Early Results of Stent Implantation in Branch Pulmonary Artery Stenosis after Tetralogy of Fallot Repair

PURPOSE: Pulmonary artery stenosis is mainly complicated by aortopulmonary shunt or total correction of tetralogy of Fallot(TOF). Results of surgical angioplasty are poor and the success rate of balloon angioplasty is 53-72%. Endovascular stents have been applied to these lesions. The purpose of this study is to evaluate the early results of stent implantation in postoperative pulmonary artery stenosis in TOF. METHODS: Nineteen children with postoperative pulmonary artery stenosis were selected and balloon-expandable stent implantation was attempted between May 1994 and Feb 2000. For assessment of the results of stent implantation, the intraluminal diameter and the pressure gradient across the narrowest point were measured, as were the ratio of a right ventricle and aorta pressure, and a radionuclide lung perfusion scan was done before and after the procedure. RESULTS: Nineteen stents were implanted in 19 children, aged 2.3 years to 25,5 years. The increase of vessel diarneter ranged from 5.0+/-1.4mm to 10.7+/-2.1mm, pulmonary perfusion ratio from 16.7+/-5.3% to 29.2+/-10.0% and pressure gradients from 28.0+/-18.0 to 11.0+/-11.0mmHg with stent implantation. The systolic pressure ratio of the right ventricle and aorta decreased from 0.55+/-0.16 to 0.45+/-0.14. All above changes were statistically significant. Implantation failure occurred in 1 case and complications arose in 4 cases. CONCLUSIONS: The success rate of stent implantation is 94.296. Stent implantation is an effective and safe treatment method for postoperative pulmonary artery stenosis of TOF in short-term follow-up.

Follow up of Patients with Total Anomalous Pulmonary Venous Return in Right Atrial Isomerism

PURPOSE: Total anomalous venous return(TAPVR) is associated in more than 60Yo of patients with right isomerism and can significantly complicate the management of single ventricle patients at any stage of management. We studied the results of management and sought to determine factors that may influence survival in patients with TAPVR in right atrial isomerism. METHODS: Between February 1991 and July 1999, 14 patients with TAPVR in right atrial isomerism underwent operations,' we reviewed our experience after performing single ventricle palliation RESULTS: Seven patients were of the obstructive type TAPVR and seven patients were of the non-obstructive type TAPVR. The mean age at operation was 17 months and mean body weight at operation was 7.3kg. Direct surgical repair for the pulmonary vein was performed in seven patients and in the others, TAPVR could be satisfactorily managed by the use of bilateral cavopulrnonary anastomosis(BCPS) to exclude the distal superior vena cava(SVC). At a mean follow-up of 27 months, there were five deaths, arid pulrnonary vein restenosis developed in four patients in the direct surgical repair group. In the other group, there was neither mortality nor morbidity. Also, the presence of pulmonary venous obstruction was associated with high mortality. CONCLUSION: According to our study, TAPVR can be satisfactorily managed by the use of BCPS to exclude the distal SVC in the non-obstructive type. But further evaluation of surgical methods about other types of TAPVR are warranted, because TAPVR not requiring intervention includes any low supracardiac and some mixed types.

Study of Congenital Mitral Stenosis Cases Requiring Surgical Correction in the First 2-Years of Life

PURPOSE: Congenital mitral stenosis(CMS) is a rare anomaly accounting for 0.4-0.5% of total heart disease. CMS which cases needed surgical correction in infancy are even rare. In this study, we analyzed 11CMS patients of less than 2 year of age who needed surgical corrections, in order to find out their diagnoses, the characteristics, the results of operation and prognoses, and the progress of disease without surgical correction. METHODS: Retrospective studies were performed on eleven CMS patients of less than 2 years of age admitted to Sejong General Hospital between Jan. 1989 and Aug. 1999. RESULTS: The surgeries were performed on 9 out of 11 enrolled patients. The median age was 8(3-20) months and the median weight was 5(4-9)kg. The mitral valves of the patients were classified anatomically as supramitral ring(4), parachute mitral valve(3), "typical" symmetric hypoplastic mitral valve(2) and asymmetric hypoplastic mitral valve(2). Three patients died after the surgical correction. Among them, fibroelastosis of left ventricle was found during the surgery in two cases, and the other case was considered to be in Eisenmenger state. 5. Reoperations were performed on 3 out of 6 surviving patients. While one case was an early reoperation, two case were late ones. CONCLUSION: The patients with severe CMS under the age of two can be surgically corrected with an acceptable success rate. Poor results were observed, however, if the decisions for surgical intervention were delayed.

