Estimation of pulmonary artery pressure from pulmonary vein wedge pressure

Correlations between pulmonary artery and pulmonary vein wedge pressures were investigated in 13 patients with atrial septal defect and 1 patient with Tetralogy of Fallot. Pulmonary vein wedge pressure wave form resembled that of pulmonary artery pressure, and the former lagged behind the latter by 70 to 110 msec (mean 88 ± 14) as observed by the fluid-filled catheter system. Diastolic pulmonary artery and diastolic pulmonary vein wedge pressures were nearly identical. Although systolic and mean pulmonary artery pressures correlated well with respective pulmonary vein wedge pressures, there were discrepancies when systolic and mean pulmonary artery pressure exceeded 35 and 20 mm Hg, respectively. However, systolic and mean pulmonary artery pressures could be estimated by adding the difference between the diastolic pulmonary vein wedge pressure and the mean left atrial pressure to corresponding systolic or mean pulmonary artery pressure. In conclusion, pulmonary artery pressures can be estimated by measuring pulmonary vein wedge pressures and the mean left atrial pressure.     

Bifurcating stents in the pulmonary arteries: A novel technique to relieve bilateral branch pulmonary artery obstruction

Balloon angioplasty and stent placement in close proximity to the bifurcation of the branch pulmonary arteries can be challenging. Multiple approaches have been previously described, though none of these approaches both treats bilateral proximal branch pulmonary artery stenosis and provides an anchor for a transcatheter pulmonary valve replacement. We report a novel approach that involves serial stent placement and balloon dilation through the struts of the stent in each pulmonary artery, along with balloon expansion of the proximal portion of the stents to the diameter of the main pulmonary artery. In the two cases we describe, this strategy resulted in significant relief of branch pulmonary artery obstruction without compromising the anatomy of the main pulmonary artery segment. This technique can be an effective way to alleviate stenoses of the bilateral proximal branch pulmonary arteries and provides a landing zone for a future transcatheter pulmonary valve. © 2015 Wiley Periodicals, Inc.     

Characterization of a new pulmonary vein variant using magnetic resonance angiography: incidence, imaging, and interventional implications of the "right top pulmonary vein"

INTRODUCTION: Catheter ablation of the pulmonary veins (PVs) for prevention of recurrent atrial fibrillation requires precise anatomic information. We describe the characteristics of a new anatomic variant of PV anatomy using magnetic resonance angiography. METHODS AND RESULTS: A 1.5-T magnetic resonance imaging system with a body coil or a torso phased-array coil was used before and after gadolinium injection. Magnetic resonance angiograms were acquired with a breath-hold three-dimensional fast spoiled gradient-echo imaging sequence in the coronal plane. Three-dimensional reconstruction with maximum intensity projections and multiplanar reformations was performed. A newly described variant PV ascending from the roof of the left atrium was found in 3 of 91 subjects. The mean ostial diameter of the roof PV was 7 +/- 2 mm, the mean distance from the ostium to the first branching point was 22 +/- 8.5 mm, and the mean distance to the right superior PV was 3.3 +/- 0.6 mm. CONCLUSION: We refer to the newly described variant of PV anatomy as the "right top pulmonary vein." It is important to be aware of this anatomic pattern to avoid inadvertent catheter intubation, which can result in misleading mapping results and PV stenosis.     

Balloon pulmonary valvuloplasty in the management of cyanotic congenital heart defects

