Author: Prof. Sven Dittrich, M.D.

Department of Pediatric Cardiology, Universitätsklinikum Erlangen, Erlangen, Germany

Patient History

2-year-old girl

Diagnosis

Patient suffered from Tetralogy of Fallot and latest angiography showed a moderate pulmonary valve insufficiency

Treatment

Past medical history
The various pathological changes in Tetralogy of Fallot resulted in a right ventricular pressure just 10 mmHg below systemic blood pressure. As the patient was suffering from severe infundibular and valvular pulmonary stenosis, six weeks after birth a pericardial patch graft was applied to the right ventricular outflow tract. In addition the central pulmonary arteries were severely hypoplastic, so that four months later 2 coronary stents (4 mm centrally, 3.5 mm peripherally) had to be implanted in a long thready stenosis of the left pulmonary artery. This was followed by the implantation of a 15 mm long Herculink stent into the right pulmonary artery which was dilated to 4 mm. At the age of one year a coil embolization of major aortopulmonary collateral arteries (MAPCAs) between either the descending aorta or the right subclavian artery and the left and right pulmonary arteries was performed (Cook detachable coils, 5 mm 4 loops to the right and 2 x 3 mm coils each with 4 loops to the left).

After this interventional cardiac catherization, a second operation was planned in order to partially close the VSD (5 mm fenestration). Additionally, ASD closure, pulmonary artery graft using bovine pericardium, insertion of a valve prosthesis RV-PA conduit (16 mm Matrix-P-Plus), closure of the last patent MAPCA originating from the aortic arch were performed on the patient. Three months later the stent in the right pulmonary artery was re-stented (7 mm diameter, 18 mm long, Terumo-Tsunami) and two stents were implanted into the left pulmonary artery (Herculink, 6 mm diameter, 12 mm long peripherally and Herculink 6.5 mm diameter, 12 mm long centrally).

Present medical treatment
One year later the stents in the right and left pulmonary arteries were re-dilated with an 8 mm Cordis Powerflex Balloon (13 atmospheres). Here the catheterization was started with a syngo DynaCT Cardiac (5 sec C-arm rotation with 30 images per second) while injecting contrast agent into the central pulmonary artery. After 3D reconstruction the 3D visualization of the complex anatomy could be used to choose appropriate guiding catheters to enter the pulmonary artery branches.

Comments

syngo iPilot was used for super-imposition of the 3D visualization on the live fluoroscopy images. Additionally, three-dimensional imaging was helpful for positioning of the X-ray tubes in an appropriate angulation without further contrast medium application. Thus the 3D image helped extend the interventionalist’s idea of the anatomy and expedited the intervention significantly.