Transcatheter Recanalization of Atretic Pulmonary Veins in Infants and Children

Pulmonary vein stenosis: future optimism

PURPOSE OF REVIEW

Pulmonary vein stenosis (PVS) is a rare disease with high morbidity and mortality. Prevention of restenosis remains challenging. This review will highlight recent advances in therapy that are beginning to show a survival benefit.

RECENT FINDINGS

Intervention for multivessel pediatric PVS may be surgical or transcatheter, both with high restenosis rates. At a threshold upstream diameter of 7 mm, the risk of restenosis decreases. Close vigilance and frequent reinterventions, typically transcatheter, are now accepted practice to maintain vein patency and achieve upstream growth. Suppressive agents targeting the exuberant myofibroblastic proliferation characteristic of PVS, specifically sirolimus, delivered locally on the surface of balloons and stents, and as adjunct systemic therapy, have been shown to increase survival and decrease reinterventions. Newer surgical techniques focused on shortening and straightening the vein to optimize flow dynamics, coupled with hybrid intraoperative stent placement in selected cases, also show a survival benefit.Adult-onset PVS, most commonly a complication of pulmonary vein isolation, now occurs rarely, and generally responds to transcatheter intervention. Further advances in ablation techniques aim to eliminate this complication.

SUMMARY

An aggressive approach of frequent reinterventions is a necessary strategy rather than treatment failure. More granular understanding of the mechanisms underlying PVS leading to novel muti-pronged anatomic and suppressive therapy are yielding improved survival.Multispecialty PVS teams at the institutional level and multiinstitutional collaboration, now possible via the PVS registry, are crucial to optimal care and future progress.

Valsartan to Prevent Acquired Pulmonary Vein Stenosis in Pediatric Patients After Total Anomalous Pulmonary Venous Connection Surgery

BACKGROUND

Recurrent pulmonary vein stenosis (PVS) following surgical repair of total anomalous pulmonary venous connection is associated with poor prognosis. Preclinical studies have shown that use of an angiotensin receptor blocker can attenuate intimal hyperplasia; notwithstanding, its clinical utility is of uncertain benefit.

METHODS

This single-center study included patients undergoing total anomalous pulmonary venous connection repair in 2020 to 2021. Since August 2020, patients have been considered for valsartan therapy early after operation. Contemporaneous participants were subcategorized into study versus control groups based on valsartan exposure. Patients in the control group were treated with the same protocolized algorithm except valsartan administration. The primary end point was postoperative PVS (PPVS) progression.

RESULTS

Overall, 104 patients operated on at a median age of 1.3 months were included (valsartan group: 25 versus control group: 79). The baseline characteristics were similar between the 2 groups. Within a median follow-up of 28.6 months, 27 patients developed PPVS noted by echocardiography and computed tomography angiography, among which 22 with clinical PPVS underwent reoperations. No between-group difference was observed in the incidence of initial PPVS (P=0.80, Cohen's h=0.06 [95% CI, -0.38 to 0.50]) and reoperation (P=0.46, Cohen's h=-0.18[ 95% CI, -0.65 to 0.29]); however, patients in the valsartan group had a significantly lower risk of PPVS progression (P=0.019, Cohen's h=-1.12 [95% CI, -1.66 to -0.57]) and subsequent PPVS progression after reoperation (P=0.011, Cohen's h=-1.71 [95% CI, -2.61 to -0.82]) compared with the control group. PPVS-related death was observed in 9 cases (11.4%) in the control group versus none (0%) in the valsartan group. No adverse event related to valsartan occurred in this series.

CONCLUSIONS

Early use of valsartan after total anomalous pulmonary venous connection surgery appears to potentially be a feasible and effective adjunct to reoperation in treating pediatric acquired PVS.

Anchoring guide catheter to facilitate recanalising occluded pulmonary vein in small children: a novel technique

Transcatheter pulmonary vein recanalisation is challenging. Herein, we described a novel technique facilitating the recanalisation of occluded three pulmonary veins in two small children. This technique enhances the catheter's alignment and stability during the recanalisation process. Referred to as the "anchoring guide catheter" technique, it can be applied only when the ipsilateral vein is patent.

Utility of simultaneous triple balloon inflation technique through a single 6-French sheath in treating pulmonary vein stenosis

Pulmonary vein stenosis continues to pose significant challenges in children, frequently requiring repeated cardiac catheterisation procedures. This report describes a successful application of a "triple kissing balloon" technique to treat complex pulmonary vein stenosis in two patients, all accomplished with the use of a single 6-French sheath.

Transcatheter recanalization of chronic total occlusion in congenital heart disease: case reports and lessons from percutaneous coronary interventions

Background

Chronic complete vascular occlusion causes significant morbidity and mortality in patients with congenital heart disease (CHD). The diversity of lesions, lack of dedicated equipment, and small number of procedures performed by individual operator continue to pose a challenge to congenital interventional cardiologists.

Case summary

We report two cases of percutaneous recanalization in CHD using percutaneous coronary intervention (PCI) equipment for chronic total occlusion (CTO).

Discussion

Careful pre-procedural planning, access site choice, use of catheter guiding systems for support, and selection of penetrating guidewires and techniques used in CTO-PCIs are key steps to a successful outcome.