Debate: Should Ductal Stent Implantation be Considered for All Newborn Infants with Reduced Pulmonary Blood Flow?_Pros Mazeni Alwi Institut Jantung Negara Kuala Lumpur, Malaysia 5 th Asia Pacific Congenital & Structural Heart Intervention Symposium 2014 (APCASH) 10 12 October 2014, Hong Kong Convention & Exhibition Centre
With permission of Dr. Wilson
Patient 1 5 days old Ebstein s anomaly Functional pulmonary atresia Severe hypoxia - SaO 2 35% PGE1 dependent
Can be a straightforward procedure Short ICU stay No risk of pleural effusion, diaphragm paralysis No adhesions clear surgical field for subsequent definitive repair
PDA in cyanotic CHD More complex morphology technically challenging More proximal origin from aorta PDA connection to LPA propensity for LPA stenosis? PDA stent aggravates stenosis LPA? Does this prevent from successful stent implantation Abrams, Int. J Cardiol, 40 (1993) 27-33
PDA in cyanotic heart disease morphologic variations Most are amenable to stent implantation modification of techniques, access sites
Techniques for PDA with complex morphology (proximal origin, long and tortuous) Proximal origin of PDA, 1 acute bend Acute angle to descending aorta PDA first crossed with BMW wire (tip load 1.0 g) with cut pigtail Then crossed with Choice PT extra support (3 g) for stent delivery
ALTERNATIVE ACCESS SITES PDA in TOF tendency to arise from underneath aortic arch PDA arising proximally from underneath aortic arch Transvenous trans-vsd Trans R. axillary artery Nur aisy Not quite stent friendly - approach via femoral artery usually not feasible Trans L. axillary artery nesha Trans R. carotid artery
PDA insertion to LPA, LPA stenosis : PDA stent in ductus-related pulmonary coarctation appropriateness of PDA stent? (Class III indication AHA guidelines 2011) Jailing of LPA, worsening and accelerated LPA stenosis in response to stent implantation? PDA stent directed towards MPA may limit impact of ductal constriction, prevent total disconnection of LPA Needs close monitoring of LPA, early repair with reconstruction
TOF-PA, ductus related LPA stenosis Stenting via right carotid artery cutdown at 3 weeks of life 9 months post PDA stenting Good growth of LPA Successful surgical repair
TOF-PA, ductus related LPA stenosis 4 weeks of life PDA stent 5 months post Good growth of LPA despite jailing by stent
PDA stenting complications Acute stent thrombosis
Complication migration of expanded stent Stent migrated to RPA Stent dilated in right middle lobe artery New stent implanted in PDA (PDA should be <2.0 mm for 4.0 mm stent)
PDA stenting (2001 2005) (Learning Curve) Outcome complications n = 164 Dislodgement and embolization (1) Spasm of PDA (1) Acute thrombosis (2) Worsening/acceleration of branch PA stenosis (7) Stenosis of unstented part of PDA (3) Intravascular hemolysis (1) Deaths o o o 1 PDA spasm 1 acute thrombosis 1 LV dysfunction in PAIVS, hypoplastic RV with major sinusoids (17 days post)
100 80 60 40 No.of patient s 20 0 0 6 12 18 24 n=51 n=26 n=9 n=2 n=1 Time Intervals (months) Alwi et al. J Am Coll Cardiol 2004; 44: 438 45 The reintervention included catheter-related procedure (balloon dilation of stent and restenting) and Blalock Taussig shunt and bidirectional Glenn shunt, Rastelli <12 months 30 36 In-stent stenosis 1 year post very restrictive flow thru PDA stent due to neointimal proliferation? Significance in modern era of cardiac surgery
Are the results of mbt shunt always superior? 10 days old infant BT shunt Acute, early thrombosis - 48 hours after procedure
Right mbt shunt Very severe RPA stenosis
Special situations where stenting is particularly advantageous TOF-PA, right aortic arch, bilateral PDA Bilateral PDA stenting in 1 session (otherwise 2 operations prior to definitive repair)
? PDA stenting is preferable in all neonates most Long, severely tortuous PDA not likely to be feasible
Thank you