Retrieval of an IV catheter fragment from the pulmonary artery 11 years after embolization

The use of a peripherally inserted central catheter (PICC) is occasionally complicated by intravascular fracture and central embolization of the catheter fragment. We present a patient in whom a PICC fragment was retrieved from the pulmonary artery 11 years after embolization following its incidental detection. Despite a history of IV drug abuse and mitral regurgitation, this patient remained asymptomatic and without complications. The catheter fragment was retrieved since the patient was believed to be at risk for endocarditis. This may be the longest duration reported of an embolized catheter fragment that was successfully removed. As the natural history of asymptomatic-retained central venous foreign bodies remains unclear, the decision to remove them should be individualized. In selected cases, these foreign bodies may be retrieved without complications even several years after embolization.     

Balloon mitral valvulotomy in children aged < or = 12 years

BACKGROUND AND AIM OF THE STUDY: Balloon mitral valvulotomy (BMV) was studied in children aged < or = 12 years to study its efficacy, to assess the effects of age and body surface area on outcome, and to determine whether the definition of mitral stenosis and recommendations for balloon size used in adults are applicable to very young patients. At present, data on BMV or guidelines for balloon size in small children are not available. METHODS: Clinical, echocardiographic and hemodynamic data were obtained from 13 patients before and after BMV. At follow up, correlation coefficients were identified for clinical, echocardiographic or procedural variables with increase in the degree of mitral regurgitation (MR), age and body surface area. RESULTS: BMV was successful in 12 patients (93%), with increased valve area and cardiac index and decreased left atrial and pulmonary artery pressure gradients. Moderate MR developed in two patients (15%), but did not correlate with any variable. Symptom improvement was seen at follow up. Seven patients (54%) experienced adverse events: restenosis occurred in five cases (38%), and symptom recurrence and valve replacement for endocarditis occurred in one patient (8%). Kaplan-Meier analysis showed that by 20 months after BMV, 60% of patients had experienced an event. The percentage fall in pulmonary artery pressure correlated with body surface area, but not age. CONCLUSION: BMV is effective in very small children, but a high incidence of moderate MR occurs, mainly because the choice of balloon size is made using an adult-style, height-based nomogram and a stepwise increase in balloon size during BMV. Correct nomograms to define mitral stenosis, restenosis and balloon size must be developed for small children.     

Balloon dilation of pulmonary venous pathway obstruction in an infant after the mustard procedure

Pulmonary venous pathway obstruction developed after a Mustard procedure in an infant with transposition of the great arteries. The stenosis was successfully dilated by the percutaneous balloon technique with immediate clinical, echocardiographic, and hemo-dynamic improvement, which has persisted for 8 months after dilation. This technique is a feasible alternative to reoperation in such an obstruction, even in infants.     

"Balloon valvulotomy" of congenital pulmonary valve stenosis with tricuspid valve insufficiency

The rare congenital anomaly of pulmonary valve stenosis and massive tricuspid valve insufficiency with intact ventricular septum is a lethal condition without reported survival after attempted treatment. In a neonate suffering from this syndrome, the pulmonary valve stenosis was relieved by rupturing the fused valve with a balloon catheter introduced transvenously. The desperate condition of the patient quickly improved after this procedure, with subsequent disappearance of the tricuspid valve incompetence. Balloon rupturing of fused valves at angiography may represent a therapeutic alternative in cases in which surgical valvulotomy is associated with a high mortality.     

Balloon dilation of pulmonary venous pathway obstruction in an infant after the mustard procedure.

Pulmonary venous pathway obstruction developed after a Mustard procedure in an infant with transposition of the great arteries. The stenosis was successfully dilated by the percutaneous balloon technique with immediate clinical, echocardiographic, and hemodynamic improvement, which has persisted for 8 months after dilation. This technique is a feasible alternative to reoperation in such an obstruction, even in infants.     

Balloon dilation of pulmonary venous pathway obstruction after Mustard repair for transposition of the great arteries

Percutaneous balloon dilation was attempted in three patients with mid baffle pulmonary venous pathway obstruction after the Mustard operation for transposition of the great arteries. The procedure was unsuccessful in a 3 year old boy. Evidence for relief of obstruction in the other two patients (7 and 14 years old, respectively) consisted of angiographic demonstration of improved caliber at the site of the pulmonary venous pathway narrowing, improvement in the Doppler spectral signal at this site from an "obstructed" to a "normal" pattern as well as symptomatic improvement. Balloon dilation was performed twice in one of these patients. The Doppler and symptomatic improvement were sustained in both patients at short-term follow-up (5 and 6 months, respectively). This technique may offer effective relief of pulmonary venous pathway obstruction in some patients with this complication of the Mustard operation.     

