Postoperative Pulmonary Artery Stenosis Research Articles

B-35 | Comparison of Premounted Drug Eluting Stents vs. Non-Eluting Stents for the Treatment of Pulmonary Artery Stenosis In Smaller Patients

Small patients with congenital or post-operative pulmonary artery stenosis (PAS) often require multiple catheterizations. Frequently, balloon angioplasty results in only temporary improvement and occasionally, stenting is necessary. Pre-mounted stents have a low profile and are easier to advance in this population, and recent evidence has shown some of these stents can be fractured longitudinally with high pressure balloons allowing for further growth potential. However, restenosis is common in bare metal stents.

Postoperative pulmonary artery stenosis in lung transplantation recipients: review of case series

Background: Postoperative pulmonary artery stenosis (PAS) is rare complication that can appear lung transplant recipients due to inappropriate donor to recipient lung size matching. In this study, we retrospectively reviewed patients who were diagnosed PAS after lung transplantation. Methods: Medical records were retrospectively reviewed in the group of lung transplant recipients from 2012 to 2019 in Sever ance Hospital, Korea. Results: Among 267 recipients who underwent lung transplantation from October 2012 to December 2019, 12 patients were diagnosed PAS and treated accordingly. Four patients received surgical treatment. Six patients were successfully received in terventional therapy: pulmonary angioplasty or pulmonary artery (PA) stent insertion. Two patients were under observation due to benign progress. Mortality were observed in three patients, and one death was related to PAS. Three patients had either left or right donor-to-recipient PA mismatch and four patients had donor lung size mismatch. After excluding the mortality and ob servant cases, eight patients had relief of symptoms and five patients showed increased outcome in before-and-after perfusion scan. Most common initial manifestation was progressive dyspnea and chest discomfort (seven cases), while median time of diagnosis-to-treatment was 36 days. Seven patients were diagnosed PAS in 2 weeks from day of lung transplantation. In this group, most common clue for diagnosis was acute change of chest X-ray (increased haziness) and hypoxemia. On contrary, five patients who were diagnosed after 2 weeks tended to not show acute change in chest X-ray, rather most common phenomenon was progressive dyspnea, chest discomfort, and prolonged pneumonia. Conclusions: PAS after lung transplantation can be managed by either PA intervention or surgical approach depending on cir cumstance of patients. Mortality were most likely associated with underlying patient’s condition such as septic shock. Progres sive dyspnea, chest discomfort, hypoxemia, and left lung haziness in chest X-ray may indicate PAS. Early diagnosis-to-treatment is vital for favorable outcome.

Repair of Anomalous Aortic Origin of Pulmonary Artery: Technique Matters

The anomalous aortic origin of a pulmonary artery (PA) is uncommon, usually occurring on the right. Less commonly, the left PA is involved, often with a right-sided arch. Although referred to by some as “hemitruncus,” two semilunar valves are present. 1 Jacobs M.L. Congenital heart surgery nomenclature and database project: truncus arteriosus. Ann Thorac Surg. 2000; 69: S50-S55 Abstract Full Text Full Text PDF PubMed Google Scholar Because the right lung is exposed to systemic pressures, and the left receives the entire (and increased) cardiac output, there is high risk for developing pulmonary vascular disease (PVD). Typically, patients present with heart failure in infancy and undergo repair on diagnosis. The crux of the repair is translocation of the anomalous vessel to the main PA using various techniques. 2 Prifti E. Bonacchi M. Vanini V. Bartolozzi F. Double-flap technique for repair of anomalous origin of right pulmonary artery from ascending aorta. Ann Thorac Surg. 2004; 78: 1883-1884 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Whereas all report excellent short-term outcomes, varied rates of postoperative PA stenosis have been demonstrated. 3 Nathan M. Rimmer D. Piercey G. et al. Early repair of hemitruncus: excellent early and late outcomes. J Thorac Cardiovasc Surg. 2007; 133: 1329-1335 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Outcomes of Surgical Reimplantation for Anomalous Origin of One Pulmonary Artery From the AortaThe Annals of Thoracic SurgeryVol. 111Issue 4PreviewAnomalous origin of one pulmonary artery from the ascending aorta (AOPA) is a rare and potentially deadly anomaly. Little research, aside from case reports on APOA, has been published, especially for patients with late referrals. Full-Text PDF

Outcomes of Surgical Reimplantation for Anomalous Origin of One Pulmonary Artery From the Aorta

