Page 46 - Journal of Structural Heart Disease Volume 5, Issue 4

Meeting Abstracts
108
Material and methods: Between 2013 and 2017, a total of89patientsunderwentaroutinecardiaccatheterization before the Fontan procedure. In 4 patients (4,4%) in the age group 2-13 years, the anterograde pulmonary blood flow was detected (including two patients with tricuspid atre- sia, one with an unbalanced atrioventricular septal defect and one with double outlet right ventricle). 3 patients had elevated MPAP (respectively 19 to 22 mmHg) and were treated percutaneously with different types of occluder devices: Amplatzer Muscular VSD Occluder (MuscVSD) (n=1), Amplatzer Duct Occluder II (ADOII) (n=1), CP cover stent (n=1).
In another patient with normal MPAP and recanalization of the surgically sutured pulmonary trunk, the procedure was performed using ADOII.
Results and Complications: Procedural success was achieved in all patients.
All three patients with elevated MPAP had thromboem- bolic incidences. Two patients had thrombus formation in the pulmonary trunk below the device. In one case thrombus formation was detected immediately after the procedure and was successfully treated with anticoagu- lation therapy. The second patient, who was lost in follow up for 10 months, was administered to our institution with thrombus and severe stroke. This patient died a month later. Patient, who was treated with CP cover stent due to significant anterograde pulmonary blood flow and left pul- monary artery stenosis had a thrombosis of the previously implanted stent.Only one patient with elevated MPAP six months later was qualified and scheduled for completion of Fontan circulation due to a normalization of MPAP.
Summary: Percutaneous closure of ventricle-pulmonary connections is technically possible but in our experience is associated with a high incidence of complications. This intervention might be considered only in the circumstance of appropriate anticoagulation.
58. CATASTROPHIC COMPLICATION ENCOUNTERED DURING TRANS-CATHETER CORONARY FISTULA CLOSURE.
Sanjay Khatri, Kanupriya Chaturvedi, Sunil Kaushal, Rajiv Lochan Tiwari, Sanjeeb Roy
Fortis Hospital, Jaipur, India
An 11 month old baby, weighing 6.8 kg was evaluated for poor weight gain and recurrent respiratory tract infections.
Physical examination was suggestive of a patent ductus arteriosus (PDA) and echocardiography confirmed the diagnosis of 3.2 mm PDA, shunting left to right and no additional significant findings.The patient underwent suc- cessful and uneventful device closure of the PDA. Follow up echocardiogram after a month revealed the PDA device in a good position with no residual shunt, however, a new finding of a coronary fistula connecting a dilated and tortuous left main coronary artery to the right atrium was evident. Subsequent echocardiograms suggested the fistula to be hemodynamically significant and the decision to close the fistula was taken.
Aortic root angiogram demonstrated a tortuous fistulous tract with multiple bends which required multiple difficult attempts to cross. A 12 mm vascular plug II was deployed distally and selective coronary angiography showed no coronary compression and the device was released. After a few seconds of device release, the patient devel- oped hypotension and bradycardia,CPR was performed and patient was intubated. An echocardiogram showed severely diminished left ventricular function.
No flow was demonstrated in the anomalous right coro- nary and circumflex arteries in the coronary angiogram. The differentials at the time included device embolization, thromboembolism or coronary artery vasospasm.
The occluded coronaries were crossed with a 0.14x 190 cm BMW wire and thrombosuction was done followed by bal- loon dilatation with1.2 x 8mm and 2.0 x 12 mm balloons sequentially and a temporary pacing lead was positioned in the right ventricle. The patient became hemodynam- ically stable and was shifted to ICU on mechanical venti- lation. GP2b /3a inhibitor bolus was given followed by its infusion and Heparin infusion also started .The myocar- dial enzymes (Trop T 9705 and CPK-MB -204) were mark- edly elevated.
After review of angiograms we concluded that due to the tortuosity of the fistulous tract, multiple bends and mul- tiple attempts to cross this, the procedure time was pro- longed which resulted in clot formation within the sheath, which embolized , during a power angiogram after the deployment of the device and lead to this catastrophe.
After 3 days the inotrops were tapered and stopped, pac- ing lead was removed and the patient was extubated. He was discharged on day 6 with LVEF 35%. On the last follow up after 6 months LVEF was 45-50%.
Journal of Structural Heart Disease, August 2019
Volume 5, Issue 4:75-205