Stenting of the ductus arteriosus and banding of the pulmonary arteries: basis for various surgical strategies in newborns with multiple left heart obstructive lesions

Abstract

Objective: To present an institutional experience with stent placement in the arterial duct combined with bilateral banding of the pulmonary artery branches as a basis for various surgical strategies in newborns with hypoplastic left heart obstructive lesions.

Design: Observational study.

Setting: Paediatric heart centre in a university hospital.

Patients: 20 newborns with various forms of left heart obstructive lesions and duct dependent systemic blood flow.

Interventions: Patients underwent percutaneous ductal stenting and surgical bilateral pulmonary artery banding. Atrial septotomy by balloon dilatation was performed as required, in one premature baby by the transhepatic approach.

Main outcome measures: Survival; numbers of and reasons for palliative and corrective cardiac surgery.

Results: One patient died immediately after percutaneous ductal stenting. One patient died in connection with the surgical approach of bilateral pulmonary banding. Stent and ductal patency were achieved for up to 331 days. Two patients underwent heart transplantation and two patients died on the waiting list. Ten patients had a palliative one stage procedure with reconstruction of the aortic arch and bidirectional cavopulmonary connection at the age of 3.5-6 months. There was one death. One patient is still awaiting this approach. Two patients received biventricular repair. In one, biventricular repair will soon be provided.

Conclusions: Stenting the arterial duct combined with bilateral pulmonary artery banding in newborns with hypoplastic left heart or multiple left heart obstructive lesions allows a broad variation of surgical strategies depending on morphological findings, postnatal clinical conditions, and potential ventricular growth.

Figure 1

Ductal stenting in patient 9 (lateral view fluoroscopy). (A) Feature of the patent ductus arteriosus (DA) for measurement of ductal dimensions. Angiography is performed through the long sheath. (B) Location of the balloon stent unit not yet exactly positioned within the DA. (C) Angiography by the aortic 4 French cobra catheter. Inflated balloon with a fully expanded 18 mm Omnilink stent. The aortic catheter positioned in the descending part of the aortic arch was used as a landmark. (D) Final angiography showing patency of the DA and excluding any site of obstruction.

Figure 2

Transhepatic cardiac catheterisation in patient 12 with hypoplastic left heart syndrome. Top left, percutaneous transhepatic puncture with a 22 gauge needle through the interspace-midaxillary line, midway between the diaphragm and lower margin of the liver after local anaesthesia under fluoroscopic guidance and gently infused contrast medium. Top right, 5 French sheath placed into the low right atrium guided by a previously placed wire. Bottom left (lateral view fluoroscopy), inflated balloon catheter placed in the restricted patent foramen ovale necessitates further gradual balloon dilatation. Bottom right, steel coil inserted through the sheath into the liver parenchyma peripheral to the hepatic vein.

Figure 3

Outcome of 20 patients with various types of hypoplastic left heart obstructive lesions.

Figure 4

The necropsied specimen. The opened aortic arch shows a diminutive orifice of the ascending aorta at the level of the innominate artery with a diameter of the inner lumen of < 1 mm.