Left Pulmonary Artery Stent Research Articles

The Effect of Extracorporeal Membrane Oxygenation in the Management of Refractory Ventricular Tachycardia Developed after Fontan Procedure (Case Report)

Aim: to evaluate the effect of extracorporeal membrane oxygenation (ECMO) as a life support in the treatment of a patient with refractory ventricular tachycardia developed after Fontan procedure. Patient and treatment. A 4-year-old child developed refractory ventricular tachycardia (up to 250 bpm) and hemodynamic depression 18 hours after the Fontan procedure. After the failure of cardiopulmonary resuscitation and antiarrhythmic therapy, resternotomy with central venoarterial (VA) ECMO support was performed, followed by diagnostic angiocardiography. Contrast-enhanced cavopulmonary angiography revealed stenosis of the left pulmonary artery, which was treated with balloon angioplasty and stenting.Results. Ventricular tachycardia resolved and sinus rhythm was restored within 24 hours after left pulmonary artery stenting, supported by continuous ECMO and antiarrhythmic therapy. On day 3, transthoracic echocardiography showed good single ventricle contractility after a trial weaning from ECMO. As a result, the ECMO support was removed and the sternum sutured. The patient was discharged from the hospital on day 47 in stable condition.Conclusion. The prompt initiation of VA ECMO support in a 4-year old patient with refractory ventricular tachycardia post-Fontan procedure along with the complex management of post-procedural residual tachycardia using a combination of antiarrhythmic agents helped restoring sinus rhythm and could contribute to preventing neurological complications.

Impact of preoperative left pulmonary artery stenting on the Fontan procedure: a retrospective multicentre study.

Left pulmonary artery (LPA) or bifurcation stenoses at Fontan palliation can be very challenging to treat and may also require cardioplegia and aortic transection. Moreover, the low pressure of Fontan circulation and the bulkiness of the aorta increase the risk of a patch angioplasty collapse. Pre-Fontan LPA stenting of stenotic LPAs overcomes those drawbacks therefore the present study aimed to evaluate its advantageous impact on Fontan surgery. A multicentre retrospective analysis was performed on 304 consecutive Fontan patients. The study population was divided into 2 groups (LPA stented, n = 62 vs not stented, n = 242); pre-and postoperative data were compared. LPA-stented patients had a higher prevalence of systemic right ventricle (P = 0.01), hypoplastic left heart syndrome (P = 0.042), complex neonatal palliations (Norwood/Damus-Kaye-Stansel) and surgical LPA patch repair at Glenn (P < 0.001). No differences were found in cross-clamp rates, early (P = 0.29) and late survival (94.6% vs 98.4, P = 0.2) or complications (P = 0.14). Complex palliations on ascending aorta/aortic arch (P = 0.013) and surgical LPA repair at Glenn (P < 0.001) proved to be risk factors for LPA stenting before Fontan at multivariable analysis. The LPA-stented group showed similar outcomes in terms of survival and complications rate compared to patients without LPA stenosis; however, they significantly differ in their higher preoperative risk profile and in their more complex anatomy. Complex neonatal palliations involving ascending aorta or aortic arch may increase the risk of pulmonary branches stenosis requiring stenting; therefore, preoperative stenting of LPA stenoses could help to reduce the surgical risk of complex Fontan procedure by avoiding the need for cross-clamp or complex mediastinal dissections to perform a high-risk surgical repair.

Possible effects of left pulmonary artery stenting in single ventricle patients on bronchial area, lung volume and lung function.

Left pulmonary artery (LPA) stenting is often required in single ventricle (SV) patients. Due to their close anatomical relationship an LPA stent could potentially compress the left main bronchus (LMB). We assessed the impact of LPA stenting on bronchial size, pulmonary volumes, and lung function in a cohort of SV patients. Forty-nine patients underwent cardiovascular magnetic resonance (CMR) and 36 spirometry 11 (8-15) years after Fontan. All patients were free of respiratory symptoms. LPA stents were inserted in 17 (35%) patients at 8.8 (3.4-12.6) years. Area/shape of the main bronchi (n = 46) and lung volumes (n = 47) were calculated from CMR-ZTE images for each lung and transformed in right-to-left (r/l) ratio and indexed for BSA. The effect of early stent insertion (prior to stage III) was analyzed. Patients with LPA stent had larger r/l ratio for main bronchus area (p < 0.001) and r/l ratio difference for lung volumes was slightly larger in patients with early stenting. A trend toward a deformation of LMB shape in patients with LPA stent and toward a higher prevalence of abnormal spirometry in patients with early stent implantation was observed. In this cohort of patients, early insertion of LPA stents seems to relate with smaller LMB sizes and a trend toward smaller left lung volume and higher prevalence of impaired lung function. Whether these findings are caused by the stent or, at least to a certain degree, present prior to the implantation needs to be verified.

