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Ann Thorac Surg 2000;69:858-864
© 2000 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, University of California, San Francisco, California, USA
b Division of Pediatric Cardiology, University of California, San Francisco, San Francisco, California, USA
Address reprint requests to Dr McElhinney, Children’s Hospital of Philadelphia, 34th Street & Civic Center Blvd, Rm 9557, Philadelphia, PA 19104
e-mail: mcelhinney{at}email.chop.edu
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Abstract |
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 Top Abstract IntroductionPatients and methodsCommentReferences |
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Methods. Seven patients who required operation after a transcatheter dilation procedure between 1992 and 1998 are described. Three patients required retrieval of retained foreign bodies (stents or balloons), and repair of the underlying abnormality. Two patients underwent repair of fistulas between 2 great vessels, or a great vessel and a cardiac chamber. One patient required operation for a postdilation aneurysm. One patient underwent urgent repair of severe aortic regurgitation after balloon aortic valvuloplasty.
Results. All patients survived and are doing well, with no further need for catheter or operative intervention, from 8 months to 6 years after operation. Additional reported complications requiring operation are discussed as well.
Conclusions. Operation for complications of catheter interventions in congenital heart disease is seldom necessary. Though uncommon, a variety of such complications may occur, including vascular, valvar, intracardiac, and foreign body complications. When operation is required, results are typically very good.
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Introduction |
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TopAbstractIntroductionPatients and methodsCommentReferences |
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Patients and methods |
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TopAbstractIntroductionPatients and methodsCommentReferences |
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Patient 1 had ventriculoarterial discordance with side-by-side great arteries and a subpulmonic ventricular septal defect. At 15 days of age he underwent an arterial switch operation with closure of the ventricular septal defect. At 4 months he underwent percutaneous balloon arterioplasty for anastomotic stenosis of the pulmonary trunk, with reduction of the gradient from 52 to 8 mm Hg. Two weeks later, he presented at clinic with a new continuous murmur, bounding pulses, and increased diaphoresis. The peripheral blood pressure was 90/38. An echocardiogram at that time revealed 3 m/s acceleration across the pulmonary valve, retrograde flow in the ascending aorta without aortic regurgitation, continuous antegrade pulmonary arterial flow, and a communication between the proximal ascending aorta and the pulmonary trunk (Fig 1). Catheterization revealed a 23% step-up in oxygen saturation from the right ventricle to the pulmonary artery, an estimated pulmonary to systemic blood flow ratio of 1.7 with an indexed pulmonary blood flow of 6.2 L/min/m2, and a 26 mm Hg peak systolic pressure gradient from the right ventricle to the pulmonary trunk. In addition, a 60 mm Hg aortic pulse pressure was measured. There was moderate pulmonary regurgitation, mild stenosis of the pulmonary trunk at the anastomosis site, and mild stenosis (10 mm Hg gradient) of both branch pulmonary arteries. An ascending aortogram showed simultaneous filling of the ascending aorta and pulmonary trunk through a fistulous connection between the right posterolateral aspect of the ascending aorta and the left anterolateral aspect of the pulmonary trunk.
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Patient 2 had undergone a Senning procedure in the neonatal period for ventriculoarterial discordance, with an anterior and rightward aorta and an intact ventricular septum. Over the next few years, she was noted to have a left ventricle to pulmonary artery gradient measured at 60 to 90 mm Hg by various modalities. At 9 years of age, catheter balloon dilation of the pulmonary outflow tract obstruction was performed, with transient improvement. At 11 years of age, she was noted to have a gradient of 90 mm Hg, with systemic or suprasystemic pressures in the morphologically left (pulmonary) ventricle. This was accompanied by mild depression of systemic right ventricular function and no rhythm abnormalities, venoatrial obstruction, or atrioventricular valvar dysfunction. By echocardiography, the subpulmonic obstruction appeared to be partially discreet and partially dynamic, due to both bowing of the ventricular septum and prolapse of the mitral valve into the left ventricular (pulmonary) outflow tract. The patient was referred for operation to relieve the subpulmonic stenosis.
After exposure of the heart and great vessels, cardiopulmonary bypass was initiated, the aorta was cross-clamped, and cold crystalloid cardioplegia was administered. The pulmonary trunk was opened and the valve appeared to be normal. However, an unexpected finding was encountered: there was a fistula measuring approximately 10 mm in diameter between the left posterior sinus of Valsalva and the left atrial appendage, which was thought to be an iatrogenic fistula resulting from the previous balloon dilation procedure. The fistula was repaired with a single layer of suture. The subpulmonic stenosis was then addressed through the pulmonary valve, with resection of nonfunctional redundant tissue associated with the mitral valve. The patient survived and was doing well at most recent follow-up, 6 years after operation. The peak instantaneous gradient from the left ventricle to the pulmonary trunk was 25 mm Hg, due to dynamic narrowing of the left ventricular outflow tract, which was unchanged from the early postoperative period.
