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Coronary stenting in the right ventricular outflow tract

Jorge Gómez, Andrea Hozbor, Andrés Lucas, Manuel Porto, Carlos Vázquez, Ramiro Pelliciari

Revista Argentina de Cardioangiología Intervencionista 2021;(2): 0099-0100 | Doi: 10.30567/RACI/20212/0099-0100


Three-month-old patient diagnosed with Down syndrome, tetralogy of Fallot with hypoplastic pulmonary branches, hypoxia, and a past medical history of prematurity, sepsis, infective endocarditis, protein-losing enteropathy, and respiratory distress syndrome. Stent implantation in the rightventricular outflow tract was decided as an alternative to surgical treatment. After the interventional procedure the properoxygen saturation was achieved. Technical details of the case and indications of this intervention are discussed in this clinical case.


Palabras clave: cardiology, pediatric, interventionism.

Paciente de 3 meses de edad con diagnóstico de síndrome de Down, tetralogía de Fallot con ramas pulmonares hipoplásicas, crisis de hipoxia y antecedentes de prematurez, sepsis, endocarditis infecciosa, enteropatía perdedora de proteína y síndrome de distrés respiratorio. Como alternativa al tratamiento quirúrgico se decide colocar un stent en el tracto de ventrículo derecho. Después del procedimiento se loga mantener una saturación estable. Detalles técnicos del caso y las indicaciones de esta intervención son discutidas en este reporte.


Keywords: cardiologia, pediatría, intervencionismo.


Los autores declaran no poseer conflictos de intereses.

Fuente de información Colegio Argentino de Cardioangiólogos Intervencionistas. Para solicitudes de reimpresión a Revista Argentina de Cardioangiología intervencionista hacer click aquí.

Recibido 2021-03-19 | Aceptado 2021-05-26 | Publicado 2021-06-30


Licencia Creative Commons
Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.

Figure 1. Angiography in right anterior oblique projection showing the body of the right ventricle (...

Figure 2. Angiography performed underneath the stent inserted in the right ventricular outflow trac...

Introduction

We present the case of a male patient with prenatal diagnosis of tetralogy of Fallot, emergency cesarian section due to pathological Doppler findings; gestational age, 32 weeks; weight, 1460 grams.

No pulmonary growth. The prenatal diagnosis of tetralogy of Fallot is confirmed. The karyotype test performed confirms a result of trisomy of chromosome 21 (Down syndrome).

During the hospital stay, prostaglandins are infused due to hypoxemia with signs of small ductus.

Until the intervention the patient shows:

• Culture-positive sepsis and 2 suspicious presentations that were medicated. Presence of suspected 7 mm x 7 mm thrombus vs endocarditis on a hyperechoic image of the right atrium that disappears 28 days after continuous antibiotic and anticoagulation therapy.

• Protein-losing enteropathy due to chronic diarrhea.

• Respiratory distress syndrome. The patient required mechanical ventilation for 27 days and, eventually, oxygen through nasal canula.

To this point and considering the patient’s general state of health including pulmonary low flow, hypoxemia due to infundibular spasm and also the long-term deleterious effects of prostaglandins, the presence of hypoplastic pulmonary branches, and the patient’s low weight, a different alternative to palliative or corrective surgery is proposed.

Coronary stent implantation in the right ventricular outflow tract is suggested to secure pulmonary flow, allow the withdrawal of prostaglandin infusion, and the development of hypoplastic pulmonary branches. 

Procedure

A coronary stent was implanted into the right ventricular outflow tract of a 3-month-old-3260-gram newborn baby after consultation with the heart team of the Cardiology and Pediatric Heart Surgery Unit.

A 6-Fr introducer sheath was inserted under general anesthesia via femoral vein access. A series of coronary angiographies in 30º right anterior oblique projection with 20º cranial tilt and 90º left profile are performed. These angiographies revealed the presence of a 15 mm-long outflow tract with severe dynamic narrowing during systole 4 mm away from the pulmonary valve (Figure 1). A 5-Fr JR catheter was mounted over a 0.035 in hydrophilic guidewire and then advanced inside the right pulmonary branch. Afterwards, the guidewire was exchanged for another 0.035 extra support guidewire for the insertion of a 6-Fr catheter to achieve good support and reach the final destination with the stent. By changing the support guidewire to the left pulmonary branch, the tip of the catheter can be placed just underneath the right ventricular outflow tract. The 4-Fr guide catheter was exchanged for a 0.014 in guidewire. To advance the coronary stent (Rebel®, from Boston Scientifics, a 4 mm x 16 mm chrome-cobalt stent) a different 0.014 in guidewire was required to better position the guide catheter and facilitate the advancement of the balloon catheter with the stent in the position indicated. This last guidewire was removed, and the balloon was inflated at 10 atm to achieve a stable 4 mm-diameter at the infundibulum (Figure 2). The angiography confirmed good blood flow through the infundibulum with valve regurgitation for having run through it plus a 4 mm-hypoplastic annulus.

