Case Reports: Congenital
Aortopulmonary window due to transcatheter pulmonary valve implantation after arterial switch operation: Where is the limit? Marıa-Teresa Gonzalez-L opez, MD,a Juan-Miguel Gil-Jaurena, MD,a Jose-Luis Zunzunegui-Martınez, MD,b and Reyes Alvarez-Garc ıa-Roves, MD,b Madrid, Spain Right-sided lesions occur in 5% to 25% of patients after the arterial switch operation (ASO). Different options of percutaneous or surgical treatment are available, although they are not complication-free.1 We present the first case of an aortopulmonary window (APW) due to transcatheter pulmonary valve implantation after ASO. CLINICAL SUMMARY A 2-month-old baby with a diagnosis of dextrotransposition of the great arteries underwent the ASO (LeCompte maneuver). At the age of 10 years, a covered stent was placed on the main pulmonary artery (PA) for supravalvular pulmonary stenosis, but secondary pulmonary regurgitation developed. The patient was referred for transcatheter pulmonary valve implantation at the age of 11 years. A 22-mm, stent-mounted valved bovine jugular vein graft (Melody valve; Medtronic Inc, Minneapolis, Minn) was implanted, but the patient became hemodynamically unstable (pulmonary-to-systemic ratio 1.96). Transesophageal echocardiography (TEE) showed a traumatic APW in the uppermost portion of the ascending aorta. Hemodynamic stability was achieved after closure using a 10-mm Amplatzer Muscular VSD Occluder (AGA Medical Corp, Golden Valley, Minn) (Figure 1, A), but he remained symptomatic in the subsequent weeks. TEE showed residual left-to-right shunt in the proximal margin, and a covered stent was implanted on the left PA to deal with the residual shunt, but the Amplatzer was dislocated (Figure 1, B) and the patient was referred for emergency surgery. Arterial cannulation was performed through the left femoral artery, and the inferior venae cavae and right atrium were cannulated separately. The patient was cooled to 18 C, From the Pediatric Cardiac Surgery Departmenta and Pediatric Cardiology Department,b Gregorio Mara~ n on Hospital, Madrid, Spain. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Oct 6, 2014; accepted for publication Oct 11, 2014; available ahead of print Nov 20, 2014. Address for reprints: Marıa-Teresa Gonzalez-Lopez, MD, Pediatric Cardiac Surgery Department, Gregorio Mara~non Hospital, C/O’Donnell 48-50, Madrid 28009, Spain (E-mail: [email protected]). J Thorac Cardiovasc Surg 2015;149:e38-9 0022-5223/$36.00 Copyright Ó 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2014.10.079
e38
FIGURE 1. A, Cardiac catheterization. Melody valve (Medtronic Inc, Minneapolis, Minn) and stent (descending aorta) are shown. Amplatzer device (yellow arrow) into the APW. B, Displacement of the Amplatzer device (yellow arrow) after implantation of the left PA stent. Ao, Aorta; LPA, left pulmonary artery; PA, pulmonary artery.
and ventricular fibrillation was achieved. Carbon dioxide field flooding was used throughout the procedure. The circulation was arrested, and the right PA was incised and extended toward the left PA (Figure 2). Both percutaneous devices were removed, and the APW was closed with a 0.5-mm–thick polytetrafluoroethylene (Gore-Tex; WL Gore & Associates Inc, Flagstaff, Ariz) patch. The PA and branches were reconstructed (total bypass time 150 minutes and total arrest time 23 minutes). TEE showed no residual shunts. The patient had an uneventful recovery and was discharged on postoperative day 10.
The Journal of Thoracic and Cardiovascular Surgery c March 2015
Case Reports: Congenital
FIGURE 2. A, APW (20 3 15 mm) is shown. No formed inferior rim was noted separating the APW from the stent-mounted valve (arrow). B, Surgeon’s view. The polytetrafluoroethylene (Gore-Tex; WL Gore & Associates Inc, Flagstaff, Ariz) patch is sutured. LPA, Left pulmonary artery; PA, pulmonary artery; RPA, right pulmonary artery.
