Percutaneous approach to residual pulmonary bifurcation stenosis in conotruncal diseases.Castaldi B, Di Candia A, Cuppini E, Sirico D, Reffo E, Padalino M, Vida V, Di Salvo G.Cardiol Young. 2024 Jan;34(1):24-31. doi: 10.1017/S1047951123000999. Epub 2023 May 4.PMID: 37138545
Take home points:
- Percutaneous treatment of pulmonary bifurcation stenoses with kissing balloon inflation using high-pressure balloons is effective in most cases.
- Stenting of the pulmonary bifurcation is required when there is a concomitant indication for pulmonary valve implantation.
Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:
Pulmonary bifurcation stenoses (PBS) are a relatively common problem after repair of conotruncal defects (CTDs). As surgical angioplasty is often inadequate due to residual stenosis, percutaneous treatment is usually preferred. However, successful ballooning and/or stenting of PBS can be very challenging and long-term results are scantly reported. In this retrospective study, the authors analyse the mid-term outcomes of different interventional strategies to treat obstructions involving the distal main pulmonary artery and/or the origin of pulmonary artery branches.
Between January 2014 and December 2021, 39 patients (age 8.7 ± 7.8 years, weight 31.0 ± 26.3 kg) with repaired CTDs (22 with tetralogy of Fallot, 8 with truncus arteriosus, and 9 with d-transposition of the great arteries) underwent percutaneous treatment of hemodynamically significant PBS at the Padua University Hospital. Types of interventions included single high-pressure balloon inflation (SB), kissing balloon inflation (KB), standard stent implantation techniques without jailing of a branch pulmonary artery (SS) and more complex stent implantation techniques involving provisional jailing of a branch pulmonary artery (JS).
Procedure success, defined as a residual invasive pressure gradient across the pulmonary bifurcation of <20 mmHg, was 15% (5/33) for SB, 60% (6/10) for SS, 82% (14/17) for KB and 100% (10/10) for JS. The treatment and outcome flowchart is presented in Figure 1. Eight patients undergoing JS also had transcatheter pulmonary valve replacement (TPVR). Complications included inadvertent jailing of a pulmonary artery in 2 patients undergoing SS and hemothorax from guidewire injury, requiring percutaneous drainage and blood transfusion, in 1 patient undergoing JS. At a mean follow-up of 20 ± 15 months, the maximum instantaneous gradient across the right ventricular outflow tract by echocardiography after successful SB, SS, KB and JS was 33.2 ± 14.7 mmHg, 30.0 ± 7.8 mmHg, 25.0 ± 11.2 mmHg and 25.4 ± 13.1 mmHg, respectively. When comparing KB to JS, patients treated with KB were younger (6.0 ± 5.2 years vs. 13.6 ± 5.4 years) and more heterogenous (6 with d-transposition of the great arteries, 8 with tetralogy of Fallot, and 3 with truncus arteriosus vs. 9/10 with TOF for JS).
This retrospective single-center study involving a small and heterogeneous patient sample suggests that kissing balloon inflation with high-pressure balloons to treat PBS after repair of CTDs is successful and sufficient in most cases and might be preferred in small children and those not needing TPVR. When insufficient or when there is an indication for concomitant TAPVR, complex bifurcation stenting requiring considerable operator experience is necessary.
Figure 1. Flowchart of treatment strategies and outcome of 39 patients with pulmonary bifurcation stenosis.