Left Pulmonary Artery Stenting for Left Pulmonary Artery Stenosis Following Patent Ductus Arteriosus Device Closure: Case Series and Review of the Literature

Percutaneous device occlusion is currently the standard of care for most cases of patent ductus arteriosus (PDA). Albeit infrequent, device‐related left pulmonary artery (LPA) stenosis is a known complication of this procedure, occasionally requiring stent placement to relieve the obstruction. We present a series of four patients who required left pulmonary stenting after ductus arteriosus device closure. A review of the current evidence is presented.

Discussion

Discussion

Preemptive stenting of the left pulmonary artery during comprehensive stage 2 procedure does not influence Fontan candidacy

ObjectivePulmonary artery reconstruction during comprehensive stage 2 (CS2) procedure can be challenging. Since 2017, we have employed preemptive left pulmonary artery (LPA) stenting. We hypothesized that LPA stenting promotes adequate growth and without compromising Fontan candidacy. Herewith, we report our midterm results. MethodsFrom 2002 to 2020, 159 patients underwent CS2. Patients were divided as follows: no stent (n = 122; Group 1) and perioperative LPA stent (n = 37; Group 2). Group 2 was subdivided according to unplanned stent (n = 17; Group 2a) or preemptive stent (n = 20; Group 2b). Relevant perioperative data was reviewed. Nonparametric statistics were utilized. ResultsMedian age and weight at surgery and hospital length of stay after CS2 did not differ between groups. Median cardiopulmonary bypass and crossclamp times were significantly greater in Group 1 (265 vs 243 minutes [P = .021] and 46 vs 26 minutes [P = .008]). In-hospital mortality was similar between Groups 1 and 2 (9.0% vs 18.9%, respectively [P = .1348]). Group 2b demonstrated a superior survival compared to Group 2a (P = .0335) but not Group 1 (P > .9999). Preemptive stenting significantly increased median hilar LPA diameter at CS2 exit angiogram compared with no stenting (P < .0001). Groups 2a and 2b significantly increased the pre-Fontan diameter of the hilar LPA when compared with Group 1 (6.1 and 6.8 vs 5.7 mm, respectively [P < .0001]). A further 120 patients underwent Fontan operation (75%). Median follow-up for Groups 1 and 2 were 7.4 and 3.0 years, respectively. ConclusionsPerioperative LPA stenting during CS2 does not adversely affect pulmonary growth. Preemptive stenting seems advantageous for LPA growth in preparation for Fontan completion.

The incidence of recurrent laryngeal nerve injury resulting in vocal cord paralysis following interventional congenital catheterisation procedures.

Recurrent laryngeal nerve injury leading to vocal cord paralysis is a known complication of cardiothoracic surgery. Its occurrence during interventional catheterisation procedures has been documented in case reports, but there have been no studies to determine an incidence. To establish the incidence of left recurrent laryngeal nerve injury leading to vocal cord paralysis after left pulmonary artery stenting, patent ductus arteriosus device closure and the combination of the procedures either consecutively or simultaneously. Members of the Congenital Cardiovascular Interventional Study Consortium were asked to perform a retrospective analysis to identify cases of recurrent laryngeal nerve injury after the aforementioned procedures. Twelve institutions participated in the analysis. They also contributed the total number of each procedure performed at their respective institutions for statistical purposes. Of the 1337 patients who underwent left pulmonary artery stent placement, six patients (0.45%) had confirmed vocal cord paralysis. 4001 patients underwent patent ductus arteriosus device closure, and two patients (0.05%) developed left vocal cord paralysis. Patients who underwent both left pulmonary artery stent placement and patent ductus arteriosus device closure had the highest incidence of vocal cord paralysis which occurred in 4 of the 26 patients (15.4%). Overall, 92% of affected patients in our study population had resolution of symptoms. Recurrent laryngeal nerve injury is a rare complication of left pulmonary artery stent placement or patent ductus arteriosus device closure. However, the incidence is highest in patients undergoing both procedures either consecutively or simultaneously. Additional research is necessary to determine contributing factors that might reduce the risk of recurrent laryngeal nerve injury.

