Iatrogenic aortopulmonary communications after transcatheter interventions on the right ventricular outflow tract or pulmonary artery: Pathophysiologic, diagnostic, and management considerations

Torres, Alejandro; Sanders, Stephen P.; Vincent, Julie A.; El‐Said, Howaida; Leahy, Ryan; Padera, Robert F.; McElhinney, Doff B.

doi:10.1002/ccd.25897

Cited by 24 publications

(13 citation statements)

References 44 publications

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“…Ten were closed: four with covered stents, 11,14,17,20 three with surgery, 12,13,19 two with aortic endografts 16,18 and one with a device. 15 In context of these few reports, we find our experience illuminating.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary artery interventions after the arterial switch operation: Unique and significant risks

Lee

Shahbah

El‐Said

et al. 2019

Congenital Heart Disease

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Background:In the modern era, results of the arterial switch operation (ASO) for transposition of the great arteries are excellent. However, because of the LeCompte maneuver, there may be a propensity for development of pulmonary artery stenosis.We encountered atypical complications of pulmonary artery stenting in patients after the ASO, including aorto-pulmonary fistula and coronary compression. Methods:We performed a 10-year retrospective review of catheterizations performed in patients after ASO in our institution with a focus on adverse events.Results: Diagnostic and interventional catheterizations were performed in 47 patients. In 29 patients, 37 interventional procedures performed, which included pulmonary artery angioplasty and/or stenting. In this group, there were five major adverse events (14%), including three aorto-pulmonary fistulae and one coronary artery compression among patients having stent implantation or stent redilation. In addition, there were 6/37 (16%) intended stent procedures, which were aborted because there appeared to be high-risk of significant adverse events.Conclusions: This review suggests that percutaneous intervention on pulmonary artery stenosis after ASO has high-risk and should be undertaken advisedly. Prior thorough evaluation of coronary arteries is mandatory as coronary reimplantation sites may be adjacent to sites of pulmonary artery stenosis. Furthermore, if pulmonary artery stent implantation or stent redilation is contemplated, the risk of stent fracture and possible AP fistula should be recognized. Primary use of reinforced covered stents should be considered. K E Y W O R D Saorto-pulmonary fistula, arterial switch operation, pulmonary artery, stents, transposition of great vessels

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Section: Discussionmentioning

confidence: 99%

Pulmonary artery interventions after the arterial switch operation: Unique and significant risks

Lee

Shahbah

El‐Said

et al. 2019

Congenital Heart Disease

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“…The majority of the iatrogenic AP fistulas cases were reported after transcatheter interventions on the PAs or RVOT in patients with TGA who underwent PA angioplasty after an ASO and most of these cases were managed by transcatheter intervention with use of covered stents or endovascular stent graft [3]. One case was reported in a patient with truncus arteriosus repaired without the use of RV-PA conduit; later on…”

Section: Discussionmentioning

confidence: 99%

Iatrogenic aortopulmonary fistula after balloon dilation of right pulmonary artery stent following truncus arteriousus type 1 repair.

Alharthi¹,

Alsahari²,

AlQahtani³

et al. 2019

Interventional-Cardiology

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Iatrogenic aortopulmonary (AP) fistula is an unusual complication after balloon pulmonary artery (PA) angioplasty or branch pulmonary arteries (PAs) stent dilation. The majority of the cases were reported after transcatheter interventions on the PAs or right ventricular outflow tract (RVOT), in patients with transposition of great arteries (TGA) who underwent PA angioplasty following arterial switch operation (ASO) or after transcutaneous pulmonary valve replacement in patients who had undergone a Ross procedure [1].We present a case of iatrogenic AP fistula in a 4-year-old patient with a history of repaired truncus arteriosus type 1 followed by bilateral PAs stent placement and balloon dilation,17 months later redilation of the right pulmonary artery (RPA) stent resulted in a AP fistula with significant left to right shunt which was successfully closed with a covered stent. This case demonstrates a previously unreported complication of transcatheter RPA stent reintervention after truncus arteriosus repair.