DISCUSSION Percutaneous treatment is an option for selected right-sided lesions after ASO, but the presented case highlights the importance of appropriate selection criteria before performing any interventional procedure in patients with congenital disease with prior surgery. Our case was a harrowing account of misguided attempts for avoiding redo surgery. The initial attempt to place a stent in the main PA was not ill considered, and it predictably caused pulmonary regurgitation. After the LeCompte maneuver, the length of the resultant main PA obviously is shorter than usual and any attempt to place a stent then ‘‘jails’’ the PA branches or the valve leaflets. Surgical PA reconstruction would be the best approach, avoiding any injury to the pulmonary valve. There are several ideas surrounding transcatheter pulmonary valve implantation in patients with ASO. The adherence between the aorta and the PA on performing the LeCompte maneuver and the protrusion of the stent-mounted valve into the PA bifurcation may result in an APW, which in the case reported could not be closed by a combination of devices. Surgical repair is a highly effective technique for the management of traumatic APW, and elective surgery should be chosen in these cases unless the patient is hemodynamically unstable.2,3 In addition, care should be taken to avoid using the Melody valve in patients with ASO, and a surgical option such as
a valved conduit is advised when significant pulmonary regurgitation has developed. Our surgical approach, including arterial peripheral cannulation, deep hypothermic circulatory arrest, fibrillation, and carbon dioxide, may provide an alternative to existing approaches, particularly when access to the ascending aorta and aortic root is extremely difficult because of the anatomic substrate. CONCLUSIONS In the era of interventional cardiology, offering novel approaches for complex congenital cases can be ‘‘attractive,’’4,5 but a feasible option is not always desirable, and stenting or device implantation in these patients should be carefully assessed. References 1. Takayama H, Sekiguchi A, Chikada M, Noma M, Ishida R. Aortopulmonary window due to balloon angioplasty after arterial switch operation. Ann Thorac Surg. 2002;73:659-61. 2. Backer CL, Mavroudis C. Surgical management of aortopulmonary window: a 40-year experience. Eur J Cardiothorac Surg. 2002;21:773-9. 3. Noonan P, Desai T, DeGiovanni J. Closure of an aortopulmonary window using the Amplatzer Duct Occluder II. Pediatr Cardiol. 2013;34:712-4. 4. Peer SM, Sinha P. Percutaneous pulmonary valve implantation after Ross-Konno aortoventriculoplasty: a cautionary word. J Thorac Cardiovasc Surg. 2014;147: 74-5. 5. Bernier PL, Hallbergson A, Schachtner SK, Rome JJ, Gaynor JW. Aortopulmonary fistula after outflow tract stent in repaired truncus. Ann Thorac Surg. 2014;98:55-7.
The Journal of Thoracic and Cardiovascular Surgery c Volume 149, Number 3
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Aortopulmonary window due to transcatheter pulmonary valve implantation after arterial switch operation: Where is the limit? Marıa-Teresa Gonzalez-L opez, MD,a Juan-Miguel Gil-Jaurena, MD,a Jose-Luis Zunzunegui-Martınez, MD,b and Reyes Alvarez-Garc ıa-Roves, MD,b Madrid, Spain Right-sided lesions occur in 5% to 25% of patients after the arterial switch operation (ASO). Different options of percutaneous or surgical treatment are available, although they are not complication-free.1 We present the first case of an aortopulmonary window (APW) due to transcatheter pulmonary valve implantation after ASO. CLINICAL SUMMARY A 2-month-old baby with a diagnosis of dextrotransposition of the great arteries underwent the ASO (LeCompte maneuver). At the age of 10 years, a covered stent was placed on the main pulmonary artery (PA) for supravalvular pulmonary stenosis, but secondary pulmonary regurgitation developed. The patient was referred for transcatheter pulmonary valve implantation at the age of 11 years. A 22-mm, stent-mounted valved bovine jugular vein graft (Melody valve; Medtronic Inc, Minneapolis, Minn) was implanted, but the patient became hemodynamically unstable (pulmonary-to-systemic ratio 1.96). Transesophageal echocardiography (TEE) showed a traumatic APW in the uppermost portion of the ascending aorta. Hemodynamic stability was achieved after closure using a 10-mm Amplatzer Muscular VSD Occluder (AGA Medical Corp, Golden Valley, Minn) (Figure 1, A), but he remained symptomatic in the subsequent weeks. TEE showed residual left-to-right shunt in the proximal margin, and a covered stent was implanted on the left PA to deal with the residual shunt, but the Amplatzer was dislocated (Figure 1, B) and the patient was referred for emergency surgery. Arterial cannulation was performed through the left femoral artery, and the inferior venae cavae and right atrium were cannulated separately. The patient was cooled to 18 C, From the Pediatric Cardiac Surgery Departmenta and Pediatric Cardiology Department,b Gregorio Mara~ n on Hospital, Madrid, Spain. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Oct 6, 2014; accepted for publication Oct 11, 2014; available ahead of print Nov 20, 2014. Address for reprints: Marıa-Teresa Gonzalez-Lopez, MD, Pediatric Cardiac Surgery Department, Gregorio Mara~non Hospital, C/O’Donnell 48-50, Madrid 28009, Spain (E-mail: [email protected]). J Thorac Cardiovasc Surg 2015;149:e38-9 0022-5223/$36.00 Copyright Ó 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2014.10.079
e38
FIGURE 1. A, Cardiac catheterization. Melody valve (Medtronic Inc, Minneapolis, Minn) and stent (descending aorta) are shown. Amplatzer device (yellow arrow) into the APW. B, Displacement of the Amplatzer device (yellow arrow) after implantation of the left PA stent. Ao, Aorta; LPA, left pulmonary artery; PA, pulmonary artery.
