Author + information
- Received June 4, 2018
- Accepted June 19, 2018
- Published online August 1, 2018.
- aDivision of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
- bDepartment of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- cDepartment of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
- ↵∗Address for correspondence:
Dr. Arka Chatterjee, University of Alabama at Birmingham, Division of Cardiovascular Disease, 510 20th Street South, FOT 920A, Birmingham, Alabama 35294.
A 47-year-old man with a history of d-transposition of the great arteries palliated with an atrial switch (Mustard) operation presented to our institution with progressive exertional dyspnea. Transthoracic echocardiography demonstrated pulmonary venous baffle stenosis, with a mean gradient of 17 mm Hg (Figures 1A and 1B), and cardiac catheterization was planned to attempt angioplasty of the baffle stenosis. Intraprocedural transesophageal echocardiography also corroborated the transthoracic findings (Figure 1C). Transseptal puncture across the systemic baffle was performed under fluoroscopic and transesophageal echocardiographic guidance in an anterior direction to enter the pulmonary atrium (Figure 1D). The pulmonary venous baffle was accessed using a Goodale Lubin catheter (Medtronic, Minneapolis, Minnesota) and a 0.035-inch angled glide wire (Terumo, Somerset, New Jersey) (Figures 1E and 1F). The stenosis was balloon-dilated with a 15 × 30 mm Tyshak 2 (NuMED, Hopkinton, New York) balloon (Figures 1G to 1J). Transesophageal echocardiographic, hemodynamic, and angiographic interrogation of the systemic venous baffle did not demonstrate obstruction during balloon inflation. On the basis of balloon length and transesophageal echocardiographic measurements, a 2910 Genesis XD (Cordis, Miami Lakes, Florida) stent mounted on an 18-mm BIB balloon (NuMED) was implanted to address the pulmonary venous baffle obstruction (Figures 1K to 1M), reducing the gradient to 2 mm Hg (Figures 1N and 1O) and eliminating the patient’s symptoms.
Pulmonary venous baffle stenosis is a very rare complication of the Mustard operation and is usually managed with surgical intervention (1). Percutaneous catheterization with balloon dilation and stenting of the obstructed baffle has been reported but is very challenging given the variability in individual atrial anatomy. To our knowledge, this is the first report incorporating 3-dimensional transesophageal echocardiography to guide pulmonary baffle stenting and is an excellent example of how this modality can assist with complex congenital interventions, similar to the entire spectrum of adult structural heart procedures.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 4, 2018.
- Accepted June 19, 2018.
- 2018 American College of Cardiology Foundation