Percutaneous coronary stent implantation in children and young infants following surgical repair of congenital heart disease

Abstract

Background: Coronary artery stent implantation (CSI) in the pediatric population is rare. Only a few reports were published on managing postoperative coronary artery obstruction using coronary stents following surgical repair of congenital heart diseases (CHD). This study aimed to analyze the feasibility, indications, procedural technique, risk factors, and short-term outcomes of CSI after pediatric cardiac surgery.

Methods: In this retrospective cohort study, we reviewed all pediatric patients who underwent surgical repair of CHD requiring postoperative CSI in two cardiac centers (King Abdulaziz University Hospital and King Faisal Specialist Hospital and Research Center) between 2012 and 2022. Survival to hospital discharge was the study's primary outcome. The secondary outcomes included procedural success, duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, need for coronary reintervention, and late mortality. A descriptive analysis was performed for the collected data from the patients' medical records.

Results: Eleven patients who underwent postoperative CSI were identified. The most common anatomic diagnosis was congenital aortic valve stenosis. All patients underwent cardiac catheterization on extracorporeal membrane oxygenation support except one patient, who presented with chest pain after cardiac surgery. Procedural success was achieved in all patients with excellent revascularization documented by post-procedural angiograms. Both patients who had late coronary events after cardiac surgery survived hospital discharge. There was no in-hospital mortality among the two patients who required stenting of only the right coronary artery. The four patients who required more than 120 minutes to complete the procedure had early mortality. After CSI, the median duration of mechanical ventilation and ICU stay was 12 and 17 days, respectively. Six patients (54.5%) survived hospital discharge post-CSI; they did not require re-intervention during the follow-up period (38-1,695 days).

Conclusions: CSI in pediatric patients can be performed with excellent procedural success for treating coronary artery stenosis after cardiac surgery. It could be considered a potential treatment strategy for this population.

Keywords: Coronary stent implantation (CSI); cardiac surgery; congenital heart disease (CHD); survival.

Figure 1

Right coronary artery stenting in a 13-month-old patient with Shone’s variant who underwent mitral valve replacement using prosthetic size 12 Saint Jude valve (yellow asterisks), Kono, aortic root replacement using aortic homograft with reimplantation of the coronary arteries. The patient came out of the operating room on ECMO due to failure to separate from CPB associated with poor cardiac function. (A) Aortic angiography shows severe proximal RCA narrowing (arrow). (B) another aortic angiography with a catheter tip at the opening or RCA showing severe narrowing of the proximal RCA (arrows), the area of RCA narrowing was zoomed and outlined in red at the lower right margin of the picture. (C) more aortic angiography using a different angle projection to delineate the area of RCA stenosis (arrow). (D) The guidewire is advanced across the RCA, and the coronary stent and balloon crossed the stenotic area of RCA (arrow) before inflation of the coronary balloon. (E) Aortic angiography after RCA stenting (arrow) shows successful proximal RCA caliber improvement. (F) Echocardiography with modified parasternal short axis view showing good flow across the stented RCA (arrow). ECMO, extracorporeal membrane oxygenation; CPB, cardiopulmonary bypass; RCA, right coronary artery; VC, venous cannula; AO, aorta; RVOT, right ventricular outflow tract.

Figure 2

Right and left coronary artery stenting in a 9-year-old patient with severe LVOTO, subaortic membrane, and aortic stenosis. The patient underwent the Ross Konno procedure using an aortic homograft with anastomosis of coronary arteries to the aortic homograft. One hundred five days after surgery, the patient had severe chest pain referred to the left shoulder with ischemic changes in ECG and elevated and progressively rising troponin. She underwent RCA stenting and steroid therapy, followed by LMCA and LAD artery stenting after three months. (A) Selective RCA angiography showing severe stenosis of proximal RCA (arrow). (B) The coronary balloon and stent were advanced across the stenotic area, inflating the balloon (arrow). (C) RCA angiography after stenting showing improvement of proximal RCA diameter (arrow). (D) Aortic angiography showing severe stenosis of proximal LMCA and extending to the LAD artery (arrow). (E) The coronary balloon and stent were advanced across the stenotic area of LMCA and LAD, and the balloon was inflated (arrow). (F) Aortic angiography after LMCA and LAD stenting shows improvement of proximal LMCA (yellow arrow) and LAD (red arrow) diameters; the LCX has a good caliber with good flow through the struts of the stent (star). LVOTO, left ventricle outflow tract obstruction; ECG, electrocardiogram; RCA, right coronary artery; LMCA, left main coronary artery; LAD, left anterior descending; LCX, left circumflex.