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“…In addition to the mild residual root distortion, this patient developed an aortic‐pulmonary fistula at the most distal aspect of the TPV. The development of aortic‐pulmonary communications following transcatheter interventions in the area of previous suture lines/surgical procedures in patients with an intimate relationship between the aorta and conduit/RVOT has been reported immediate retrosternal location of the RVOT could potentially increase the risk of aortic root distortion and/or AI as there is only room for posterior expansion of the conduit during balloon dilation/stent implantation. This is a relatively common finding following cardiac surgery, and was shown in a prior study to be a risk factor for Melody TM valve stent fracture .…”

Section: Discussionmentioning

confidence: 99%

“…Although coronary artery compression can have catastrophic consequences, significant compression of other structures in close proximity to the RVOT, including the aortic root, sinuses of Valsalva, or ascending aorta, can occur as well, and may also constitute important contraindications for TPV implantation. Significant distortion of the aortic root, aortic valve insufficiency (AI), and pulmonary artery (PA) to aorta fistulas following Melody TM TPV implant have been reported . However, data regarding the potential risks and clinical implications of aortic root distortion and/or AI during RVOT balloon sizing/dilation are limited.…”

Section: Introductionmentioning

confidence: 99%

Aortic Root Distortion and Aortic Insufficiency During Balloon Angioplasty of the Right Ventricular Outflow Tract Prior to Transcatheter Pulmonary Valve Replacement

Torres

McElhinney

Anderson

et al. 2016

J Interven Cardiology

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Objective To describe the significance of aortic root distortion (AD) and/or aortic valve insufficiency (AI) during balloon angioplasty of the right ventricular outflow tract (RVOT) performed to rule out coronary artery compression prior to transcatheter pulmonary valve (TPV) implantation. Methods AD/AI were assessed by retrospective review of all procedural aortographies performed to evaluate coronary anatomy prior to TPV implantation. AD/AI was also reviewed in all pre-post MPV implant echocardiograms to assess for progression. Results From 04/2007 to 3/2015, 118pts underwent catheterization with intent for TPV implant. Mean age and weight were 24.5 ± 12 years and 64.3 ± 20 kg respectively. Diagnoses were: TOF (53%), D-TGA/DORV (18%), s/p Ross (15%), and Truncus (9%). Types of RV-PA connections were: conduits (96), bioprosthetic valves (14), and other (7). Successful TPV implant occurred in 91pts (77%). RVOT balloon angioplasty was performed in 43/118pts (36%). Aortography was performed in 18/43pts with AD/AI noted in 6/18 (33%); two with D-TGA (1 s/p Lecompte, 1 s/p Rastelli), 2 with TOF, 1 Truncus and 1 s/p Ross. Procedure was aborted in the 2 who developed severe AD/AI. TPV was implanted in 3/4 pts with mild AD/AI. Review of pre-post TPV implantation echocardiograms in 83/91pts (91%) revealed no new/worsened AI in any pt. Conclusion AD/AI is relatively common on aortography during simultaneous RVOT balloon angioplasty. Lack of AI progression by echocardiography post-TPV implant suggests these may be benign findings in most cases. However, AD/AI should be carefully evaluated in certain anatomic subtypes with close RVOT/aortic alignments.

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Iatrogenic aortopulmonary communications after transcatheter interventions on the right ventricular outflow tract or pulmonary artery: Pathophysiologic, diagnostic, and management considerations

Abstract: Cardiologists performing PA or RVOT interventions should be aware of the possibility of a traumatic AP communication and consider this diagnosis when confronted with suggestive signs and symptoms.

Cited by 24 publications

References 44 publications

Pulmonary artery interventions after the arterial switch operation: Unique and significant risks

Pulmonary artery interventions after the arterial switch operation: Unique and significant risks

Iatrogenic aortopulmonary fistula after balloon dilation of right pulmonary artery stent following truncus arteriousus type 1 repair.

Aortic Root Distortion and Aortic Insufficiency During Balloon Angioplasty of the Right Ventricular Outflow Tract Prior to Transcatheter Pulmonary Valve Replacement

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