Page 22 - Journal of Structural Heart Disease Volume 3, Issue 6

Case Report 178
Figure 2. Panel A. Chest radiograph 1 day prior to stent placement. Di use pulmonary edema is seen. Panel B. Chest radiograph 1 day after stent placement in the vertical vein. The stents are visible along the left sternal border. There is improvement in the pulmonary edema.
MA, USA) was advanced into the right lower pulmo- nary vein, and the Glide catheter was exchanged for a Palmaz Blue 6 × 16 mm stent (Cordis, Fremont, CA, USA) that was deployed in the VV. Due to a persistent residual gradient, a Palmaz Blue 6 × 12 mm stent was telescoped proximally within the prior stent to ensure resolution of the obstruction within the VV (Figure 1B). Repeat hemodynamics demonstrated a pressure gradient between the pulmonary venous con uence and the left innominate vein of 4 mmHg. Oxygen saturation improved to 95% on 50% oxygen, which was reduced to room air over 48 hours. Repeat chest X-ray showed improvement of the pulmonary edema (Figure 2A and 2B).
Over the following 3 weeks, pulmonary edema developed again despite medical management with diuretics. At 26 days of age, the patient had gained approximately 200 g and underwent TAPVC repair. He recovered well, was extubated, and weaned to room air by postoperative day 5. He was discharged on postoperative day 21 on once daily furosemide.
Discussion
Low birth weight is an independent risk factor in the operative management of obstructive TAPVC [5, 6, 9]. Patients who undergo emergent VV stent im- plantation prior to de nitive surgery often present with respiratory distress and cyanosis secondary to pulmonary congestion [4]. In this case, the patient showed no evidence of pulmonary venous obstruc- tive disease, the presentation of which leads to emer- gent surgery. The patient’s respiratory support was more suggestive of pulmonary overcirculation due to the large left-to-right shunt produced by the anom- alous pulmonary venous return. Our clinical strategy was to allow the patient to achieve additional somat- ic growth to mitigate the increased morbidity and mortality observed in low birth weight neonates with this disease.
Over the last decade, surgical outcomes of TAPVC repair have improved with better control of pulmo- nary hypertension and preoperative clinical stabili- zation due to more aggressive medical management [6, 9]. Our case presents an opportunity to consider an interventional strategy that palliates the disease to prevent an urgent need for de nitive repair. Stent
Journal of Structural Heart Disease, December 2017
Volume 3, Issue 6:176-179