A Case of Transcatheter Occlusion of Aortopulmonary Window(APW) after PAW Banding

Aortopulrnonary window is an uncommon cardiac anomaly accounting for approximately 0.2-0.6% of all congenital cardiac anomalies in which there is a connection between the ascending aorta and pulmonary trunk. Since the first report of successful surgical repair, many investigators have advocated surgical closure of all types of aortopulmonary windows using different technique. The majority of aortopulmonary windows require surgical therapy due to extensive size or location. A few cases of interventional closure of APW with double umbrella and buttoned device are reported, but Gianturco coil has not been used previously. A case is described in an infant with a small aortopulmonary window which was closed by Gianturco coil after APW banding. He did not receive corrective operation because his parents who are Jehovahs Witnesses refused transfusion. Complete occlusion of the defect was achieved without complications. Transcatheter coil closure of a small aortopulmonary window is feasible in infancy and the technique is likely to be applicable in a few cases.

Repair of Corrected Transposition of the Great Arteries

PURPOSE: To assess the clinical characteristics and surgical approaches in different anatomical and hemodynamic types of corrected transposition of great arteries(TGA) and learn the surgical results of those patients. METHODS: All 52 patients who were diagnosed as corrected TGA between December 1987 and November 1999 and their medical records were reviewed. Three groups were identified according to associated anomalies', Group 1: TGA with intact ventricular septum(n=7), Group 2: TGA with ventricular septal defect(n=6), Group 3: TGA with ventricular septal defect and pulmonary stenosis(n=39). RESULTS: The clinical manifestations and managements according to associated anomalies were different. The average ages at operation were 190, 8.8 and 47 months in Groups 1, 2, and 3, respectively. The five patients underwent double switch operation and the remainder were managed conventionally without correcting discordant connection. Four patients died and 5 patients were re-operated. Eleven patients developed complete heart block, and 7 of them had permanent pacemakers. Progressive systemic tricuspid valve regurgitation developed in 15 patients and progressive systemic right ventricle dysfunction developed in 3 patients. CONCLUSION: The results of conventional management were disappointing, with significant morbidity of tricuspid failure, right ventricle failure and conduction system failure. Anatomical repair of corrected TGA can be achieved with favorable immediate surgical results but long-term follow up will be necessary.

Management of Post-operative Pulmonary Artery Stenosis in Tetralogy of Fallot

PURPOSE: Pulmonary artery stenosis is a common finding in post-operative tetralogy of Fallot (TOF), and it is one of the most frequent indication of reoperation. The objective of this study was to determine the procedural success rate of balloon angioplasty(BAP), endovascular stent, and reoperation for pulmonary artery stenosis in terms of its clinical impact on the subsequent management of these patients. METHODS: Hemodynamic and angiographic data from 71 patients who underwent balloon dilatation, stent implantation and reoperation for pulmonary artery stenosis between Jan. 1984 and Nov. 1999 were reviewed, retrospectively. The 71 patients had 94 vessels dilated by BAP. Criteria of BAP and stent implantation for success were > or =50% increase in vessel diameter or > or =20% decrease in right ventricular to aortic pressure ratio. Stent implantation was attempted in 16 patients and reoperation was performed in 11 patients. RESULTS: Of the 94 balloon angioplasty, 70(74%) were successfully dilated. In 16 patients, balloon angioplasty was ineffective for stenosis relief, thus endovascular stent implantation was attempted. All cases of endovascular stent were successfully implanted except one case which was dislodged. Reoperation was attempted in 11 patients in who balloon angioplasty failed or had ineffective results. CONCLUSION: BAP is beneficial for pulmonary artery stenosis. Left pulmonary artery kinking should be suspected at long-term follow up after tetralogy repair in patients with significant pulmonary regurgitation and right-side dilatation. Stent implantation or reoperation is considered when aneurysmal dilatation of pulmonary trunk, kinking components are suspected.