Patient 3 had situs solitus, d-looped ventricles, and an anterior and leftward aorta, with ventriculoarterial concordance, a subaortic conus, and a ventricular septal defect. She had undergone closure of the ventricular septal defect at 6 months of age, and at the age of 4 years developed progressive subaortic stenosis and aortic regurgitation. A subaortic stent was placed in the left ventricular outflow tract using endovascular techniques, which reduced the gradient from 60 to 10 mm Hg. Six months later, she was noted to have an increased gradient across the left ventricular outflow tract and was taken back to the catheterization lab for evaluation and repeat dilation of the stent. During the second catheterization, prior to repeat dilation, a fracture was noted in the subaortic stent. During unsuccessful attempts at placement of another stent, 1 fragment embolized distally into the descending aorta and the rest remained in the subaortic outflow tract. After dislodgment of the stent, the gradient across the left ventricular outflow tract increased from 30 to 85 mm Hg.
The patient was taken to the operating room the following day. After cannulating the ascending aorta and the right atrium, and placing a vent into the left atrium through the right upper pulmonary vein, the patient was placed on cardiopulmonary bypass and cooled to 25°C. During this time, initially with the heart beating, a pursestring suture was placed in the ascending aorta and a balloon catheter was advanced into the descending aorta. Under fluoroscopic guidance, the balloon was inflated distal to the embolized fragment of stent, which was pulled back into the proximal ascending aorta. The aorta was cross-clamped and cardioplegia was administered. The aorta was opened with an oblique aortotomy into the noncoronary sinus of Valsalva, and the fragment of stent was removed from the aorta. The remaining part of the stent was in two pieces and barely attached to the endocardium of the subaortic region. These were removed and an extensive resection of fibromuscular tissue obstructing the subaortic region was performed. The regurgitant aortic valve was then repaired. The left coronary leaflet was large and prolapsing, so the free edge of this leaflet was effectively shortened by plicating and suspending both of its commissures. The noncoronary leaflet was hypoplastic, and was augmented along its free edge with a piece of autologous pericardium. Postbypass transesophageal echocardiography demonstrated no significant gradient across the left ventricular outflow tract. At follow-up of 5.5 years, she continues to do well with no significant gradient.
Patient 4 was born with critical aortic stenosis, moderate hypoplasia of the left ventricle, and endocardial fibroelastosis. On the 5th day of life, he underwent balloon aortic valvotomy, which successfully relieved the obstruction at the valvar level but caused severe aortic regurgitation. He remained dependent on mechanical ventilation with a metabolic acidosis, which was slowly progressive over the following 2 days. At 7 days of age, he was taken to the operating room. He was placed on cardiopulmonary bypass, and due to the severe aortic regurgitation the aorta was cross-clamped immediately and cardioplegia was given into the coronary ostia. The aortic valve was bileaflet, and 1 of the leaflets was avulsed and completely flail. It was decided that a Ross-Konno procedure should be performed, with pulmonary autograft aortic valve replacement, enlargement of the subvalvar left ventricular outflow tract with a Konno ventriculoplasty, resection of endocardial fibroelastosis, and reconstruction of the right ventricular outflow tract with an allograft valved conduit. The patient survived and has done well over the subsequent 4 years, requiring no reinterventions or hospitalizations.
Patient 5 had undergone coarctation repair as an infant elsewhere, and a Ross-Konno procedure at our institution for tunnel subaortic stenosis and progressive aortic regurgitation at 7 years of age. Ascending aortic obstruction at the cannulation site led to increased proximal aortic pressures and consequent neoaortic regurgitation. As a result, at 9 years of age he underwent catheterization and attempted stent placement at the site of obstruction. The balloon ruptured during stent deployment and could not be removed in the catheterization suite. It was positioned in the descending aorta and the patient was sent to operation, where he underwent removal of the balloon, along with successful augmentation of the arch and resuspension of an autograft leaflet, which was partially avulsed but not perforated.