Pulmonary Perfusion Asymmetry in Patients after Repair of Tetralogy of Fallot: A 4D Flow MRI-Based Study

Background: Repaired Tetralogy of Fallot (rTOF) patients may have residual lesions such as main (MPA) and branch pulmonary artery stenosis (BPAS). While MPA stenosis is well studied, few data are available on BPAS in rTOF. We aimed to describe pulmonary perfusion in a large paediatric cohort of rTOF and its impact on right ventricular and outflow-tract hemodynamics using 4D flow CMR. Methods: 130 consecutive patients (mean age at CMR 14.3 ± 4.6 years) were retrospectively reviewed. 96 patients had transannular patch without valve preservation while 34 patients had conserved annulus or valved conduit. A pulmonary blood flow ratio (right pulmonary artery (RPA)/left pulmonary artery (LPA)) between 0.75 and 1.56 was considered normal. Results: Asymmetric pulmonary perfusion was present in 59/130 patients (45%), with 54/59 (91%) having left lung hypoperfusion (blood flow ratio >1.56). RPA/LPA perfusion ratio in the whole cohort was independently associated with the LPA Z-score (−0.053, p = 0.007), the RPA regurgitant fraction (RF) (0.013, p = 0.011) and previous LPA stenting (0.648, p = 0.004). Decreasing LPA % perfusion (and conversely increasing RPA % perfusion) was significantly associated with higher MPA diameter Z-score (−0.06, p = 0.007). On multivariate analysis, MPA Z-score was independently associated with pulmonary RF (0.48, p

Emergency Department Presentation and Outcome of Children With Cyanotic Congenital Heart Diseases.

ObjectiveThis study aimed to assess the outcome and see the spectrum of presenting symptoms of children with cyanotic congenital heart diseases (CHDs) admitted through the emergency department in Lady Reading Hospital (LRH) in Peshawar, Pakistan.Materials and methodsThis cross-sectional study included 104 children with cyanotic CHD admitted through the emergency department in the pediatric cardiology unit of LRH from February 2019 to January 2020. Diagnosis of cyanotic CHD was confirmed through two-dimensional echocardiography. Patients were treated according to standard protocols for their presenting symptoms. The data were analyzed using Statistical Package for the Social Sciences (SPSS), version 20.0 (IBM Corp., Armonk, NY) and frequencies were expressed as percentages.ResultsThe study included 65 male cases (62.5%) and 39 female cases (37.5%), and participant ages ranged from 10 days to 15 years (mean, 2.7 ± 3.4 years). Of 104 patients, 70 presented with cyanotic spells (84.5%), 53 with fever (10.7%), 28 with respiratory distress (26.5%), 11 with loose stools (10.5%), 10 with hemiplegia (9.6%), and eight with seizures (7.6%). Pneumonia was a precipitating factor in 13 patients (12.5%), infective endocarditis in 12 patients (11%), gastroenteritis in 11 (11%), brain abscess and cerebrovascular accidents in seven patients each (6% each), meningitis in six patients (6%), and tuberculous pericardial effusion in one patient (<1%). The primary CHD was tetralogy of Fallot (TOF) in 52 patients, tricuspid atresia in 14 patients, pulmonary atresia in 13 patients, double outlet right ventricle in 10 patients, transposition of great arteries (TGA) in seven patients, and total anomalous pulmonary venous return (TAPVR), truncus arteriosus, congenitally corrected TGA, and critical pulmonary stenosis in two patients each. Twenty-six patients received treatment of the acute problem and instructions for follow-up monitoring. Twelve patients died during their hospital stay, and three left against medical advice. Fifteen patients received patent ductus arteriosus stenting, and six received right ventricular outflow tract stenting. One patient received a Blalock-Taussig (BT) shunt stent, and one received a left pulmonary artery stent. Two patients received a balloon pulmonary valvotomy, and one received pericardial effusion drainage. Eleven patients received surgical correction of TOF, 11 received surgical correction for BT shunt, four received surgical correction for brain abscess drainage, and two received TAPVR repair.ConclusionTOF was the most common cyanotic heart disease in our study. Cyanotic spells or increased cyanosis was the most common presenting concern. Cyanotic CHDs present with variable extracardiac signs and symptoms in emergencies. Appropriate assessment, immediate management of the acute problem, and timely intervention or surgical management result in good outcomes.