Anomalous origin of one pulmonary artery from the ascending aorta (AOPA) is a rare and potentially deadly anomaly. Little research, aside from case reports on APOA, has been published, especially for patients with late referrals. This study was a retrospective review of 57 patients with AOPA who underwent reimplantation of the pulmonary artery (PA) from 2009 to 2019. Two different reimplantation methods were used to correct the anomaly, including direct anastomosis in 36 patients and angioplasty with autologous tissue in 21 patients. The median age at repair was 2.8 months (range, 8 days to 3.6 years). In-hospital death occurred in 2 patients (3.5%). Five patients (9.1%) with a median age of 9.3 months (range, 5.2 months to 3.6 years) experienced a pulmonary hypertensive crisis. Patients older than 4.9 months were more likely to have a pulmonary hypertensive crisis (P= .001). The 2-year freedom from postoperative PA stenosis rate was 75.3% in patients who underwent direct anastomosis and 46.8% in patients who underwent autologous tissue angioplasty (χ2= 4.878; P= .027). Angioplasty with autologous tissue (hazard ratio, 5.03; 95% confidence interval, 1.61 to 15.71; P= .005) and an innately smaller diameter of the aberrant PA (hazard ratio, 0.65; 95% confidence interval, 0.45 to 0.92; P= .015) were 2 independent risk factors for postoperative PA stenosis. Surgical reimplantation of the PA in patients with AOPA has resulted in favorable early and midterm outcomes. Pulmonary hypertensive crisis occurs more commonly in patients who receive a diagnosis after the age of 4.9 months. Reimplantation with autologous tissue augmentation and an intrinsically smaller diameter in affected PAs are 2 independent risk factors for postoperative PA stenosis.

Bronchial compression as adverse effect of right pulmonary artery stenting in a patient with truncus arteriosus communis and interrupted aortic arch: a case report

Aortic arch obstruction and bronchial compression are possible post-operative complications in patients with truncus arteriosus communis (TAC) with interrupted aortic arch (IAA). We present a case of bronchial compression as adverse effect of right pulmonary artery (PA) stenting in an infant with TAC (type 4A)-IAA (type B) repair. Due to growth potential, self-expandable metal stent was applied for postoperative proximal right PA stenosis, which caused bronchial compression. Later, we found patient having bronchomalacia. Surgical removal was needed. Stent insertion might be an option for postoperative PA stenosis, but bronchial compression might be a potential risk particularly in patients with bronchomalacia.

Postoperative pulmonary artery stenosis: current options and future directions.

This study by Kim et al . (1) addresses an important and frequent issue in pediatric cardiac surgery, which is the management of postoperative pulmonary artery (PA) branches stenoses. Different options are currently available to treat a PA branch stenosis, including a conventional surgical plasty using (or not) a biological patch (autologous pericardium, human cryopreserved pericardium, bovine or equine pericardium, or decellularized porcine intestinal submucosa extracellular matrix) or a synthetic patch (polytetrafluoroethylene, terephtalate, ...), percutaneous procedures (balloon dilation, stent placement, cutting balloon dilation, ...) and hybrid procedures.

7. Long term results of quadrangular autologous pericardial patch reconstruction of the pulmonary artery during arterial switch operation on post-

The aim of this retrospective study is to evaluate the technique of Quadrangular Fresh Autologous Pericardial Patch for the reconstruction of the pulmonary artery in Arterial Switch Operation (ASO) to prevent the post-operative pulmonary artery stenosis (PAS). A total of 287 consecutive infants with transposition of great arteries were treated with ASO in our center between January 2000 and September 2014. The mean age was (7.76 days) and mean weight was (3.67 kg). The new pulmonary arterial root was reconstructed with a fresh quadrangular autologous patch. The technique includes extensive mobilization of both pulmonary artery branches and direct suturing of the parch to 2/3 of the annulus of the new pulmonary artery trunk first, and then reconstruction finish by the re-suspension of the posterior commissure of the new pulmonary valve inside the patch. Patients were examined using trans-thoracic echocardiography consecutively at discharge form the hospital, and at 3–6 months and yearly after discharge. The mean follow up time was 78 months. The early mortality was 5.19% (17 patients), and there were no late mortality. The highest mortality was reported during the beginning of the pediatric surgical program. The mortality for the last 100 patients was 1%. The pressure gradient across the pulmonary valve in 249 patients (87%, was less than 20 mmHg. Mild pulmonary stenosis (pressure gradient of 20–40 mmHg) was present in 32 patients (11.14%) and moderate pulmonary stenosis with gradient 40–60 mmHg was manifested in 4 patients (1.39%). Reconstruction of the new Pulmonary artery during the ASO, using the quadrangular autologous fresh pericardial patch, is effective and reproducible in reducing the incidence of post-operative pulmonary stenosis.