Patient 6 had stenosis of the pulmonary valve and hypoplastic branch pulmonary arteries, and had undergone balloon pulmonary valvuloplasty as an infant. On echocardiographic evaluation at 9 years of age, he was found to have a peak gradient across the proximal left pulmonary artery of 50 mm Hg, so he was taken to the catheterization laboratory for balloon dilation and possible stent placement. Balloon dilation was unsuccessful at relieving the gradient, so a stent was placed across the proximal left pulmonary artery, with a resultant decrease in gradient to 15 mm Hg. He was discharged the following day after chest roentgenogram and echocardiography showed the stent to be in place with no recurrence of obstruction. Four days after discharge, he underwent follow-up echocardiography, which showed the stent to be in the pulmonary trunk.
The patient was taken to the operating room the same day. On opening the pulmonary trunk, it was noted that the stent had migrated to the right pulmonary artery, which was much larger than the left. The stent was removed, and the left pulmonary artery was augmented all the way into the lower lobe branch with a pedicled flap of tissue from the pulmonary trunk, which was very dilated. It was also noted that the pulmonary valve was partially avulsed (probably from the initial balloon valvuloplasty) and the commissural stenosis was still present. Thus, the avulsed leaflet was resuspended and a commissurotomy was performed. At follow-up of 1.5 years, the patient remains well, with no significant pulmonary valvar or arterial gradient.
Patient 7 had undergone an arterial switch operation as a neonate for ventriculoarterial discordance, an anterior and rightward aorta, and an intact ventricular septum. She underwent balloon dilation of the right pulmonary artery at 6 months of age, and of the pulmonary trunk and left pulmonary artery at 9 months. At 6 years of age, she was again referred for balloon pulmonary arterioplasty, after echocardiography showed a peak right ventricular pressure of 65 mm Hg and bilateral proximal branch pulmonary artery stenosis, and a perfusion scan revealed 67% of flow to the left lung. At cardiac catheterization, she was found to have gradients of 30 mm Hg from the proximal pulmonary trunk into the left pulmonary artery and 42 mm Hg into the right pulmonary artery. Simultaneous dilation of the stenotic left and right pulmonary artery orifices was performed on 2 occasions. Despite disappearance of the balloon waists, there was no significant reduction in gradient. An angiogram in the pulmonary trunk after dilation showed a small aneurysm of the anterosuperior pulmonary trunk, with contained extravasation of contrast.
The patient underwent operation the following morning. Upon opening the chest and dissecting the heart, a pseudoaneurysm measuring approximately 2 cm in diameter was observed on the anterior aspect of the distal pulmonary trunk. After the establishment of cardiopulmonary bypass, the pseudoaneurysm was opened and excised completely. There was a 1-cm full-thickness tear in the anterior aspect of the pulmonary artery, at the site of the arterial switch anastomosis. There was also a full-thickness cruciate tear in the posterior pulmonary trunk, which extended into the orifices of both branches, and was contained by fibrous tissue between the pulmonary trunk and ascending aorta. This was repaired. The pulmonary arteries were augmented from the proximal pulmonary trunk into both branches, beyond the origin stenoses, using a patch of pulmonary artery allograft tissue. There was no significant gradient after operation, and at follow-up of 8 months, the patient is doing well, with no recurrence of stenosis.
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Comment |
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TopAbstractIntroductionPatients and methodsCommentReferences |
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Despite the relative infrequency of complications in patients undergoing transcatheter dilation procedures, serious complications occur nevertheless, some resulting in death and some requiring operation [1–4]. As such, it is important for cardiac surgeons to be aware of the spectrum of complications that may require surgical attention. In this study, we have presented our experience with 7 select patients who developed complications requiring operation. We will review the full range of complications requiring operation that have been reported in patients with congenital heart disease undergoing transcatheter dilation procedures, which we have categorized as vascular, valvar, intracardiac, and foreign body complications (Table 1). We have not attempted to determine the incidence of such complications in our experience, and the review that follows is not exhaustive.
