic pulmonary oedema perioperatively after apparently successful dilation of the pulmonary valve. In three cases, there was evidence of some degree of pulmonary hypertension before ballooning. Despite intensive care, the complication proved fatal in three cases. Clinicians should therefore be aware of this life-threatening complication, previously undescribed in dogs.     

Outcome in 55 dogs with pulmonic stenosis that did not undergo balloon valvuloplasty or surgery

Objective : To determine the outcome, independent predictors of cardiac death, and the Doppler‐derived pressure gradient cut‐off for predicting cardiac death in dogs with pulmonic stenosis, with or without tricuspid regurgitation, that do not undergo balloon valvuloplasty or valve surgery. Methods : Review of medical records of two UK referral centres between July 1997 and October 2008 for all cases of pulmonic stenosis that had no balloon valvuloplasty or valve surgery. Inclusion criteria included a diagnosis of pulmonic stenosis; spectral Doppler pulmonic velocity greater than 1·6 m/s; characteristic valve leaflet morphological abnormalities. Exclusion criteria included concurrent significant cardiac defects, including tricuspid dysplasia. Dogs with tricuspid regurgitation were included. Dogs were classified according to Doppler‐derived pressure gradients into mild, moderate or severe pulmonic stenosis categories. Results : Presence of tricuspid regurgitation and severe stenosis were independent predictors of cardiac death. A pulmonic pressure gradient of more than 60 mmHg was associated with 86% sensitivity, and 71% specificity of predicting cardiac death. Clinical Significance : There is an increased probability of cardiac death in those cases which have a pulmonary pressure gradient greater than 60 mmHg and tricuspid regurgitation, though the effect of severity of tricuspid regurgitation on outcome was not measurable because of small sample sizes. These animals might benefit from intervention.     

Evaluation of collagenase-induced mitral valve regurgitation in dogs

OBJECTIVE: To investigate the hemodynamic changes induced by injecting collagenase into the mitral valve to induce mitral valve regurgitation (MVR) in dogs. ANIMALS: 9 healthy Beagles. PROCEDURE: Dogs were randomly assigned to 3 groups: control (saline [0.9% NaCl] solution; n = 3), single collagenase injection (C1; 3), and 2 collagenase injections (C2; 3). Open-heart surgery was performed, and saline or collagenase solutions were injected into the mitral valve. Before and weekly for 11 weeks after surgery, radiography, echocardiography, and phonocardiography were performed. Mean pulmonary arterial pressure and mean pulmonary arterial wedge pressure (mPAWP) were measured before and 11 weeks after surgery. Postmortem examinations were performed after dogs were euthanatized. RESULTS: No changes were detected in the control group during the 11-week follow-up period. A systolic murmur and MVR developed 1 week after surgery in groups C1 and C2. The murmur changed from a protosystolic to a pansystolic murmur, and left atrial diameter and the left atrial-to-aortic root diameter ratio increased with time. Mean pulmonary arterial pressure and mPAWP were greater 11 weeks after surgery in groups C1 and C2, compared with presurgery values. During necropsy, tissue loss was detected in the mitral valve at the site of collagenase injection. Degree of regurgitation corresponded to lesion size. CONCLUSIONS AND CLINICAL RELEVANCE: Injection of collagenase into the mitral valve of healthy dogs induced MVR, and dogs with MVR developed progressive hemodynamic changes without acute overload. Collagenase-induced MVR may be an appropriate model for evaluation of prognostic markers of idiopathic MVR in dogs.     

The relevance of echocardiography heart measures for breeding against the risk of subaortic and pulmonic stenosis in Boxer dogs

