Ann Thorac Surg 2009;88:1710-1711. doi:10.1016/j.athoracsur.2009.02.017
© 2009 The Society of Thoracic Surgeons
How To Do It
Hybrid Approach to Repair of Pulmonary Venous Baffle Obstruction After Atrial Switch Operation
Basar Sareyyupoglu, MDa,
Harold M. Burkhart, MDa,*,
Donald J. Hagler, MDb,
Joseph A. Dearani, MDa,
Allison Cabalka, MDb,
Frank Cetta, MDb,
Hartzell V. Schaff, MDa
a Division of Cardiovascular Surgery Department, Mayo Clinic, Rochester, Minnesota
b Division of Pediatric Cardiology and Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
Accepted for publication February 6, 2009.
* Address correspondence to Dr Burkhart, Mayo Clinic, 200 First St SW, Joseph 5th Floor, Cardiovascular Surgery, Rochester, MN 55905 (Email: burkhart.harold{at}mayo.edu).
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Abstract
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Pulmonary venous pathway obstruction is a late complication of the atrial switch operation for transposition of the great arteries. Gaining peripheral access to the pulmonary venous baffle obstruction to treat the obstruction with stent deployment is difficult if not impossible. We present three patients in which we used hybrid procedures in the operating room to relieve the pulmonary venous pathway obstructions.
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Introduction
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The atrial switch operation was the first surgical intervention to provide physiologic repair in d-transposition of the great arteries (d-TGA). Atrial switch procedures are still part of double switch operations for patients with atrioventricular discordance [1]. Venous baffle obstructions, both systemic and venous, are common late complications of the atrial switch. A few published reports have described interventional catheterization procedures to relieve systemic venous baffle obstructions [2, 3]. Reports of successful treatment of pulmonary venous baffle obstructions have involved surgical reoperation [4, 5]. We developed a hybrid approach to treat pulmonary venous baffle obstruction in atrial switch patients.
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Technique
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A 28-year-old woman with d-TGA, who had undergone a Senning procedure at age 11 months and aortic valve replacement at 18 years, presented with chest discomfort, exertional dyspnea, and fatigue. A transthoracic echocardiogram revealed severe pulmonary venous baffle obstruction with a mean gradient of 14 mm Hg (Fig 1). The inferior vena cava and superior vena cava pathways were widely patent. She had moderate right ventricle enlargement with mild dysfunction and an ejection fraction of 0.45. An attempt in the interventional catheterization suite at stent implantation through a transseptal approach was unsuccessful, and a hybrid procedure was undertaken.
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Fig 1. Two-dimensional transesophageal echocardiograph during hybrid procedure demonstrates severe narrowing (8 mm) of the pathway between the pulmonary venous atrium (PVA) and the native right atrium (RA).
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After a mini right anterior thoracotomy through the fourth intercostal space, a Prolene purse string (Ethicon, Somerville, NJ) was placed on right atrial free wall. An 11F long sheath was advanced over a 0.035-in extra stiff exchange wire across the stenosis into the left atrium and eventually into the right lower pulmonary vein. Through the 11F long sheath, a 14-mm Tyshak balloon (B. Braun Medical, Bethlem, PA) with a P301 Palmaz stent (Cordis Corp, Warren, NJ) was advanced across the pulmonary venous baffle obstruction. The stent was inflated with transesophageal and fluoroscopic guidance. The 14-mm balloon was removed, and an 18-mm balloon was exchanged and the stent was redilated with the 18-mm balloon. The mean gradient across the stenosis was 12 mm Hg measured by intraoperative transesophageal echocardiogram before stent placement and 4 mm Hg after stent placement (Fig 2). There was no sign of systemic venous obstruction after stent deployment.
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Fig 2. Two-dimensional transesophageal echocardiograph after placement of a stent across the stenosis between the pulmonary venous atrium (PVA) and the native right atrium (RA). Pulmonary venous pathway diameter equals 14 mm with stent deployed.
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After an uneventful hospital course, she was discharged on postoperative day 5. One year after the procedure, an echocardiogram revealed a widely patent stent. We performed the same technique with similar results in 2 more patients who had undergone atrial switch operations before (Table 1).
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Table 1 Perioperative Information of Patients Who Underwent Hybrid Approach to Repair Pulmonary Venous Baffle Obstruction
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Comment
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Baffle obstruction is a common long-term complication of the atrial switch operation. Horer and colleagues [5] recently reported a 27% (24 of 88 patients) incidence of baffle complications requiring reoperation. In patients with a failing systemic right ventricle, surgical intervention with the use of cardiopulmonary bypass has certain inherent risks and concerns [4].
Catheter intervention offers an attractive and efficient alternative to complicated surgical interventions. Interventional catheterization for systemic venous obstruction has been used in the past decade [2, 3]. Superior vena cava obstructions have been successfully repaired by stent placement through internal jugular access. Percutaneous catheter interventions, however, are not very useful in pulmonary venous baffle obstructions because direct access to the target obstruction is not possible. Performing a transseptal puncture can be difficult and time consuming in calcified, scarred baffles. In addition, transseptal or transbaffle access may be complicated by residual leaks through the baffle, necessitating occlusion devices.
Hybrid procedures in congenital cardiac surgical interventions are evolving [6]. Muscular ventricular septal defect repair, pulmonary artery stenting, and first-stage treatment of hypoplastic left heart syndrome are just a few examples of recent innovative hybrid procedures. This report documents 3 patients with a hybrid procedure to correct pulmonary venous baffle obstruction after an atrial switch operation. We found several advantages to repairing the pulmonary venous obstruction using a hybrid approach. The minithoracotomy was quite small but was more than sufficient to access the right atrial wall. Approaching the lesion with this technique provided a direct approach to the area of obstruction, thereby avoiding the sharp angles associated with a peripheral catheterization transseptal approach. Other advantages include the avoidance of cardiopulmonary bypass, cardiac arrest, and redo median sternotomy.
A hybrid approach to pulmonary venous baffle obstruction in the atrial switch patient offers a reproducible, straightforward alternative to a conventional operation. We would recommend considering the hybrid approach as first-line therapy for these complex patients.
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References
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- Koh M, Yagihara T, Uemura H, et al. Intermediate results of the double-switch operations for atrioventricular discordance Ann Thorac Surg 2006;81:671-677discussion 677.[Abstract/Free Full Text]
- Dragulescu A, Sidibe N, Aubert F, Fraisse A. Successful use of covered stent to treat superior systemic baffle obstruction and leak after atrial switch procedure Pediatr Cardiol 2008;29:954-956.[Medline]
- Ebeid MR, Gaymes CH, McMullan MR, Shores JC, Smith JC, Joransen JA. Catheter management of occluded superior baffle after atrial switch procedures for transposition of great vessels Am J Cardiol 2005;95:782-786.[Medline]
- Hörer J, Karl E, Theodoratou G, et al. Incidence and results of reoperations following the Senning operation: 27 years of follow-up in 314 patients at a single center Eur J Cardiothorac Surg 2008;33:1061-1067.[Abstract/Free Full Text]
- Hörer J, Herrmann F, Schreiber C, et al. How well are patients doing up to 30 years after a mustard operation? Thorac Cardiovasc Surg 2007;55:359-364.[Medline]
- Bacha EA, Marshall AC, McElhinney DB, del Nido PJ. Expanding the hybrid concept in congenital heart surgery Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2007:146-150.
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Abstract
Introduction