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Complications at the site of intervention include ruptures or tears, perforations, dissections, aneurysms or pseudoaneurysms, and fistulas. Ruptures have been reported most often after balloon dilation of the branch pulmonary arteries, but have also been reported to occur along the ascending aorta and arch following dilation of the aortic valve [3–5, 13–15, 17, 22, 25, 27]. Depending on the location of the tear, this complication may cause hemopericardium or hemothorax and their concomitant sequelae. Surgical repair of the tear is often required, though small breaches in the arterial wall may be self-limited or treated with endovascular occlusion techniques. Because the mechanism of successful balloon dilation of vascular stenoses is tearing of the intima and sometimes media, there is often an identifiable intimal flap at the site of balloon dilation. On occasion, a dissection may occur, and has been reported in both right and left-sided dilation procedures [2, 7]. More commonly, however, an aneurysm or pseudoaneurysm will form at the site of dilation [15, 22, 25, 27]. This complication is most frequently recognized after dilation of native or recurrent aortic coarctation [25, 27] or balloon pulmonary arterioplasty [15, 22]. All such aneurysms do not require surgical attention, but some do, as in our patient, who developed a relatively small pseudoaneurysm with extravasation of contrast that was contained by periarterial fibrous scarring. As proposed by Nakanishi and colleagues [15], scarring after the arterial switch procedure may contain ruptures resulting from balloon dilation of the anastomosis site, which seemed to be the case in our patient. This may lead to a misleading picture on angiography or echocardiography, as the pseudoaneurysm may appear small due to this factor. Regarding aneurysms at the site a dilated coarctation, it is not known how often postdilation aneurysms will enlarge to the point where operation is required. In fact, this may be one of the most important questions that remains to be answered about the results of balloon dilation of aortic coarctation.
Although acquired vessel-to-vessel fistulas can result from a variety of pathologic conditions, including penetrating trauma, atherosclerosis, aortic dissection, coronary angioplasty, and aortic aneurysms [28–30], they are extremely uncommon after dilation procedures for congenital heart disease [11]. In addition to our patient, we are aware of only 1 prior report of traumatic vessel to vessel fistula after transcatheter intervention for congenital heart disease. This was also an aortopulmonary fistula that occurred after dilation of anastomotic stenosis in a patient who had undergone arterial switch. In contrast to our patient, who developed symptoms subacutely, the previously reported patient experienced inexplicable pulmonary edema and hypotension 36 hours after the procedure, and was taken back to the catheterization lab for further evaluation. At this time, the fistula was recognized, and was palliated by percutaneously placing a stent covered with a vascular graft. It was repaired surgically the following day, after the patient had stabilized [11]. It is interesting to note that both of the reported cases of aortopulmonary fistula occurred after attempted dilation of anastomotic stenosis of the neopulmonary artery, after arterial switch. Presumably, there is scarring at the anastomosis sites of the neoaorta and neopulmonary artery and between these anastomoses. Dilation disrupts the vascular wall, and although scarring may prevent rupture in many cases, the disruption may track through planes of scar tissue that are common to both great arteries, resulting in a fistula between them.
Vascular complications at the site of percutaneous access are fairly common (including the iliac arteries in cases of groin access), but are minor and either self-resolving or amenable to medical therapy in most cases [1–4, 31, 32]. Thrombosis occurs frequently and seldom requires surgical treatment, with anticoagulant or thrombolytic therapy sufficient in the majority of cases. The most common indications for surgical intervention after transcatheter procedures are arterial tear or avulsion (partial or incomplete), arterial thrombosis, or arterial pseudoaneurysm [4, 31]. The same complications occur in adults undergoing percutaneous coronary angioplasty or stent placement, with incidence of surgical intervention of 0.6% after all catheterizations and 2.4% after interventional catheterization procedures [32].
Complications at the access site are more common after catheter dilation procedures than other catheterizations (both diagnostic and interventional), primarily because the profiles of catheter sheaths that can accommodate balloon catheters and/or stents are larger than those required for other types of catheterization. In the population of pediatric patients undergoing catheterization, arterial complications tend to be more common in younger patients (neonates and infants especially) undergoing balloon dilation procedures that require relatively large sheaths. As smaller sheaths and catheters have come to be developed, the need for surgical exploration and/or repair appears to be declining. In a review of their experience from 1984 to 1987, the Toronto group found that 29 of 64 patients undergoing aortic valvuloplasty or dilation of coarctation developed arterial complications at the access site [31]. Fifteen of these (23% of 64 patients) underwent surgical exploration and repair. When the same group reviewed their experience from 1987 to 1993, the incidence of surgical intervention for arterial complications was substantially lower [4]. As technology continues to improve and smaller catheters and sheaths become available for interventional procedures, complications of this nature will almost certainly continue to decline.
Valvar complications
Valvar complications are not particularly common, although the rate of complications during balloon valvuloplasty is probably higher than during other types of catheter intervention for congenital heart disease. Many of the complications that occur following balloon valvuloplasty of the aortic or pulmonary valves are vascular, as discussed above. Most of the valvar complications of dilation procedures consist of semilunar valvar regurgitation after balloon aortic or pulmonary valvuloplasty [10, 12, 13, 18, 19]. This complication is more significant when it occurs in the systemic circulation, and is described in almost every reported series of balloon aortic valvuloplasty. The mechanism of regurgitation is most often avulsion or prolapse of a leaflet, though there have also been cases described in which the catheter was advanced not through the valvar orifice but through a leaflet, after which the balloon was expanded, resulting in a sizable perforation of the leaflet [3, 12]. Significant regurgitation will usually require operation, though the need for emergent surgical intervention is rare. The leaflet can often be repaired surgically, but if the valve is irreparable and/or the aortic annulus is small, it may be preferable to perform a Ross or Ross-Konno procedure.
