Case Report :177
Transient Transcatheter Balloon Closure of Patent Foramen Ovale Following Surgical Repair of Critical Pulmonary Stenosis W Engelha rdt. B. J. Messmer", an d G. v. Bernu tli Depa rtment of Pediatric Cardiology * Department of Thoracic - and Cardiovascular Surgery BWTII Aac he n. I;]{(j
Seve re cya nos is resu lting fro m postopera tive at ria l right-to-left s hu nt is a life-threate ning complicat ion. We p resen t a tech niqu e of tran sient tra nscath eter ba lloon clos ure of a patent for am en ovalc in a new born op erated on for critica l pulmon a ry stenos is , where the fora men ova le had been le ft open int ra operatively. Car diac cat hete rization was perform ed under ccho card iogra phic contro l in th e intensive care un it an d the fora me n oval e wa s occlude d with a wate r-filled balloon-ca th et er. Significa nt improvement of arterial oxygen tension a llowed d elayed definitive surgical clos ur e in a second ste p. Unfor tu na tely, the child developed right-sided pneumo thorax postop era tively a nd d ied of ca rdiopulmona ry fa ilure. Never the less, th is proced ure see ms a suitab le way to relie ve atrial right-to-left shu nt temp or a rily until definitive s urg ica l clos u re ca n be perfor med . Key wo rd s Critical pulmon a ry stenosis - Paten t for am en ovalo - Tra nsient balloo n occlusio n
Introduc tio n Ca rd iac cathete riza tion for the rapeutic purpose s has becom e common practice, also in childre n (2). However, with the exception of the Rashkind manocver for ba lloon atriose ptost omy in comp lete transposition of the great arteries (41. the indi cation s arc limited in newb or ns. Thi s is a report on temporar y ba lloon closure of a patent for am en ovale in a severe ly cyanotic neonat e in ord er to relieve the at rial right-to-left sha nt following rep a ir of critical pulm ona ry ste nosis. Cas e Report In a 3-days-old cyanotic new born critical pulmon a ry stenos is wi th intac t vent ricula r se ptum was diagnosed by sccto r-cc hoca rdlogruphy. The bo rderl ine-sized righ t ven tricle was tripartite with a tricus pid valve mea s uring 11 mm in diam eter . wh ich is at the lower 95 u/. , co nfide nce limit accordi ng to the dat a of Hotolutt et al. (51. The fa irly good -sized pulmona ry arteries we re perfused th ro ugh a paten t du ctu s arterios us , w hic h was ke pt open by prosta gla nd in E1 infusi on. Ilea rt catheterization revealed s up rusysteruic rig ht ve ntricula r pr ess ure a nd moderate tricus pid incom pet e nce . Repa ir of right-ventricu la r outflow ob stru ct ion by commiss uro to my, infu ndi bular resection , an d placem ent of an outflow patch wa s per formed using ca rdiop ulmona ry bypass, deep hypothermia . a nd
Thorac. ca rdiovasc. Surgeon 38 (199013 77 - 3 78 © Georg Thieme Verlag Stuttgart - New York
vo rubcrgcbc nde r Ver schluU c ines offe nen Foramen nval e m ittels Ball onka theter bel elnem Neugeboro nen nac h chlrurgisch er Korrektur elner krltischen Pulmunalsten nse Eine schw e re Zyanose au fgrun d eln es inte ra triale n Hecht sllnk s-Shuntes stellt ci ne ernste Komplika tion na ch Korrektu r einer Rech tsh erzobst r ukt io n da r. Bei eine m Neona te n na ch Opera tion ei ne r kritisc he n Pulmonalst enose gela ng es uns , da s int raoperati v offcn belasscnc Foramen ova lo wa h rc nd ci ner Herzsondl e run g m ittels Bailon zu versc hlieBen u nd d ie Zyanos e da mit deu tlich zu mildern. Der Bullonverschl uf der interat rialen Kommu nikation w u rde unt er ec hoka rd iogra phisc he r Sichtkontrolle au f der Int ensivstation vorge nom me n und tiber Stunden oh ne Komp likation en tolerier t. In einer zwe ite n Sitz ung w urde das For a men ovale ch iru rgisch verschlossen . Ungtncklicherweise entwick elte da s Kind post operativ ei nen re cht sseitigon Pneu moth orax und versta rb. Den noch e ignet sich diose Metho de im Notfa ll, ci ne kritische Zyanose vc ru berge he nd zu beh an d eln .