Twenty-three children with cyanotic congenital heart defects, aged 3 days to 11.5 years, weighing 2.9 to 30 kg, underwent percutaneous balloon pulmonary valvuloplasty to improve pulmonary oligemia. The patients were divided into two groups: group I with intact ventricular septum and group II with ventricular septal defect. In 12 group I patients, there was an increase of systemic arterial oxygen saturation [83 ± 8% (mean ± SD) vs. 94 ± 5%, P < 0.001] and pulmonary-to-systemic flow ratio (0.7 ± 0.1 vs. 1.0 ± 0.2, P < 0.001). Peak systolic pressure gradient across the pulmonary valve decreased (P > 0.001) from 105 ± 48 to 25 ± 18 mm Hg. In 11 group II patients, arterial oxygen saturation (67 ± 13 vs. 83 ± 13%, P < 0.01) and pulmonary-to-systemic flow ratio (0.7 ± 0.4 vs. 1.2 ± 0.5, P < 0.02) increased following valvuloplasty. Peak systolic pressure gradient across the pul-monic valve (52 ± 16 vs. 32 ± 22 mm Hg, P < 0.05) decreased while infundibular and total pulmonary outflow tract gradients were unchanged (P > 0.1). Immediate surgical intervention was avoided in all cases in both groups. On follow-up, 1 to 36 months after valvuloplasty, arterial oxygen saturation, pulmonary-to-systemic flow ratio, and pulmonary valve gradients remain improved in both groups. However, in group I, repeat balloon valvuloplasty was required in two children. In group II, six children with tetralogy of Fallot (TOF) underwent successful total surgical correction 4 months to 2 years after valvuloplasty. Two children with transposition of the great arteries required Blalock-Taussig shunts 6 and 18 months after valvuloplasty for further improvement of hypoxemia. Demonstrable increase in pulmonary artery diameter occurred in several children. These data suggest that pulmonary valvuloplasty offers an excellent relief of pulmonary valve obstruction in the intact ventricular septum group and palliation of pulmonary oligemia in the ventricular septal defect group. In the latter group, avoiding immediate surgical shunts in all patients and achieving growth in pulmonary arterial size in many patients, thus making them suitable for further surgical palliation or correction, are additional advantages.     

Prenatal diagnosis of tetralogy of Fallot associated with pulmonary artery sling: Two case reports

Tetralogy of Fallot (TOF) is a common condition accounting for 10%–20% of all fetal cyanotic congenital heart disease cases. Pulmonary artery sling (PAS), or aberrant left pulmonary artery, is a rare congenital cardiovascular malformation. Approximately 58%–83% of PAS is associated with other cardiovascular malformations, TOF being rarest. The diagnosis of PAS is generally incidental or made at autopsy. Cases of prenatal diagnoses of TOF associated with PAS have not yet been reported. Here, we report two cases of TOF associated with PAS diagnosed prenatally in our hospital.     

Contained rupture of patched right ventricular outflow tracts during balloon sizing for percutaneous pulmonary valve implantation

Transcatheter pulmonary valves are being used off‐label to treat pulmonary insufficiency in patched right ventricular outflow tracts (RVOTs). We describe the first reported cases of patched RVOT rupture, during balloon sizing for percutaneous pulmonary valve implantation, in two patients with tetralogy of Fallot status post repair. Both RVOTs were too large for subsequent catheter‐based intervention. The ruptures remained stable over time, and both patients were managed conservatively with follow‐up imaging. © 2015 Wiley Periodicals, Inc.     

Valve perforation and balloon pulmonary valvuloplasty in an infant with tetralogy of Fallot and pulmonary atresia

We report an infant who had tetralogy of Fallot, hypoplastic pulmonary arteries, and membranous pulmonary atresia who underwent successful perforation of the atretic valve and subsequent balloon pulmonary valvuplasty. Because of the inability to access the pulmonary arteries via a patent ductus arteriosus, two-dimensional echocardiography was used to confirm wire position prior to perforation. The branch pulmonary arteries initially measured 1.5 mm in diameter and enlarged to 2.8 mm immediately after valvuloplasty. Four months postprocedure, the patient underwent a successful repeat balloon pulmonary valvuloplasty. The pulmonary arteries had grown to approximately 6 mm in diameter. Although it is a rare occurrence, patients with tetralogy of Fallot and membranous pulmonary atresia can be dilated with successful growth of the pulmonary arteries. Cathet. Cardiovasc. Diagn. 40:403–406, 1997. © 1997 Wiley-Liss, Inc.     