Sutureless Patch Angioplasty for Postoperative Pulmonary Artery Stenosis in Congenital Cardiac Surgeries

Reconstruction of branch pulmonary arteries (PAs) can be demanding in redo congenital cardiac surgeries. Sutureless patch angioplasty could be a useful method to solve this problem, and we evaluated the feasibility of sutureless patch angioplasty for postoperative PA stenosis in patients who underwent congenital cardiac surgery. We retrospectively reviewed 28 patients (19 males and 9 females) who underwent sutureless patch angioplasty for postoperative PA stenosis between November 2004 and April 2015. The median age was 7.3 months (range, 4.3 to 54.7), and the median weight was 7.2 kg (range, 5.3 to 12.2 kg). Right PA angioplasty was performed in 5, left PA angioplasty in 10, and both sides in 13 patients. The most common original diagnosis was hypoplastic left heart syndrome (n = 18 of 28, 64.3%). Concomitant surgeries were the bidirectional cavopulmonary shunt in 24 patients, the Fontan operation in 3, and the Rastelli operation in 1 patient. No operative death occurred. However, 2 late deaths were recorded, and both were unrelated to PA angioplasty. Mean follow-up duration was 60.9 ± 33.1 months. None of the patients had postoperative bleeding or thrombotic occlusion. No reoperation for PA restenosis was performed, and only 1 patient (3.6%) had a PA balloon angioplasty with a good result 12.9 months after the operation. Echocardiography or computed tomography angiography at the recent follow-up showed good branch PAs in all patients. Sutureless patch angioplasty for postoperative PA stenosis could simplify PA angioplasty, and be a safe and effective method for PA reconstruction in patients who undergo congenital cardiac surgery.

Initial experience with the new Pul-Stent in treating postoperative branch pulmonary artery stenosis

The Pul-stent is a new cobalt alloys stent, specially licensed for pulmonary artery stenosis. The aim of this study was to investigate the value of the stent implantation as the treatment of postoperative pulmonary artery stenosis. Clinical practice was carried out to evaluate effectiveness, safety and maneuverability of Pul-stent in the defined clinical setting. Transthoracic echocardiography, chest roentgenography and electrocardiography were carried out as follow-up studies at 1 and 3 months after procedures. Ten patients (7 males and 3 females) received Pul-stent implantation in left or right pulmonary arteries (9 stents in left and 1 stent in right). For 9 cases transcatheter stent implantation was performed and in I case hybrid procedure. The median age was 7. 9 years (range 3. 4 - 13. 7 years). The median weight was 22. 3 kg (range 13 - 32 kg). Among them 6 cases were post surgical repair of tetralogy of Fallot, 2 cases were after Fontan procedures, 1 patient was post surgical repair of pulmonary atresia with ventricular septal defect, and 1 patient had stenosis at Glenn pathway. The pressure gradient at the stenosis decreased from (31. 6 ± 10. 2) mmHg(1 mmHg =0. 133 kPa) to (7. 3 ± 10. 3) mmHg, and the diameter of the narrowest segment increased from (4. 0 ± 2. 3) mm to (9. 6 ± 2. 7) mm, the right ventricle to aortic pressure ratio decreased from 0. 54 to 0. 36, all of these improvements were statistically significant (t = 3. 9, -9. 7, 4. 5; P =0. 008, 0. 000, 0. 004). The total procedure time ranged from 55 to 220 min (median 117 min) , and the fluoroscopy time ranged from 9 to 67 min (median 26 min). There were 2 cases of post-stenting pneumorrhagia. No stent fracture, stent malposition and other severe complications were observed. Initial follow-up of 1 and 3-months showed good results with maintenance of improved caliber of the stented vessel, and the gradient across the stenosis area measured by echocardiography was (32. 0 ± 14. 6) mmHg after 3 months. Compared with before stentifng ((40.6 ± 15. 2) mmHg) and 1 month later ((30. 6 ± 13. 6) mmHg), the difference was not statistically significant (t =2. 2,1. 76; P =0. 07, 0. 10). Pul-Stent tracking and delivery was excellent, the initial experience has shown that Pul-stent implantation was effective and safe in treating post-operative branch pulmonary artery stenosis. Further follow-up study should be conducted to make sure whether those good results would be kept constant.

