Pulmonary Artery Branch Stenosis After The Arterial Switch Operation: Accept or Attack?

James S. Tweddell, MD Warren W. Bailey Chair and Director of Cardiothoracic Surgery

Executive Co-Director of the Heart Institute,

Cincinnati Children’s Hospital Medical Center

Professor of Surgery and Pediatrics,

University of Cincinnati

Cincinnati, Ohio

February 9, 2018, Utrecht, The Netherlands

Mechanisms of Pulmonary Artery Stenosis

•  Lesions with small aortic root, coarctation, Taussig-Bing malformation

•  Side-by-side great vessels

•  Larger neoaortic root

Morgan CT et al Euro Heart J 2017

Can Branch PS Be Avoided?

• Wide mobilization of the branch pulmonary arteries

• LeCompte Maneuver • Patulous reconstruction of sites of

coronary button excision • Avoid certain materials - Gore-Tex • Preoperative anatomy remains

important

Formigari A Cardiovasc Interv 2000

Can Branch PS Be Avoided? • Wide mobilization of branch pulmonary artreries • Generous pantaloon(s) patch

How big a problem is branch pulmonary artery stenosis after the arterial switch operation? •  7% to 28% incidence at long-term follow-up •  Reintervetion up to10%

1.  Ruda HS et al Ann Thorac Surg 2011 2.  Wiggins LM et al Ann Thorac Surg 2015

What is the impact of branch pulmonary artery stenosis? • Branch pulmonary artery stenosis results in exercise intolerance

1.  Giardini A et al Am J Cardiol 2009 2.  Giardini A et al Am J Cardiol 2010 3.  Baggen VJM et al J Thorac Cardiovasc Surg 2015

What can we do for branch PS?

• Surgical patch arterioplasty of the main and branch pulmonary arteries

• Catheter based therapies: •  Balloon angioplasty •  Stent placement

The Problem With Stents

•  Eliminates growth potential – further enlargement requires dilatation •  Diameter of pulmonary artery limited by:

•  Maximal diameter of stent •  Neointimal proliferation

•  Stent fracture •  Replaces pulmonary artery with rigid non-compliant fixed tube •  Caging of proximal branches – particularly upper lobe branch – up to 50%* •  Pulmonary artery rupture

•  Hemorrhage •  Pseudoaneurysm •  Aortopulmonary fistulas

•  Coronary artery compression

* Law MA et al Cath Cardiovasc Interv 2010

Iatrogenic aortopulmonary window

Vida VL et al Pediatr Cardiol 2013

Coronary Artery Occlusion

Baraona F. et al J Clin Exp Cardiolog 2008 Raimondi F, Bonnet D. Diagnostic and Interventional Imaging 2016

Coronary Artery Occlusion

Gewillig M Brown S Cath Cardiovasc Interv 2009

Surgical Repair

• Longer freedom from reintervention • Growth potential is preserved • Better compliance • Low risk – 0% mortality in recent

series*

* Wiggins LM et al Ann Thorac Surg 2015

What are we to do? •  Single center study comparing strategies of management of supravalvar

pulmonary stenosis after ASO •  n = 29

Nellis JR et al Ann Thorac Surg 2016

Pulmonary Artery Branch Stenosis After The Arterial Switch Operation: Accept or Attack? •  If the patient is symptomatic, has elevated RV pressure or significant

gradient therapy should be offered •  For branch pulmonary artery stenosis

•  Surgery should be offered as primary treatment and especially for recurrent stenosis •  Balloon dilatation is reasonable first step for proximal stenoses •  Balloon dilatation for distal stenoses •  Stents should generally be avoided

•  Limit growth in children •  Risk of rupture •  Risk of coronary occlusion

•  Stents may be considered for •  Near adult sized patients •  If coronary anatomy is suitable •  Recurrent stenosis especially the left pulmonary artery •  Poor surgical candidates

Surgeon and interventional cardiologist should work as a team and identify the best strategy for each patient. Frequently a combined strategy will be the best!

Thank You James.Tweddell@CCHMC.org

Thank you James.tweddell@cchmc.org