1. NEERAJ AGGARWAL; MRIDUL AGARWAL; REENA K JOSHI; RAJA JOSHI
PEDIATRIC CARDIAC SCIENCES, SIR GANGA RAM HOSPITAL; NEW DELHI
Retrograde Balloon Pulmonary Valve Dilatation in a neonate with critical pulmonary stenosis
Introduction
ANGIOGRAM AND BALLOON PULMONARY VALVE DILATATION
DISCUSSION
Percutaneous femoral venous access is the most preferred and successful route for balloon pulmonary valvuloplasty (BPV) but rarely with little antegrade flow in right ventricular outflow tract (RVOT) along with right ventricular hypertrophy (RVH), it may be difficult to cross the pulmonary valve antegradely. We present a retrograde approach to cross pulmonary valve in a neonate with critical pulmonary stenosis
Alternate routes for BPV- transumbilical, transjugular and transhepatic.
Transjugular route has been strongly advocated in cases of difficult to cross pulmonary valves (or Interrupted IVC) as it provides better angulation and relatively easy access.
Transhepatic route is not favoured due to lack of experience .
Transumbilical route for BPV has been used in few cases of interrupted IVC (with great difficulties to manipulate catheters).
We chose to use Trans PDA route as RV hypertrophy and subsequent manipulation will pose challenges in all of antegrade routes and we can avoid these to a large extent through retrograde method.
Pt was taken up for BPV. We could reach RV and RVOT through 4 F Swan Ganz and Right Judkin catheter but even after repeated attempts, valve could not be crossed. There were repeated ventricular ectopics and short runs of ventricular tachycardia during RV manipulation.
Plan was changed to cross pulmonary valve through PDA via femoral arterial access as it may offer the direct access to pulmonary valve. A j tipped terumo wire was used with 4 F Right Judkin catheter to cross the PDA.Terumo wire could be crossed across pulmonary valve in second attempt with relative ease which was exchanged over the catheter with a coronary wire. A 3 mm coronary balloon was first inflated followed by low pressure Tyshak balloon (size 7 mm/2 cm) .There was no acute event, ventricular ectopics or desaturation during the procedure.
HISTORY
A male neonate presented with sudden onset respiratory distress and cyanosis (saturation 65%) at 36 hours of life.
Echocardiogram showed severe valvular pulmonary stenosis (pulmonary annulus= 7 mm) with minimal antegrade flow in RVOT,RVH with RV dysfunction, PFO shunting predominantly right to left, small PDA and adequate tricuspid valve annulus (Z score >2).He was started on prostaglandin E1 and saturations improved to 75 %.
CLINICAL IMPLICATIONS
Trans PDA balloon BPV is a feasible alternative in neonates where antegrade route is challenging due to right ventricular hypertrophy and minimal antegrade flow