septum - those with a thin atretic membrane, near normal-sized right ventricle and pulmonary artery, and a ductus arteriosus in the usual posi tion - without surgical interven tion. The technique describedis technically demanding and not without risks, but we believethat useof a fine wire to perforate the valve, and then controlling the distal tip of the wire
to maintain the ability to force a valvuloplasty catheter through the very small opening, should result in a reasonablesafetymargin in experienced handscomparedwith the surgical alternatives.
1. C&s JG, Freedom RM, Lightfoot NE, Dasmahap&a HK, Williams WC, Trusler GA, Burrows PE. Long-term results in neonates with pulmonary
Catheterizing Modified Blalock-Taussig Shunts and Ascending Aorta to Pulmonary Artery Shunts Ian C. Balfour, MB, BS, Saadeh B. Jureidini, MB, ChB, and Soraya Nouri, MB, BS ssessingthe anatomy, pressure and resistance of the pulmonary vascular bed is an essentialpart of the preoperative evaluation of patients with congenital heart disease. In patients with pulmonary atresia or other complex defectswhen anterogradepassageof a catheter into the pulmonary artery is not possible, pulmonary venous wedge pressureshave been used to assessthe pulmonary arterial pressure, and angiograms recorded close to systemic to pulmonary artery shunts have been used to assessthe anatomy of the pulmonary vascular bed. These techniques often do not provide accurate information. It is preferable to directly measure pulmonary artery pressureand pulmonary vascular resistance, and perform angiography in the pulmonary artery. White’ previously described a technique for catheterizing Blalock-Taussig (B-T) shunts (subclavian artery to pulmonary artery anastomosis) using specially preformed catheters.In this report we describea
A
method of retrogradecatheterization of the pulmonary artery via modified B-T shunts and ascending aorta to pulmonary artery shunts. A number of catheters,Gensini (USCI, Billerica, Massachusetts),pigtail (Cordis, Miami, Florida), GL (Goodale-Lubin, USCI, Tewksbury, Massachusetts), have been used at our institution to enter such shunts. We have found that the shunts may be most easily catheterized using a Cordis Judkins 5Fr right coronary artery catheter with a 4-cm curve.
The patient’s right or left femoral artery is entered and a 5Fr or larger sheath is introduced. An angiogram is then recorded in the aortic root to determine the exact location of the shunt. The SFr right coronary catheter is introduced and advanced to the arch of the aorta. In the case of left-sided modified B-T shunts, the catheter may be advanced directly to the left subclavian artery. For rightsided shunts, the catheter is manipulated around the arch of the aorta beyond the innominate arFrom the Division of Cardiology, Department tery, and is then withdrawn with of Pediatrics and Adolescent Medicine, St. clockwise rotation so that its tip Louis University, 1465 South Grand Boule- engages the innominate artery. The vard, St. Louis, Missouri. Manuscript received November 19, 1990; revised manuscript re- catheter is now advanced to the ceived and acceptedMarch 1, 1991. right subclavian artery and just
atresia and intact ventricular septum. Ann Tfiorac Surg 1989;47:213-217. 2. Laks H, Billingsley AM. Advances in the treatment of pulmonary at&a with intact ventricular septum: palliative and definitive repair. Cardiol Clin 198%7:387-39X. 3. Latson LA, Fleming WH, Hofschire PJ, Kugler JD, Cheatham JP, Moulton AL, Danford DA, Gumbiner CH. Balloon valvuloplasty in pulmonary valve atresia. Am Heart / 1991;121:1567-1569. 4. Latson LA. Antegrade catheter snare for retrograde catheterization of left ventricle: new technique to facilitate balloon aortic valvuloplasty. Carhet Cardiouasc Diagn 1990;19:56-57.