cardiac a r res t on the 6 th da y of life. Th e ductus arte riosus was closed but the fora me n oval e wa s left open to se rve as a sa fet y valve in case of right hea rt fa ilure . After operation arte rial oxygen tension d ecre a sed to a bout 1i Tor r . Cont rast ec hoca rdiogr a phy revea led a sig nificant righ t-to-left s hu nt at atr ial level. In a n attem pt to re lieve the life-th rea tenin g cya nosis we decided to occlude the pa tent fora men oval e by a balloon ca the te r , hoping th at the right ventricle wo uld be able to receive a nd pu mp the tota l sys tem ic veno us re tu rn . In the in te ns ive ca re unit the righ t sa phe nous vein was sectio ned , a nd a e-P ren ch balloon-a tri osep tostom y ca theter was inserted a nd a dva nce d to th e right atri um . Under ec hoca rdiograp h ic co ntrol the t ip of the ca the te r wa s introdu ced into the left a trium . Subse que ntly, the balloo n was fully inflated with wate r a nd pulled under slight tr action agains t th e atria l se ptum th us occludi ng th e pa tent for a men ova le (Fig. 1I. Insta nt an eou sly the oxygen tension rose from 21 to 47 Torr a nd st a bilized in this ra nge within the next hours (Fig. 21The pa tient' s co nd itio n imp roved significa ntly w hile right atrial a nd systemic a rte ria l pr ess ur e rema ined stable. We , the refore , assumed th a t the right vent ricle was com pete nt to rece ive a nd pum p a s ufficient ca rdiac output. Conse quently, the pa tent foram en ovale was closed s urgically 9 hours later using a n inflow occlusion tech niq ue . Initit ally, postoper ative arterial oxyge n tension remai ned sta ble. But, unfortuna tely, a righ t-s ide d pneum othorax deve loped compromising right at rial filling. Despi te im mediate tho raci c d ra inage extr aalvcola r air could not be rem oved su fficie ntly and the child d ied of com bined cardio pulmo nary fail ur e a few hou rs lat er.
Rece ived for Pu blication : May 15. 1l)l)()
Downloaded by: Universite Laval. Copyrighted material.
Sum mar}'
W Engelhardt. B. J. Messme r", G. v. Bernuth
Thorae. eardioL'ase. Surgeon 38 ( 1990)
80 I Qf .~ n
oval" ocel usion
70
60 50
~, ""
."
o
JO
20
oL-o
-
-
-
-6 -
-8 -
-
10
hours lpos l -opl
--:-::-
"
"'C':""-
"
'-""-
"
Fig. 1 Echocardiogramfromtranscatheter balloon closureof patent foramen ovale,illustratingthe interatrialpositionof inflated atrtoseptostorny catheter (B'" ba lloon, LA - left atrium, RA - right atrium, Vel = Venacava inferior)
Fig. 2 Arterial oxygentension(P.02) before andaftertranscatheter balloon closure of patentforamen ovate
Disc ussion
safe ly proceed with surgical closure of the foramen ovaIe. It is unfortunate. that our pa tient died after this second operation, but this fact does not invalid ate the method.
Surgical management of critica l pulmonary stenos is may be difficult becaus e of uncertain postoperative right ven tricu-
lar function. Postoperative outcome depends on tbe size of tricuspid valve and right ventricular cavity. relief of pulmonary steno sis. and degree of tricuspid regur gitation. In case ofa norma lly sized right ventricle. comp lete repair is recommend ed by relief of outflow tr act obstruc tion an d closure of the patent foramen ovale (3). In the pr esence of a hypoplastic right ventricle, palliative surgery including pulmona ry commissurotomy and creation of an aorto-pulmonary shunt is favoured, leaving the foramen ovate open . In our case ,
borde rline-sized dimensions of the right ventricular cavity and tr icuspid annu lus lead us to perform a complete repa ir of the outflow tract but to leave an interatrial communi cation. The operation was followed by severe cyanosis due to atri al right-t o-Ieft shunting. In this situation . reversible occlusion rather than definitive surgical closure of the fora men ovale appeared indicat ed in order to test the capability of the sm all right ventricle to man age the total systemic venous return. Reversible and temporary occlusion of the foramen ovale by means of a balloon-tipped catheter app ears to be well suited for this pur pose. The procedur e can be performed in the intensive care unit under echoca r-
diographic control as has been described previously for balloon-at riose ptostomy (I l. If, after inflation of the balloon, right heart failure develops, the balloon can easily be deflated and the ca theter be withdrawn . If. however, the patient's arte rial oxygen tension increases significantly while his hemodynamic condition remains stable or improves as in our patient, one may
It is not the aim of our report to pres ent a new strategy
for the treatment of critical pulmonary stenosis with a n intact ventricular septum . However, in critically sick postoperative patients suffering from severe cyanosis due to
atrial right to left shunt, the pro cedure described may offer a timesavin g diagnosti c and temporarily therapeutic a pproac h for tran sient closure of the patent foram en ovale. Refer en ces 1
Allen. L. D.. R. Leanage. R. lVainwright. M . C. Joseph, and M .