and ventricular fibrillation was achieved. Carbon dioxide field flooding was used throughout the procedure. The circulation was arrested, and the right PA was incised and extended toward the left PA (Figure 2). Both percutaneous devices were removed, and the APW was closed with a 0.5-mm–thick polytetrafluoroethylene (Gore-Tex; WL Gore & Associates Inc, Flagstaff, Ariz) patch. The PA and branches were reconstructed (total bypass time 150 minutes and total arrest time 23 minutes). TEE showed no residual shunts. The patient had an uneventful recovery and was discharged on postoperative day 10.
The Journal of Thoracic and Cardiovascular Surgery c March 2015
Case Reports: Congenital
FIGURE 2. A, APW (20 3 15 mm) is shown. No formed inferior rim was noted separating the APW from the stent-mounted valve (arrow). B, Surgeon’s view. The polytetrafluoroethylene (Gore-Tex; WL Gore & Associates Inc, Flagstaff, Ariz) patch is sutured. LPA, Left pulmonary artery; PA, pulmonary artery; RPA, right pulmonary artery.
DISCUSSION Percutaneous treatment is an option for selected right-sided lesions after ASO, but the presented case highlights the importance of appropriate selection criteria before performing any interventional procedure in patients with congenital disease with prior surgery. Our case was a harrowing account of misguided attempts for avoiding redo surgery. The initial attempt to place a stent in the main PA was not ill considered, and it predictably caused pulmonary regurgitation. After the LeCompte maneuver, the length of the resultant main PA obviously is shorter than usual and any attempt to place a stent then ‘‘jails’’ the PA branches or the valve leaflets. Surgical PA reconstruction would be the best approach, avoiding any injury to the pulmonary valve. There are several ideas surrounding transcatheter pulmonary valve implantation in patients with ASO. The adherence between the aorta and the PA on performing the LeCompte maneuver and the protrusion of the stent-mounted valve into the PA bifurcation may result in an APW, which in the case reported could not be closed by a combination of devices. Surgical repair is a highly effective technique for the management of traumatic APW, and elective surgery should be chosen in these cases unless the patient is hemodynamically unstable.2,3 In addition, care should be taken to avoid using the Melody valve in patients with ASO, and a surgical option such as
a valved conduit is advised when significant pulmonary regurgitation has developed. Our surgical approach, including arterial peripheral cannulation, deep hypothermic circulatory arrest, fibrillation, and carbon dioxide, may provide an alternative to existing approaches, particularly when access to the ascending aorta and aortic root is extremely difficult because of the anatomic substrate. CONCLUSIONS In the era of interventional cardiology, offering novel approaches for complex congenital cases can be ‘‘attractive,’’4,5 but a feasible option is not always desirable, and stenting or device implantation in these patients should be carefully assessed. References 1. Takayama H, Sekiguchi A, Chikada M, Noma M, Ishida R. Aortopulmonary window due to balloon angioplasty after arterial switch operation. Ann Thorac Surg. 2002;73:659-61. 2. Backer CL, Mavroudis C. Surgical management of aortopulmonary window: a 40-year experience. Eur J Cardiothorac Surg. 2002;21:773-9. 3. Noonan P, Desai T, DeGiovanni J. Closure of an aortopulmonary window using the Amplatzer Duct Occluder II. Pediatr Cardiol. 2013;34:712-4. 4. Peer SM, Sinha P. Percutaneous pulmonary valve implantation after Ross-Konno aortoventriculoplasty: a cautionary word. J Thorac Cardiovasc Surg. 2014;147: 74-5. 5. Bernier PL, Hallbergson A, Schachtner SK, Rome JJ, Gaynor JW. Aortopulmonary fistula after outflow tract stent in repaired truncus. Ann Thorac Surg. 2014;98:55-7.
The Journal of Thoracic and Cardiovascular Surgery c Volume 149, Number 3
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