術後肺動脈狭窄に対するnoncompliant balloonの有効性に関する検討

背景：先天性心疾患術後の肺動脈狭窄に対するバルーン拡大術 balloon dilatation （BD）は，術後肺循環の改善を目指すうえで重要な治療戦略である．最近では，従来よりもカテーテルの追従性が良いnoncompliant balloons（NBs）が開発され，その使用が広まってきている．目的：術後肺動脈狭窄に対するNBの有効性を，semi-compliant balloons（SBs）と比較し検証する．方法：2007年4月から2013年4月の間に当院でBDを行った術後肺動脈狭窄136症例154病変を対象に，後方視的に検討した．結果：術後肺動脈狭窄に対するBDの内訳は，SB群70症例78病変，NB群66症例76病変であった．BD後のwaist解除率は，SB群で45％に対しNB群では80％（p < 0.001）と，NB群で有意にwaistを解除し得た．一方，使用されたバルーンサイズの最狭窄部径に対する比率では，SB群で259 ± 6.6％に対しNB群では214.9 ± 6.1％（p < 0.001）と，NB群においてより小さなバルーンサイズ比率で有効な拡大が得られていた．結論：NBは，SBよりも小さなバルーンサイズ比率でより確実に狭窄を解除し得る．

Comprehensive management of branch pulmonary artery stenosis.

Branch pulmonary artery stenosis may occur as an isolated finding or in conjunction with other cardiac malformations; it may be congenital or acquired postoperatively. Transcatheter management with balloon pulmonary angioplasty (BPA) and/or endovascular stenting is generally considered the procedure of choice for most patients. With the introduction of high-pressure balloons, the results of BPA have improved significantly (75%). Stent implantation has increased the success rate to over 90%. However, BPA continues to be the initial procedure of choice for distal stenoses, or those associated with branching points, and in small children or infants. Stent implantation is preferred over BPA for central or proximal stenoses, and those due to kinking or tenting, external compression, intimal flaps, failed balloon dilation, and early postoperative procedures. Certain lesions, such as supravalvar pulmonary stenosis, or stenosis at the branch pulmonary arteries bifurcation, are better dealt with at surgery. High-risk situations for the development of postoperative pulmonary artery (PA) stenosis exist in small infants with hypoplastic branch PAs after a conotruncal procedure, after duct ligation, after shunt insertion, after PA band placement, or after pulmonary arteriotomies or anastomoses of any kind. A combined collaborative transcatheter and surgical approach is essential for many patients with PA stenosis, particularly in complex forms of tetralogy of Fallot.

Balloon angioplasty for postoperative pulmonary artery stenosis in transposition of the great arteries

Objectives. This study was designed to assess the success rate and determinants of success or failure of balloon angioplasty for postoperative pulmonary stenosis in patients with transposition of the great arteries.Background. Previous reports have suggested that pulmonary stenosis that develops after the arterial switch operation is not likely to be dilated.Methods. Twenty-eight patients with transposition of the great arteries underwent 39 balloon angioplasty procedures after the arterial switch operation. The mean age at dilation was 4.5 ± 2.2 years (range 0.7 to 9.8), and the interval between operation and balloon dilation was 3.6 ± 1.8 years. The criterion of successful dilation was a ≥50% increase in predilation diameter or a ≥50% decrease in predilation pressure gradient. If the right ventricular/ aortic pressure ratio decreased by ≥0.2, so that the ratio became <0.68, reoperation was thought to be not indicated.Results. The success rate of balloon angioplasty for pulmonary artery stenosis was 51% (20 of 39 dilations). The mean age at dilation in the group with successful dilation (3.6 years) was significantly younger than that in the group with unsuccessful dilation (5.4 years). The interval between operation and dilation in the successful dilation group (2.4 years) was significantly less than that in the unsuccessful dilation group (4.6 years). In 13 patients who underwent balloon angioplasty <3.5 years after operation, balloon dilation was successful in 92%. The balloon/artery ratio was significantly greater in the successful than in the unsuccessful dilation group. A right ventricular/aortic pressure ratio ≥ 0.68 was observed in 20 patients, and reoperation was not indicated in 10 patients (50%). There was no death, but one pulmonary artery rupture that did not require surgical intervention occurred. Aneurysmal dilation of the pulmonary artery was observed in three patients.Conclusions. These data indicate that although the success rate of balloon angioplasty for pulmonary artery stenosis after the arterial switch operation is low (≈50%), balloon angioplasty can be the first therapeutic choice owing to the low complication rate and the potential benefit of the procedure. The success rate can be high if angioplasty is performed <3.5 years after operation and a balloon of adequate size is used.