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[Treatment of supravalvular pulmonary stenosis after arterial switch operations (ASO)]
W Kuroczynski1, C Kampmann, Y H Choi
1Klinik und Poliklinik für Herz-, Thorax- und Gefässchirurgie Johannes Gutenberg-Universität Mainz Langenbeckstr. 1 55131 Mainz, Germany.
Insights
Balloon angioplasty is effective for treating pulmonary stenosis after arterial switch in patients with d-transposition of the great arteries (d-TGA). While not always curative, it reduces pressure gradients and complications, making it a preferred initial treatment.
Area of Science:
- Cardiology
- Pediatric Surgery
- Interventional Cardiology
Background:
- Congenital heart defects like d-transposition of the great arteries (d-TGA) often require surgical correction.
- Postoperative pulmonary supravalvular stenosis is a known complication following arterial switch operation (ASO).
Purpose of the Study:
- To determine the incidence of pulmonary supravalvular stenosis after ASO in d-TGA patients.
- To evaluate the success and failure rates of balloon angioplasty for this condition.
Main Methods:
- Retrospective analysis of 70 d-TGA patients who underwent ASO.
- Assessment of 12 children who developed severe supravalvular pulmonary stenosis.
- Performance of 19 high-pressure balloon dilatations with defined success criteria.
Main Results:
- Balloon angioplasty reduced pressure gradients in most patients, with complete resolution in one.
- Seven patients achieved significant gradient reduction; two required palliative stent implantation.
- Two patients needed subsequent surgery due to unsuccessful intervention, and three experienced restenosis requiring further surgery.
Conclusions:
- Balloon angioplasty is a low-complication, beneficial first-line treatment for pulmonary stenosis post-ASO in d-TGA.
- Surgical intervention is recommended for recurrent or combined stenoses involving a narrow pulmonary valve annulus.
Abstract:
The aim of this study was to evaluate the incidence of postoperative pulmonary supravalvular stenosis in patients with d-TGA and to assess the rate of success or failure of balloon angioplasty. Out of 70 patients with d-TGA 67 patients underwent successful arterial switch operation. Twelve children developed severe supravalvular pulmonary stenosis with a peak gradient above 50 mmHg (range: 50-120 mmHg). In these patients 19 high pressure dilatations were performed up to a diameter of 130% of the native valve dimension. The mean age at angioplasty was 17 months (range: 3-36 months). Successful intervention was defined as a > 50% decrease of predilatation peak pressure gradient or right ventricular pressure < 50 mmHg. Dilatations were performed without complications. Complete resolution was primarily achieved in 1 patient. In 7 patients the pressure gradients could be reduced to 10-45 mmHg (mean: 25 mmHg). In another two patients a palliative stent-implantation into the pulmonary trunk was necessary to reduce the pressure gradient. Because unsuccessful intervention, two patients needed subsequent operation. During follow-up of 6-9 months after intervention severe restenosis occurred in 3 patients (2 after stent-implantation; 1 after re-re-dilatation) who then also needed operation. Balloon dilatation should be the first treatment in patients with pulmonary stenosis after ASO in TGA owing to the low complication rate and the potential benefit of this procedure. Recurrent and combined stenoses with narrow pulmonary valve annulus should be treated surgically.