Hybrid Pulmonary Artery Stenting at the Bidirectional Glenn or Fontan Operation in Patients With Single Ventricle Congenital Heart Disease

Schwartz, Matthew C.; DeCampli, William M.; Pourmoghadam, Kamal; Iacono, Karen; Nykanen, David

doi:10.1177/2150135116633389

Cited by 5 publications

(2 citation statements)

References 14 publications

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“…The report by Schwartz and colleagues describes their experience utilizing intraoperative stent deployment to address the issue of retro-aortic pulmonary artery stenosis. 3 While this work illustrates some important points, including the essential teamwork and collaboration necessary for hybrid interventions as well as feasibility and early success, it also raises questions about the real need and wisdom of this type of intervention. As suggested by the authors, this hybrid intervention does not avoid a surgical procedure, but it is rather aimed to avoid a ''complex'' reconstruction of the central pulmonary arteries (PA).…”

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confidence: 93%

First Things First

Pizarro

2016

World J Pediatr Congenit Heart Surg

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Appropriate growth and development of the branch pulmonary arteries are among the essential features to achieve an optimal Fontan circulation. Patients who undergo the Norwood procedure not infrequently can exhibit abnormal growth and development of these vessels leading to stenosis or diffuse hypoplasia of the left branch pulmonary artery (LPA) in particular. 1 Plausible explanations include distortion associated with the creation of a new source of pulmonary blood flow as well as dilatation and/or scarring and fibrosis following reconstruction of the neoaorta and aortic arch. To mitigate the negative impact of central pulmonary hypoplasia or stenosis on the passive flow of systemic venous return across the pulmonary vascular bed, Norwood and colleagues described their experience with a surgical procedure which among its essential features included a generous patch reconstruction of both right and left pulmonary arteries at the time of the superior cavopulmonary connection. 2 The idea behind this procedure was not only to mitigate the impact of volume changes in ventricular compliance and set the stage for the completion of the Fontan circuit but also to eliminate the possibility of central pulmonary stenosis and its adverse impact on single ventricle physiology.The report by Schwartz and colleagues describes their experience utilizing intraoperative stent deployment to address the issue of retro-aortic pulmonary artery stenosis. 3 While this work illustrates some important points, including the essential teamwork and collaboration necessary for hybrid interventions as well as feasibility and early success, it also raises questions about the real need and wisdom of this type of intervention. As suggested by the authors, this hybrid intervention does not avoid a surgical procedure, but it is rather aimed to avoid a ''complex'' reconstruction of the central pulmonary arteries (PA). That being said, a number of concerns could be raised about the durability and potential for morbidity with this approach. In fact, only two-thirds of the patients received a stent that could be dilated to adult size, therefore creating the need for a more complex pulmonary arterioplasty in the future. In addition, although there was no mortality, morbidity was not minor, particularly when ventilation or pulmonary gas exchange was significantly compromised in these patients with single ventricle physiology. This is not surprising when reviewing a recent and comprehensive multicenter interventional report, which describes a 75% success of pulmonary artery stenting in patients with single ventricle, as well as a 14% complication rate and 9% incidence of death or major adverse event. 4 In contradistinction, the surgical reconstruction described by Norwood et al would address this issue by patch augmentation of the central PA during the second, (Hemifontan procedure) or this could be done at the time of Fontan procedure using an extracardiac conduit (ECC) with a beveled anastomosis extending to the underside of the LPA. These surgical inter...

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confidence: 93%

First Things First

Pizarro

2016

World J Pediatr Congenit Heart Surg

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“…The postsurgical flow distribution to the lungs is difficult to predict, and various surgical or endovascular interventions may be required to address specific circulatory issues. For example, endovascular angioplasty may be required to dilate hypoplastic pulmonary arteries in an effort to remove even discrete stenosis and optimize pulmonary flow distribution (Noonan et al ., ; Schwartz et al ., ). Furthermore, assuring equal distribution of hepatic blood flow to both lungs is important to avoid pulmonary arteriovenous malformations that decrease systemic oxygenation (Duncan & Desai, ).…”

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confidence: 99%

Simulation of aortopulmonary collateral flow in Fontan patients for use in prediction of interventional outcomes

Frieberg

Sjöberg

Revstedt

et al. 2017

Clin Physio Funct Imaging

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4D-flow; cardiac magnetic resonance; patientspecific simulation; prediction of invasive interventions; total cavopulmonary connection Purpose Patients with complex congenital heart disease may need to be converted to a Fontan circulation with systemic venous return surgically connected to the pulmonary circulation. These patients frequently form aortopulmonary collaterals (APC), that is arterial inflows to the pulmonary artery vascular tree. The aim of this study was to develop a method to calculate the effect of APC on the pulmonary flow distribution based on magnetic resonance imaging (MRI) measurements and computational fluid dynamics simulations in order to enable prediction of interventional outcomes in Fontan patients. Methods Patient-specific models of 11 patients were constructed in a 3D-design software based on MRI segmentations. APC flow was quantified as the difference between pulmonary venous flow and pulmonary artery flow, measured by MRI. A method was developed to include the modulating effect of the APC flow by calculating the patient-specific relative pulmonary vascular resistance. Simulations, including interventions with a Y-graft replacement and a stent dilatation, were validated against MRI results. Results The bias between simulated and MRI-measured fraction of blood to the left lung was 2Á9 AE 5Á3%. Including the effects of the APC flow in the simulation (n = 6) reduced simulation error from 9Á8 AE 7Á0% to 5Á2 AE 6Á3%. Preliminary findings in two patients show that the effect of surgical and catheter interventions could be predicted using the demonstrated methods. Conclusions The work demonstrates a novel method to include APC flow in predictive simulations of Fontan hemodynamics. APC flow was found to have a significant contribution to the pulmonary flow distribution in Fontan patients.

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Utilizing Hybrid Techniques to Maximize Clinical Outcomes in Congenital Heart Disease

Bearl

Fleming

2017

Curr Cardiol Rep

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The earliest experiences with hybrid interventions included intraoperative stenting of pulmonary arteries and perventricular device closure of ventricular septal defects. Newer hybrid interventions have focused on a hybrid approach to stage 1 palliation for infants with hypoplastic left heart syndrome and hybrid approaches to transcatheter pulmonary valve replacement in patients of all ages. Hybrid approaches to complex congenital heart disease are important in the management of congenital heart disease offering a less invasive approach, and novel hybrid procedures will likely be a focus of future research in this field.

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Hybrid Pulmonary Artery Stenting at the Bidirectional Glenn or Fontan Operation in Patients With Single Ventricle Congenital Heart Disease

Abstract: Hybrid stenting of the retroaortic pulmonary artery at the bidirectional Glenn or Fontan operation is an effective treatment of pulmonary artery stenosis and prevents the need for a complex surgical arterioplasty.

Cited by 5 publications

References 14 publications

First Things First

First Things First

Simulation of aortopulmonary collateral flow in Fontan patients for use in prediction of interventional outcomes

Utilizing Hybrid Techniques to Maximize Clinical Outcomes in Congenital Heart Disease

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