Oval stenting in left pulmonary artery stenosis: a novel double balloon technique to prevent airway compression in single ventricle.

Left pulmonary artery (LPA) stenosis is common in patients with cavopulmonary connections. Stent implantation is the treatment of choice but may be complicated or contraindicated by left main bronchus (LMB) compression due to limited retro-aortic space after a Damus-Kaye-Stansel (DKS) or Norwood operation. This study describes a novel double balloon technique of LPA stenting in patients at risk of LMB compression. A cohort study was performed in 11 patients who underwent LPA stenting with an oval stent technique between 2015 and 2018. Retro-aortic anatomy was evaluated periprocedurally by three-dimensional rotational angiography (3DRA). Pre-existing LMB compression was demonstrated by 3DRA in seven out of eight patients who had undergone previous LPA stenting and in one patient without stenting. Primary ovalisation with immediate stent implantation on double balloons was performed in one patient. Ten patients had secondary ovalisation with single balloon stent implantation followed by the double balloon technique for ovalisation. The procedures were successful in all patients and guaranteed LMB patency without increasing pre-existing compression. The 3DRA-guided oval stent technique with double balloon inflation is successful in treating LPA stenosis after a DKS or Norwood operation in patients at risk of bronchial compression, guaranteeing LMB patency without increasing pre-existing compression.

Cardiac catheterization procedures in pediatric patients undergoing extracorporeal membrane oxygenation cardiac catheterization, ECMO.

Objective:Extracorporeal membrane oxygenation (ECMO) is a lifesaving intervention for pediatric patients with respiratory and/or cardiovascular failure. In this study, we evaluated the cardiac catheterization results of pediatric patients on ECMO support.Methods:Between January 2012 and October 2016, 98 patients (5.2% of all surgery patients) needed ECMO support during perioperative cardiac surgery. We retrospectively reviewed the clinical data of 16 patients who underwent cardiac catheterization under ECMO support.Results:The median age at catheterization was 6.5 months (range, 3.3–60 months), and the median weight was 6.0 kg (range, 3.7–16 kg). Eight of the catheterizations were diagnostic, and the remaining eight were interventional. Five out of these eight patients underwent surgical palliation after diagnostic catheterization. Right pulmonary artery (RPA) stenting, right ventricular outflow tract (RVOT) stenting, combined left pulmonary artery (LPA) and RVOT stenting, combined LPA and modified Blalock-Taussig shunt stenting, bilateral pulmonary artery balloon angioplasty, and bilateral pulmonary artery stenting were each performed once, whereas LPA stenting was performed in two different patients. In one patient undergoing RVOT stenting, a complete atrioventricular block developed, resulting in hypotension; however, this was overcome with an ECMO flow increase. In another patient, the ECMO tubing disconnected from the arterial line. Minor vascular complications were seen in three patients. Twelve patients (75%) were successfully weaned from ECMO after the procedure and ten (63%) were discharged.Conclusion:Diagnostic and interventional cardiac catheterization can be safely and effectively performed in patients on ECMO. If the patient cannot be weaned from ECMO support, clinicians should consider performing an early angiogram either to treat or clarify the underlying problem.

Интраоперационное стентирование левой легочной артерии при выполнении операций гемодинамической коррекции у больных со сложными врожденными пороками сердца с одножелудочковой гемодинамикой сердца

Врожденные и послеоперационные сужения легочных артерий – серьезная проблема при гемодинамической коррекции по методу Фонтена у пациентов с унивентрикулярной анатомией сердца. Особый подход при коррекции гипоплазии и сужений в легочных артериях в условиях операционной гибридным методом позволяет значительно облегчить подход к суженному участку и выполнить успешную имплантацию стента с расширением ветвей легочных артерий. В статье анализируется пер- вый опыт лечения сужений легочных артерий при помощи интраоперационного гибридного стентирования у трех пациентов со сложными врожденными пороками сердца (ВПС). Успешная имплантация стентов у всех трех пациентов позволила выпол- нить гемодинамическую коррекцию порока по методу Фонтена, без летальных исходов. Анализ лечения представленных пациентов посвящен актуальным вопросам эндоваскулярного лечения ВПС гибридным методом и соответствует мировым тенденциям решения этой проблемы.

