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Pulmonary Artery Branch Stenosis After The Arterial Switch Operation: Accept or Attack?
James S. Tweddell, MD Warren W. Bailey Chair and Director of Cardiothoracic Surgery
Executive Co-Director of the Heart Institute,
Cincinnati Children’s Hospital Medical Center
Professor of Surgery and Pediatrics,
University of Cincinnati
Cincinnati, Ohio
February 9, 2018, Utrecht, The Netherlands
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Mechanisms of Pulmonary Artery Stenosis
• Lesions with small aortic root, coarctation, Taussig-Bing malformation
• Side-by-side great vessels
• Larger neoaortic root
Morgan CT et al Euro Heart J 2017
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Can Branch PS Be Avoided?
• Wide mobilization of the branch pulmonary arteries
• LeCompte Maneuver • Patulous reconstruction of sites of
coronary button excision • Avoid certain materials - Gore-Tex • Preoperative anatomy remains
important
Formigari A Cardiovasc Interv 2000
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Can Branch PS Be Avoided? • Wide mobilization of branch pulmonary artreries • Generous pantaloon(s) patch
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How big a problem is branch pulmonary artery stenosis after the arterial switch operation? • 7% to 28% incidence at long-term follow-up • Reintervetion up to10%
1. Ruda HS et al Ann Thorac Surg 2011 2. Wiggins LM et al Ann Thorac Surg 2015
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What is the impact of branch pulmonary artery stenosis? • Branch pulmonary artery stenosis results in exercise intolerance
1. Giardini A et al Am J Cardiol 2009 2. Giardini A et al Am J Cardiol 2010 3. Baggen VJM et al J Thorac Cardiovasc Surg 2015
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What can we do for branch PS?
• Surgical patch arterioplasty of the main and branch pulmonary arteries
• Catheter based therapies: • Balloon angioplasty • Stent placement
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The Problem With Stents
• Eliminates growth potential – further enlargement requires dilatation • Diameter of pulmonary artery limited by:
• Maximal diameter of stent • Neointimal proliferation
• Stent fracture • Replaces pulmonary artery with rigid non-compliant fixed tube • Caging of proximal branches – particularly upper lobe branch – up to 50%* • Pulmonary artery rupture
• Hemorrhage • Pseudoaneurysm • Aortopulmonary fistulas
• Coronary artery compression
* Law MA et al Cath Cardiovasc Interv 2010
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Iatrogenic aortopulmonary window
Vida VL et al Pediatr Cardiol 2013
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Coronary Artery Occlusion
Baraona F. et al J Clin Exp Cardiolog 2008 Raimondi F, Bonnet D. Diagnostic and Interventional Imaging 2016
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Coronary Artery Occlusion
Gewillig M Brown S Cath Cardiovasc Interv 2009
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Surgical Repair
• Longer freedom from reintervention • Growth potential is preserved • Better compliance • Low risk – 0% mortality in recent
series*
* Wiggins LM et al Ann Thorac Surg 2015
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What are we to do? • Single center study comparing strategies of management of supravalvar
pulmonary stenosis after ASO • n = 29
Nellis JR et al Ann Thorac Surg 2016
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Pulmonary Artery Branch Stenosis After The Arterial Switch Operation: Accept or Attack? • If the patient is symptomatic, has elevated RV pressure or significant
gradient therapy should be offered • For branch pulmonary artery stenosis
• Surgery should be offered as primary treatment and especially for recurrent stenosis • Balloon dilatation is reasonable first step for proximal stenoses • Balloon dilatation for distal stenoses • Stents should generally be avoided
• Limit growth in children • Risk of rupture • Risk of coronary occlusion
• Stents may be considered for • Near adult sized patients • If coronary anatomy is suitable • Recurrent stenosis especially the left pulmonary artery • Poor surgical candidates
Surgeon and interventional cardiologist should work as a team and identify the best strategy for each patient. Frequently a combined strategy will be the best!
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Thank You [email protected]
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Thank you [email protected]
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