beyond the origin of the modified B-T shunt. For both right- and left-sided shunts a Cook 0.038mm exchange wire with a 3-mm J curve (Cook, Bloomington, Indiana) is introduced and advanced just beyond the end of the catheter so that its tip points in the direction of the shunt. The catheter is now slowly withdrawn until the wire engages the orifice of the shunt. Clockwise or counterclockwise rotation of the catheter and the wire may be necessary to achieve this. Once the wire has entered the shunt it is usually easily advanced to the ipsilateral pulmonary artery and turned medially so that it can be advanced to the main and contralateral pulmonary artery. In the case of ascending aorta to pulmonary artery shunts the Judkins catheter is advanced to the aortic root. It is then slowly withdrawn with clockwise or counterclockwise rotation so that its tip engages the shunt. The exchange wire may then be introduced. After the exchange wire has been securely positioned in the pulmonary artery, the Judkins catheter may be removed and a 5Fr pigtail catheter (Cordis) is advanced over the wire to the pulmonary artery to obtain angiograms (Figure 1). If the modified B-T shunt arises at an acute angle from the subclavian or innominate artery it may be easier to advance a more flexible catheter such as a 4Fr Cook catheter (Cook, Bloomington, Indiana) CASE REPORTS
279
FIGURE 1. Pulmonary artery angiogram in a patient with tetralogy aortic arch and ascending aorta to main pulmonary artery cenduit.
rather than a pigtail catheter over the exchange wire. Occasionally the Judkins catheter can be directly manipulated into the shunt without using a guidewire.
We have been successfulin catheterizing the pulmonary artery through a modified B-T shunt or an ascendingaorta to pulmonary artery shunt 20 times in 20 patients (1 patient underwent catheterization twice). An attempt to enter the right pulmonary artery through a 5-mm right modified B-T shunt was unsuccessful becauseof “kinking” of the conduit at its anastomosiswith the right pulmonary artery. The mean age of the patients at the time of the catheterization was 43.8 months (range 11.5 to 109) and their mean weight was 13.8 kg (range 6.7 to 28.8). Eight modified B-T shunts and 4 ascendingaorta to pulmonary artery shunts have beencatheterized using the Judkins catheter. A GL, Gensini, or end-holeballoon catheter (Arrow, Reading, Pennsylvania) was used in the other patients. The patients’ diagnoses were tricuspid
280
ot Fallot, right
atresia with or without pulmonary atresia (n = 3), pulmonary atresia with an intact septum or with a ventricular septal defect (n = 4) single ventricle with pulmonary stenosisor atresia (n = 5), tetralogy of Fallot (n = 6), double-outlet right ventricle with pulmonary stenosis (n = l), and l-transposition of the great arteries with a ventricular septal defect and main pulmonary artery band (n = 1). In the latter 2 patients, anterograde catheterization of the pulmonary artery was unsuccessful. Two patients with 4-mm diameter shunts have undergone catheterization using this technique. Both of these patients had alternate sources of pulmonary flow. One of the 4-mm shunts was an ascending aorta to pulmonary artery shunt. No complications, e.g., worsening hypoxia or dysrhythmia occurred. All patients were given heparin, 50 U/kg, after femoral artery puncture. No patient had vascular complications. The angulation of the 5Fr Judkins right coronary catheter makesit suitable for entering modified B-T
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68
JULY 15, 1991
shunts and ascending aorta to pulmonary artery shunts. Becausedirect accessis provided to the pulmonary bed, its hemodynamicsmay be better evaluatedand adequateangiograms obtained. This technique avoidsproblemsassociatedwith other methods of determining pulmonary artery pressures.For example, pulmonary vein wedge pressure recordings may be unreliable and dysrhythmias may be provoked when pulmonary venous wedge pressures are recorded. The diameter of the 5Fr catheter is 1.67 mm; therefore obstruction of 4- or 5-mm shunts is unlikely. However, the technique probably should not be used in patients who have preexisting obstruction of shunts; the patients’ pulmonary artery pressuretracings should be observedfor damping and the systemic arterial saturation monitored to ensurethat the catheter is not obstructing the shunt. The method used by White’ required specially preformedcatheters,whereaswe use standard catheters. In addition, White entered classic B-T shunts. These tend to be larger in diameter and arise at a less acute angle than modified B-T shunts, and therefore are more accessiblethan modified BT shunts. We have presenteda method of catheterizing surgically created systemic to pulmonary artery conduit shuntsin children with cyanotic congenital heart disease.This method provides direct accessto the pulmonary vascular bed and accurate information for planning the definitive surgical therapy of these patients.
