Page 68 - Journal of Structural Heart Disease Volume 5, Issue 4

Meeting Abstracts
130
Medicine, Grand Rapids, USA. 3West Michigan Anesthesia, Grand Rapids, USA
Introduction: Neonates with muscular pulmonary atresia with intact ventricular septum (PA/IVS) are traditionally managed by surgical intervention. We describe hybrid approach for decompressing the right ventricle (RV) in a neonate with muscular PA/IVS, and severe tricuspid regur- gitation (TR).
Case Description: A 3-day-old male was born with mus- cular PA/IVS, dysplastic tricuspid valve, severe TR, secun- dum atrial septal defect (ASD), adequate RV size, and tortuous patent ductus arteriosus (PDA) with left-to-right shunt. Prostaglandin E-2 (PGE-2) was initiated to main- tain patency of the ductus arteriosus. A multidisciplinary team recommended diagnostic cardiac catheterization for hemodynamic assessment, rule out RV-dependent coro- nary circulation (RV-DCC), and attempt decompressing the RV via hybrid approach.
Intervention: Hemodynamic assessment showed supra-systemic RV systolic pressure with no angiographic evidence of RV-DCC. However, a large area of the ante- rior RVOT wall and RV free wall were stained by contrast with small amount of contrast spread in the pericardium. To avoid further trauma to the RV, we elected not to per- form simultaneous RV and main pulmonary artery (MPA) angiogram, and proceeded with the planned median ster- notomy. Spreading RVOT hematoma was noticed. A purse string suture was placed in the RV free wall below the hematoma. A 7 cm 21-gauge One-Part Percutaneous Entry Needle was attached to the pressure tracing, advanced via the purse-string suture, and directed towards the atretic pulmonary valve. Once a pulmonary artery tracing was obtained, a 0.014’’ mailman guidewire was inserted inside the 21-gauge needle with the tip in the distal left pulmo- nary artery. To facilitate stenting the atretic pulmonary valve, a 6-Fr sheath was placed in the RV free wall. The RV wall and atretic valve were dilated with the inner dilator of a 3-Fr sheath. The positioning of the tip of the inner dila- tor in the MPA was confirmed by angiogram. A 6-Fr vas- cular sheath was then exchanged for the 3-Fr inner dilator over the mailman guidewire. Subsequently, an 8mm x 12mm transhepatic biliary stent was deployed. RV angio- gram showed only the proximal row of the stent was across the atretic valve. To maximize the stability of the stent, a 6mm x 12mm Herculink Elite stent was deployed. The distal 1/3 of the second stent was deployed inside the first stent with the proximal 2/3 inside the RV across the atretic pul- monary valve. Subsequently, this stent was dilated with an 8mm x 12mm balloon. RV angiogram showed the stents in
a stable position with good expansion. At the end of case, systolic RV pressure was near systemic. PGE-2 was turned off. Transthoracic echocardiogram 2 days later revealed mild TR with gradient of 28mmHg, predominantly left-to- right shunt across the ASD, good stent configuration with no obstruction to the flow, normal cardiac systolic func- tion, and small PDA.
Conclusion: Hybrid approach for decompression of the hypertensive RV in patients with muscular PA/IVD is fea- sible and safe in selective cases. In order to avoid cardio- pulmonary bypass in neonates, hybrid approach must be considered as a treatment option.
90. AORTIC REMODELING IN PATIENTS TREATED WITH INTRAVASCULAR STENT THERAPY FOR COARCTATION: A LONG-TERM FOLLOW-UP SINGLE CENTRE EXPERIENCE
Louise Pei1, Annamalar Muthuppalaniappan2, Ricardo Romero2, Mark Osten2, Jaime Sklar1, Eric Horlick2
1University of Toronto, Toronto, Canada. 2UHN, Toronto, Canada
Background: It is generally perceived that repaired aortic coarctation no longer requires further surveillance, hence asymptomatic patients are discharged without long-term follow up. However, complications are still seen in this population post-repair. To understand the development of these abnormalities, analysis of serial catheterizations and other cross-sectional imaging as well as defining the long- term outcomes is crucial.
Objective: We wished to define long-term clinical and pro- cedural outcomes after stent implantation in a single cen- ter population with a focus on serial imaging.
Methods: We analyzed paired serial cross-sectional imaging of patients post stent therapy and compare this to baseline data. Volumetric and cross-sectional aortic remodeling on CT/MR images and catheterizations were measured using medical imaging programs and indexed to patient BSA.
Results: 133 patients underwent transcatheter coarcta- tion closure in a single center. 32% of patients underwent at least 1 follow-up MR/CT, and 78% of patients underwent at least 1 follow-up post-op catheterization. Total mean follow-up time was 2.16 years. 5% of patients underwent re-intervention due to complications. 3% of the cohort developed aneurysms and 3% saw stent fractures during FU. An approximate 40% reduction in hypertensive states was seen when comparing baseline to post-stent therapy reports. There was significant cross-sectional negative
Journal of Structural Heart Disease, August 2019
Volume 5, Issue 4:75-205