The aims of this study were to investigate the role and relative importance of auscultation and echocardiography traits as risk factors for the diagnosis of subaortic (SubAS) and pulmonic (PS) stenosis and to estimate the heritability (h(2)) of cardiac measurements taken through echocardiography for a random sample of Italian Boxer dogs. The data were cardiovascular examination results of 1,283 Italian Boxer dogs (686 females and 597 males) enrolled in the national screening program for heart defects arranged by the Italian Boxer Club. Examinations were performed during a 6-yr period by a group of 7 veterinary cardiologists following a standard protocol. Occurrence and severity of SubAS and PS were diagnosed, taking into account clinical and echocardiography findings such as the grade of cardiac murmur, direct ultrasound imaging of the anatomic obstructive lesions, and values of aortic or pulmonary blood flow velocities. A Bayesian logistic regression analysis was performed to identify clinical and echocardiography variables related to SubAS and PS diagnosis. Estimation of variance components for clinical and echocardiography traits was performed using a mixed linear animal model, Bayesian procedures, and the Gibbs sampler. Prevalence of SubAS (PS) was 8.4% (2.2) and 10.7% (6.4) for female and male dogs, respectively. Cardiac murmur, peak velocities, and annulus areas behaved as risk factors for SubAS and PS. The risk of a positive diagnosis for SubAS was 3 times greater for dogs with aortic annulus area <2.1 cm(2) relative to dogs with areas >2.37 cm(2), 84 times greater for dogs showing aortic peak velocities >2.19 m/s relative to dogs with peak velocities <1.97 m/s, and 41 times greater for dogs with moderate to severe murmur grades relative to dogs with absent murmur. Similar results were obtained for PS. The estimated h(2) for the occurrence of cardiac defects was 23.3% for SubAS and 8.6% for PS. Echocardiography and cardiac murmur grades exhibited moderate h(2) estimates and exploitable additive genetic variation. The estimated h(2) was 36, 24, and 20% for aortic annulus area, aortic peak velocity, and cardiac murmur score, respectively. For the area of the pulmonary annulus and peak pulmonary velocity, the estimated h(2) were smaller, ranging from 9.5 to 12.8%. These measures are candidate indicator traits that might be effectively used in dog breeding to reduce the prevalence and severity of cardiac defects.     

Long-term clinical evaluation of mitral valve replacement with porcine bioprosthetic valves in dogs

This study evaluated the long-term clinical performance of newly developed porcine bioprosthetic valves cross-linked with glutaraldehyde and polyepoxy compound for mitral valve replacement (MVR) in dogs. Five beagle dogs underwent MVR using the porcine bioprosthetic valves during cardiopulmonary bypass. Antithrombotic drugs were administered only for one month after MVR. Six months after MVR, transvalvular regurgitation was not observed in all dogs, paravalvular leakage was seen only in one dog. Twelve months after MVR, mild transvalvular regurgitations were observed in two dogs. Although diastolic atrioventricular pressure gradient was increased gradually, no significant differences were observed. Pressure half-time and valve area were within normal ranges as the bioprosthetic value. There was no clinical symptom of the thrombosis and the thrombogenesis was not observed in the porcine bioprosthetic valve and the annulus in all dogs for twelve months after MVR. The clinical findings suggest that antithrombogenicity of the valves were maintained, though the duability might not be enough in the long-term period.     

Transthoracic echocardiographically-guided interventional cardiac procedures in the dog

ObjectivesInterventional cardiac procedures are traditionally performed using fluoroscopy, or, more recently, transesophageal echocardiography (TEE). Neither modality is widely available to practicing cardiologists worldwide. We examined whether balloon valvuloplasty of pulmonic stenosis (PS) and transarterial occlusion of patent ductus arteriosus (PDA) in dogs could be performed safely with transthoracic echocardiography (TTE).AnimalsA prospective consecutive case series of 26 client-owned dogs with PS (n = 10) and PDA (n = 16).MethodsThe cardiovascular procedures were performed using TTE. Each dog was positioned on a standard echocardiography table in right lateral recumbency (dogs with PS) or left lateral recumbency (dogs with PDA). Guide wires, balloon catheters, Amplatz^® Canine Ductal Occluder (ACDO) delivery sheaths, and ACDO were imaged by standard echocardiographic views optimized to allow visualization of the defects and devices.ResultsProcedures were performed successfully without major complications in 20 dogs. In 2 dogs (German shepherds) with Type III PDA, ACDO placement was unsuccessful; 2 other German Shepherds were excluded from the procedure because their ductal diameters, measured echocardiographically, exceeded the limits of the maximal ACDO size. Two dogs weighing ≤3.5 kg had suboptimal echocardiographic visualization of the PDA and were considered too small for safe ACDO deployment. All intravascular devices at the level of the heart and great vessels appeared hyperechoic on TTE image and could be clearly monitored and guided in real-time.ConclusionsWe have demonstrated that TTE monitoring can guide each step of pulmonic balloon valvuloplasty and PDA occlusion without fluoroscopy.