1. White RI. Technique and preliminary results of selective catheterization of patients with BlalockTaussig shunts. Radiology 1972;105:703-706,
to maintain the ability to force a valvuloplasty catheter through the very small opening, should result in a reasonablesafetymargin in experienced handscomparedwith the surgical alternatives.
1. C&s JG, Freedom RM, Lightfoot NE, Dasmahap&a HK, Williams WC, Trusler GA, Burrows PE. Long-term results in neonates with pulmonary
Catheterizing Modified Blalock-Taussig Shunts and Ascending Aorta to Pulmonary Artery Shunts Ian C. Balfour, MB, BS, Saadeh B. Jureidini, MB, ChB, and Soraya Nouri, MB, BS ssessingthe anatomy, pressure and resistance of the pulmonary vascular bed is an essentialpart of the preoperative evaluation of patients with congenital heart disease. In patients with pulmonary atresia or other complex defectswhen anterogradepassageof a catheter into the pulmonary artery is not possible, pulmonary venous wedge pressureshave been used to assessthe pulmonary arterial pressure, and angiograms recorded close to systemic to pulmonary artery shunts have been used to assessthe anatomy of the pulmonary vascular bed. These techniques often do not provide accurate information. It is preferable to directly measure pulmonary artery pressureand pulmonary vascular resistance, and perform angiography in the pulmonary artery. White’ previously described a technique for catheterizing Blalock-Taussig (B-T) shunts (subclavian artery to pulmonary artery anastomosis) using specially preformed catheters.In this report we describea
A
method of retrogradecatheterization of the pulmonary artery via modified B-T shunts and ascending aorta to pulmonary artery shunts. A number of catheters,Gensini (USCI, Billerica, Massachusetts),pigtail (Cordis, Miami, Florida), GL (Goodale-Lubin, USCI, Tewksbury, Massachusetts), have been used at our institution to enter such shunts. We have found that the shunts may be most easily catheterized using a Cordis Judkins 5Fr right coronary artery catheter with a 4-cm curve.
The patient’s right or left femoral artery is entered and a 5Fr or larger sheath is introduced. An angiogram is then recorded in the aortic root to determine the exact location of the shunt. The SFr right coronary catheter is introduced and advanced to the arch of the aorta. In the case of left-sided modified B-T shunts, the catheter may be advanced directly to the left subclavian artery. For rightsided shunts, the catheter is manipulated around the arch of the aorta beyond the innominate arFrom the Division of Cardiology, Department tery, and is then withdrawn with of Pediatrics and Adolescent Medicine, St. clockwise rotation so that its tip Louis University, 1465 South Grand Boule- engages the innominate artery. The vard, St. Louis, Missouri. Manuscript received November 19, 1990; revised manuscript re- catheter is now advanced to the ceived and acceptedMarch 1, 1991. right subclavian artery and just
atresia and intact ventricular septum. Ann Tfiorac Surg 1989;47:213-217. 2. Laks H, Billingsley AM. Advances in the treatment of pulmonary at&a with intact ventricular septum: palliative and definitive repair. Cardiol Clin 198%7:387-39X. 3. Latson LA, Fleming WH, Hofschire PJ, Kugler JD, Cheatham JP, Moulton AL, Danford DA, Gumbiner CH. Balloon valvuloplasty in pulmonary valve atresia. Am Heart / 1991;121:1567-1569. 4. Latson LA. Antegrade catheter snare for retrograde catheterization of left ventricle: new technique to facilitate balloon aortic valvuloplasty. Carhet Cardiouasc Diagn 1990;19:56-57.
