Page 29 - Journal of Structural Heart Disease Volume 4, Issue 2

Case Report
Journal of Structural Heart Disease, April 2018, Volume 4, Issue 2:50-55
DOI: https://doi.org/10.12945/j.jshd.2018.045.17
Received: November 05, 2017 Accepted: December 19, 2017 Published online: April 2018
Evolution of Approach to Right Ventricular Out ow Tract Stenting in Infants ≤ 2Kgs
Niall Linnane, MB, BCh, BAO*, Kevin P. Walsh, MD, Jonathan McGuinness, MB, PhD, Damien Kenny, MD
Department of Paediatric Cardiology and Cardiac Surgery, Our Lady’s Children’s Hospital, Crumlin, Crumlin, Drimnagh, Dublin, Ireland
Abstract
Surgical palliation or repair of symptomatic Tetralogy of Fallot in the neonatal period is associated with a relatively high mortality rate. Stenting of the right ventricular out ow tract is a newer procedure that has evolved to allow its performance in low birth weight neonates. In this case series, we describe the evolution of our approach to right ventricular out ow tract stent implantation in neonates weighing < 2 kg.
Copyright © 2018 Science International Corp.
Key Words
Congenital heart disease • Cardiac catheterisation • Tetralogy of Fallot • Low birth weight
Introduction
Surgical palliation or repair of symptomatic Tetral- ogy of Fallot (ToF) in the neonatal period is associat- ed with a relatively high mortality rate. A large con- temporary database of over 3,000 patients reports 6.2% mortality associated with palliative modi ed Blalock-Taussig-Thomas (BTT) shunt and 7.8% mor- tality for primary neonatal repair [1]. Thus, in many centers, alternative palliative options for promot- ing pulmonary arterial blood ow and growth have been evaluated, including stenting of the arterial duct [2], pulmonary balloon valvuloplasty [3], and, more recently, stenting of the right ventricular out- ow tract (RVOT) [4-10]. Pulmonary balloon valvu-
loplasty has not gained widespread acceptance, as subvalvar muscular obstruction has been shown to be unresponsive to ballooning alone; however, in some substrates with predominant valvar obstruc- tion, this option remains [11-13]. RVOT stenting was initially described by Gibbs et al. [4]; however, a larger, more contemporary series of 52 patients reported by Stumper et al. [5] demonstrated excellent outcomes. The authors concluded that RVOT stenting is a viable rst-line treatment option for selected patients with severe RVOT obstruction as an alternative to system- ic-to-pulmonary artery shunting procedures and for whom early complete repair carries signi cant ad- ditional risk or complexity. Only one patient in this cohort weighed < 2 kg. Despite signi cant advance- ments in stent design and pro le to support stent de- livery in low birth weight (LBW) infants, this cohort of patients remains a challenge, with a recent report suggesting a procedural mortality of 12% associated with interventions in infants < 2 kg [14].
In the past 4 years, we have placed 58 RVOT stents in 53 patients, with 4 patients weighing ≤ 2 kg. Ini- tially, we pursued a percutaneous approach in all pa- tients; however, we have now moved to a perventric- ular approach through a small subxiphoid incision for patients < 2 kg. This approach provides a more direct route to the RVOT and possibly lessens the likelihood of hemodynamic instability induced by splinting the tricuspid valve. This report outlines these cases and
* Corresponding Author:
Niall Linnane, MB, Bch, BAO
Department of Paediatric Cardiology and Cardiac Surgery
Our Lady’s Children’s Hospital, Crumlin
Cooley Road, Crumlin, Drimnagh, D12 V004, Ireland
Tel. +353 1 4096160; Fax: + 353 1 4096181; E-Mail: niall.p.linnane@gmail.com
Fax +1 203 785 3346
E-Mail: jshd@scienceinternational.org http://structuralheartdisease.org/
© 2018 Journal of Structural Heart Disease Published by Science International Corp. ISSN 2326-4004
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