Pulmonary perfusion after endovascular stenting of pulmonary artery stenosis.

UNLABELLED: Pulmonary artery stenosis is a well-known condition after surgical correction of tetralogy of Fallot. Endovascular stenting of the stenosis is a new technique for correction without surgical intervention. Objective evaluation of the procedure, however, is often hampered by moderate or severe pulmonary valve insufficiency. This disadvantage does not apply to 99mTc-macroaggregates of albumin (MAA) scintigraphy of the lungs. Moreover, quantification can be performed relatively easy. METHODS: Seven patients with surgically corrected tetralogy of Fallot (4 men, 3 women, mean age 15.7 yr, range 5-24 yr) were studied. The mean diameter decrement of a pulmonary artery was 69% +/- 8.7%. Before and after stenting, relative uptake in the left and right lung was assessed after injection of 37-55 MBq 99mTc-MAA. Three patients were studied twice after stenting. RESULTS: In all patients, perfusion of the affected lung increased significantly: before 22.7% +/- 10.8%, after 38.6% +/- 12.3% (p < 0.0001). All patients claimed clinical improvement of their condition after stenting. The perfusion gain did not correlate with the prestenting diameter decrement or with the pressure gradient over the stenosis. Lung uptake in the patients studied twice after stenting was similar between the initial and poststenting study (< or = 2% difference). CONCLUSION: Quantitative 99mTc-MAA lung imaging is a noninvasive technique without patient discomfort that objectively measures the effect of stenting pulmonary artery stenosis. The final outcome of stenting with regard to increment of pulmonary blood flow is not predicted by the severity of the stenosis or the pressure gradient over the stenosis.

[Endovascular stent in the treatment of residual pulmonary stenosis in patients operated on for congenital heart defects; initial results]. / Endovasculaire stent ter behandeling van resterende pulmonalistakstenose bij patiënten geopereerd wegens aangeboren hartafwijking; eerste ervaringen.

OBJECTIVE: Evaluation of the preliminary results of stent implantation as a new technique of intervention cardiology to treat (residual) stenosis of pulmonary arteries in congenital heart disease. DESIGN: Descriptive. SETTING: Children's Heart Centre, University Hospital Nijmegen, the Netherlands. METHODS: Data about physical condition, heart catheterization/angiography and lung perfusion scan were collected. Special attention was paid to the lung perfusion scan as a potential parameter of evaluation. RESULTS: The physical condition was not a useful parameter to judge the result of the pulmonary intravascular stenting, due to a simultaneously present important pulmonary valve insufficiency in most cases. Angiography showed a good result immediately after the procedure in all cases, except in one with kinking of the stent. The increase of lung perfusion could be confirmed by lung scintigraphy in most cases. The relative perfusion of the affected lung increased from 22.7% (SD: 10.8) to 38.6% (12.3) (p < or = 0.001). CONCLUSION: Percutaneous implantation of endovascular stents in pulmonary artery branch stenosis is a welcome alternative to (reconstructive) cardiac surgery. Objective quantification of this stenting by lung perfusion scintigraphy, a technique without patient discomfort, is possible.

Management of ventricular septal defect with associated aortic incompetence.

Twenty-two patients with a ventricular septal defect and aortic incompetence underwent surgical repair. Mean age was 9.6 years (range, 9 to 15 years). Mean follow-up was 32.4 +/- 15.8 months. The ventricular septal defect was perimembranous in 19 patients and doubly committed or juxtaarterial in 3. Most showed only a small left-to-right shunt. Mean diameter was 11.9 +/- 4.8 mm. Aortic incompetence was mild in 6 patients, moderate in 4, and severe in 12. In 16 patients closure of the ventricular septal defect and aortic valvoplasty were both performed through the aortic root. There were no deaths. All patients retained normal sinus rhythm. No complete heart block was found. In 3 patients secondary aortic valve replacement was required for severe incompetence; in 1 the cause was bacterial endocarditis, in another technical failure, and in a third progressive incompetence over an 8-month period. All patients showed substantial clinical improvement, marked decrease or disappearance of the valvar incompetence, diminution of the left ventricular end-diastolic diameter, and decreased cardiothoracic ratio. We conclude that primary repair is the operation of choice for this combination of lesions. This can avoid or delay considerably valvar replacement. The left-sided approach proves safe and is our preferred technique.

Complete right bundle branch block after surgical closure of perimembranous ventricular septal defect. Relation to type of ventriculotomy.

The ECGs of a 100 consecutive children who had surgical repair of their ventricular septal defects (VSDs) were analyzed for postoperative right bundle branch block (RBBB). Seventy of them had an atriotomy and the other 23 also a ventriculotomy. The ventriculotomy always consisted of a transverse incision a short distance below the pulmonary annulus. Of these children 93 had a perimembranous VSD and the other 7 a pure muscular defect. The ECG results of the 93 children with perimembranous VSDs were statistically analysed. The incidence of postoperative complete RBBB (CRBBB) in the ventriculotomy group was not higher than in the atriotimy group. Infants operated in the first half year of life were more prone to the development of CRBBB than the older children, probably because the VSDs were relatively larger in the younger than the older children. The risk of postoperative CRBBB was less in the children who had direct suture closure of the VSD compared with those who needed a Dacron patch to close the defect. The data in the literature generally indicate a higher incidence of CRBBB after a ventriculotomy than an atriotomy. The absence of this difference and the lower incidence of CRBBB after a ventriculotomy in our series compared with those of several other authors are suggested to be due to the type of ventriculotomy.

Subcostal two-dimensional echocardiographic recognition of a criss-cross heart with discordant ventriculo-arterial connection.

Two-dimensional echocardiography was performed on a patient with criss-cross atrioventricular (AV) relationship and ventriculo-arterial discordance. A systematic approach from the subcostal area revealed the complex cardiac pathology including the criss-cross AV relationship of right and left heart, indicating that this very abnormal relationship can be identified echocardiographically. The echocardiographic findings were confirmed by angiocardiography. Post-mortem investigation showed that much of the complexity, including the criss-cross AV relationship, had been caused by a secondary leftward torsion of the entire ventricular part of the heart.

Anatomical correction of transposition of great arteries with persistent ductus arteriosus. One year after operation.

The postoperative data are described of a boy who had a 'switch' operation for transposition of the great arteries with persistent ductus arteriosus more than a year before. The child is living a normal active life. Electrocardiography, echocardiography, and angiocardiography show persistent abnormality of structure and function of the right ventricle but no evidence of reduced coronary blood flow, coarctation at the suture lines of the great arteries, or aortic regurgitation. Reference is made to an identical case operated upon 2 1/2 years ago.

Removal of a fragment of catheter entrapped in a Bjork-Shiley aortic valvular prosthesis. Transarterial approach using a modified loop-snare technique.

Fracture of a left atrial catheter made of polyethylene and its subsequent embolization and entrapment in a Bjork-Shiley aortic valvular prosthesis is reported in a 62-year-old woman. The entrapped fragment of the catheter was retrieved by a transarterial approach using a homemade modified snare-loop device. Measures to prevent such a complication should be directed towards avoidance of force when removing such catheters. In addition, their length should be determined prior to insertion and again after removal, in order to detect their possible fracture and loss at once.