Technique and results of pulmonary vein angiography in patients undergoing catheter ablation of atrial fibrillation

INTRODUCTION: Delineation of pulmonary vein (PV) anatomy is an integral part of the PV isolation procedure. The aims of the present study were to (1) describe the technique of selective PV angiography, (2) show the typical fluoroscopic locations and appearance of the PVs, and (3) compare the ostial diameters of PVs measured by angiography and magnetic resonance imaging (MRI). METHODS AND RESULTS: Twenty consecutive patients undergoing a PV isolation procedure underwent selective PV angiography using a deflectable 8-French lumened catheter (Naviport, Cardima). The left superior PV (LSPV) runs upward and away from the spine in the right anterior oblique (RAO) projection and upward and toward the spine in the left anterior oblique (LAO) projection. The opposite is true for the right superior PV (RSPV). The left inferior PV (LIPV) has a bull's-eye appearance in the RAO projection, and the right inferior PV (RIPV) has a bull's-eye appearance in the LAO projection due to their end-on trajectories. The LIPV in the LAO projection and the RIPV in the RAO projection run horizontally toward the spine. An excellent correlation was noted in PV ostial size as assessed by angiography and MRI (r(2) < 0.90, P < 0.0001). CONCLUSION: This study describes the technique and results of PV angiography and fluoroscopy. The study also demonstrates good correlation of PV ostial diameters by contrast venography and MRI. PV angiography can be used as an alternate to MRI or computed tomographic imaging, particularly when these tests are unavailable or are contraindicated in the patient.     

Percutaneous occlusion of a pulmonary aneurysm causing hemoptysis in a patient with pulmonary atresia and aortopulmonary collaterals

A 28‐year‐old male was referred for cardiac catheterization because of recurrent severe hemoptysis necessitating resuscitation and subsequently preventing weaning from ventilation. He had a history of pulmonary atresia, ventricular septal defect, overriding aorta with right‐sided aortic arch diagnosed at birth. Eisenmenger's syndrome ensued and he was not felt to be suitable for corrective cardiac surgery. He had multiple major aortopulmonary collateral vessels to both lungs with a large aneurysm in an artery to the right lower lobe, which was suspected to be the source of his bleeding. Occlusion of this aneurysm was achieved percutaneously using an Amplatzer septal occluder device. He had no further bleeding and was successfully weaned from ventilation. Six months later, he has recovered to his functional baseline and has not had any further episodes of hemoptysis. © 2005 Wiley‐Liss, Inc.     

Early and late results and the effects on pulmonary arteries of balloon dilatation of the right ventricular outflow tract in tetralogy of Fallot

Background Balloon dilatation of the pulmonary valve remains controversialas a palliative procedure in tetralogy of Fallot. Aims To determine the clinical outcome, growth of the pulmonary vasculartree and findings at surgery of balloon dilatation of the pulmonaryvalve performed as a palliation in infants with tetralogy ofFallot. Methods and Results Thirty-three severely cyanosed infants (mean age of 3 monthsfor the whole population, including seven neonates) underwentthis procedure from June 1990 to January 1997. After balloondilatation, systemic oxygen saturation increased from a meanvalue of 76±9% to 88±7% (P<0·001). Theprocedure was accomplished without complications. Four patientshad recurrent hypoxic spells after dilatation leading to surgicalrepair within 30 days of dilatation (three modified Blalock-Taussigshunts and one complete repair). A control study was performedat a mean of 6·1±4·5 months after dilatationin 16 patients to establish growth of the pulmonary vasculartree (repeat catheterization in nine patients and surgical pulmonaryannulus calibration in seven). The pulmonary annulus increasedfrom a mean Z score of –4·1±0·9 SDto –2·5±1·1 SD (P<0·001),Z score for the right pulmonary artery from –3·0±0·6SD to –1·9±1·2 SD (P=0·007)and the Z score for the left pulmonary artery from –2·7±0·7SD to –1·6±1·3 SD (P=0·021).At late follow-up (mean of 9 months after dilatation, range3 to 54 months), 28 patients underwent complete repair. Trans-annularpatching was required in 43% of patients. Four post-operativedeaths were observed, none dilatation related. Conclusion Balloon dilatation of the pulmonary valve is an effective andsafe palliation in tetralogy of Fallot. It promotes growth ofthe pulmonary vascular tree, reducing the need for trans-annularpatching and is recommended in symptomatic infants of very youngage, with a small pulmonary annulus (Z value below –4SD) and associated cardiac anomaly.     

