PERFORATING THE ATRETIC PULMONARY VALVE IN NEONATES USING CORONARY TOTAL OCCLUSION HARDWARE

Abstract

Interventional therapy is possible in selected patients with of pulmonary atresia with intact ventricular septum (PA- IVS). Among the various interventional options available, radiofrequency and laser assisted perforation may be more successful, but have substantial cost and expertise involved. On the other hand coronary hardware used to cross totally occluded coronary arteries is often readily available in catheterization labs and interventional cardiologists are familiar with their use. We describe the technique of mechanical catheter pulmonary valve (PV) perforation using currently available coronary hardware meant for coronary chronic total occlusion. Eight neonates diagnosed to have PA- IVS underwent PV perforation using the coronary hardware. All these babies had a well formed right ventricle (RV) with no evidence of RV dependent coronary circulation. After complete echocardiographic evaluation and an informed parental consent, patients were electively intubated, mechanically ventilated, adequately heparinized and were put on intravenous prostaglandin infusion. Basic steps involved localizing the atretic segment and coaxial alignment of catheters using biplane fluoroscopy, crossing the atretic segment with soft end of perforating guide wire, stabilizing the assembly, followed by graded balloon dilatation never exceeding 130% of pulmonary annulus. The PV was crossed retrogradely in one patient when antegrade approach was not possible. Procedure was successful in 7 / 8 cases (89.5%). Valve opening was achieved in all patients with immediate fall in RV systolic pressures. One neonate died following surgery after catheter induced RV perforation. All surviving cases were discharged from hospital in good general condition with no evidence of heart failure and room air saturation of > 85 %. No patient required an additional procedure over a short follow up period. With appropriate patient and hardware selection, PV perforation using readily available coronary hardware is feasible in PA-IVS.