What is the most appropriate management option for a pediatric patient with aortic stenosis, an aortic valve gradient of 60 mmHg, and symptoms of shortness of breath (SOB) on exertion, but no chest pain or syncope, and normal blood pressure (BP) and heart rate (HR), with good left ventricular systolic function on echocardiogram (ECHO)?

Aortic Balloon Valvoplasty is Indicated

This pediatric patient with symptomatic aortic stenosis and a gradient of 60 mmHg meets clear Class I criteria for aortic balloon valvoplasty (Answer C). The combination of exertional dyspnea and a gradient >50 mmHg mandates intervention regardless of the absence of chest pain or syncope.

Guideline-Based Indication for Intervention

The American Heart Association provides explicit Class I recommendations for this clinical scenario:

• Aortic valvuloplasty is indicated in children with isolated valvar AS who have a resting peak systolic valve gradient (by catheter) of >50 mm Hg 1
• The patient's gradient of 60 mmHg exceeds this threshold, making intervention appropriate even without considering symptoms 1
• When symptoms are present (as in this case with exertional SOB), the indication becomes even stronger, as aortic valvuloplasty is indicated in children with a gradient >40 mm Hg if there are symptoms 1

Why Symptoms Matter at This Gradient

The presence of exertional dyspnea in a pediatric patient with a 60 mmHg gradient represents significant hemodynamic compromise:

• Children with peak Doppler gradients ≥64 mmHg or mean gradients >40 mmHg who have symptoms should be considered for cardiac catheterization and balloon dilation 1
• The gradient of 60 mmHg places this patient in the range where intervention is reasonable even in asymptomatic patients, and symptoms make the indication definitive 1
• Good left ventricular systolic function indicates the intervention is being performed before irreversible myocardial damage occurs, which is optimal timing 1

Why Other Options Are Inappropriate

Follow-up alone (Option A) is contraindicated:

• Class III recommendation explicitly states that intervention should not be deferred in symptomatic patients with gradients >40 mmHg 1
• Delaying intervention risks progression to left ventricular dysfunction and worse outcomes 2

Anticoagulation (Option B) has no role:

• There is no indication for anticoagulation in isolated aortic stenosis without valve replacement or atrial fibrillation 1
• This would expose the patient to bleeding risk without addressing the underlying obstruction 1

Diuretics (Option D) are not appropriate:

• The patient has normal left ventricular systolic function and no evidence of heart failure 1
• Diuretics do not address the mechanical obstruction and may reduce preload, potentially worsening symptoms 1

Expected Outcomes with Balloon Valvoplasty

The procedure has well-established efficacy in pediatric populations:

• Balloon dilation typically reduces the catheter peak-to-peak systolic valve gradient to 20-35 mmHg, representing approximately 60% reduction 1
• The VACA Registry of 606 children showed good outcomes with optimal balloon-annulus diameter ratios of 0.9-1.0 1
• Freedom from reintervention is 86% at 1 year and 67% at 5 years in children beyond infancy 1
• Severe aortic regurgitation occurs uncommonly when appropriate technique is used 1

Important Caveats

Gradient confirmation at catheterization:

• The 60 mmHg gradient should be confirmed by catheter measurement during the procedure, as echocardiographic gradients may differ from catheter-obtained values 1
• Gradients obtained under sedation are typically used for decision-making; general anesthesia may lower gradients somewhat 1

Long-term perspective:

• Balloon valvoplasty is palliative rather than curative, with eventual reintervention required in the majority of children 1
• However, it delays the need for valve replacement and allows for growth, enabling implantation of adult-sized prostheses if replacement becomes necessary 3, 2
• Lifetime follow-up is mandatory for all children with aortic stenosis regardless of intervention 2