2
Tynan: Balloon atrial se ptostomy under two -dimensional echoca rdiographi c co ntrol. Br. Heart J. 47 (982 ) 41 -4 3 Bull, Interventional catheterization in infa nts and children. Hr.
3
c.:
lIeart J. 56 (1986) 197- 200 del.eoal. M.. C. Bull, J. Stark. R. I/. Anderson. J. F. N. Tay lor, and F. J. Macartney : Pulmo nary atres ia and intact ve ntricular se ptum : Surgica l managem ent based on a revised class ification . Circulation
-I
.5
66 (1982127 2-2 80 Rashkind. W. 1., and W. W. Miller: Creatio n of an atria l septum defect with out thor acotomy: a palliati ve appro ach to co mplete transposition of the great arte ries . J. Am. Med. Assoc. 196 ( 96 6) 99 1-992 Roudatt. U. F., H. J. A. Rimotdi. and M . Lev: The Quantitative anatomy o f the norm al child's heart. Pediatr. Clin . North . Am. 10
(196 3)499-509
Dr. med.
w: Engelha rd t
Departm ent of Ped iatric Cardiology HWTH Aaac he n PauwelsstraBe 5 100 Aac he n
Downloaded by: Universite Laval. Copyrighted material.
378
Transient Transcatheter Balloon Closure of Patent Foramen Ovale Following Surgical Repair of Critical Pulmonary Stenosis W Engelha rdt. B. J. Messmer", an d G. v. Bernu tli Depa rtment of Pediatric Cardiology * Department of Thoracic - and Cardiovascular Surgery BWTII Aac he n. I;]{(j
Seve re cya nos is resu lting fro m postopera tive at ria l right-to-left s hu nt is a life-threate ning complicat ion. We p resen t a tech niqu e of tran sient tra nscath eter ba lloon clos ure of a patent for am en ovalc in a new born op erated on for critica l pulmon a ry stenos is , where the fora men ova le had been le ft open int ra operatively. Car diac cat hete rization was perform ed under ccho card iogra phic contro l in th e intensive care un it an d the fora me n oval e wa s occlude d with a wate r-filled balloon-ca th et er. Significa nt improvement of arterial oxygen tension a llowed d elayed definitive surgical clos ur e in a second ste p. Unfor tu na tely, the child developed right-sided pneumo thorax postop era tively a nd d ied of ca rdiopulmona ry fa ilure. Never the less, th is proced ure see ms a suitab le way to relie ve atrial right-to-left shu nt temp or a rily until definitive s urg ica l clos u re ca n be perfor med . Key wo rd s Critical pulmon a ry stenosis - Paten t for am en ovalo - Tra nsient balloo n occlusio n
Introduc tio n Ca rd iac cathete riza tion for the rapeutic purpose s has becom e common practice, also in childre n (2). However, with the exception of the Rashkind manocver for ba lloon atriose ptost omy in comp lete transposition of the great arteries (41. the indi cation s arc limited in newb or ns. Thi s is a report on temporar y ba lloon closure of a patent for am en ovale in a severe ly cyanotic neonat e in ord er to relieve the at rial right-to-left sha nt following rep a ir of critical pulm ona ry ste nosis. Cas e Report In a 3-days-old cyanotic new born critical pulmon a ry stenos is wi th intac t vent ricula r se ptum was diagnosed by sccto r-cc hoca rdlogruphy. The bo rderl ine-sized righ t ven tricle was tripartite with a tricus pid valve mea s uring 11 mm in diam eter . wh ich is at the lower 95 u/. , co nfide nce limit accordi ng to the dat a of Hotolutt et al. (51. The fa irly good -sized pulmona ry arteries we re perfused th ro ugh a paten t du ctu s arterios us , w hic h was ke pt open by prosta gla nd in E1 infusi on. Ilea rt catheterization revealed s up rusysteruic rig ht ve ntricula r pr ess ure a nd moderate tricus pid incom pet e nce . Repa ir of right-ventricu la r outflow ob stru ct ion by commiss uro to my, infu ndi bular resection , an d placem ent of an outflow patch wa s per formed using ca rdiop ulmona ry bypass, deep hypothermia . a nd
