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Table I. Pressure data before and after balloon of aortic coarctations

Transumbilical balloon coarctation angioplasty in neonates with critical aortic coarctation P. Syamasundar Rao, MD, Allen Jane Brazy, MD Madison, Wis.

D. Wilson,

Peak Site

MD, and

Balloon angioplasty of previously unoperated, “native,” aortic coarctation has been successfully used in neonates and infants younger than 1 year of age.l-14 Symptomatic improvement and pressure gradient reduction after balloon angioplasty14 has been well documented. The high incidence of recoarctation and the potential for development of aneurysms and arterial complieations15-*7 are of concern. We report the feasibility of balloon angioplasty for native coarctation via an umbilical artery approach, which spares the femoral arteries. An 11-day-old infant who weighed 3.9 kg was first seen in the local physician’s office with a 3-day history of upper respiratory tract infection. He was found to be grunting, cyanotic, and poorly perfused. He was immediately ventilated manually and rushed to a local emergency room. There he was intubated, given volume expansion, and started on vasopressor agents; only a transient improvement in color and perfusion was observed. The initial pH was 7.1 with a base deficit of 12.8. Chest x-ray films showed cardiomegaly and evidence of pulmonary venous congestion. Pediatric cardiology consultation along with a Doppler echocardiographic study was obtained immediately. An echocardiogram showed evidence of severe aortic coarctation, mild aortic stenosis, no ventricular septal defect, and poor left ventricular shortening fraction. Because severe aortic coarctation was diagnosed, intravenous prostaglandin Ei infusion was started, and significant improvement occurred over the next 30 minutes of observation. The infant was transferred to the University of Wisconsin Children’s Hospital. After further stabilization in the pediatric intensive care unit, the infant was taken to the cardiac catheterization laboratory. Percutaneous right heart catheterization and antegrade left ventricular angiography, which was performed via the right femoral vein, revealed severe aortic coarctation with a large gradient (Table I) across the aortic coarctation. The coarcted aortic segment measured 2 mm, and the descending aorta at the level of the diaphragm measured 6 mm. Because the need for relief of aortic coarctation was indicated, the previously placed 3.5F umbilical arterial catheter was exchanged for

From the Department Neonatology, University

of Pediatrics, of Wisconsin

Divisions Medical

Reprint requests: P. Syamasundar Rao, ogy H4/416 CSC, University of Wisconsin 537924108.

41414 1395

1622

of Pediatric Cardiology School, Madison.

MD, Division Children’s

and

of Pediatric CardiolHospital, Madison, WI

Before

Left ventricle Ascending aorta Descending aorta Aortic valve gradient* Coarctation gradient* BA, Balloon *Peak-to-peak

systolic

angioplasty; gradient.

pressure

BA

110/15 90/50, m = 70 55/48, m = 51 20 35

angioplasty (mm After

Hg) BA

107/S 81/59, m = 68 78158, m = 68 26 3

m, mean.

a 5F umbilical artery catheter over a guide wire, and the tip of the catheter was advanced proximal to the aortic coarctation. Four hundred units of heparin was administered. Then a 0.032 inch extrastiff Amplatz guide wire (Cook Inc., Bloomington, Ind.) was positioned within the 5F catheter, and the tip of the guide wire was positioned proximal to the coarctation. The catheter was exchanged for a 5.3F Proflex 5 balloon dilatation catheter (Peripheral Systems Group, Mountainview, Calif.), which carried a 6 mm balloon. This is a very low profile balloon catheter that is coated with a silicone-based material so that it can be easily advanced over the umbilical artery-iliac artery-aorta junctions without difficulty. The deflated balloon was positioned across the aortic coarctation, and the balloon was inflated twice at 6 atm of pressure for a 5-second duration with a 5-minute interval in between dilatations. Waisting of the balloon was seen during the initial phases of balloon inflation, which abated on further balloon inflation. The Proflex catheter was removed and replaced with a 5F Multi A-2 catheter (Cordis Corp., Miami Lakes, Fla.). Fifteen minutes after the procedure, angiography was repeated, and a pressure pullback tracing across the dilated aortic coarctation was recorded. The peak systolic pressure gradient across the aortic coarctation decreased from 35 mm Hg to 3 mm Hg (Table I), and the coarcted aortic segment increased from 2 mm to 5.5 mm. Because it was concluded that there was excellent relief of aortic coarctation, the Multi A-2 catheter was replaced with a 5F umbilical artery catheter and its tip was positioned at the third lumbar vertabra, below the level of renal arteries. The prostaglandin El infusion was discontinued in the catheterization laboratory. The infant improved markedly, and there was no blood pressure difference between arms and legs. The infant was weaned from the respirator over the next several hours and extubated 20 hours after balloon angioplasty. The infant was discharged 2 days later. Reexamination in the outpatient clinic 2 weeks after discharge revealed good weight gain, no signs of heart failure, and no significant arm-to-leg blood pressure difference. Hemodynamic, angiographic, and clinical improvement after