Transcatheter Closure of PatentDuctusArteriosus in ExtremelyPrematureNewborns: Early Results and Midterm Follow-Up.

The goal of this study was to describe early and midterm outcomes of extremely premature newborns (EPNs) who underwent transcatheter echocardiographically guided patent ductus arteriosus (PDA) closure. Surgical ligation of PDA in EPNs confers significant risk for procedural morbidity and adverse long-termoutcomes. The Amplatzer Vascular Plug II was used in all cases. Post-ligation syndrome was defined using previously published parameters. Patients were followed at pre-specified intervals, and prospectively collected data were reviewed. Transcatheter closure was attempted in 24 EPNs (mean procedural age 30 days [range 5 to 80 days], mean procedural weight 1,249 g [range 755 to 2,380 g]) and was successful in 88%. The 3 procedural failures were related tothe development of left pulmonary artery (LPA) stenosis caused by the device, and all devices were removed uneventfully. Complications included 2 instances of device malposition, resolved with device repositioning, and 1 instance of LPA stenosis, requiring an LPA stent. There were no procedural deaths, cases of post-ligation syndrome, residual PDA, or device embolization. Survival to discharge was 96% (23 of 24), with a single late death unrelated to the procedure. After a median follow-up period of 11.1 months, all patients were alive and well, with no residual PDA or evidence of LPA or aortic coarctation. This newly described technique can be performed safely with a high success rate and minimal procedural morbidity in EPNs. Early and midterm follow-up is encouraging. Future efforts should be directed toward developing specific devices for this unique application.

50th Annual Meeting of the Association for European Paediatric and Congenital Cardiology, Rome, Italy, June 1–4, 2016

Introduction: Four-dimensional (4D) flow magnetic resonance imaging (MRI) enables kinetic energy (KE) quantification of intraventricular blood flow. In this study we aimed to quantify the KE in in patients with univentricular heart and to assess the change in the KE after different types of interventions. Methods: 4D flow MRI was acquired in patients with Fontan circulation (n=12; median age 12, range 3-29 years) and in healthy volunteers (n =8; median age 26, range 23-36 years). MRI was repeated after transcatheter embolization of significant aortopulmonary collaterals (APC; n = 1), after stenting of left pulmonary artery (n=1) and after surgical replacement of hepatic flow tunnel with a Y graft due to significant central pulmonary artery stenosis with secondary formation of arteriovenous (AV) fistulas in the right lung (n= 1). Intraventricular KE was calculated throughout the cardiac cycle and indexed to stroke volume (SV). Results: The systole/diastole ratio of KE in Fontan patients was similar to the ratio of the controls' left ventricle (LV) or right ventricle (RV) depending on the ventricular morphology (Cohens kappa =1.0). Peak systolic KE/SV did not differ in patients compared to the LV in controls (0.016 ± 0.006 mJ/ml vs 0.020 ±0.004 mJ/ml, p= 0.09). Peak diastolic KE/SV in Fontan patients was lower than in the LV of the control group (0.028 ±0.010 vs 0.057± 0.011 mJ/ml, p (Less)