Thorac. ca rdiovasc. Surgeon 38 (199013 77 - 3 78 © Georg Thieme Verlag Stuttgart - New York
vo rubcrgcbc nde r Ver schluU c ines offe nen Foramen nval e m ittels Ball onka theter bel elnem Neugeboro nen nac h chlrurgisch er Korrektur elner krltischen Pulmunalsten nse Eine schw e re Zyanose au fgrun d eln es inte ra triale n Hecht sllnk s-Shuntes stellt ci ne ernste Komplika tion na ch Korrektu r einer Rech tsh erzobst r ukt io n da r. Bei eine m Neona te n na ch Opera tion ei ne r kritisc he n Pulmonalst enose gela ng es uns , da s int raoperati v offcn belasscnc Foramen ova lo wa h rc nd ci ner Herzsondl e run g m ittels Bailon zu versc hlieBen u nd d ie Zyanos e da mit deu tlich zu mildern. Der Bullonverschl uf der interat rialen Kommu nikation w u rde unt er ec hoka rd iogra phisc he r Sichtkontrolle au f der Int ensivstation vorge nom me n und tiber Stunden oh ne Komp likation en tolerier t. In einer zwe ite n Sitz ung w urde das For a men ovale ch iru rgisch verschlossen . Ungtncklicherweise entwick elte da s Kind post operativ ei nen re cht sseitigon Pneu moth orax und versta rb. Den noch e ignet sich diose Metho de im Notfa ll, ci ne kritische Zyanose vc ru berge he nd zu beh an d eln .
cardiac a r res t on the 6 th da y of life. Th e ductus arte riosus was closed but the fora me n oval e wa s left open to se rve as a sa fet y valve in case of right hea rt fa ilure . After operation arte rial oxygen tension d ecre a sed to a bout 1i Tor r . Cont rast ec hoca rdiogr a phy revea led a sig nificant righ t-to-left s hu nt at atr ial level. In a n attem pt to re lieve the life-th rea tenin g cya nosis we decided to occlude the pa tent fora men oval e by a balloon ca the te r , hoping th at the right ventricle wo uld be able to receive a nd pu mp the tota l sys tem ic veno us re tu rn . In the in te ns ive ca re unit the righ t sa phe nous vein was sectio ned , a nd a e-P ren ch balloon-a tri osep tostom y ca theter was inserted a nd a dva nce d to th e right atri um . Under ec hoca rdiograp h ic co ntrol the t ip of the ca the te r wa s introdu ced into the left a trium . Subse que ntly, the balloo n was fully inflated with wate r a nd pulled under slight tr action agains t th e atria l se ptum th us occludi ng th e pa tent for a men ova le (Fig. 1I. Insta nt an eou sly the oxygen tension rose from 21 to 47 Torr a nd st a bilized in this ra nge within the next hours (Fig. 21The pa tient' s co nd itio n imp roved significa ntly w hile right atrial a nd systemic a rte ria l pr ess ur e rema ined stable. We , the refore , assumed th a t the right vent ricle was com pete nt to rece ive a nd pum p a s ufficient ca rdiac output. Conse quently, the pa tent foram en ovale was closed s urgically 9 hours later using a n inflow occlusion tech niq ue . Initit ally, postoper ative arterial oxyge n tension remai ned sta ble. But, unfortuna tely, a righ t-s ide d pneum othorax deve loped compromising right at rial filling. Despi te im mediate tho raci c d ra inage extr aalvcola r air could not be rem oved su fficie ntly and the child d ied of com bined cardio pulmo nary fail ur e a few hou rs lat er.
