Percutaneous transluminal coronary angioplasty in an infant with coronary artery stenosis after arterial switch operation

Abstract

The arterial switch operation (ASO)l has improved the outlook for the neonate with transposition of the great arteries (TGA). The results of immediate and mid-term follow-up of these patients have been encouraging. However, recent studiesz5 justify the theoretical concern about coronary artery reimplantation. We present a case report of an infant with severe coronary artery stenosis after ASO. The diagnosis, management, and results of percutaneous transluminal coronary angioplasty (PTCA) are described. R.M. was a 5 lb full-term newborn male infant. At age 35 days, the patient developed respiratory distress with cyanosis. The cardiac catheterization showed d-TGA, nonrestrictive ventricular septal defect (VSD), patent ductus arteriosus (PDA), and type A coronary arteries. Oxygen saturation was 77 % , and balloon atria1 septostomy was performed. Two days later, the patient underwent AS0 with VSD closure. Postoperatively the patient did well; the electrocardiogram (ECG) showed no ischemic changes and the echocardiogram (ECHO) showed good left ventricular (LV) function. The patient was discharged on postoperative day (POD) 12. He presented at age 11 weeks in profound cardiogenic shock. ECG showed ST-T wave changes consistent with LV ischemia. Creatinine phosphokinase (CPK) was 2628 IU/L, and the ECHO showed severe global LV dysfunction with an ejection fraction (EF) of 19 % . After stabilization, cardiac catheterization showed moderate mitral valve insufficiency and a large left ventricle with LVEF of 12%. Aortogram did not demonstrate coronary artery stenosis. Selective left coronary angiogram was done using a 4F JL-1 catheter (Jorgensen Laboratories, Loveland, Colo.) that was fashioned to engage the left coronary ostium. This coronary angiogram showed 80 % stenosis of the proximal left coronary artery (LCA) (Fig. 1) with poststenotic coronary diameter of 1.8 mm. Because the coronary artery was small, surgical intervention was considered a high risk. Therefore PTCA was done after obtaining the parents’ informed consent. The patient received 75 units/kg body weight intravenous heparin. An 0.014 inch standard guide wire (Advanced Cardiovascular