Percutaneous Implantation of a Systemic-to-Pulmonary Shunt
A 20-day-old boy (2.3 kg) with tetralogy of Fallot and right aortic arch was sent to our department because he had a history of episodes of cyanosis. Basal peripheral oxygen saturation was 65%. Hypoplasia of the pulmonary artery was seen on a transthoracic echocardiography, and isolation of the left pulmonary artery was suspected.
A cardiac catheterization was performed on the patient’s 22nd day of life. The procedure was performed under general anesthesia, and the patient was fully heparinized (100 IU/kg). From the right femoral vein, using a 4-Fr sheath and a Berman angiographic catheter, right ventriculography showed a hypoplastic pulmonary trunk and right pulmonary artery (Figure 1 and Movie I). From the right femoral artery, using a 4-Fr sheath and a pigtail catheter, angiography in the horizontal aorta showed a significantly stenosed patent arterial duct at the origin of the left pulmonary artery (Figure 1 and Movie II). After discussion with the surgeon and because of the infant’s weight, we decided to perform a percutaneous treatment.
A right carotid approach was chosen so that we would have a straighter way to the left pulmonary artery. A 5-Fr sheath was used. The arterial duct was cannulated using a 0.014-inch guide wire and was subsequently stented with a premounted coronary stent (Multi-Link Vision 3.5×15 mm). Because this stent did not completely cover the duct (Figure 2 and Movie III), we implanted a second premounted coronary stent (Multi-Link Vision 3.5×8 mm) that partially overlapped the first stent. Angiography after the stent was implanted showed a significant improvement in the vessel’s diameter (Figure 2 and Movie IV), and the patient’s peripheral oxygen saturation increased to 92% in room air.
The postprocedural course was uneventful. The patient was discharged taking aspirin (5 mg/kg per day) 1 week after the procedure and weighing 2.5 kg. At 4 months of age, the infant weighs 5.5 kg, his peripheral oxygen saturation is stable around 90% to 92%, and the shunt is patent on physical examination (continuous murmur) and echocardiographic evaluation. If the clinical situation remains stable, the patient will undergo complete surgical correction when he reaches the weight of 8 kg. At present, the percutaneous systemic-to-pulmonary shunt is functioning correctly.
The online-only Data Supplement, which consists of 4 movies, can be found at http://circ.ahajournals.org/cgi/content/full/114/20/e581/DC1.