Left main coronary artery compression by aneurysmal pulmonary artery in a patient with tetralogy of Fallot with absent pulmonary valve

We describe an 11-year-old girl with tetralogy of Fallot and absent pulmonary valve, who on selective coronary angiography was found to have extrinsic compression of the left main coronary artery by the aneurysmally dilated pulmonary artery. This abnormality has not been reported previously. Cathet. Cardiovasc. Intervent. 46:438–440, 1999. © 1999 Wiley-Liss, Inc.     

Percutaneous pulmonary valve implantation for reconstruction of a patch‐repaired right ventricular outflow tract

Percutaneous pulmonary valve implantation (PPVI) is nowadays an accepted treatment option to repair post‐surgical conduit dysfunction of the right ventricular outflow tract (RVOT). In addition, many patients need a pulmonary valve to reconstruct a hemodynamically incompetent native or conduit free outflow tract. Based on our experience with percutaneous stent‐valve placement in a cohort of 125 patients, we report here transvenous reconstruction of a conduit‐free, patch repaired outflow tract by utilizing balloon‐expandable stent‐valves in 23 patients with a median age of 22 years (5‐60 years). In 20 patients, the step‐by‐step procedure was performed uneventful with the aimed success. Severe RVOT dysfunction in term of a clinical relevant regurgitation could be changed to mild, as it was confirmed by follow‐up color Doppler echocardiography. In a 5‐year‐old girl a Melody® valve was placed as a surgical‐interventional hybrid approach. In one patient, the procedure was complicated by stent embolization during preparation of the RVOT for stent‐valve implantation. Reposition of the embolized stent was nevertheless successful for finishing percutaneous valve‐implantation. In one patient, surgical approach became necessary because of the inability to advance the balloon‐mounted stent‐valve through a pre‐stented RVOT. Considering the current available balloon‐expandable stent‐valves, transvenous pulmonary valve implantation is feasible to treat even an incompetent conduit‐free RVOT. However, preparation of the RVOT by pre‐stenting, in most patients with more than two stents in telescope technique remains challenging. Reconstruction of RVOT by the current available valves is promising only for a carefully selected group of patients.     

Pulmonary wedge angiography for the evaluation of the pulmonary vascular bed in congenital heart disease

Pulmonary wedge angiograms (PWA) were analyzed qualitatively and quantitatively to evaluate the pulmonary vascular bed in 40 patients with congenital heart disease. The patients were divided into four groups: group 1, normal pulmonary hemodynamics; group 2, increased pulmonary blood flow; group 3, pulmonary hypertension (PH); and group 4, PH with elevated pulmonary vascular resistance. The PWA were analyzed for tapering, pulmonary circulation time (PCT) index, and vascular image. The tapering was normal in groups 1 and 2 and was more rapid in groups 3 and 4. The PCT index was slightly lower in groups 3 and 4 than in groups 1 and 2. With 100% oxygen, the tapering became less severe and the PCT index increased in group 3. However in group 4, these parameters did not improve with 100% oxygen, suggesting that more advanced vascular changes had developed. These studies confirm the usefulness of the PWA in evaluating the pulmonary vascular bed of patients with congenital heart disease and PH.