EXPERIENCE WITH REPAIR OF CONGENITAL HEART-DEFECTS USING ADJUNCTIVE ENDOVASCULAR DEVICES

The use of endovascular devices as an adjunct to repair of congenital heart anomalies represents a novel but unproven therapeutic approach. Intraoperative implantation of pulmonary arterial stents (5 to 15 mm d iameter) was done in 11 patients,vith pulmonary atresia with ventricul ar septal defect (n = 4), classic tetralogy of Fallot (n = 2), truncus arteriosus (n = 1), hypoplastic left heart syndrome (stage II [n = 1] and stage III [n = 1] Norwood procedure), and miscellaneous pulmonary arterial stenoses (n = 3), as well as in patients with congenital (n = 1) and postoperative (n = 3) pulmonary venous osbstruction and in 1 patient with combined pulmonary arterial and venous obstruction. The s tents were effective at achieving immediate patency in all patients. T here were two early deaths, one related to acute thrombosis of a small -diameter left pulmonary artery stent. Reintervention because of stent -related pulmonary arterial stenosis was frequently necessary, In five ;of seven patients who survived more than 1 month after implantation o f stent size 8 mm or smaller severe stent-related pulmonary arterial o bstruction developed, In four of the five patients with pulmonary vein stent implantation intractable obstruction developed, resulting in de ath in all three patients who had bilateral pulmonary vein stent impla ntation, Intraoperative occlusion of apical muscular ventricular septa l defect with use of a clamshell device inserted from the right atrial approach was accomplished in four patients, One patient who underwent associated aortic arch reconstruction died as a result of left ventri cular hypoplasia, The results in the remaining three patients were fav orable on the basis of absence of significant late residual intraventr icular shunting, left ventricular dysfunction, or arrhythmia. We concl ude that recurrent intraluminal obstruction as a result of neointimal hyperplasia appears to be an eventual certainty in currently designed small-diameter endovascular stents, For this reason, we would recommen d standard surgical techniques for repair of obstructive lesions of th e pulmonary arterial confluence to maximize growth potential, Device o cclusion of muscular ventricular septal defects is feasible but probab ly only indicated for complex cases of ventricular septal deficiency t hat otherwise necessitate a left ventriculotomy.