P16 Safety and efficacy of transcatheter PDA occlusion in infants less than 6kgs

<h3>Background</h3> The technique of transcatheter patent ductus arteriosus (PDA) closure has evolved in the past two decades and is increasingly used in smaller patients. We sought to report a multicentre experience of transcatheter PDA occlusion in infants weighing &lt;6kg. <h3>Methods</h3> A multicentre, retrospective analysis of children weighing &lt;6 kg in whom transcatheter PDA occlusion was attempted between January 2004 and December 2014 from 10 tertiary paediatric cardiology units in the UK and Ireland. <h3>Results</h3> A total of 361 patients underwent attempted transcatheter PDA closure. The mean weight at catheterization was 4.8 ± 1.0 kg and mean age was 5.7 ± 2.7 months. Successful device closure was achieved in 321(89%) patients without major complication. Device placement was attempted but failed in in 13 cases. Device malposition or embolization post release occurred in the remaining 27 cases. Of these, 11 patients had surgical retrieval of the embolized device and PDA ligation; 6 patients were referred for surgery at a later date after transcatheter retrieval of device and 10 patients had ductal closure with a different device after transcatheter retrieval of the initial device. In the 331 patients who had transcatheter PDA occlusion, 34 had coils and 297 had occluders, including Amplatzer Duct Occluder (ADO) (n = 197); ADO II (n = 51); ADO II Additional Sizes (n = 42); Amplatzer Vascular Plug (n = 6); Occlutech Duct Occluder (n = 1). Complete occlusion was achieved in a 312(94%) patients at either catheterization or last available follow-up. Three of 19 patients had mild residual flow which persisted at less than a year post procedure; but follow up data was not complete in the rest. There were 17 cases of mild left pulmonary artery (LPA) stenosis related to device impingement with velocity &gt;2m/s; 11 of which resolved with time, 5 had persistent mild LPA stenosis at last review with Doppler velocity of 2.5m/s or less; and 1 underwent LPA stenting. Mild aortic obstruction was recognised in 10 patients during catheterisation or on post procedure echocardiogram, 7 of which resolved; one had persistent increased velocity at the arch with no diastolic tail at last review and 2 had incomplete follow up data. Other complications include loss of pulse requiring TPA (n = 5) temporary reduction in pulse requiring heparin infusion (n = 16); bleeding requiring transfusion (n = 2); anaesthesia or airway related (n = 1); small pericardial effusion (n = 1); haemopericardium requiring percutaneous drainage (n = 1); tricuspid valve injury (n = 1); and cerebrovascular event (n = 1). There were 13 deaths in the cohort which were unrelated to the procedure. The causes of death were mainly related to underlying chronic lung disease and pulmonary hypertension. <h3>Conclusions</h3> Transcatheteter closure of PDA can be safely accomplished in selected infants who are less than 6 kg despite the manufacturer’s recommended weight limit of 6 kg for most ductal occluders. The embolization rate (7%) in this group appeared to be higher than published series in infants &gt;6kg, therefore thorough delineation of ductal anatomy and attention to device selection are vital to the success of the procedure.

Intra-procedural Bronchoscopy to Prevent Bronchial Compression During Pulmonary Artery Stent Angioplasty.

Stenosis of the pulmonary arteries frequently occurs during staged palliation of hypoplastic left heart syndrome and variants, often necessitating stent angioplasty. A complication of stent angioplasty is compression of the ipsilateral mainstem bronchus. Following such a case, we re-evaluated our approach to PA stent angioplasty in these patients. The incident case is described. A retrospective observational study of children and adults with superior (SCPC) and/or total cavopulmonary connection (TCPC) undergoing left pulmonary artery (LPA) stent angioplasty between January 1, 2005 and January 5, 2014 and subsequent chest CT was performed to assess the incidence of bronchial compression. The current strategy of employing bronchoscopy to assess bronchial compression during angioplasty is described with short-term results. Sixty-five children and adults underwent LPA stent angioplasty. Other than the incident case, none had symptomatic bronchial compression. Of the total study population, 12 % had subsequent CT, of which one subject had moderate bronchial compression. To date, seven subjects have undergone angioplasty of LPA stenosis and bronchoscopy. In one case, stent angioplasty was not performed because of baseline bronchial compression, exacerbated during angioplasty. In the rest of cases, mild-moderate compression was seen during angioplasty. Following stent angioplasty, the resultant compression was not worse than that seen on test angioplasty. Bronchial compression is a rare complication of stent angioplasty of the pulmonary arteries in children and adults with SCPC/TCPC. Angioplasty of the region of interest with procedural bronchoscopy can help to identify patients at risk of this complication.

Left recurrent laryngeal nerve palsy secondary to left pulmonary artery stent in a child

We report a 10-year-old girl who developed persistent hoarseness after stent placement for the treatment of left pulmonary artery stenosis. Laryngoscopy performed 21 months after stent placement revealed left vocal cord paralysis, presumed secondary to compression of the left recurrent laryngeal nerve by the stent. Pediatric cardiologists should be reminded of this possible rare complication after stent placement.

