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. 2021 Feb 15;11(1):21-28.
eCollection 2021.

Optimal management of pulmonary atresia with intact ventricular septum in a developing country: the art of pulmonary valve mechanical perforation in the era of CTO hardware

Raymond N Haddad  1 , Zakhia Saliba  2
Affiliations

Optimal management of pulmonary atresia with intact ventricular septum in a developing country: the art of pulmonary valve mechanical perforation in the era of CTO hardware

Raymond N Haddad et al. Am J Cardiovasc Dis. .

Abstract

Background: Transcatheter valve mechanical perforation (TVMP) in pulmonary atresia with intact ventricular septum (PAIVS) is an acceptable yet challenging alternative to radiofrequency.

Aims: To evaluate and compare safety, feasibility, and efficiency of two TVMP techniques.

Methods: Clinical data of neonates with PAIVS who underwent an attempt for TVMP between 2009 and 2019 were retrospectively reviewed. Patients were divided into two groups according to perforation technique: using the stiff end of a percutaneous transluminal coronary angioplasty (PTCA) ordinary 0.014" wire (group A) and subsequently with the floppy tip of a chronic total occlusion (CTO) guidewire (group B). The technical aspects, procedural and discharge outcomes of both groups were compared.

Results: A total of 19 antegrade TVMP procedures (Group A, n=10, and Group B, n=9) were attempted in 18 neonates with an overall success rate of 73.7% and no procedure-related mortality. Groups' analysis showed that the introduction of CTO hardware maximized procedure success rates (P=0.002) with zero failure and misperforations (P=0.022). The significant drop in perforation time (P < 0.001) and irradiation exposure (P=0.006) allowed additional ductal stenting during the same procedure, optimizing patients' clinical outcomes and shortening overall hospital stay. Discharged patients had room air mean oxygen saturation of 91.4% (± 5.5) with no evidence of heart failure.

Conclusions: In selected cases of PAIVS, TVMP using CTO wires is a safer, highly efficient, and simplified alternative to other mechanical perforation techniques. It substantially revolutionized the management of PAIVS in our center optimizing short-term prognosis.

Keywords: Pulmonary atresia; cardiac catheterization; chronic total occlusion; guidewire; mechanical perforation.

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Conflict of interest statement

Z. Saliba is a proctor and consultant for Abbott Vascular since 2017. R. Haddad has no conflict of interest to declare.

Figures

Figure 1
Figure 1
Perforation using the stiff end of a PTCA ordinary 0.014” wire. Wire advanced to the tip of the JR catheter with the snare ready to receive it for the arterial side (A). Gentle pushing of the wire against the atretic valve (B). Established arteriovenous circuit after successful perforation over which the venous catheter is gently pushed into the pulmonary artery lumen (C).
Figure 2
Figure 2
Perforation using the floppy tip of 0.014” CTO wire (Cross-it 200XT). Directly snared wire after successful perforation (A, B) and pulled to the descending aorta (C), providing a stable position for balloon pulmonary valvuloplasty (D).
Figure 3
Figure 3
Misperforation using a stiff end of a PTCA ordinary 0.014” wire. Wire stiffness straightening the catheter and disorienting its tip leading to misperforation (A, B). Note the angled rigid tip (B). Another case of misperforation (C).
See this image and copyright information in PMC

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