The Transcatheter Management of the Neonate and Infant with Pulmonary Atresia and Intact Ventricular Septum

Abstract

The optimal management of the neonate and infant with pulmonary atresia (PA) and intact ventricular septum (IVS) remains controversial. The ultimate aim of any treatment algorithm is to achieve a four‐chambered, biventricular, completely separated circulation. In 1991, transcatheter perforation of the atretic membrane followed by successful balloon valvuloplasty was reported using a laser‐assisted guidewire in the United Kingdom and the stiff end of a guidewire in the United States. The following year, a radiofrequency (RF) guidewire was successfully used, while stenting of the ductus arteriosus to maintain adequate pulmonary blood was also reported. Most recently, a steerable 5 Fr RF catheter was used to “burn” the atretic membrane. From a series of 15 publications, a total of 69 neonates underwent attempted pulmonary valve perforation: 17 laser guidewire, 28 RF guidewire, 25 stiff end guidewire, and 1 steerable RF catheter. Successful perforation by technique was: 82.4% laser, 88.5% RF, 68% stiff end, and 100% steerable RF. The accumulative success rate was 79.7%, mortality 4.3%, major complication 18%, and need for additional pulmonary blood 48%. Follow‐up thus far has been encouraging. The technique of transcatheter perforation of the atretic pulmonary valve membrane is demanding and not without risk, but in experienced hands can be successful nearly 90% of the time using the RF guidewire. RF energy is commonly used for other cardiac problems and has inherent cost and availability advantages over laser energy. Since nearly 50% of the neonates still require additional pulmonary blood flow, the interventionalist must be capable and ready to stent the PDA, or send to surgery. The neonate with right ventricular (RV) dominant coronary circulation remains a high risk group. However, careful cardiac catheterization with temporary transcatheter RV decompression may lead to a better understanding of this complex physiology.