Bronchial Compression as Adverse Effect of Left Pulmonary Artery Stenting in a Patient with Hypoplastic Left Heart Syndrome

A 5-year-old child with hypoplastic left heart syndrome (HLHS) was noted to have left pulmonary artery stenosis after Glenn shunt placement. Therefore, a stent was implanted into the left pulmonary artery to relieve stenosis. After redilatation of the pulmonary artery stent, wheezing, fatigue, asymmetric bronchial sound, and desaturation was noted. Computed tomography, bronchoscopy, and bronchography confirmed critical left main bronchus compression as a consequence of the mass effect of the dilated stent. Balloon plasty of the left bronchus successfully relieved bronchial stenosis. Tracheobronchial obstruction is a possible adverse effect of vascular stenting in children with congenital heart defects. Balloon plasty seems to be a safe and efficient therapeutic option in those cases.

Completion Angiography After Cardiac Surgery for Congenital Heart Disease: Complementing the Intraoperative Imaging Modalities

Residual structural pathology after cardiac surgery for congenital heart disease may complicate postoperative recovery. Completion angiograms obtained in the operating room may facilitate early detection and therapy of residual structural abnormalities. Our objective here is to report our institutional experience performing completion angiograms after cardiopulmonary bypass surgery. Between October 2007 and August 2008, 31 patients underwent completion angiograms after 32 cardiac surgical procedures. The median age was 7.5 months (range, 50 days to 31.2 years) and the median weight was 6.5 kg (range, 3.1-153 kg). Type of procedure, angiographic findings, and therapeutic decision were retrospectively reviewed. Procedures (proc) evaluated through completion angiography included comprehensive stage II or Glenn (n = 13), aortic arch reconstruction/conduit (n = 3), repair/palliation of tetralogy of Fallot or pulmonary atresia with ventricular septal defect (n = 4), PVR or conduit replacement (n = 5), and others (n = 7). Unexpected pathology was identified in 18 of 32 (56.3%) proc, which included left pulmonary artery (LPA) stenoses (n = 15), right pulmonary artery (RPA) stenoses (n = 11), and stenosis impairing coronary blood flow (after DKS; n = 1). In 9 of 32 (28.1%) proc, findings may have led to a change in therapeutic management. This included surgical revision (n = 1), 'Hybrid' therapy in the same setting (n = 2: LPA stent, 1; RPA balloon, 1), early catheterization within 3 months (n = 4), and change in medical management (n = 2: change in anticoagulation, 1; early CT, 1). Complications related to completion angiography were seen in only a single procedure (LPA staining). In conclusion, completion angiograms using a dedicated Hybrid cardiac operating suite may aid in early diagnosis and therapy of postsurgical abnormalities. They complement other methods of intraoperative imaging and may reduce the potential need for early surgical or transcatheter reintervention.

Hybrid Intraoperative Pulmonary Artery Stent Placement for Congenital Heart Disease

Percutaneous branch pulmonary artery (PA) stenting can be challenging, especially in patients with stenosis of the right ventricular (RV) outflow tract or tortuous PA branches. In these cases, a hybrid procedure deploying PA stent(s) during cardiac surgery provides an alternative to relieve branch PA stenosis. The Mayo Clinic Congenital Cardiac surgical database was used to identify all patients having hybrid PA stent procedures. Retrospective analysis of clinical data, procedural details, and outcomes was performed. Between January 1997 and November 2006, 24 patients (15 females), median age 15 years (range 3 to 67 years), had hybrid PA stent procedures. A total of 27 stents were deployed. A left PA stent was placed in 13, right PA stent in 8; 3 patients had bilateral PA stents. Primary cardiac diagnoses were pulmonary atresia (9), tetralogy of Fallot (7), tricuspid atresia (2), and others (6). Maximum balloon diameters ranged from 8 to 16 mm (median = 12 mm). Concomitant surgical procedures performed were RV to PA conduit replacement or RV outflow tract reconstruction (14), pulmonary valve replacement (7), and others (3). Two procedures were performed following complications of percutaneous procedure. There were no deaths or PA damage. There were 2 cases of distal stent migration. Repeat stent dilations within 6 months were performed in 3 patients. In conclusion, hybrid PA stenting can play an important role in the management of congenital heart disease with complex branch PA anatomy. It also can be used as an emergency rescue procedure following complications of percutaneous transcatheter procedures, such as stent embolization. Hybrid procedures were safe and effective in most patients, although stent positioning remains critical. Intraoperative fluoroscopy and active suture fixation of the proximal stent may reduce the need for late reintervention.