balloon

angioplasty

was

achieved

by the

transumbil-

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Fig. 1. Selected video frames from suprasternal notch, two-dimensional, echocardiographicviews of the aortic arch before (panels a and b) and after (panels c and d) transumbilical balloon angioplasty of aortic coarctation. The coarctation is marked with unfilled white arrowsin panels a and b. Panel b is a magnified view of panel a showingthe shelf of the aortic coarctation and narrowed aortic segment.After angioplasty the area of the coarctation was markedly improved (filled black arrows) as seenin panel c with nonturbulent flow (panel d). AA, aortic arch.

ical artery approach in a manner similar to our previous experiencewith balloon angioplasty of aortic coarctation in neonatesand infants younger than 1 year of age that was performed via the femoral artery. The method that we have usedis similar to that usedby Beekman et al.ls for balloon aortic valvuloplasty. Availability of low-profile catheters that are coatedwith silicone-like material (Proflex 5) made this procedure possible. Issuesrelated to development of recoarctation14,lg and development of aneurysm14,2ohave been discussedelsewhere and will not be reviewed here. Development of femoral artery complications, namely poor perfusion and thrombosed femoral artery, after useof the femoral artery for balloon dilatation procedure is well documented.‘3-17 To avoid arterial complications, alternative antegradeg,2o

and retrogradei 21approacheshave been used.Useof the umbilical artery for balloon angioplasty is one such approach and can be employed safely and successfullyin the neonatewhile the umbilical arteries are patent. Useof the umbilical artery sparesthe use of the femoral artery and thus avoids potential arterial complications. Although no complicationsthat were related to umbilical artery useoccurred in this infant, such complications can occur. However, the complications were related to the length of time that the catheter was in situ rather than to exchange of catheters. On the basis of this experience, we highly recommendthe umbilical artery route. In conclusion, we report successfuluseof a transumbilical arterial approach to balloon angioplasty of aortic coarctation. The availability of new catheter technology has madethis feasible. We

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American

suggest that the transumbilical arterial route is the preferred method for balloon angioplasty of aortic coarctation in the neonate. Addendum. Since the submission of this report, we applied the same technique in a lo-day-old infant with severe aortic coarctation that was associated with common atrioventricular canal with marked right heart dominance and hypoplasia of the left heart. A 5.3F Proflex 5 balloon dilation catheter, which carried a 6 mm balloon, was used for transumbilical balloon angioplasty. The infant improved clinically, and echocardiographic images from the SUprasternal notch (Fig. 1) showed anatomic improvement of the coarctation site. No procedure-related complications were encountered. We continue to believe that the transumbilical approach for balloon angioplasty for severe aortic coarctation is a useful technique in the neonate with patent umbilical arteries. REFERENCES 1.

Lock JR, Bass JL, Amplatz K, Fuhrman BP, CastasnedaZuniga W. Balloon dilation angioplasty of aortic coarctations in infants

2.

3. 4.

5.

and children.

Circulation

1983;68:109-16.

Finley JP, Beaulieu RG, Nanton MA, Roy DL. Balloon catheter dilatation of coarctation of the aorta in young infants. Br Heart J 1983;50:411-5. Labadidi Z. Neonatal transluminal balloon coarctation angioplasty. AM HEART J 1983;106:752-3. Sperling DR, Dorsey TJ, Rowen M, Gazzaniga AB. Percutaneous transluminal angioplasty of congenital coarctation of the aorta. Am J Cardiol 1983;51:562-4. Lababidi ZA, Daskalopoulos DA, Stoeckle H Jr. Transluminal balloon Am J

coarctation

angioplasty:

experience

with

27 patients.

7.

Cardiol 1984;54:1288-91. Suarez de Lezo J, Fernandez R, Sancho M, et al. Percutaneous transluminal angioplasty for aortic isthmic coarctation in infancv. Am J Cardiol 1984:54:1147-g. Rao Ps. Balloon angioplasti for coarctation of the aort,a in in-

8

fancy. J Pediatr 1987;110:713-8. Beekman RH, Rocchini AP, Dick

6.

DC, Serwer

balloon angioplasty for native Co11 Cardiol 1987;10:1078-84. 9.