beyond the origin of the modified B-T shunt. For both right- and left-sided shunts a Cook 0.038mm exchange wire with a 3-mm J curve (Cook, Bloomington, Indiana) is introduced and advanced just beyond the end of the catheter so that its tip points in the direction of the shunt. The catheter is now slowly withdrawn until the wire engages the orifice of the shunt. Clockwise or counterclockwise rotation of the catheter and the wire may be necessary to achieve this. Once the wire has entered the shunt it is usually easily advanced to the ipsilateral pulmonary artery and turned medially so that it can be advanced to the main and contralateral pulmonary artery. In the case of ascending aorta to pulmonary artery shunts the Judkins catheter is advanced to the aortic root. It is then slowly withdrawn with clockwise or counterclockwise rotation so that its tip engages the shunt. The exchange wire may then be introduced. After the exchange wire has been securely positioned in the pulmonary artery, the Judkins catheter may be removed and a 5Fr pigtail catheter (Cordis) is advanced over the wire to the pulmonary artery to obtain angiograms (Figure 1). If the modified B-T shunt arises at an acute angle from the subclavian or innominate artery it may be easier to advance a more flexible catheter such as a 4Fr Cook catheter (Cook, Bloomington, Indiana) CASE REPORTS
279
FIGURE 1. Pulmonary artery angiogram in a patient with tetralogy aortic arch and ascending aorta to main pulmonary artery cenduit.
rather than a pigtail catheter over the exchange wire. Occasionally the Judkins catheter can be directly manipulated into the shunt without using a guidewire.
We have been successfulin catheterizing the pulmonary artery through a modified B-T shunt or an ascendingaorta to pulmonary artery shunt 20 times in 20 patients (1 patient underwent catheterization twice). An attempt to enter the right pulmonary artery through a 5-mm right modified B-T shunt was unsuccessful becauseof “kinking” of the conduit at its anastomosiswith the right pulmonary artery. The mean age of the patients at the time of the catheterization was 43.8 months (range 11.5 to 109) and their mean weight was 13.8 kg (range 6.7 to 28.8). Eight modified B-T shunts and 4 ascendingaorta to pulmonary artery shunts have beencatheterized using the Judkins catheter. A GL, Gensini, or end-holeballoon catheter (Arrow, Reading, Pennsylvania) was used in the other patients. The patients’ diagnoses were tricuspid
280
ot Fallot, right
atresia with or without pulmonary atresia (n = 3), pulmonary atresia with an intact septum or with a ventricular septal defect (n = 4) single ventricle with pulmonary stenosisor atresia (n = 5), tetralogy of Fallot (n = 6), double-outlet right ventricle with pulmonary stenosis (n = l), and l-transposition of the great arteries with a ventricular septal defect and main pulmonary artery band (n = 1). In the latter 2 patients, anterograde catheterization of the pulmonary artery was unsuccessful. Two patients with 4-mm diameter shunts have undergone catheterization using this technique. Both of these patients had alternate sources of pulmonary flow. One of the 4-mm shunts was an ascending aorta to pulmonary artery shunt. No complications, e.g., worsening hypoxia or dysrhythmia occurred. All patients were given heparin, 50 U/kg, after femoral artery puncture. No patient had vascular complications. The angulation of the 5Fr Judkins right coronary catheter makesit suitable for entering modified B-T
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68
JULY 15, 1991
shunts and ascending aorta to pulmonary artery shunts. Becausedirect accessis provided to the pulmonary bed, its hemodynamicsmay be better evaluatedand adequateangiograms obtained. This technique avoidsproblemsassociatedwith other methods of determining pulmonary artery pressures.For example, pulmonary vein wedge pressure recordings may be unreliable and dysrhythmias may be provoked when pulmonary venous wedge pressures are recorded. The diameter of the 5Fr catheter is 1.67 mm; therefore obstruction of 4- or 5-mm shunts is unlikely. However, the technique probably should not be used in patients who have preexisting obstruction of shunts; the patients’ pulmonary artery pressuretracings should be observedfor damping and the systemic arterial saturation monitored to ensurethat the catheter is not obstructing the shunt. The method used by White’ required specially preformedcatheters,whereaswe use standard catheters. In addition, White entered classic B-T shunts. These tend to be larger in diameter and arise at a less acute angle than modified B-T shunts, and therefore are more accessiblethan modified BT shunts. We have presenteda method of catheterizing surgically created systemic to pulmonary artery conduit shuntsin children with cyanotic congenital heart disease.This method provides direct accessto the pulmonary vascular bed and accurate information for planning the definitive surgical therapy of these patients.
1. White RI. Technique and preliminary results of selective catheterization of patients with BlalockTaussig shunts. Radiology 1972;105:703-706,