Balloon dilation of critical pulmonary stenosis in the first week of life

Although balloon dilation or valvular pulmonary stenosis is established in infants and children, the techniques for and results of balloon dilation in neonates with critical pulmonary stenosis remain largely unreported. Since January 1, 1985, six successive neonates with critical pulmonary stenosis (aged 1 to 6 days) underwent attempted balloon dilation. Each was cyanotic and three of the six were on prostaglandin E₁therapy and three required tracheal intubation and ventilation. All had suprasystemic right ventricular pressures (mean 122.8 ± 6.6 mm Hg).After hemodynamic evaluation and right ventricular angiography, the valve was crossed in five patients, and was first dilated with a low profile, 5 or 6 mm diameter, 2 cm long balloon. At least one more balloon was used in each patient, the largest being 95 to 133% of the diameter of the pulmonary valve anulus. The anulus size was 6.8 ± 1.1 mm and the largest balloon size used was 6 to 10 mm.Right ventricular pressure decreased to nearly systemic level or less in live of five patients (58.8 ± 6.7 mm Hg). Pressure gradients, measured in four infants, were 7, 12, 16 and 35 mm Hg, respectively, but were unreliable indicators of obstruction because of a patent ductus arteriosus. The five patients were discharged 3 to 8 (days after balloon dilation. All are currently symptom free 10.6 ± 11.7 months later, and all but one are believed clinically to have mild obstruction. Complications included iliac vein occlusion (n = 1) and complete right bundle branch block (n = 1).Although follow-up has been brief, neonates with critical pulmonary stenosis can safely undergo balloon dilation, usually with good short-term results.     

The incidence and significance of pulmonic regurgitation after pulmonary valvulotomy

Detailed clinical and hemodynamic studies were made in 23 patients after surgical correction of valvular pulmonic stenosis. In each, pulmonic regurgitation was shown to be present by the appearance of a diastolic murmur postoperatively and/or by the results of indicator-dilution studies made during postoperative cardiac catheterization. The latter method proved that the pulmonic valve was incompetent in every patient in whom it was applied, including those in whom no diastolic murmur was audible. Satisfactory relief of stenosis was achieved in every patient but right ventricular prominence frequently persisted radiographically in spite of electro-cardiographic evidence of regression of right ventricular hypertrophy. These findings suggest that the principal response to the incompetent valve is ventricular dilatation.The results of the study indicate that pulmonic regurgitation is an invariable sequel to adequate pulmonary valvulotomy. In the absence of an associated lesion, however, the hemodynamic burden imposed by the regurgitant flow is apparently well tolerated.     

Balloon dilation of critical valvar pulmonary stenosis in the first month of life

Between 1985 and 1992, 36 consecutive neonates, aged 1–29 days, weight 2.4–5.0 kg, with critical valvar pulmonary stenosis underwent attempted balloon dilation (BD). At catheterization, 30 were on prostaglandin (PGE₁) therapy and 20 were intubated. The valve was successfully crossed and dilated in 34/36 (94%), including three with an echocardiographic diagnosis of valvar pulmonary atresia and a right ventricle of adequate size. The valve was first dilated with a 2- to 5-mm balloon and then with serially larger ones (up to 12 mm) to a final balloon/annulus value of 126%. The RV/systemic pressure value fell from 150 ± 32 to 83 ± 30%, O₂ saturation rose from 91 ± 6% to 96 ± 4%, and PGE₁ was discontinued at the end of the procedure. There were 11 complications (31%) including one early death from sepsis and necrotizing enterocolitis, endocarditis in another, two myocardial perforations, one femoral-iliac vein tear, and one transient pulse loss. A repeat BD was carried out in five patients, two of whom subsequently had surgery. At follow-up (33 ± 23 months), the 31 patients managed by BD alone were well and had echocardiographic gradients of < 30 mm Hg in 90% and pulmonary regurgitation, considered mild in most, in 52%. In neonates with critical valvar pulmonary stenosis, we believe BD mortality is less than with surgery and is the treatment of choice.     

Balloon dilation of postsurgical subaortic obstruction

Two children aged 10 and 5.5 years underwent balloon dilation for postsurgical subaortic obstruction. The outcome and the role of this procedure are discussed.