Ann Thorac Surg 2002;73:659-661
© 2002 The Society of Thoracic Surgeons
Case report
Aortopulmonary window due to balloon angioplasty after arterial switch operation
Hiroo Takayama, MD*a,
Akihiko Sekiguchi, MDa,
Masahide Chikada, MDa,
Mio Noma, MDa,
Ryoichi Ishida, MDa
a Division of Cardiovascular Surgery, National Children’s Hospital, Tokyo, Japan
Accepted for publication June 25, 2001.
* Address reprint requests to Dr Takayama, Division of Cardiovascular Surgery, National Children’s Hospital, 3-35-31 Taishido Setagaya-ku, Tokyo, 154-8509, Japan
e-mail: hirofu2{at}hotmail.com
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Abstract
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We report 2 cases of aortopulmonary window that developed after balloon angioplasty for pulmonary artery stenosis. Both patients had undergone arterial switch operations for complete transposition of the great arteries before the angioplasty. These aortopulmonary windows were repaired through elective operations. The clinical features, diagnosis, management, and proposed mechanisms of this complication are described.
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Introduction
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Aortopulmonary (AP) window as a complication of pulmonary artery (PA) balloon angioplasty has rarely been reported [1]. We report 2 cases of traumatic AP window, both of which developed in patients after an arterial switch operation (ASO).
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Case reports
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Patient 1
A female newborn with d-transposition of the great arteries with intact ventricular septum underwent an ASO on day 15 of life. Follow-up cardiac catheterization demonstrated bilateral PA stenosis, which was 4.4 mm at the right and 6.0 mm at the left in diameter. Fifteen months after the operation, serial dilations were successfully performed under the pressure of 10 atmospheres using 12-mm Ultrathin diamond balloon (Boston Scientific Corporation, Natick, MA). Echocardiography after the procedure demonstrated AP communication at PA bifurcation, although pulmonary angiography immediately after the dilation showed no such findings (Fig 1).
Because the patient was hemodynamically stable, evaluation catheterization was performed 6 months after the intervention. Oxymetric data revealed a step-up in oxygen saturation in the right PA, and pulmonic-to-systemic ratio (Qp/Qs) was calculated to be 1.56. The AP window was confirmed by ascending aortography. The patient underwent surgery for this defect 21 months after the balloon dilation. A defect that was oval in shape and 5 mm at greatest diameter was examined through a pulmonary arteriotomy (Fig 2).
The surgical procedure included direct closure of this defect and patch angioplasty of PA bifurcation.
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Fig 1. (A) Long-axis view of two-dimensional echocardiography with color flow Doppler imaging demonstrated a window between aorta and pulmonary artery. (B) Short-axis view revealed a shunting flow from aorta to right pulmonary artery. (AO = aorta; LPA = left pulmonary artery; PA = pulmonary artery; RPA = right pulmonary artery.)
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Fig 2. A defect, oval in shape and 5 mm in greater diameter, in the wall between aorta and main pulmonary artery (arrow) was inspected through a pulmonary arteriotomy.
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Patient 2
A male newborn diagnosed with d-transposition of the great arteries with intact ventricular septum underwent left modified Blalock-Taussig shunt and PA banding at 3 months, as well as ASO at 9 months. The patient developed bilateral PA stenosis, and underwent dilation with balloon angioplasty 3 years after ASO. Follow-up cardiac catheterization demonstrated restenosis of right PA, which was 3.7 mm in diameter. Balloon angioplasty was attempted with 12-mm Blue-Max balloon catheter (Boston Scientific Corporation, Natick, MA) 3.5 years after ASO. At the time of this procedure, the patient collapsed hemodynamically and was resuscitated. Chest roentgenography revealed abnormal shadow at the hilar portion of right lung. The patient was observed closely under the suspicion of a PA rupture, and recovered with conservative treatment. Cardiac catheterization 5 months after this intervention demonstrated a communication between the aorta and right PA. Oxymetric data revealed a step-up in oxygen saturation in right PA. The Qp/Qs was calculated to be 1.78. Surgery was attempted 21 months after the balloon angioplasty. A defect 5 mm in diameter was found between the two arteries. The edge of this defect was so friable that the defect needed to be closed with a patch. The PA bifurcation was enlarged using an autologous pericardial patch. Follow-up cardiac catheterization demonstrated a residual communication around the closure site.
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Comment
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Supravalvular pulmonary stenosis is widely recognized as one of the most common complications of ASO. Pulmonary artery stenosis occurs in 7% to 28% of patients after ASO for correction of the d-transposition of the great arteries [2, 3]. Treatment for this entity is either reoperation or balloon angioplasty. Although balloon angioplasty has been less successful in these types of lesions compared with other types of right ventricular outflow tract obstruction, it can be the first therapeutic choice because of its low complication rate and the potential benefit of the procedure [4]. Reported complications include aneurysm formation, vessel dissection or rupture, transient unilateral pulmonary edema, and thrombosis [5]. In this report, we describe 2 cases of traumatic AP window as a complication of catheter intervention.
In our series, development of the AP windows was associated with balloon angioplasty for peripheral pulmonary stenosis after ASO. The success of PA angioplasty occurs by tearing either part or all of the vascular intima and media, allowing vascular remodeling and healing at a larger diameter [6]. Development of AP window in patients after ASO presumably resulted from a combination of a complete transmural tear occurring where the great vessels were in densely adherent as a result of prior surgery. In addition, the anatomical position of the two great arteries translocated by the LeCompte maneuver might contribute to the development of this window. Accordingly, we believe that the development of AP window after balloon angioplasty is highly specific to cases after ASO with the LeCompte maneuver.
Because the 2 patients reported here were in stable condition in the outpatient clinic, they underwent operation after several months of observation. Elective surgery should be chosen unless a patient is hemodynamically unstable.
In conclusion, AP window is a rare but an important complication that can develop after PA balloon angioplasty, especially in patients after ASO.
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References
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Preminger T.J., Lock J.E., Perry S.B. Traumatic aortopulmonary window as a complication of pulmonary artery balloon angioplasty: transcatheter occlusion with a covered stent. A case report. Cathet Cardiovasc Diagn 1994;31:286-289.[Medline]
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Wernovsky G., Hougen T.J., Walsh E.P., et al. Midterm results after the arterial switch operation for transposition of the great arteries with intact ventricular septum: clinical, hemodynamic, echocardiographic, and electrophysiologic data. Circulation 1988;77:1333-1344.[Abstract/Free Full Text]
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Lupinetti F.M., Bove E.L., Minich L.L., et al. Intermediate-term survival, and functional results after arterial repair for transposition of the great arteries. J Thorac Cardiovasc Surg 1992;103:421-427.[Abstract]
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Nakanishi T., Matsumoto Y., Seguchi M., Nakazawa M., Imai Y., Momma K. Balloon angioplasty for postoperative pulmonary artery stenosis in transposition of the great arteries. J Am Coll Cardiol 1993;22:859-866.[Abstract]
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Abstract
Introduction
