Page 43 - Journal of Structural Heart Disease Volume 3, Issue 4

Case Reports 130
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Figure 3. Transthoracic echocardiogram color- ow Doppler image on post-operative day 5 after the Fontan operation. (Panel A) Evidence of persistent to-and-from ow into the proximal pulmonary artery stump. (Panel B) No evidence of signi cant antegrade ow across the sutured main pulmonary artery into the Fontan circuit.
raphy and uoroscopy. Vascular access consisted of a 5-F percutaneously-placed sheath in the left femoral artery. Angiography of the femoral arterial system con- rmed an appropriate vessel diameter of 4.2 mm for upsizing the arterial sheath. From the left femoral ar- tery sheath, a 5-F pigtail catheter was positioned using a 0.035-in J wire across the aortic valve and through the ventricular septal defect into the right-sided morpho- logic left ventricle. Subsequently, a 0.032-in J wire was positioned through the 5-F pigtail, and an 8.5-F (inter- nal diameter) Agilis steerable sheath (St. Jude Medical, St. Paul, Minnesota) was positioned over the 0.032-in J wire and into the mid-right-sided morphological left ventricular cavity. The Agilis sheath was de ected to allow an angle directly toward the pulmonary valve (Figure 4). During this maneuver, there was a brief (< 3 s) episode of transient complete heart block with no hemodynamic changes. Subsequently, a 6-F multi- purpose A-1 catheter was advanced through the Agilis sheath and positioned immediately distal to the pul- monary valve apparatus for an angiogram (Figure 5). Subsequently, a 0.038-in standard J-wire was advanced into the proximal pulmonary artery, and the 6-F multi- purpose catheter was removed. A 6-F JL 3.5 coronary guide catheter was inserted over this wire into the pulmonary valve stump. This wire was removed, and the coronary guide catheter was used to position a 12- mm Amplatzer Vascular Plug (St. Jude Medical) across the pulmonary valve apparatus. The device was fully
deployed with a waist in the mid-portion (Figure 6), suggesting engagement with the pulmonary valve annulus. A ventriculogram demonstrated a well-posi- tioned device and no evidence of ow into the pulmo- nary valve or pulmonary artery (Figure 7). Subsequent angiography and transesophageal echocardiography demonstrated no signi cant leak around the device but a trivial leak through the device mesh. The previ- ously noted thrombus material remained within the pulmonary out ow stump, with thrombus egress prevented by the device. The femoral arterial sheath was removed, periprocedural antibiotics were admin- istered, aspirin and warfarin were restarted, and there were no unanticipated adverse events.
The patient was maintained on warfarin and aspi- rin post-procedure. An early pre-discharge transtho- racic echocardiogram demonstrated that the vascu- lar occlusion device was in a good position across the pulmonary valve with elimination of lea et motion. A trace amount of prograde ow by color- ow Dop- pler was observed through the device mesh without re ux back across the valve lea ets. The previously noted thrombus remained along the posterior wall of the pulmonary stump. After 6 months, warfarin was discontinued, and aspirin was continued inde nite- ly. No evidence of thrombus recurrence or propaga- tion was detected, nor was there any sign of systemic embolism.
Journal of Structural Heart Disease, August 2017
Volume 3, Issue 4:128-134