Durable Benefit of Particle Occlusion of Systemic to Pulmonary Collaterals in Select Patients After Superior Cavopulmonary Connection

Original Article

Abstract

Systemic to pulmonary arterial collaterals (SPC) are commonly found in patients undergoing staged operative palliation for single ventricle heart disease. Occlusion of SPC as part of pre-Fontan catheterization has been shown to improve hemodynamics acutely. Anecdotally, the effect of this intervention appears to be transient, and to our knowledge there is no data supporting its durability in these patients. Between 1/1/2016 and 5/1/2017, 24 children underwent Glenn operations at our institution. Of these, 3 patients had signs and symptoms deteriorating clinical status suggestive of volume overload in the period between their Glenn operation and Fontan completion, prompting heart catheterization. SPC were occluded with a combination of polyvinyl alcohol embolization particles, and in some cases coils or vascular plugs. Clinical course and data from echocardiograms and serial catheterizations are presented. SPC occlusion was performed over 6 procedures in 3 subjects with technical success in each case. Hemodynamic evaluation was repeated in 2/3 patients with improvement in collateral burden and hemodynamics in both cases. One patient previously thought to be unsuitable for Fontan completion improved sufficiently to undergo late Fontan completion, which was ultimately successful. In all patients, there was improvement in clinical status. In patients with severe SPC collateral durable benefit was seen, suggesting that in certain cases intervention on SPC remote from Fontan completion may have clinical benefit.

Keywords

Pediatric cardiology Hypoplastic left heart syndrome Pulmonary atresia intact ventricular septum Transcatheter intervention Vascular embolization 

References

  1. 1.
    Spicer RL, Uzark KC, Moore JW, Mainwaring RD, Lamberti JJ (1996) Aortopulmonary collateral vessels and prolonged pleural effusions after modified Fontan procedures. Am Heart J 131(6):1164–1168CrossRefPubMedGoogle Scholar
  2. 2.
    McElhinney DB, Reddy VM, Tworetzky W, Petrossian E, Hanley FL, Moore P (2000) Incidence and implications of systemic to pulmonary collaterals after bidirectional cavopulmonary anastomosis. Ann Thoracic Surg 69(4):1222–1228CrossRefGoogle Scholar
  3. 3.
    Banka P, Sleeper LA, Atz AM, Cowley CG, Gallagher D, Gillespie MJ et al (2011) Practice variability and outcomes of coil embolization of aortopulmonary collaterals before Fontan completion: a report from the Pediatric Heart Network Fontan Cross-Sectional Study. Am Heart J 162(1):125–130CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Whitehead KK, Gillespie MJ, Harris MA, Fogel MA, Rome JJ (2009) Noninvasive quantification of systemic-to-pulmonary collateral flow: a major source of inefficiency in patients with superior cavopulmonary connections. Circ Cardiovasc Imaging 2(5):405–411CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Grosse-Wortmann L, Al-Otay A, Yoo S-J (2009) Aortopulmonary collaterals after bidirectional cavopulmonary connection or Fontan completion: quantification with MRI. Circ Cardiovasc Imaging 2(3):219–225CrossRefPubMedGoogle Scholar
  6. 6.
    Downing TE, Whitehead KK, Dori Y, Gillespie MJ, Harris MA, Fogel MA et al (2013) Accuracy of conventional oximetry for flow estimation in patients with superior cavopulmonary connection: a comparison with phase-contrast cardiac MRI. Circ Cardiovasc Imaging 6(6):943–949CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Prakash A, Rathod RH, Powell AJ, McElhinney DB, Banka P, Geva T (2012) Relation of systemic-to-pulmonary artery collateral flow in single ventricle physiology to palliative stage and clinical status. Am J Cardiol 109(7):1038–1045CrossRefPubMedGoogle Scholar
  8. 8.
    Prakash A, Satiroglu E, Porras D, McElhinney DB, Keane JF, Lock JE et al (2013) Risk factors for profuse systemic-to-pulmonary artery collateral burden in hypoplastic left heart syndrome. Am J Cardiol 112(3):400–404CrossRefPubMedGoogle Scholar
  9. 9.
    Dori Y, Glatz AC, Hanna BD, Gillespie MJ, Harris MA, Keller MS et al (2013) Acute effects of embolizing systemic-to-pulmonary arterial collaterals on blood flow in patients with superior cavopulmonary connections: a pilot study. Circ Cardiovasc Interv 6(1):101–106CrossRefPubMedGoogle Scholar
  10. 10.
    Stern HJ (2009) The argument for aggressive coiling of aortopulmonary collaterals in single ventricle patients. Catheter Cardiovasc Interv 74(6):897–900CrossRefPubMedGoogle Scholar
  11. 11.
    Grosse-Wortmann L, Drolet C, Dragulescu A, Kotani Y, Chaturvedi R, Lee K-J et al (2012) Aortopulmonary collateral flow volume affects early postoperative outcome after Fontan completion: a multimodality study. J Thorac Cardiovasc Surg 144(6):1329–1336CrossRefPubMedGoogle Scholar
  12. 12.
    Prakash A, Rathod RH, Powell AJ, McElhinney DB, Banka P, Geva T (2012) Relation of systemic-to-pulmonary artery collateral flow in single ventricle physiology to palliative stage and clinical status. Am J Cardiol 109(7):1038–1045CrossRefPubMedGoogle Scholar
  13. 13.
    Glatz AC, Harrison N, Small AJ, Dori Y, Gillespie MJ, Harris MA et al (2015) Factors associated with systemic to pulmonary arterial collateral flow in single ventricle patients with superior cavopulmonary connections. Heart 101(22):1813–1818CrossRefPubMedGoogle Scholar
  14. 14.
    Haroutunian LM, Neill CA (1972) Pulmonary complications of congenital heart disease: hemoptysis. Am Heart J 84(4):540–549CrossRefPubMedGoogle Scholar
  15. 15.
    Grosse-Wortmann L, Hamilton R, Yoo S-J (2007) Massive systemic-to-pulmonary collateral arteries in the setting of a cavopulmonary shunt and pulmonary venous stenosis. Cardiol Young 17(5):548–550CrossRefPubMedGoogle Scholar
  16. 16.
    Nelson-McMillan K, Hornik CP, He X, Vricella LA, Jacobs JP, Hill KD et al (2016) Delayed sternal closure in infant heart surgery-the importance of where and when: an analysis of the STS congenital heart surgery database. Ann Thoracic Surg 102(5):1565–1572CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Division of CardiologyChildren’s National Medical Center and the George Washington University School of Health SciencesWashingtonUSA
  2. 2.Division of Cardiology and Center for Pediatric Clinical EffectivenessThe Children’s Hospital of PhiladelphiaPhiladelphiaUSA

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