The patient was referred back to the Neonatology Unit. The next day, the patient progression was good with a more stable oxygen saturation between 90% and 93%. The follow-up echocardiogram revealed a 46 mmHg-gradient through the stent.

Discussion

Surgical interventions in newborn babies with tetralogy of Fallot, whether corrective or palliative, as it is the case with Blalock Taussig shunt, are a huge challenge, particularly in the presence of hypoplastic pulmonary branches or other comorbidities like prematurity, respiratory distress, post-sepsis syndrome, etc.1 No treatment in the presence of cyanotic events increases the risk of complications.2 The latest protocols published on stent implantation in the right ventricular outflow tract for the palliative management of these patients have given excellent results, effective lower-risk treatments, high clinical improvement, better oxygen saturation, and good development of pulmonary branches when they are hypoplastic.3 As an option to the subclavian-pulmonary artery shunt, this procedure allows us to postpone corrective surgical procedures ideally between 3 and 4 months after stenting and after crossing the threshold that increases the chances of a torpid postoperative period and/or reduces the rate of success.4,5 

This case was presented to back up the results obtained in the aforementioned publications and keep this option alive as an alternative to surgical palliative therapy.

  1. Sandoval JP, Chaturvedi RR, Benson L, Morgan G, Van Arsdell G, Honjo O, et al.Right Ventricular Outflow Tract Stenting in Tetralogy of Fallot Infants With Risk Factors for Early Primary Repair. Circulation: Cardiovascular Interventions Vol. 9, No.12.

  2. Bertram H, Emmel M, Ewert P, Grohmann J, Haas NA, Jux C, et al.Stenting Of Native Right Ventricular Outflow Tract Obstructions In Symptomatic Infants. J Interven Cardiol 2015;28:279-87.

  3. Peirone A, Contreras A, Ferrero Guadagnoli A, Francucci V, Juaneda I, Cabrera M, et al. Implante de stent en tracto de salida de ventrículo derecho en Tetralogía de Fallot grave: alternativa a la anastomosis de Blalock-Taussig. Revista Argentina de Cardiología Vol. 87, No 2 (2019).

  4. Right Ventricular Outflow Tract Stent as a Bridge to Surgery in a Premature Infant with Tetralogy of Fallot. Laudito A, Bandisode VM, Lucas JF, Radtke WA, Adamson WT, Bradley SM. Ann Thorac Surg 2006;81:744-6.

  5. Stenting of the right ventricular outflow tract as primary palliation for Fallot-type lesions D. Quandt G, Penford B, Ramchandani V, Bhole C, Mehta O. Stumper. Journal of Congenital Cardiology volume 1, number 3 (2017).

Autores

Jorge Gómez
Hemodinamista Infantil.
Andrea Hozbor
Jefa Servicio de Cardiología Infantil.
Andrés Lucas
Médico de planta, Servicio de Cardiología Infantil.
Manuel Porto
Médico de planta, Servicio de Cardiología Infantil.
Carlos Vázquez
Jefe de Servicio de Cirugía Cardiovascular Infantil.
Ramiro Pelliciari
Médico de planta, Servicio de Cirugía Cardiovascular Infantil. Hospital Materno Infantil Victorio Tetamanti Mar del Plata Buenos Aires. Rep. Argentina.

Autor correspondencia

Jorge Gómez
Hemodinamista Infantil.

Correo electrónico: drjorgrgomez@gmail.com

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Revista Argentina de Cardioangiología intervencionista
Issue # 2 | Volumen 11 | Año 2021

Titulo
Coronary stenting in the right ventricular outflow tract

Autores
Jorge Gómez, Andrea Hozbor, Andrés Lucas, Manuel Porto, Carlos Vázquez, Ramiro Pelliciari

Publicación
Revista Argentina de Cardioangiología intervencionista

Editor
Colegio Argentino de Cardioangiólogos Intervencionistas

Fecha de publicación
2021-06-30

Registro de propiedad intelectual
© Colegio Argentino de Cardioangiólogos Intervencionistas

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