Complications of the atrioventricular valves or their subvalvar apparatus are uncommon, but have been reported. Perforation of the mitral valve requiring operation has been described as a complication of balloon aortic valvuloplasty using the antegrade approach, after septal puncture [13, 19]. Avulsion of a papillary muscle supporting the anterior leaflet of the tricuspid valve, with resultant tricuspid regurgitation, has been described as a complication of balloon pulmonary valvuloplasty [9]. The authors ascribed this to the use of a long balloon that protruded too far into the right ventricle proximally. Successful surgical repair was achieved.
Intracardiac complications
The most common type of intracardiac complication is almost certainly perforation [1–4, 13]. Often, with perforation of the atria, operation is not required. In many cases, however, surgical intervention is necessary. The sites most commonly perforated are the atrial appendage and right ventricular outflow tract, the latter generally being of greater significance. However, puncture of the left ventricle, with resulting cardiac tamponade, has also been reported [13].
Fistulas between a cardiac chamber and another cardiac chamber or great vessel are extremely uncommon. Although such lesions may occur secondary to other forms of trauma or acquired vascular disease (such as sinus of Valsalva aneurysm), we are not aware of any previously reported cases of a fistula between a great artery and a cardiac chamber after dilation procedures for congenital heart disease. The second patient in our series developed a fistula between the pulmonary artery and left atrium after dilation of the pulmonary outflow tract, 11 years following a Senning operation. Because this patient had undergone a Senning repair, a shunt between the pulmonary artery and left atrial appendage (still in continuity with the atrium draining to the pulmonary left ventricle) was hemodynamically similar to pulmonary regurgitation, insofar as it increased the volume load on the ventricle and allowed low-resistance runoff from the pulmonary artery. Moreover, in the circumstance of subvalvar pulmonary stenosis and secondarily elevated end-diastolic pressure and systemic venous pressure, the pulmonary artery to left atrium gradient was less than it might have been. Had it not been for the need to relieve the outflow obstruction surgically, the fistula may not have been recognized. It is possible, however, that given the nature of this patient’s subpulmonary obstruction, which had a significant dynamic component, with mitral valve prolapse into the left ventricular outflow tract, the pulmonary artery to left atrial fistula may have exacerbated the subpulmonary stenosis to a small degree, according to the Venturi effect.
Foreign body complications
Three of the 7 complications described in this report are retained, embolized, or fragmented foreign bodies. This is not representative of the reported experience with complications of interventional catheterization, as surgical intervention for retrieval of foreign bodies is relatively uncommon [1, 4, 13, 15, 21]. Foreign bodies such as stents or detached balloons that embolize during the dilation procedure can often be retrieved by means of catheter-based techniques. If the embolization occurs after the procedure has been completed, attempted retrieval by catheterization must be weighed against the therapeutic needs of the patient and the likelihood of successful retrieval. In some cases, such as our third patient, operation may be the optimal means of correcting the underlying abnormality. In other cases, where surgical repair of the underlying lesion is deemed the best approach, it may be expeditious to attempt retrieval using a combination of surgical and transcatheter techniques in the operating room, with the aid of fluoroscopy, as in our third patient. Rupture of the dilating balloon is not an uncommon occurrence, particularly when the structure being dilated is an outflow tract conduit [3, 4, 16, 21]. Fragmentation of dilating balloons has become uncommon in recent years, due to technological improvements in balloon materials and design.
Conclusion
Complications of transcatheter dilations in congenital heart disease are uncommon. Overall, the rate of complications during interventional catheterization is significantly higher than among patients undergoing diagnostic catheterization, and is significantly higher in infants than older patients [4]. These risk factors apply to major complications as well [4]. Although surgical intervention is seldom necessary, a variety of complications requiring operation may occur, with wide variation in the urgency of surgical attention. When operation is required for complications of catheter interventions, results are typically very good. In this report, we have not discussed surgical intervention for complications related to transcatheter embolization procedures in congenital heart disease. Most such complications involve distal embolization of occluding devices, such as coils, balloons, and septal occluding devices, or vascular problems at the catheter access site.
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TopAbstractIntroductionPatients and methodsCommentReferences |
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