M II, Snider

GA, Spicer RL, Rosenthal coarctation

AR,

Crowley

A. Percutaneous of the aorta.

J Am

Al Yousef S, Khan A, Nihill M, Lababidi Z, Mullins C. Perkutane transvenose angegrade Balloonangioplastie bei Aortenisthmusstenose. Herz 1988;13:36-40.

10

Suarez de Lezo J, Sancho M, Pan M, Romero M, Olivera C, Luque M. Angiographic follow-up after balloon angioplasty for coarctation of the aorta. J Am Co11Cardiol1989:13:689-95.

11.

Rao PS, Thapar MK, Gala1 0, Wilson AD. Follow:up

results

of balloon angioplasty of native coarctation in neonates infants. AM HEART J 1990;120:1310-4. 12. Redington AN, Booth P, Shore DF, Rigby ML. Primary loon dilatation of coarctation of the aorta in neonates.

and balBr

Heart J 1990;64:277-81. 13. Tvnan M. Finlev JP. Fontes V. Hess J. Kan J. Balloon anpioilasty fdr the t;eat&ent of native coaictation: results of v>vuloplasty and angioplasty of congenital anomalies registry. Am J Cardiol 1990;65:790-2. 14. Rao PS, Chopra PS. Role of balloon angioplasty in the treatment of aor& coarctation. Ann Thorac Surg 1$91;52:621-31. 15. Wessel DL. Keane JF. Fellows KE. Robichaud H. Lock JE. Fibrinolytic therapy fdr femoral arterial thrombosis after cardiac catheterization in infants and children. Am J Cardiol 1986;58:347-51. 16. Burrows PE, Benson LN, Williams WG, Trusler GA, Coles J,

December 1992 Heart Journal

Smallhorn JF, Freedom RM. Iliofemoral arterial complication of balloon angioplasty for systemic obstructions in infants and children. Circulation 1990;82:1697-1704. 17. Booth P, Redington AN, Shinebourne EA, Rigby ML. Earl\ complications of interventional balloon catheterization in infants and children. Br Heart J 1991;65:109-12.

18. Beekman RH, Rocchini AP, Andes A. Balloon valvuloplasty for critical aortic stenosis in the newborn: influence catheter technology. J Am Co11 Cardiol 1991;17:1172-6. 19.

of new

Rao PS. ThaDar MK. Kutavli F. Carev P. Causes of recoarr-

tation a’fter dalloon angioplasty bf uno”perated aortic coarctation. J Am Co11 Cardiol 1989;13:109-15. 20. Rao PS. Balloon angioplasty of native aortic coarctation. In: Rao PS, ed. Transcatheter therapy in pediatric cardiology.

New York: Wiley-Liss,

(in press).

21. Fontes VF, Esteves CA, Brago SLM, da Silva MVD, e Silva MAP, Sousa EMR, de Souza JAM. It is valid to dilate native aortic coarctation with a balloon catheter. Int J Cardiol 1990: 27:311-6.

Transcatheter coil embolitation of a fistula from the posterior descending coronary artery to the right ventricle in a two-year-old child Larry A. Latson, MD, Thomas J. Forbes, MD, and John P. Cheatham, MD Omaha, Neb.

Coronary artery fistulas, though relatively rare, are the most common hemodynamically significant congenital anomalies of the coronary artery system.’ Because large fistulas have been associated with complications including cardiac failure, myocardial ischemia, infective endocarditis, and atria1 fibrillation, surgical repair of clinically detectable lesions is generally recommended, even in small children.2 Conventional surgical repair has been either by ligation of the anomalous coronary connection or by direct closure of the orifice of the fistula with the patient on cardiopulmonary bypass. More recently, transcatheter embolization of fistulas, either with detachable balloons or coils, has been reported in a small number of cases with an excellent success rate.3‘6 Most of these reported cases have been in older children or adults and have involved fistulas that arise from the proximal branches of the main coronary arteries. We report successful closure of a fistula from the posterior descending coronary artery, fed by both the right and left coronary arteries, to the posterior right ventricle in a Z-year-old child. A a-year-old girl who was free of symptoms was referred From the Department ter, Omaha.

of Pediatrics.

University

of Nebraska

Medical

Cen-

Reprint requests: Larry A. Latson, MD, Department of Pediatric Cardiology, University of Nebraska Medical Center, 600 S. 42nd St., Omaha, NE 68198-2166. 4/4/41396

Transumbilical balloon coarctation angioplasty in neonates with critical aortic coarctation.

BRIEF COMMUNICATIONS Table I. Pressure data before and after balloon of aortic coarctations Transumbilical balloon coarctation angioplasty in neonat...
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