Rece ived for Pu blication : May 15. 1l)l)()
Downloaded by: Universite Laval. Copyrighted material.
Sum mar}'
W Engelhardt. B. J. Messme r", G. v. Bernuth
Thorae. eardioL'ase. Surgeon 38 ( 1990)
80 I Qf .~ n
oval" ocel usion
70
60 50
~, ""
."
o
JO
20
oL-o
-
-
-
-6 -
-8 -
-
10
hours lpos l -opl
--:-::-
"
"'C':""-
"
'-""-
"
Fig. 1 Echocardiogramfromtranscatheter balloon closureof patent foramen ovale,illustratingthe interatrialpositionof inflated atrtoseptostorny catheter (B'" ba lloon, LA - left atrium, RA - right atrium, Vel = Venacava inferior)
Fig. 2 Arterial oxygentension(P.02) before andaftertranscatheter balloon closure of patentforamen ovate
Disc ussion
safe ly proceed with surgical closure of the foramen ovaIe. It is unfortunate. that our pa tient died after this second operation, but this fact does not invalid ate the method.
Surgical management of critica l pulmonary stenos is may be difficult becaus e of uncertain postoperative right ven tricu-
lar function. Postoperative outcome depends on tbe size of tricuspid valve and right ventricular cavity. relief of pulmonary steno sis. and degree of tricuspid regur gitation. In case ofa norma lly sized right ventricle. comp lete repair is recommend ed by relief of outflow tr act obstruc tion an d closure of the patent foramen ovale (3). In the pr esence of a hypoplastic right ventricle, palliative surgery including pulmona ry commissurotomy and creation of an aorto-pulmonary shunt is favoured, leaving the foramen ovate open . In our case ,
borde rline-sized dimensions of the right ventricular cavity and tr icuspid annu lus lead us to perform a complete repa ir of the outflow tract but to leave an interatrial communi cation. The operation was followed by severe cyanosis due to atri al right-t o-Ieft shunting. In this situation . reversible occlusion rather than definitive surgical closure of the fora men ovale appeared indicat ed in order to test the capability of the sm all right ventricle to man age the total systemic venous return. Reversible and temporary occlusion of the foramen ovale by means of a balloon-tipped catheter app ears to be well suited for this pur pose. The procedur e can be performed in the intensive care unit under echoca r-
diographic control as has been described previously for balloon-at riose ptostomy (I l. If, after inflation of the balloon, right heart failure develops, the balloon can easily be deflated and the ca theter be withdrawn . If. however, the patient's arte rial oxygen tension increases significantly while his hemodynamic condition remains stable or improves as in our patient, one may
It is not the aim of our report to pres ent a new strategy
for the treatment of critical pulmonary stenosis with a n intact ventricular septum . However, in critically sick postoperative patients suffering from severe cyanosis due to
atrial right to left shunt, the pro cedure described may offer a timesavin g diagnosti c and temporarily therapeutic a pproac h for tran sient closure of the patent foram en ovale. Refer en ces 1
Allen. L. D.. R. Leanage. R. lVainwright. M . C. Joseph, and M .
2
Tynan: Balloon atrial se ptostomy under two -dimensional echoca rdiographi c co ntrol. Br. Heart J. 47 (982 ) 41 -4 3 Bull, Interventional catheterization in infa nts and children. Hr.
3
c.:
lIeart J. 56 (1986) 197- 200 del.eoal. M.. C. Bull, J. Stark. R. I/. Anderson. J. F. N. Tay lor, and F. J. Macartney : Pulmo nary atres ia and intact ve ntricular se ptum : Surgica l managem ent based on a revised class ification . Circulation
-I
.5
66 (1982127 2-2 80 Rashkind. W. 1., and W. W. Miller: Creatio n of an atria l septum defect with out thor acotomy: a palliati ve appro ach to co mplete transposition of the great arte ries . J. Am. Med. Assoc. 196 ( 96 6) 99 1-992 Roudatt. U. F., H. J. A. Rimotdi. and M . Lev: The Quantitative anatomy o f the norm al child's heart. Pediatr. Clin . North . Am. 10
(196 3)499-509
Dr. med.
w: Engelha rd t
Departm ent of Ped iatric Cardiology HWTH Aaac he n PauwelsstraBe 5 100 Aac he n
Downloaded by: Universite Laval. Copyrighted material.
378
